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F0677
D

Failure to Provide Required Shower Assistance for Resident with Severe Cognitive Impairment

Torrance, California Survey Completed on 07-29-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A review of facility records and interviews revealed that a resident with severe cognitive impairment and a history of muscle weakness, difficulty walking, and traumatic brain injury was not assisted with showers at least twice a week as required. The resident's Minimum Data Set (MDS) assessment indicated a need for partial assistance with showering and toileting hygiene, and supervision with oral and personal hygiene. The care plan, initiated in April 2022, specified that the resident required assistance with activities of daily living (ADLs), including a directive to ensure showers two to three times per week. During a review of shower documentation and Point of Care (POC) response history for the month of July, it was confirmed by a registered nurse that the resident did not receive the required number of showers. The Director of Nursing also acknowledged that residents are to be assisted with showers at least twice weekly for personal hygiene. Facility policies reviewed indicated that staff are to assist residents with ADLs and promote cleanliness and comfort, but these were not followed in this instance.

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