F0677

D

Failure to Honor Resident Shower Preferences and Document ADL Care

Los Angeles, California Survey Completed on 01-27-2026

Penalty

No penalty information released

Summary

The facility failed to ensure that a resident received showers and grooming in accordance with his assessed needs and stated preferences. The resident was admitted with multiple mobility- and strength-related diagnoses, including generalized muscle weakness, abnormal gait and mobility, prior stroke, lumbar spondylosis, prior right femur fracture with internal fixation, and right hip osteoarthritis. His care plan for activities of daily living indicated he required one-person assistance with most bathing tasks due to decreased strength, limited balance, and reduced functional independence. An MDS assessment documented intact cognition, independence with eating and personal hygiene, and a need for maximal assistance with bathing and dressing. An IDT conference note recorded that the resident preferred showers before 10:00 a.m. on Mondays, Tuesdays, Wednesdays, Thursdays, and Saturdays, and preferred to be shaved every two days.

Despite these documented needs and preferences, staff followed a shower schedule based on bed assignment rather than the resident’s individualized preferences. A CNA reported that residents in Bed A were scheduled for showers on Mondays and Thursdays during the 3 p.m. to 11 p.m. shift and that she reminded the resident his showers were scheduled for that shift when he requested showers during the day. The CNA stated the resident frequently asked for showers during the day and became upset when told of the evening schedule. The resident reported that he was not offered showers on several specific dates and that when he reminded staff, they told him they were too busy or not his assigned nurse, and they also refused to shave him when requested. He stated that on one scheduled shower day he left the facility in the morning and returned before lunch but was not offered a shower upon his return.

The facility’s documentation and communication practices contributed to the missed showers and grooming. The CNA stated she was required to complete paper shower sheets and an ADL task flowsheet in the EHR, but the flowsheet did not indicate whether a shower was actually completed, and if a shower sheet was not completed and turned in, nursing staff would not know if a resident received a shower. An LVN confirmed that showers were documented only on shower sheets, which were reviewed and then sent to the Director of Staff Development (DSD), and that showers were not documented in the EHR; if a shower sheet was missing, there was no way to verify in the medical record that a shower occurred. The DSD stated that shower sheets, which listed multiple residents per page, were kept in her office and were not part of the resident’s medical record, and that there were no shower sheets for the resident for certain dates when showers were due. The DSD acknowledged that the CNA assigned on one of those dates did not offer the resident a shower, that staff were not accommodating the resident’s shower preferences, and that staff communication regarding showers was not clear. Facility policies on dignity, resident rights, and ADL support required that residents be groomed as they wished and receive appropriate assistance with hygiene in accordance with their plan of care.