F0677

E

Failure to Honor Shower Preferences and Provide Scheduled Showers

Clinton, Illinois Survey Completed on 01-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s repeated failure to honor residents’ shower time preferences and to consistently provide scheduled showers to dependent residents, despite facility policy requiring bathing according to resident preference at least twice weekly. Multiple residents with intact cognition and no documented refusal behaviors did not receive showers as scheduled, and staff did not consistently document whether showers were offered, completed, or refused. The Director of Nursing confirmed that all residents are to receive two showers per week, that CNAs are to sign off when showers are given, and that refusals must be documented with reasons and multiple attempts; however, the records and interviews showed this was not occurring.

One resident with muscle wasting, atrophy, and coordination problems, and a BIMS score indicating no cognitive impairment, was care planned as needing partial to moderate assistance with bathing and to be kept clean and dry. This resident was scheduled for showers on the night shift but requested showers on the day shift. Despite this documented preference, the resident continued to be scheduled and bathed on the night shift, with multiple weeks showing no shower sheets at all and several dates where showers were either not given, not documented as offered, or documented as declined at night without any change to the schedule. The resident and a family member both reported that showers were not being provided as supposed, and a CNA stated that this resident was among those who rarely received showers because they took a long time to complete.

Another resident with epilepsy, muscle wasting, gait abnormalities, and generalized edema, and a BIMS score indicating no cognitive impairment, was scheduled for day-shift showers. On multiple documented shower dates, there was no indication that the shower was offered, done, or refused. The resident reported receiving showers but not consistently twice a week, stating that agency staff said they did not have time and that the resident often had to request showers to receive them. A third resident with primary progressive multiple sclerosis, gait abnormalities, and muscle wasting, also cognitively intact, was scheduled for showers but had gaps of a week or more with no shower documentation. This resident reported not receiving showers routinely twice a week and described being offered showers at approximately 3:00 a.m., which the resident refused as unacceptable given a known preference to sleep until mid-morning; the resident stated they generally liked showers and did not usually refuse.

A fourth resident with vertebral compression fractures, restless leg syndrome, chronic pain, muscle wasting, and gait abnormalities, and a BIMS score indicating no cognitive impairment, had long periods with no shower sheets to show that showers were scheduled or provided. When showers were scheduled, documentation was often incomplete, with some entries lacking any indication of whether the shower was offered, done, or refused, and one entry noting a refusal due to pain without further documented offers. During observation, this resident was in bed with greasy, uncombed shoulder-length hair and stated needing a shower, reporting that a shower had not been offered the prior week because staff were too busy. A fifth resident with visual disturbance, cognitive communication deficit, morbid obesity, multiple pain diagnoses, muscle wasting, and difficulty walking, also cognitively intact, had multiple shower dates with no documentation of whether showers were offered, done, or refused. This resident reported receiving the first shower in two weeks the previous night, stated never refusing showers, and indicated typically receiving only one shower per week despite being told two were scheduled.

Staff interviews corroborated the pattern of missed and undocumented showers. A CNA reported that three specific residents rarely received showers because they took a long time to bathe, and that the CNA tried to make up missed showers when working. Another agency CNA who frequently worked nights stated that other night staff reported resident refusals for care and showers, but that this CNA personally did not have issues with residents refusing care and was able to provide care when answering call lights, regardless of assignment. Overall, the documentation gaps, resident statements, and staff interviews demonstrate that residents’ preferences for shower timing were not honored and that scheduled showers were repeatedly not provided or properly documented, contrary to facility policy and stated expectations.