F0677

E

Failure to Provide Scheduled Showers and Bathing per Orders and Resident Preference

Chagrin Falls, Ohio Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide showers and bathing in accordance with residents’ physician orders, care plans, stated preferences, and the facility’s Hygiene, Bathing, and Showering Policy. Multiple residents who required staff assistance with activities of daily living (ADLs) did not receive scheduled showers or bed baths, and in several cases there were prolonged gaps between bathing events with little or no documentation of refusals or completed care. The facility’s own policy required that hygiene and bathing services be provided according to residents’ needs and preferences, yet records and interviews showed that this was not consistently done.

One resident with metabolic encephalopathy, dementia, heart failure, and incontinence was ordered to receive showers and skin checks twice weekly on specific days per her preference. She reported that she had not been receiving her scheduled showers and could not recall the last time she had a shower or bed bath. Review of shower sheets over a two‑month period showed only two documented showers, and the EMR CNA task record showed only one shower documented, with only a single refusal noted in the progress notes. Another resident with quadriplegia and malignant neoplasm of the spinal cord, who was cognitively intact and dependent on staff for bathing and transfers, was ordered and scheduled to receive showers with skin checks twice weekly. He reported that in approximately three weeks he had only two showers, that two scheduled showers were missed because staff said they did not have time, and that his wife had to come in to provide a shower. Facility records confirmed only two showers since admission and a nine‑day period without a shower or bath, including missed scheduled shower days.

A cognitively intact resident with prostate cancer, diabetes, and hypertension was ordered to receive skin checks twice weekly on bath/shower days. He and his wife reported that he had not received a bed bath since admission and that he felt dirty. There were no shower/bath sheets from admission until nine days later, and the only shower sheet present documented a refusal on a specific date but was actually completed several days after the event. Another resident with impaired cognition and functional dependence was ordered to receive skin checks twice weekly on bath/shower days; facility records showed only two bed baths during his stay and no evidence of any shower or bed bath for extended periods of 11 and 13 days, despite the DON confirming there was no medical reason he could not receive at least a bed bath.

Additional residents with intact cognition and mobility limitations also did not receive showers as ordered. One resident with macular degeneration, Crohn’s disease, osteoarthritis, and a history of falls was ordered to receive showers and skin checks twice weekly and required partial to moderate assistance. Shower sheets over two months showed irregular and infrequent showers, including gaps of 10 and 14 days between showers, and the resident stated she did not get showers when she was supposed to. Another resident with a hip fracture, diabetes, congestive heart failure, and a history of falls, ordered to have showers and skin checks twice weekly, had only one documented bed bath from admission with no other shower sheets present and reported not getting enough showers. Agency CNAs reported they were unable to complete all scheduled showers and baths because there were too many assigned, and the Interim DON acknowledged that residents were to receive showers twice weekly as scheduled and per preference, verified the missing documentation and missed showers for multiple residents, and stated there had been an ongoing problem with showers getting completed.