F0677

D

Failure to Provide Scheduled Showers and Hygiene Care for Dependent Residents

Newberg, Oregon Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure dependent residents received showers as needed to maintain personal hygiene and dignity, contrary to its Activities of Daily Living policy requiring necessary services for grooming and hygiene. One resident with quadriplegia, aphasia, severe cognitive deficit, and total dependence for bathing was care planned to receive one-person total assistance for showers, but the care plan did not specify shower frequency. Bathing task logs for a one‑month period showed this resident was scheduled for showers twice weekly on Wednesdays and Saturdays, with 10 shower opportunities. The resident received showers on only four of those dates, two bed baths on two dates, and had no documented showers or make‑up showers on three Saturdays and one additional date when a shower was refused. There was no evidence in the clinical record that missed showers were made up, and a family grievance documented concerns about strong body odor and greasy hair and face, as well as a request to increase shower frequency.

Interviews with CNAs and nursing staff confirmed that the resident was dependent on staff for showering, usually did not refuse showers, and that the expected practice was to make up missed showers later the same day or the next day, and to offer a bed bath if a shower was refused. Staff reported that showers were important for this resident due to sweating, smelly hair, and oily skin. Staff also acknowledged that showers were not consistently completed, particularly on Saturdays, and attributed this to heavy reliance on agency CNAs. The Assistant DNS/Resident Care Manager and DNS were aware that scheduled showers were missed during the review period, and observations over several days showed the resident in bed or in a Geri chair with oily facial skin.

A second resident with diabetes, metabolic encephalopathy, bowel and bladder incontinence, and total dependence on staff for bathing was care planned to receive showers twice weekly and as necessary, with a preference for showers. The shower schedule listed this resident for Wednesday and Saturday evening showers, but bathing task logs over a one‑month period showed only one documented shower. Progress notes contained no evidence of additional shower opportunities when showers were refused or not provided. During observations, the resident was noted in bed with greasy hair and wearing a gown, and reported not being showered regularly, estimating the last shower was about a month prior, and stating that staff had not offered showers in a long time and that refusals were rare. CNAs confirmed the resident was frequently soiled, rarely refused showers, and that agency CNAs often documented refusals without actually offering showers. Staff also reported that scheduled showers were often not completed due to workload, staffing patterns, and the need for two staff and a mechanical lift for this resident, and the DNS and regional clinical leader confirmed that the last documented shower date for this resident was not acceptable.