F0584

E

Failure to Maintain Resident Bathroom Access and Homelike Environment During Prolonged Shower Renovation

New Braunfels, Texas Survey Completed on 01-30-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide a safe, comfortable, and homelike environment by not ensuring that resident bathrooms and showers were maintained in usable condition for an extended period. Four bathrooms in the women’s secured unit had their doors screwed shut after a contractor began but did not complete shower renovations around July or August 2025. The Maintenance Supervisor reported that the contractor discovered more damage than expected, requested additional funds, and when that request was denied, the renovation work stopped. To address the unfinished and potentially unsafe showers, the facility screwed the bathroom doors shut, leaving multiple residents without access to the toilets and showers in their own rooms for about six months.

Resident #1, who had Alzheimer’s disease, a psychotic disorder with delusions due to a known physiological condition, anxiety disorder, and major depressive disorder, had moderate cognitive impairment with a BIMS score of 12/15 and was frequently incontinent of bowel and bladder. She required supervision and setup or clean-up assistance with toileting. Her bathroom door was observed to be screwed shut, and she stated she could not use her own toilet because it was locked and that she did not like having to use a different bathroom. Her family member reported that Resident #1 could not remember where the designated bathrooms were and had to be led there by CNAs, and that Resident #1 disliked using another resident’s bathroom. The family member described feeling awkward entering other residents’ rooms, noted that other residents stared at them, and stated this had been an ongoing issue since at least October 2025.

Resident #2, who had unspecified intellectual disabilities, unspecified dementia of unspecified severity without behavioral, psychotic, mood, or anxiety disturbance, and bipolar disorder, had a BIMS score of 9/15 indicating moderate cognitive impairment and was occasionally incontinent of bowel and bladder. She required supervision to extensive assistance with toileting, and her care plan called for routine and PRN toileting assistance. She stated she hated not having her own bathroom and having to go to another resident’s room to use the toilet, and reported that the residents whose bathrooms she used did not like it either. Resident #3, with age-related cognitive decline, lack of coordination, and unsteadiness on her feet, had a BIMS score of 8/15 indicating severe cognitive impairment, was continent of bowel and bladder, and required supervision or setup assistance with toileting. She stated it was an inconvenience to use another resident’s bathroom and to walk down a cold hallway to the shower carrying her toiletries, and that it had been a long time since her bathroom had been locked and she wished they would fix her shower.

CNA A, who had worked at the facility for about one year, confirmed that four bathrooms in the women’s secured unit had been inaccessible since July or August 2025 because their doors were screwed shut after the incomplete shower remodeling. She stated that affected residents, including Resident #1, Resident #2, and Resident #3, were instructed to use toilets in specific other resident rooms (rooms 36 and 38), the main shower room, and the room across from the shower room, which were at a distance and not liked by residents, especially at night when it was cold. She reported that residents in the designated rooms questioned why others were using their bathrooms and that affected residents and some family members complained frequently about when the bathrooms would be fixed. CNA A described the situation as inconvenient for the affected residents and a privacy issue for the residents sharing their bathrooms. The ADON and Maintenance Supervisor acknowledged that the four bathrooms were locked down and that residents were directed to other bathrooms, and the ADON stated he understood all residents should have their own bathroom and that it was an inconvenience, but said he could not do anything because approval for renovations rested with upper management. The Administrator and DON reported that corporate had requested bids for the shower renovations, that bids were obtained and sent to corporate, and that the matter was stalled with the main owner, while acknowledging that the situation had been ongoing for months, that affected residents should have their own bathrooms, and that it created inconvenience and privacy issues. The facility’s Homelike Environment policy stated that staff should provide person-centered care emphasizing residents’ comfort, independence, and personal needs and preferences, and that management should maximize characteristics reflecting a personalized, homelike setting.