Failure to Provide Scheduled Showers to Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a dependent resident received scheduled showers as required. The resident, admitted in mid-2025 with muscle weakness, morbid obesity, chronic pain, and gait and mobility abnormalities, had a prior medical order for showers on the day shift every Monday and Thursday, which was discontinued on 9/2/25. A quarterly assessment dated 9/18/25 documented in section GG that the resident required substantial/maximal assistance to safely complete shower activities, indicating dependence on staff for this ADL. A complainant reported that the resident would go 11 days without staff providing showers. Record reviews conducted in early February 2026 showed no active shower order and no documentation in the medication administration record that showers were being provided. Facility staff reported that shower/skin sheets are completed whenever a shower is given, and that all residents are scheduled for showers twice weekly based on room and bed number, which would have placed this resident’s showers on day shift every Wednesday and Saturday. Review of September 2025 shower/skin sheets showed only one documented shower on an evening shift, and review of nursing aide task documentation showed one additional shower on a day shift. No other documentation was found to show that showers were provided or refused on the other scheduled days. In an interview, the DON confirmed that in that month the resident received only one scheduled and one unscheduled shower and acknowledged the concern.
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