F0677

E

Failure to Provide and Document Scheduled Showers and ADL Care for Multiple Residents

Kalamazoo, Michigan Survey Completed on 02-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide scheduled and appropriate ADL care, particularly bathing and showering, to multiple dependent residents, and to accurately document refusals and care provided. One resident with a history of traumatic brain injury and total dependence for care was care planned as totally dependent on two staff for baths or showers twice weekly and as needed. Hospital records later documented that this resident was admitted soaked in urine, with a crusted right eye and crusting around the mouth. A family member reported visiting frequently for several hours at a time and never seeing staff assist with care, describing the resident as often disheveled, with peeling skin, soiled briefs, double briefs, and saliva on the mouth and face, and stated that scheduled showers were often missed despite repeated complaints to nursing staff, the unit manager, DON, and social worker. Review of shower sheets for a two‑month period showed only seven documented showers or bed baths when fourteen should have been provided or refusals documented.

Staff interviews confirmed that showers and bed baths were frequently missed, especially when the facility was short staffed or when the designated shower aide was pulled to work the floor. Multiple LPNs reported that residents were missing showers due to staffing issues and that the shower aide was often reassigned, resulting in missed showers. A CNA stated it was very common to skip ADL care such as showers and bed baths because there was not enough time. The unit manager acknowledged awareness of the family member’s concerns, admitted that shower sheets were not consistently completed, and confirmed that she had not conducted follow‑up on ADL care after the resident’s hospital admission in soiled condition. The DON stated she was not aware of the family member’s concerns and indicated that unit managers were supposed to review shower sheets and care tasks daily.

For other residents reviewed, records and interviews showed additional failures to provide scheduled showers and to document refusals. One male resident with multiple sclerosis, dementia, and weakness was care planned to receive showers twice weekly with assistance; task documentation showed a shower as given on a date when the shower sheet recorded a refusal, and there were no progress notes documenting refusals on that or another refusal date, despite multiple missed shower opportunities over 30 days. Another male resident with chronic pain, muscle weakness, wheelchair dependence, and long hair reported he did not get a shower every week and sometimes only every other week, especially when the shower aide was off; documentation across several months showed fewer showers than the scheduled opportunities, substitution of bed baths in some months, and missing progress notes for documented refusals. A female resident requiring setup and moderate to maximum assistance for bathing was scheduled for twice‑weekly showers but, over a 30‑day period, had only two showers and one refusal documented, with no corresponding refusal note in the progress notes despite nine scheduled opportunities. Another female resident with multiple sclerosis and overactive bladder reported that staffing ratios affected care, that it was difficult to get assistance, and that when the shower aide called in, floor CNAs did not complete scheduled showers; she also reported that the shower aide had too many showers scheduled to complete. The shower aide confirmed starting work very early, being pulled to the floor at least three times per week, and being unable to complete the high number of scheduled showers, resulting in residents not receiving showers on those days. The unit manager stated that when the shower aide was pulled, the assigned CNA was responsible for the shower and that refusals were to be re‑approached and documented with a nurse progress note, but the documentation reviewed did not consistently reflect this process.