F0677

E

Failure to Provide and Document Adequate ADL Hygiene and Bathing Care

Southfield, Michigan Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide and document adequate ADL care, including personal hygiene, bathing, and nail care, for multiple dependent residents. One resident reported that there were sometimes not enough aides on the unit and stated it took a long time to get assistance, resulting in missed scheduled bed baths and going about a week without a bed bath. Review of this resident’s CNA task documentation over a 30‑day period showed a bed bath on 1/21/26, with the next not until 1/28/26, and the last documented bed bath on 2/3/26.

Another resident with severely impaired cognition, dependent on staff for all ADLs, was repeatedly observed in the same hospital gown with a persistent foul, sour body odor in the room. This resident’s fingernails were long, with debris under the nails, and the fingers were contracted into the palms. When the unit manager partially opened the contracted hand, a very strong foul, bitter, sour odor emanated from the palm, which the manager confirmed. The unit manager stated the resident was scheduled for a shower later that day and reported that about a month earlier the therapy department had worked with the resident to clean the palm of the hand. Review of this resident’s CNA bathing task documentation for the prior 30 days showed the last scheduled shower documented on 2/3/26.

A third resident, with vascular dementia, hemiparesis, ROM impairment, and dependent for showers/baths and personal hygiene, had family concern forms documenting delays in personal care, including being left in bed undressed and in the same facility gown with a strong urine smell from the bed, suggesting unchanged linens. The ADL care plan called for assistance with scheduled and as‑needed bathing/showering via gurney with two‑person assist, but shower/bath documentation for the past 30 days showed only one shower, with no refusals documented. A fourth resident, cognitively intact and dependent on staff for toileting hygiene and bathing, reported preferring showers but stated that when there was not enough nursing staff they received a bed bath or no shower. Review of this resident’s record showed only three showers documented in the past 30 days, with no refusals, despite a care plan specifying assistance with ADLs and a preference for a specific shower chair. The DON stated that CNAs were instructed to document all showers/baths in the electronic medical record and that no additional shower forms were used. The facility’s ADL policy stated that residents unable to carry out ADLs independently would receive services necessary to maintain grooming and personal hygiene.