F0677

D

Failure to Provide Scheduled Showers and 2-Hour Check-and-Change for Dependent Resident

Milwaukee, Wisconsin Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide required Activities of Daily Living (ADL) services, specifically bathing and toileting, to a resident who was fully dependent on staff for care. The resident had diagnoses including bladder cancer, cerebral infarction (stroke), Alzheimer’s disease, vascular dementia, and depression, and was documented as severely cognitively impaired and dependent on staff for all care, mobility, and transfers. The resident’s ADL care plan, initiated 4/14/22, required staff assistance of one person for bathing/showers, with showers scheduled twice weekly on Tuesdays and Saturdays, and instructions to offer an alternative if a bath or shower was refused. The facility’s ADL support policy required that residents unable to carry out ADLs independently receive appropriate hygiene and toileting assistance in accordance with the plan of care.

Surveyors reviewed the resident’s shower and bathing documentation for December 2025, January 2026, and February 2026, including shower sheets and CNA task documentation. They identified multiple dates on which the resident was scheduled to receive showers but there was no documentation that bathing or showering occurred, specifically on four scheduled shower days in January and February 2026. Interviews with CNAs and the ADON confirmed that residents were supposed to receive showers twice weekly, that shower days and shifts were listed in a binder at the nurse’s station, and that CNAs were responsible for documenting showers or bed baths on shower sheets and in the electronic medical record (EMR), with nurses completing skin checks and forwarding completed shower sheets to the DON.

The resident’s care plan also included a toileting intervention from the fall care plan to review and revise a toileting program with checks and toileting every two hours and as needed. Surveyors reviewed an every-2-hour check and change log dated 2/17/26–2/20/26 and found multiple blank rows with no documentation, showing that on 2/17/26 the resident was not checked or changed from sometime before noon until 10 PM (at least 10 hours), and on 2/18/26 from 6 AM until 2 PM (8 hours). CNA bowel and bladder documentation in the EMR showed long gaps with no entries, including over 15 hours on 2/17/26 and almost 17 hours between the evening of 2/17/26 and the afternoon of 2/18/26. Staff interviews revealed inconsistent explanations about the purpose and duration of the check and change logs, with some CNAs stating they had been used long term for every two-hour checks and an ADON stating they were short-term tools without a formal policy. The Director of Social Services reported personally noticing the resident sitting in the common area most of the day and detecting an odor, and later learning that the family had raised the same concern, supporting the surveyor’s conclusion that the resident was not checked and changed every two hours as care planned.