Failure to Provide Scheduled Showers and to Process Hygiene-Related Grievances
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services according to a resident’s needs and preferences, specifically related to hygiene and the handling of grievances about that care. The resident was admitted with diagnoses including hepatic encephalopathy, type 2 DM, and legal blindness, and had moderately impaired cognition but was able to understand and be understood. The resident required partial to moderate assistance with ADLs, including bathing. Despite this, the bathing log from 2/10/2026 to 2/23/2026 showed that the resident, who was scheduled for showers on Tuesdays and Fridays, received only one shower on 2/20/2026 over a 13‑day period, with no documentation of any shower refusals. During an observation on 3/10/2026, the resident was found in bed wearing a stained T‑shirt on stained bedsheets, appearing ungroomed, and reported inconsistent assistance with showering and being given only a towel to wash up at times. The resident and the responsible party (RP) repeatedly reported concerns about inadequate showering and hygiene that were not properly addressed or documented as grievances. The RP stated that during visits in February, the resident was found in dirty clothes and dirty bed linens and not groomed, including on the resident’s birthday when the RP arrived to take the resident to a medical appointment and celebration. The RP reported calling an LVN the evening before a scheduled appointment to request that the resident be showered and ready, and was assured this would occur, but found the resident the next morning in dirty clothes and eating breakfast instead of being prepared. The resident corroborated these concerns, stating that staff accused him of refusing showers, which he denied, and that he would like to shower daily. He also reported developing a rash he believed was related to lack of showering and described specific incidents when he was not provided an opportunity to shower before going out. The facility did not follow its grievance policy in response to these complaints. The RP reported difficulty reaching the SSD and a lack of response to concerns about showers and a subsequent police report. The resident stated he had tried to reach out to the SSD but did not receive daily follow‑up and asked his RP to make complaints on his behalf, yet neither he nor the RP received a response from the facility regarding their concerns. The SSD stated that the grievance log, last updated on 3/3/2026, contained no grievances from the resident or RP from 12/2025 to 2/2026 and that she was not aware of any outstanding grievances. An IDT note dated 2/25/2026 documented that the team discussed the resident’s and RP’s concerns about lack of showering and referenced generalized body dermatitis noted on 2/24/2026, but there was no documentation that the allegations were investigated or that outcomes were communicated to the resident or RP. The DON acknowledged awareness of the concerns raised at the IDT meeting and of the RP’s complaint about the missed shower on 3/2/2026 and the police call, but confirmed that these allegations were not entered into the grievance log to initiate the grievance process, and that the facility did not provide a written update to the RP, contrary to the facility’s written grievance policy.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.