Failure to Provide Scheduled Showers and ADL Support
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate assistance with activities of daily living (ADLs), specifically scheduled showers, for one resident. The resident was admitted in late winter 2026 with diagnoses including walking and mobility abnormalities, need for assistance with personal care, and heart failure. An MDS dated 1/26/26 showed the resident had no memory impairment and was totally dependent on staff for shower transfers. The resident’s ADL care plan, initiated 1/28/26, identified ADL self-care needs and risk for pressure injury and skin breakdown, with instructions that skin discoloration should be noted during baths. Review of shower documentation showed the facility could not produce a shower sheet for the week of 1/14/26, indicating the resident did not receive a shower that week, and subsequent weekly shower sheets dated 1/22/26, 1/26/26, and 2/2/26 each showed only one shower provided that week. Staff interviews confirmed that facility practice and expectation were for residents to receive showers twice weekly, with showers offered on either AM or PM shifts and refusals documented on shower sheets. A licensed nurse stated showers were expected two times per week and could be offered in the evening if a resident was unavailable due to appointments. A CNA reported that all residents were scheduled for baths twice per week, that no residents were scheduled once weekly unless they refused, and that refusals and skipped baths were reported to the nurse and documented. The ADON confirmed that shower sheets were used to document all showers and refusals, and that showers were scheduled twice weekly. In contrast, the resident and a family member reported that multiple showers had been missed, with the resident stating he sometimes skipped an entire week and only received one shower, and that he had not requested to receive only one shower per week. Facility policies on Abuse and Neglect and on ADLs required staff to institute measures to address residents’ needs to minimize neglect and to provide services necessary to maintain grooming and personal hygiene, which were not followed in this case.
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