Failure to Provide Ordered Showers and Maintain Resident Hygiene
Penalty
Summary
The facility failed to provide necessary services to maintain personal hygiene for one of four residents reviewed, identified as Resident R5. Facility policy titled "Flow of Care" dated 11/1/25 stated that care would be provided as needed 24 hours a day to help residents attain and maintain the highest level of functioning. Clinical records showed that Resident R5 was admitted with diagnoses including fibromyalgia, adult failure to thrive, and diabetes mellitus. Physician orders dated 1/2/26 directed that the resident was to receive showers on the evening shift on Tuesdays and Fridays. Review of the resident’s January 2026 bathing records revealed that instead of the ordered showers, the resident received only two bed baths on 1/6/26 and 1/16/26, resulting in six missed showers during that month. In an interview on March 4, 2026, at 2:30 p.m., the Director of Nursing confirmed that the resident missed six showers and did not receive showers as scheduled. The deficiency was cited under 28 Pa. Code 211.5(f) Clinical records and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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