Failure to Provide Scheduled Showers per Resident’s Care Plan and Preferences
Penalty
Summary
The facility failed to provide scheduled showers for a resident who was unable to perform activities of daily living independently. Facility policy on ADLs, last reviewed in December 2024, required staff across all shifts and departments to provide person-centered care that honors each resident’s preferences, including bathing preferences. One resident, diagnosed with seizure disorder, anxiety, COPD, and multiple sclerosis, had a significant change MDS dated January 21, 2026 documenting that she was awake, alert, and oriented. Her person-centered care plan for ADLs stated that she had a self-care performance deficit, required assistance of one person for bathing and showering, and preferred showers on Wednesday and Saturday evenings. During an interview, the resident reported she had not received a shower since May 5, 2025 because staff told her the facility no longer had a bariatric shower bed that could accommodate her. Review of her bathing record from early February through early March 2026 showed no documentation of showers on her scheduled shower days; instead, only bed baths were recorded on those days. When this was discussed with the DON, it was noted that the bathing records completed by the assigned nurse aide did not show evidence that the resident was provided showers as designated in her care plan, resulting in a failure to follow resident rights, resident care policies, and nursing services requirements under the cited Pennsylvania regulations.
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