Resident 24 at South Shore Rehabilitation and Nursing Center was supposed to receive showers twice weekly according to their care plan. Instead, staff gave bed baths and avoided the more challenging task of getting the resident to the shower room.
The resident's last documented shower was July 26. When inspectors arrived August 12, Certified Nursing Assistant 2 was scheduled to give the resident a shower that day but chose a bed bath instead.
"The resident was physically aggressive," the assistant told inspectors during an interview at 1:43 PM. The assistant said they notified Registered Nurse Supervisor 5 and documented providing a bed bath on the accountability record.
But there was a problem. Review of progress notes from July 26 through August 12 revealed no documentation that the resident had refused showers or exhibited behavioral issues during bathing attempts.
Registered Nurse Supervisor 5 confirmed the resident should have been getting showers twice weekly and "had no explanation as to why the resident was not getting showers."
The supervisor wrote a nursing progress note at 3:18 PM on August 12 stating the resident "was combative this morning and, as a result, was not shaved or showered; however, the resident was given a bed bath." Staff administered 0.5 milligrams of Xanax with "much relief."
This was the first time anyone had documented behavioral issues affecting the resident's care.
The Assistant Director of Nursing reviewed the electronic medical record and determined "there was no documentation that the resident received showers as per their plan of care." The nursing director acknowledged the resident "has unpredictable, erratic behaviors, including grabbing and reaching for things, and that is probably why they did not get showers."
The facility had no comprehensive care plan addressing the resident's activities of daily living until August 13 — the day after inspectors questioned staff about the missing showers.
That same day, the Director of Nursing Services added to the resident's behavioral care plan, documenting for the first time that the resident had "agitation and attempting to stand, combative and impulsive behavior during care, causing potential for a safety issue during shower."
A new activities of daily living care plan was also created August 13, instructing staff to "provide shower/bed bath, based upon resident's preference/ability, twice per week and as needed."
Physical Therapist Rehabilitation Department Director 1 explained that due to the resident's behaviors, showers required two staff members for safety. The resident was dependent on two people for transfers to and from the shower chair.
On August 14, inspectors observed Certified Nursing Assistant 2 and Concierge 1 bringing Resident 24 back from a shower. Later that day, the resident was observed in the day room, "groomed, showered, and shaved."
The Director of Nursing Services acknowledged the breakdown in care during an interview August 15. The resident "should have received showers twice a week," the director said. "If the resident was combative during care, then it should have been documented, and the staff should have reviewed the current interventions and put new interventions in place to provide needed care to the resident."
The violation represents a failure in basic hygiene care that nursing homes are required to provide. Federal regulations mandate that facilities ensure residents receive appropriate personal care services, including bathing, to maintain good hygiene and prevent health complications.
For nearly three weeks, staff at South Shore Rehabilitation chose the easier option of bed baths while avoiding the more labor-intensive task of safely showering a resident with challenging behaviors. The facility only developed proper documentation and care strategies after inspectors questioned why required care wasn't being provided.
The resident's experience illustrates how behavioral challenges can lead to care shortcuts when facilities lack proper protocols and oversight. Without documentation of behavioral incidents or alternative care approaches, there was no way to track whether the resident's hygiene needs were being met or if staff were simply avoiding difficult care situations.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for South Shore Rehabilitation and Nursing Center from 2025-08-15 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for South Shore Rehabilitation and Nursing Center
- Browse all NY nursing home inspections