The man, identified as Resident #44 in inspection records, received only four of his nine scheduled showers during a month-long period at Addison Heights Health and Rehabilitation Center. His care plan called for showers twice weekly on Mondays and Thursdays, but staff provided them sporadically on different days instead.
When inspectors observed him on September 8, the resident said he was unsure who his assigned nursing assistant was for the day. He explained that the wound specialist had removed dressings from his legs specifically because he was supposed to receive a shower.
The resident requires substantial to maximal assistance with daily activities due to multiple medical conditions including bipolar disorder, hypertension, anemia, and a fractured fourth lumbar vertebra. He uses a walker or wheelchair for mobility and has sustained multiple falls since admission.
His nursing care plan, developed in April, specifically outlined interventions including assistance with personal hygiene and putting on and taking off footwear. The facility scheduled his showers for Mondays and Thursdays according to activity records.
But shower documentation from August 9 through September 8 told a different story. Records showed showers provided on August 11, August 18, August 25, and August 28. The sporadic timing meant the resident missed more than half his scheduled hygiene care.
Two hours after inspectors observed the unwashed resident, they interviewed Certified Nurse Aide #481, who was assigned to his care from 7 a.m. to 3 p.m. that day. The aide initially stated the resident was scheduled for Tuesday and Friday showers and hadn't received one that day.
When inspectors showed the aide the actual scheduling documentation, it confirmed showers were supposed to occur on Mondays and Thursdays. The aide's confusion about the basic schedule highlighted gaps in communication about resident care needs.
Activity records lacked documentation indicating showers were provided as scheduled throughout the review period. The pattern suggested systemic problems with both delivering and tracking basic hygiene services.
Three days later, inspectors interviewed the Director of Nursing, who verified that showers were not provided as scheduled facility-wide. The admission came during a complaint investigation that had prompted the federal review.
The facility's own Activities of Daily Living policy, revised just five months earlier in April 2025, promised appropriate care and services for residents unable to carry out daily activities independently. The policy specifically mentioned hygiene support including bathing, dressing, grooming, and oral care.
The policy also required staff to monitor, evaluate, and revise resident responses to interventions as appropriate. But the month-long documentation gap suggested little monitoring occurred for this resident's basic hygiene needs.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm to some residents. The finding emerged from two separate complaint investigations numbered 2593504 and 2608577.
The resident's medical complexity made consistent hygiene care particularly important. Beyond his mobility limitations and history of falls, he dealt with vascular myelopathies and required wound care that specialists coordinated around his shower schedule.
When the wound specialist removed his leg dressings expecting a shower that never came, it illustrated how the facility's scheduling failures rippled through multiple aspects of his medical care.
The inspection occurred on September 15, but the hygiene problems had persisted for weeks beforehand. The resident's appearance during the September 8 observation suggested the missed showers had accumulated over time, leaving him with visibly unwashed hair and significant facial hair growth.
His statement that he "often does not get his showers as scheduled" indicated this wasn't an isolated incident but an ongoing pattern of neglect. The resident seemed resigned to the irregular care, suggesting he had learned not to expect the basic hygiene services outlined in his care plan.
The confusion between his assigned aide and the actual shower schedule revealed deeper problems with staff communication and training. When nursing assistants don't know basic details about their assigned residents' care plans, it suggests systemic breakdowns in how the facility manages daily operations.
The Director of Nursing's acknowledgment that showers weren't provided as scheduled confirmed what the documentation and resident's appearance already made clear. But the admission came only after federal inspectors had gathered evidence of the facility's failures to meet its own hygiene policies.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Addison Heights Health and Rehabilitation Center from 2025-09-15 including all violations, facility responses, and corrective action plans.
Additional Resources
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