The shower problems at Lewis & Clark Gardens began during the week before September 15, when the drain stopped working properly on the facility's COVID isolation unit. Staff were supposed to offer bed baths or provide wash basins for residents to clean themselves when the shower was unavailable.
But documentation tells a different story.
Nursing Assistant A returned to work September 9 after being away from the facility for nearly two weeks. The aide managed to complete just one shower before the drain backed up again. After that, residents on the unit couldn't access shower facilities.
Resident #1, who was receiving hospice care, specifically asked the nursing assistant for help with a shower that day. The aide couldn't provide one because the shower was broken.
The facility's Administrator acknowledged the shower wasn't working properly for two days. Staff reported they gave bed baths during that time, she said, but they didn't complete shower sheets for those bed baths.
That gap in documentation matters. Federal regulations require nursing homes to maintain records of all bathing assistance provided to residents. The missing paperwork means inspectors couldn't verify whether alternative bathing actually occurred.
The confusion extended to staff responsibilities. The Assistant Director of Nursing said hospice aides were supposed to assist residents with showers twice a week, but facility staff could also provide showers if residents requested them or if staff noticed residents needed bathing.
However, the ADON also stated that nursing assistants were responsible for helping residents with showers on the COVID isolation unit even if those residents were receiving hospice services.
Nursing Assistant A said Resident #1 was on hospice and that hospice aides typically provided showers for the resident. But when the resident asked for assistance on September 9, the broken shower prevented any bathing.
The nursing assistant didn't know Resident #2 and couldn't say whether Resident #3 received showers during the nearly two-week period when the aide was away from work.
Staff were supposed to follow a strict shower schedule. Residents received showers on Monday and Thursday or Tuesday and Friday, with Wednesday serving as a makeup day for anyone who missed their scheduled shower day.
Nursing assistants documented completed showers on shower sheets and turned them into the nursing office. The Assistant Director of Nursing was responsible for auditing those sheets daily.
But the ADON had been out of the facility for medical reasons, disrupting the normal oversight process.
The facility's shower protocols seemed clear on paper. All residents, including those on the COVID isolation unit, were supposed to receive showers twice a week and as needed or requested. The bathing requirement was the same for residents receiving hospice services.
When hospice aides didn't provide baths or showers, facility staff were required to complete the bathing for hospice residents.
The Administrator said hospice aides typically provided care while residents were on the COVID unit. But the system broke down when the shower drain failed and staff couldn't document their alternative care efforts.
Nursing Assistant C, interviewed on September 10, said there was a functional shower on the COVID isolation unit and that the drainage problem from the previous week had only lasted a few hours.
But Nursing Assistant A's account contradicted this timeline. The aide said the shower was still broken on September 9, preventing assistance for Resident #1's bathing request.
The facility's shower schedule depended on working equipment and consistent staffing. When Nursing Assistant A was away from August 28 through September 8, other staff presumably covered shower duties. But the aide couldn't confirm whether Resident #3 received proper bathing during that period.
The inspection revealed a facility where policies existed but implementation faltered. Staff knew they should offer bed baths when showers weren't available. They knew they should document all bathing assistance. They knew hospice residents still needed facility support when hospice aides couldn't provide care.
Yet when the shower drain backed up, residents went without documented bathing care. The missing shower sheets meant inspectors couldn't verify whether vulnerable residents on the COVID isolation unit received the basic hygiene assistance they needed during those two days when the plumbing failed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lewis & Clark Gardens from 2025-09-15 including all violations, facility responses, and corrective action plans.