Federal inspectors found that all three residents reviewed from a sample of 19 had missed multiple scheduled showers over a 30-day period in August and September 2025. The violations affected residents dependent on staff assistance for bathing, including patients with Parkinson's disease, chronic kidney disease, and pressure ulcers.
R6, diagnosed with dementia, Parkinson's disease, and a pressure ulcer on the sacral region, received only five showers in 30 days despite being scheduled for twice-weekly baths on Tuesdays and Fridays. The resident's electronic medical record showed showers on August 20, August 23, September 3, September 6, and September 17, with no documentation of additional baths or refusals for the remaining scheduled dates.
The facility's own policy, dated January 2018, states that showers will be offered "two times per week or according to the resident's preferred frequency" to maintain proper hygiene and dignity. Staff are required to document all bathing assistance in electronic records, including relevant observations.
R8, who has chronic kidney disease, muscle wasting, sepsis, gangrene, and diabetes, fared even worse. The resident received only three showers in 30 days on August 26, September 2, and September 12. Records showed two documented refusals on September 3 and September 5, but no attempts or documentation for other scheduled shower days.
Despite requiring partial assistance for bathing due to multiple serious medical conditions, R8's care plan called for showers twice weekly from 6:00 PM to 6:00 AM on Tuesdays and Fridays.
R9, diagnosed with dementia, delusional disorder, depression, and needing assistance with personal care, received the fewest showers. Records documented only two showers in 30 days on August 26 and September 9, along with documented refusals on August 22 and September 12.
The resident was scheduled for twice-weekly showers on Tuesdays and Fridays between 6:00 AM and 6:00 PM but received no documented attempts at bathing for most scheduled dates.
All three residents require staff assistance for bathing according to their Minimum Data Set assessments. R6 is completely dependent on staff, while R8 and R9 need partial or moderate assistance.
Administrator V1 confirmed during the September 18 inspection that the facility provides two showers per week to residents and that staff should document when showers are given or refused.
Director of Nurses V2 acknowledged the same day that staff should document all showers in residents' electronic medical records under the bathing task section. V2 said staff should record whether a shower was given or refused, and if refused, should notify the nurse to reapproach the resident and address any barriers.
The facility's shower schedule from August 1 clearly outlined when each resident should receive care. Yet inspection records revealed systematic gaps in documentation and service delivery across all three cases reviewed.
For residents with conditions like pressure ulcers, chronic kidney disease, and dementia, regular bathing serves critical health functions beyond basic hygiene. Poor bathing practices can worsen existing skin conditions, increase infection risk, and compromise overall health outcomes for vulnerable populations.
The inspection found no evidence that staff attempted to address barriers when residents refused showers or that nurses were notified to reapproach residents as required by facility policy.
Federal regulators classified the violation as causing minimal harm or potential for actual harm to residents. The deficiency affected "some" residents according to the inspection report, though the full scope beyond the three reviewed cases remains unclear.
The complaint-driven inspection on September 19, 2025, revealed systematic failures in basic care delivery at the 19-resident facility. Missing scheduled showers represents a fundamental breakdown in activities of daily living assistance that nursing homes are required to provide.
Records showed no alternative bathing methods were documented when scheduled showers were missed, leaving residents with serious medical conditions without adequate hygiene care for extended periods.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Goldwater Care Clinton from 2025-09-19 including all violations, facility responses, and corrective action plans.