The facility's Director of Nursing admitted she was "unable to provide additional evidence of showers provided" to the dozen residents when inspectors asked for documentation during their September 3 visit. The missing records covered residents numbered 1, 2, 3, 5, 7, 29, 41, 44, 45, 49, 53, and 63.
The documentation gap emerged from a broader breakdown in the facility's shower system. Staff told inspectors that the designated shower aide had been repeatedly pulled away from bathing duties to cover other roles during August, leaving residents without their scheduled hygiene care.
CNA #563, who worked as the shower aide Monday through Friday, told inspectors she was responsible for all second-floor residents across four halls. That meant up to 12 showers per shift. But during August, she said, "she had been pulled to go out on appointments with residents" and "had not been able to complete her showers."
The facility's shower tracking system relied on paper records kept in a "shower book" on the second floor. After each shower, staff were supposed to fill out a shower sheet and log the task electronically. The shower aide would notify a nurse if anything abnormal was observed during bathing.
But when CNA #563 was pulled to other duties, the system fell apart. Regular aides were supposed to pick up the shower responsibilities, she explained, but "sometimes they are short staffed and have three aides instead of five so she gets pulled to be an aide rather than the shower aide."
The understaffing created a cascade of missed care. CNA #563 told inspectors that "the aides were instructed that when there was no assigned shower aide, they are all responsible to complete their resident's shower." But the missing documentation suggests those instructions weren't followed.
Licensed Practical Nurse #510 confirmed the shower book system to inspectors, explaining that shower sheets were filled out for residents from both the first and second floors. CNA #541 described how staff were supposed to complete the shower task in the electronic medical record under a "shower/bath tab" after finishing the documentation.
The facility's own policy, dating to October 2010, required detailed record-keeping for each shower or bath. Staff were supposed to document the date and time, the name and title of the person assisting, assessment data obtained during bathing, how the resident tolerated the shower, and any refusals or interventions taken.
Director of Nursing #581 told inspectors she had provided "the complete book of shower sheets" but acknowledged the gaps in documentation. She confirmed that what appeared in both the shower book and the electronic medical record represented "what was charted was what was completed."
The missing shower records represented more than paperwork problems. The facility's policy stated that bathing served multiple purposes: "to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin." Without documentation, there was no proof these essential hygiene and health monitoring functions had occurred.
The inspection revealed a facility struggling with basic staffing and care coordination. When the designated shower aide was reassigned to cover other duties, the system for ensuring residents received regular bathing broke down entirely. The result was 12 residents with no documented proof they had received this fundamental aspect of personal care.
CNA #563's description painted a picture of constant crisis management. She worked weekends in addition to her regular shower aide duties, sometimes "picked up as an aide too," and was frequently pulled away from her primary responsibility to fill staffing gaps elsewhere in the facility.
The federal inspection occurred as part of a complaint investigation, suggesting someone had raised concerns about conditions at Gardens of Euclid Beach. The shower documentation failures represented what inspectors classified as "minimal harm or potential for actual harm" affecting "some" residents.
For the 12 residents whose shower records were missing, the inspection findings meant there was no official proof they had received basic hygiene care during the period under review. The facility's Director of Nursing could not provide any additional evidence beyond the incomplete shower book to demonstrate these residents had been bathed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Gardens of Euclid Beach from 2025-09-23 including all violations, facility responses, and corrective action plans.