The resident required substantial assistance for bathing due to muscle weakness, seizures, lack of coordination, and muscle wasting. Federal assessments showed helpers needed to do more than half the effort, lifting and holding her trunk or limbs during care.
Despite her physical limitations, the woman remained cognitively intact with a mental status score of 15 out of 15.
From August 19 through August 31, 2025, nursing assistants entered code 97 on daily documentation reports for her bathing care. The code meant "not applicable."
She received no baths for 13 consecutive days.
During a September 22 phone interview, the resident told state inspectors she had not received a bath for two weeks. Three days later, the facility's Director of Nursing confirmed the woman did not receive bathing on any of those 13 days.
The Director of Nursing verified that code 97 meant "not applicable" but could not explain why staff used it for a resident who clearly needed bathing assistance.
A Corporate Nurse interviewed by inspectors was more direct. She said code 97 should not be used for bathing documentation and confirmed that marking care as "not applicable" was the same as not providing the bath.
Multiple certified nursing assistants told inspectors the resident required assistance for bathing. One demonstrated the facility's electronic documentation system, showing inspectors various options for recording bathing care based on residents' needs.
The system included an option for "Not Applicable."
The resident had been admitted to Meadowview earlier in 2025 and was discharged on September 2, just three days after her two-week period without baths ended. Her diagnoses included multiple sclerosis, muscle weakness, seizures, lack of coordination, muscle wasting and atrophy, altered mental status, restlessness and agitation, arthritis, and schizoaffective disorder with bipolar features.
Federal regulations require nursing homes to provide care and assistance with activities of daily living for residents who cannot perform them independently. Bathing is considered a fundamental activity of daily living.
The inspection occurred after a complaint was filed against the facility. State inspectors found the violation represented minimal harm or potential for actual harm to residents.
Staff used the facility's electronic kiosk system to document all care provided to residents. The Director of Nursing confirmed that nursing assistants were responsible for recording what they completed for each resident in their care through this system.
The systematic use of "not applicable" codes for 13 straight days suggested the documentation failure was not an oversight but a deliberate misrepresentation of care provided.
The resident's cognitive abilities made the situation particularly troubling. With a perfect mental status score, she was fully aware that she was not receiving basic hygiene care her condition required.
Her multiple sclerosis diagnosis meant she faced progressive muscle weakness and coordination problems that would only worsen without proper care and hygiene. The muscle wasting and atrophy noted in her medical record indicated her physical condition was already deteriorating.
The facility discharged her just days after the inspection period ended, though the timing may have been coincidental given the complaint-driven nature of the state review.
The violation affected what inspectors classified as "some" residents, suggesting the documentation and care failures may have extended beyond this single case.
Meadowview's staff demonstrated they understood both the resident's needs and the proper documentation procedures. Multiple nursing assistants confirmed she required bathing assistance, and the Corporate Nurse acknowledged the improper use of "not applicable" codes.
Yet for nearly two weeks, a disabled woman who could not bathe herself went without this basic care while staff recorded that bathing was somehow not relevant to her situation.
The woman's discharge came as state inspectors were completing their review of the complaint that brought the violations to light.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Meadowview Health & Rehab Center from 2025-09-25 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Meadowview Health & Rehab Center
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