The resident, identified as #28 in inspection records, missed showers on July 5, July 9, July 12, August 23, August 30, and September 10. Her care plan required supervision or assistance from one staff member for bathing, but workers sometimes refused to change or shower her when she displayed difficult behaviors.
"She can have behaviors or be a little feisty so they won't change her or shower her some days," Anonymous Staff #178 told inspectors during a September 16 interview.
The 78-year-old woman had recently moved from the facility's memory care unit to the first floor. Her medical conditions included dementia, mobility problems, and a displaced fracture in her left ankle bone diagnosed in May. She also struggled with bone density disorders, anxiety, a history of hip pain and falling, malnutrition, and substance dependencies.
A second resident also missed multiple scheduled showers without explanation. Resident #24, who has Alzheimer's disease, chronic lung disease, and high blood pressure, was supposed to receive showers twice weekly on Wednesdays and Saturdays. Shower records showed she missed baths on July 5, July 9, July 12, August 6, and September 10.
Both residents were completely dependent on staff for bathing, according to their care assessments. Neither displayed behavioral problems that would typically interfere with personal care, inspectors noted.
The facility's own policy, dated April 28, states that residents can take baths, showers, or bed baths "as often as they would like" and choose their preferred bathing time. But shower schedules showed both women were assigned specific days rather than given choices about when to bathe.
Director of Nursing confirmed during a September 22 interview that both residents had "missed multiple showers" and acknowledged there was no additional documentation showing they had received alternative bathing on the missed days.
The violations affected two of five residents whose daily living assistance was reviewed during the September 30 inspection. The facility houses 35 residents total.
Resident #24 required mechanical lift assistance and help from two staff members for bathing due to cognitive deficits, vision problems, and physical weakness. Her care plan specifically noted her dependence on staff for all bathing needs.
For Resident #28, the missed showers represented a broader pattern of care avoidance. Staff admitted they sometimes simply refused to provide basic hygiene assistance when the woman became difficult to manage.
The inspection was conducted in response to complaints filed against the facility. Federal regulators classified the violations as causing "minimal harm or potential for actual harm" to residents.
Both residents' shower schedules called for twice-weekly bathing, a frequency that meets basic hygiene standards for nursing home care. However, the gaps in their bathing records stretched across multiple weeks during the summer months.
Resident #28's complex medical history included protein-calorie malnutrition and electrolyte imbalances that can affect skin health and infection risk. Her ankle fracture, diagnosed just four months before the inspection, would have required careful attention to hygiene around any surgical sites or immobilization devices.
The facility's bathing policy emphasized resident choice and preference, stating people could bathe "as often as they would like." But the shower schedules and staff interviews revealed a more rigid system where residents were assigned specific days regardless of their preferences.
Staff #178's comments about avoiding care for the "feisty" resident highlighted how behavioral challenges can lead to neglect of basic needs. Rather than developing strategies to provide necessary hygiene care, workers simply skipped showers when they anticipated resistance.
The Director of Nursing's acknowledgment that multiple showers were missed, combined with the lack of documentation for alternative bathing methods, suggested systemic problems with tracking and ensuring basic care delivery.
Federal inspectors found no evidence that either resident received bed baths, sponge baths, or other hygiene assistance on the days their scheduled showers were skipped. The facility's records showed only the missed appointments, not alternative care provided.
The violations were documented under complaint numbers 1398689 and 1398688, indicating multiple concerns had been raised about the facility's care practices.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Stellar Care Center from 2025-09-30 including all violations, facility responses, and corrective action plans.