The assistant told state inspectors on October 21 that Resident #9 wanted to wait until after breakfast for his shower on October 20. When she returned after lunch to bathe him, he was lying down in his room. She never gave him the shower.
Resident #8 also missed his scheduled shower that day. The assistant provided no explanation for why he didn't receive bathing care.
Despite neither resident receiving showers, the assistant documented in the facility's charting system that both had been bathed. She admitted to inspectors that only three of five scheduled residents actually received showers on October 20.
"She accidentally documented that both received their showers in the charting system, but they did not," the inspection report stated.
The Director of Nursing, who started at Wells LTC on September 29, told inspectors the documentation violated facility policy. When residents refuse showers, nursing assistants should notify the nurse, who should then try to persuade the resident to bathe. If the resident still refuses, staff must document the refusal in a progress note.
"It was false documentation if they documented a shower was received when it was not given," the DON said during her October 21 interview.
The charge nurse should supervise nursing assistants to ensure residents receive their scheduled showers, according to the DON. The facility's charting system includes a specific task category for bathing where refusals should be documented.
Administrator interviews revealed the facility had established procedures for handling bathing refusals. When residents refuse showers, staff should inform the nurse, who must talk to the resident and document the refusal. The administrator said staff should make a third attempt to provide the care.
"She said if a resident did not receive a shower, they need to document that they did not receive the care," inspectors noted. "She said documenting care received when it was not was falsifying a document."
The administrator told inspectors she expected staff to strike out documentation errors and make corrections when mistakes occurred. The DON and Assistant Director of Nursing were responsible for conducting audits to ensure residents weren't refusing care and reviewing 24-hour reports.
Wells LTC's own documentation policy, revised in July 2017, requires that "documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate."
The false documentation affected basic hygiene care for vulnerable nursing home residents. Regular bathing prevents skin breakdown, infections, and maintains dignity for elderly patients who often cannot bathe themselves.
Federal nursing home regulations require facilities to assist residents with personal hygiene and bathing based on their individual needs and preferences. When residents refuse care, facilities must document the refusal and make reasonable attempts to provide the service later.
The inspection found the facility failed to ensure accurate documentation of resident care services. The violation carried a determination of minimal harm or potential for actual harm, affecting few residents.
State inspectors completed their investigation on November 25, 2025, following the October complaint that triggered the review. The facility must submit a plan of correction detailing how it will prevent future documentation falsification and ensure residents receive scheduled hygiene care.
The case highlights ongoing challenges nursing homes face with accurate record-keeping and adequate staffing supervision. When nursing assistants document care that wasn't provided, it creates false medical records that could affect treatment decisions and mask patterns of neglected care.
For residents like #8 and #9, the missed showers represented more than documentation errors. Regular bathing maintains health, prevents complications, and preserves dignity for elderly people who depend on staff for basic personal care needs.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Wells Ltc Nursing & Rehabilitation from 2025-11-25 including all violations, facility responses, and corrective action plans.
Additional Resources
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