The resident, identified only as a woman in her 80s, was supposed to receive showers on Tuesday, Thursday and Saturday evenings according to her care plan. Electronic records showed she received no baths on October 30, November 1, November 4, or November 6.
When inspectors asked her about bathing during their November 12 visit, the woman said she had not received a bath "in a while" but could not provide specific dates. Her medical records showed she had severe cognitive impairment and required substantial help with basic tasks like dressing and toileting.
The woman was re-admitted to the facility in November with diagnoses including unspecified dementia, generalized anxiety disorder, and major depressive disorder. Her care plan specifically noted she was "dependent" for shower and bathing assistance.
A nursing assistant told inspectors she was not assigned to the woman on any of the four missed shower dates and was unaware the resident had gone without baths. The assistant said residents who miss scheduled showers "would smell bad or could have skin breakdown."
The facility's own policy, dated December 2020, states staff must provide hygiene assistance to residents "to prevent an odor problem and to prevent skin breakdown." The policy emphasizes that personal hygiene tasks include bathing and that the amount of assistance will be indicated in each resident's care plan.
Assistant Director of Nursing confirmed that nursing assistants were responsible for giving residents baths and showers. She told inspectors that residents who miss their scheduled bathing "could develop an odor or a skin issue" and said she expected all residents to receive showers as scheduled.
The facility's administrator echoed those expectations. He said residents would develop odors if they did not receive baths per their shower schedule and that he expected all residents to receive showers as planned.
Federal inspectors found the missed showers violated regulations requiring facilities to provide care and assistance with daily living activities for residents who cannot perform them independently. The woman required maximum assistance with most personal care tasks and was completely dependent on staff for bathing.
The inspection was conducted in response to a complaint. Inspectors reviewed seven residents' care for quality of life issues and found the bathing failures affected one resident.
Electronic medical records showed the woman's shower schedule as "T-TH-Sat evenings" with a note that these were her preferred times. Despite this documented preference and care plan requirement, no nursing assistant completed the bathing tasks on any of the four scheduled dates.
The facility's policy states that residents are "encouraged and responsible for their personal hygiene" but acknowledges that staff must provide assistance when needed. For residents requiring help, the policy says the amount of assistance will be "discussed with the resident and indicated in his/her Person-Centered Service Plan."
The woman's severe cognitive impairment, reflected in her BIMS score of 07, indicated she could not make decisions about her care or advocate for herself when showers were missed. Her diagnoses of dementia and depression meant she relied entirely on staff to maintain her basic hygiene.
Nursing assistants are required to document completed showers in electronic records. The absence of any bathing documentation for the four dates suggests either the showers were not provided or staff failed to record completed care.
The facility received a citation for minimal harm or potential for actual harm. Inspectors determined the missed showers could place residents at risk of declining overall health.
The woman remained at the facility during the inspection, still dependent on staff for all bathing assistance according to her care plan.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lily Springs Rehabilitation and Healthcare Center from 2025-11-26 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Lily Springs Rehabilitation and Healthcare Center
- Browse all TX nursing home inspections