The Director of Nursing at Mustang Park Therapy and Living Center admitted during an October inspection that certified nursing assistants worked on an "honor system" for documenting resident showers. She told inspectors the facility had no proof residents were receiving their scheduled baths.
Resident 12, who required total assistance with bathing due to muscle weakness and unsteadiness, was supposed to receive three showers per week according to her care plan. When inspectors requested her bath records for September 2025, neither the Director of Nursing nor the Assistant Director of Nursing could provide any documentation.
The nursing director confirmed what residents had been telling her since she started at the facility in September. "When she first started with the facility on 9/01/25, she received complaints from residents of not receiving their showers and she confirmed residents were either not receiving their showers or the CNAs were not updating the system of records of the shower occurring," the inspection report stated.
Multiple nursing assistants had been placed on performance improvement plans because of the shower documentation failures. Many resigned rather than comply with the corrective measures.
The Assistant Director of Nursing acknowledged the problem during his interview with inspectors. He blamed high CNA turnover and changes in record-keeping systems following a change in facility ownership. While he thought residents were receiving their scheduled showers, he couldn't confirm it.
Both nursing leaders understood the medical consequences of missed bathing. The Director of Nursing told inspectors that if residents didn't receive their showers, "they could have skin breakdown." The Assistant Director similarly warned that missing scheduled showers "could impact their skin integrity."
The facility's own policy, dating to 2001, required appropriate support and assistance with hygiene, including bathing. The policy emphasized that activities of daily living should not diminish unless unavoidable due to clinical conditions.
Resident 12's case illustrated the documentation breakdown. Her October comprehensive assessment showed she had intact cognitive abilities with a BIMS score of 15, meaning she was mentally capable of reporting whether she received care. The same assessment confirmed she required total assistance with bathing, making accurate documentation essential for ensuring her basic hygiene needs were met.
The nursing director had recently conducted in-service training on showers with nursing staff, attempting to address the systemic failure. She told inspectors she spot-checked with residents to confirm they were receiving baths, but this informal verification system clearly wasn't working.
The inspection found that since the new company took ownership, "they did not have a consistent way of tracking when residents received their showers." This left vulnerable residents like Resident 12, who couldn't bathe herself, dependent on staff honesty rather than verifiable records.
When inspectors specifically requested shower records for Resident 12, the Director of Nursing stated flatly that "she did not have any records for this resident either." The admission came after complaints from three separate residents about missing their scheduled baths.
The facility's policy required maintaining residents' ability to perform activities of daily living and providing appropriate assistance when they couldn't perform tasks independently. Basic hygiene care like regular bathing represents a fundamental aspect of nursing home care, particularly for residents requiring total assistance due to physical limitations.
The honor system approach to documentation left no way to verify whether the most vulnerable residents received basic care. For residents like Resident 12, who relied entirely on staff assistance for bathing, the absence of any documentation meant no accountability for whether essential hygiene care actually occurred.
The nursing leadership's acknowledgment that residents faced potential skin breakdown without regular bathing made the documentation failure more concerning. Skin integrity problems can develop quickly in elderly residents who don't receive adequate hygiene care, particularly those with limited mobility.
Both nursing directors connected the shower documentation problems to broader staffing instability following the ownership change. The combination of high turnover among certified nursing assistants and inadequate record-keeping systems left residents without reliable access to basic hygiene care or any way to verify they received it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mustang Park Therapy and Living Center from 2025-11-26 including all violations, facility responses, and corrective action plans.
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