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F0677
E

Failure to Provide Scheduled Bathing and Hygiene Assistance Due to Staffing Shortages

Mandan, North Dakota Survey Completed on 05-15-2025

Penalty

Fine: $12,73525 days payment denial
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that several residents who required assistance with activities of daily living, specifically bathing and personal hygiene, received the necessary services. Observations and record reviews revealed that multiple residents did not receive scheduled showers or baths as outlined in their care plans and physician orders. For example, one resident was observed with long, dirty fingernails, and their records showed they received only one of four scheduled showers and one bed bath over a two-week period. Another resident, diagnosed with seborrheic dermatitis, received only three of eight scheduled baths in one month and two of four in the following two weeks, and reported not having a bath in over a week, feeling neglected, and experiencing worsening scalp conditions due to missed showers. Additional residents with conditions such as candidiasis, eczema, and severe dry skin also did not receive the required number of showers, with one resident receiving only half of the physician-ordered showers and no bed baths or refusals documented. Residents reported being told that showers could not be provided due to lack of staff or bath aides, and some expressed dissatisfaction with sponge baths as a substitute for showers. Another resident stated that a family member had to provide a shower due to missed scheduled baths, and voiced concerns about future missed hygiene care due to ongoing staffing shortages. Staff interviews confirmed that scheduled baths and showers were not consistently provided, often due to insufficient staffing. There was also confusion among staff regarding the difference between sponge baths and bed baths, with some staff indicating that sponge baths involved minimal assistance and did not constitute full body hygiene care. The facility was unable to provide a policy regarding bathing and personal hygiene, and documentation often conflicted with resident statements about care received.

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