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F0677
E

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

Cheyenne, Wyoming Survey Completed on 08-28-2025

Penalty

No penalty information released
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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 provide routine bathing and assistance with activities of daily living for multiple residents who were unable to perform these tasks independently. Several residents, including those with cognitive impairments, physical disabilities, and complex medical conditions such as morbid obesity, quadriplegia, and recent trauma, experienced extended periods without bathing. Documentation and interviews revealed gaps in bathing records, with some residents going up to 23 days without a bath or shower. Residents reported dissatisfaction and discomfort due to missed bathing, and some had to escalate their requests to facility leadership to receive basic hygiene care. Staffing shortages were repeatedly cited as a reason for the lack of timely care. Resident interviews and concern forms indicated that call lights were not answered promptly, and staff communicated to residents that showers and other care could not be provided due to insufficient staffing. On at least one occasion, there were no CNAs present in the building, and no baths were given that day. Resident Council and individual grievances highlighted ongoing issues with delayed or missed care, including showers, bed changes, and assistance with personal hygiene. Facility policy required that residents be provided showers according to their requests or the facility's schedule, based on safety considerations. However, the regional clinical director confirmed that bathing was not being performed as required, and there were no additional records to support that residents received the necessary care. The failure to provide routine bathing and personal hygiene assistance was substantiated through resident and staff interviews, medical record reviews, and grievance documentation.

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