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F0677
D

Incomplete Hygiene Care During Bathing

Tyler, Texas Survey Completed on 08-07-2025

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

A resident with a history of diabetes, moderate cognitive impairment, and total dependence on staff for activities of daily living was observed not receiving complete hygiene care during a scheduled bath. The resident, who was always incontinent of bowel and bladder, required extensive assistance from two staff members for bathing as per her care plan. During the observed bath, CNA A cleaned the resident's arms, chest, abdomen, peri-area, and legs, but did not clean the vaginal folds or the feet. The CNA stated he did not clean the feet due to the presence of a small diabetic ulcer and did not clean the vaginal folds because the area was tight and he was unable to do so. Interviews with facility staff, including the ADON and DON, confirmed that staff are expected to wash residents' feet and thoroughly clean the vaginal area during bathing, especially for diabetic residents, to maintain hygiene and prevent complications. Facility policies reviewed also required perineal care and washing from head to toe during bathing. The failure to follow these procedures was directly observed and acknowledged by staff, constituting a deficiency in providing necessary services to maintain the resident's hygiene and skin integrity.

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