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F0677
D

Failure to Consistently Provide Bathing Opportunities Due to Staffing and Documentation Issues

Elk Horn, Iowa Survey Completed on 10-08-2025

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 assist residents with activities of daily living by not consistently offering or providing opportunities for bathing to two of three residents reviewed. One resident, with diagnoses including arthritis, anxiety disorder, bipolar disorder, COPD, and fibromyalgia, required moderate to total assistance with personal hygiene and toileting. Despite being cognitively intact, this resident and their family reported that staff would ask about bathing preferences but would not return, later documenting refusals that did not occur. Electronic health records showed inconsistent bathing frequency, with some months showing only a few baths and refusals not always documented in progress notes. Another resident, also cognitively intact and requiring maximal assistance with bathing, reported receiving baths 2-3 times a week but noted that if a bath was missed, it was sometimes not rescheduled promptly. Documentation for this resident also showed irregular bathing schedules and lacked consistent refusal documentation. Staff interviews revealed that residents were expected to be bathed twice a week, but missed baths were common due to staffing shortages, with staff sometimes moving baths to the next day or relying on medication aides for assistance. Staff also indicated that refusals should be documented in progress notes and communicated to nurses, but this was not always done. Multiple staff members acknowledged that it was not uncommon for residents to go several days without bathing due to call-ins and short staffing. Review of facility policy found no written policy regarding the frequency of bathing.

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