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F0584
E

Unsafe and Unsanitary Bathing Environment Maintained for Residents

Bayard, Nebraska Survey Completed on 11-24-2025

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 maintain a safe, sanitary, and homelike bathing environment for its residents. Observations of the 200 hall shower room revealed significant structural damage, including missing wall tiles, broken drywall with exposed wood studs and pipes, and an area covered with torn paper and clear tape. The floor in front of the damaged wall also had broken and missing tiles, exposing rough cement and creating uneven surfaces. Debris, unidentified powders, and discoloration were present throughout the affected areas. These conditions were directly observed while residents were being assisted with bathing, and the facility was aware of the damage but had no plan in place to repair it. This deficiency affected all six sampled residents, each with complex medical histories such as diabetes mellitus, dementia, respiratory failure, urinary tract infection, depression, anxiety, back pain, hypertension, osteoporosis, chronic kidney disease, heart failure, failure to thrive, broken ribs, and prostate cancer. On the day of the survey, multiple residents received showers in the compromised environment, as confirmed by staff interviews and the facility's bathing schedule. The lack of a safe and sanitary bathing area was evident during direct care activities, impacting the residents' right to a safe and comfortable environment.

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