F0725

E

Insufficient Staffing Leading to Missed Restorative Services and Scheduled Baths

Lake City, Iowa Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient nursing staff to complete restorative nursing programs as planned for three residents. One resident with heart failure, atrial fibrillation, asthma, arthritis, and advanced age had a care plan revised in September that called for daily upper extremity exercises with Thera bands or light weights, 3–6 days per week, but documentation showed restorative exercises were completed only five times in the previous 30 days. A second resident with multiple sclerosis, moderate cognitive impairment, and dependence on staff for transfers had a care plan for active range of motion to the neck and shoulders with specified repetitions and sets, but the restorative program was documented as completed only four times in the previous 30 days. A third resident with hemiplegia, moderate cognitive impairment, and functional limitations in range of motion of one side of the body had a care plan for daily active and passive range of motion to upper and lower extremities, 3–6 days per week, yet the point-of-care records showed restorative services were provided only once per week over multiple weeks.

The report further documents that the certified nursing assistant assigned as the restorative aide stated she tried to complete all required tasks but, when the facility was short-staffed, she was pulled from restorative duties to work on the floor. The facility’s Restorative Program Process, updated in October, stated that its purpose was to ensure residents achieved and maintained their highest level of function and that licensed nurses would monitor daily restorative documentation and follow up with staff as needed. Despite this written process, the recorded frequency of restorative interventions for the three residents did not match the planned frequency outlined in their care plans and task lists.

The deficiency also includes the facility’s failure to ensure three residents received at least two baths per week as planned. One resident with severe cognitive impairment, COPD, osteomyelitis, and diabetes with neuropathy was care planned to receive assistance of one to two staff for bathing and was documented as dependent for baths, with records showing two baths per week except for one week when only one bath was provided. A second resident with no cognitive impairment, diabetes, muscle weakness, and gait abnormalities required supervision or touching assistance with bathing and was care planned for bathing assistance of one, but documentation showed only one bath during a particular week instead of the usual two. A third resident with severe cognitive impairment, non-Alzheimer’s dementia, and limited mobility required partial to moderate assistance and was care planned for assistance of one with bathing, yet records showed only one bath during a specified week. A CNA reported that staffing had been short, that most residents were scheduled for two baths per week, and that with increased use of agency staff she could not confirm whether all baths were being completed. The DON later stated they were experiencing a staffing crisis and had recently admitted a new resident.