F0684

E

Failure to Provide Scheduled Weekly Bathing and Hygiene Care

Sioux Falls, South Dakota Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

Staff failed to provide scheduled bathing and hygiene care to four sampled residents over the months of February and March 2026. One resident was observed with a strong urine odor emanating from his closed room, with the smell intensifying when the door was opened. His bed contained large urine stains on the sheets and incontinence pad, and he appeared not to have bathed in some time, with dry, flaky skin and greasy, tangled hair. He reported needing assistance with bathing and expressed a desire to bathe more than once per week, noting that Thursdays were his scheduled bath days. His care plan identified an ADL self-care performance deficit related to CHF and hypothyroidism, with interventions indicating he required assistance of one staff member for bathing and personal hygiene, but the care plan did not document his bathing or showering preferences or frequency.

Record review showed that this resident received a whirlpool bath on 2/24/26 and then not again until 3/19/26, indicating a 23‑day gap without a documented bath, bed bath, or shower, and there were no documented refusals during this period. Another resident reported missing showers in recent weeks, explaining that the bath aide had been gone for two weeks and that he also missed a bath due to an appointment; he stated he felt "gross" before being bathed on 3/18/26. His records showed a whirlpool bath on 2/18/26 and the next on 3/18/26, a 16‑day interval without documented bathing or refusals. A third resident stated he did not always receive baths as scheduled and that sometimes there was no bath aide available; his documentation showed a whirlpool bath on 2/20/26 and then a bed bath on 3/6/26, a 14‑day gap without documented bathing or refusals.

A fourth resident’s bathing record showed a shower on 2/24/26 and the next on 3/17/26, a 21‑day period without a documented bath, bed bath, or shower and no documented refusals. The interim DON stated residents were to receive a bath each week and that when the full‑time bath aide was on vacation, CNAs were assigned to provide scheduled baths. The administrator also stated he expected residents to receive a weekly bath and that there was a plan to ensure this when the bath aide was on vacation, though he did not specify the plan. The bath aide reported she was responsible for bathing 14 residents per day, that residents were scheduled for baths Monday through Friday, that she was on vacation from 2/23/26 through 3/8/26, and that when she was reassigned to CNA duties, residents did not receive baths. Review of the staff schedule for the bath aide’s vacation period showed that on five of ten weekdays no staff member was assigned to provide resident baths, despite a facility bathing policy emphasizing cleanliness, hygiene, circulation, comfort, observation of resident condition, assistance with personal care, and safety.