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F0561
D

Failure to Honor Resident Bathing Preferences and Document Care

Grand Junction, Colorado Survey Completed on 06-11-2025

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 honor and facilitate resident self-determination by not providing bathing opportunities in accordance with the preferences and care plans of two residents who were dependent on staff for their activities of daily living (ADLs). Both residents had documented preferences for bathing frequency and schedule, but records showed that these preferences were not consistently followed. For one resident, the care plan specified a preference for showers twice a week, but documentation revealed that she received significantly fewer showers than scheduled, with long gaps between bathing opportunities and insufficient documentation of refusals or reasons for missed showers. The care plan also lacked interventions to address any refusals of care. Another resident expressed a desire for showers every other day, a preference that was documented during admission. However, the care plan did not reflect this preference, nor did it indicate that the resident required staff assistance with ADLs. Bathing records showed that this resident received only a fraction of the expected bathing opportunities, and there was no documentation of refusals or changes in preference. The resident's representative reported that the resident often had to be taken home for bathing due to inadequate hygiene at the facility, and staff provided explanations that were not supported by the resident's documented wishes. Staff interviews confirmed that there were gaps in documentation and inconsistencies in offering and recording bathing opportunities. The DON acknowledged that residents were not always offered showers according to their preferences and that refusals were not properly documented or addressed in care plans. Staff education on proper documentation and procedures for addressing refusals had been provided, but the deficiencies persisted during the review period, resulting in a failure to support resident choice and autonomy regarding personal care.

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