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F0561
D

Failure to Honor Resident's Shower Preference and Timely Assistance

Great Falls, Montana Survey Completed on 12-16-2025

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

A dependent resident's right to self-determination and preference for shower timing was not honored when staff failed to provide a shower as scheduled and requested. The resident, who relies on staff for assistance with activities of daily living (ADLs), typically receives showers before breakfast and prefers to be up by 8:00 a.m. On the day of the incident, the resident's shower was delayed, and he was left in bed past his preferred time. Documentation shows that the resident's call light was activated twice that morning, with response times of 47 and 43 minutes, indicating significant delays in staff response. The resident expressed frustration, feeling trapped and missing breakfast due to the delay in receiving his shower. Interviews with staff revealed confusion and lack of communication regarding shower assignments. One staff member admitted to not providing the shower, expecting another staff member to handle it upon their later arrival, while the incoming staff was not informed of the assignment until after their shift began. The resident's care plan clearly documented his preference for morning showers and being up by 8:00 a.m., but these preferences were not followed. Facility records also indicated that not all residents' bathing preferences were documented, and staff acknowledged challenges in accommodating resident preferences due to workload and communication issues.

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