GRAND JUNCTION, CO- MESA MANOR CENTER

Based on resident, staff interviews and record review, the facility failed to ensure two (#36 and #6) of five residents reviewed for abuse out of 30 sample residents, were free from physical and verbal abuse.

Resident #36 said in an interview on 4/21/21 that he was verbally abused by certified nurse aide (CNA) #4 about a month and a half ago. He said it made him feel not respected and he was shocked and angry. He said that nursing staff were aware but no one had come to talk to him about the issue. Resident #36 said that approximately two months ago he had heard angry yelling in his hallway and as he passed a resident room, he saw CNA #1 standing next to a resident who had his face down on his plate of food. Record review revealed that Resident #36 had a verbal interaction with CNA #4 on 3/7/21. There was no documentation found that the facility followed up on the matter. There was no documentation found regarding Resident #36’s observation of the angry yelling involving CNA #1.

Resident #6 said in an interview on 4/26/21 that he had been verbally and physically abused by CNA #1 and #6. He said CNA #1 had called him pathetic and had thrown him into bed one night. He said CNA #6 tried to pry open his two fingers that were frozen (contracted) on his left hand and it hurt him. He said that the interactions with both CNAs made him feel undignified, disrespected, and like he was being pushed around. He said he also felt angry and did not know how to defend himself. He said he did not say anything to anyone and did not like talking about it. He said he just wanted to forget about it. There was no documentation found to demonstrate that the facility further investigated the incident with Resident #6 and CNA #6. In addition, CNA #6 was allowed to continue working with residents after the facility was aware of Resident #6’s abuse allegation.

The facility’s failures subjected Resident #36 and #6 to verbal and physical abuse by three CNAs assigned to provide care to vulnerable residents, and the potential for other facility residents to suffer abuse. Cross-reference F609, failure to report alleged allegations of abuse; and F610, failure to thoroughly and timely investigate allegations.

ULCER CARE

Based on observations, record review and interviews, the facility failed to prevent pressure ulcers from developing for two (#10 and #106) of three residents reviewed for pressure ulcers out of 30 sample residents. The facility failed to ensure Resident #10 did not develop an unstageable (stage 3 or above-see reference below) pressure ulcer to the trunk area on her back, which was acquired in-house. This resident was chair-fast with [CONDITION(S)]. The development of the pressure ulcer caused pain to the resident. The facility failed to consistently monitor and provide adequate and timely wound cares, including routine measurements of the wound. No documentation was found for this wound (which was first observed on 2/22/21) from 2/22/21 through 3/27/21. The facility failed to create a care plan related to actual pressure ulcers and treatment. Furthermore, on 4/27/21, nursing staff was observed using a product which was not ordered for Resident #10’s wound care.

Additionally, the facility failed to ensure Resident #106 did not develop a stage 2 pressure ulcer to his sacrum and right gluteal area, which was acquired in-house. This resident was bed-bound and was not provided with an air mattress. He was not provided with therapy for five days following his admission. There was also a delay in implementing interventions after his wound had been discovered.