COLORADO SPRING, CO- Medallion Post Acute Rehabilitation

Facility failed to ensure residents experienced a dignified living experience by not being subjected to disrespectful remarks when the resident questioned the way staff were providing care; and not leave residents waiting for care (i.e. incontinent care) when they asked for and needed assistance.

The feelings of dehumanization and being treated in an undignified manner were evidenced by the residents’ and interviews.

Resident #23 did not really want to discuss incontinent episodes, but said she was frustrated and embarrassed if she was unable to make it to the bathroom on time. She also felt staff were disrespectful towards her and did not want to help her, because they told her she could move out if she did not like living in the facility.

Resident #11 said it was frustrating, humiliating and caused her to feel depressed over her current living situation, to have to continually ask for assistance only to have staff ignore her request for help by saying they would be right back and then not coming back in a reasonable time. As a result of long waits she had often been left wet and soiled. She said that was not a good feeling. She felt frustrated when this happened, and said, I feel that we are warehoused here; services are impersonal and concerns are not adequately addressed. I have to prepare myself for the weekend and fight off depression because I know the care on the weekends will be even worse. The weekends are worse because there is no leadership here to supervise the staff.

As a result of long waits she had often been left wet and soiled. She said that was not a good feeling, and she had some moisture associated skin breakdown on her buttocks and in the folds of her groin. She was being seen by the wound care doctor, but felt that better and timely care would improve skin integrity.

Resident #11 acknowledged there had been one occasion where she filled out a grievance report because staff was not responding to a request to use the bathroom and she wet the bed and was left wet for and without toileting assistance for approximately 24 hours. Resident #11 never received a reasonable response to that grievance. (Cross-referenced to F610 for failure to investigate an allegation of abuse/neglect).

On [DATE], Resident #15 and #33 filed a grievance identifying concerns that communication with their CNAs was poor and certain CNAs were taking long periods of time to answer call lights. The CNAs were educated on the expectations for customer service and answering call lights timely. There was no documentation of an investigation into the grievance, associated failures, or any plans to monitor for continued compliance with facility expectations.

CNA #2 was interviewed on 10/20/21 at 2:07 p.m. CNA #2 said was aware of members of the nursing staff who would rush through providing care to residents, and who would not take the time to listen to resident concerns. CNA #2 said some staff would refuse to go into certain resident rooms if they felt the resident was difficult. The CNA said that the residents were justified in being upset over not being cleaned or cared for properly, and it made her work more difficult when other staff would refuse to assist particular residents. CNA #2 believed that when a staff refused to provide care to a resident it was a means of intimidation especially when it was done after a resident filed a complaint. The CNA believed these incidents needed to be reported to the nurse on duty.

The DON acknowledged that there had been an increase in residents reporting that staff had been rude or not taking care of their care concerns timely, as evidenced by the reviewed grievance reports (cross-reference F585, grievances.)

The Nursing Home Administrator acknowledged the above listed grievances for Resident #23 and Resident #11 lacked documentation to show a full investigation into the details of the residents’ complaints, and did not confirm or deny the potential for abuse, or provide interventions to prevent continued violations in failures to protect the resident from neglect and or abuse.