Health inspection·December 28, 2022

F600 Free from Abuse and Neglect CFR(s): 483.12(a)(1) §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: Based on observation, interviews, and record review, the facility failed to ensure staff attended to three of four sampled resident's needs in a timely manner (Resident 1, 2, and 4). Resident 2 expressed anger and frustration when she had to wait for a prolong period for staff to assist her with incontinent care. Residents 1 and 4 were not interviewed due to their medical conditions. However, a reasonable person would feel anger and lack of respect when staff failed to attend to a dislodged Foley catheter (a tube to drain urine from the bladder) for at least two hours for Resident 1. A reasonable person would feel anger and lack of respect when no staff assisted Resident 4 with his lunch tray for 58 minutes. Resident 4 Review of Resident 4 ' s MDS (Minimum Data Set: a standardized patient assessment tool), dated 04/08/2022, indicated he was admitted to the facility on 04/01/2022. According to his MDS he required the supervision of one staff for eating, Review of Resident 4 ' s "Medical Nutrition Therapy Assessment", dated 04/07/2022, indicated he was " ... ...(moderate to) high nutrition risk ... (resident is) having difficulty using utensils likely ...(due to) dementia. (brain disorders exhibiting memory problems, personality changes, and impaired reasoning) ...". During an observation on 05/02/2022 at 12:43 PM on the fifth floor, Resident 4 was in bed and his call light was going off. His untouched lunch tray was on his tray table on the right side of his bed approximately two feet away. There were two staff at the nursing station talking to each other and the chime of the call light was audible ten feet away from the nursing station. Three staff were around the corner talking to each other. During the fifteen minutes observation, Resident 4 ' s call light was ringing and none of the five staff attempted to answer Resident 4 ' s call light. At 12:58 PM observation was terminated and the DON (Director of Nursing) was alerted regarding Resident 4 ' s call light. The DON talked to a staff member to assist Resident 4. A staff member was later seen donning an isolation gown and gloves and assisting Resident 4 with his lunch. During an interview on 05/02/2022 at 1:00 PM, Dietary Cook 1 stated she brought Resident 4 ' s tray up to the fifth floor around 12:00 noon. Resident 4 ' s lunch tray sat untouched in his room for at least 58 minutes. During an interview on 05/23/2022 at 12:36PM, RD 1 (Registered Dietitian 1) stated Resident 4 " ...had a significant decline. We put him on supplements, (he had) dementia. It was hard for him to feed himself, so he needs assistant." RD 1 stated her expectation was that when food trays are delivered to the unit, staff should be assisting with meals within 15 minutes. During an interview on 05/26/2022 at 2:36 PM, the DON stated the reason for the delay in assisting Resident 4, on the date of the observation (05/02/2022), was that the fifth floor was short two CNAs (Certified Nursing Assistant) and there was only one nurse on the floor. Normally, there should be four CNAs and two nurses on the fifth floor. Resident 2 Review of Resident 2 ' s MDS dated 04/26/2022, she was admitted to the facility on 04/21/2022. Her MDS assessment indicated she had no mental impairment and required extensive assistance of one staff for toileting. Resident 2 and her daughter were interviewed on 04/28/2022 at 3:56 PM. During the interview, Resident 2 stated when she used her call light to ask for assistance, sometimes it takes staff one to two hours to respond. Resident 2 stated most of the time when she asked for assistance, she needed help to go to the bathroom. Resident 2 stated she would have to hold it (urine or bowel) in because she did not know when someone would come to answer her call light. Resident 2 stated she felt frustrated, mad, and scared to speak up because she was fearful of retaliation. Resident 2's daughter stated her mom complained to her about this delayed response to call lights numerous times. Resident 2's daughter said this was the main reason she visits the facility almost on a daily basis to ensure her mom gets the assistance she needed. Resident 1 Review of Resident 1 ' s "Progress Notes" dated 04/27/2021, indicated she was admitted to the facility on 03/26/21 for comfort focused care. During an interview on 04/20/2022 at 2:30 PM, Resident 1 ' s daughter stated on 04/24/2021, Resident 1 ' s Foley catheter was dislodged for two hours before staff came to re-insert the catheter. Resident 1 ' s daughter proceeded to share two photos of a dislodged Foley catheter on the floor. Resident 1 ' s daughter stated a facility staff told Resident 1 she had to stay in bed until a nurse can come to re-insert the catheter. Resident 1 ' s daughter stated "Can you imagine telling my mom to stay in bed waiting. Not being able to go to the bathroom, soiling your bed, while you wait, not knowing when someone is coming or IF anyone is coming to help you." During an interview on 05/27/2022 at 10:23 AM, RN 2 stated she remember what happened to Resident 1 back in April of 2021. RN 2 stated "I remember I was the only nurse on that day. they (other staff) asked me a couple of time to take care of the Foley catheter (for Resident 1) but I was ...(busy)." RN 2 stated it took "Maybe a couple of hours before I got to her (Resident 1)." Review of the facility ' s policy titled "Call Lights", dated 07/01/2020, indicated " ...It is the policy of this facility to maintain call light system in an operable manner, and to answer call lights in a timely manner. ..." These violations resulted in Residents 1, 2, and 4 not receiving timely assistance with care. Failure to receive these services may cause humiliation, indignity, anxiety, or other emotional trauma for Resident 2. For Resident 1, a reasonable person would feel neglect and uncared for when told to wait and lay in bed for prolong period for staff to re-insert a catheter to manage her urine incontinence. For Resident 4, a reasonable person would feel neglected, uncared for when staff did not assist him with his lunch in a timely manner.