Every finding on record at Belgrade Nursing Home

Based on observation, interview, and document review, the facility failed to ensure hand hygiene was completed while providing morning cares for 1 of 3 residents (R8) when observed. Findings include: R8's significant change Minimum Data Set, dated [DATE], indicated diagnosis of dementia. During an observation on 5/28/26 at 7:29 a.m., nursing assistant (NA)-A got clothing out that R8 wanted to wear. NA-A assisted R8 to the wheelchair and took R8 to the bathroom. NA-A put on clean gloves and took down R8's pants. R8 sat down on the toilet. NA-A put on clean underwear, pants and socks. NA-A gave R8 a wet cloth to wash the face and R8 dried the face. NA-A removed R8's soiled brief and took soiled gloves off. NA-A put on clean gloves on and removed R8's shirt and washed arm pits, dried them, put on R8's deodorant. NA-A took off the soiled gloves and put on R8's shirts. NA-A put on clean gloves and had R8 stand to wipe the bowel moment from R8's bottom. R8 sat down on toilet. NA-A removed her soiled gloves and put on new gloves. R8 stood up and NA-A washed R8's peri area with a soapy washcloth and dried the area. NA-A pulled up R8's brief, underwear and pants. R8 sat in the wheelchair. NA-A removed the soiled gloves and brushed R8's hair. NA-A put clean gloves on and cleaned R8's dentures and gave to R8 to place in her mouth. NA-A took soiled gloves off and tied up the garbage bag. R8 requested a hat and NA-A got one for R8. NA-A straightened up the bed then gave R8 her glasses. NA-A brought R8 to be weighed then brought the garbage to the soiled room and placed bag in the bin. NA-A then brought R8 to the dining room for breakfast. During an interview on 5/28/26 at 7:58 a.m., NA-A stated she should change gloves when soiled or have body fluids on the gloves. NA-A stated you washed your hands after the bathroom use, after toileting the residents, and after feeding the residents. NA-A stated she washed her hands whenever. NA-A stated she was supposed to wash hands or us hand sanitizer. NA-A stated I do not know why I did not wash my hands or use hand sanitizer after removing gloves today. During an interview on 5/28/26 at 11:34 a.m., the director of nursing (DON) stated hand hygiene should be completed when taking gloves off, before and after care, before and after passing trays, before and after meals, and when donning and doffing of personal protective equipment (PPE). The DON stated hand hygiene audits were completed monthly and staff are retrained in the moment when not doing appropriate hand hygiene. At 11:39 a.m., the DON stated the NA should have been following the policy and procedure for hand hygiene. The DON stated appropriate hand hygiene should have been completed when the NA removed her gloves. The facility policy Handwashing reviewed 5/28/26, indicated hand hygiene is considered the single most important procedure for preventing health care associated infections. Bacteria are easily spread in the hospital environment from patient to patient via the hands of healthcare workers. Any contact with the patient or the patient's environment could conceivably result in the transfer of microorganisms to the hands. Following standard precautions and avoiding contamination of the hands is essential in helping to prevent the spread of microorganisms. The policy indicated wearing gloves is not a substitute for hand hygiene. Dirty gloves can soil hands. Disposable gloves should be used only once and may not be washed for reuse. Always clean your hands after removing gloves.

Based on observation, interview and document review the facility failed to ensure survey results were provided to 1 of 1 residents (R4) upon request. Findings include: R4's quarterly Minimum Data Set, dated [DATE], identified intact cognition. During interview on 6/12/25 at 4:05 p.m., R4 stated she had requested the results from the last re-certification survey and said they tell me they don't have the results yet. R4 stated she had concerns about infection control practices as she had been sick three times this year already, and wanted to know the facility had been dinged for infection control. R4 said she had asked the activity director most recently at the resident council meeting the previous week. During interview on 6/12/25 at 4:32 p.m. the director of nursing stated the survey results were available and hanging on a bulletin board near the dining room. During observation on 6/12/25 at 4:35 p.m., the survey results posted on the bulletin board only contained the results of the recertification survey from 2024 and started on page 9. (The most recent re-certification survey was completed 2/20/25). During an interview on 6/13/25 at 9:32 a.m., the activity director stated on 6/10/25, R4 had asked if the most recent survey results had been posted. The activity director stated she had passed on the request to the social services designee and the administrator. Facility policy Resident Rights dated 12/17/24, indicated federal and stated laws guarantee certain basic right to all residents in the facility. These rights include the resident's right to: Examine survey results.

Based on observation, interview and document review the facility failed to supervisor 1 of 3 residents (R1) at risk for elopement when R1 was able to leave the facility (remained on campus) without staff knowledge despite wearing a working wander guard device. Findings include: R1's admission Record indicated he admitted to the facility 9/11/20. Diagnosis included anxiety, unsteadiness on feet, history of falls and weakness. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and indicated he did not wander. The MDS indicated R1 required supervision to stand and ambulate and did not require the use of personal alarms. R1's facility Progress Notes indicated on 5/9/25, R1 was pleasantly confused, telling everyone he did not live at the facility and had just arrived the previous day. 5/11/25, The first time R1 went outside, nursing assistant (NA) was alerted he was outside the building. The NA said he was on his way back in so NA assisted him into the building. The second time R1 went outside he made it to the parking lot before he was returned back inside the building. Facility Incident Investigation dated 5/10/25, indicated R1 was seen leaving the building out the front door two times. Each time R1 was seen by another resident who alerted staff. R1's Elopement/Wandering Risk assessment dated [DATE], identified severe cognitive impairment and indicated he could ambulate without assistance and was able to communicate. The assessment indicated R1 did not wander aimlessly and did not have a history of wandering. The assessment indicated prior to 5/10/25 had not attempted to leave the facility, however, on 5/10/25, R1 walked out the front door twice. It was felt R1 became confused. A wander alert device was placed on 5/10/25. R1's care plan dated 5/13/25, indicated he was at risk to wander related to confusion, cognitive impairment and impaired safety awareness. The care plan directed staff to locate wander alert device each shift on body, wheelchair or walker and test each night to ensure divide was in working condition. The care plan identified the use of a wander alert on his left wrist. R1's Progress Note created 6/5/25, indicated on 6/4/25, physical therapy aide (PTA)-A alerted nurse that resident was outside of facility at 4:20 p.m. The wander alert alarm malfunctioned and did not alert staff when resident exited the facility. When nurse returned resident back inside the facility the alarm was working. The administrator was notified at 4:30 p.m., that the wander guard did not work when he exit the facility but worked when he returned to the facility. The administrator replaced the wander alert device. Facility Incident Investigation dated 6/9/25, indicated on 6/4/25, at approximately 3:15 p.m., PTA-A notified licensed practical nurse (LPN)-A that R1 was outside alone. Wander alert in place at the time but malfunctioned and was replaced. A facility report titled Full Event Report, Call Statistics printed 6/10/25, indicated the following: 6/4/25 at 3:21 p.m., Peripheral Disc (R1) at room [ROOM NUMBER], indicating the wander alert device on R1's wrist triggered the alarm. 6/4/25 at 3:21 p.m., messages sent to five alert boxes. 6/4/25 at 3:26 p.m., messages sent to the same five boxes. 6/4/25 at 3:28 p.m., Peripheral Disc (R1) canceled at 134, indicating it was canceled at the device on his wrist. During interview on 6/12/25 at 12:32 p.m., PTA-A stated she was in the therapy room and saw R1 wheeling himself in the parking from the main entrance to the south. PTA-A said he was alone so she found LPN-A and reported it. During interview on 6/12/25 at 1:14 p.m., the director of nursing (DON) stated staff ensured the wander alert was working by pushing the button on the device on the residents arm or chair. The DON said the device displayed a blinking red light. She said if a resident was near a door with an alarm box the boxes would display who was near the door and beep quietly. The DON said after 30 seconds the beep would get louder. The DON said staff tested the individual devices placed on the resident but they did not test to ensure the individual alarm boxes were working. During interview on 6/12/25 at 1:34 p.m., the social services designee (SSD) states she assisted in the investigation following R1's elopement. The SSD stated she had interviewed NA-A who had checked the R1's device that day and confirmed the device had been working properly and PTA-A. The SSD said none of the other staff who worked that shift had been interviewed. During interview on 6/12/25 at 1:44 p.m., a representative (R)-A from Ideacom (company who installs and maintains the wander alert system) stated the company installs and maintains the system. R-A said if there were any issues they would trouble shoot remotely and if needed would send someone out. R-A said the last ticket submitted at the facility had been 47 days prior due to the report software. R-A said in order for the alarm to fail, the battery would have to be low or if the device was hidden (meaning the resident would have removed the device). R-A said if there was a low battery, the device would signal a low battery alert. R-A said if the door did not alarm when R1 went outside it would not have alarmed when he went back in the door. R-A further stated he would recommend testing of the gingival alarm boxes located at the doors. During interview on 6/12/25 at 2:03 p.m., NA-A stated at the time of the elopement, she had been working in another resident room and only heard about the incident from other staff. NA-A stated R1 liked to pack up his belongings and did that a lot. During interview on 6/12/25 at 1:58 p.m., NA-B said the wander alert device were checked daily. NA-C was present and said staff located the device on the resident and pushed the button on the device. NA-C said a blinking light indicated it was working. During interview on 6/12/25 at 2:13 p.m., NA-D said she had been working when R1 had eloped. NA-D said she was in a resident room and was unable to hear any alarms. During interview on 6/12/25 at 2:14 p.m., LPN-A stated the wander alert was tested by bringing the resident near the door and said if the device was working, the alarm would sound. LPN-A said she never saw a low battery warning on the device. During interview on 6/12/25 at 2:20 p.m., NA-E said he had been working when R1 exited the building. NA-E said he had been down the hall in a room at the time and was unable to hear an alarm from the room he was in. NA-E said he heard about the incident an hour after it happened. During interview on 6/13/25 at 9:26 a.m., registered nurse (RN)-A stated she was in the facility the day R1 exited the building. RN-A stated she had been down the south hall and when she returned to the office she heard PTA-A tell LPN-A that R1 was outside. LPN-A said she had not heard the alarm until R1 was returned to the building. RN-A said R1 returned willingly with LPN-A and said LPN-A turned off the alarm about a minute after they re-entered the building. During observation on 6/12/25 at 3:02 p.m., an observation using R1's old wander alert device (the one he was wearing at the time of the elopement) was completed with the DON. The DON brought the old device to each door that had an alarm box. When brought to all five door that had a wandering alert box, each time the device signaled an alarm, indicating the battery in the device was working. During interview on 6/13/25 at 9:51 p.m., the DON stated they felt R1's device had malfunctioned. The DON said she was unable to explain why the old device was still functioning properly or why it would signal only when R1 returned inside the building. The DON further stated she did not know why it would have taken seven minutes to shut the alarm off after R1 returned. The DON further stated the facility had not implemented and increased supervision or staff training because if the alarm had malfunction, staff did everything correctly. Facility policy Elopement/Missing Resident/Wander Management dated 10/23/21 and reviewed 6/13/21, indicated staff will check and document the testing of the wander management alarms that are in use daily. If the systems failed, staff will contact the plant operations manager or licensed nursing staff. The systems will be maintained under the manufacturers recommendations. An operation manual for the wander alert system was requested however the facility was unable to provide one.

Based on record review, and interview the facility failed to conduct and document a comprehensive facility-wide assessment which included all necessary components to provide adequate care and services to the residents in the facility. The deficient practice had the potential to affect all 22 residents in the facility. Findings include: Review of the facility's facility assessment on 2/19/25, showed it did not include the following requirements: 1) No input received or requested from the residents or resident families during the creation of the assessment. 2) No recruitment or retention plan for employees. 3) No contingency plan for staffing that does not evoke the emergency preparedness plan. On 2/19/25 at 5:15 p.m., the administrator confirmed they did not use or request input from residents or residents families to help create and complete their facility assessment. Furthermore, the administrator confirmed they did not have a recruitment and retention plan, or contingency staffing plan in place. A facility assessment policy was requested, and none was provided.

Based on observation, interview, and record review the facility failed to comprehensively assess and provide timely treatment of suspected urinary tract infection (UTI) for 1 of 1 residents (R20) who reported UTI symptoms and had repeated infections. Findings include: R20's quarterly minimum data set (MDS) dated [DATE], indicated R20 had a brief interview for mental status (BIMS) score of 15 indicating R20 was cognitively intact. R20 required substantial/maximal assistance with toileting including toilet transfers, incontinent of bladder but was not on a scheduled toileting program. R20's face sheet printed 2/20/25 indicated R20 had the following diagnoses of Type II Diabetes, high blood pressure, and a history of acute cystitis (a sudden inflammation of the bladder, commonly known as a urinary tract infection (UTI)), and history of UTI's. During interview on 2/18/25 at 12:57 p.m., R20 stated she had been having pain and burning when she urinated. R20 stated she had told facility staff 'over the weekend' but nothing had been done and she was still experiencing pain. R20 stated she had UTI's in the past and recognized when she was experiencing related symptoms. R20's historical care plan printed 2/20/25, indicated R20 required extensive staff assistance with toileting to include staff performing peri cares. The care plan also indicated R20 had a history of urinary tract infections with interventions including monitoring for signs and symptoms such as urgency, frequency, pain and dysuria (discomfort or burning during urination). The care plan further indicated R20 had mixed bladder incontinence and required assistance to clean peri area after each incontinent episode. Progress note dated 2/15/25 at 09:48 a.m., indicated R20 reported complaints of discomfort and burning during urination. Progress note dated 2/15/25 at 9:52 a.m., revealed staff nurse requested an order for a urinalysis and urine culture (UA/UC-a test that identifies a urinary tract infection). Progress note dated 2/18/25 at 04:02 a.m., indicated R20 continued to report burning and itching with urination and staff would update physician with change in status via fax to check for possible UTI. Progress note dated 2/18/25 at 10:15 a.m., indicated the physician had approved an order for a UA/UC to check R20 for UTI. During interview on 2/19/25 at 04:22 p.m., licensed practical nurse (LPN)A stated if a resident had complaints of burning or pain with urination the physician would be updated of the resident's change, and a request would be made for an order for a UA/UC. LPN-A stated the process is the same on the weekend as during the week. LPN-A went on to state a UA/UC is included in standing orders if a resident is symptomatic. LPN-A stated this was to ensure no delay in identifying or treatment if a provider was not immediately available. LPN-A stated she collected the urine sample on the evening shift of 2/18/25, however this was not taken to the lab until sometime the next day. During interview on 2/20/25 at 09:53 a.m. director of nursing (DON) stated staff were expected to assess a resident using LOEB's criteria (a set of clinical guidelines used to help healthcare providers determine when to initiate antibiotic therapy in long term care facilities) for residents reporting signs or symptoms of a UTI, and document those findings in the medical record for other staff would have access to that information. DON confirmed R20's chart did not contain documentation of LOEB's criteria being completed. DON stated staff could contact a provider over the weekend to obtain orders and could also transport a urine sample to the lab for analysis. DON confirmed R20's medical record lacked any follow up from the initial request for a UA/UC on 2/15/25 and stated four days was too long to wait to do anything. DON stated it was important to take immediate action with reported symptoms to prevent sepsis related to a bladder infection. Facility document titled Belgrade Nursing Home Standing orders included the following: Suspect urinary tract infection or resident has symptoms: Cath PRN for UA/UC urine specimen.

Based on interview and document review, the facility failed to identify indications (reason) for medications for 1 of 5 residents (R14) reviewed for unnecessary medications. Findings include: R14's admission Minimum Data Set (MDS) dated [DATE], included R14 had moderate cognitive impairment and diagnoses of hypertension, depression, and schizoaffective disorder. R14's order summary report dated 2/14/25, included amlodipine besylate (used to treat high blood pressure) 10 milligrams (mg) one tab by mouth every morning, lisinopril (used to treat high blood pressure) 10 mg one tab by mouth every morning, and psyllium (often used to treat constipation) 400 mg capsule give one by mouth at bedtime. All medication orders failed to include reason for use or associated diagnosis. During interview on 2/20/25 at 9:29 a.m., registered nurse (RN) case manager (CM)-A stated all orders were entered either by the case manager or a floor nurse with a new admission. Orders are then checked by two additional staff members. Orders should have had an associated diagnosis or reason for use. The provider should have been updated for clarification for any missing diagnosis. CM-A confirmed R14 did have multiple medications missing a reason for use associated with them. CM-A confirmed this should have been noticed and corrected within 14 days of admission. During interview on 2/20/25 at 12:26 p.m., director of nursing (DON) stated new admission orders were typically entered by case manager upon admission. Any missing diagnosis or order confusion should have been clarified by a provider. All orders should have been double or triple checked after being entered. The DON confirmed some of the orders for R14 were missing a diagnosis. The DON stated it was important to have the diagnosis in the order so everyone would know why the medication was being given. Facility policy transcribing/processing doctor's orders dated 2/20/25, included to remember the diagnosis with all orders received and to call to clarify orders with a provide.

Based on interview and document review, the facility failed to identify indications (reason) for medications for 1 of 5 residents (R14) reviewed for unnecessary psychotropic medications. Findings include: R14's admission Minimum Data Set (MDS) dated [DATE], included R14 had moderate cognitive impairment and diagnoses of hypertension, depression, and schizoaffective disorder. R14's order summary report dated 2/14/25, included deutetrabenazine 18 mg one tab by mouth every morning, risperidone 3 mg give one tablet by mouth two times a day, and trazodone 100 mg give one tablet by mouth at bedtime. All medication orders failed to include reason for use or associated diagnosis. During interview on 2/20/25 at 9:29 a.m., registered nurse (RN) case manager (CM)-A stated all orders were entered by the case manager or a floor nurse with a new admission. Orders are then checked by two additional staff members. Orders should have had an associated diagnosis or reason for use. The provider should have been updated for clarification for any missing diagnosis. CM-A confirmed R14 did have multiple medications missing a reason for use associated with them. CM-A confirmed this should have been noticed and corrected within 14 days of admission. During interview on 2/20/25 at 12:26 p.m., director of nursing (DON) stated new admission orders are typically entered by case managers upon admission. Any missing diagnosis or order confusion should have been clarified by a provider. All orders should have been double, or triple checked after being entered. The DON confirmed some of the orders for R14 were missing a diagnosis. The DON stated it was important to have the diagnosis in the order so everyone would know why the medication was being given. Facility policy transcribing/processing doctor's orders dated 2/20/25, included to remember the diagnosis with all orders received and to call to clarify orders with a provide.

Based on observation, interview and record review, the facility failed to complete proper disinfection of multi-use equipment (pulse oximeter) was implemented to prevent the spread of infection for 4 of 4 residents (R3, R24, R27, R29). This had the potential to affect all 30 residents and staff. Findings include: On 12/20/23 at 7:26 a.m., trained medication aide (TMA)-A was observed placing pulse oximeter (blood oxygen level) on R24's finger and did not disinfect equipment following use. Continuous observation initiated. At 7:50 a.m., TMA-A was observed in process of placing un-sanitized equipment on R3's finger prior to surveyor interrupting process. TMA-A stated all shared equipment was cleaned with an alcohol disinfecting wipe between resident use. However, she had not sanitized the oximeter after using it on R24 and prior to R3. Disinfecting equipment was important to prevent spreading germs . On 12/20/23 at 7:59 a.m., TMA-B was observed placing pulse oximeter on R29's finger and did not disinfect equipment following use. Continuous observation initiated. At 8:22 a.m., TMA-B placed the un-sanitized pulse oximeter on R27's finger. At 8:23 a.m., TMA-B stated the pulse oximeter needed to be sanitized between residents. However, she had not done so. It was important to prevent the spread of germs. On 12/21/23 at 1:08 p.m., director of nursing (DON) stated facility had recent COVID-19 outbreak, with seven residents and eight staff testing positive for COVID-19 from 11/17/23 through 12/19/23. DON stated the facility was performing resident vital checks every shift to monitor for COVID-19 due to recent outbreak. DON expected staff to disinfect equipment between resident use, specifically the oximeter because it was placed directly on resident fingers, and it was important to prevent infection control issues. The facility's Cleaning Guidelines and Environmental Services policy, reviewed 12/12/2022, indicated it was important that a clean, safe and sanitary environment was maintained for residents.

Based on observation, interview, and document review the facility failed to ensure restorative nursing care was provided for 2 of 2 residents (R28 & R9) reivewed for restorative care. Findings included: R28's Significant change Minimum Data Set (MDS) dated [DATE], indicated fully intact cognition (able to fully understand). Diagnoses of depression and displaced Tri-malleolar fracture of left lower leg (Broken Ankle). R28 walked in corridor once or twice and required one staff physical assistance. R28 needed assistive devices of a walker and wheelchair. Care Plan identified R28 had a restorative nursing walking program and was to be walked once daily with a front wheeled walker and wheelchair with the assistance on 1 staff and gait belt. R28 was to walk as far as tolerated. This intervention was to restore R28's activities of daily living (ADL). During observation on 12/19/23 at 12:16 p.m., R28 was seated in recliner with feet elevated, covered with blanket, and watching tv. No staff observed in room with R28. Interview on 12/20/23 at 1:32 p.m., trained medical assistance (TMA-A) stated R28 didn't walk often because she got tired, but R28 was to be walked every morning and evening. Walks were recorded in R28's Kardex. Interview on 12/20/23 at 2:11 p.m., R28 stated she was doing well and that she had not been walked today. Interview on 12/20/23 at 2:45 p.m., certified nursing assistant, (CNA-B) stated that she worked both halls and was familiar with R28. CNA-B continued that R28 was back in therapy and should be walked in morning and evening, and that R28 usually walked more in the evening. Facility Document, titled, Belgrade Nursing Home Survey Report, dated 12/21/23, indicated documentation for restorative nursing walking program had been completed 2 out of 40 opportunities total between AM shift and PM shift for month of December, with the others entries showing NA. Interview on 12/21/23 at 11:15 a.m., TMA-A stated transferring was recorded in the Kardex form. The survey report showing 2 out of an available 40 opportunities was the correct space and document where walking would be offered. TMA-A stated the documentation did not show restorative walking had been done, nor did it show a refusal by the resident. The documentation appeared correct. TMA-A continued, if R28 had refused then it should be charted as refused and not NA. Interview on 12/21/23 at 11:22 a.m., R28 stated that she had been walked more over the last couple days, but that was it. R28 stated she had brought it up to go for walks to staff, but that it often did not occur. Interview on 12/21/23 at 1:07 p.m., registered nurse (RN-A) stated she was aware of the walking program for R28 and staff recorded in the Kardex. RN-A stated she wasn't sure how much R28 had walked and did believe R28 would often refuse. R9's MDS dated [DATE], indicated resident was cognitively intact. R9's care plan indicated resident had limited physical mobility. Interventions included NuStep for 10 minutes, arm bike for 10 minutes, and the use of TheraBands (stretchy elastic bands used for resistance exercises). This intervention was ordered as part of the Restorative and Wellness Nursing Program by therapy. Facility report titled Documentation Survey Report created 12/20/23, for R9 indicated the arm bike was charted as NA or not charted on for 6 of 13 possible days in November. NuStep was charted NA or not charted on for 16 of 17 days in November. Arm bike was charted as NA or not charted on for 8 of 9 days in November. NuStep was charted as NA or not charted on for 10 of 10 days in December. On 12/18/23 at 1:12 p.m., R9 stated staff were supposed to walk with her and they did not. One aide brought her down to therapy but the other staff did not offer. On 12/21/23 at 1:37 p.m., director of nursing (DON) stated the wellness task was shared by both day and evening shift. Staff documented refused when the resident refused. If the staff documented not applicable or NA, she assumed the task was not completed. DON stated completion of Wellness and Restorative nursing was important as it was in the best interest of the resident. DON stated she had reviewed the documentation for R28 and R9. Staff had the option to document when a resident refused. DON confirmed the restorative program was not offered appropriately and documentation was an issue. Facility document titled, Nursing Activities of Daily Living with date of 9/11/2023, indicated the facility will provide a maintenance and restorative program to assist the resident in achieving and maintain the highest practicable outcome based on comprehensive assessment. Document failed to identify need for proper documentation of activities of daily living. Facility provided Document, titled, Nursing Activities of Daily Living with date of 9/11/2023, indicated the facility will provide a maintenance and restorative program to assist the resident in achieving and maintain the highest practicable outcome based on comprehensive assessment. Document failed to identify need for proper documentation of activities of daily living. 49035

Based on interview and document review, the facility failed to ensure registered nurse (RN) coverage for 8 consecutive hours per day, 7 days per week. This had the potential to affect all 28 residents. Findings include On 11/3/22, review of the schedule revealed no RN coverage existed for 8/27/22, 8/28/22, 9/10/22, 9/11/22, 9/24/22, 9/25/22, 10/8/22, 10/9/22, 10/22/22, and 10/23/22. On 11/03/22, at 12:44 p.m. administrator stated facility was occasionally without RN coverage for 8 hours. RN was available on-call during hours lacking RN in the facility. Administrator confirmed no RN coverage existed for 8/27/22, 8/28/22, 9/10/22, 9/11/22, 9/24/22, 9/25/22, 10/8/22, 10/9/22, 10/22/22, and 10/23/22. Further, the facility did not have a staffing waiver. Review of schedule indicated when no RN was scheduled in the facility, there was an RN on-call to consult as needed.

Based on observation, interview, and document review the facility failed to have a system in place to monitor and record refrigerator temperatures for resident personal food items. This had the potential to affect all 28 residents. The facility also failed to have a process in place to indicate proper food storage of butter blend product and cheese products. This had the potential to affect 27 of 28 residents who receive food prepared with the butter product and cheese products. Findings include: During an observation and interview on 11/2/22, at 5:01 p.m. temperature log on refrigerator designated for resident food items indicated temperatures at 42 degrees and 44 degrees on 10/16/22. Temperature log lacked temperature verification from 10/17/22 through 11/2/22. Further, the refrigerator contained three Ativia yogurt containers with an expiration date of 10/1/22 and a piece of pie without resident name or date. Certified dietary manager (CDM) stated nurses were responsible to monitor and log resident personal food items and refrigerator temperatures. During an interview on 11/2/22, at 6:10 p.m. Administrator stated the nurses were responsible to monitor and log the temperature of the refrigerator designated for resident personal food items twice daily. Administrator confirmed the temperatures on 10/16/22 were outside of the policy temperatures for safe food handling. Administrator confirmed temperature monitoring and logging had not been documented from 10/17/22 through 11/2/22. During observation on 11/2/22, at 1:55 p.m. butter blend was on kitchen counter and labeled KEEP REFRIGERATED on the cover. CDM confirmed this product was taken out of the refrigerator each morning, at approximately 5:30 a.m. and returned to the refrigerator by the evening cook each afternoon at approximately 1:30 p.m. CDM stated this product was used within approximately three days, once opened. CDM removed cover to reveal approximately 25% of the product remained. During an interview on 11/02/22, at 2:51 p.m. Cook-A stated if she wasn't going to use the butter blend, she would put it away when she arrived at noon. If she had food prep to complete, she would put the butter in the fridge at approximately 1:30 p.m. During an interview on 11/2/22, at 2:27 p.m. food distributor representative at Martin [NAME]. Distributing, provided product information which indicated to keep refrigerated, left out at four hours maximum. During observation on 11/2/22, at 5:01 p.m. four opened plastic bags labeled as: -[NAME] cheese dated 10/22/22, -Swiss American cheese dated 9/29/22 and 10/24/22, -shredded cheddar cheese dated 10/23/22. Cook (CK)-A referenced chart on outside of refrigerator used to determine length of time food safely stored in refrigerator. Chart has three columns: food item, first date mark, use-by. CK-A stated American cheese was to be discarded seven days after opening. Shredded cheese was discarded within seven days after opening. Cook disposed of cheese in garbage can. Review of policy on 11/02/22, at 6:33 p.m. labeled 6.173 SUBJECT: Food Storage indicated #13 Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 7 days or discarded. Check state regulations for more detail. #14 Refrigerated Food Storage: #2: PHF/TCS foods must be maintained at or below 41 degrees F unless otherwise specified by law. Periodically take temperatures of refrigerated foods to assure temp are maintained at or below 41 degrees F. Temp for refrigerators should be between 35-41F. Thermometers should be checked at least daily to two times per day. Check for proper functioning of the unit at the same time. #3: Every refrigerator must be equipped with an internal thermometer. #4: Every nursing unit with a refrigerator/freezer unit will be supplied with thermometers and monitored for appropriate temperatures. #6: all foods must be covered, labeled, and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded.

Based on interview and document review, the facility failed to ensure residents were free from verbal and physical abuse for 6 of 6 residents (R1, R2, R3, R4, R5, R6) who were involved in resident to resident verbal and/or physical altercations involving R1. Further, the facility failed to ensure allegations of resident to resident verbal and physical abuse were thoroughly investigated, assessed, and interventions care planned to ensure residents in the vicinity of R1 were safe after R1 demonstrated an escalation in verbal and physically aggressive behaviors directed at other residents in the facility. Findings include: R1's significant change Minimum Data Set (MDS) dated [DATE], identified R1 was severely cognitively impaired, sometimes understood others and sometimes others understood her. R1 required extensive physical assist with mobility and displayed one to three days of physical behaviors. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's care plan, printed 5/24/22, identified the following information: -Revised 5/17/22, R1 has a history of delusional (fixed/false beliefs) thoughts related to dementia secondary to [CONDITION(S)] disease with rapid changes in mood and behaviors without definitive cause. Interventions direct staff to not argue with R1; offer simple direct explanations; provide distraction and reorient as she allows; provide reassurance as needed; remove from areas and attempt to calm with one on one activities. -Revised 12/29/21, R1 has potential to be physically aggressive due to advanced cognitive loss with episodes of hitting, kicking, swinging out at staff and residents. Goal identified R1 would have fewer than three episodes of physical abuse per month. Interventions directed staff in communication techniques; when R1 becomes agitated, intervene before it escalated, guide her away from source of distress, if response is aggressive staff walk calmly away and approach later; -Initiated 4/13/21, R1 has dementia with impaired cognitive function, short/long term memory loss, and impaired thought process. Interventions direct staff to use R1's preferred nickname, identify themselves at each interaction, face R1 when speaking and make eye contact, reduce any distractions; engage R1 in simple structured activities that ovoid overly demanding tasks; break tasks into one step at a time. R1's care plan lacked a safety/abuse/vulnerability plan of care with associated goals and interventions to decrease R1's risk of abuse from others. Review of R1's record identified R1's verbal and physical aggressive behaviors directed towards residents increased around 3/30/22, in which R1 was documented to demonstrate multiple occurrences of verbal and physical aggression towards other residents; however, facility records lacked evidence of further identification and assessment of the residents who were and might have been effected by R1's verbally and physically abusive behaviors. In addition, there was no evidence of ongoing protection plans for all residents potentially affected. Furthermore, R1's record did not include a completed comprehensive analysis/evaluation of verbal and/or physical behaviors and/or effectiveness of behavioral interventions to determine if R1 required new interventions as a result of the increased behaviors in order to mitigate further episodes of verbal and physical aggression. R1's record lacked evidence R1's primary physician was updated on R1's increased verbal and physical aggression prior to 5/13/22 or evidence the facility followed up on the lack of physician response prior to a return fax on 5/20/22. R1's progress note, dated 3/30/22, at 7:27 a.m. identified R1 was mocking her tablemates at supper the previous evening. R1's progress note, dated 4/14/22, at 10:01 p.m. identified R1 entered R4's room and after R4 raised his voice and told R1 to leave, She started screaming at him and waving both arms, pointing and getting increasingly agitated. [R4] then yelled back and was going to shut his bedroom door when [R1] threw her partial glass of Ensure (nutritional supplement) at [R4] . After the incident, R1 calmed for short periods; however, displayed quick, intense outbursts of anger, yelling, and being short with other residents . After the incident, R1 threatened to smack R3, who was located in the lobby, if he stood up again. R4's annual MDS dated [DATE], identified R4 was diagnosed with dementia and was severely cognitively impaired; however, he was able to understand others without issues and others understood him. R4's progress note, dated 4/14/22, at 10:07 p.m. identified the interaction with R1. R4's care plan, printed 5/25/22, lacked a safety/abuse/vulnerability plan of care with associated goals and interventions to decrease R4's risk of abuse from others. R3's quarterly MDS dated [DATE], identified R3 was diagnosed with dementia and was severely cognitively impaired; however, he was usually able to understand others and others understood him. R3's progress notes lacked documented evidence that on 4/14/22 he was threatened by R1. R3's care plan, printed 5/25/22, lacked a safety/abuse/vulnerability plan of care with associated goals and interventions to decrease R3's risk of abuse from others. R1's progress note, dated 4/15/22, at 1:33 p.m. identified R1 was very anxious this shift in which she yelled at other residents. A physician's communication form, dated 4/22/22, updated R1's neurologist R1 was impulsive and becomes fixated on things at times .delusional at times. Communication form lacked any update on R1's verbal/physical aggression towards other residents. A dictated Minneapolis Clinic of Neurology progress note, dated 4/22/22, identified R1 was seen, in person, by neurology. R1's history of present illness (HPI) indicated for the past few months she demonstrated delusions (fixed/false beliefs) and was more confused and disoriented about time and space. So far she still can be directed. No agitation or aggressive behavior. The physician suggested the facility continue behavior justification and try redirecting. If not helping, will consider [MEDICATION(S)] (antipsychotic medication) 12.5 milligrams (mg) as needed. R1's Order Summary Report, dated 5/24/22, identified on 4/22/22 R1 was setup to monitor the following behaviors: hitting, kicking, biting, screaming, delusions, hallucinations, yelling at other residents, going after other residents aggressively. R1's progress note, dated 4/23/22, at 7:32 p.m. identified R1 was yelling at other resident(s) and appeared very agitated this shift. R1's progress note, dated 4/25/22, at 8:50 p.m. identified R1 was hitting another resident [R5]. R5's significant change MDS dated [DATE], identified R5 was diagnosed with dementia and depression and was severely cognitively impaired. R5 was rarely or never understood and only sometimes understood others. R5's progress notes lacked documented evidence that on 4/25/22 she was hit by R1. R5's care plan, printed 5/25/22, lacked a safety/abuse/vulnerability plan of care with associated goals and interventions to decrease R5's risk of abuse from others. R1's progress note, dated 5/1/22, at 8:04 p.m. identified R1 was attempting to scold other residents . R1's progress note, dated 5/6/22, at 8:31 p.m. identified R1 was verbally aggressive with other residents. R1's progress note, dated 5/11/22, at 9:14 p.m. identified R1 wheeled up to other residents and hugged them from behind and was hollering at them when she said something to them and they did not answer or she could not hear them. Further, [R1] wheeled up to R6 and slapped R6 five times with a rolled up newspaper. R6's quarterly MDS dated [DATE], identified R6 was diagnosed with Alzheimer's Disease and was severely cognitively impaired. R6 usually understood others and other usually understood her. R6's progress notes lacked documented evidence that on 5/11/22 she was slapped by R1. R6's care plan, printed 5/25/22, lacked a safety/abuse/vulnerability plan of care with associated goals and interventions to decrease R6's risk of abuse from others. R1's progress note, dated 5/13/22, at 9:36 p.m. identified LPN-B, after she responded to screaming and yelling from the lobby, witnessed NA attempting to stop R1 from hitting R2 with articles of baby clothing. R1 became combative with NA. R2 yelled she was hitting me! R2 was asked to go her room, which she did. R1 continued to try and make contact with R2 as she hit and kicked at NA. LPN-B then got behind [R1] and put her arms beck [sic] her back and assisted her back into her wheelchair. A Physical Event Risk Management report, dated 5/13/22, identified R1 and R2's physical interaction. The report indicated R1 was oriented to person only. There were no predisposing environmental, physiological, or situation factors identified. Immediate action taken described R2 was assessed for injury, staff attempted to redirect R1, R1 continued to seek out R2, R1 was assisted with a bath to which after she was up and down the hall looking angry, and then NA assisted her to bed. A Facility Reported Incident (FRI) submitted to the Stage Agency (SA) on 5/13/22, at 9:16 p.m. identified the following occurred at 7:48 p.m.: [R1] physically went after [R2]. [R2] began screaming and yelling for help. When the [nursing assistant - NA] arrived on scene she witnessed [R1] hitting [R2] with clothing. [NA] then tried to stop [R1], then [R1] physically went after [NA], hitting, kicking and screaming at [NA], [R1] still trying to get past [NA] to get to [R2]. Nurse arrived on scene shortly after [NA] and instructs [R2] to go to their room while attempting to redirect [R1] and return [R1] to their wheelchair, [R1] had to be physically restrained from hitting [NA] and [R2]. [R1] was then again attempted to be redirected, but she continued to be angry and look for people to go after. [R2] did leave the room when asked. R2's quarterly MDS dated [DATE], identified R2 was moderately cognitively impaired. R2 understood others and others understood her. R2's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's progress notes lacked documented evidence that on 5/13/22 she was hit by R1. R2's care plan, printed 5/25/22, lacked a safety/abuse/vulnerability plan of care with associated goals and interventions to decrease R2's risk of abuse from others. A facility nursing home communication form, dated 5/14/22, identified the facility faxed R1's provider R1's 5/13/22 behavior progress note. The providers response, dated 5/20/22, provided an order to start [MEDICATION(S)] 50 mg twice a day. R1's progress note, dated 5/15/22, at 9:58 p.m. identified R1 has been up and down with behaviors in which she swung out and slapped at other residents. A facility nursing home communication form, dated 5/17/22, identified the facility faxed R1's provider a 5/17/22 S.B.A.R (situation, background, assessment, recommendation) progress note related to incidents that occurred on 5/13/22 and 5/15/22. The form indicated R1's 5/10/22 - 5/16/22 progress notes were attached. The providers response, dated 5/20/22, provided an order to start [MEDICATION(S)] 50 mg twice a day. R1's progress note, dated 5/23/22, at 7:34 p.m. identified R1 was yelling at other residents in the dining room. Event Risk Management reports were requested for R2, R3, R4, R5, and R6 which identified investigation and follow-up related to R1's resident-to-resident behavioral interactions with them. None were provided. During interview via telephone on 5/24/22, at 12:22 p.m. R1's representative (FM)-A stated she knew R1's behaviors were escalated and identified the facility contacted her after an episode where R1 was not very nice to another resident and R1 required an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . FM-A was contacted again shortly after when the facility called and updated her [R1] had another bad episode and needed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . FM-A confirmed R1 hollered out at times in the dining room, hit out at staff and pinched her personally in the past; however, she denied knowledge R1 was combative to other residents. FM-A explained R1 had a longer standing history of behaviors prior to her facility admission and at that time family could not determine the behavior's etiology. FM-A denied the facility reached out to her to partake in a comprehensive behavior assessment/analysis process related to R1's escalated behaviors. When interviewed via telephone on 5/24/22, at 12:40 p.m. FM-B acknowledged she was not aware R2 was involved in a resident-to-resident altercation on 5/13/22. She explained she expected a phone call if such an event occurred: I am surprised I never got one [phone call]. When interviewed on 5/24/22, at 12:53 p.m. registered nurse (RN)-A stated verbalized threat(s) directed at others, which was intended to hurt someone else, was a form of verbal abuse, along with throwing things at another resident. If abuse was witnessed she was expected to report the incident to the SA within two hours if serious injury occurred. RN-A explained R1's dementia and disease process has gradually gotten further into it and we are seeing more behaviors with her. Examples given included aggression and being verbally loud or yelling in which R1 was a definition of impulsive and demonstrated a Jackal and Hide kind of thing. She confirmed R1 is allowed to self-propel her wheelchair unsupervised throughout the facility; however, she attempted to keep a closer eye on her when she worked. RN-A described R1's 4/14/22 incident with R3 and explained R1 yelled at R3 to sit down or she was going to smack him. RN-A indicated R1 became agitated by the situation and her environment when R3's chair alarm continued to engage with his attempted self-transfers. RN-A was unsure as to why she failed to follow-up with management about the episodes she witnessed when R1 verbally and physically abused other residents. During interview on 5/24/22, at 1:43 p.m. R2 stated R1 hit her in the past: just once maybe twice. She acknowledged she lacked remembrance of specific details related to the incident with R1; however, she commented it occurred maybe the other day. I think it was around 5:00 p.m. R2 explained she avoided R1 because she hit me; however, continued, She tells me what to do and she does not like when R1 does that. She felt bad when the incident occurred; however, felt better currently and denied signs or symptoms of physical or psychological harm related to the incident. During interview on 5/24/22, at 1:48 p.m. licensed practical nurse (LPN)-B stated [R1] has been stopped from slapping others before and R1's aggressive behaviors have occurred longer than a few weeks. She identified, There are things [R1 behaviors] that I have not charted on as no one was injured. LPN-B stated if R1 was physically or verbally abusive to other residents there needs to be a report; however, she continued, If [R1] was threatening to slap another resident I would not report that to the state [SA]. She explained R1's behavior monitoring was initiated when R1's behaviors started to escalate and one of her main concerns was directed at documenting R1's escalated behaviors for assist with medication management, not reporting to management every behavior R1 exhibited. LPN-B explained, on 5/13/22 when she entered the lobby, R1 was hitting R2 with an article of clothing. NA-A stopped the immediate action; however R1 stood and continued to swing her arms at NA-A as R1 tried to get to R2 which was unsafe. She confirmed she did not investigate the incident any further after R1 and R2 left the lobby, nor did she assess R1 or R2 for injury or mood changes, update R2's representative or physician, update R1's plan of care to mitigate further abuse or document a progress note in R2's chart. LPN-B explained, [R2] was scared but she was okay. I am confident she did not suffer any physical harm; but, I did not do an assessment to ensure that: If something would have happened, [R2] would have let me know; If the nursing assistant would have seen anything she would have told me also. She identified the interventions centered around separating R1 and R2 and to re-direct R1 to sit in her wheelchair so she did not fall. She denied she assisted with a comprehensive assessment/analysis process of R1's behaviors. During interview on 5/24/22, at 3:51 p.m. LPN-A stated physical abuse occurred when one resident hit another with a newspaper. She explained, on 5/11/22, R1 was having a bad night and wheeled around and slapped other residents on the back, pushed them out of the way, and hit R6 with a rolled up newspaper a few times. LPN-A indicated R6 put her arms up in defense. She could not recall if she reported the incident to management and denied she filed a report with the SA, No one told me to. She explained R1's behaviors were monitored at that time and for R1 it [aggressive behavior] was nothing out of the ordinary .that is what she does. I did not view that as something I needed to report to state [SA]. She verbalized the only intervention implemented that evening was staff sat with R1 until she calmed down, fed her at supper, and put her to bed after. She denied she assessed R1 or R2 for injury: [R6] had on a really bulky sweater with a sweatshirt on underneath. She explained R2's skin was paper thin and R1 does not have the strength to hurt. She identified the important thing was to get them separated. When interviewed on 5/24/22, at 2:50 p.m. NA-A confirmed when she entered the lobby on 5/13/22 she witnessed R1 standing in front of R2 in which R1 held onto baby cloths and was hitting [R2] with it while R1 yelled at R2. NA-A explained she approached R1 and R2 and got between them where she placed her arms around R1 like I was hugging her. R1 started to hit NA-A and continue to yell at R2. After LPN-B arrived, she directed R2 to her room and LPN-B went behind R1 and together they coaxed R1 to sit down. NA-A denied she witnessed R1 physically abuse other resident prior to this; however, she indicated she was aware of such events. She explained R1 is impulsive and can be fine one moment and agitated the next. Further, she explained R1 yells at other residents every day and gets in their faces. She acknowledged R1's behaviors were escalated; however, she denied knowledge of any new interventions put into place to mitigate R1's aggressive behaviors towards other residents. During interview on 5/24/22, at 3:59 p.m. the medical director (MD) identified he provided primary physician care to R1. He confirmed he lacked knowledge of the degree to which R1's increased verbal and physical aggression were directed at other residents, even after staff discussed R1's behavioral status with him that afternoon and commented he was on vacation and returned 5/20/22. He explained he preferred to attempt behavior monitoring when behaviors exhibited and then based on that information medication orders would be initiated if needed. When questioned on his expectation for abuse follow-up, he stated he was unsure what his expectations were as he did not know what the facility policy directed staff to do. He denied he was involved in a comprehensive assessment/analysis of R1's aggressive behaviors. He indicated he was unable to comment if examples of R1's behaviors were abuse or not when presented to him, in which he followed up with, All [residents] are vulnerable adults already and did not know why all episodes of abuse would need to be reported [to the SA]. When interviewed on 5/25/22, at 10:25 a.m. R4 stated he felt safe in the facility and denied being involved in any resident-to-resident altercations. He denied a resident yelled or screamed at him and denied a resident threw anything at him in his room. He commented if another resident were to yell at him, he would holler back at them. When interviewed on 5/25/22, at 10:34 a.m. clinical manager RN-B stated abuse occurred when behaviors were directed specifically at a resident from another, which included other residents. She gave examples of verbal threats and hitting. She expected staff to report any episodes of abuse to their immediate supervisor and follow-up per their policy as it was important that information be utilized to determine interventions to mitigate further behaviors and potential resident harm. She stated a body audit/skin assessment would be conducted if contact was present and would only assess the one struck as she would assume the one doing the striking out would not be injured. RN-B denied she updated R1's care plan after R1 demonstrated escalated behaviors. She explained R1 does not target specific residents just whoever is convenient at the time. In addition, she confirmed she did not comprehensively assess residents for abuse risk related to their vulnerability factor(s) and thus she did not initiate care plans for abuse risk. When interviewed on 5/25/22, at 11:07 a.m. social services designee (SSD) acknowledged she was only aware of R1's 5/13/22 resident-to-resident SA reported abuse allegation and not aware of the incidents which pertained to R1 being verbally and physically aggressive to other residents prior to that: I know she does become upset with cares when approached but not toward other residents. After R1's behaviors were discussed, SSD confirmed R1's resident-to-resident verbal and physical aggression was considered abuse and should have been reported and followed-up on per their policy. The SSD denied R1's behaviors and interventions were comprehensively assessed or analyzed after the 5/13/22 incident. Further, she confirmed residents were not comprehensively assessed for abuse risk related to their vulnerability factor(s) and thus care plans for abuse risk were not initiated. During interview via telephone on 5/25/22, at 11:52 a.m. FM-C denied knowledge R4 was involved in a resident-to-resident altercation where another resident threw something at him. FM-C explained she expected to be updated with such events and commented, I am very angered by this. If staff would have followed up on it appropriately, I would have been called. When interviewed via telephone on 5/25/22, at 12:03 p.m. FM-D denied knowledge R3 was involved in a resident-to-resident altercation where another resident threatened him. FM-D explained she would like to be called if such incidents occurred. During interview via telephone on 5/25/22, at 12:14 p.m. activity director (AD) stated verbal abuse included name calling, using a shaming tone of voice, mocking someone, belittling someone or words that would make someone feel uncomfortable. AD explained R1's mocking behavior on 3/30/22 may have been directed at R6; however, she was not totally certain and she also could not remember the words R1 verbalized towards the other residents. I think a lady said something and [R1] went back at her. AD identified she was expected to report abuse to the person in charge and if the abuse caused harm then she was expected to report it right away. She explained she did not report R1's mocking behavior to the person in charge as she was able to stop the behavior and did not feel it was blowing out of proportion. When interviewed on 5/25/22, at 12:41 p.m. the director of nursing (DON) stated she expected staff to complete an incident report for all episodes of abuse. She identified examples of abuse occurred when a resident was targeted by someone else, screamed or hollered at, threaten, or hit; however, she commented so much of it depends [on what is considered abuse] when a resident diagnosed with dementia is involved in resident-to-resident behavioral interactions. Further, she explained her staff expectations for resident-to-resident abuse follow-up investigation also depended on the situation, the results of the initial investigation and if the allegation was witnessed or not. The DON explained her expectations related to injury assessment centered around staff visualizing the area where the resident stated they were hit or the area staff visualized was hit and she did not expect a full body audit/assessment to be completed or formally documented: a progress note was only required. The DON stated staff resident progress note documentation of resident-to-resident behavioral interactions depends if back and forth or one sided. If both residents were abusive to each other than a progress note was expected for both residents and if only one resident was the abuser then only that resident had a progress note completed. Continued expectations required staff to notify herself, the administrator, the physician, and the resident contact when abuse was witnessed or alleged. She denied R1's behaviors were comprehensively assessed/analyzed and documented after R1 was determined to have escalated behaviors and demonstrated such behaviors. Further, she denied R1's care plan was reviewed and interventions implemented and reviewed to ensure approaches in place to protect other residents from R1's verbal and physically aggressive behaviors: We just remove [R1] out of areas. In addition, the DON confirmed residents were not comprehensively assessed for abuse risk related to their vulnerability factor(s) and thus care plans for abuse risk were not initiated: .everyone is considered a vulnerable adult. A policy Abuse Policy & Procedure, dated 12/8/20, identified It is the policy of the Belgrade Nursing Home that each resident will be free from Abuse. Abuse included verbal and physical abuse in which residents would be protected from abuse while they resided at the facility. The policy directs staff to report witnessed or suspected resident abuse immediately to the nurse on duty and management in order for the abuse to be promptly and thoroughly investigated. In the instance of resident-to-resident abuse, the policy identified ensuring the safety and well-being for the vulnerable individual was of utmost priority which included a staff member to remain with the perpetrator resident until further instruction from administration. The policy further directs staff to examine, assess, and notify medical providers as soon as possible to determine any injury and identify any immediate clinical interventions necessary.

Based on interview and document review, the facility failed to report allegations of resident-to-resident verbal and physical abuse to the State Agency (SA) within 2 hours of the allegation for at least 5 of 5 residents (R1, R3, R4, R5, R6) reviewed for resident-to-resident abuse. Findings include: R1's significant change Minimum Data Set (MDS) dated [DATE], identified R1 was severely cognitively impaired. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R3's quarterly MDS dated [DATE], identified R3 was diagnosed with dementia and was severely cognitively impaired. R4's annual MDS dated [DATE], identified R4 was diagnosed with dementia and was severely cognitively impaired; however. R5's significant change MDS dated [DATE], identified R5 was diagnosed with dementia and depression and was severely cognitively impaired. R6's quarterly MDS dated [DATE], identified R6 was diagnosed with Alzheimer's Disease and was severely cognitively impaired. Facility records lacked evidence the following incidents were reported to the SÄ: R1's progress note, dated 4/14/22, at 10:01 p.m. identified R1 entered R4's room and after R4 raised his voice and told R1 to leave, She started screaming at him and waving both arms, pointing and getting increasingly agitated. [R4] then yelled back and was going to shut his bedroom door when [R1] threw her partial glass of Ensure (nutritional supplement) at [R4] . After the incident, R1 calmed for short periods; however, displayed quick, intense outbursts of anger, yelling, and being short with other residents . After the incident, R1 threatened to smack R3, who was located in the lobby, if he stood up again. R1's progress note, dated 4/25/22, at 8:50 p.m. identified R1 was hitting another resident [R5]. R1's progress note, dated 5/6/22, at 8:31 p.m. identified R1 was verbally aggressive with other residents. R1's progress note, dated 5/11/22, at 9:14 p.m. identified R1 wheeled up to other residents and hugged them from behind and was hollering at them when she said something to them and they did not answer or she could not hear them. Further, [R1] wheeled up to R6 and slapped R6 five times with a rolled up newspaper. R1's progress note, dated 5/15/22, at 9:58 p.m. identified R1 has been up and down with behaviors in which she swung out and slapped at other residents. R1's progress note, dated 5/23/22, at 7:34 p.m. identified R1 was yelling at other residents in the dining room. When interviewed on 5/24/22, at 12:53 p.m. registered nurse (RN)-A stated verbalized threat(s) directed at others, which was intended to hurt someone else, was a form of verbal abuse. RN-A explained R1 yelled at R3 to sit down or she was going to smack him. RN-A indicated R1 became agitated by the situation and her environment when R3's chair alarm continued to engage with his attempted self-transfers. Further, she acknowledged physical abuse could be demonstrated by throwing things at others. RN-A stated if she witnessed abuse she was expected to report to the SA within two hours if serious injury occurred. She was unsure as to why she failed to follow-up with management about the episodes she witnessed when R1 verbally and physically abused other residents. During interview on 5/24/22, at 1:48 p.m. licensed practical nurse (LPN)-B stated [R1] has been stopped from slapping others before and R1's aggressive behaviors have occurred longer than a few weeks. She identified, There are things [R1 behaviors] that I have not charted on as no one was injured. LPN-B stated if R1 was physically or verbally abusive to other residents there needs to be a report; however, she continued, If [R1] was threatening to slap another resident I would not report that to the state [SA]. She explained R1's behavior monitoring was initiated when R1's behaviors started to escalate and one of her main concerns was directed at documenting R1's escalated behaviors for assist with medication management, not reporting to management every behavior R1 exhibited. During interview on 5/24/22, at 3:51 p.m. LPN-A stated physical abuse occurred when one resident hit another with a newspaper. She explained, on 5/11/22, R1 was having a bad night and wheeled around and slapped other residents on the back, pushed them out of the way, and hit R6 with a rolled up newspaper a few times. LPN-A indicated R6 put her arms up in defense. She could not recall if she reported the incident to management and denied she filed a report with the SA, No one told me to. She explained R1's behaviors were monitored at that time and for R1 it [aggressive behavior] was nothing out of the ordinary .that is what she does. I did not view that as something I needed to report to state [SA]. LPN-A stated she was expected to report severe physical abuse and followed up with, I do not know about [when to report] verbal abuse. When interviewed on 5/24/22, at 3:59 p.m. the medical director (MD) identified he provided primary physician care to R1. He confirmed he lacked knowledge of the degree to which R1's increased verbal and physical aggression were directed at other residents, even after staff discussed R1's behavioral status with him that afternoon. When questioned on his expectation for abuse reporting, he stated he was unsure what the reporting expectations were as he did not know what the facility policy on reporting directed staff to do. Further, he indicated he was unable to comment if examples of R1's behaviors were abuse or not when presented to him, in which he followed up with, All [residents] are vulnerable adults already and did not know why all episodes of abuse would need to be reported [to the SA]. During interview on 5/25/22, at 10:34 a.m. clinical manager RN-B stated abuse occurred when behaviors were directed specifically at a resident from another, which included other residents. She gave examples of verbal threats and hitting. She expected staff to report any episodes of abuse to their immediate supervisor as it was important that information be utilized to determine interventions to mitigate further behaviors and potential resident harm. When interviewed on 5/25/22, at 11:07 a.m. social services designee (SSD) acknowledged she was only aware of R1's 5/13/22 resident to resident SA reported abuse allegation and not aware of the incidents which pertained to R1 being verbally and physically aggressive to other residents prior to that. Due to this, R1's verbal and physical resident directed behaviors prior to 5/13/22 were not reported to the SA as per their policy. After R1's behaviors were discussed, SSD confirmed R1's resident directed verbal and physical aggression was considered abuse and should have been reported to the SA immediately or at least within the two hours that is required. During interview on 5/25/22, at 12:14 p.m. activity director (AD) stated verbal abuse included name calling, using a shaming tone of voice, mocking someone, belittling someone or words that would make someone feel uncomfortable. AD explained R1's mocking behavior on 3/30/22 may have been directed at R6; however, she was not totally certain and she also could not remember the words R1 verbalized towards the other residents. I think a lady said something and [R1] went back at her. AD identified she was expected to report abuse to the person in charge and if the abuse caused harm then she was expected to report it right away. She explained she did not report R1's mocking behavior to the person in charge as she was able to stop the behavior and did not feel it was blowing out of proportion. When interviewed on 5/25/22, at 12:41 p.m. the director of nursing (DON) stated she expected all episodes of abuse to be reported per their policy. She identified examples of abuse occurred when a resident was targeted by someone else, screamed or hollered at, threatens, or hit and she expected the incident to be reported within two hours if the allegation was identified as abuse during the initial investigation process. A policy Abuse Policy & Procedure, dated 12/8/20, defined physical abuse included, but was not limited to, hitting and slapping, and defined verbal abuse as the use of oral or gestured communication or sounds to residents within hearing distance, regardless of ability to understand. The policy identified a procedure for internal reporting which directed Employees must always report any abuse or suspicion of abuse immediately to the Administrator. Further, the policy directed staff to report all alleged violations of abuse immediately, but not later than 2 hours after the allegation is made.

Based on interview and document review, the facility failed to ensure 1 of 1 residents (R1) was free from restraint (restricts the resident's freedom of movement or normal access to his/her body) use. In addition, the facility failed to obtain a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: R1's significant change Minimum Data Set (MDS) dated [DATE], identified R1 was severely cognitively impaired, sometimes understood others and sometimes others understood her. R1 required extensive physical assist with mobility and displayed one to three days of physical behaviors. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Facility Reported Incident (FRI) submitted to the Stage Agency (SA) on 5/13/22, at 9:16 p.m. identified the following occurred at 7:48 p.m.: [R1] physically went after [R2]. [R2] began screaming and yelling for help. When the [nursing assistant - NA] arrived on scene she witnessed [R1] hitting [R2] with clothing. [NA] then tried to stop [R1], then [R1] physically went after [NA], hitting, kicking and screaming at [NA], [R1] still trying to get past [NA] to get to [R2]. Nurse arrived on scene shortly after [NA] and instructs [R2] to go to their room while attempting to redirect [R1] and return [R1] to their wheelchair, [R1] had to be physically restrained from hitting [NA] and [R2]. [R1] was then again attempted to be redirected, but she continued to be angry and look for people to go after. [R2] did leave the room when asked. Facility records lacked documented evidence of the following: -An immediate order from R1's medical provider, or on-call physician, was obtained for the use of the restraint after the manual physical hold was discontinued. -Attempted interventions and response(s) to those interventions prior to the application of the manual physical hold. -The restraint was the last resort to protect R1's and other residents safety. -R1 was assessed for injury after the manual physical hold was discontinued. -R1 was assessed by staff and R1's medical provider to address other interventions that identified symptoms or cause of the situation. -R1's resident representative was immediately notified of the symptoms and temporary use of the manual physical hold intervention. -Care planned restraint interventions. When interviewed via telephone on 5/24/22, at 12:22 p.m. R1's representative (FM)-A stated she knew R1's behaviors were escalated and identified the facility contacted her after an episode where R1 was not very nice to another resident and R1 required an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . FM-A was contacted again shortly after when the facility called and updated her [R1] had another bad episode and needed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . FM-A denied staff updated her that on 5/13/22, R1 required a restraint related to a resident-to-resident altercation. During interview on 5/24/22, at 1:48 p.m. LPN-B indicated when initially asked about facility restraint use, that she personally physically restrained a resident at the facility. She confirmed R1 to be that resident. She explained when she entered the lobby R1 was hitting R2 with an article of clothing. NA-A stopped the immediate action; however R1 stood and continued to swing her arms at NA-A as R1 tried to get to R2 which was unsafe. LPN-B verbally and physically explained how she restrained R1 and assisted her into her wheelchair. She identified she placed R1's wheelchair behind R1 and when R1 brought her arms down LPN-B took her own arms and looped R1's arms behind R1's back just long enough to get her to sit down .[R1] was not even restrained for a minute. When LPN-B was questioned on facility expectations when a restraint was utilized, she stated an order was required. She confirmed she did not obtain an order, she did not notify management or R1's family she utilized a restraint on R1, she did not assess R1 for injury related to the technique she used, she did not investigate the incident any farther, and did not update R1's plan of care. She identified the interventions prior to the restraint use centered around separating R1 and R2 and to re-direct R1 to sit in her wheelchair so she did not fall. When interviewed on 5/24/22, at 2:50 p.m. NA-A confirmed when she entered the lobby on 5/13/22, she witnessed R1 standing in front of R2 in which R1 held onto baby cloths and was hitting [R2] with it while R1 yelled at R2. NA-A explained she approached R1 and R2 and got between them where she placed her arms around R1, like I was hugging her. R1 started to hit NA-A and continue to yell at R2. After LPN-B arrived, she directed R2 to her room and LPN-B went behind R1 and together they coaxed R1 to sit down. NA-A explained R1 sat in her wheelchair after she assumed LPN-A grabbed the back of R1's pants, It felt kind of like she was guided backwards and then plopped into the wheelchair. She denied she visualized LPN-B's arms at the time R1 was assisted to sit. During interview on 5/24/22, at 3:59 p.m. the medical director (MD) identified he provided primary physician care to R1 and he stated a physical restraint would be a last resort if there was a risk of resident injury. He indicated he was unable to comment on his restraint expectations for facility staff as he was not there and lacked knowledge of the facility's restraint policy. Further, he denied knowledge R1 required a restraint during the 5/13/22 resident to resident incident. When interviewed on 5/25/22, at 10:34 a.m. clinical manager RN-B stated she initially thought R1 was not restrained when LPN-B assisted R1 back into her wheelchair on 5/13/22. She denied she was involved in the incident investigation. After RN-B was physical explained LPN-B's technique, she exclaimed, Oh my gosh, that is not okay. She stated she expected staff to follow a restraint use process to determine if the restraint was necessary and what could have been done differently so as not to restrain that person, determine if there was immediate harm or danger to the resident(s), report the restraint use to the director of nursing (DON), update the doctor and obtain an order, and update the care plan. Further, she denied knowledge of the facility's restraint policy and directed processes; however, she indicated she restraint use should be discussed with management and the nurse involved. During interview on 5/25/22, at 11:07 a.m. social services designee (SSD) stated during her part into R1 and R2's 5/13/22 abuse report, she interviewed LPN-B via a telephone call in which LPN-B verbally explained she physically restrained R1 from hitting; however, LPN-B indicated she grabbed R1 around her waist and sat her on the chair. SSD denied she followed up with LPN-B once LPN-B returned to work for a physical explanation. She explained during her investigation she lacked an alarming thought about the maneuver; however, after the maneuver was physically explained to her by the surveyor, she acknowledged concern because she was not able to release herself from that position, even if a matter of five seconds .We definitely need to do some behavioral intervention education on this not being your initial response. The SSD denied R1's behaviors and interventions were comprehensively assessed or analyzed after the 5/13/22 resident to resident incident. When interviewed on 5/25/22, at 12:41 p.m. the DON stated an emergency restraint may be necessary if a resident is swinging at someone's face or if they continue to try to go through you to get to another resident. The DON explained if an emergency restraint was required, a nurse may not necessarily need to document all actions taken prior and after the event unless you had to do a bear hug hold like children who need to calm down. We do not do that here however. Updating the doctor would take something drastic, such as, you had to take someone to the ground. The DON explained based on LPN-B's verbal explanation of the manual hold during the initial facility investigation that LPN-B only placed her arms around R1's mid-section and assisted her back into the wheelchair. She denied LPN-B demonstrated the manual hold at that time. After the technique used by LPN-B on R1 was physically explained to the DON, the DON acknowledged the manual hold was considered a restraint for a short period of time, probably. Further, she stated, based on the new understanding, she expected R1's chart to indicate exactly what the staff's actions were pre and post the manual hold, that R1's doctor was updated right after the progress note was written, R1 and her range of motion were assessed for any signs of injury, and R1's representative was notified about the incident and interventions required. The DON denied R1's behaviors and interventions were comprehensively assessed or analyzed after the 5/13/22 resident to resident incident. A policy Resident Physical Restraint, dated 3/29/22, identified a physical restraint was any manual method attached or adjacent to the resident that the resident could not easily remove and that restricted freedom of movement or normal access to their body. The policy directed staff to consider alternatives to restraints before applying any kind of physical restraint, in which the alternatives and their responses need to be documented. Examples of alternative interventions was provided. In addition, the policy directed staff to obtain a restraint order, along with representative notification.

Based on interview and document review the facility failed to implement and follow their abuse policy related to implementing resident assessment and abuse prevention, investigation, and reporting for 1 of 1 residents (R1) who had multiple incidents of resident to resident abuse involving multiple residents (R2, R3, R4, R5, R6) . This had the potential to adversely affect all 28 residents who resided in the facility. Findings include: A policy Abuse Policy & Procedure, dated 12/8/20, indicated every resident was unique and may be subject to abuse. A component of abuse prevention identified Upon admission and periodically after that, each resident will have a safety or vulnerability assessment completed which identified potential vulnerability such as cognitive, physical, psychosocial, environment and communication concerns. In addition, the policy identified resident-to-resident altercation investigation processes. The processes included, but was not limited to, the following: prompt reporting of incident occurrences to the nurse supervisor, director of nursing (DON), and administrator; identify event circumstances, notification to each resident's representative and attending physician; event review to include interventions to prevent incident reoccurrence; attending physician consult to identify treatable conditions that may have caused or contributed to the problem; care plan approach adjustments to any or all of the involved residents; document in the resident's clinical record all interventions and their effectiveness; consult psychiatric services as needed; Report of Incident/Accident form completion and document findings; resident transfer as needed; report incidents, findings and corrective measures to appropriate agencies as outlined in the policy. R1's significant change Minimum Data Set (MDS) dated [DATE], identified R1 was severely cognitively impaired. R1 displayed one to three days of physical behaviors. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's care plan, printed 5/24/22, identified the following information: -Revised 5/17/22, R1 has a history of delusional (fixed/false beliefs) thoughts related to dementia secondary to [CONDITION(S)] disease with rapid changes in mood and behaviors without definitive cause. Interventions direct staff to not argue with R1; offer simple direct explanations; provide distraction and reorient as she allows; provide reassurance as needed; remove from areas and attempt to calm with one on one activities. -Revised 12/29/21, R1 has potential to be physically aggressive due to advanced cognitive loss with episodes of hitting, kicking, swinging out at staff and residents. Goal identified R1 would have fewer than three episodes of physical abuse per month. Interventions directed staff in communication techniques; when R1 becomes agitated, intervene before it escalated, guide her away from source of distress, if response is aggressive staff walk calmly away and approach later; -Initiated 4/13/21, R1 has dementia with impaired cognitive function, short/long term memory loss, and impaired thought process. Interventions direct staff to use R1's preferred nickname, identify themselves at each interaction, face R1 when speaking and make eye contact, reduce any distractions; engage R1 in simple structured activities that ovoid overly demanding tasks; break tasks into one step at a time. R1's record identified R1's verbal and physical aggressive behaviors directed towards residents increased around 3/30/22, in which R1 was documented to demonstrate multiple occurrences of verbal and physical aggression towards other residents; however, facility records lacked evidence of further identification, assessment, and notification processes for the residents who were and might have been effected by R1's verbally and physically abusive behaviors. In addition, there was no evidence of ongoing protection plans for all residents potentially affected. Furthermore, R1's record did not include a completed comprehensive analysis/evaluation of verbal and/or physical behaviors and/or effectiveness of behavioral interventions to determine if R1 required new interventions as a result of the increased behaviors in order to mitigate further episodes of verbal and physical aggression. R1's record lacked evidence R1's primary physician was updated on R1's increased verbal and physical aggression prior to 5/13/22. In addition, facility records lacked evidence staff updated management related to R1's witnessed resident-to-resident abuse which resulted in each witnessed allegation not investigated and reported per facility policy. R1's progress note, dated 3/30/22, at 7:27 a.m. identified R1 was mocking her tablemates at supper the previous evening. R1's progress note, dated 4/14/22, at 10:01 p.m. identified R1 entered R4's room and after R4 raised his voice and told R1 to leave, She started screaming at him and waving both arms, pointing and getting increasingly agitated. [R4] then yelled back and was going to shut his bedroom door when [R1] threw her partial glass of Ensure (nutritional supplement) at [R4] . After the incident, R1 calmed for short periods; however, displayed quick, intense outbursts of anger, yelling, and being short with other residents . After the incident, R1 threatened to smack R3, who was located in the lobby, if he stood up again. R4's annual MDS dated [DATE], identified R4 was diagnosed with dementia and was severely cognitively impaired. R4's progress note, dated 4/14/22, at 10:07 p.m. identified the interaction with R1. R3's quarterly MDS dated [DATE], identified R3 was diagnosed with dementia and was severely cognitively impaired. R1's progress note, dated 4/15/22, at 1:33 p.m. identified R1 was very anxious this shift in which she yelled at other residents. A physician's communication form, dated 4/22/22, updated R1's neurologist R1 was impulsive and becomes fixated on things at times .delusional at times. Communication form lacked any update on R1's verbal/physical aggression towards other residents. A dictated Minneapolis Clinic of Neurology progress note, dated 4/22/22, identified R1 was seen, in person, by neurology. R1's history of present illness (HPI) indicated for the past few months she demonstrated delusions (fixed/false beliefs) and was more confused and disoriented about time and space. So far she still can be directed. No agitation or aggressive behavior. The physician suggested the facility continue behavior justification and try redirecting. If not helping, will consider [MEDICATION(S)] (antipsychotic medication) 12.5 milligrams (mg) as needed. R1's progress note, dated 4/23/22, at 7:32 p.m. identified R1 was yelling at other resident(s) and appeared very agitated this shift. R1's progress note, dated 4/25/22, at 8:50 p.m. identified R1 was hitting another resident [R5]. R5's significant change MDS dated [DATE], identified R5 was diagnosed with dementia and depression and was severely cognitively impaired. R1's progress note, dated 5/1/22, at 8:04 p.m. identified R1 was attempting to scold other residents . R1's progress note, dated 5/6/22, at 8:31 p.m. identified R1 was verbally aggressive with other residents. R1's progress note, dated 5/11/22, at 9:14 p.m. identified R1 wheeled up to other residents and hugged them from behind and was hollering at them when she said something to them and they did not answer or she could not hear them. Further, [R1] wheeled up to R6 and slapped R6 five times with a rolled up newspaper. R6's quarterly MDS dated [DATE], identified R6 was diagnosed with Alzheimer's Disease and was severely cognitively impaired. R1's progress note, dated 5/13/22, at 9:36 p.m. identified LPN-B, after she responded to screaming and yelling from the lobby, witnessed NA attempting to stop R1 from hitting R2 with articles of baby clothing. R1 became combative with NA. R2 yelled she was hitting me! R2 was asked to go her room, which she did. R1 continued to try and make contact with R2 as she hit and kicked at NA. LPN-B then got behind [R1] and put her arms beck [sic] her back and assisted her back into her wheelchair. R2's quarterly MDS dated [DATE], identified R2 was moderately cognitively impaired. R1's progress note, dated 5/15/22, at 9:58 p.m. identified R1 has been up and down with behaviors in which she swung out and slapped at other residents. R1's progress note, dated 5/23/22, at 7:34 p.m. identified R1 was yelling at other residents in the dining room. R1's resident-to-resident altercation progress notes, dated 3/20/22, 4/15/22, 4/23/22, 5/1/22, 5/6/22, 5/15/22, 5/23/22, lacked documented evidence of the involved resident(s), investigation processes performed, or facility management notification. R1's resident-to-resident altercation progress notes, dated 4/14/22, 4/25/22, 5/11/22, 5/23/22, lacked documented evidence of the investigation processes performed or facility management notification. R1, R2, R3, R4, R5, and R6's medical records were reviewed and lacked evidence of a safety/abuse/vulnerability assessment which identified their abuse risk. These assessments were requested. None were provided. R1, R2, R3, R4, R5, and R6's care plans were reviewed and lacked a safety/abuse/vulnerability plan of care with associated goals and interventions to decreased abuse risk. R2, R3, R5, and R6's medical records were reviewed and each lacked documented evidence of their witnessed resident-to resident altercation(s) with R1 following the incident(s). Event (Incident) Risk Management reports were requested for R2, R3, R4, R5, and R6 which identified investigation and follow-up related to R1's resident-to-resident behavioral interactions with them. None were provided. During interview via telephone on 5/24/22, at 12:22 p.m. R1's representative (FM)-A stated she knew R1's behaviors were escalated and identified the facility contacted her after an episode where R1 was not very nice to another resident. FM-A was contacted again shortly after when the facility called and updated her [R1] had another bad episode. FM-A confirmed R1 hollered out at times in the dining room, hit out at staff and pinched her personally in the past; however, she denied knowledge R1 was combative to other residents. When interviewed via telephone on 5/24/22, at 12:40 p.m. FM-B acknowledged she was not aware R2 was involved in a resident-to-resident altercation on 5/13/22. She explained she expected a phone call if such an event occurred: I am surprised I never got one [phone call]. When interviewed on 5/24/22, at 12:53 p.m. registered nurse (RN)-A explained R1's dementia and disease process has gradually gotten further into it and we are seeing more behaviors with her. Examples given included aggression and being verbally loud or yelling in which R1 was a definition of impulsive and demonstrated a Jackal and Hide kind of thing. She confirmed R1 is allowed to self-propel her wheelchair unsupervised throughout the facility; however, she attempted to keep a closer eye on her when she worked. RN-A was unsure as to why she failed to follow-up with management about the episodes she witnessed when R1 verbally and physically abused other residents. During interview on 5/24/22, at 1:48 p.m. licensed practical nurse (LPN)-B stated [R1] has been stopped from slapping others before and R1's aggressive behaviors have occurred longer than a few weeks. She identified, There are things [R1 behaviors] that I have not charted on as no one was injured. LPN-B stated if R1 was physically or verbally abusive to other residents there needs to be a report; however, she continued, If [R1] was threatening to slap another resident I would not report that to the state [SA]. She explained R1's behavior monitoring was initiated when R1's behaviors started to escalate and one of her main concerns was directed at documenting R1's escalated behaviors for assist with medication management, not reporting to management every behavior R1 exhibited. LPN-B explained, on 5/13/22 when she entered the lobby, R1 was hitting R2 with an article of clothing. She confirmed she did not investigate the incident any further after R1 and R2 left the lobby, nor did she assess R1 or R2 for injury or mood changes, update R2's representative or physician, update R1's plan of care to mitigate further abuse or document a progress note in R2's chart. LPN-B explained, [R2] was scared but she was okay. I am confident she did not suffer any physical harm; but, I did not do an assessment to ensure that: If something would have happened, [R2] would have let me know; If the nursing assistant would have seen anything she would have told me also. She identified the interventions centered around separating R1 and R2 and to re-direct R1 to sit in her wheelchair so she did not fall. She denied she assisted with a comprehensive assessment/analysis process of R1's behaviors. During interview on 5/24/22, at 3:51 p.m. LPN-A explained, on 5/11/22, R1 was having a bad night and wheeled around and slapped other residents on the back, pushed them out of the way, and hit R6 with a rolled up newspaper a few times. LPN-A indicated R6 put her arms up in defense. She could not recall if she reported the incident to management and denied she filed a report with the SA, No one told me to. She explained R1's behaviors were monitored at that time and for R1 it [aggressive behavior] was nothing out of the ordinary .that is what she does. I did not view that as something I needed to report to state [SA]. She verbalized the only intervention implemented that evening was staff sat with R1 until she calmed down, fed her at supper, and put her to bed after. She denied she assessed R1 or R2 for injury: [R6] had on a really bulky sweater with a sweatshirt on underneath. She explained R2's skin was paper thin and R1 does not have the strength to hurt. She identified the important thing was to get them separated. During interview on 5/24/22, at 3:59 p.m. the medical director (MD) identified he provided primary physician care to R1. He confirmed he lacked knowledge of the degree to which R1's increased verbal and physical aggression were directed at other residents, even after staff discussed R1's behavioral status with him that afternoon and commented he was on vacation and returned 5/20/22. He explained he preferred to attempt behavior monitoring when behaviors exhibited and then based on that information medication orders would be initiated if needed. When questioned on his expectation for abuse follow-up, he stated he was unsure what his expectations were as he did not know what the facility policy directed staff to do. He denied he was involved in a comprehensive assessment/analysis of R1's aggressive behaviors. He indicated he was unable to comment if examples of R1's behaviors were abuse or not when presented to him, in which he followed up with, All [residents] are vulnerable adults already and did not know why all episodes of abuse would need to be reported [to the SA]. When interviewed on 5/25/22, at 10:34 a.m. clinical manager RN-B stated she expected staff to report any episodes of abuse to their immediate supervisor and follow-up per their policy as it was important that information be utilized to determine interventions to mitigate further behaviors and potential resident harm. She stated a body audit/skin assessment would be conducted if contact was present and would only assess the one struck as she would assume the one doing the striking out would not be injured. RN-B denied she updated R1's care plan after R1 demonstrated escalated behaviors. She explained R1 does not target specific residents just whoever is convenient at the time. In addition, she confirmed she did not comprehensively assess residents for abuse risk related to their vulnerability factor(s) and thus she did not initiate care plans for abuse risk. When interviewed on 5/25/22, at 11:07 a.m. social services designee (SSD) acknowledged she was only aware of R1's 5/13/22 resident-to-resident SA reported abuse allegation and not aware of the incidents which pertained to R1 being verbally and physically aggressive to other residents prior to that: I know she does become upset with cares when approached but not toward other residents. After R1's behaviors were discussed, SSD confirmed R1's resident-to-resident verbal and physical aggression was considered abuse and should have been reported and followed-up on per their policy. The SSD denied R1's behaviors and interventions were comprehensively assessed or analyzed after the 5/13/22 incident. Further, she confirmed residents were not comprehensively assessed for abuse risk related to their vulnerability factor(s) and thus care plans for abuse risk were not initiated During interview via telephone on 5/25/22, at 11:52 a.m. FM-C denied knowledge R4 was involved in a resident-to-resident altercation where another resident threw something at him. When interviewed via telephone on 5/25/22, at 12:03 p.m. FM-D denied knowledge R3 was involved in a resident-to-resident altercation where another resident threatened him. During interview via telephone on 5/25/22, at 12:14 p.m. activity director (AD) explained R1's mocking behavior on 3/30/22 may have been directed at R6; however, she was not totally certain and she also could not remember the words R1 verbalized towards the other residents. I think a lady said something and [R1] went back at her. AD identified she was expected to report abuse to the person in charge and if the abuse caused harm then she was expected to report it right away. She explained she did not report R1's mocking behavior to the person in charge as she was able to stop the behavior and did not feel it was blowing out of proportion. When interviewed on 5/25/22, at 12:41 p.m. the director of nursing (DON) stated she expected staff to complete an incident report for all episodes of abuse. She identified examples of abuse occurred when a resident was targeted by someone else, screamed or hollered at, threated, or hit; however, she commented so much of it depends [on what is considered abuse] when a resident diagnosed with dementia is involved in resident-to-resident behavioral interactions. Further, she explained her staff expectations for resident-to-resident abuse follow-up investigation also depended on the situation, the results of the initial investigation and if the allegation was witnessed or not. The DON explained her expectations related to injury assessment centered around staff visualizing the area where the resident stated they were hit or the area staff visualized was hit and she did not expect a full body audit/assessment to be completed or formally documented: a progress note was only required. The DON stated staff resident progress note documentation of resident-to-resident behavioral interactions depends if back and forth or one sided. If both residents were abusive to each other than a progress note was expected for both residents and if only one resident was the abuser then only that resident had a progress note completed. Continued expectations required staff to notify herself, the administrator, the physician, and the resident contact when abuse was witnessed or alleged. She denied R1's behaviors were comprehensively assessed/analyzed and documented after R1 was determined to have escalated behaviors and demonstrated such behaviors. Further, she denied R1's care plan was reviewed and interventions implemented and reviewed to ensure approaches in place to protect other residents from R1's verbal and physically aggressive behaviors: We just remove [R1] out of areas. In addition, the DON confirmed residents were not comprehensively assessed for abuse risk related to their vulnerability factor(s) and thus care plans for abuse risk were not initiated: .everyone is considered a vulnerable adult.

Based on interview and document review, the facility failed to report allegations of abuse to the State Agency (SA), within two hours, for 2 of 3 residents (R1,R2) who were reviewed for abuse. Findings include: R1's quarterly Minimal Data Set (MDS) dated [DATE], indicated R1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's quarterly MDS dated [DATE], indicated R2's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's progress note dated 1/15/22, indicated this resident became verbally upset and started calling [resident's name] an[OBSCENITY] , and to get the hell out of his way. Verbal altercations continued between residents until this writer intervened. This resident would not stop swearing at resident even as writer standing between them. This resident propelling his wheelchair across lobby cursing and still yelling. On 2/17/22, at 12:56 p.m. licensed practical nurse (LPN)-A indicated on 1/15/22, she witnessed R2 and another resident in a verbal altercation in the lobby. LPN-A indicated between the two residents there were many explicit words and names used by both R2 and the other resident. LPN-A de-escalated the alteration and separated the two residents to prevent a re-occurrence. LPN-A confirmed she did not report the verbal altercation to administration, however, LPN-A indicated she communicated the altercation through nursing report and a note in R2's medical record. Further, LPN-A defined verbal abuse as cursing at someone and indicated facility's policy was to report verbal abuse immediately. On 2/17/22, at 2:30 p.m. NA-B indicated she was aware of a verbal altercation that occurred between R2 and another resident approximately one week ago. NA-B indicated staff were educated to keep the two residents separated. Review of facility's report to the SA dated 2/4/22, at 1:09 p.m. indicated R1 reported nursing assistant (NA)-A entered R1's room and said, If you don't shut up, I'll smack you one. Review of facility's 5-day investigation to the SA dated 2/8/22, indicated SW was notified by maintenance to see R1 in regard to complaints related to NA-A who cared for him the previous evening. On 2/17/22, at 1:47 p.m. plant operations manager (POM) indicated he was assisting housekeeping in R1's room, when R1 reported to POM NA-A got after me. POM indicated he reported this allegation to the social worker (SW) at approximately 8:00 a.m. on 2/4/22. Further, POM indicated he didn't report to the SW the details of R1's allegation due to the concerns being out of his realm, but reported to go speak with R1. On 2/17/22, at 2:48 p.m. SW indicated she was made aware of R1's allegation of abuse on 2/4/22, at approximately 8:30 a.m. by POM. SW indicated POM reported R1 had complaints related to NA-A. SW indicated she went to speak with R1 about 10 minutes later and R1 had left the facility for an appointment. SW confirmed she did not ask POM for any further details related to the allegation that was reported to POM at that time. R1 returned to the facility around noon and SW interviewed R1 at that time. R1 reported to the SW and director of nursing (DON) NA-A stated, if you don't shut up, I am going to [NAME] you. SW indicated she did not recall the verbal altercation between R2 and another resident that was noted on 1/15/22, and confirmed the altercation was not reported to the SA. Further, SW defined verbal abuse as swearing or using unkind words and indicated both incidents could be considered verbal abuse. In addition, SW indicated facility's policy on reporting verbal abuse to the SA was within 24 hours if there was no harm or crime occurred. On 2/17/22, at 3:22 p.m. administrator indicated she was made aware of R1's allegation on 2/4/22, in the early morning by SW when POM reported NA-A had yelled at R1. Further, administrator indicated the facility's policy for reporting abuse allegations to the SA was within 2 hours. Administrator indicated she was not aware the allegation was reported late to the SA until today. Administrator confirmed she was not aware of a verbal altercation that occurred between R2 and another resident. Administrator defined verbal abuse as any comment or statement that would degrade or make someone feel bad or uncomfortable and indicated, she expected staff to notify the DON and herself of any abuse concerns. In addition, administrator indicated it was important to report abuse allegations to the SA with in two hours to begin the investigation and remove the alleged perpetrator to protect the other residents. Review of facility policy titled Abuse Policy and Procedure dated 12/8/20, defined verbal abuse as the use or oral, written, or gestured communication, or sounds, to resident within hearing distance, regardless of age, ability to comprehend, or disability. Further, policy indicated facility staff will monitor residents for aggressive/inappropriate behavior towards other residents and occurrences of such incidents will be promptly reported to the nurse supervisor, director of nursing and to the administrator. In addition, the policy directs facility staff to report alleged violations involving abuse, neglect, exploitation or mistreatment immediately, but not later than 2 hours after the allegation is made.

Based on observation, interview and record review the facility failed to report an allegation of abuse to the state agency (SA) immediately, but not later than 2 hours after an allegation of abuse was made for 1 of 3 residents (R5) reviewed for abuse. Findings include: R5's Minimum Data Set (MDS), dated [DATE], indicated cognitive impairment and [DIAGNOSES REDACTED]. During an interview on 7/21/20, at 2:10 p.m. LPN-1 stated she had been trained on abuse and neglect. Further, LPN-1 stated she had witnessed abuse by a staff person poking a resident in the head during a family visit but failed to report the incident. LPN-1 stated I should have reported it last week. LPN-1 immediately went to the director of nursing's (DON) office and reported the incident. During an interview on 7/21/20, at 2:48 p.m. R5 stated she recently had an outdoor visit with family and R7. Further, R5 stated no one had ever poked her in the head and that staff have never hurt her. During an interview on 7/21/20, at 3:05 p.m. R7 stated he'd recently had outdoor visits with R5 and family members. R7 stated he felt safe in the facility. During an interview on 7/21/20, at 3:16 p.m., family (F)-2 stated she had been to visit R5 a couple times during the previous few days and had no concerns of abuse. During an interview on 7/21/20, at 4:10 p.m. F1 stated she had been to visit R5 on 7/5/20 and there had been no physical abuse by staff. During an interview on 7/22/20, at 9:30 a.m. the Administrator stated at about 2:47 p.m. on 7/21/20 the alleged perpetrator (AP) was suspended pending investigation. Further, the Administrator stated it was LPN-1 responsibility to file the report to SA within 2 hours, however, it was not completed until around 7:00 p.m. that night. Further, the Administrator stated the alleged incident had happened on July 5, 2020 during a family visit and was not aware of the reason why LPN-1 had not reported the incident earlier. During an interview on 7/22/20, at 9:47 a.m. the DON stated LPN-1 was responsible to file the report of alleged abuse on 7/21/20 within 2 hours of reporting it to her. However, the DON did not receive confirmation until 7:34 p.m. on 7/21/20 and therefore the report was late. DON stated LPN-1 was immediately re-educated to report within 2 hours of an allegation and planned further counseling related to abuse policy for LPN-1. The facility's Abuse policy, not dated, stated the facility would ensure all alleged violations of abuse would be reported immediately, but not later than 2 hours after the allegation was made.

Based on interview and document review, the facility failed to follow care plan intervention of 2 staff to assist in transfer to reduce risk of or prevent a fall for 1 of 3 residents, (R1) reviewed for accidents. Findings include: R1's face sheet included [DIAGNOSES REDACTED]. R1's significant change Minimum Data Set ((MDS) dated [DATE], indicated R1 had moderate cognitive impairment and required extensive assistance from two staff for transfers and bed mobility, he was not able to ambulate. R1's activities of daily living (ADL) Care Area Assessment (CAA) worksheet, dated 1/22/20, identified R1 required extensive assistance with transfers. The CAA for falls indicated R1's strength and balance was moderate to poor in the upper and lower extremities. R1's care plan dated 4/13/20, indicated R1 had an ADL self-care performance deficit related to bilateral lower extremity weakness, activity intolerance, deconditioning, impaired balance and poor motivation towards independence. R1's care plan, revised on 2/17/20, indicated R1 required assist of two between bed/wheelchair/recliner/bedside commode. The care plan further indicated, resident has a history of leaning to the right. R1's progress note dated 4/14/20, reported a staff was transferring R1 from recliner to wheelchair using gait belt. Resident slipped while wearing gripper socks and slippers and was lowered to the floor by staff. Per incident report dated 4/14/20, R1 was transferred with one staff assist instead of two staff as noted was his need in the care plan. The progress note further indicated R1 stood, but was unable to step and pivot, his legs and knees became weak and was lowered to the floor. R1's progress noted dated 4/15/20, identified R1 was lowered to the floor during transfer. Care plan stated, R1 required two assist for transfer, only one assist was used during transfer. Nursing assistant (NA-A) was standing on his right side and wheelchair was locked in place on his left. Electric recliner was raised up to standing position. Extensive assist used to help to standing position with gait belt (a safety device used to help someone move). R1 grabbed his walker. He was able to lift his feet to pivot transfer to wheelchair, his knees and legs gave out due to weakness. R1 grabbed for the side of the wheelchair and disengaged the brake. NA-A lowered him to the ground. During interview on 7/22/20, at 12:01 p.m. director of nursing (DON), confirmed at time of fall, R1 was care planned to receive assistance from two staff for transfers. She further confirmed that R1's care plan was not followed at the time of his fall, as he received assist from one staff for the transfer. DON stated the overnight nurse printed a document each night which provided information with resident changes. This was given to the staff at the start of their shift. Furthermore, the staff had access to the care plan for each resident. Staff were also alerted of changes to resident needs when they logged into the computer, which they did at the start of their shift. DON stated she provided staff with re-education, but did not complete a re-education form as it was verbal. During interview on 7/22/20, at 2:34 p.m. NA-A, stated she transferred R1 from his recliner to his wheelchair using his gait belt. NA-A stated she did not ask for help from another staff member. R1 was lowered to the floor when his legs gave out and he was not able to hold himself up. NA-A stated she called for assistance while she lowered him to the floor and again once he was on the floor. NA-A stated she checked the computer at the start of her shift for changes with R1 and didn't see any changes. The previous shift told her R1 had a good day and was doing good with his transfers so she thought she could transfer him by herself. NA-A stated she did not check his care plan before she completed the transfer. Facility fall policy, revision date 2/22/2018, did not address following care plan interventions to reduce risk of fall.

Based on interview and document review, the facility failed to ensure allegations of abuse were reported within two hours to the administrator and State agency (SA), for 1 of 3 residents (R22) reviewed for abuse. Findings Include: R22's quarterly Minimum Data Set ((MDS) dated [DATE], identified severe cognitive impairment and required extensive assist of two for transfers, dressing and toileting. R22 required extensive assistance of one staff for personal hygiene. An Incident Report submitted to the Minnesota department of health (MDH) on 3/13/19, at 4:50 p.m. identified an incident occurred on 3/11/19, at 10:00 p.m. The report indicated nursing assistant (NA)-A witnessed NA-B treat R22 roughly and with disrespect. During interview on 5/14/19, at 3:44 p.m. NA-A stated she did not report the witnessed incident right away, she went in after school on 3/13/19 to report the incident to the administrator and went on to say she thought she had a couple days to report anything. NA-A stated she was trained during orientation regarding vulnerable adults and reporting but could not remember how soon she had to report. When interviewed on 5/16/19, at 11:56 a.m. director of nursing (DON) stated NA-A did not report the incident within two hours. DON stated NA-A made a comment that she wasn't sure if she should report the incident or not. DON stated that NA-A had vulnerable adult report training during her orientation. During interview on 5/16/19, at 1:27 p.m. administrator stated NA-A did not report the incident immediately, and would expect any staff member to report any abuse immediately. The facility's Freedom from Abuse, Neglect, and Exploitation Policy and Procedure directs employees must always report any abuse or suspicion of abuse immediately to the Administrator, Director of Nursing Services, and Nurse on Duty. The covered individual shall report the suspicion immediately, but not later than 2 hours after forming the suspicion.

Based on interview and document review, the facility failed to thoroughly investigate allegations of abuse, for 1 of 3 residents (R22) reviewed for allegations of abuse. Findings Include: R22's quarterly Minimum Data Set (MDS), dated [DATE], identified severe cognitive impairment and required extensive assist of two for transfers, dressing and toileting. R22 required extensive assistance of one staff for personal hygiene. An Incident Report submitted to the Minnesota department of health (MDH) on 3/13/19 at 4:50 p.m. identified an incident occurred on 3/11/19, at 10:00 p.m. The report indicated nursing assistant (NA)-A witnessed NA-B treat R22 roughly and with disrespect. An Incident Investigation form dated 3/13/19, at 3:55 p.m. included the following information. Director of nursing (DON) interviewed R22 and assessed R22's arm, neck and legs. No bruising or discoloration of skin noted on right arm, left arm had three small red areas likely from R22's watch clasp. No other bruising or discoloration of skin observed. DON asked R22 if she had ever been treated roughly by staff. R22 replied, If they have, they got it back. I don't take any[***] I really have no complaints . An Incident Investigation form dated 3/13/19 indicated the following staff were interviewed by the DON on 3/13/19, but lacked any interviews with other residents: 3:45 p.m. nursing assistant (NA)-A. 4:03 p.m. licensed practical nurse (LPN)-A. 4:07 p.m. with LPN-B. The alleged perpetrator (AP) was called on 3/13/19 and came to the nursing home at 5:00 p.m. to speak with the DON and Administrator and was suspended pending completion of investigation. When interviewed on 5/16/19, at 11:56 a.m. DON stated she interviewed R22 and completed an examination of R22's skin, no signs of abuse were observed. DON stated R22 said she didn't have any concerns. DON went on to say she interviewed two LPN's that worked that evening but did not conduct any interviews with any other residents. DON stated to check with social worker who may have conducted further interviews with other residents. During interview on 5/16/19, at 12:04 p.m. social worker (SW) stated, the only people interviewed were the ones the DON interviewed. SW stated she did not know why other residents weren't interviewed. SW went on to say the typical practice is to interview the resident, other residents and then staff. When interviewed on 5/16/19, at 1:27 p.m. administrator stated she missed that part of the investigation that other residents were not interviewed. Administrator went on to say that is one of our minimum requirements during an investigation. The facility Abuse Policy directs the individual conducting the investigation will, as a minimum . 9. Interview other residents to whom the accused employee provides care or services.

Based on interview and record review, the facility failed to ensure mechanical lift transfers were conducted in a safe manner for 1 of 3 residents (R1) reviewed for transfers. The deficient practice is an example of past non-compliance and caused actual harm for R1, after falling from a mechanical lift which resulted in laceration, fractured sacrum, ribs and severe pain. Findings include: R1's annual Minimum Data Set (MDS), dated [DATE], indicated R1 was cognitively intact and had [DIAGNOSES REDACTED]. The MDS further indicated R1 required extensive assistance for bed mobility, transfers, dressing, locomotion, toileting, and personal hygiene, and was independent with eating. The MDS identified R1 did not walk, and had no falls. R1's quarterly MDS, dated [DATE], indicated R1 was cognitively intact and had [DIAGNOSES REDACTED]. The MDS further indicated R1 required total assistance with transfers, extensive assistance with bed mobility, dressing, locomotion, toileting, and personal hygiene, and supervision with eating. The MDS identified R1 did not walk, and had no falls. R1's annual Care Area Assessment (CAA), dated 2/19/18, indicated R1 had a potential for falls related to [DIAGNOSES REDACTED]. R1's care plan, last revised 11/28/18, indicated R1 had a self-care performance deficit related to impaired mobility, inoperable left [MEDICAL CONDITION], left-sided [MEDICAL CONDITION] and weakness in hand, arm, and leg. The care plan directed staff to transfer R1 with a full body lift and total assist of two staff. Review of Investigation Report Summary, dated 11/27/18, indicated Resident was being moved from her bed to recliner chair in her room with the use of the full body (Pal Pro-Lift) lift. Two aids were performing the task as required. Resident was in the lift sheet which is to be secured to the lift, onto 4 U-shaped hooks that have a clasp that snaps back to cover the U opening. Upon investigation and re-enactment of the incident, it is suspected that the lift sheet was partially in the way (on top of the U) of one of the hooks., thus not allowing the clasp to snap back. The lift sheet slid out/off of the hook when resident was being wheeled from bed to chair and resident fell to floor. The lift and sling were immediately inspected by Plant Operations Manager and no defects found. Review of Progress Notes from 11/21/18, to 12/10/18, revealed: - 11/21/18, at 8:55 a.m., nurse STAT (medical abbreviation for urgent or rush) was called to R1's room. R1 was observed on the floor with head at a south-east position and legs pointed west. Mechanical lift sheet was under R1 and two nursing assistants (NA) were present with R1 for transfer with total lift. R1 was alert and able to talk. R1 was noted to have bleeding from the back of the head, as some was pooling on the floor, pressure was applied. Registered nurse (RN) was present and left and called emergency transport. A quick range of motion (ROM) done on lower extremity and R1 had no outward rotation. R1 complained of pain in the right lower back region. The total lift was off to the right of R1 at R1's feet as NAs had tried to help ease R1 to the floor. Mechanical lift was taken out of room and given to head of maintenance for inspection. R1 was not moved due to unknown extent of injury until ambulance arrived with back board. Pressure remained applied to R1's head and R1 kept talking with staff. R1 had been in bed for a check and change (of incontinence product) and was being transferred to the recliner per R1's request. No other bleeding noted. R1 stated the thing is coming out meaning the strap of the lift sheet. R1 also complained of middle back pain. At 9:15 a.m. ambulance arrived. R1 was assisted to back board and then gurney by ambulance and facility staff and transferred to acute care facility. -11/21/18, staff called emergency room (ER) to get an update on R1. ER nurse stated all scans were negative for fractures and head Cat Scan were negative. R1 had a 1 centimeter (CM) laceration on back of head along with a 1.0 CM laceration on left forearm. R1 had received intravenous [MEDICATION NAME] (pain medication) since being at ER. -11/23/18, after incident the two nursing assistant (NA)s who were involved were interviewed and it was found they were working on transferring R1 to the recliner and heard R1 state the thing is coming out and R1 fell to the floor. The lift sheet and lift were inspected immediately. The sheet was in proper working order with no frays or tears, and the lift and it's hooks were in proper working order. R1 went to a full body lift after [MEDICAL CONDITION] of the left side. Care plan was reviewed and followed. The two NAs were pulled and re-educated on the proper use of the lift. Safe resident handling was also reviewed with the two staff members. Audits are being completed to observe staff with proper use of the lifts and sheets. Staff will work on scheduling a refresher in-service on the use of the lift and sheets. -11/26/18, R1 has had an increase in pain rated at 8 (pain scale of 1 to 10, with 10 being worst pain ever), which was unrelieved with as needed [MEDICATION NAME] (pain medication), ice packs, repositioning, and massage since recent fall. Leg spasms are happening frequently which aggravate the pain. [MEDICATION NAME] has been used with little to no relief frequently. -11/30/18, R1 was admitted to hospital with a left rib fracture, right sacrum fracture, high potassium and very low sodium. All R1's labs were out of whack. They anticipate a several day stay. Review of History and Physical dated 11/30/18, indicated On 11/21/2018, (R1) was in a lift at the nursing home. My understanding is that it was not secured properly and (R1) fell . (R1) did strike her head as well as injuring her neck, and right hip. Family noted difficulty with right leg spasms and believe these have been increased since the fall and R1 was noted increased pain in the proximal femur. R1 had acute fractures of the 10th rib laterally on the right as well as left posterior 11th rib fractures. A CT scan of the right proximal lower extremity, which did include some of the sacrum does note a fracture-dislocation of S2-S3 (sacrum). On 12/11/18, at 1:57 p.m. NA-A stated on 11/21/18, she assisted NA-B to transfer R1 from the bed to a recliner. NA-A stated she was on the right side of R1's bed and NA-B was on the left side of R1's bed. She indicated she attached the lift's sling's two straps on her side, to the lift as NA-B attached the lift's other two straps to NA-B's side of the lift. NA-A stated after placing the straps into the U-shaped sling holding mechanism, she walked around the bed and stood in front of the lift and operated the controls. NA-A stated she used the lift controls to lift R1 off of her bed and pulled the machine away from the bed and started to turn the lift and R1 towards the recliner. NA-A indicated R1 was approximately waist height in a seated position, when R1 stated the strap was coming loose. She stated she and NA-B tried to catch R1 when she started to fall from the lift, but they could not stop her from falling. NA-A stated the strap which came loose from the lift was on NA-B's side of the sling by R1's head. NA-A stated nothing was wrong with the lift and did not want to throw anyone under the bus, but it was human error. On 12/11/18, at 2:12 p.m. NA-B stated on 11/21/18, she assisted NA-A to transfer R1 from the bed to the recliner. NA-B indicated she was on the left side of R1's bed and attached the lift sling's two straps on her side, and NA-A placed the other two straps on the lift's sling other side. She indicated NA-A walked around the bed and used the lift's controls to lift R1 from the bed. NA-A stated she then turned around and pulled R1's recliner into a better position to lower R1 into it. R1 then stated the sling was coming loose. NA-B stated R1 then fell as NA-A and herself tried to catch her. NA-B indicated she was unsure what part of R1 hit the floor first as it happened so fast. NA-B stated R1 was approximately 2.5 to 3.5 feet off the ground in a seated position. NA-B stated the strap that came loose from the lift was on NA-A's side by R1's leg. On 12/11/18, at 3:08 p.m. licensed practical nurse (LPN)-A stated she was called to R1's room immediately after the fall. LPN-A indicated R1 was on floor with the lift's sling's straps were already unhooked from the lift. She stated R1 was bleeding from the back, left of her head. She had applied pressure to the back of R1's head with gauze until the ambulance arrived. LPN-A stated she interviewed NA-A and NA-B after the fall and at that time they were unsure which strap came loose from the lift which caused R1 to fall. LPN-A stated she had called the ER and the ER nurse stated all the x-rays and scans were negative for fractures at that time. LPN-A stated R1 was sent back to the hospital on [DATE], due to increased pain and she understood R1 had a pelvic fracture and rib fractures. On 12/12/18, at 10:15 a.m. registered nurse (RN)-A stated after R1's fall on 11/21/18, she re-interviewed NA-A and NA-B. During her interviews, she indicated NA-A stated she had checked her side of the lift sling's straps and had pulled on them to ensure they were in correctly, but stated she did not check NA-B's two straps. RN-A stated NA-B, at that time, could not recall placing the straps into the lift. RN-A stated after R1 returned from theER on [DATE], all the x-rays and scans were negative for fractures. She indicated R1's pain was close to her baseline that day, but started to become worse after a couple more days. RN-A stated R1's physician saw her on 11/29/18, and increased her pain medications. She stated R1's pain became worse and she was transferred to the hospital. At the hospital R1 was diagnosed with [REDACTED]. On 12/12/18, at 10:58 a.m. a telephone call was placed to R1's physician. However, a return call was not received. On 12/12/18, at 11:02 a.m. the facilities lift manufacturer's chairman of the board (COB) was present at the facility for an in-service training on the facility's lifts. The COB indicated, the manufacturer recommended following the procedure guide in the lift's manual. The COB stated to make sure the lift's sling straps are in the U and the safety tab shuts was very important and the lift should not be used if the straps are not in the U properly. On 12/12/18, at 11:15 a.m. the director of nursing (DON) indicated she was on leave from the facility at the time of R1's fall. She stated she expected all nursing staff to know how to use the lifts properly and watch each other for safety. The DON stated staff should use the procedure for the lift every time they use it. On 12/12/18, at 11:25 the administrator stated she expected facility staff to use the lifts according to policy and their training. Review of Volaro Lift User Manual, revised 11/1/12, transfer procedure directed staff Note: Raise (sling) until there is tension on the straps and then double-check to make sure the loops are nested in the bottom of the hooks. A facility policy titled Use of Full Body Lift, revised on 12/3/18, indicated staff should check the lift's attachments, straps, and seams to ensure they are in good condition before using. Under the Safety Measures section, the policy directed staff when slings are in place pull/yank on the lift sheet and check to ensure the Us are locked and clamped. Past non-compliance occurred on 11/21/18, after the last standard survey dated 4/5/18. Through record reviews, observations and staff interviews, it was determined re-education and auditing of all staff had been completed to correct the deficient practice to ensure mechanical lift transfers were conducted in a safe manner. The facility corrected the non-compliance when they : -re-educated the two NAs which were involved in the transfer of R1 that caused R1 to fall and sustain a laceration to the back of the head, acute fractures of the 10th rib laterally on the right as well as left posterior 11th rib fractures, and a fracture-dislocation of S2-S3 (sacrum). -re-educated all nursing staff on the proper procedure for mechanical lift transfers. -Audited all nursing staff on the proper procedure for mechanical lift transfers. -Held an in-service training for all nursing staff with the facility's mechanical lift manufacturer on 12/12/18.