Every finding on record at Halstad Living Center

Based on observation, interview and document review, the facility failed to store pans sanitarily manner. This had the potential to affect all 43 residents in the facility.Findings include: On 5/12/26 at 10:34 a.m., there was a stack of five 10-inch (in.) x 12 in. steam table pans (pans used to hold and serve food from a steam table). When the pans were separated, two of the pans had water dripping from them on to the pans below them. The dietary manager (DM) stated when the dishes were washed, they are supposed to completely air dry and should not have been stored wet. The DM stated the staff may have been in a hurry and had not allowed the pans to completely air dry. When the pans were stored wet, there was a chance for bacteria to grow in the stacked pans and potentially cause illness. During an interview on 5/13/26 at 10:51 a.m., the administrator stated all dishes in the kitchen were expected to be completely dry before they are stored. Storing dishes while still wet could allow germs and bacteria to grow and then may be passed on to the residents. The facility's Sanitation of Dishes policy dated June 2018, identified dishes and food prep equipment are not to be towel dried for potential risk of contamination. Dishware was to be stored to prevent contamination in a clean, dry area. The 2022 Food Code from the United Stated Food and Drug Administration (FDA) identified all dishes and prep equipment must be allowed to drain and air dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow.

Based on interview and document review, the facility failed to submit complete and accurate direct care staffing information, including information for agency and contracted staff, based on payroll and other verifiable and editable data, during 1 of 1 quarters reviewed (Quarter 1), October 1-December 31st 2024, to the Centers for Medicare and Medicaid Services (CMS) according to specifications established by CMS. This deficient practice had the potential to affect all 43 residents residing in the facility. Findings include: Review of the Payroll Based Journal Report (PBJ) [NAME] Report 1705 D for quarter 1 identified excessively low weekend staffing, one star staffing rating, no RN hours for every day in quarter 1 and failed to have licensed nursing coverage 24 Hours/Day for every day in quarter 1. Review of staff timecards from the first quarter verified the facility did not have excessively low weekend staffing. Further identified, the facility had RN coverage for at least 8 hrs per day and the facility had licensed nursing coverage 24 Hours/Day. During an interview on 6/3/25 at 10:33 a.m., administrator verifed she was the one that submitted PBJ reports for the facility and she was unaware the facility was triggering for the areas listed above on the PBJ report. Administrator stated on 12/2/24, the director of nursing (DON) hours were submitted as 26.25 hours and anytime staff hours were submitted for over 24 hours in a day, all the staff hours for that whole quarter were rejected. Administrator further stated it was a clerical error that caused all of the PBJ data to be rejected for the quarter. Administrator stated her expectation was that all PBJ data would have been submitted accurately to reflect the correct amount of staffing for the facility. Review of a facility policy titled Payroll Based Journal revised 10/24, identified it was the policy of this facility to electronically submit timely to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS. Further identified the administrator was responsible for reviewing validation reports and ensuring that any needed corrections were made before the quarterly deadline.

Based on observation, interview, and document review, the facility failed to ensure three years of survey results were readily accessible for residents or visitors. This deficient practice had the potential to affect all 43 residents currently residing in the facility and any visitors. Findings include: During an observation on 6/2/25 at 12:23 p.m., the facility survey results were located in a binder which was placed in a plastic bin attached to the wall across from the dining room approximately four feet from the ground. The last survey results noted in the folder were from a recertification survey dated 8/23/23. In review of survey results from 11/22 to 6/2/25, the binder lacked the following survey results: -11/15/22, an abbreviated survey was completed. -12/22/22, an abbreviated survey was completed. -9/21/23, an abbreviated survey was completed. -4/17/24, a recertification survey was completed. During an interview on 6/2/25 at 1:40 p.m., administrator confirmed survey results prior to and after 8/23/23, were not included in the binder and were not readily accessible for the residents or visitors to review. Administrator stated her expectation was the folder would have been kept up to date with all surveys. A policy on posting survey results was requested however, one was not provided.

Based on interview and document review, the facility failed to ensure 4 of 5 residents (R5, R8, R16 and R32) were offered or received pneumococcal vaccinations based on shared clinical decision-making in accordance with the Center for Disease Control (CDC) recommendations reviewed for immunizations Findings include: Review of the current CDC recommendations 3/15/2023, revealed The CDC identified Adults [AGE] years of age or older received the ( PPSV23) or ( PCV13) at any age and who have not received the Pneumo 20-valent conjugate Vaccine (PCV20) should receive a dose of the PCV 20 at least one year after the most recent PPSV23 or PCV13 vaccine. In addition, the CDC identified adults 65 and older who had previously received both PCV13 and PPSV23 was received at age 65 and older, based on shared clinical decision-making with the patient and the provider one dose of PCV20 at least five years after the last pneumococcal vaccine dose. Review of R5's facesheet identified R5, age 88 was admitted to the facility on [DATE]. Review of R5's Minnesota Immunization Information Connection (MIIC) undated, identified R5 received the PPSV23 on 2/2/2005, and the PCV13 on 10/21/20016. R 5's medical record lacked documentation R5 had been offered or received the PCV20 based on shared clinical decision-making. Review of R8's facesheet identified R8, age 81 was admitted to the facility on [DATE]. Review of R8's MIIC record undated, identified R8 received the PPSV23 on 9/9/2010, and the PCV13 on 2/29/2016. R8's medical record lacked evidence R8 had been offered the PCV20 based on shared clinical-decision making. Review of R16's facesheet identified R16, age 75 was admitted to the facility on [DATE]. Review of R16's MIIC record undated, identified R16 received the PPSV23 on 3/11/2009, and the PCV13 on 8/27/2020. R16's medical record lacked evidence R16 had been offered the PCV20 at least one year after the most current dose of the PPSV23 or the PCV13. Review of R32's facesheet identified R32, age 94 was admitted to the facility on [DATE]. Review of R32's MIIC record undated, identified R32 had received the PPSV on 1/2/1997, and the PCV13 on 7/29/2015. R32's medical record lacked evidence R32 had been offered or received the PCV20 based on shared clinical decision- making. During an interview on 4/17/24 at 8:50 a.m., infection preventionist (IP) confirmed R5, R8, R16, and R32 had not been offered or received the pneumococcal vaccines as recommended by the CDC. IP stated her expectation was the facility would offer and administer all vaccine per CDC recommendation. During an interview on 4/17/24 at 8:58 a.m., director of nursing (DON) confirmed R5,R8, R16, and R32 had not been offered or received the pneumococcal vaccinations as recommended by the CDC. DON stated her expectation would have been that all residents were offered and received all pneumococcal vaccines per CDC recommendations. Review of a facility policy titled Pneumococcal Vaccine (Series) revised 4/24, identified the facility was to offer residents immunizations against pneumococcal disease in accordance with current CDC guideline and recommendation. Identified each resident would have been offered a pneumococcal immunization unless it was medically contraindicated or the resident had already been immunized.

Based on observation, interview and document review, the facility failed to ensure appropriate hand hygiene and donning/doffing of personal protective equipment (PPE) was performed in order to prevent the spread of infection for 3 of 3 residents (R3, R4, R2) observed. In addition, the facility failed to ensure PPE was readily available for use for 1 of 2 residents (R24) observed for enhanced barrier precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). Further, the facility failed to ensure personal laundry was transported and delivered in a manner that prevented risk of contamination for 2 of 4 hallways observed for linen transportation. In addition, the facility failed to ensure catheter drainage bags were properly placed to prevent the risk for cross contamination for 1 of 2 residents (R34) reviewed for catheter care. Findings include: Review of Centers for Disease Control (CDC ) guidance, Appendix D - Linen and Laundry Management updated 5/4/23, identified linens must be sorted, packaged, transported, and stored in a manner that prevented risk of contamination by dust, debris, soiled linens or soiled items. Review of CDC guidance dated 4/1/24, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) indicated Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator and wound care: any skin opening requiring a dressing. LAUNDRY/ HAND HYGIENE During an observation on 5/15/24 at 12:47 p.m., housekeeper aide (HA)-A pushed an uncovered laundry cart down the 400 hallway to R11's room, removed clothing from the uncovered laundry cart, placed clothing into R11's closet, removed hangers from R11's closet and returned the hangers to the uncovered laundry cart. HA-A returned to the uncovered laundry cart, removed clothing and delivered the clothing to R 38's room as a visitor walked by the uncovered laundry cart. HA-A returned to the uncovered laundry cart, removed clothing and delivered the clothing to R 29's closet, removed hangers from R29's closet and returned hangers to the uncovered laundry cart. HA-A returned to the uncovered laundry cart, removed clothing and delivered the clothing to R 6's closet as a staff member walked by the uncovered laundry cart. HA-A returned to the laundry cart, placed the cover over the laundry cart and pushed the laundry cart to the 100 wing. HA-A uncovered the laundry cart, removed clothing and placed the clothing in R5's closet. HA-A returned to the uncovered laundry cart, removed clothing and delivered the clothing to R22's room as a resident in a scooter drove past the uncovered laundry cart. At no time during the above observation did HA-A perform hand hygiene. During an interview on 4/15/24 at 12:59 p.m., HA-A confirmed the laundry cart had been uncovered when she distributed laundry and stated she should have covered the laundry cart while delivering the laundry. HA-A indicated she should have sanitized hands before starting to deliver laundry and after she exited each room. During an interview on 4/16/24 at 9:25 a.m., housekeeping director (HD) stated her expectation was staff would have kept the laundry cart covered during transport and HA-A would have performed hand hygiene when entering and exiting residents rooms while delivering the laundry. During an observation on 4/17/24 at 8:03 a.m., nursing assistant (NA)-E came out of R3's room carrying soiled bed linen with her bare hands against her clothing and placed it in a cart in the soiled utility room. NA-E proceeded to remove a clean blanket from the clean utility room and delivered it to R3's room. At no time during the above observation did NA-E perform hand hygiene. During an interview on 4/17/24 at 8:05 a.m., NA-E confirmed she had carried soiled bed linen with her bare hands against her clothing from R3's room,removed a clean blanket from the clean utility room, delivered it to R3's room and had not performed hand hygiene at any time. NA-E stated she should have worn gloves, placed soiled linen in a bag before bringing into the hallway. NA-E indicated she should have performed hand hygiene before touching the clean blanket. ENHANCED BARRIER PRECAUTIONS AND PPE USE R24's quarterly minimum data set (MDS) dated [DATE], identified R24 had moderate cognitive impairment and diagnoses which included stroke, peripheral artery disease (PAD), and depression. Identified R24 required moderate assistance for activities of daily living (ADL's) which included toileting, transfer, and dressing. Indicated R24 had a venous ulcer. R24's care plan revised 7/7/23, indicated R24 had a non- pressure chronic ulcer on his left calf. Care plan directed staff to follow facility policies/protocols for prevention and treatment of skin breakdown and to monitor dressing to ensure it was intact and report loose dressing to the nurse. During an observation on 4/15/24 at 12:25 p.m., there was no PPE located near R24's room for staff to wear while providing care for R24 (who was on enhanced barrier precautions). R2's MDS dated [DATE] identified R2 had intact cognition and diagnoses which included MRDO, hypertension (elevated blood pressure) and obesity. Identified R2 required extensive assistance with activities of daily living (ADL's) which included toileting, transfer, and dressing. R2's care plan revised 4/13/24, identified R2 had a history of open wounds on his legs and directed staff to follow facility protocols regarding wounds. During an observation on 4/15/24 at 12:30 p.m., hanging behind R2's door was an organizer that contained gowns, gloves, masks, and a sign that said Enhanced Barrier Precautions; Everyone Must clean their hands, including before entering and when leaving the room. Wear gloves and gown for the following high contact resident activities: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator and wound care: any skin opening requiring a dressing. In addition, the sign contained a picture of hand sanitizer gown, and gloves. During an observation on 4/17/24 at 7:30 a.m., NA-C brought a hoyer lift into R2's room. NA-C and NA-D were wearing no PPE. NA-C and NA-D proceeded to hook R2 up to a hoyer lift sheet which was placed under R2. NA-C and NA-D were standing within an inch of R2 during the hoyer lift transfer. NA-C proceeded to place deodorant under R2's armpits and assisted R2 with putting his shirt on. NA-C then sanitized the lift and his hands while NA-D sanitized her hands and wheeled R2 out of the room to breakfast. During a joint interview on 4/17/24 at 7:39 a.m., NA-C and NA-D verified they had not worn any PPE when transferring R2 into his wheelchair and assisting R2 to put his shirt on. NA-C and NA-D indicated they understood PPE was only required when providing personal cares for R2 and that they had removed the PPE after providing his personal cares and prior to transferring R2 into the wheelchair and assisting R2 with putting his shirt on. 48740 HAND HYGIENE/PPE: R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated R4 was severely cognitively impaired and had diagnoses which included dementia, neurogenic bladder and paraplegia. Indicated R4 required total assistance from staff with all activities of daily living (ADLs). Identified R4 was incontinent of bowel and had a suprapubic urinary catheter. R4's care plan dated 11/21/23 indicated possible Methicillin-resistant Staphylococcus aureus (MRSA, an infection caused by a type of staph bacteria) to open areas and blisters on the back and was on contact isolation. During an observation on 4/15/24 at 7:40 p.m., NA-A and NA-B sanitized hands and donned the appropriate PPE for contact isolation precautions. NA-A and NA-B knocked on the door and went into R4's room. NA-A explained to R4 that they were going to change his brief. NA-B placed the head of the bed down and took the wedge out from R4's right side used for positioning. NA-A removed the blanket off of his legs and wedge under the legs used for positioning. NA-A and NA-B unhooked the tabs of R4's brief. NA-A and NA-B rolled R4 on his right side and tucked the brief under R4 partially. NA-B took the urinary catheter and moved it to the left side of the bed. NA-A and NA-B then rolled R4 to his left side. NA-B removed the dirty brief and placed it in a trash can next to the bed. On the left gluteal region, there were three open areas approximately with no drainage noted. NA-B performed peri care to the coccyx region with a wet wipe and placed the used wipe in the trash can. NA-B grabbed a clean brief with the same gloved hands that she used to perform peri-cares. The clean brief was tucked under R4. NA-A and NA-B rolled R4 to his right side to adjust the brief into place. The brief was pulled between legs and NA-A and NA-B hooked the tabs of the brief on the left and right side. NA-A and NA-B then explained to R4 that he needed to be moved up in bed. NA-A and NA-B grabbed the lift sheet and then lifted R4 in bed so that his head was about two inches from the headboard. NA-A repositioned the pillow behind R4's head and replaced the wedge under the legs. NA-A placed the blanket over R4's legs. NA-B took R4's urinary catheter drainage bag and placed it on the right sided bed frame. NA-B placed the side table next to the bed. NA-A and NA-B went into the bathroom to remove PPE and performed hand hygiene. NA-B picked up the trash bag with the dirty brief and exited the room. During an interview on 4/15/24 at 7:52 p.m., NA-B stated soiled gloves should have been removed between touching the soiled brief and clean brief to prevent contamination. During an interview on 4/16/24 at 2:08 p.m., LPN-B stated R4 had a history of MRSA and infections to the blisters on the thigh area. CATHETER CARE: R34 quarterly MDS dated [DATE], indicated R34 was severely cognitively impaired and had a diagnoses which included cerebrovascular accident (CVA), and transient ischemic attack (TIA or stroke). Identified R4 required total assistance from staff with all ADL's. Indicated R34 was always incontinent of bowel and had a urinary catheter. During an observation on 4/15/24 at 2:22 p.m., R34 was lying in bed, which was in the lowest position. A urinary drainage bag was hanging on the right bed frame. The urinary drainage bag lacked a privacy covering. The urinary catheter bag had about 100 milliliters (cc) of cloudy urine. The bottom of the urinary catheter bag was touching the floor. During an observation on 4/15/24 at 3:47 p.m., R34 was lying in bed. The bed was in the lowest position. The urinary drainage bag was on the right side of the bed frame. No privacy bag covering was used on the urinary drainage bag. The urinary drainage bag had approximately 150 cc of yellow urine. The bottom of the urinary bag continued to be touching the floor. During an observation on 4/16/24 at 1:15 p.m., R34 was lying in a low bed. The urinary drainage bag was attached to the right side of the bed frame. No privacy bag covering was over the drainage bag. The urinary drainage bag had approximately had 100 cc of yellow urine and was touching the floor. During an interview on 4/16/24 at 1:35 p.m., LPN-C, entered R34's room and verified the urinary drainage bag was touching the floor. LPN-C confirmed the urinary drainage bag should not have been touching the floor due to the potential for the spread of bacteria. During an interview on 4/16/24 at 2:05 p.m., LPN-A stated catheter bags should not touch the floor due to the potential of cross contamination. Catheter bags should have a privacy bag on them to prevent the catheter drainage bag from touching the floor. During an interview on 4/17/24 at 7:54 a.m., RN-A indicated the facility used privacy bags and a bucket under the catheter bag to keep the catheter drainage bag off the floor. During a joint interview on 4/17/24 at 8:40 a.m., infection preventionist (IP) confirmed R2 and R24 were on Enhanced Barrier Precautions and R4 was on Contact precautions. IP stated her expectations were PPE would have been readily available to care for any residents in EBP and staff would wear PPE when indicated. In addition,IP expected clean laundry would have been covered when delivered and dirty linen would have been transported appropriately. IP further stated her expectation was for staff to perform hand hygiene, change gloves when appropriate and ensure that catheter bags were not touching the floor. DON further stated her expectations were the same as above and that staff would receive training on infection control and prevention. According to the Center for Disease Control and Prevention (CDC) on Catheter-Associated Urinary Tract Infections dated 11/5/2015, section 111.B.2, indicated staff were to keep the collection bag below the level of the bladder at all times. Do not rest the bag on the floor. Review of a facility policy titled Enhanced Barrier Precautions revised 3/24, identified It was the policy of the facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.(EBP) referred to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employed targeted gown and glove use during high contact resident care activities. Indicated the facility would make gowns and gloves available immediately near or outside of the resident's room; PPE for enhanced barrier precautions was necessary when performing high-contact care activities. Review of a facility policy titled Hand Hygiene revised 4/24, identified all staff would perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Alcohol-based hand rub with 60 to 95% alcohol was the preferred method for cleaning hands in most clinical situations. Indicated the use of gloves did not replace hand hygiene. If your task required gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. In addition, directed staff to use hand hygiene during resident care, moving from a contaminated body site to a clean body site. Review of a facility policy titled Handling clean linen revised 4/24, identified it was the policy of this facility to handle, store, process, and transport clean linen in a safe and sanitary method to prevent contamination of the linen, which could lead to infection. Clean linens must be transported by methods that ensured cleanliness and protect from dust and soil during intra or inter-facility loading, transport and unloading, such as placing clean linen in a properly cleaned cart and covering the cart with disposable material or a properly cleaned reusable textile material that could be secured to the cart. Review of a facility policy titled Handling Soiled Linen revised 4/24, identified linen should not be allowed to touch the uniform or floor and should be handled as little as possible, with minimum agitation to avoid contamination of air, surfaces, and persons. Indicated used or soiled linen should be collected at the bedside (or point of use, such as dining room) and placed in a linen bag or designated lined receptacle. When the task was complete, the bag should be closed securely and placed in the soiled utility room. A review of the facility policy titled Personal Protective Equipment dated 4/24, directed staff to change gloves and perform hand hygiene between clean and dirty tasks, when moving from one body part to another, when heavily contaminated, or when torn. A policy titled Catheter Care dated 4/24, indicated privacy bags would be available and catheter drainage bags would be covered at all times while in use. The policy lacked information regarding keeping urinary catheter drainage bags off of the floor.

Based on interview and document review, the facility failed to obtain informed consent and provide education to the resident representative on the risks and benefits regarding the use of psychotropic medications for 1 of 5 residents (R33) reviewed for unnecessary medications. Findings include: R33's quarterly Minimum Data Set (MDS) dated [DATE], identified R33 had severe cognitive impairment and diagnoses which included: non traumatic brain dysfunction, dementia with behavior disturbance and paranoid personality disorder. Indicated R33 received antipsychotic medication. R33's care plan dated 7/28/23, identified R33 used antipsychotic medication related to dementia. Care plan directed staff to discuss with R33's family and MD regarding ongoing need for psychotropic medication and to educate family and caregivers regarding risks and benefits of medication. R33's Order Summary Report dated 4/17/24, identified orders for the psychotropic medications Seroquel (an antipsychotic) for dementia with behavioral disturbance and paranoid personality disorder with a start date of 10/16/23, and Paxil (an antidepressant) for anxiety with a start date of 11/16/23. R33's medical record lacked evidence of consent from R33's representative for the psychotropic medication. In addition, the medical record lacked evidence of education to R33's representative regarding the risks and benefits of the psychotropic medication. During an interview on 4/17/24 at 11:27 a.m., registered nurse (RN)-A confirmed R33 was receiving the psychotropic medication and the facility had not received consent from R33's representative for the psychotropic medication. In addition, R33 confirmed the facility had not provided R33's representative education regarding the potential side effects of the psychotropic medication. RN-A stated the usual process was to provide resident or representative with education regarding risks and benefits and obtain consent before the psychotropic medication was started. During an interview on 4/17/24 at 11:33 a.m., director of nursing (DON) stated her expectation was the facility would have provided education on risks and benefits and received consent from R33's representative prior to R33 starting the psychotropic medication. A facility policy titled Use of Psychotropic Medications dated 1/24, indicated Residents and/or representatives would be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments/non-pharmacological interventions. Review psychotropic medication consent form with resident and/or representative. .

Based on interview and document review, the facility failed to protect 1 of 3 residents (R1) from mental and emotional abuse by staff when two staff were found to be taunting, teasing and tickling a resident regularly despite visual signs and verbal communication the resident was upset/angry with their treatment of him during care. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1's cognition intact, no behaviors, and had diagnoses which included major depressive disorder, obesity, diabetes mellitus (DM), and moderately impaired vision. The MDS identified R1 required total assistance of one to two for most activities of daily living (ADLs) which included eating, personal hygiene, dressing, toileting, locomotion, transfers, and did not walk. MDS also identified R1 required extensive assistance of two for bed mobility. R1's care plan revised [DATE], identified R1 was at risk for injury related to vulnerable adult (VA) status with a goal R1 will be free from abuse and neglect every day. R1's care plan also identified R1 had a preferred name he wanted to be called. During an interview with the external complainant (EC) on [DATE], at 3:45 p.m. volunteered that she was previously employed by the facility and had shared concerns about abuse pertaining to R1 by staff the end of [DATE]. EC stated the director of nursing (DON) informed her to either quit, or she would be fired, adding that if EC kept reporting like she did the facility would not have any employees left. EC indicated the DON informed her, if there were no marks or signs of abuse, she could not do anything about it. EC stated she indicated to the DON it was a lot of emotional, mental abuse, and that cannot be seen. EC identified R1 was blind but was cognitively able to know what as going on around him and he could recognize voices. EC also indicated she had worked an evening shift with nursing assistant (NA)-A and NA-B and they had certain attitudes towards R1 and told EC there was no management to tell them what to do on the evening shift. EC indicated staff made fun of R1 because he was a bigger sized man and missing all fingers on left hand. EC stated NA-B called R1 names such as Big Daddy and P****. EC stated she requested the name calling be stopped but it continued. EC indicated she informed NA-B it was inappropriate to call him names he did not want to be called. EC stated NA-B informed her that was how they got along with R1, he would not say anything, and does not know who they are. EC stated she informed licensed practical nurse (LPN)-A about the interaction and concern, LPN-A wrote it down, and indicated she would pass it along to the DON in report. EC also stated R1 told the staff to stop calling him names, and R1 informed EC he felt they seemed to like to see him get mad. EC indicated she reported concerns many times during her employment at this facility to the DON. EC stated the DON wrote it down and indicated she would look into it. During an interview on [DATE], at 10:40 a.m. R1 sat in his room by himself in wheelchair with door closed in silence. R1 stated the night shift give him a hard time on his name and do not treat his name right. R 1 stated, They keep saying P****, P****, P**** in a funny voice. R1 indicated it bothered him and there was nothing he could say or do adding, it hurts me, they are having fun, but I don't think it is fun at all. R1 added, When they tickle my feet, it makes me want to hurt them back and if I could just get a hold of them, it would not be nice. R1 stated the staff giggle and make fun of him even when asked to stop. R1 indicated it was hurtful and had been going on for two years now. R1 indicated he told a staff nurse that had seen other staff do this to him, but she did not seem to care, and thought they were having fun. R1 indicated it usually happened when staff placed him back into bed and they laughed and got so much enjoyment out of doing it, that is what was so awful and upset him. R1 stated he told them to stop, he started to swear, and then it got worse, and they tickled him more, then laughed, and laughed more. R1 also stated there were usually two staff in the room together, a male and female when it happened which made him feel frustrated, angry, and alone. R1 indicated every once in while he wished he could just swing out at them, but he knew he would be in big trouble so held back. R1 stated he did not feel comfortable talking to any staff about this because the nurse did not seem to care and did not want to get anyone into trouble, so he kept it to himself. During a telephone interview on [DATE], at 1:24 p.m. with family member (F)-A indicated she had just talked to R1 on the telephone, and he told her staff on the graveyard shift had been tickling his feet and his reaction was so full bodied , tried to get the staff to stop and they won't. FA stated obviously it is entertaining for some people that work there and that is very disturbing. FA also stated she had no leverage with his care and just beside herself with what had happened to R1. FA indicated R1 had gotten such good care at that facility. FA stated R1 did not want to get anyone fired from their job but she also stated it was totally disrespectful. During an interview on [DATE], at 2:37 p.m. social service designee (SSD) approached surveyor and stated she had just received a phone call from R1's family regarding concerns about the night staff tickling his feet for their own entertainment and the family indicated it was torture for him. SSD also stated she notified the ombudsman, DON, and administrator after 1:00 p.m. today. SSD verified she filed a vulnerable adult report and asked a registered nurse to assess resident for any injuries, none noted. SSD indicated she had not heard of any reports prior to this regarding the tickling of R1's feet. SSD stated she initiated the facility emotional distress/discomfort checks every shift for seven days. SSD stated she was on her way to R1's room to interview him and would remind him he had not gotten staff into trouble, the staff had gotten themselves in trouble. During a follow up interview on [DATE], at 10:43 a.m. SSD stated she talked with R1 in his room along with the DON on [DATE], and R1 made reference it had been a guy and a gal that most likely did not realize how ticklish his feet had been. SSD also stated R1 did not know the names of the staff, did not want to get anyone in trouble, and wished he would have never said anything. SSD also stated she had just spoke with R1 briefly again this morning, and R1 denied any issues and mood was fine per him. SSD indicated she had interviewed three NAs and one more left to get a hold of and two staff nurses. SSD indicated no concerns were identified, however, during the interview with NA-B stated she might be the feet tickler when she applied lotion R1 stated he did not want it applied and yelled out when NA-A removed his socks. During an interview on [DATE], at 3:20 p.m. NA-A stated R1 was more confused and forgetful after he wakes up from sleeping. NA-A indicated R1 was able to verbalize if something was bothering him and normally, we have a pretty good time, we joke a lot, it is all good in fun, and give each other shit. During an interview on [DATE], at 4:15 p.m. NA-F stated R1 was able to verbalize if something had bothered him. NA-F also stated earlier this summer, R1 complained some of the staff were not saying his name right and how it bothered him. NA-F indicated she had told only one person and that was RN-A but she was not sure if anything was done about it. RN-A was contacted but never returned phone call and was absent from work during survey. During an interview on [DATE], at 12:39 p.m. NA-G stated R1 was able to tell you if something bothered him, very blunt, and says what was on his mind. NA-G has heard NA-C call R1 Big Daddy and not sure who called him M*** M******** but R1 did say that both those names bothered him. NA-G stated she had told the DON over two days ago and was told she would figure out who said it. NA-G indicated she did not confront NA-C about calling R1 Big Daddy and should have because NA-G knew better and R1 preferred to be called by his chosen name. NA-G stated those other names may be used in a joking manner but R1 had made it clear he does not like it. During an interview on [DATE], at 1:07 p.m. the DON stated staff are expected to listen to a resident's concerns, report it to charge nurse or myself, and just follow the chain of command. DON also stated the importance of addressing a complaint right away was to help protect the resident, and start an investigation. DON indicated on [DATE], an employee who was no longer with the facility reported to her, staff had called R1 P**** instead of what he wanted to be called. DON indicated she met with R1 and he reported that sometimes the staff called him P**** and he did not like to be called that but also did not want to get anyone in trouble because he liked it here. DON stated she placed a note in the staff communication book that indicated do not call residents by anything other than their name. DON identified she had worked a night shift on [DATE], asked R1 how things were going and he repeated the concern but did not identify who the staff was. DON then stated on [DATE], during a positive partners meeting (RNs, LPNs, and NAs) discussed R1 being called P*** and readdressed the concern. DON indicated she knew nothing about the tickling of his feet until she received a phone call from a family member on [DATE]. DON stated she felt it was concerning and if it was true they want to fix it. DON stated staff are expected to treat residents the way they want to be treated, use proper interventions to help prevent staff from treating R1 in a way he does not want to be treated. DON stated staff are expected to communicate with R1 as to what cares they plan on starting in advance due to his poor vision and PVD. During a follow up interview on [DATE], at 12:00 p.m. DON stated the abuse policy regarding reporting was just posted in the communication right now. DON also stated on [DATE], she posted written communication regarding R1's concerns about being called P**** and tickling of his feet. DON verified the communication book is kept at the nurse's station and all nursing staff are expected to read updates daily prior to each shift prior to when they last worked. DON added that this expectation was important so that staff are up to date on new changes on how to care for residents, new happenings within the facility, and education provided. When asked how the facility new the staff were reading the communication book updates, the DON indicated staff do not initial that book daily and upon hire and annually they signed a job description they would keep abreast of happenings within the facility and residents. DON stated on [DATE], NA-D came to see her prior to leaving the facility and informed her R1 did not like being called P****. DON stated she then visited with R1 and he confirmed yes sometimes staff called him [NAME] and he did not like it and wanted to be called by his name. DON indicated R1 stated he did not want to identify staff and did not want anyone to get into trouble. DON stated she asked R1 to let her know if it continued to happen. DON verified she posted a note in the nursing communication book on [DATE], and no investigation was completed. DON indicated a positive partners committee meeting was held, discussed facility issues, and one that came up was a staff member NA-C said to another unidentified staff member regarding R1, do you want to come and help me get Big Daddy ready for bed. DON indicated the RN that worked that shift informed her of this incident and addressed it with NA-C. DON stated NA-C felt bad about it and no further follow up was completed. Facility employee communication book located at the central nursing station included the following documents posted by the DON: -On [DATE], [R1] has complaints that staff are calling him P**** and he does not like it. Residents are to be called ONLY by their preferred name. Please report this if you see it happening. -On [DATE], Notes from the PP (Positive Partners) committee meeting: [R1] does not want to be called P**** or Big Daddy and if you hear anyone doing it SQUASH IT, PLEASE! -On [DATE], Regarding MDH (Minnesota Department of Health) and [R1]: Please call [R1] his preferred name, he does not like to be called P**** or any other name that staff have been calling him. This goes for all residents. We can not call them dear, honey, sweetheart, etc. Do not tickle resident's feet or anything else of that nature. [R1] has complained that staff tickle his feet and they do it as pure entertainment for themselves. RN (registered nurses)/licensed practical nurses (LPN): Please complete the emotional assessment under assessment tab. Monitor emotional status and report abnormalities to RN on call or social worker designee times 7 days. Also, [R1] reports that he doesn't get to choose his bedtime as staff tell him it's now or never. Bedtime choice is his right and there are always three or more staff that can help. During an interview on [DATE], at 11:34 a.m. NA-E stated R1 does not like lotion applied to his legs and feet. NA-E indicated R1 had complained about other staff tickling his feet and how he did not like it but did not mention names. NA-E also stated it was not reported to anyone because it seemed as though his feet were just sensitive and that did not seem reportable. NA-E verified she had heard him yell out when lotion was applied but had not witness staff treat him inappropriately. During an interview on [DATE], at 1:30 p.m. administrator stated R1 was interviewed on [DATE] in the early afternoon. Administrator indicated they had knowledge of a male nursing assistant that worked evening and/or night shift that may have been involved in the incident. Administrator stated she asked R1 if he felt safe at the facility and if he felt abused by staff, he denied both. Administrator then stated NA-A entered the room and came up to R1's bedside and administrator asked R1 what about this guy? Administrator verified R1 stated, Oh that kid I like to give him bull shit! Administrator identified that observation as a positive interaction with good rapport noted between R1 and NA-A. Administrator also stated she had never seen R1 upset with NA-A, made sure the resident was safe, and felt good about allowing all staff to care for R1. Administrator stated she did not stay and witness cares completed by NA-A, nor observed any cares being performed with R1 and staff. Administrator indicated there was only one nursing assistant they had been unable to interview and would not be allowed to care for R1 until that interview was completed. Administrator indicated no additional residents had been interviewed to determine if they felt safe or were experiencing abuse. Facility policy titled Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property, revised ,d+[DATE], identified verbal abuse as the use of oral, written, or gestured language that willfully inflicts disparaging or derogatory terms to residents or their families. The policy also identified mental abuse as humiliation, harassment, threats of punishment or deprivation. The policy indicated each resident would be free from abuse in the facility and indicated abuse included verbal, mental, sexual, or physical abuse. Additionally, immediately upon receiving a report of alleged abuse, the administrator, and or designee will coordinate delivery of appropriate medical and/or psychological care and attention to ensure safety and well-being for the vulnerable individual are utmost priority. Facility policy titled Dignity dated ,d+[DATE], identified each resident shall be cared for in a manner that promoted and enhances quality of life, dignity, respect, and individuality. Staff should always speak respectfully to residents, including addressing the resident by his or her name of choice. Facility policy titled Employee Handbook undated identified staff expected behavior: -Treating employees, residents, and guests, with dignity, courtesy, and respect. -Keep the residents, and staff, and guests safe, and free from harm, abuse, including reporting such incidences. -Refraining from behavior or conduct deemed offensive, undesirable, or which reflects badly on the facility. Facility prohibited conduct would be grounds for immediate termination, but not limited to such as: -Assaulting, threatening, intimidating, harassing or abuse of a resident, guest or and employee. -Making false, hostile, or disloyal statements about other staff, the facility, residents, or guests.

Based on interview and document review, the facility failed to ensure an alleged violation of staff to resident abuse was immediately reported to the administrator and immediately, no later than two hours, reported to the State Agency (SA) for 1 of 3 residents (R1) reviewed for allegations of abuse. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had severe cognitive impairment and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated R1 required extensive assistance with most activities of daily living (ADL's) which included bed mobility, transfers, dressing, toileting and personal hygiene. The MDS identified R1 did not walk and required limited assistance with locomotion. R1's care plan revised 12/27/20, identified R1 was at risk for injury due to vulnerable adult (VA) status with a goal of R1 to be free from abuse and neglect every day. The care plan identified R1 required extensive assistance with most ADL's which included bed mobility, transfers, toileting, personal hygiene and dressing. The care plan indicated R1 had an alteration in thought processes and communication problem due to dementia and instructed staff to anticipate and meet R1's needs. The facility's incident report indicated that on 1/9/21, at 10:45 p.m. staff stated LPN-A said to a resident quit being an[OBSCENITY] . The allegation was reported to the SA on 1/10/21, at 7:10 p.m. 20 hours and 25 minutes after the incident occurred. Review of the facility internal investigation handwritten notes revealed on 1/10/21, at 2:33 p.m. the director of nursing (DON) received a report from staff regarding allegations of staff to resident verbal abuse which occurred on 1/9/21. The DON spoke to nursing assistant (NA)-A on 1/10/21, who was working on 1/9/21, and she confirmed LPN-A told R1, quit being an[OBSCENITY] . The DON spoke to NA-B on 1/10/21, who was also working on 1/9/21, and she confirmed LPN-A told R1, quit being an[OBSCENITY] . The DON notified the administrator immediately and started the investigation. On 1/12/21, at 12:59 p.m. during an interview, NA-A verified she worked on 1/9/21. NA-A stated she, NA-B and LPN-A were seated at the nurses station at around 10:45 p.m. when R1 who was in his wheelchair wheeled himself up to the nurses station. NA-A confirmed R1 had used foul language and LPN-A stated to R1, quit being an[OBSCENITY] . NA-A confirmed it was a form of verbal abuse and should not have happened at all. NA-A confirmed she did not report the verbal abuse to anyone until the next day on 1/10/21, when she reported it to the charge nurse sometime that day. NA-A confirmed she was aware of the requirement to report it immediately and stated since LPN-A was her charge nurse on 1/9/21, she felt too intimidated to report it immediately. On 1/12/21, at 1:11 p.m. during an interview, NA-B stated she worked 1/9/21, from 6:00 pm. to 6:00 a.m. NA-B confirmed she, NA-A and LPN-A were seated at the nurses station around 10:45 p.m. when R1 wheeled up to the desk and used foul language when he was talking. NA-B could not recall exactly what R1 said. NA-B confirmed LPN-A stated to R1, quit being an[OBSCENITY] . NA-B confirmed this was a form of verbal abuse. NA-B confirmed she did not report the verbal abuse immediately and believed NA-A had reported it immediately. NA-B confirmed she was aware all allegations of abuse were expected to be reported immediately. On 1/12/21, at 2:00 p.m. during an interview, licensed social worker (LSW) stated she received a phone call from the DON on 1/10/21, at around 6:00 p.m. and asked her to go to the facility to file a VA report due to an allegation of verbal abuse. LSW stated she was informed by the DON on 1/9/21, at 10:45 p.m. LPN-A told R1, quit being an[OBSCENITY] . LSW confirmed it was verbal, mental and emotional abuse and stated it should not be condoned. LSW confirmed the allegation of abuse occurred on 1/9/21, at 10:45 p.m. and was not reported to the SA until 1/10/21, at 7:10 p.m. The LSW stated all allegations of abuse were to be reported immediately. On 1/12/21, at 2:10 p.m. during an interview with the DON, she stated she was called by the charge nurse working on 1/10/21, at 2:33 p.m. of an allegation of verbal abuse that occurred on 1/9/21, at 10:45 p.m. DON stated she spoke with NA-A and NA-B on 1/10/21, and both confirmed LPN-A stated to R1, quit being an[OBSCENITY] . DON confirmed it was a form of verbal abuse and stated the facility had no tolerance for it. DON stated it was expected any form of abuse should never occur at the facility. DON stated she believed the facility had 24 hours to report it since the abuse did not result in physical or psychosocial harm. After review of the facility policy, DON confirmed the facility should have reported the allegation immediately or within two hours after the incident occurred. DON confirmed the allegation occurred on 1/9/21, at 10:45 p.m. and the facility did not report the allegation until 1/10/21, at 7:10 p.m. 20 hours and 25 minutes after the incident occurred. On 1/12/21, at 3:03 p.m. during an interview with the administrator she stated she expected all allegations of abuse be reported immediately. Administrator confirmed she was informed of the allegation on 1/10/21, at around 2:30 p.m. and she went to the facility to assist with investigating further. The administrator stated she and the DON spoke with NA-A and NA-B on 1/10/21, to discuss further and confirmed it was a form of verbal abuse towards R1. The administrator stated they provided education to NA-A and NA-B about the expectation to report all allegations of abuse immediately or within two hours after the allegation occurred. The administrator confirmed the allegation of verbal abuse was not reported timely as required. Review of the facility policy titled Abuse, Neglect, Mistreatment and Misappropriation of resident Property revised 5/17, indicated abuse allegations were to reported per federal and state law. The policy stated the facility would ensure all alleged violations of abuse were to be reported immediately but not later than two hours after the allegation was made.

Based on observation, interview, and document review, the facility failed to ensure food items were properly stored and dated for 1 of 1 kitchens of the facility. In addition, the facility failed to ensure 1 of 1 ice and water machines was properly cleaned and sanitized in the facility. Further, the facility failed to serve food in a sanitary manner during 1 of 1 observation of food service of the supper meal when staff did not properly utilize hairnets when serving residents food. This deficient practice had the potential to affect 38 residents that received food from the kitchen and received water from the ice and water machine. Findings include: On [DATE] at 1:50 p.m during an initial tour of the facility kitchen area with dietary manager (DM) the following concerns were identified: Drink Refrigerator: - 3 individual plastic containers of food which held meatloaf, dumplings and vegetable on the lower shelf of fridge and was undated. -1 large silver container covered with tin foil with a handwritten note on the top of the tin foil dumplings and undated. Walk in Cooler: - five one half gallons of milk with expiration date of [DATE] and one was half full and the other four were full. - a large bag of shredded cheese, which was opened and one quarter full was not dated. - a bag of prunes with the outside wrapper very sticky and expiration date of [DATE]. - a large bag of lettuce salad mixture, which was opened and one half full was not dated. DM confirmed the above findings and removed the undated and expired food items and discarded them. On [DATE], at 2:10 p.m. during observations of the dining room, the ice and water machine located on the counter in the dining room had heavy encrusted hard water lime scale build up with flakes and rust under the dispenser and the tray area of the ice and water machine. The ice and water machine was also leaking water onto the counter. ICE MACHINE On [DATE] at 11:28 a.m. during a tour of the kitchen with the DM the following concerns were identified: - the ice and water machine located in the dining room area of the facility, continued to have heavy encrusted hard water lime scale build up with flakes and rust under the dispenser and the tray area of the ice and water machine. The ice and water machine was also leaking water onto the counter. The DM confirmed the above findings and indicated staff clean the ice and water machine weekly and de-scale it weekly. The DM indicated staff had just cleaned the ice and water machine that day. On [DATE] at 11:52 a.m. the DM indicated the lettuce, cheese, prunes, dumplings, containers of food should be labeled and dated when opened. The DM also indicated she would expect staff to not to use products with expired dates and indicated these items were not safe to serve when expired and should be discarded. The DM indicated the facility had issues with the ice and water machine for sometime, but would expect staff to clean it and indicated maybe staff needed to try something else. On [DATE] at 11:58 a.m. the maintenance supervisor (MS) confirmed the ice machine had lime scale build up and currently leaked water. The MS indicated staff were responsible for cleaning the ice and water machine monthly and did not think the lime scale build up was a health concern. The MS indicated he could not control the lime scale build up on the ice and water machine and it was currently leaking. The MS confirmed he had no cleaning schedules for the ice and water machine and no policies. Food service: On [DATE], at 5:18 p.m. a portable steam table was observed parked just outside the kitchen entrance in the facility dining room. Dietary cook (DC)-A placed trays into the steam table including; chicken fajita, meat sauce, cauliflower, ravioli, and mashed potatoes. On [DATE], at 5:22 p.m. DC-A donned gloves and was observed to wear a hair net covering her pony tail only. DC-A had long pieces of brown shoulder length hair hanging down around her face with a hair net that only covered the pony tail portion of her head. DC-A dished the first plate and handed the plate of food items to dietary assistant (DA)-[NAME] DA-A took the plate from DC-A and walked the plate to a resident seated at a table in the dining room. DA-A was observed to be wearing a beard restraint and a hairnet that only covered the longer hair on the top part of his head with the bottom half of his head and hair exposed. On [DATE], at 5:55 p.m. DA-A was setting up room trays for individual residents in the kitchen area. DA-A stated he wore a beard net and hairnet to prevent hair from falling into the food and stated he normally wore his hairnet on only the long hairs on the top of his head and left the bottom half of his head and hair exposed. On [DATE], at 6:01 p.m. DC-A stated she usually wore her hair in a pony tail or bun and verified her hair was hanging loose around her face, not covered by a hairnet when she was serving food. She indicated her hair should have been covered when she worked with food. On [DATE], at 6:03 p.m. DM stated it was the normal practice for staff to cover their hair when they enter the kitchen or handle food, and would expect hair to be covered at all times. The DM stated she had not noticed that DC-A had her hair hanging down while she served the food to the residents for supper. DM stated hairnets were to be worn to keep hair contained and out of the food, and all hair should be covered. Review of facility policy titled, Cleaning of Coffee Maker, Juice Machine, Ice Machine, Ice Cream Machine dated [DATE], indicated the coffee maker, juice machine, ice machine and ice cream machine will be cleaned thoroughly following the manufactures instructions. Review of facility policy titled, Food Dating and Handling of expired foods dated [DATE], indicated the best practice for a date marking system would be to include a tabled with the product name, the day or date, and time is was prepared for opened. Follow state or local health department requirements. A review of the facility provided policy and procedure dated [DATE], and titled Preventing Food Born Illness, described various implementations to prevent food born illness including number 12. hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens.

Based on observation, interview and document review, the facility failed to provide arrangements for follow up care with a dentist for 1 of 1 residents (R20) reviewed for dental care. Findings include: R20's annual Minimum Data Set ((MDS) dated [DATE], identified R20 had [DIAGNOSES REDACTED]. The MDS identified R20 required extensive assistance with bed mobility, transfers, dressing, toileting, personal hygiene and total dependence with bathing tasks. The MDS indicated R20 had a weight loss, had abnormal mouth tissue and obvious or likely cavity or broken natural teeth. R20's annual Care Area Assessment (CAA) dated 10/5/19, identified R20 required assistance with most activities of daily living (ADL's) due to generalized weakness. The CAA identified R20 had multiple missing teeth/caries and thrush. R20's care plan revised on 10/10/19, identified R20 required extensive assistance with personal hygiene. The care plan identified R20 had her own teeth and required oral inspections quarterly. On 12/2/19, at 6:42 p.m. R20 was observed lying in bed watching TV. R20 smiled and revealed several missing teeth from her upper and lower palates. R20 stated she had several teeth that had been pulled by a dentist. R20 stated there had been no discussion with the facility staff regarding scheduling a dental visit for follow-up dental work. Review of R20's facility form titled Oral Health assessment dated [DATE], revealed R20 had obvious or likely cavity or broken natural teeth. The form indicated R20 had been to the dentist prior to admission and had some of her teeth pulled. Further, the form indicated R20 had planned to get fitted for partials and had not been back to the dentist prior to admission. Review of R20's oral/dental assessment form dated 10/28/19, indicated R20 had obvious or likely cavity or broken natural teeth. The form identified R20 had natural teeth present with several root tips visualized on top and bottom. Further, the form identified R20 had been interested in seeing a dentist for an exam and cleaning. On 12/4/19, at 11:58 a.m. licensed practical nurse (LPN)-A stated R20 had missing natural teeth and had never expressed a desire to be seen by a dentist. LPN-A stated the LPN in medical records (MR) made appointments for residents to be seen by the dentist and further stated the dentist made visits twice a year to the facility. On 12/4/19, at 1:22 p.m. registered nurse (RN)-A stated the RN's competed the oral health assessments in the facility and if a resident had a need or desire to see a dentist the LPN in MR would have scheduled the appointments. RN-A stated there had been an expectation for the appointment to have been scheduled within 24 hours after a request had been made. RN-A reviewed R20's electronic health record (EHR) and verified R20 had expressed a desire to be fitted for partial dentures upon admission. Further, RN-A verified R20 had been seen by a dental hygienist on 10/28/19, and R20 had expressed an interest in seeing a dentist for an exam and cleaning. RN-A verified there had been no dental appointment made for R20. On 12/4/19, at 1:56 p.m. LPN in MR (LPNMR)-C stated nursing staff reported to her when an a dental appointment should have been made. LPNMR-C reviewed R20's EHR and verified she had not scheduled a dental appointment for R20. LPNMR-C verified an appointment should have been made upon R20's first request which had been made upon R20's admission to the facility. On 12/4/19, at 2:15 p.m. director of nursing (DON) stated her expectation was the facility would have made an a dental appointment within three days of R20's request. The DON confirmed a dental appointment had not been made for R20 as requested. Review of facility policy titled Dental Services revised 10/2019, identified if an oral issue had been identified, the nursing staff needed to discuss dental care and a dental appointment with the resident or family within three days of the finding. Further, the policy identified the facility had been responsible for assisting the resident and or family in making a dental appointment and transportation arrangements as necessary.

Based on interview and document review, the facility failed to conduct a thorough investigate regarding an allegation of physical abuse for 1 of 1 resident (R[AGE]) reviewed for abuse. Findings include: R[AGE]'s significant change Minimum Data Set ((MDS) dated [DATE], indicated R[AGE] had [DIAGNOSES REDACTED]. The MDS indicated [AGE] required extensive assistance of two staff transfers, extensive assistance of one staff for bed mobility, dressing, toileting, personal hygiene and bathing. On 12/5/19 at 9:06 a.m. during a telephone interview with nursing assistant (NA)-C. NA-C indicated she and the alleged perpetrator(AP) had been attempting to put residents to bed after supper and R27 needed one on one supervision due to being a fall risk and repeatedly trying to get up out of his wheelchair. NA-C indicated the AP got frustrated with R27 trying to get up out of his wheelchair all the time and the AP took two gait belts, hooked them together, placed it around R27's waist and hooked it behind the back of R27's wheelchair. NA-C indicated the incident happened on a weekend in July, around 7:00 or 8:00 p.m. NA-C indicated she had not reported the incident to anyone working with her that shift but had placed a note in the director of nursing (DON) mailbox regarding the incident. NA-C indicated she had also reported the incident a few weeks later to licensed practical nurse (LPN)-B during a scheduling discussion. The facility provided a copy of R[AGE]'s report submitted to the SA, Incident Report # 6, submitted to the SA on 7/20/19 at 12:12 p.m. listed an allegation of physical abuse with use of manual or physical restraints and listed the incident had occurred on 11/20/19 at 11:00 a.m. in the sitting area of the nursing home. The report indicated a staff member had reported the incident happen on a previous shift and the alleged perpetrator restrained R[AGE] in his wheel chair using gait belts. The facility provided a copy of R[AGE]'s Investigation Status Report # 6, submitted to the SA on [DATE] at 1:34 p.m. The report indicated R[AGE]'s family had been notified, staff were re-educated on use of restraints, the restraint policy and procedure was reviewed and the AP was terminated. However, the report lacked documentation the facility had interviewed other residents regarding further allegations of abuse from staff. On 12/5/19 at 12:28 p.m. LPN-B provided the facility's internal investigation which listed an interview on 7/20/19 with NA-C and other staff working on the evening of 7/7/19. LPN-B indicated she had not interviewed all the staff that was working that evening and had not interviewed other residents or visitors regarding the allegation of abuse. No further information regarding the investigation was provided. On 12/5/19 at 11:37 a.m. the DON confirmed the above findings and indicated the incident with R[AGE] should of been thoroughly investigated. The DON indicated she would expect staff to follow the abuse prevention policy and to complete a thorough investigation which included interviewing staff, other residents and visitors regarding potential abuse by staff. On 12/5/19 at 11:50 a.m. the administrator confirmed the above findings and indicated she would expect staff to follow the facility policy. The administrator indicated staff should of done a thorough investigation and should of talked to more staff about the incident and should of talked to visitors and other residents that may have seen something. Review of facility policy titled, Vulnerable Adult and Abuse and Neglect Prevention revised on 8/17, indicated it is the policy of Halstad Living Center that reports of abuse allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per federal and state law. The facility will ensure that all alleged violations involving abuse, neglect exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately, but no later that 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the state survey agency and adult protection services where state law provides for jurisdiction in long-term care facilities) in accordance with state law through established procedures. It is the policy of Halstad Living Center that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated.

Based on interview and document review, the facility failed to ensure an allegation of physical abuse was immediately reported to the administrator and immediately reported to the State Agency (SA) , no later than two hours, for 1 of 1 residents (R[AGE]) reviewed for abuse. Findings include: R[AGE]'s significant change Minimum Data Set ((MDS) dated [DATE], indicated R[AGE] had [DIAGNOSES REDACTED]. The MDS indicated R[AGE] had severe cognitive impairment, required extensive assistance of two staff transfers, extensive assistance of one staff for bed mobility, dressing, toileting, personal hygiene and bathing. On 12/5/19 at 9:06 a.m. during a telephone interview with nursing assistant (NA)-C. NA-C indicated she and the alleged perpetrator(AP) had been attempting to put residents to bed after supper and R27 needed one on one supervision due to being a fall risk and repeatedly trying to get up out of his wheel chair. NA-C indicated the AP got frustrated with R27 trying to get up out of his wheel chair all the time and the AP took two gait belts, hooked them together, placed it around R27's waist and hooked it behind the back of R27's wheel chair. NA-C indicated the incident happened on a weekend around 7:00 or 8:00 p.m. in July. NA-C indicated she had not reported the incident to anyone working with her that shift but had placed a note in the director of nursing (DON) mailbox regarding the incident. NA-C indicated she had also reported the incident a few weeks later to licensed practical nurse (LPN)-B during a scheduling discussion. On 12/5/19 at 9:30 a.m. LPN-B confirmed NA-C had reported AP had used two gaits hooked together to restrain R27 in his wheelchair. LPN-B indicated NA-C reported this had occurred on 7/7/19 around 6:30 p.m. after supper. LPN-A indicated NA-A reported the incident to her on 7/20/19 and LPN-B then reported the incident again to the DON. The facility provided a copy of R[AGE]'s Incident Report # 6, submitted to the SA on 7/20/19 at 12:12 p.m. which listed an allegation of physical abuse with use of manual or physical restraints and listed the incident had occurred on 7/20/19 at 11:00 a.m. in the sitting area of the nursing home. The report indicated staff had reported the incident happen on a previous shift and AP restrained R[AGE] in his wheel chair using gait belts. On 12/5/19 at 11:37 a.m. the DON confirmed the above findings and indicated a allegation of physical abuse involving a staff member restraining R[AGE] in his wheel chair using gait belts occurred on 7/7/19. The DON indicated she had not received a note from NA-C in her box regarding the incident and NA-C had not reported the incident to other licensed staff until 7/20/19. She confirmed she would expect all staff to immediately report the allegation of abuse to licensed staff and the facility would report the allegation of abuse within 2 hours to the SA. On 12/5/19 at 11:50 a.m. the administrator confirmed the above findings and indicated the allegation of physical abuse of restraining R[AGE] in his wheelchair with gait belts occurred on 7/7/19 and she had been notified on 7/20/19. The administrator confirmed the allegation of abuse was reported late and she would expect staff to follow the facility policy and to report the allegation of abuse immediately, within 2 hours to the SA. Review of facility policy titled, Vulnerable Adult and Abuse and Neglect Prevention revised on 8/17, indicated it is the policy of Halstad Living Center that reports of abuse allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per federal and state law. The facility will ensure that all alleged violations involving abuse, neglect exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately, but no later that 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the state survey agency and adult protection services where state law provides for jurisdiction in long-term care facilities) in accordance with state law through established procedures. It is the policy of Halstad Living Center that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated.

Based on interview and document review, the facility failed to review and/or revise the infection control program's policies and procedures annually. This deficient practice had the potential to affect all 38 residents currently residing in the facility. Findings include: A review of the facility's infection control program was conducted on 12/5/19, at 11:18 a.m. with the infection control coordinator (ICC) present. The facility provided copies of policies and procedures associated with the infection control program. A review of the policies and procedures indicated a lack of an annual review. The ICC stated the policies and procedures should have been reviewed annually at the quality assurance meetings. Further, the ICC stated the review date was documented on each policy and procedure at the top right corner of each policy. The ICC reviewed the policies and procedures and verified the policies and procedures had not been reviewed annually. Review of the infection control program's policies and procedures revealed the following: - The facility policy titled Infection Prevention and Control Program had last been reviewed on 4/10/18. - The facility policy titled Infection Surveillance (Process/Outcome/Recording/Reporting) had last been reviewed on 5/16/18. - The facility policy titled Employee Training on Infection Control had last been reviewed on 4/10/18. - The facility policy titled Infection Prevention and Control Committee had last been reviewed on 4/10/18. - The facility policy titled Infection Prevention and Control Program had last been reviewed on 4/10/18. - The facility policy titled Infection Preventionist had last been reviewed on 4/10/18. - The facility policy titled Outbreak of Communicable Diseases had last been reviewed on 4/11/18. - The facility policy titled Antibiotic Stewardship had last been revised on 5/3/18. - The facility policy titled Contact Precautions had last been reviewed on 5/18/18. - The facility policy titled Personal Protective Equipment PPE had last been reviewed on 5/11/18. - The facility policy titled Laundry- Infection Control had last been reviewed on 7/2018. On 12/5/19, at 12:06 p.m. the director of nursing (DON) stated it had been expected all policies and procedures in the infection control program had been reviewed annually in the facility's quality assurance committee. DON confirmed the infection control policies and procedures had not been reviewed annually. Review of the facility policy titled Infection Prevention and Control Program revised on 4/10/18, identified the policies and procedures had been utilized as the standards of the infection prevention and control program. Further, the policy indicated the infection prevention and control committee reviewed the policies annually. Additionally, the policy identified the annual review would have included updating or supplementing policies as needed, an assessment of staff compliance with existing policies and any trends or significant problems since the previous review.

Based on observation, interview and document review, the facility failed to ensure unlicensed nursing staff administered medications in compliance with State law for 2 of 2 residents (R10, R32) observed to receive insulin by injection, and 1 of 1 resident (R3) observed to recieve medications by gastrostomy. In addition, this deficient practice had the potential to affect three additional residents residing in the facility (R7, R20 and R21) who received insulin by injection. Findings include: Minnesota State Law 4658.1360 ADMINISTRATION OF MEDICATIONS BY UNLICENSED PERSONNEL, Subp. 4 Medication administration; indicated an unlicensed person who completed the required training course, could be delegated the responsibility to administer regularly scheduled medications-oral, suppository, eye dropps, ear drops, inhalent and topical. On 4/24/19, at 8:29 a.m. trained medication aid (TMA)-A brought a Basaglar insulin pen (an insulin pen is a cartridge of insulin in which a needle is added and the amount of insulin to be dispensed is determined after a metered dial is turned. The needle is then inserted into the resident, a button on the end of the cartridge is pushed to administer the medication) to R32's room for administration. TMA-A donned gloves after completing hand hygiene, checked R32's blood sugar, stating the results were 205. TMA-A then proceeded to cleanse R32's left upper arm with an alcohol wipe and administered 20 units of Basaglar insulin via pen to R32. TMA-A removed gloves, disposed the used needle in the sharps container and cleansed hands. Review of R32's electronic administration record (EMAR) from 4/1/19 to 4/25/19, indicated R32 received insulin from a TMA every day. On 4/24/19, at 10:45 a.m. TMA-A retrieved a [MEDICATION NAME]vial from the medication cart, cleansed the vial with an alcohol wipe and withdrew 18 units from the vial using an insulin syringe. TMA-A tapped the syringe to expel any air to ensure accuracy of the dose. Licensed practical nurse (LPN)-A double checked the syringe with TMA-A and verified the dose was correct. TMA-A then took the prepared insulin syringe to R10's room to administer. TMA-A cleansed hands, donned gloves and checked R10's blood sugar, stating the results of the blood sugar were 173. TMA-A then proceeded to cleanse the left abdomen with an alcohol wipe and subsequently administered the 18 units of insulin to R10. TMA-A removed gloves, disposed the used needle in the sharps container and cleansed hands. Review of R10's EMAR from 4/1/18, to 4/25/18, indicated R10 received insulin from a TMA every day. On 4/24/19, at 8:37 a.m. TMA-A stated he routinely administered insulin to residents residing in the facility. TMA-A further stated he had received insulin administration competency training at the facility over a two to three day period that included return demonstration. TMA-A explained the insulin administration process he followed involved applying the needle to the insulin pen, dialing up the ordered dose and having a licensed nurse double check the dose for accuracy. TMA-A stated he had not primed (the task of dialing up two units of insulin to expel air that ensures accuracy of the dose) the pen prior to dialing up the 20 units of Basaglar insulin for R32. TMA-A further stated it had been his understanding priming the Basaglar insulin pen was not a requirement. The facility provided the (YEAR) manufacturer's instructions for Basaglar KwikPen insulin The instructions indicated the staff were to prime the insulin pen with two units prior to dialing up the correct dose to ensure air had been expelled and proper dosing occurred. On 4/25/19, at 8:50 a.m. TMA-B stated she started administering insulin to residents at the facility about a year ago. TMA-B explained all TMA's who worked in the facility received competency training which included insulin administration about a year ago from a registered nurse who worked in the facility. TMA-B stated the training involved observation of the task and return demonstration. On 4/25/19, at 10:39 a.m. the director of nursing (DON) confirmed TMAs administered insulin to residents in the facility and further stated the practice of TMAs administering insulin began prior to her assuming the DON role at the facility.The DON stated the facility had not been aware administering insulin had been outside of the scope of practice for TMAs and explained that all of the TMAs in the facility had received competency training from a registered nurse in the facility, and return demonstrations had been completed as well. The DON stated there had been one insulin related medication error involving a TMA in the past year which had occurred on 1/3/19. The DON further stated no adverse outcome occurred as a result of the error. Review of the competency assessment on insulin administration indicated the competency involved completing hand hygiene, checking blood glucose levels, preparing the insulin pen and/or syringe and administration of the insulin. TMA-A's insulin administration competency had been completed on 3/27/19. Review of the facility's policy Nursing Competency dated (YEAR), indicated the facility would implement and maintain policies and procedures for verification of appropriate educational competency of facility staff which included certification and licensure in good standing. The policy further indicated the DON would plan and provide education and evaluation of licensed nurses based upon resident needs, standards of practice and regulatory requirements. Review of the facility's policy Administering Medication dated 5/4/18, indicated only persons licensed or permitted by this State to prepare, administer and document the administration of medications may do so. Review of the facility's policy Insulin administration dated 2/28/18, indicated the facility provided guidelines for the safe administration of insulin to residents with diabetes. The policy further identified only appropriately licensed or certified personnel would draw up and administer insulin. R3's quarterly Minimum Data Set ((MDS) dated [DATE], identified R3 had [DIAGNOSES REDACTED]. R3's MDS also identified severe cognitive impairment and R3 required total assistance with activities of daily living (ADLs). On 4/24/19, at 9:55 a.m. TMA-A set up the following medications at the medication cart. TMA- placed all medications in separate plastic 30 ml medication cups, after crushing tablets as needed. -Mirilax 17 grams, 5 milliliters (ml) -[MEDICATION NAME] 50 mg/5 ml -aspirin 325 mg one tablet -[MEDICATION NAME]-Levadopa 25 mg/100 mg one and one half tablets -[MEDICATION NAME] 0.125 mg one tablet -[MEDICATION NAME] two 325 mg tablets On 4/24/19, at 10:03 a.m. TMA-A entered R3's room, set a plastic tray containing the medications set up in the plastic med cups and water glasses, on R3's bedside table. TMA-A used a plastic syringe and stethoscope to check placement of R3's gastrostomy tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach). TMA-A administered approximately 5 cubic centimeters (cc) of air into the tube, then drew back on the syringe revealing a tan colored liquid into the syringe. TMA-A then added 15 cc of water to each med cup, and had two 240 cc of water in larger plastic cups. TMA-A administered water then gave each medication with 15 cc of water administered between each medication. TMA-A then administered eight ounces of [MEDICATION NAME] (supplemental nutrition) slowly through the syringe, administered 120 cc of water, then capped R3's gastrostomy tube. Review of R3's (MONTH) 2019, Medication Administration Record [REDACTED]. The Halstad Living Center Job Description titled Trained Medicaiton Aide (TMA) revised 5/14, signed by TMA-A on 7/18/18, identified duties which included to administer all oral, rectal, opthalmic, ear and topical medications in accordance with the standards set forth in the Pharmaceutical Policy and Procedure Manuel of the facility. The untitled facility competency form for TM-A, identified feeding tube care skills testing was completed 3/1/19. Administrating medications through an enteral tube was completed on 3/27/19. On 4/25/19, at 9:55 a.m. the DON confirmed TMA-A was not a licensed nurse. The DON indicated she was not aware what routes of medication a TMA could administer, and indicated she would have to look into that. The DON also stated TMA-A had completed competency training for administration of tube feeding and medication administration through an enteral tube 3/27/19. On 4/25/19, at 11:47 a.m. during a phone interview TMA-A indicated he had been a TMA for four years. TMA-A indicated he had completed competency training yearly. TMA-A indicated when first taught about administering medications through an enteral tube the first two days he shadowed a licensed practical nurse, then on the third day he administered the medication while being observed by a registered nurse. TMA-A indicated he had never had a medication error with an enteral tube. On 4/25/19, at 3:00 p.m. registered nurse (RN)-A and surveyor reviewed quarterly medication errors from 8/2018, through 4/2018. RN-A confirmed there had been no medication errors through an enteral tube during that time. The facility policy titled Administering Medications Through An Enteral Tube revised 2/23/19, did not include identification of which staff could administer the medications.

Based on observation, interview and document review, the facility failed to provide privacy during personal cares for 1 of 2 residents (R3) observed during personal cares. Findings include: R3's quarterly Minimum Data Set ((MDS) dated [DATE], identified R3 had [DIAGNOSES REDACTED]. R3's MDS also identified severe cognitive impairment and R3 required total assistance with activities of daily living (ADLs). R3's comprehensive care plan revised 4/25/19, identified R3 was totally dependent on staff for all ADLs. On 4/22/19, at 7:15 a.m. R3 was lying in his bed. Nursing assistant (NA)-D was in R3's bathroom preparing a basin of water. At 7:16 a.m. NA-E entered R3's room and left R3's door to the hallway 3/4 of the way open. NA-D left R3's bathroom and proceeded next to R3's bed, placed the basin of water down on the bedside stand then stood on the right side of R3's bed with her back to the doorway. NA-D began to wash R3's face. NA-E stood on the left side of R3's bed, facing the doorway. NA-D pulled R3's bedding down, exposing R3's abdomen to his knees, with R3's white incontinence brief covering his perineal area. NA-E began to undo the tape on the right side of R3's brief. Surveyor intervened and informed NA-E that R3's door to the hallway remained open, NA-E said oh yea then went to close R3's door. On 4/24/19, at 11:52 a.m. R3 was in his bed, covered with a sheet. NA-F and NA-B entered R3's room to check on R3 and complete incontinence cares for R3. NA-F stood on the left side of R3's bed, with her back towards the window, and NA-B stood on the right side of R3's bed facing the window. R3's door was closed at this time. NA-F and NA-B completed incontinence cares by removing R3's wet brief, turning him side to side, while washing his perineal area with wet wipes. NA-F and NA-B applied a new brief, then pulled up R3's pants. R3's window curtains were pulled open the entire time R3's personal cares were completed. Outside the room was an open lawn area, with no side walks. From the window another wing of the facility could be observed on the left. After completing R3's cares NA-B indicated she just remembered R3's curtain was left open and indicated it should have been closed. On 4/24/19, at 11:57 a.m. NA-B indicated R3 required total assistance for all ADLs. NA-B indicated R3's curtains and doors should always be shut during cares and indicated her usual practice was to do this always. On 4/25/19. at 1:31 p.m. director of nursing (DON) indicated her expectation was for residents to be provided privacy when personal cares were completed. DON indicated that obviously the doors should be closed and the curtain or blinds should be closed. DON indicated she would personally hate to have privacy forgotten and indicated it was a standard part of care. The facility policy titled Dignity revised 2/2017, identified each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. The policy further instructed staff to promote, maintain and protect resident privacy, including bodily privacy, during assisting with personal cares and during treatment procedures.

Based on interview and document review, the facility failed to provide notification to the resident and/or resident representative of the facility's bed hold policy at the time of an emergency transfer for 1 of 1 resident (R25), reviewed for hospitalization . Findings include: R25's significant change Minimum Data Set ((MDS) dated [DATE], indicated R25 had [DIAGNOSES REDACTED]. The MDS identified R25 had severe cognitive impairment and required extensive assistance with bed mobility, transfers, locomotion, grooming, dressing, bathing, toileting and eating. The MDS indicated R25 had a fall within the past six months that resulted in a fracture. Review of R25's progress notes from 3/1/2019 to 3/18/19, revealed the following: 3/6/19, at 4:36 p.m. R25 sustained a fall in the hallway that resulted in severe pain with movement and shortening of R25's left leg. R25 was transferred via ambulance to the Emergency Department. 3/6/19, at 10:51 p.m. R25's family member informed the facility R25 had been hospitalized with a left [MEDICAL CONDITION]. 3/15/19, at 1:36 p.m. R25 returned to the facility via a ride service. Review of physician discharge summary dated 3/15/19, indicated R25 had been hospitalized from [DATE] to 3/15/19, and had surgical repair of her left hip on 3/7/19. On 4/25/19, at 12:30 p.m. review of R25's medical record lacked documentation of a bed hold notice given to R25 or R25's representative upon transfer to the hospital. On 4/25/19, at 12:48 a.m. medical records coordinator (MRC) confirmed R25's medical record lacked documentation of a bed hold provided to R25 or R25's representative when transferred emergently to the hospital. MRC stated the process had been the nursing staff were to send the bed hold packet with any resident transferred to a hospital and nursing staff were expected to document in the progress notes after completion of the task. On 4/25/19, at 1:25 p.m. director of nursing (DON) stated nursing staff were expected to provide a copy of the bed hold policy to R25 or R25's representative when an emergency transfer to a hospital occurred. DON further stated the nurses were expected to document in R25's progress notes after completion of the task. DON reviewed R25's medical record and confirmed the record lacked documentation of a bed hold provided to R25 or R25's representative. A facility policy titled Bed Hold and Return dated 1/11/18, indicated the facility would provide a written notice to the resident or resident representative of the bed hold policy before a resident would have been transferred to a hospital or placed on therapeutic leave. The policy futher instructed staff to document the notification in the progress notes of the resident's medical record.

Based on observation, interview and document review, the facility failed to evaluate, monitor and obtain physician orders [REDACTED]. Findings include: R30's quarterly Minimum Data Set ((MDS) dated [DATE], identified R30 had [DIAGNOSES REDACTED]. R30's MDS further identified R30 had severe cognitive impairment and required extensive assistance with activites of daily living (ADLs). R30's Physical Restraint Care Area Assessment (CAA) dated 1/10/19, identified R30 used a perimeter mattress at all times when in bed to prevent him from falling out of bed, and receiving serious injury. R30's CAA indicated R30 was still able to get over the edge of the mattress and be found on the floor. R30's comprehensive care plan revised 1/21/19, identified R30 had a potential for falls. R30's care plan interventions included the use of a deeper perimeter mattress on bed. On 4/24/19, at 9:25 a.m. nursing assistant (NA)-B brought R30 to his room. NA-C entered the room. NA-B and NA-C proceeded with the use of a mechanical sling lift to transfer R30 from his wheelchair to his bed. R30's bed had a perimeter mattress, with an approximately 3 inch high raised area around the entire edge of the mattress. NA-B and NA-C checked R30 for incontinence, then transferred R30 back into his wheelchair with the use of the lift. Review of R30's Order Summary Report signed 4/3/19, failed to include an order for [REDACTED]. R30's progress notes reviewed from 1/25/19, to 4/25/19, revealed on 4/15/19, a MDS note identified no restraints were in use. No other notes identified the evaluation for the use of a restraint. R30's clinical records failed to identify on-going evaluation of R30's use of the perimeter mattress physical restraint. On 4/24/19, at 9:35 a.m. NA-B indicated R30 was at risk for falls. NA-B indicated R30 had a scoop mattress to keep him from rolling or getting his legs out of bed. NA-B indicated she had seen R30 try to get out of bed, but did not know if he had ever gotten over the edge of the mattress. On 4/25/19, at 12:29 p.m. clinical manager (CM)-A indicated R30 was at risk of falls with his most recent fall on 3/4/19, when he slid out of bed. CM-A indicated R30's perimeter mattress use began on 1/21/19, and R30 may have had a different mattress before that. Registered nurse (RN)-A indicated the usual facility practice should include first a consent for the use of restraints. RN-A indicated the usual facility process included a pre-screening of the need for the restraint, obtain physician orders, make sure there is a medical symptom and start with the lease restrictive intervention. RN-A indicated restraints should definitely be reviewed at least quarterly. RN-A indicated after each fall the care plan should be reviewed, including interventions to determine what is effective and not effective. CM-A indicated she had learned from recent education that restraints were sometimes checked every fifteen minutes and reassessed often. CM-A indicated she was new and would have to review the facility process. CM-A indicated the process also included education to the resident and families. On 4/25/19, at 1:42 p.m. director of nursing (DON) indicated she would expect the facility process to be followed for R30. DON indicated she had reviewed the facility process during another surveyor interview. R12's quarterly minimum data set ((MDS) dated [DATE], revealed [DIAGNOSES REDACTED]. R12 was cognitively impaired, and required extensive assistance from two staff with bed mobility, transfers, toileting, and bathing, and required extensive assistance from one staff with dressing, personal hygiene, and locomotion on/off the unit using a tilt wheelchair. R12's annual care area assessment (CAA) dated 6/12/18, indicated due to alterations in thought processes related to [MEDICAL CONDITION], R12 had impaired judgement, decision making, and lacked logic and reasoning to provide insight into his medical issues. The CAA indicated R12 was at risk for falls with injury due to need for assistance with activities of daily living (ADL)'s and co-morbidities; including Dementia, [MEDICAL CONDITION], shortness of breath with exertion, refusing staff assistance, impaired balance, and repeated falls. In addition, indicated R12 used a physical restraint contour mattress on his bed, to prevent future falls from occurring, and keeps him from getting out of bed per self, transferring and falling. R12's care plan failed to include ongoing evaluation for the need for the restraint, effectiveness, or monitoring when in use. Instead, was listed on the care plan under accessories, and indicated the perimeter mattress was implemented 10/27/17. A review of the current signed physicians orders dated 2/25/19, was reviewed and did not include orders for R12's bed restraint to prevent falls. Progress notes were reviewed from 8/17/18 to 4/24/19, and revealed no falls had occurred since 10/18, but also lacked any documentation of monitoring in place for R12 when the the perimeter mattress restraint was in use. On 4/24/19, at 7:17 a.m. upon knocking and entering R12's room, he was observed laying on a scoop perimeter mattress, with the bed in low position. On 4/24/19, at 7:22 a.m. nursing assistant (NA)-G stated R12 required extensive assistance with a standing lift, and needed assistance with all ADL's. NA-G stated R12 had fallen many times in the past, and indicated he continued to try to self transfer, but indicated he could not because they use a scoop mattress and tilt chair to prevent falls. NA-G stated she was not aware of any recent falls since they started using the scoop mattress, and indicated it was used to prevent him from self transferring. NA-G indicated they toileted and repositioned him ever couple of hours. On 4/24/19, at 7:58 a.m. R12 remained in bed, no change in position. On 4/24/19, at 8:06 a.m. during an interview, the MDS coordinator- E verified R12 had not had a restraint assessment completed, consent obtained, or physician order [REDACTED]. The MDS coordinator - E stated a restraint assessment should have been completed, and the normal process was for the interdisciplinary team (IDT) to discuss the restraint with the provider and family. In addition, the MDS coordinator-E stated there should be a physicians order, consent for use, and re-assement for the ongoing need for the restraint every 60 days or at least quarterly, and verified it had not been done for R12 On 4/24/19, at 8:29 a.m. the DON stated she would expect that the least restrictive interventions would have been tried, and the IDT team would review and discuss if a restraint was necessary. The DON stated if a restraint was needed, an assessment should be completed, and a physicians order obtained. The DON stated when a restraint was in use she would expect monitoring in place and included on the care plan. The DON stated they would need to evaluate the need for the restraint at least quarterly. The DON stated she would expect daily monitoring to be in place for R12, and ongoing evaluation for the continued need for the restraint. The DON stated she would expect the assessment for R12 to have been completed and the care plan to include the use of the restraint. The DON verified R12 had no orders for the restraint scoop mattress currently in use, and verified it was not in R12's current care plan, and a restraint risk assessment had not been completed prior to implementing the restraint. On 4/24/19, at 12:04 p.m. LPN- A stated R12 still tried to get up, and indicated he had gotten his feet out of bed but could not get up on his own because of the scoop mattress. LPN-A stated staff had to help to get out of bed, and stated the scoop mattress was put in place to prevent R12 from attempting to transfer himself. A review of the facility provided policy and procedure titled Halstad Living Center - Use of Restraints, dated 4/5/18, defined a physical restraint as any manual method, material, or equipment which the resident can not remove easily and restricts normal movement and access to ones body, and/or restricts his/her ability to change position. The policy/procedure section 6. instructed staff to complete an assessment prior to implementing a restraint to determine if there are underlying medical causes or if there are less restrictive interventions available. Further, the policy/procedure section 9. indicated a restraint would only be used after obtaining a physicians order, section 16. indicated the restraint use would be reviewed at least quarterly, and section 17. indicated the care plan would reflect interventions, and measures taken to reduce or eliminate the restraint use. Finally, the document section 19. instructed staff to provide documentation on use of the restraint.

Based on observation, interview and document review, the facility failed to implement measures to prevent pressure ulcers for 1 of 1 resident (R3) investigated for pressure ulcer prevention. Findings include: R3's quarterly Minimum Data Set ((MDS) dated [DATE], identified R3 had [DIAGNOSES REDACTED]. R3's MDS also identified severe cognitive impairment and R3 required total assistance with activities of daily living (ADLs). R3's Pressure Ulcer Care Area Assessment (CAA) dated 8/11/19, idenfied R3 had a potential for a pressure ulcer problem. R3's risk factors included immobility and cognitive loss. Pressure ulcer/injury-functional status would be addressed in R3's care plan to avoid complications and minimize risk. R3's comprehensive care plan revised 4/25/19, identified a potential risk of pressure ulcer related to a history of a stage 4 pressure ulcer and multiple health reasons and [DIAGNOSES REDACTED]. On 4/22/19, at 7:15 p.m. R3 was lying in his bed, with the head of bed slightly raised and he was covered with a sheet. R3 had two blue Prevlon boots (soft boots to minimize pressure to resident's heels) sitting in a chair in the corner of the room. Nursing assistant (NA)-F was in R3's bathroom, and at 7:16 p.m. NA-E entered R3's room. NA-F and NA-E completed ADL cares for R3. NA-F identified R3's boots were in the chair, but indicated she would assure R3 had the boots on during the night. NA-E indicated R3 had the Prevlon boots on only when laying in bed and indicated R3 did not have boots on at this time while he was in bed. NA-F indicated she would put the boot on R3's left foot, not the right and would keep an eye on R3, as he kicked them off at times. On 4/23/19, at 9:12 a.m. R3 was lying in bed, head of bed slightly elevated and he was covered with a white sheet. R3's feet were visible through the sheet, and he was not wearing the Prevlon boots at this time. R3's left leg was bent at the knee, and his left foot and lower leg were lying with the lateral side resting on the mattress. On 4/24/19, at 11:52 a.m. NA-F and NA-B entered R3's room. R3 was lying in bed on his back. R3 had no Prevlon boots on his feet. NA-F and NA-B performed incontinence cares and repositioning for R3. NA-B asked NA-F if they normally put a pillow under R3's knees. NA-F indicated they put it under his feet, and they proceeded to put a pillow under R3's feet with his heels resting on top of the pillow, then sanitized their hands, then left R3's room. R3's treatment administration record (TAR) dated (MONTH) 2019, included an order to monitor placement of suspension boot to left foot when in bed every shift for skin. The TAR was signed off every shift from 4/1/2019, to the day shift of 4/25/19. R3's progress note dated 4/16/19, identified a clinical assessment of pressure ulcer risk was completed. The note indicated R3 was very high risk for possible pressure ulcers with skin currently intact. The note further indicated R3 had a stage 1 pressure ulcer to left heel, which had resolved quickly with a protective foam dressing and suspension boots. On 4/24/19, at 10:43 a.m. NA-E indicated NA-D had applied a Prevlon boot to R3 after they completed cares on the evening of 4/22/19, but could not remember which foot. On 4/24/19, at 11:57 a.m. NA-F indicated R3 required total assistance for cares and was repositioned every two hours. NA-F indicated they would position a pillow between R3's legs when positioned on side, but today placed the pillow under R3's feet so he would not have pressure on the bottom of feet. NA-F indicated R3 had Prevlon boots, but NA-F usually used a pillow during the day because R3 would kick off the Prevlon boots. On 4/25/19, at 12:41 p.m. clinical manager (CM)-A confirmed R3 was at risk for pressure ulcers, and required Prevlon boots to be worn when in bed to prevent pressure ulcers on heels. CM-A confirmed the nurses were to check and sign off on R3's TAR every shift that R3 had Prevlon boots on and she expected the Prevlon boots to be worn when R3 was in bed. Surveyor and CM-A went to check R3's heels. R3 was lying in bed and had a Prevlon boot on his left foot. CM-A confirmed R3 had no redness on either heel at this time. CM-A indicated she felt R3 should have the Prevlon boots on both feet while in bed to prevent pressure ulcers, so she applied a Prevlon boot to his right foot as well. CM-A indicated the use of Prevlon boots was not included on the NA's tasks so she would add it to their tasks and re-educate the staff. On 4/25/19, at 1:31 p.m. director of nursing (DON) indicated she would expect residents with pressure ulcers or those at risk for pressure ulcers to have their care plan followed. DON reviewed R3's documentation and identified on 3/9/19, R3 had a blanchable redness to his heel which was quickly resolved on 3/17/19, with the use of a foam dressing and the use of Prevlon boots. DON confirmed she would expect R3 to have the Prevlon boots while in bed to prevent pressure ulcers or that R3's heels would be suspended. DON confirmed placing R3's heels directly on a pillow would not suspend R3's heels to prevent pressure. The facility policy titled Prevention of Pressure Ulcers/Injuries revised 3/23/19, identified the purpose was to provide information regarding identification of pressure ulcer risk factors and interventions for specific risk factors. Risk factor of immobility, instructions included when in bed, every attempt should be made to float heels (keep heels off the bed) by placing a pillow from knees to ankles or with other devises recommended by clinical staff or by the physician.

Based on observation, interview and document review the facility failed to follow infection control standards in the dining room while assisting residents at meal time for 2 of 5 residents (R13, R26) observed during an evening meal. Findings include: R13's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R13 had [DIAGNOSES REDACTED]. R13's MDS also identified R13 had severe cognitive impairment and required extensive assistance with eating. R26's quarterly MDS dated [DATE], identified R26 had [DIAGNOSES REDACTED]. On 4/22/19, at 5:39 p.m. R13 was sitting in her wheelchair next to the table in the dining room. R26 was sitting in a chair on R13's right side at the table. Nursing assistant (NA)-E sat on R13's left side and was feeding R13. NA-E tore R13's breadstick into small pieces then placed them into her mouth with her bare hands. At 5:43 p.m. R26 reached out and pulled another resident's partially eaten plate of lasagna towards her then picked up the fork and a breadstick off the plate. NA-E stood up, and removed the plate and breadstick before R26 could put it into her mouth. R26 then had two forks lying on top of her lasagna. NA-E sat down next to R26 and asked if she wanted anything more to eat. NA-E then picked up one of the forks placed it into the lasagna and gave R26 a forkful of lasagna from the plate. On 4/22/19, at 6:13 p.m. NA-E acknowledged she had ripped R13's bread into smaller pieces so she could chew it. NA-E stated she had used her bare hands to place the food into R13's mouth. NA-E also stated she could have cut up the bread and used a spoon to feed her. NA-E verified she had not paid attention when she gave R26 a forkful of lasagna, and stated she was not aware that R26 had taken a fork from the other resident's plate and placed it on top of her lasagna. As a result, NA-E stated she was unsure whether she'd used R26's fork or the other resident's to feed her. On 4/25/19, at 1:43 p.m. the director of nursing (DON) stated she would expect that a glove, or a barrier like a napkin always be used between a staff member's hand and a resident's mouth. The DON stated she would expect new food be provided if a resident placed another resident's fork on top of her food, and if there were two forks, staff should have removed both since they were unsure which fork was the resident's. The facility's policy Dining Room Service And Feeding Assistance, revised 6/03, indicated the policy was to ensure residents were served and assisted with eating in a manner that enhanced dignity, promoted independence and customer satisfaction, while [MEDICATION NAME] safe feeding techniques and infection control standards. Procedures included to not physically place items in the resident's mouth (example: cut bread and place it into the resident's mouth with a fork).

Based on observation, interview, and document review, the facility failed to ensure clean and sanitary kitchen equipment, refrigerated food items were disposed of after expiration dates and frozen foods were properly stored and dated for 1 of 1 walk in cooler/freezer. This had the potential to affect 38 of the 39 residents that received food from the kitchen. In addition the facility failed to maintain the water and ice machine to prevent potential contamination for all 38 out of 39 residents who currently resided in the facility. Findings include: On [DATE] at 6:22 p.m. during an initial tour of the facility with cook (C)-A the following concerns were identified in the walk in freezer: - a box of french fries which contained six 5 pound packages of french fries was setting in the middle of the floor of the walk in freezer floor - two 5 pound bags of ice in a plastic grocery bag was setting on the floor under the shelf to the left of the walk in freezer - a box of apple pie filling was setting on the floor on the floor in the back left corner of the walk in freezer. - a serving tray with eleven dessert cups filled with ice cream uncovered and undated setting in the middle of the walk in freezer was setting on top of a cardboard box. C-A confirmed the above findings and indicated food items should not to be on the floor and should be properly covered and dated. On [DATE] at 10:39 a.m. during a tour of the kitchen with the dietary manager (DM) the following concerns were identified: - a white microwave setting on the counter out in the main dining room area had yellow grease splatters covering all surfaces of the inside of the microwave oven. - the water and ice machine located in the main dining room of the facility had encrusted hard water lime scale build up with flakes under the ice and water dispenser. The tray was also noted to have light water lime scale build up and the metal grate was rusted. - one half gallon of milk, with expiration date of [DATE]. The DM confirmed the above findings and indicated the microwave should be cleaned daily. The DM indicated the inside of the water and ice machine was cleaned monthly and indicated they use a de-limer to clean the outside of the ice and water dispenser and indicated this was to be done weekly or when needed. The DM also indicated food should not be stored on the floor due to it being dirty and the items could become contaminated. The DM confirmed the facility should not have expired products in the fridge and should be properly stored and labeled. Reviewed of facility policy titled, Food and Nutrition undated, indicated Halstad Living Center will provide safe and sanitary storage, handling, and consumption of all foods including those brought to the resident by family and other visitors. The policy listed various definitions of terms related to sanitary conditions and the prevention of foodborne illness which included cross contamination, food contamination and identified a highly susceptible population as persons who are more likely than the general population to experience foodborne illness because of their susceptibility to becoming ill if they ingest microorganisms or toxins. Increased susceptibility may be associated with immune-compromised health status, chronic disease and advanced age. The Food and Drug Adminstration's Food Code includes nursing facilities in its definition of a highly susceptible population. Review of facility policy titled, Cleaning Schedule revised on ,[DATE], indicated the following items will be cleaned daily: microwaves and ice machine (exterior). Under weekly: ice machines (preventive maintenance), refrigerators and freezers. Review of facility policy titled, Ice Machine dated ,[DATE], indicated under: monthly- preventive maintenance cleaning allows cleaning the ice machine without removing all of the ice from the bin. It removes mineral deposits from areas or surfaces that are in direct contact with water during the freeze cycle.

Based on observation, interview and record review, the facility failed to ensure for 2 of 2 residents (R16 and R21)freedom from verbal and physical abuse from the abusive behavior of Resident #36. Residents expressed an ongoing fear of being physically harmed which affected their daily activity and resulted in psychological harm for these residents. Finding include: R 16 had verbalized to facility staff recurrent fear and felt he had been stalked and harassed by R36, and the facility did not take adequate precautions to protect R16 which resulted in psychological harm. R16's [DIAGNOSES REDACTED]. The annual minimum data set ((MDS) dated [DATE], indicated R16 had no short or long term memory problems, and had some difficulty in new situations with cognitive skills for daily decision making. R16's care plan updated 3/14/11 for the area of alteration in mood and behavior indicated that R16 had alteration in thought processes, manifested by "has difficulty making decisions in new situations." The care plan also indicated that R16 had inappropriate behavior and staff were to remind him of consequences of actions, and remove from activities and current setting if inappropriate. The social service note on 1/4/11 indicated that R16 had minimal depression, had little interest or pleasure in doing things and has exhibited inappropriate verbal behavior towards others. During an interview on 3/14/11, at 6:14 p.m., R16 verbalized that he felt he had been stalked and harassed by R36. The behaviors of R36 had included verbal threats, following R16 in the hallways, and blocking the doorway to R16's room. R16 further stated that he had discussed the matter with the facility administrator , the director of nursing services, and his physician. He had informed the director of nursing and the administrator and his physician that he would seek a transfer to another facility if the situation could not be resolved. He stated the administrator and the director of nursing advised R16 to avoid R36. He also stated that the physician had encouraged R16 to allow more time for the situation to be resolved. On 3/16/11, at 1:00 p.m., an interview with the facility administrator was conducted. The administrator confirmed he had talked to R 16 more than one time, however, he did not have any documentation of these discussions. The administrator did recall R16 had concerns about R36 verbally harassing and blocking the doorway to his room, and coming at him from behind. In addition, the administrator recalled that another resident had approached him with similar concerns. He had advised both residents to avoid R36. The administrator further stated that he had not been involved in daily staff meetings, or R36's behaviors and he was not aware of any discussion during the quarterly quality assurance meetings. He did not feel nursing would have needed to report to him if they had "handled it". The administrator further indicated that R36 should have had a psychiatric consult if his behaviors had been disruptive to other residents and he was going to see if this had been done. On 3/16/11, at 1:25 p.m., R16 was observed in his room. R16 indicated R36 had not bothered him that morning. R16 also indicated that R36 had not been bothering him recently and thinks that he has been more of a problem for the staff. On 3/17/11, interviews had been conducted with staff members that included: at 8:15 a.m., licensed practical nurse A (LPN A) indicated she was aware that R16 felt uncomfortable around R36. At 8:17 a.m., registered nurse B (RN B) indicated she was unaware of any incidents between the 2 residents. At 8:20 a.m., trained medication aid A (TMA A) stated she had reported to nursing two incidents where R16 had expressed discomfort regarding R 36. At 8:27 a.m., nursing assistant A (NA A) indicated she had discussed with R16 the reason for his refusal to come to therapy. R16 had indicated he did not want to go to therapy at the same time as R36. NA A indicated that she reported the incident to nursing and arranged for the two resident to go to therapy at different times. At 8:35 a.m., LPN B indicated that she had witnessed R36 approach and threaten to kill R16 in the day room on 3/9/11. LPN B removed R36 from the area and reported the incident to the RN. At 8:38 a.m. RN A stated she was unaware of problems between the two residents. At 9:45 a.m. housekeeping A stated R16 had indicated he was afraid of R36, and R16 was staying in his room more to avoid R36. Housekeeping A further indicated she had reported the conversation to the nursing staff approximately 3 weeks ago. The nursing progress notes were reviewed and revealed that on 2/22/10, at 8:40 a.m., R16 presented to the director of nursing office to express concerns regarding another resident. R16 stated that R36 had told him he had to leave his own room and cursed and swore at R16. R16 also expressed his desire to transfer to another facility if the problem was not resolved. The director of nursing offered to put a stop sign across the door of R16's room, which was refused by R16. On 3/10/11 a nurses notes read," Reminded R16 to please inform staff for intervention when this happens, and again offered to put a 'stop' sign across his doorway. Response "no, I guess it'll be okay." After further discussion, he stated, "well, you wait till my sister comes, and then you talk to her, and if she says I should have it, then I will." A nursing progress notes on 2/16/11, at 6:09 p.m. indicated R16 reported to LPN C that staff needed to address behaviors of R36, and if they didn't R16 had planned to call the police on this resident. The note further stated that LPN C had not heard of any issues between R16 and R36 on the earlier shift report. No further information was provided. A nursing progress note on 3/10/11, at 7:30 a.m., indicated R16 again presented to the director of nursing office and indicated R36 had informed R16 that he was the sheriff and would have had R 16 arrested if he didn't listen to him. The director of nursing again offered a stop sign across the door and advised R16 to inform staff for intervention. A physician visit progress note entered on 3/10/11, at 1:20 p.m. was reviewed and included a concern expressed to the physician by R16 about another resident agitating him. He had discussed moving to another facility, however, after a long discussion it was hoped that the issue could be resolved here. An interview with the director of nursing was conducted on 3/17/11, at 9:50 a.m. The director of nursing confirmed that she had been aware of problems that had occurred between R16 and R36, and indicated they had been trying to keep R36 under closer observation. The director of nursing further indicated that she would have expected the nursing staff to file an incident report following any altercation between residents, and confirmed that no incident reports had been completed. The director of nursing also confirmed she had been aware that R16 had previously avoided therapy while trying to avoid R36. The director of nursing also indicated she would have expected the social services (SS) designee to have been notified, an investigation should have been completed and documented. An interview was held on 3/17/10, at 10:50 a.m. with the SS designee (SS A) who stated that R16 had never come to her with any concerns and she visited with residents on an as needed basis. SS A further stated she had been aware of the concerns of R16 as expressed to the director of nursing, and that she had not followed up with R16 about his concerns. SS A further indicated awareness of problems which concerned R 36 behaviors with more that one resident in the facility and "things could have been handled differently". R 21 had verbalized to facility staff recurrent fear and told staff R36 was blocking her in the hallways and she was being harassed and the facility did not take adequate precautions to protect R21 resulting in psychological harm for this resident. The quarterly minimum data set ((MDS) dated [DATE] indicated R21 had no short or long term memory problems, and had some difficulty in new situations with cognitive skills for daily decision making. Record review indicated that on 2/18/11, at 10:05 a.m. R21 had gone outside to get away from another resident. R21 has complained numerous times in the past about this specific resident. R21 said , "he blocks the path for me to get to my room. I am sick of it I have rights too. " SSA allowed her to vent but did not indicate any new interventions. During an interview on 3/17/07 at 11:15 a.m. the SSA stated that she was aware of some minor conflicts between the two residents. The SSA stated the resident's aggressive behavior was reported to the nurses. She stated, "we try to keep them separated as much as possible. We offered her a stop sign for her room twice, and she refused. I spoke with her daughter about this and she was pleased we were monitoring R36". She stated the family was very aware of the situation and they also were familiar with their mother's behavior. The SSA stated that R21 tends to pick out one male resident to pick on and bother him. SSA stated that there was a male resident before R36 that R21 would report on and complain that he was harassing her and since he has passed away she was now focusing her attention on R36. R21 was interviewed on 3/15/11 at 6:50 p.m. and the resident indicated," I went to the head man and I told him about R36 and he said I'll see if I can keep a better eye out." The resident then said that the administrator, " remains in the office most of the time and that he also runs another facility so isn't here all of the time." On 3/16/11, at 1:00 p.m., an interview with the facility administrator was conducted. The administrator recalled that another resident had approached him with concerns of being blocked in the hallway and not being able to go to her room. The administrator also said at the time of this interview that he could not remember what resident it was as he does not take any notes of these discussions with the residents. He also verified that he had not seen any incident reports. R36 was observed throughout the survey to be sleeping on/off in his wheelchair and no behaviors were observed. The medication sheet revealed that on 3/16/11, at 5:30 p.m. R36 received [MEDICATION NAME] 5 mg IM at 6:46 p.m. because he was screaming, hollering, and threatening others. R36's had a history of [REDACTED]. Record review of 36 's care plan dated 10/29/10 indicated that the resident had verbal outbursts , and socially inappropriate behavior. On 3/4/11, the care plan had an additional problem added that indicated that R36 antagonized other residents. The approaches were to redirect as needed, and to monitor his mood and report any changes. The care plan noted on 10/21/10 R36 was receiving antipsychotic medications, approaches included to monitor and the goal was to have minimal or no side effects, and for the physician to review medication use during every routine exam and as needed. There were no interventions to minimize abusive behavior. On 3/17/11, at 3:17 p.m. the director of nursing said, R36 ,"was getting worse slowly, and we all have been trying to redirect him. We have been trying to do much closer monitoring since his behavior had been getting worse." She further stated that ,"they had been in close communication with R36's physician and he had been adjusting his medication frequently. We are monitoring, intervening when the behaviors occur and informing his doctor continually. " Record review indicated that nurses notes on 2/16/11 read," discussion held, reviewed increase in [MEDICAL CONDITION] that negatively impact R36 and others around him. Orders received to increase [MEDICATION NAME] to 50 mg in the morning and 25 mg in the PM." Record review on 2/18/11,"Discussion held with (MD) this afternoon regarding R36's behaviors. There have been multiple verbal altercations between R36 and other residents. He has also been angry with staff, insisting that large amounts of money are missing, and that he wants something done about it. These behaviors have been escalating all day. Staff have been unable to redirect his behaviors and [MEDICAL CONDITION]. Orders received from (MD) for [MEDICATION NAME] 5 mg IM every 4 hours PRN times 5 days." Record review on 2/28/11 "orders received to increase [MEDICATION NAME] to 50 mg twice a day. " Record review on 3/2/11 "Physician visited and (MD) reviewed behavioral status/[MEDICAL CONDITION] and orders received to increase [MEDICATION NAME] to 100 mg every AM and 50 mg every PM." Record review on 3/10/11 "faxed (MD) for review of R36's daily [MEDICAL CONDITION] that are negatively affecting himself and others around him. Current medications also sent for review." Record review on 3/13/11 "[MEDICATION NAME] 5 mg IM every 6 hours PRN (as often as necessary) through 3/16/11 and then reevaluate for physical/verbal aggression." Record review 3/14/11" Increase [MEDICATION NAME] to 100 mg in the morning, 50 mg at noon, and 50 mg in the evening everyday." Record review on 3/16/11 "orders received for a psychiatric consult. " Examples of altercations as documented in the nurses notes in R36's medical record were as follows: A nurse's note on 1/17/11 R36 " as soon as resident was up and out by the center he spotted another male resident and started to run into his w/c (wheelchair) with his w/c. He started to swear at the other resident. He than raised his hand at him. At this time, this writer removed resident to another area of the center. Later this morning he spotted the same resident and started a fight with him. After intervening, they were talking and following each other. Will continue to monitor. " On that same day R36 went up to a female resident who was rocking in a wheelchair and told her to stop rocking. He then grabbed the back of her rocking chair and started pulling on it. The staff intervened and moved him to another location however, he continued to talk about the resident saying, " who would ever want her she crazy she should be put out of her misery, " The nurses notes on 1/22/11 noted that R36 wheeled up to another resident and pushed her wheelchair, she told him to stop it. He wheeled away then turned around and went up to her (wheelchairs facing each other) and was about to kick her, staff intervened and R36 stated, " I just wanted to kick her some. " The nurses note from 1/23/11 revealed, " resident has been going up to residents pushing there wheelchair telling them their crazy. Very hard to redirect him. He wheels away when told to stop bothering them but as soon as you walk away he is wheeling back at them and starting to bother them again. " A nurse's note on 2/7/11 read " resident has been aggressive with other residents has been swearing and yelling out for his wife going in and out of rooms very hard to redirect. Resident was in front of another residents room holding the door closed asked resident what he was doing he said, " holding the door closed so this jackass can ' t get out " . A nurse's note on 2/13/11 read Late Entry 2-12-11 p.m. shift " (yells and shouts) (swings hands/fists) (kicks) (swears) Resident went up to another Resident and hit him on the head and took his hat off him and throw it. The other resident kicked this Resident in the groin and then this Resident was really mad. Staff got them apart and made them stay away from each other. This Resident told LPN that " that man makes me so mad sometimes he makes comments all the time to me " that why I hit him. Told just to stay away from him and not to look, talk, or anything with him. " A nurse's note on 2/14/11 stated " Resident was in his wheelchair and he took his wheelchair and tried to run another female resident over. When this writer called his name, he replied " Oh, I did not see her coming. " This writer was sitting down watching him go for the other resident. When she came back to the center, he did the same thing, and then another female resident went up to him and was talking about the incident. " A nurse's note on 2/15/11 read " yelled at another resident to get off the phone. He pulled the recliner from behind when another resident was sitting in it. He told another resident that he didn ' t ' t need to eat here and to go away. Went into another female resident ' s room telling her that those gold rings didn ' t ' t belong to her and that she should give them back. Female resident yelled to get out of my room which he did. He has been up and down every hallway looking for his money, very hard to redirect tonight. " A nurse's note on 2/17/11 read " resident went up to another resident and took her juice and frog told her he wouldn ' t ' t give it back til she gave the money back. Removed items from R36 and returned them to the other resident. He also went up to another resident and started pushing her wheelchair telling her that she didn ' t ' t belong here and to go back were you came from. " The notes further indicated that it took 2 staff to remove R36 from another resident ' s room. The nurses note on 2/18/11 read (R36) " arguing with another resident outside of the resident ' s room. Writer came out of rehab room to assist the other resident back safely into room and shut the door, and asked R36 to leave. He turned down the hallway as to leave and writer went back into the rehab room when heard arguing coming from across the way. R36 had come back and entered the room of the resident he was just arguing with resident about money. Writer called for assistance and asked R36 to please come out of room which he did. Writer again returned to the rehab room to continue to help another resident with her exercises, when R36 came into the rehab room went into the cabinet took out cuff leg weights and stated, " you see this " , I'm gonna hit and kill you both with this. " Writer than tried to get around R36 as he held out his arm as to grab for writer. When writer got to the door resident stated, " sure run but, I' ll kill her " , meaning the resident sitting in the chair. R36 was persuaded to come out into the hallway and down to another area to be watched. " The nurses note on 3/14/11 read " resident has been taking shirt off yelling at other residents to move and get out of my way. Grabbed another resident by the arm and pulled her she was in a wheelchair so she rolled with it." The facility policy dated 1/20/10 indicated that physical abuse was hitting, slapping, pinching, kicking and controlling behavior and mental abuse was harassment, threats of punishment or contact with others. The policy also indicated that allegations of abuse will be thoroughly investigated by a team and the administrator will be notified within 24 hours. Although residents reported being hit, blocked in the hallway, harassed and fearful of being harmed by R36 there were no incident reports written for the 9 incidents of resident to resident altercations listed above, there was no investigation conducted for these reports or reporting to the administrator or the state agency.