**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 1 of 1 residents (R27) reviewed for dignity, received services in a dignified manner to promote quality of life when staff failed to respond timely to call light and provide toileting assistance resulting in incontinent episodes and adult son of R27 provided toileting assistance. Findings include: R27's admission minimum data set (MDS) dated [DATE], indicated R27 was cognitively intact, did not reject cares and was dependent on staff assistance for all toileting needs. During an interview on 5/12/25 at 1:49 p.m., R27 stated she needed help to use the bathroom, some call light times exceeded 20 minutes and once over two hours. R27 stated there had been times she became incontinent because of the long wait time. It was embarrassing. R27 stated during a visit with family on Mother's Day (5/11/25) she had turned on her call light and requested help to use the bathroom. Staff came to the room, shut the light off and said they would be right back. When staff had not returned after approximately 5 minutes, R27 turned the light back on. Again, staff came in and shut the light off and said they would be right back. When staff did not return immediately, she was assisted to the bathroom by her adult son. R27 stated it was horrible, he had to pick me up and carry me. My son, not my husband. R27 shook her head and looked away and stated, how would that make you feel? I hated it. R27 stated she was embarrassed and ashamed her son had to help her with such a personal thing. R27 stated her son turned the call light on after transferring her into the bathroom so staff could assist with helping her off the toilet. R27 stated staff came after a couple of minutes and stated they would come back to assist when she was finished. R27 stated she was done about 15 minutes later and pushed for assistance and staff then came to help. Review of call light call logs indicated the following data: 5/11/25 R27's call light was activated at 1:03 p.m. and staff responded within 11 seconds. 5/11/25 R27's call light was activated at 1:06 p.m. and staff responded within 8 seconds. 5/11/25 R27's call light was activated at 1:37 p.m. Staff responded within 1 minute and 24 seconds. 5/11/25 R27's call light was activated at 1:47 p.m. and staff responded within 2 minutes and 16 seconds. 5/11/25 R27's call light was activated at 5:38 p.m. and staff responded after 29 minutes and 16 seconds. During interview on 5/14/25 at 11:32 a.m. Director of Nursing (DON) stated all staff can answer call lights, but primarily they are answered by certified nursing assistants (CNA). DON stated typically call lights were answered right away but it was reasonable to expect a 5-10-minute wait time during busier times of days such as early morning, mealtimes and bedtimes. DON stated she expected staff to check in with residents who use their call light and if multiple lights are on at once, to triage the highest priority lights first, and always return to residents and follow up that their needs are met. DON stated it could be embarrassing for a continent resident to become incontinent as a result of extended wait times and it is important that all residents' needs are met timely to promote dignity and general wellbeing. A policy for dignity was requested but not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to ensure the care plan included management and monitoring of anticoagulant (blood thinner) therapy for 1 of 5 residents (R1) reviewed for unnecessary medications. Findings include: R1's admission minimum data set (MDS) dated [DATE], indicated R1 was cognitively intact, received anticoagulation medications and had the following diagnoses: A-fibrillation (irregular heartbeat), Acute Embolism and Thrombosis of Deep Veins (blood clots within a blood vessel), and heart failure. R1's order summary report printed 5/14/25 indicated R1 took the following medications: Warfarin 1 mg by mouth one time daily every Friday for A-fib. Warfarin 1.5 mg by mouth one time a day every Monday, Wednesday for A-fib. Warfarin 2 mg one time every Tuesday, Thursday, Saturday and Sunday for A-fib. R1's care plan printed 5/13/25 identified a potential for injury related to history of falls, decreased/impaired mobility, diuretic medications and decline in activities of daily living. R1's care plan lacked evidence of anticoagulant use, increased risk for bleeding, or need for anticoagulant side effect monitoring. During interview on 5/13//25 at 10:13 a.m. registered nurse manager (NM) stated residents on anticoagulant therapy should be monitored for increased bruising, bleeding and staff should be aware of risks associated with these medications. During interview with Director of Nursing on 5/14/25, at 11:32 a.m. Director of Nursing (DON) confirmed R1 was receiving anticoagulant therapy. DON stated residents receiving anticoagulant therapy care plans should include anticoagulant use and instruct staff to monitor for potential side effects including bleeding risks, and an increased risk for bruising. DON confirmed R1's care plan lacked evidence of a focus area related to anticoagulant therapy or monitoring for side effects of anticoagulant therapy. DON stated she expected care plans to include staff instructions for monitoring of side effects related to anticoagulant therapy, completing associated labs as ordered by physicians and updating physicians with any pertinent findings. DON stated this was important because a resident was at a higher risk for complications related to these medications and potential accidents could result in increased bleeding or a resident bleeding out. Facility policy Anticoagulation-Clinical Protocol dated 2018, instructed staff to, Assess for any signs or symptoms related to adverse drug reactions due to the medication alone or in combination with other medications. The policy instructed staff to monitor for possible complications such as excessive bruising, hematuria (blood in urine), hemoptysis (coughing up blood), or other bleeding and to contact provider before administering next dose of anticoagulant. A care plan policy was requested but not provided.

Based on record review and interview the facility failed to ensure the correct advanced directives were documented and stored in the resident's paper chart for 1 of 1 resident (R110) reviewed for advanced directives. Findings include: R110's face sheet dated 7/30/2024, indicated R110's advance directive wishes were Do Not Resuscitate (DNR). R110's current order summary report dated 8/2/24, indicated R110 was a DNR. On 7/29/24 at approximately 2:25 p.m., R110's paper chart included an Advanced Directive Consent (ADC), however it was for Full code, and had another residents name on the form, not R110's. On 7/29/24 at 2:30 p.m., registered nurse (RN)-A stated they would go to the paper chart to verify the residents code status. On 7/29/24 at 2:30 p.m., licensed practical nurse (LPN)-A stated they would go to the paper chart to verify the residents code status. LPN-A retrieved R110's paper chart and stated R110 was a full code. LPN was directed to verify the resident's name on the ADC and LPN-A stated the person was not the same. It was not R110's ADC. On 7/29/24 at 2:39 p.m., the unit manager RN-B stated they expected staff to look at the paper chart for code statuses and if for some reason the ADC was not there, they expected them to refer to point click care (PCC) the resident's electronic health record. RN-B retrieved R110's paper chart, and identified the form for another resident was present in R110's chart, not R110's. On 8/1/24 at 10:28 a.m., the director of nursing (DON) (O)-A stated if their staff needed to verify a code status of a resident they should go to the paper chart. O-A stated their policy was, upon admission to review the residents advance directive wishes, have the physician sign off on the order, put it in the paper chart and update orders and care plans accordingly. The Advance Directive Facility Policy last revised September of 2022, indicated if the resident or the residents representative has executed one or more advance directives, or executes one upon admission, copies of these documents are obtained and maintained in the same section of the residents medical record and are readily retrievable by any facility staff.

Based on observation, interview, and record review facility failed to follow infection control protocol for 1 of 1 residents (R21) on contact precautions. Findings include: On 7/29/24 at 2:10 p.m., a sign was observed posted on R21's door that indicated the resident was on contact precautions. The sign had two stop signs, one in each of the upper corners of the sign, and bold upper-case wording Contact precautions everyone must. The sign included instructions to wash hands before entering and when leaving the room, put on gown and gloves before entering the room and remove before exiting the room. Gloves and gowns were in a hanging yellow container on the door next to the sign. A progress noted dated 7/29/24 included the resident was on contact precautions until further notice or update. On 7/31/24 at 8:00 a.m., housekeeper (H)-A was observed in R21's room adjusting a blanket on R21's bed. H-A was wearing only gloves, no gown. H-A swept the floor and exited the room, removing gloves upon exit. On 7/31/24 at 8:02 a.m., H-A stated R21 was only on precautions when she was having personal cares completed. H-A stated since she was only adjusting the blanket and cleaning, she did not have to wear a gown. H-A did confirm R21 had a sign on her door indicating the resident was on contact precautions and did confirm the sign included everyone should wear a gown and gloves. During interview on 7/31/24 at 8:11 a.m., unit manager registered nurse (RN)-A confirmed anyone who has direct contact with the resident or items in the resident's room, such as bedding, should wear a gown and gloves when a resident was on contact precautions. RN-A confirmed gown and gloves should be worn when adjusting a blanket or when providing housekeeping. RN-A confirmed R21 was currently on contact precautions for an unknown rash. During interview on 7/31/24 at 10:05 a.m., director of nursing (DON) stated she expected staff to follow contact precautions signage posted on the door. A gown and gloves were required for contact precautions. DON confirmed a gown and gloves should be worn when providing housekeeping services and when adjusting blankets on residents. Facility policy Isolation - Categories of Transmission-Based Precautions dated September 2022, included contact precautions were implemented for residents with known or suspected infections that could be transmitted with direct contact. Signage would be placed on the resident's door with instructions on the type of precautions. Staff and visitors were to wear a disposable gown when entering the room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure 4 of 5 residents (R21, R25, R28, R53) were offered and/or provided the pneumococcal vaccine series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s). Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/15/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R21's significant change minimum data set (MDS) dated [DATE], indicated hypertension (high blood pressure), peripheral vascular disease (poor blood vessel flow) malnutrition (poor nutrition), and respiratory failure (difficulty breathing). R21 had not received any pneumococcal immunization, and MDS had indicated it had been offered and declined. R25's quarterly minimum data set (MDS) dated [DATE], indicated heart failure (failing heart), hypertension (high blood pressure), and age-related physical debility (reduced physical ability). R25 had not received any pneumococcal immunization, and MDS had indicated it had been offered and declined. R28's quarterly minimum data set (MDS) dated [DATE], indicated coronary artery disease (heart and artery disease), cerebrovascular accident (stroke), Parkinson's disease (involuntary movement), and malnutrition (poor nutrition). R28 had not received any pneumococcal immunization, and MDS had indicated it had been offered and declined. R53's quarterly minimum data set (MDS) dated [DATE], indicated age-related physical debility (reduced physical ability), malnutrition (poor nutrition), and dementia (Poor memory). R53 had not received any pneumococcal immunization, and MDS had indicated it had been offered and declined. R21, R25, R28, and R53's Immunization record indicated that no pneumococcal immunization had been administered, offered, or refused. R21 and R25's Pneumococcal Vaccination Consent Declination indicated refusal and resident dated 7/31/24. Consent Form offered residents and representatives the PPSV23, PCV13, PCV15, and PCV20 immunizations. R28's Pneumococcal Vaccination Consent Declination indicated yes to receiving a pneumococcal vaccination and was dated 7/31/24. Consent Form offered residents and representatives the PPSV23, PCV13, PCV15, and PCV20 immunizations. R53's Pneumococcal Vaccination Consent Declination indicated yes to receiving a pneumococcal vaccination and was dated 11/9/23. Consent Form offered residents and representatives the PPSV23, PCV13, PCV15, and PCV20 immunizations. During an interview on 7/31/24 at 3:57 p.m., director of nursing (DON) stated she is the infection preventionist and the records for R21, R25, R28, and R53 failed to indicate the PCV20 vaccinations had been administered. The DON stated the declinations were just preformed for those residents that day. During an interview on 8/1/24 at 9:16 a.m., DON stated a recent audit had been done for all facility residents, and that it had not been done until 7/31/24. DON stated the vaccinations should have been reviewed earlier and offered. The DON stated it was an issue and was reviewing the facility policy. A facility policy titled Pneumococcal Vaccine, was provided. Policy indicated: Residents will be offered the pneumococcal vaccination and administered, according to CDC recommendations. Facility policy failed to indicate the administration of the PVC15 and PVC20.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to notify the ordering physician of x-ray results, which revealed newly identified fractures, in a timely manner for 1 of 3 residents (R1) reviewed. Findings included: R1's annual Minimal Data Set (MDS) dated [DATE], indicated R1's had a diagnosis of severe vascular dementia with anxiety and mood disturbance. R1's Progress Notes revealed the following: -On 7/15/24 @ 12:17 p.m., R1 reported he fell overnight last night in his bathroom, however, was unable to describe the fall, if he was using an assistive device, and how he got up off the floor. R1 reported pain in his ribs on the left side but no skin alterations were noted at the time. Physician updated and staff requested an x-ray for the left side ribs. -On 7/15/24 at 6:01 p.m., R1 reported pain 7 out of 10 and pain got worse with movement. X-ray was obtained and staff were awaiting results. Physician ordered 25 milligrams (MG) Tramadol twice daily and as needed for pain. -On 7/15/24 at 9:43 p.m., X-ray results obtained by fax and were as follows: 1. Subacute mildly displaced fracture to left 9th and 10th ribs. In comparison with prior examination, fractures were not visible on prior study and may be new since prior study. Staff would update R1's daughter via phone and put the x-ray report in the physician's folder. Progress notes lacked evidence of staff notifying physician of x-ray results. On 7/25/24 at 10:55 a.m., licensed practical nurse (LPN)-A stated she was R1's floor nurse on the day R1's x-rays were obtained, and the results were received between 7:30 and 9:00 p.m. LPN-A stated the x-ray results revealed R1 had fractures of his 9th and 10th ribs. LPN-A stated she then notified R1's family by phone, and notified the physician by fax and called the on-call nurse. Further, LPN-A could not recall which nurse she notified. LPN-A stated staff were expected to notify the resident's physician, supervisor, and family right away when staff were aware of a significant injury. On 7/25/24 at 12:20 p.m., registered nurse (RN)-A stated she became aware of R1's x-ray results on the morning of 7/16/24, at approximately 9:00 a.m. when she went searching for the faxed results. RN-A discovered the x-ray results were received the night prior at approximately 9:30 p.m., and R1's floor nurse would have been LPN-A. RN-A stated LPN-A failed to notify R1's physician or the on-call nurse, which would have been the director of nursing (DON). RN-A stated R1's physician and DON were not aware of R1's fractures until RN-A notified them both on the morning of 7/16/24. RN-A stated staff were expected to notify the physician and the on-call nurse immediately when staff become aware of a serious injury. RN-A stated as part of the investigation, staff were educated on importance of following a resident's plan of care specifically regarding toileting and repositioning, but RN-A was not aware of education related to reporting serious injuries timely. On 7/25/24 at 1:18 p.m., DON stated she received a call from RN-A on 7/15/24, in the morning, and RN-A had reported R1 self-reported a fall and had been complaining of increased pain and the physician was notified and ordered x-rays. Further, DON confirmed LPN-A did not notify the physician or the on-call nurse, which would have been the DON, upon receiving R1's x-ray results. DON discovered LPN-A had put the x-ray results on the board for the physician which was for non-emergent things and LPN-A should have immediately called the physician with the x-ray results. In addition, DON stated she was not aware of the delay in notifying the physician or on-call nurse until 7/25/24, and was attempting to interview LPN-A regarding the reasoning as to why LPN-A didn't feel she needed to update the physician when she knew R1 had newly diagnosed fractures. DON stated staff were expected to report serious injury or injuries of unknown as soon as they were aware of an injury. Review of facility policy titled Acute Condition Changes revised 3/18, indicated direct care staff would be trained on recognizing subtle but significant changes in the resident and how to communicate those changes to the nurse. Phone call to the attending or on-call physicians should be made by an adequately prepared nurse who had collected and organized pertinent information, including the resident's current symptoms and status. The nursing staff would contact the physician based on the urgency of the situation. For emergencies, they would call or page the physician and request a prompt response (within approximately one-half hour or less).

Based on interview and document review the facility failed to notify the Office of the State Long-Term Ombudsman of transfers for 1 of 1 resident (R22) reviewed for hospitalization. This had the potential to affect any hospitalized resident. Findings include: Progress note dated 2/18/23 at 3:34 p.m., was titled emergency room transfer note and indicated R22 was sent to the hospital for labored breathing, delayed speech, and weakness. The note indicated the medical doctor (MD) and family were notified and the bed hold was signed. The note lacked documentation of Ombudsman notification. The Notice of Residents/Patient Transfer or Discharge attached to the bed hold policy signed and dated 2/18/23 by R22 lacked information indicating the Ombudsman was notified. Progress note dated 2/19/23 at 3:14 p.m., indicated the resident returned to the facility from St. Cloud Hospital. Progress note dated 2/21/23 at 6:00 p.m., titled emergency room transfer note indicated R22 was sent to the hospital on 2/21/23, for slurred speech and left sided weakness. The note indicated the MD and family were notified and the bed hold was signed but lacked documentation of Ombudsman notification. The Notice of Residents/Patient Transfer or Discharge attached to the bed hold policy signed and dated 2/24/23, by R22 lacked information indicating the Ombudsman was notified. Progress note dated 9/24/23 at 1:55 p.m., indicated R22 returned to the facility at 1:30 p.m. from St. Cloud hospital. On 5/23/23 at 4:34 p.m., the licensed social worker (LSW)-B stated the nurse or health unit coordinator (HUC) were responsible to fax the Ombudsman after every bed hold was signed. They were expected to date and time the bed hold form when it was faxed and put in a progress note. During an interview on 5/24/23 at 9:38 a.m., registered nurse (RN)-A stated when residents were transferred to the hospital, the Ombudsman was notified by fax. RN-A stated staff were to print a fax confirmation page and put it in the chart or document notification of the Ombudsman in the nursing note. During an interview on 5/24/23 at 1:06 p.m., the director of nursing (DON) stated social services were to send a fax to the Ombudsman when residents were transferred to the hospital. The DON stated if it was not documented then it was not done. During an interview on 5/24/23 at 1:24 p.m. social services (SS)-A stated the bed hold procedure included notification of Ombudsman by sending a faxed copy of the resident's transfer discharge form. Staff were to sign off on the bottom of the form when it was completed. Facility policy Discharge-Involuntary Discharge of Resident-Long Term Care/Swing Bed indicates; Before a facility transfers or discharges a resident, the facility will notify the resident and resident's representatives of the transfer or discharge and the reasons for the move in writing in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to identify a situation as an alleged violation involving abuse and failed to immediately report this allegation to the State Agency (SA) for 1 of 3 residents (R1) who were evaluated for abuse. Findings include: R1's diagnoses list printed 12/28/22, included spastic diplegic cerebral palsy, unspecified cervical disk degeneration, generalized anxiety disorder, dependent personality disorder, chronic pain syndrome, and major depressive disorder recurrent. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact. The MDS also indicated R1 had moderate to severe depression and needed extensive assistance with all activities of daily living (ADL). When interviewed on 12/27/22, at 3:01 p.m. R1 stated on the night shift on 11/20/22, a nursing (NA) assistant entered her room, but R1 could not remember which NA it was. R1 stated she had given the NA. a metal emery board and asked her to put it in her drawer across the room. R1 stated the NA threw the emery board in a tomahawk motion and the board flew across the room and fell to floor. R1 stated she became upset at that time. R1 stated the NA then became very angry and stated, you called me in for things that were not important. R1 stated that she told NA she needed a brief change because it was wet and had been wet for over two hours. The NA told her she could not do it because there were no other staff to assist her. She was the only aide worked that shift. R1 stated NA, told me 'Your stuff isn't important. R1 stated NA told her, You're not important and you are just a disrespectful son of a bitch. R1 stated she started to cry and felt, my God Am I ever going to do anything right. R1 stated she felt like she just wanted to kill herself. R1 stated she did feel like what was said was mental abuse and she had reported the incident to licensed social worker (LSW)-A and registered nurse (RN)-A the morning of 12/21/22. R1's progress note dated 11/21/22, indicated R1 requested to meet with LSW-A and RN-A. R1 shared concerns related to staff and nutrition from over the weekend. Resident stated that she is, at the point of suicide. R1's progress note lacked any details related to staff concern. When interviewed on 12/28/22, at 10:14 a.m. LSW-A stated she remembered meeting with R1 on 12/21/22, there was a discussion about staff concerns, but could not remember the details. After LSW-A was told what R1 reported, LSW-A stated that was what the conversation between LSW-A and R1 involved. LSW-A stated the facility did not report the incident to the SA as possible mental abuse. LSW-A acknowledged R1 had mental anguish but that the mental anguish did not fall to the level of needing to be reported. When interviewed on 12/28/22, at 10:40 a.m. RN-A stated she recalled the meeting she was in with R1 and LSW-A/ RN-A stated R1 reported R1 told them NA told R1 her needs did not matter, were not important and that R1 was a son of a bitch. RN-A acknowledged there was mental anguish, but after meeting with the interdisciplinary team, decided it did not meet the level of needing to be reported. When interviewed on 12/28/22, at 11:03 a.m. the director of nursing (DON) stated that if abuse rose to the level of mental anguish, it should be reported to the SA as possible abuse. The DON stated the IDT, which consisted of LSW-A, social services director, RN-A, and the DON, met at noon and discussed what R1 reported to LSW-A and RN-A. The DON acknowledge R1 had mental anguish, but stated the IDT felt it did not need to be reported. When interviewed on 12/28/22, at 12:27 p.m. the administrator stated his expectation was that complaints that involved mental anguish be reported as possible abuse. A facility policy Vulnerable Adults-Abuse Prevention Policy-Long Term Care last reviewed 8/22, indicated all alleged violations involving abuse would be reported to the SA immediately, but not later than two hours after the allegation was made if the allegation involved abuse. The policy also indicated emotional or psychological abuse was defined as verbal or nonverbal infliction of anguish, pain or distress that resulted in mental or emotional suffering.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure allegations of potential abuse were investigated for 1 of 3 residents (R1) who reported an allegation of abuse. Findings include: R1's diagnoses list printed 12/28/22, included spastic diplegic cerebral palsy, unspecified cervical disk degeneration, generalized anxiety disorder, dependent personality disorder, chronic pain syndrome, and major depressive disorder recurrent. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact. The MDS also indicated R1 had moderate to severe depression and needed extensive assistance with all activities of daily living (ADL). When interviewed on 12/27/22, at 3:01 p.m. R1 stated on night shift on 11/20/22, a nursing assistant (NA) entered her room, but R1 could not remember which NA it was. R1 stated she had given the NA. a metal emery board and asked her to put it in her drawer across the room. R1 stated the NA threw the emery board in a tomahawk motion and the board flew across the room and fell to floor. R1 stated she became upset at that time. R1 stated the NA then became very angry and stated you called me in for things that were not important. R1 stated that she told NA she needed a brief change because it was wet and had been wet for over two hours. The NA told her she could not do it because there were no other staff to assist her. She was the only aide worked that shift. R1 stated NA told me Your stuff isn't important. R1 stated NA told her You're not important and you are just a disrespectful son of a bitch. R1 stated she started to cry and felt my God Am I ever going to do anything right. R1 stated she felt like she just wanted to kill herself. R1 stated she did feel like what was said was mental abuse and she had reported the incident to licensed social worker (LSW)-A and registered nurse (RN)-A the morning of 12/21/22. A progress note dated 11/21/22, indicated R1 requested to meet with LSW-A and RN-A. R1 shared concerns related to staff and nutrition from over the weekend. Resident stated that she is at the point of suicide. Progress note lacked any details related to staff concern. When interviewed on 12/28/22, at 10:14 a.m. LSW-A stated she remembered meeting with R1 on 12/21/22, there was a discussion about staff concerns, but could not remember the details. After LSW-A was told what R1 reported, LSW-A stated that was what the conversation between LSW-A and R1 involved. LSW-A stated she had not talked with any other staff or residents related to possible abuse. LSW-A stated all she did was report it to LSW-B, her supervisor. When interviewed on 12/28/22, at 11:03 a.m. the director of nursing (DON) stated the IDT, which consisted of LSW-A, social services director, RN-A, and me, met at noon and discussed what R1 reported to LSW-A and RN-A. The DON stated they called the NA in question and asked her side of the story. The DON stated they had not spoken with any other staff or residents. When interviewed on 12/28/22, at 12:27 p.m. the administrator stated his expectation was that complaints that involved mental anguish would be investigated by talking to the vulnerable adult, the accused staff member, other staff members and other residents so the complaint can be investigated thoroughly. A facility policy Vulnerable Adults-Abuse Prevention Policy-Long Term Care last reviewed 8/22, indicated all alleged violations involving abuse would be investigated started when the alleged perpetrator was relieved from duties and placed on administrative leave until completed. Then the resident, staff involved, and witnesses would be interviewed. The policy lacks talking with other residents about concerns with the accused staff member.