Based on interview, record review, facility document review, and review of the facility policy titled Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, the facility failed to thoroughly investigate an allegation of abuse for one of 27 sampled residents (R) (R13). Findings included: A facility policy titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, revised 02/2025, indicated, Compliance Guidelines: The facility will develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property. The section of the policy, Procedure for Response and Reporting Allegations of Abuse /Neglect/ Exploitation, indicated the following: When suspicion of abuse/neglect/exploitation or reports of abuse/neglect/exploitation occur, the following procedure will be initiated: 1. The Licensed Nurse will: a. Respond to the needs of the resident and protect him/her from further incident. b. Remove the accused employee from resident care areas. c. Notify the Administrator or designee. d. Notify the attending physician, resident's family/legal representative, and Medical Director. e. Monitor and document the resident's condition, including response to medical treatment or nursing interventions. f. Document actions taken in the medical record. g. Complete an incident report is [sic] indicated. h. Revise the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. 2. The Administrator or designee will: a. Notify the appropriate agencies immediately: as soon as possible, but no later than 24 hours after discovery of the incident. In the case of serious bodily injury, no later than 2 hours after discovery or forming the suspicion. b. Obtain statements from direct care staff. The policy also indicated the Administrator would, f. Within 5 working days of the incident, report sufficient information to describe the results of the investigation, and indicate any corrective actions taken, if the allegation was verified. Review of R13's admission Record indicated the facility admitted R13 on 11/25/2024. Diagnoses included, but not limited to, dementia of unspecified severity, anxiety disorder, depression, and cognitive communication deficit. Review of R13's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/29/2025, revealed R13 was usually understood when they expressed their ideas and wants, and usually understood others. The MDS revealed R13 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident did not exhibit physical, verbal, or other behavioral symptoms towards others in the seven-day look-back period. Review of R13's Care Plan Report, included a focus area, revised 4/21/2025, that indicated the resident had socially inappropriate behavior as evidenced by yelling out. Interventions directed staff to attempt to redirect the resident when they had inappropriate behavior, and to observe the resident for inappropriate behavior and report to the charge nurse, social worker, and physician. Review of a Facility Incident Report Form, dated 2/4/2025, indicated the facility reported an allegation of abuse for R13 on 2/4/2025 at approximately 4:00 pm. The Facility Incident Report Form revealed that during a routine telephone call to the resident's family member, the facility was informed that the prior Friday [1/31/2025], the resident told the family member that someone hit them on the head with a book. The report indicated the resident was immediately assessed by staff, and no injuries were visible. According to the report, R13 was unable to recall the incident or allegation secondary to significant cognitive impairment. The report indicated an investigation was pending. The report indicated that during a review of camera footage in common areas, it was revealed that another resident (R35) was seen ambulating toward the dining room and lightly patted several residents on top of their heads. The report indicated the Director of Nursing (DON) spoke with this resident, who stated, I was just saying hey. The report indicated the resident was encouraged not to place their hands on others, even in a friendly manner, in case they did not wish to be touched. The facility's investigation documentation included a typed summary that indicated staff and R13's roommate were interviewed regarding the report; however, only two typed witness statements were included in the facility's investigation documentation, one from the nurse who received the allegation from R13's family member and one from Business Office Manager (BOM), who indicated they had spoken with the resident's family member regarding financial matters on 1/31/2025, but received no complaints or comments about the resident's care. There were no witness statements from other staff or residents. Review of R13's Progress Notes revealed no documentation on 2/4/2025 to indicate that staff conducted a skin assessment or implemented other interventions for R13. During an interview on 5/21/2025 at 11:47 am, Family Member (FM)12 revealed that while visiting the facility, R13 stated their head hurt and they were struck on the head with a book. FM12 stated they checked the resident's head and noted two very small abrasions that appeared to be new. According to FM12, R13 stated they could not see the person who hit them on the back of their head. FM12 stated they left the building without telling anyone, but when contacted by the facility the following week, they informed staff of the allegation. FM12 indicated that after the incident, R13 was moved to a different room due to not getting along with the roommate, but this was unrelated to the abuse allegation. (According to the facility's census report, the resident's room change occurred on 4/4/2025). During an interview on 5/21/2025 at 12:00 pm, Licensed Practical Nurse (LPN)1 stated she called FM12 on 2/4/2025 to provide an update regarding R13's wound care treatment. LPN1 stated during the call that FM12 stated that when they visited the facility the previous week, R13 stated someone struck them on the head, and FM12 noted two small marks on the resident's head. LPN 1 stated that after the call with FM12, she looked at R13's head and did not see red marks or anything else. LPN1 stated she informed the Assistant Director of Nursing (ADON) and also gave the ADON a written statement. LPN1 stated she did not think she wrote a progress note, but maybe she should have. During an interview on 5/21/2025 at 1:09 pm, R13 could not recall any details of the incident. During an interview on 5/21/2025 at 10:07 am, the ADON stated that when informed of an abuse allegation, she would tell the Administrator and Director of Nursing (DON). She stated the DON would then assess the resident, identify any immediate problems and injuries, or remove the resident, get statements from residents and staff, and do an environmental assessment. The ADON confirmed LPN1 received the abuse allegation in a phone call and reported it to her. The ADON stated she immediately notified the DON. During an interview on 5/22/2025 at 8:25 am, the DON confirmed LPN1 did not document that she completed an assessment or write a progress note after being informed that R13 reported being hit on the head with a book. The DON stated that when she returned to work, the day after she was notified, she interviewed R13, but the resident could not remember the details of the incident. The DON stated she reviewed camera footage and saw that on the morning of 1/31/2025, at about 7:30 am, another resident was walking in the hallway and gently tapping other residents on their heads and arms in a friendly manner. The DON acknowledged she had no documentation of interviews with the resident's day and night shift nurses, other staff, or residents. The DON stated she never kept documentation of interviews, and this was a lesson learned. The DON stated that her expectation was that all interviews and assessments would be documented and kept on file. During an interview on 5/22/2025 at 10:35 am, the Administrator stated her expectation was that investigations related to allegations of abuse would include interviews with staff, residents, the victim, and the perpetrator. She confirmed that everything must be documented. The Administrator acknowledged that R13's abuse allegation was not thoroughly investigated.

Base on observation, staff interview, and the facility policy titled Servicing Product Dispensers, the facility failed to maintain the cleanliness and sanitation of the ice machine. This had the potential to effect 61 residents receiving an oral diet. The facility census was 63. Findings include: Review of the facility policy titled Servicing Product Dispensers dated reviewed/revised 2/22 revealed: All product dispensers are to be maintained in a clean, hygienic serviceable manner. 2. Staff will ensure product dispensers are clean and fully operational. An observation and interview conducted on 5/20/22 at 7:15 a.m. revealed the ice machine in the kitchen had a dark black grime substance on the ice deflector in the back of the inside of the ice machine. Staff wiped the grime build up and it came off easily with a paper towel. Interview with [NAME] BB indicated the Maintenance Supervisor cleans the machine. The Dietary Manager was unavailable for interview. An observation and interview conducted on 5/20/22 at 7:30 a.m. with the Director of Nursing (DON) revealed that the ice machine had dark black grime build up in it. She indicated she will get the Maintenance Supervisor to clean it and she will ensure the ice currently in use will be discarded. She indicated she would expect it to be clean. An observation and interview conducted on 5/20/22 at 8:34 a.m. with the Maintenance Supervisor revealed the facility leases the ice machine and the company comes out every few months and cleans it and he cleans it in between. He indicated he cleans it at least monthly. He verified the dark black grime build up and will clean it. He began to empty the ice that was currently in the machine. Review of the document titled Ice Machine Maintenance Check indicated the Maintenance Supervisor cleaned the machine monthly and it was last cleaned on 4/16/22. Review of the Service Report revealed the ice machine company serviced, cleaned and sanitized the ice machine on 3/16/22.