**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a cognitively impaired resident on an altered diet did not have access to a regular consistency sandwich. This failure resulted in R5 who was found choking and subsequently died. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 10/12/24 when R5 experienced a choking episode and dying at the hospital on [DATE]. V1 (Administrator) was notified of the Immediate Jeopardy on 11/14/24 at 9:44 AM. This surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 11/14/24; however, noncompliance remains at a Level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R5 is a [AGE] year-old male admitted to the facility on [DATE] with terminal illness under hospice services with diagnoses of frontotemporal neurocognitive disorder, dementia, diabetes, bipolar schizophrenia. Per facility assessment dated [DATE], R5's BIMS (Brief Interview for Mental Status) score was 7 which means R5 has severe cognitive impairment. The same assessment showed R5 was in need of supervision when eating and R5 is up and ambulatory independently. Physician Order Sheet (POS) dated 10/2024 showed R5's diet order as: no added salt and no concentrated sweets diet, pureed texture, nectar consistency. R5's progress note dated 10/12/24 timed at 7:45 PM, documents: at approximately 7:40 PM showed staff reported that resident appeared to be choking, Heimlich Maneuver performed, 911 arrived and took over Heimlich maneuver. Resident left via emergency services with a pulse and was breathing. R5's progress note dated 10/12/24 timed at 8:20 PM, showed a call as received from the local hospital ER (Emergency Room) that the resident had expired. Resident was pronounced dead at 7:48 PM, cause of death recorded as hypoxic cardiopulmonary arrest. R5's incident report dated 10/12/24 by V8 (License Practical Nurse-LPN) showed observed resident standing struggling for breath appeared to be choking as he was trying to cough .attempted Heimlich maneuver and when resident continued to be SOB [shortness of breath], we sat him down on his buttocks and continued Heimlich [maneuver]. I had already instructed staff to call 911. When 911 arrived, they continued Heimlich [maneuver] no food removed and then placed him on cart to hospital. Emergency Medical Services (EMS Police Dept) report dated 10/12/24 showed, summoned for [AGE] year old male unresponsive. Upon arrival patient was found at the nursing home being held up sitting up by nursing staff. Per the staff on scene they state that the patient was eating a sandwich when he began choking. Heimlich maneuver was not being performed by nursing staff. Patient continued choking and [the] crew initiated Heimlich maneuver on the patient. Patient was unresponsive with agonal respirations, crew initiated ventilations on the patient. Patient was transferred to the ambulance where crew continued patient care . Patient became pulseless and initiated ACLS [Advanced Cardiac Life Support] protocols. Patient arrived at the receiving ED [Emergency Department] nursing staff. R5's ED hospital records dated 10/12/24 showed, Patient was found choking at nursing home called EMS. Upon EMS arrival at the nursing home, patient was unresponsive but had a pulse. said they performed Heimlich maneuver and was transported to ER. On the way patient arrested and intubated patient for airway protection. EMS said after intubation patient arrested .CPR [Cardiopulmonary Resuscitation] was performed. Upon arrival to ER, patient was actively vomiting with ET [endotracheal tube] tube in mouth, information from nursing home showed he was hospice and DNR [Do Not Resuscitate]. CPR was terminated. Confirmed deceased at 7:48PM (10/12/24). On 11/8/24 at 3PM, V20 (Medical Legal Investigator (Local County)) said R5's cause of death was: Immediate-asphyxiation-choked on food bolus, Secondary-neuro cognitive disorder manner of death- accident. An autopsy was performed on R5. On 11/12/ 24 at 8:53 AM, V21 (Medical Examiner (Local County)) said he performed an external autopsy on R5. External autopsy result showed R5 was found with solid foods on his distal trachea. V21 also said that a police report showed that facility staff V8 (License Practical Nurse-LPN) and V12 (Certified Nursing Assistant-CNA) both informed the police responders that R5 grabbed a turkey sandwich and ate the sandwich. (R5 was on pureed diet.) On 11/8/24 at 10:42 AM, V12 (Certified Nursing Assistant-CNA) said it was after dinner approximately around 7PM. V12 said he was coming out from the dining room after having break. He saw R5 by the elevator wearing just an incontinent brief with no gown on. V12 said he went to R5 to redirect him to his room. We made few steps then he suddenly stopped, put his head down so I asked him, 'Are you ok?' He did not respond gasped for air, so I called the nurse. The Nurse (V22 LPN) came and did the Heimlich maneuver. On 11/14/24 at 8:28 AM, V22 (LPN) said he was by the nurses' station when he heard V12 (CNA) calling for help. V22 said he ran to R5. R5 was clutching his throat. R5 was trying really hard to cough. V22 said he tried to open R5's mouth and R5's mouth was full of saliva. V22 said he cannot recall if he did a mouth sweep. Heimlich maneuver was done and 911 was called R5 was sent to the emergency room. On 11/8/24 at 1:30 PM, V8 (LPN) said she was R5's nurse last 10/12/24. At around 6:30ish on 10/12/24, she was in the nurses' station with the other nurse when they were alerted by V12 that R5 appeared to be choking. V8 said she ran by the elevator where R5 and V12 were. R5 was short of breath, gasping for air and not talking. R5 was tall, so R5 was lowered to the floor, the Heimlich maneuver was done, back blows, and abdominal thrust. No food was coming out, did a mouth sweep did not feel any food. 911 was called. Paramedics came and also performed Heimlich maneuver then R5 was brought to the ER. Later, got a call from the ER and asked for his code status. R5 was a DNR. R5 coded on his way to the ER. V8 said she was informed R5 passed away shortly. V8 said R5 is up and able to ambulate independently. R5 has dementia and was on pureed diet. V8 said she does not recall telling the paramedics about R5 having a sandwich. V8 said residents with pureed diets should not have regular sandwich. On 11/8/24 at 11:15 AM, V13 (CNA) said she was R5's CNA for the day and PM shift last 10/12/24. R5's dinner was pureed food. R5 ate 100%. After dinner V13 walked with R5 to his room because he needed to be changed. R5 was provided bedtime care. R5 was left in his room lying in bed with gown and clean incontinent brief. V13 said he later learned R5 was sent to ER due to possible choking. R5 might have gotten up from bed after he was provided bedtime care. R5 was able to walk around independently. On 11/11/24 at 3:23 PM V23 (CNA) said she was one of the CNAs working on 10/12/24 PM shift. She was in one of the residents room taking care for another resident when she heard what happened to R5. V23 said the incident happened around 7PM. V23 said she had taken care of R5 in the past. R5 is a tall, large guy, able to walk, he can come out in his room, walks around the hallways then goes back to his room. V23 said bedtime snacks come around that time. R5 gets apple sauce. Other resident gets either PBJ or turkey sandwich. On 11/18/24 at 10:15 V16 (Dietary Manager) said she was at the facility that time 10/12/24 during the evening meal. The kitchen was short of staff, so dinner trays were prepared in the kitchen instead of the usual steam table. The menu on 10/12/24 evening meal was grilled cheese sandwich, tossed salad and pudding. V16 said R5 was served pureed diet. After dinner was when bedtime snacks were served that consisted of deli sandwiches- turkey sandwich and peanut butter and jelly sandwich. Residents on puree diets cannot have regular sandwich On 11/8/24 at 1:10 PM V18 (Assistant Director of Nursing (ADON)) said she was on call (10/12/24) and that evening, she was informed code blue was called on R5. Not sure what happened or how R5 choked. Staff performed Heimlich maneuver and was sent to the hospital via 911. R5 expired that same evening. R5 has behaviors of paces and wanders, R5 had declined in cognition that was why he was on hospice. On 11/8/24 at 2:35 AM V2 (Director of Nursing) said she was informed that on Saturday 10/12/24, R5 was in distress and was sent to the ER via 911. V2 said she was told the incident happened around 7PM when dinner was already done. Dinner was at 5:30ish (PM) V2 said she was told that V12 (CNA) was the first staff who noticed R5 was having SOB. R5 was trying to talk and cannot talk so he called for the nurses (V8 and V22 both LPN) who performed Heimlich on R5. V2 said R5 was on pureed diet, ambulatory on hospice due to dementia. V2 said V3 (Chief Nursing Officer) did the investigation. On 11/8/24 at 9:30 AM, V3 (Chief Nursing Officer) said she was the one who did R5's possible choking episode investigation. R5 was able to feed himself on pureed diet. R5 was ambulatory, on hospice services due to dementia and was DNR. V3 said her investigation showed that none of the staff could tell her what happened. V3 said the coroner has an ongoing investigation regarding R5's death. The updated policy and procedure dated 11/14/24 showed: -Supervision of Residents on Puree diets; residents that are on pureed diet require supervision that they are not able to get non pureed foods as it relates to their swallowing ability as determined by a speech therapist. Delivery of food to the Nursing Units; To ensure that food, such as snacks and meals is always under supervision. The dietary department will ensure that the food delivered is handed to the nursing department or dietary staff are serving the food. During this investigation, R5's police report and death certificate were requested, but both were unavailable as of 11/14/24. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the immediate jeopardy: The facility respectfully submits this abatement plan today, November 14, 2024. The facility requests that this abatement plan is accepted today, November 14, 2024 and requests that the immediacy be removed. Actions taken by the facility -On November 14, 2024, the facility did the following: -Assessed the residents on a pureed diet and ensured that they cannot obtain food that is not on their pureed diet; -Speech therapy is currently reevaluating all 4 residents who are on a pureed diet to ensure that it is still the most appropriate diet for them; In-servicing has been initiated which included all Nursing, dietary and activity staff regarding residents on Pureed diets and supervision of the residents on pureed diets that they do not have access to other food. In servicing is on-going and will continue until all staff in serviced. -In regards to delivery of bedtime snacks and all snack deliveries, dietary staff must get a signature from nursing for the snacks that were delivered. All snacks delivered to the floors will be held in the locked Nutrition Room on each floor. -An audit tool was created to supervise residents on pureed diets - auditing will be conducted 5 times a week for 2 weeks, 2 times a week for 2 weeks and 1time a week for 2 months. -Emergency QAPI (Qaulity Assurance and Perfomance Improvement) Meeting informed Medical Director of the citation as it relates to an IJ called for F689 on 11/14/24 at 0944 (am). Medical Director reviewed the abatement plan and approved it. IDT (Interdisciplinary Team) has been notified of the IJ 689 as well in the emergency ad hoc QAPI meeting held today, November 14, 2024. The following was reviewed in the emergency ad hoc QAPI meeting held today: Policy and Procedure/System Revision 1) Food delivery 2) Care of residents on pureed diets. QAPI is held on a monthly basis and the DON, ADON and Dietary Manager will be responsible for reporting on the on-going audit tools. Education: In-servicing began today, November 14, 2024, and is on-going. The following staff are included in the in-servicing: Licensed nursing staff, certified staff, dietary staff, restorative staff, social services, and activity staff. In-servicing topics are as follows: New Policy and Procedures as it relates to providing Pureed diet to those residents that are on a Pureed diet and safeguarding that they do not have access to regular foods. 1) QAPI Plan The IDT Team have been educated on the IJ that was 11/14/24. Topic: New Policy and Procedures relating to pureed diets/supervision as it relates to IJ. Education, Audits, and Plan: -New Policy Resident Access to food. -Care of residents on Pureed Diets.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** There are multiple deficient practice statements. Based on interviews and records reviewed the facility failed to prevent an incident of staff to resident inappropriate sexual behavior. This affected 1 of 3 residents (R2) reviewed for staff to resident sexual abuse. This failure resulted in V7 being observed receiving oral sex from R2 and V7's finger observed inserted in or on R2's exposed vagina. The Immediate Jeopardy began on 6/6/2023 when V7 was observed naked engaging in an inappropriate sexual act with R2. V4 (Co-Administrator) was notified of the Immediate Jeopardy and the Immediate Jeopardy template was presented on 06/27/2023 at 11:04AM. The survey team confirmed by observation, interview and record the Immediate Jeopardy was removed on 06/28/2023, but noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the removal plan. The findings include: 1. R2 is a [AGE] year-old with diagnosis include but not limited to bipolar disorder with psychotic features, schizoaffective disorder, bipolar type, personal history of traumatic brain injury, auditory hallucinations, and post-traumatic stress disorder. R2 is alert and oriented to person, place, time, and situation. On 6/16/23 at 11:20 R2 stated I had relations with my baby daddy in the facility. R2 stated they (the staff) accuse me of all sorts of things. During a second interview on 6/20/23 at 10:30AM R2 was shown a picture of V7 from his employee file. R2 responded I recognize him from the facility. R2 stated we talked before about life, goals, and futures. R2 stated he told me I looked nice. R2 stated I don't know his name. On two phone interviews on 6/16/23 at 1:37PM and 3:07PM V11 Certified Nursing Assistant (CNA), stated I was sitting at the nurse's station and saw V7 Psych Tech, enter the floor from the stairs. V11 stated V7 came to the floor around 11:00PM. V11 stated I did not see him enter R2's room. V11 stated the evening shift nurses had left and the night shift nurses had not arrived, I was on the floor alone. V11 said I got up to do my rounds and went to R2's room. V11 stated I saw R2 giving him (V7) head (oral sex) and he (V7) was fingering R2's exposed vagina. V11 said she told V7 to leave several times and he just stared at me. V11 said V7 would not leave. V11 said I think because he had no clothes on, he didn't want me to see him. V11 said R2 never said nothing to her but was mad and agitated after V7 left. V11 said R2 left the floor like 5-7 minutes after she told him (V7) to leave. V11 stated V15 Supervisor came to the floor, but V7 had left. V11 stated she saw V7 go to the stairs and leave. V11 said all of R2's roommates slept thru everything and never woke up. V11 stated R2 lied to the police and to V15 and said no one was in her room and then she told V15 that a staff member was on the floor. V11 state this is my first time I am talking to anyone about this. V4 Co-Administrator and V20 Administrator, did not talk to me about this. V11 stated I gave V15 a written witness statement and she said she put it in V8's Director of Nursing, mailbox. V11 stated she recognized the male as staff when he came to the floor. V11 stated V7 should not be doing this because he is staff, and it is not right. V11 stated the facility tells us we can't do that, there is no sleeping with the residents. V11 stated this would be abuse, sexual abuse. On a follow up, in person interview on 6/20/23 at 3:20PM V11 stated I notified V15 that the guy in R2's room was naked. V11 stated I never spoke with V4 Assistant Administrator, V20 Administrator, or a V23 Chief Nursing Officer. V11 stated you are the only one that has called me about this incident. V11 stated I knew I had seen the staff member on social media, so I pulled up his picture and showed it to the police. V11 stated I gave the police my statement that night. On 6/16/23 at 1:43PM V19 Social Services Director, stated he heard R2 was flirting with security. V19 stated staff spoke with R2 and let her know that sex with a staff person is inappropriate and V19 said R2 said she consented to it. V19 said R2 is alert and oriented times four. V19 said it is inappropriate because this is her home and R2 is here for a reason. On 6/16/23 at 2:23PM V12 Security/Psych Tech/ Central Supply Manger stated V7 was usually assigned to the 3rd or 6th floor. V12 stated I know V7 was terminated for a policy violation, and he was not where he was supposed to be while on duty. V12 stated on 6/6/23 V20 called me at night and told me to remove V7 from the schedule pending investigation. V12 stated I tried to call V7 to tell him, and he did not answer his phone. On a follow up interview on 6/20/23 at 12:56PM V12 stated I never had the chance to ask V7 anything about R2 because he never answered my calls. On 6/16/23 at 3:02PM the surveyor requested to see camera footage from V13 Maintenance Director. V13 said he calls the company to obtain a code to watch the security camera footage. V13 said the footage is available for 24 hours. No footage was available to view from 6/6/23 or 6/7/23. On 6/20/23 at 10:37AM V8 Director of Nursing, stated she was made aware that a male entered a resident room and V11 told him to come out of the room. V11 said all I know is R2 was going to be sent out for evaluation and that R2 refused evaluation and was returned to the facility. V8 stated she had a statement in her mailbox from V11.V8 said I gave the written statement to V4 Co-Administrator. On 6/20/23 during a phone interview from 11:05AM until 11:28PM V7 Psych Tech, stated I worked at the facility as a psych tech. V7 stated on 6/6/23 I was assigned to the 5th floor. V7 said I was terminated by phone on 6/7/23 for not following the rules. V7 stated I was not on my assigned floor. V7 said I have not been asked anything about R2 by anyone at the facility. V7 said not being on my assigned area means I was in R2's room. V7 said we were just talking and then R2 began removing her clothes. V7 said R2 said she wanted to do something. V7 said staff saw me standing over R2, in her bed without clothes, and her legs open. The surveyor asked if V7 was clocked in when this occurred and V7 said yes. V7 stated this was like at 11:00PM. V7 said after the staff saw me, I went down the stairs, punched out, and left the facility. V7 said the interaction with R2 started off friendly, we were just talking, then it went left. V7 elaborated and said it went left when the nurse walked in on us. V7 said I got no training on what to do if a resident makes sexual advances or flirts with me. V7 stated I had no training on not having sex with a resident. On 6/20/23 during a phone interview at 11:05AM until 11:2AM V20 Administrator stated I started the investigation as soon as I was notified in the night hours of 6/6/23. V20 said she had V15 take the phone to R2's room but R2 was not cooperative and refusing to be examined. V20 stated the allegation was that V11 was in R2's room and should not be on the unit and the staff saw him in R2's room. V11 stated they weren't sure what happened V15 did not see anything. V11 stated I never spoke with V11 or V7. V20 stated V12 spoke with V7 and V7 told V12 nothing happened in R2's room. V20 stated inappropriate friendships with staff and residents should not happen and V7 was terminated because he was in an inappropriate location in the building. V20 stated I reviewed camera footage and saw V7 go down the hall, on the unit and go into R2's room. V20 stated V7 left R2's room and went thru the stairwell, and V20 state she watched V7 leave the building. V20 stated on the camera footage she saw V11 at the nurse's station, get up, and go to R2's room. V20 stated my conclusion of the investigation is that the allegation cannot be substantiated. On 6/20/23 at 12:11PM thru 12:21PM during a phone interview, V21 R2's Guardian, stated R2 is upset right now because I told her she can't be having sex in her room while the room mates are present. V21 stated R2 does not understand boundaries. V21 said R2 interprets niceness as an advance, and she is needing male attention. On 6/20/23 at 3:00PM V4 Assistant Administrator, stated we don't have a statement from V11, I checked. On 6/21/23 at 9:05AM V15 RN Supervisor, stated on 6/6/23 V11 reported that R2 observed an inappropriate interaction between a male staff and a patient. V11 stated it was of a sexual nature. V15 stated I was instructed by V20 to get a statement from V11. V20 stated I took V11's statement and put it in V8's box. V11 stated I did not see anything or the male staff person. V15 stated I did call the police. V15 stated there were no witness everyone was asleep. R2's care plan includes identification that R2 is sexually active and is a trauma survivor. R2 has diagnosis and history of severe mental illness, and poor ability to control impulses. R2's PASRR (preadmission screening and resident review) denotes R2 was admitted to the hospital on [DATE] from a shelter, you were not taking your medications, using drugs, and engaging in high risk sexual behavior. You have a court appointed guardian ad litem. You have been ordered by the court for placement in a nursing facility. You state that you do not need your medication. You are homeless. When manic the patient has a history of engaging in risky sexual behaviors and self-neglect. R2's trauma screening dated 9/26/22 and 6/7/23 both denote a score of 1. V11's timecard record identifies he punched in on 6/6/23 at 3:00PM and his end of shift was 11:00PM. The facility investigation incident date 6/7/23 denotes It was reported by staff that V7 was inappropriate towards R2. Conclusion: Facility conducted a thorough investigation and interviewed staff and residents. (Per V20 and V11, V11 was not interviewed.) Final sentence in the reports denotes abuse is not substantiated. R2's Hospital records dated 6/7/23 denote R2 refused assault/rape kit. Records note R2 reported to hospital staff that she has been in a romantic relationship with the security guard for a while now. Police Report obtained dated 6/7/2023 denotes officer responded to the facility for an alleged criminal sexual assault. Allegedly V11 reported to V15 that V11 walked in on a staff member with R2 engaged in sexual acts. V15 stated R2 did confirm a male staff member was in the room with her but refused to answer any other questions. V11 told officer she observed a male psych tech who she did not know by name naked in R2's bed and was getting head (receiving oral sex) from R2 while he fingered her. The facility Resident Rights document states You must not be abused by anyone- physically, verbally, mentally, financially, or sexually. The Immediate Jeopardy that began on 06/06/23 was removed on 06/28/23 when the facility took the following actions to remove the immediacy confirmed by the survey team onsite observation, interview, and record review. Policy and Procedure/System Revision 1) Abuse policy revision to include that staff understand inappropriate sexual behaviors/acts or prevention of staff manipulation of residents for sexual gratification. 2) The residents will be educated by the social service team on Sexual Practices within the facility. 3) Residents with known sexual abuse (Trauma Screening Assessment reviewed in electronic medical record) will be encouraged to attend a group with the focus on Trauma survival and support placing boundaries and safe sexual practices. R2 was reassessed for Trauma on 6/7 and was identified as high risk for abuse. The care plan was updated with revised interventions on 6/7/23. Her state guardian was made aware. Education 1) Abuse quiz revision and all facility staff will be reeducated and quiz completion by CNO, Administrator, or Co Administrator. The education of all facility started on 6/28/23 and will continue until all staff have a face-to-face meeting. Staff that are on FMLA or have extended vacations if they have capacity to connect to a zoom meeting, we will complete education in that manner). No employee will be on schedule until they have completed abuse in servicing on new policy and quiz. Completion date June 29, 2023. 2) The new employee orientation program will include face to face meetings with their specific department supervisor and administrative staff to evaluate their job policy. These meetings will occur weekly for 1 month, biweekly for 1 month, then monthly until staff and administration are ensured of employee's confidence/comfort level within their job and knowledge of the facility abuse policy. Current employees will meet with their direct supervisor and administrative staff to evaluate their job performance, how comfortable they are with resident interaction, reassessment of abuse policy. 3) Social Service will be adding on a group or individual meetings for those residents who have been evaluated as significant Trauma as per their trauma screening. Those residents with significant passed trauma will have a new trauma assessment completed. Those cognitively impaired residents will be assessed for signs and symptoms of abuse. 4) V7 is no longer working at this facility 5) Qapi Plan The qapi plan as follows has been initiated with the following as written on 6/27/23: Topic: Abuse F600 IJ Abuse Data collected: This information was provided on 6/27/23. Education, Audits, and Plan: 1) Abuse policy Revision 2) Abuse Quiz Revision 3) Staff follow up Meetings for New Hires and Current employees, the meeting will discuss job performance comfort level understanding of policies and job description as well as abuse. A) New employees will meet with Department Head and Administration person 1 time/week for 4 weeks, 2times/month for 1 month, then 1 time a month until Employee and Department head and administration feel they are confident in their job and have a clear understanding of abuse. B) Current employees will have an initial meeting and they department head and administration as well as the employee are knowledgeable on all topics listed above evaluations minimally yearly and attendance at in-services for abuse. 4) On going staff education, face to face meetings with the department heads and administration staff, social service, and nursing monitoring of R2 and all residents for any signs and symptoms of abuse, charting accordingly with any follow up concerns to administration. 5) Team members responsible for following up on the items listed in the plan: Administration, CNO, DON, Social Service, and Interdisciplinary Team. 6) Audit tool 7) R2 was provided wellbeing checks and individual consoling she continues to be monitored and encouraged to attended or meet individual with social service. State guardian has continued to be updated. 2. Based on observation, interview, and record review the facility failed to ensure staff does not physically harm residents during Crisis Prevention Intervention (CPI) technique. This affected one (R30) of nine residents reviewed for physical abuse. This failure resulted in R30 being observed with a bump on left side of face, lips swollen, and facial bruises after an incident with V69 (Security). The findings include: R30's diagnosis include anxiety, bipolar disorder, major depressive disorder, lack of coordination, schizoaffective disorder and weakness. R30's cognitive assessment dated [DATE] indicates a score of 13 (cognitively intact). On 7/7/23 at 1:50PM the surveyor was escorted to R30's room by V37 Licensed Practical Nurse (LPN). R30 observed in gown and underwear on (no pants or shirt) gown open in the front. R30's arms, chest, belly exposed. Surveyor saw no bruises or marks on R30's, neck, belly, chest, arms, or hands. R30 has three purple bruises about the size of a quarter on the right side R30's forehead/temple region. R30 has one round purple bruise along R30's lower left chin. All three bruises same color and similar shape. R30 said the guy beat me up for no reason. R30 said he said to me you think you hard a** then he attacked me. R30 said this happened yesterday. R30 said he broke my fingers. R30 said he works here, his name is [derogatory slur]. R30 stated I told the police the same thing I just told you. R30 said my hand and jaw hurts. R30 was unable to say who V37 was by name. R30 became agitated during conversation and surveyor ended interview. On 7/7/23 at 2:07PM in R5's room. R5 said I saw V69 Security Guard, go into R30's room, right next door, and the door was closed. R5 said I was in the hall and heard noises. R5 said I peeked in the room and saw V69 punch R5 in the face. R5 said I saw V69 and R30 standing face to face with each other hands on each other, close to each other, they were standing by the bed. R5 said I waited outside the room and then saw V69 come out, it went on for like 3-5 minutes. R5 said V69 came out the doorway and said, I F*** people up. R5 stated I have pictures and showed the surveyor two pictures on his personal broken screen phone. R5 showed two blurry pictures and one picture has R30 holding a white cloth to his face, bright red blood on a white cloth. R5 said I saw V69 hit R30 two or three times. R5 said when V69 came out of the room he was wearing black gloves, like baseball gloves on his hands and was taking them off, he carries them in his pocket. R5 said I saw both, V37 and V69, carrying bloody towels and sheets. On 7/7/23 at 1:48PM V37 Licensed Practical Nurse (LPN) stated I approached R30 on 7/6/23 because he needed assistance, he wasn't dressed properly, and R30 became aggressive. V37 stated I called V69 to assist. I then left the facility for an appointment. V37 stated I did not see the altercation, but I was told about it when I returned. V37 stated in the morning while I was here R30 had no bruises on his face, but when I returned in the afternoon, I saw the bruises on R30's face. V37 stated R30 is alert and oriented times two, he has confusion, and he may have some delusions and hallucinations. On a follow up interview on 7/8/23 at 9:25AM V37 stated V69 approached R30 saying Mr. (R30) follow me and R30 followed V69 to R30's room. V37 stated V69 then called V37 to look at the mess in R30's room. V37 stated I went to see and there was a mess of linens. V37 stated I did not see blood anywhere at that time. V37 stated R30 was standing in the room with V69 and R30 was not saying anything. V37 stated I did not see V69 with a ripped pocket and no bleeding. V37 stated I left the facility around 10:00AM on 7/6/23 and returned at 4:00PM. V37 stated I did not punch out when I left, because my appointment is related to a facility injury. V37 stated I called V68 Nurse, to notify her I was leaving, and she said she was coming to the unit. V68 said V69 and V57 Scheduler, were on the floor when I left. V37 stated V69 did not report to me the incident that occurred with R30. V37 stated V69 should have told me or to the administrator when it happened. On 7/7/23 at 2:52PM during a phone interview, V69 Security, stated R30 was argumentative at the nurses' station. V69 stated R30 then grabbed me by the neck and scratched my neck. V69 said I tried to de-escalate the situation by myself, and I did not call for help or a code gray. I didn't think of it. V69 stated after R30 got his clothes, linens, and shower - everything he wanted R30 calmed down. V69 stated I never put my hands on R30. V69 stated R30 didn't fall. R30 was never on the ground. R30 was trying to grab me by the neck. V69 stated I was in the room for 3-5 minutes. During follow up call on 7/11/23 at 10:20AM V69 stated I didn't tell anyone after the incident. I should have reported but V37 was gone. V69 stated I used proper CPI (crisis prevention institute). I didn't touch R30's face. V69 stated R30 only had me in a bear hug from the front he never came at me from behind. On 7/11/23 at 10:03AM V71 Director of Customer Experience, stated I was doing my rounds and R5 pulled me to the side and showed me some pictures on his phone, and stated the resident had been beat up by a staff member. V71 said this was reported to him a little before 10:00AM. V71 said R5 was holding his phone with a picture in which he saw a man's face and some blood, and his face was down. V71 gave the room number and R30's name as the man in the picture R5 was showing him. V71 stated R30's face should not look like that. You don't engage in CPI and his face should not look like that. V71 said you need to call a code and get out the room when behaviors are coming like that. V71 described R30's face as swollen and said V30 said the [derogatory name] did it. V71 said I have seen V69 with black motorcycle gloves at work. On 7/7/23 at 2:58PM by phone, V68 (Nurse) stated she received a call from V37 (Nurse) around 10:00AM that she was to cover the floor, while he was out to an appointment. V68 stated she went to the unit shortly after 10:00AM. V68 stated she did not stop on any other unit. V68 said it was around 12:00-12:30PM when V4 (co-administrator) arrived on the unit and asked V49 to come with her because there was an allegation. V68 stated they went to R30's room. V68 stated that R30 reported he got into it with a male security guard. V68 said she did a head-to-toe assessment on R30, and she observed R30's forehead was swollen and R30's lip was swollen. V68 said the inside of R30's lip was swollen, too. V68 requested the surveyor read the incident report that she completed. V68 said she asked R30 what happened to his forehead and lip, R30 replied, the male security guard did it, I told the nurse. V68 said she and V4 went toward V69 he was sitting by the elevator. V68 said V69 said no, no, the resident was aggressive. V68 said she observed V69's shirt pocket was ripped and V69 pointed out very minor scratches to his neck. On 7/7/23 at 4:21PM by phone, V12 Security Supervisor, stated a code gray is called when a resident is combative. V12 said if a resident puts their hands on you, that should be a reason to call a code gray. V12 said if you are using CPI to get the resident's hands off your neck the technique would not involve touching the resident's head or face. V12 said the code is called to prevent the situation from escalating and to show the resident they are outnumbered. I did not respond to a code gray involving V69 on 7/6/23. V12 said I did not hear the code gray, I was outside. V12 stated I was called by V20 Administrator, about 12:30PM and told to watch the security footage. I watched the video about 12:45PM. V12 said on the video, I saw R30 at the nurses' station and V37 waving for someone. V12 said I only saw footage at the nurses' station not the hallway. V12 said I was told that R30 said he was hurt. V12 said when I went into the video room, I watched the video alone. V12 said I didn't talk to V69, and I didn't see him before he left. On 7/8/23 at 1:40PM V4 Co-Administrator, stated I was notified by V71 Director of Customer Service, there was an incident where a resident alleged a staff member was inappropriate. V4 said I went to speak with R30 sometime in the morning of 7/6/23. V30 said she went to the floor and when she got there the first place, she went was to R30's room. V4 said R30 reported he and staff possibly had some kind of altercation. V4 said R30 said a staff member had physical contact with him. V4 said R30 described the person as having military fatigue, clean cut, and the color of his uniform was black, R30 gave no name. V4 said I asked R30 for a description of the altercation and he seemed disorganized and confused, he cognitively was coming in and out, and seemed tired. V4 said from the description of the staff person R30 gave it was V69. V4 said V68 Nurse, was present during R30's interview. V4 said I obtained R30's written statement before he left. V4 said V69 said he had redirected R30 back to his room. V4 said V69 said that Crisis Prevention Interventions (CPI) was utilized. V4 said generally CPI requires a party of two, but maybe done with one person. V4 said I would expect the incident to be reported if one person CPI technique was used, right after the situation occurred. V4 said the nurse would document in a progress note if CPI occurred. V4 said I am not trained to see if I saw on injury on R30. V4 said I did not see blood. V4 said I read V68's progress note where she reported R30 had some possible skin discolorations. V4 said CPI is verbal de-escalation of a situation, physical techniques are a last resort, and the holds are nonaggressive. V4 said R5 reported to her that V69 was in R30's room. V4 said R5 had said he was standing in the hallway. V4 said R5 said he opened the door to R30's room, looked inside, and he possibly witnessed they were having a disagreement and closed the door. V4 said R5 said there was a possibility that V69 was using CPI on R30. V4 said R5 is alert and oriented times four. V4 said it sounds like the CPI used could have been verbal and possible holds. V4 said the investigation is not yet completed. On 7/7/23 at 3:12PM V20 Administrator, said I was not in the facility, but I was told by V12 that V69 grabbed R30 from the back. V20 said I did not watch the security video; I was not in the facility on 7/6/23. On 7/8/23 at 12:40PM the surveyor inquired if the facility has a specific code gray policy, other than the Facility Codes Policy. V20 replied there is no other policy for code gray. Facility incident report dated 7/6/23 at 11:30AM completed by V68 denotes in-part incident location- resident room, resident location- (room number). Resident (R30) alleged staff member was inappropriate towards him. Head to toe assessment completed, resident noted with bloody lips, and swelling to forehead, ice applied. Co-Administrator (V4) made aware; investigation initiated. Injury type- swelling, right forehead. No witness found. R30 plan of care dated 04/05/2023 denotes in-part that R30 comprehensive assessment reveals a factor that may increase my susceptibility to abuse/neglect. The resident demonstrates: Diagnosis of Mental Illness The resident will be treated with/ respect, dignity & reside in the facility free of mistreatment (i.e., abuse/neglect) (on-going). Review assessment information. Emphasize treatment of causal factors &/or interventions designed to moderate/reduce symptoms, make treatment of compulsive behavior, substance abuse, anger & mental health issues available to the resident, as indicated. Assure the resident that he/she is in a safe & secure environment with/ caring professional. Explain that psychosocial adjustment is often facilitated by developing a trusting relationship with another person (i.e., social worker, nurse, CNA, peer) & by verbalizing thoughts, needs & feelings. Assure the resident that staff members are available to help & department heads maintain an open door policy. R30's plan of care dated 04/10/2023 denotes in-part has a Self-Care Deficit with impaired dressing and grooming abilities and would benefit from participation in a dressing/grooming restorative nursing program as evidenced by the following risk factors and potential contributing diagnosis: bipolar disorder, requires one person assist with dressing and grooming, schizophrenia and/or schizoaffective disorder. R30 will be able to dress self-up and comb hair with staff provided ones daily for clean appearance/hygiene potential with no more than supervision assists times one staff, six- seven days weekly to help improve and/or maintain current level of function, unless disease process causes unavoidable deterioration through next review. Explain all tasks prior to performing R30 dressing and grooming assistance. Use task segmentation and verbal cues as needed. Gather all of R30 clothing and grooming supplies prior to assisting me with restorative dressing and grooming program. Notify MD (Medical Director) for significant decline in dressing and grooming status and request an order for skilled PT/OT (physical therapy/ occupational therapy) evaluation and TX (treatment) as indicated. Praise R30 efforts in dressing and grooming program. MDS (Minimum Data Set) dated 4/10/23 denotes in-part R30 requires limited assist with one-person physical assist with dressing. Progress Notes include documentation by V37 between 10:08AM and 10:10AM, 5 entries. V37's written statement dated 7/6/23 denotes he was sitting at the nurse's station when R30 presented partially naked. V37 wrote R30 became agitated. V69 came back to nurse and reported the condition of R30's room. V69 said he provided towels for R30 and then left for his appointment. V69's written statement signed 7/6/23 denotes between 10:00AM and 10:30AM R30 spoke very rudely to the nurse. R30 got aggressive, and the nurse called for security. V69 wrote he instructed R30 to go to his room and wait for the nurse when R30 tried to pull V69 to the floor. Security try to back up but R30 kept trying to get on top of security while scratching security face. R5 has a cognitive score of 15, intact, dated 6/16/23. Facility abuse policy with last revision date of 6/28/2023 (a different version that what had been presented prior to 7/6/23) denotes in part the purpose of the policy is to ensure that the facility is doing all that is within its control to prevent and reduce the risk of abuse incidences to the residents of city view multicenter. The types of abuse include neglect, exploitation, mistreatment, sexual, involuntary seclusion, and misappropriation of property. Staff and other relevant ancillary personnel shall have ongoing training on the abuse policy. The education consist of the following: procedure for reporting incidents of abuse, dementia management, abuse prevention, inappropriate staff relationships with the residents, and CPI (crisis prevention intervention). The facility Abuse Policy dated 6/28/23 (a different version that what had been presented prior to 7/6/23) states staff will be trained on the procedures for reporting incident of abuse including CPI. Prevention includes identifying inappropriate behavior including rough handling. Facility Codes Policy and Procedure dated 1/2/23 mentions the code gray is used for behavioral health emergency. No instruction for use given. Based on observation, interview, and record review the facility failed to prevent incidents of resident-to-resident physical assault, and staff to resident mental abuse. This affected 5 of 9 (R11, R14, R9, R24, and R6) residents reviewed for physical and mental abuse. This failure resulted in R14 hitting R11 with a chair. R1 sustained a facial laceration and multiple left orbital fractures. R24 assaulted R9 with a food tray sustaining a laceration to mouth, and V2 CNA challenging R6 to a fight. Findings include: R11's face sheet shows in-part that R11 has diagnosis of cognitive deficits, lack of coordination, weakness, personal history of traumatic brain injury. Facility incident report to the department with date of incident 6/7/2023 denotes in-part, reported by V8 (Director of Nursing), resident (R11) observed with laceration/slight swelling below left eye. Head to toe assessment completed. Area cleaned with NS (normal saline) and ice pack applied to left eye. Resident denies pain. MD (Medical Doctor)