**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure all facility door alarms sounded loud enough for immediate staff response, immediately search the premises for a resident once a door alarm was heard sounding and provide adequate supervision to a cognitively impaired resident with a history of exit seeking for one of three residents (R1) reviewed for elopement risk in the sample of five. These failures resulted in R1, a severely cognitively impaired resident with the diagnosis of Dementia, exiting the facility without staff knowledge or supervision on 9-10-24, walking over 1635 feet down a hill, falling by a tree that was located approximately 25 feet from a main street, causing R1 to sustain two fractures to the end of the forearm (at the wrist), excruciating pain, abrasions to the chin and right arm, and hospitalization for treatment. Findings include: These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 9-19-24, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and Quality Assurance monitoring. The facility's Elopements and Wandering Residents policy dated 5-6-24 documents, Policy: The facility ensures that resident who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering and elopement risk. Definition: Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. Policy explanation and compliance guidelines: 1. The facility is equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risk, implementing interventions to reduce hazards and risk, and monitoring of effectiveness and modifying interventions when necessary. 4. Monitoring and managing residents at risk for elopement or unsafe wandering. a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary team. b. The interdisciplinary team will evaluate the unique factors to contributing the risk in order to develop a person-centered care plan. c. Interventions to increase staff awareness of the resident's risk, modify the residents' behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopements. e. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff. R1's admission Record documents R1 is a [AGE] year-old that was admitted to the facility on [DATE] with the diagnoses of Parkinsonism, Dementia, Neurocognitive Disorder with Lewy Bodies, Altered Mental Status, Depression, Muscle Weakness Unsteadiness on Feet, Lack of Coordination, Hallucinations, and a History of Falling. R1's current Order Summary Report documents, Order date 1-31-24: (electronic monitoring bracelet) check for function and placement daily. R1's current Care Plan documents, Focus 2-2-24: I (R1) wander with no rational purpose, seemingly oblivious to my needs or safety throughout the healthcare center. Goal: I will wander safely within the facility by next review. Interventions: I wear an (electronic monitoring bracelet) to my left wrist. Please check it works routinely to ensure my safety. I am at risk for falling due to lack of coordination, limited mobility, forgetting my limits, the diagnosis of Parkinsonism, and due to psychotropic medication use. R1's Fall assessment dated [DATE] documents R1 was at a high risk for falls. R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 is severely cognitively impaired. R1's Elopement Risk assessment dated [DATE] documents R1 was a high risk for elopement, was fully ambulatory, wanders aimlessly, and has two or more diseases (Dementia, any type of mental illness). R1's Social Service Note dated 2-2-24 at 1:26 PM and signed by V10 (Social Services) documents, (R1) admits for long term care. (R1) did reside with (V6/R1's Family member) but due to (R1's) progression of Dementia, (V6) is unable to care for (R1) at home safely. (R1) at times is able to answer conversations appropriately (and) other times seems to not understand or articulate answer that goes with conversation at hand. (R1) is in the memory unit. (R1) also has displayed exit seeking behaviors generally toward afternoon and nights. (R1) does have an (electronic monitoring device bracelet) for safety measures as (R1) is new to her environment and does have episodes of active wandering and exit seeking behavior. R1's Local Police Department Incident #24-EUREKA-03436 dated 9-10-24 at 4:55 PM and signed by V3 (Local Police Officer) documents, On 9-10-24 at approximately 4:55 PM, I (V3) was on routine patrol around the (facility campus) and I was flagged down by (V4/Chief Executive Officer Assisted Living) in regard to a missing resident (R1). I advised (V4) that I was not notified of any missing person and advised that I was just driving through, but that I would help locate (R1). (V4) advised (R1) has been reported missing from the memory care facility within (the facility) about 15 minutes prior to (V4) flagging me down. Several staff members were on foot looking for the missing female. While searching the area, (V1/Administrator) flagged me down and advised that the missing resident (R1) had been located in the front of the building. I was advised that (R1) was walking and fell down the steep hill and has several injuries. It appeared that (R1) had a broken left wrist, a laceration on her right elbow, a laceration on her chin, had bit her tongue which was causing her mouth to bleed, and was complaining of back pain. It should be noted that (R1) told nearby staff that she was trying to escape from the building on purpose. (R1) said she was waiting on everyone to leave for the day, and she was planning her escape out the doors, which (R1) was successful at and had been missing for about 15 minutes before it was noticed that (R1) was gone from the facility. R1's Health Status Note dated 9-10-24 at 5:09 PM and signed by V5 (Agency LPN/Licensed Practical Nurse) documents, (R1) noted outside in front of facility laying on her backside. Upon assessment (R1) has a swollen left wrist and an abrasion to her chin area. (R1) c/o (complains of) pain and states she is unable to stand with assistance. When asked what occurred prior to fall (R1) states that she was on her way to her appointment, when she lost her balance and fell, landing on her back. AMT (Advanced Medical Transport) contacted for transportation to ER (Emergency Room). (V6/R1's Family Member) also notified of (R1's) fall and elopement. Staff waiting along with (R1) until AMT is here for transport. Will continue to monitor. R1's Health Status Note dated 9-10-24 at 5:22 PM and signed by V5 (Agency LPN) documents, AMT present to transport (R1) to (local hospital) for evaluation and possible treatment. All appropriate parties notified. Bed hold sent with (R1). Will continue to monitor. R1's Health Status Note dated 9-10-24 at 5:55 PM and signed by V8 (LPN) documents (V8) was reported that elopement of (R1) outside of the parking lot. (V8) went to observe (R1) laying on the ground. (R1) was on her back side with open areas on her elbow and knee. (V8) also noticed that (R1's) left wrist was swollen. EMT (Emergency Medical Transport) were called and (V6/R1's Family Member) and (V7/R1's Physician) notified. (V8) went to check doors to see how (R1) escaped. (V8) noticed that hall six fire exit door alarm was going off. (V8) came back upstairs and noted that no sound of alarm or light (was) going off at the nurse's station. (V8) notified staff to call maintenance man to come assess the alarm system. R1's Emergency Department Note dated 9-11-24 documents, Chief Complaint: (R1) left the (facility) and was found lying down after rolling down/sliding down a hill. EMS (Emergency Medical Service) reports deformity to the left wrist. (R1) complained a 10/10 pain and EMS provided 50 mcg (micrograms) of Fentanyl, four mg (milligrams) of Zofran, and splint the left wrist. (R1) has dementia. (R1) states she was going out to get her car when she began to stumble and slid down a hill and hit a tree. Has pain in her left wrist but denies further pain. Abrasion to midline chin noted. Clinical Impressions: Closed fracture of distal end of left ulna and left radius (end of forearm bones at the wrist). R1's X Ray Report of the Left Wrist dated 9-11-24 documents, Impression: Acute distal forearm fractures with associated soft tissue swelling. R1's Health Status Note dated 9-11-24 at 4:35 AM and signed by V9 (LPN) documents, (R1) arrived back to facility at approximately 3:30 this am via transport from (V6). (R1) has an ulnar (forearm) fracture as well as a radial (wrist) fracture. (R1) also has an abrasion of the face. (R1) has a referral made with (Orthopedics). (V6) will keep us updated on exact date of appointment. (R1) currently in room in bed resting. On 9-13-24 at 2:00 PM V23 (Maintenance Director) used a measuring wheel to measure and determine the distance from the door of where R1 exited the building on 9-10-24 to where R1 was found lying on the ground by the tree. There were two routes R1 could have taken. V23 measured both routes with one route measuring 1635 feet from the exit door to the right, through the parking lot, and down a hill to the tree. The other route measured 2475 feet from the exit door to the left and around the building to the bottom of the tree. The tree where R1 was located was approximately 25 feet from the main street in (City facility is located). On 9-13-24 at 3:15 PM R1 was lying in bed at a local hospital. R1 had a four-centimeter scabbed abrasion to the chin, seven-centimeter-long dark purple bruise to the right elbow, and a few small abrasions to the right lower arm. R1's left forearm was in a removable casting splint. R1 was confused to time and place. On 9-13-24 at 6:15 AM V1 (Administrator) stated, On 9-10-24 around 4:47 PM, (V11/Housekeeping Supervisor) heard an (electronic monitoring device) alarm going off at the north door of the basement level. (V11) was trying to shut the alarm off and could not get the alarm to shut off. (V11) grabbed me to help. We initially looked around outside and did not see any residents. (V22/Human Resource Director) called a 'code yellow' over the intercom and we did a head count in the facility and noticed (R1) was missing. (V11) and I went outside and searched the entire perimeter of the facility. Other staff helped look for (R1) and (V12/CNA/Certified Nursing Assistant) found (R1) down by the road, on the ground by a tree. It appeared (R1) had fractures her wrist and was sent to the emergency room. After the incident I watched the cameras and saw (R1) go to the elevator and go downstairs at approximately 4:20 PM. I saw (R1) go down the hallway and around to the back. There are no cameras in the back hallway to see what (R1) did after that. Since the (electronic monitoring device) alarm was sounding we determined (R1) had exited out of the north door. That door has a delayed egress of 15 seconds but there is no alarm hooked up to sound when the door opens except for the (electronic monitoring device) alarm. On 9-13-24 at 6:30 AM V14 (CNA) stated, (R1) says frequently that she wants to go home. (R1) forgets her walker and we must remind her to use it. On 9-13-24 at 6:40 AM V18 (CNA) stated, (R1) is not safe to go outside unattended and forgets to use her walker. On 9-13-24 at 8:00 AM V20 (Activity Director) stated, (R1) tries to exit seek and gets confused. (R1) goes to the lobby doors and tries to go out. On 9-13-24 at 8:10 AM V11 (Housekeeping Director) stated, I heard an alarm that sounded muted like a phone alarm going off (on 9-10-24). It was around 4:45 PM. I had to look around to find where the alarm was sounding off. I found the north basement door (electronic monitoring device) alarm sounding at the north door in the basement. (R5) was standing down by the door, so I thought (R5) had sounded the alarm. I tried to shut the alarm off and could not get the alarm to shut off. I found (V1) and had (V1) go down with me to try to shut the alarm off. In the meantime, two CNAs (V12 and V21) came down and were looking for (R1) to give (R1) a shower. (V1) then said maybe (R1) had set off the alarm. (V1) and I went outside to look for (R1) and a 'code yellow' was sounded over the intercom. (V1) and I searched the entire perimeter and could not find (R1). A little while longer (V12) found (R1) on the ground, down the bottom of a hill, by a tree, that was by the road. (R1) had walked a long way without her walker and had fallen. (R1) had to be sent to the emergency room. The tree is close to the road. On 9-13-24 at 10:00 AM V12 (CNA) stated, I was working on 9-10-24 from 2:00 PM to 10:00 PM. Sometime before supper (V21) was looking for (R1) to give (R1) a shower and could not locate her. Me and (V21) searched all the hallways and resident rooms and could not find (R1). We went downstairs and looked for (R1) and could not find her. That is when I found (V11) by the back door. I got (V13/MDS/Minimum Data Set Coordinator) to help look for (R1). I have been a CNA for a long time and thought I needed to search by the road first. I found (R1) down a hill, lying by a tree on her back with her left leg crossed over her right leg. (R1) had blood on her chin, had bit her tongue, had abrasions to her arms, and her left wrist looked deformed. I got help from (V1 and V13) and 911 was called. On 9-13-24 at 10:20 AM V13 (MDS Coordinator) stated, On 9-10-24 (V12) asked for my help to find (R1). I went outside to help find (R1). (R1) was found lying on her back by a tree and her left wrist was swollen. (R1) was sent to the emergency room and had a broken wrist. Earlier that day (R1) had asked for a code to try to leave through the front door. (R1) was always saying she wanted to go home. (R1) came to this facility for more security because she had eloped from another facility prior to her admission here. (R1) is not safe to be outside unattended by staff. On 9-14-24 at 10:10 AM V6 (R1's Family Member) stated, I was called on 9-10-24 and was told (R1) was being sent to the hospital because she had got out of the building and had fell. (R1) had broken her wrist in two places and had abrasions on her legs, arms, and chin. I had put (R1) in the nursing home because (R1) needed more supervision and her dementia was worsening. I put (R1) in a nursing home and (R1) had got outside of that nursing home unattended, so that nursing home decided (R1) needed more supervision. So, back in January (R1) was transferred to this facility. (R1) cannot be outside without supervision. (R1) does not even know where she is at or what town she is in. The Immediate Jeopardy started on 9-10-24 at 4:20 PM when R1 left the facility without knowledge or supervision of staff and eloped over 1635 feet down a hill, falling by a tree that was located approximately 25 feet from a main street, causing R1 to sustain two fractures to the end of the forearm (at the wrist), excruciating pain, abrasions to the chin and right arm, and hospitalization for treatment. On 9-17-24 at 9:45 AM, V1 (Administrator) was notified of the Immediate Jeopardy. On 9-19-24 this surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 9/10/2024 and 9/12/2024 V1 (Administrator) in-serviced all staff in the facility regarding policies and procedures on elopement and wandering residents, prompt response to door alarms, utilization of facility protocol internal alert code alerts code yellow for elopement wandering residents, head count, and notifications. All staff not in the facility were in-serviced prior to their next scheduled shift. 2. On 9/12/2024 V24 (Social Service Director/SSD) and V13 (MDS Coordinator) conducted an audit to ensure all current residents at high risk for wandering and elopement had a care plan in place and interventions in place to ensure their safety. 3. On 9/12/2024 V1 and V25 (Vice President of Clinical Services) ensured the communication book was updated with all residents at high risk of wandering. 4. On 9/11/2024 V25 completed new elopement assessments for all residents. 5. V23 is continuing audits of door function daily for six weeks. 6. V1 is continuing to audit the communication book daily for 6 weeks to ensure the elopement procedure is fully implemented. 7. On 9/11/2024 V25 provided in-service to the Interdisciplinary Team (IDT) regarding assessing all residents quarterly who wander/exit seek and with any changes in behavior. IDT continues to review the 24/72-hour notes to assess for changes in behavior and possible completion of a current wandering risk assessment. 8. On 9/10/2024 V6 (R1's Family Member) and V7 (R1's Physician) were notified of R1's elopement with injuries and an order was given to send R1 to the emergency department for evaluation and treatment. 9. On 9/19/2024 at 11:45 AM a tour was done, and all exit doors were checked for enunciators. The front entrance door and the basement service doors were not alarmed with an enunciator as stated by the abatement plan. V1 revised the abatement plan to include applying an enunciator to the basement service doors on 9/19/24 by V26 (Corporate [NAME] President of Plant Operations) and assuring the front entrance door was double alarmed. On 9/19/24 at 1:46 PM the basement service door was alarmed with an enunciator and the front entrance door was double alarmed. Abatement completion date: 9-19-24

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to protect one resident (R1) from continued sexual abuse from a known sexually aggressive resident (R2) reviewed for abuse in the sample of three. This failure resulted in an Immediate Jeopardy. Findings Include: The Immediate Jeopardy was identified to have begun on 6/2/2024. The facility was notified of the IJ on 7/2/24 at 11:30 A.M. The Facility's Abuse, Neglect and Exploitation policy dated 6/8/2020 documents Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subject to abuse by anyone, including but not limited to facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friend or other individuals. The Facility's Abuse, Neglect and Exploitation policy dated 6/8/2020 documents Abuse means the willful infliction injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial wellbeing. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse including abuse facilitated or enabled through the use of technology. Willful means the individual acted deliberately, not that the individual must have intended to inflict injury or harm. The Facility Abuse, Neglect and Exploitation policy dated 6/8/2020 documents that Sexual abuse is nonconsensual sexual contact of any type with a resident. On 6/28/24 V1 (Administrator) provided a State Report dated 4/1/24 involving R1 and R2 being found with their hands in each other laps. Upon investigation into the incident on 4/1/24 an Immediate Jeopardy was Identified. The Removal Plan of the Immediacy was accepted on 4/2/24 with the facility remaining out of compliance at a Severity Level II while the removal plan implementation and effectiveness were monitored. V1 stated We just had a (Citation) for this, not three months ago. For these same two residents. V1 provided all related information. R2's Medical Record and psychiatric evaluations done after previous incident of R2 sexually abusing R1 on 4/1/24 document diagnosis of depression, posttraumatic stress disorder, and sexually inappropriate behavior. The Abatement plan dated 4/2/24 documented that R2 would be put on 1:1 supervision. The State Report dated 6/2/24 documents that at approximately 6:30 AM V3 (Certified Nurse Aide) witnessed R1's right hand up the shirt of another resident (R2). The written staff interviews from the date of the incident 6/2/24 document that V14 (Certified Nurse Aide) got R2 up and ready on 6/2/24 and left her in her room around 6:20 AM. The statements document that on 6/2/24 around 6:30 AM V3 (Certified Nurse Aide) and V14 (Certified Nurse Aide) both saw R2 wheel herself up to R1 in the lobby and put his hands on her breasts under her shirt. V14 (Certified Nurse Aide) noted that R2 stated I know I am not supposed to touch him, but it feels so good. R1's Minimum Data Set Assessment (dated 02/28/24) documents a Brief Interview of Mental Status score of 6, indicating severe cognitive impairment. R2's Care Plan last updated on 4/12/24 documents (R2) has a potential for behavior problem due to personal dynamics, false statements of staff, rejection of cares, crying, repetitive activities, attention seeking behaviors, non-compliance of cares, facility policy, manipulative behaviors towards staff, poor safety awareness, refusal to go to doctor's appointments or counselling, inappropriate behaviors, attempting to touch others. On 6/28/24 at 10:30 AM R2 was in bed, alert and oriented to time, place and situation. R2 was very upset about having a 1:1 care giver states I don't need a baby sitter. R2 confirmed that she put R1's hand on her breast. Stated It felt good, he and I are lovers and I don't care what you think. When asked if she thought R1 could consent to being touched or by being made to touch her, R2 stated I think he (R1) knows that he is a warm blooded man and he wants it. I do believe that. R2 confirmed that she understands that R1 cannot answer any simple yes or no questions for himself yet she stated she felt that he (R1) would love to feel my breast, I can tell when he (R1) wants to. On 6/29/24 at 9:00AM V2 (Director of Nursing) confirmed that she was aware of issues of R2 being found sexually abusive to R1 in the recent past (4/1/24.) V2 stated she came to work on 6/2/24, she got in verbal report that (R2) was in her room. V2 stated I then carried on about my day as normal until (V9/Certified Nurse Aide) brought R2 to me and explained that she had just witnessed R2 put R1's hands on her breasts. V2 stated When they (previous staff) said she (R2) was in her room, I assumed they meant in her bed, I didn't check, and she was actually up in her chair, and she can propel herself once up in the chair. V2 confirmed that R1 is in a reclining cushioned wheelchair that he is completely dependent on staff moving for him and that R2 can propel her wheelchair independently once she is up. V2 reported that as of 6/2/24 R2 had been changed to increase monitoring after her previous issues with R1. V2 stated that we had meetings and kind of went over her behaviors and stuff. I don't really remember when she came off of 1:1 and became increased monitoring. On 7/1/24 V1 (Administrator) stated that R2's 1:1 monitoring was discontinued as of 4/4/24 and she was on increased monitoring from 4/4/24 until the date of the second incident on 6/2/24. On 6/29/24 at 9:30 AM V1 (Administrator) stated that increased monitoring is kind of like a step down from being on 1:1, we want to always know where the resident is. For example, if a CNA took a resident that is on increase monitoring to an activity, she would stop and tell an activity member that she is leaving the resident there and for that person to keep an eye on her. V1 stated that there would be no documentation of such monitoring of an increase monitoring resident, and she also could not provide a written policy on increase monitoring. While the Immediacy was removed on 6/2/24, the facility remains out of compliance at a Severity Level II as additional time is needed to implement and evaluate effectiveness of their removal plan and quality improvement plan. 1. Immediate action(s) taken: On 6/2/2024, R2 was put on 1:1 supervision when out of bed and will continue on 1-1 supervision, that removed the immediacy. On 6/5/2024, Staff were in-serviced by LNHA(V1/Administrator) and IDT (Interdisciplinary Team) regarding facility abuse prevention and reporting policy, including definitions of abuse and immediate actions needed, identification of sexual abuse and protection of residents, and increasing supervision for a sexually aggressive resident. Psychiatric services and psychotherapy will continue, and SSD notified Psych provider on 6/4/2024 of recent behaviors. IDT revised and reviewed care plans for R2 and R1 to identify patterns in residents' behaviors and implement interventions. Care plan revisions and interventions communicated to the nursing staff, activity staff and IDT that are caring for R1 and R2. On 6/7/2024, R1 was interviewed by LNHA for any signs or symptoms of psycho-social changes and no changes were noted. R2 will not be seated near male residents during dining, activities, etc. 2. Immediate action(s) taken to ensure all abuse issues are reported and assessed: On 6/5/2024, Staff were in-serviced by Administrator and IDT regarding facility abuse prevention and reporting policy, including definitions of abuse and immediate actions needed, identification of sexual abuse and protection of residents, and increasing supervision for a sexually aggressive resident. 3. Immediate action(s) taken to ensure all abuse issues are reported and assessed: Administrator, SSD, and DON interviewed a sample of employees regarding any concerns, or reports, of resident abuse, with emphasis on inappropriate touching. On 6/5/2024 Administrator and DON educated Nurse Aides and Licensed Nurses on documenting behaviors. Behavior documentation will be monitored by the Social Services Director or designee and care plans will be updated as indicated. Staff will be educated on new interventions either verbally or in written form by the Care Plan Coordinator or designee. In the event of any future resident to resident sexual abuse, the perpetrating resident will immediately be placed on 1:1 supervision until primary care, nursing, and psych evaluations can be complete. The outcomes of these evaluations will be used to determine next steps for care and treatment which could include continued 1:1 supervision or the initiation of discharge planning to a facility with a focus on behavior management. 4. Immediate action(s) taken to ensure the facility is continuing to monitor for and address any concerns regarding abuse or neglect. Director of Operations with The [NAME] will meet with department managers to educate regarding their roles and responsibilities related to abuse/neglect prevention, reporting, investigation, and follow-up. All concerns related to abuse/neglect within the facility will be reviewed by the QA team in regularly scheduled meetings, next scheduled for July 25, 2024, as well as through the QAPI process. SSD or Designee with interview 5 residents and 5 staff members, each week for 6 weeks, to ensure no complaints or concerns of abuse have been noted. Medical Director has been notified of IDPH concerns and will continue to participate in the QA process. On 7/2/24 the surveyor confirmed through observation, interview and record review the facility fully implemented all components of its abatement plan and immediacy was removed.

Based on interview observation and record review, the facility failed to adequately supervise a resident (R4) exhibiting sexually aggressive behaviors, and failed to identify and protect a resident (R5) from multiple episodes of sexual abuse reviewed for abuse in the sample of five. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 04/02/24, the facility remains out of compliance at a Severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and quality assurance program. Findings Include: The facility's Abuse, Neglect and Exploitation policy (revised 12/05/22) documents the following: Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. 'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain or mental anguish. Abuse also includes deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychological well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse including abuse facilitated or enabled through the use of technology. This same policy documents, Sexual Abuse is non-consensual sexual contact of any type with a resident. This policy also documents under the section titled Prevention of Abuse, Assess, monitor, and develop appropriate plans of care for residents with inappropriate sexual behavior, whether towards staff or other residents. The facility's State Report Incident Investigation (dated 03/04/24) documents the following: On March 4, at approximately 8:20 AM, it was reported by the therapist that she had walked through the dining room and saw that (R4) was attempting to touch (R5) in the area of his lap. Both were sitting in the dining room area after breakfast and no other residents were present. (R4) was leaning in towards (R5) and (R5) was not talking and sitting quietly in his wheelchair. When the therapist intervened and questioned (R4) what they were doing, (R4) stated they were doing nothing wrong and just talking. The therapist took (R4) to the activity room. (R5) was taken to the elevator to go back upstairs to his room where a nurse assessed and found no sign of injury. On March 4, at approximately 9:00 am, Social Worker interviewed both (R4) and (R5). When (R4) was interviewed, she expressed her and (R5) were, 'in love' and doing nothing wrong in the dining room. Educated (R4) regarding the necessary cognitive ability for two residents to give consent before touching each other. (R4) verbalized that she wants (R5) to touch her, and he wants her to touch him. When (R5) was interviewed, he stated, No one touches me, I have no problems. Both POAs (Power of Attorneys) and MD (physician) were notified. On March 4, at approximately 9:40 am, Social Worker interviewed six residents with BIMS (Brief Interview for Mental Status) higher than a 10 and asked if they felt safe and comfortable in the facility and they all said 'yes'. Disposition: The facility cannot find evidence of intent to harm or any negative psycho-social outcomes. The two residents do not reside on the same hall and do not sit together at meals. They will remain separated. Care Plans were updated, and Social Services will monitor residents for any negative psycho-social outcomes. R4's Minimum Data Set Assessment (dated 02/19/24) documents a Brief Interview of Mental Status score of 10, indicating moderate cognitive impairment. R4's current care plan documents the following: (R4) has a potential for behavior problem due to current personal dynamics such as: false statements of staff, rejection of cares, crying, repetitive activities, attention seeking behaviors, noncompliance of cares/facility policy, manipulative behavior towards staff, poor safety awareness, refusal to go to doctor's appointments/hospital or counseling. 02/29/24 - inappropriate behaviors attempting to touch others. R4's Medical Practitioner Progress Note (dated 03/01/24) documents: Chief Complaint: Patient reports feeling anxious all the time with occasional panic attacks. History Of Present Illness: Female with a history of MDD (Major Depressive Disorder), Anxiety and PTSD (Post Traumatic Stress Disorder). Per staff, patient requested to go to the hospital to have, 'things removed from her vagina.' Had a stylus in vagina; nursing staff report ER (Emergency Room) doctor documented patient could benefit from a vibrator/safe device to prevent recurrence of foreign objects getting stuck in patient's vagina. No records from hospital visit in EMR (electronic medical record) to review. Per staff, she has history of being inappropriate with other residents, i.e tried to grab another resident's penis in the past. (R4) is seen in her room, sitting in her wheelchair. She reports her mood is 'not good at all.' She shares about the incident. She states she struggles with hyper-arousal/hypersexuality and inserted stylus into her vagina. She states she had multiple inserted into her vagina prior to being sent to the ER. She becomes tearful. She states she has a lot of shame related to this and feels depressed. She requests something to help with her hyper arousal. She also reports feeling anxious all the time with occasional panic attacks. She denies suicidal or homicidal thoughts. She states she does not sleep well at night, because of leg pain and fear that she won't be able to walk again. Appetite is good. No manic or psychotic symptoms reported. Tolerating her medications without side effects reported. In agreement with ER doctor to allow patient to purchase appropriate item to prevent inserting inappropriate objects in her vagina and rectum. Patient is already taking the maximum dose of sertraline, discussed that SSRI/SNRI (Selective serotonin reuptake inhibitors/Serotonin and norepinephrine reuptake inhibitors) can lower libido, but she does not seem to be getting this effect. I think it's fair to trial a higher dose of buspirone to help decrease patient's anxiety and help some of her symptoms. If patient continues to be distressed by her symptoms or becomes inappropriate with another resident again, may need to trial divalproex in the future. No other concerns. On 03/27/24 at 12:45 PM, R4 was sitting in a wheelchair in the basement of the facility near the activity room. R4 was alert to person and place, but could not recall the date. R4 was questioned about recent events, and she stated the following: I am ok. Most of what's happened is my doing. I really don't want to talk about it. I am just a crazy old lady with a horrible sex drive. But I want to be with an adult that's my age and more alert. (R5) is confused. Anything we did was beautiful. He liked it too. When I see him, something sparks. It's nobody's business, and I think he (R5) enjoys sex as much as I do. R5's Minimum Data Set Assessment (dated 02/28/24) documents a Brief Interview of Mental Status score of 6, indicating severe cognitive impairment. R5's current care plan documents the following focus: (R5) is at potential risk for abuse related to Dementia, dependency on staff. On 03/27/24 at 12:30 PM, R5 was sitting in a wheelchair near the facility's front door. R5 was pleasantly confused and could answer simple questions. R5 confirmed that he had just eaten lunch, but could not recall what he had just eaten for lunch when asked. R5 could not recall any recent interactions with R4. R5 stated, yes, when asked if things were going ok, and stated no when asked if he had any issues or concerns. On 03/25/24 at 11:50 PM, V3 (Assistant Director of Nursing) stated, (R4) targets (R5). He (R5) is not cognizant. He cannot give a verbal response that he wants (R4) to do that (touching). (R4's) sexual behavior heightened about 3 weeks ago. She only behaves this way toward (R5), and she has been inappropriate with the two male CNAs (Certified Nursing Assistants) that currently work here. (R4) has been pulling her shirt up in the lobby in front of (R5). (R5) barley converses and does not like to be bothered. Every time (R4) comes out of her room she looks for (R5). We try to keep them separated, but (R4) can be quick. On 03/25/24 at 12:15 PM, V4 (Activity Director) verified the following written statement documented in R4 and R5's 03/04/24 Incident Investigation: On 03/03/24 at approximately 10:00 AM, I saw (R5) in (R4's) room and they were not talking, just sitting there. I walked in and started moving (R5) out of the room and (R4) said to me 'We are in love and in our own private room.' (R5) was in (R4's) room. I don't know how he got in there. My best guess is (R4) lured (R5) in there. He would not purposefully go into someone's room, but he would follow commands if someone gives him instructions. I removed (R5) from the room at that time. (R4) had been pursuing (R5) for about a month, and I feel like it really heightened about 2 to 3 weeks ago. I feel like it's been a situation where the more you tell her 'no' the more she wants to do it. We have been told to keep them separated, and if (R4) is out of her room, she will find (R5). (R5) is cognitively impaired, so he hasn't seemed bothered by any of this. But you wonder how much he really understands since he is impaired. I've had to separate them a few times this past month, mostly when (R4) has made herself close to (R5). On 03/25/24 at 12:50 PM, V2 (Director of Nursing) stated she has been employed at the facility since January 2024. V2 stated, (R4) has been sexually inappropriate towards (R5). We have been keeping them separated. (R5) is impaired and doesn't know what happening. (R4) does know. I have told her that (R5) doesn't understand being in love with you. He cannot consent. (R4) likes to sleep naked and does what she wants to do. She wants male staff to see her naked. One day she made the comment 'what are you supposed to do when your mind still thinks you're a size 6?' She has only been inappropriate with (R5). This has not occurred with any other male resident. (R5) has been indifferent about all of what's occurred with (R4). I don't even know if any of it has registered. I think if it bothered him, he would be swearing because he swears at staff often during cares. (R4) is attention seeking. She is monitored for behaviors, and it may not be documented as frequently as it occurs because staff has normalized her behaviors after observing her display them so often. R4's Behavior Monitoring and Interventions Report (dated 01/01/24 - 03/27/24) has no documentation of behaviors exhibited throughout this timeframe, with the exception of the following: an episode of grabbing others and public sex acts, both noted on 03/04/24; an episode of express frustration/anger at others and agitation noted on 03/09/24; and an episode of express frustration/anger at others and disruptive sounds noted on 03/17/24. V5's (Certified Nursing Assistant) witness statement noted in the facility's 03/04/24 Incident Investigation documents, (R4) wheeled herself up to (R5) at the table in the lobby. (R4) was crouched over to her side, leaning in towards (R5). I said, '(R4), keep it PG' (parental guidance, some material may not be suitable for children), and she said 'OK.' I continued with my vitals but I kept circling around and watching her and she was inching herself closer to (R5) and then I turned and looked and her shirt was up and he was grabbing her breast. I told (R4) 'that is inappropriate' so I unlocked her wheelchair and moved her closer to the TV. (R4) was upset and shouting that she can have relationships and it is her right. On 03/25/24 at 01:40 PM, V5 verified the above statement and stated this incident occurred on 03/04/24 at approximately 10:00 AM. V5 then stated, I have been on light duty and was sitting at the receptionist desk when this occurred. (R4) has been approaching (R5). She inches up to him and has been sexually inappropriate previously. (R4) will gravitate toward (R5) if she sees him. This has been happening since some time in February. (R5) doesn't get angry or really react at all. He definitely does not have the mental capacity to consent. Once you move (R4) away from him, she will find a way to return. She has said 'it's not a crime to love somebody.' I have told her that her actions out in the open are inappropriate. She has been lifting her shirt up in the front lobby when (R5) is present, and I have had to intervene a few times. I went and mentioned this to (V1, Administrator) in the beginning when it first had started. I wrote a statement about it. (R4) was always lifting up her shirt and (R5) being next to her with his hand there. She would begin touching and rubbing his hand and it would escalate to her shirt lifted up and his hand ends up on her breast. I never witnessed her shirt going up but would catch it once it was up. I would see her display the initial behavior and knew it was going to progress to her shirt up with his hand on her, so I knew to watch closely and be more aware. I never intervened when they were handsy but knew to step in when her shirt was up. She has also tried reaching in (R5's) pants. R4's Custom Alert (dated 03/04/24 and written by V5) documents the following: (R4) was addressed by multiple aides out in the hall to keep it PG and hands to herself. (R4) sneaks in the second eyes are off of her. Her breast was out with another resident's hand up her shirt while (R4) was reaching to (R5's) pants. V6's (Certified Nursing Assistant) witness statement noted in the facility's 03/04/24 incident investigation documents the following: (R4) was trying to hold (R5's) hand and I moved them apart, but she seemed to find him again and we kept an eye on her. On 03/25/24 at 02:25 PM, V6 verified the above statement and stated, She had found her way back to him and I had to separate them again. This was on 03/04/24 around 10:30 AM. (R4) is always the one approaching (R5). She has the awareness and knows she shouldn't be doing what she's doing. If she can see him, you've got to watch her. She's 100% with it and knows right from wrong. V7's (Certified Nursing Assistant) witness statement noted in the facility's 03/04/24 incident investigation documents, I was told she (R4) was trying to get her hands down his (R5) pants and asking him to do the same. On 03/25/24, V7 verified the above witness statement and then stated the following: We tried to keep them separate, but she will go back to him if you don't completely separate them, meaning not just moving her away from him in the same vicinity. She has to be moved to where she cannot see him, like she needs to be taken downstairs for activities. (R4's) behaviors started about two months ago. Initially she made comments. It went from her making these inappropriate comments to talking about doing things to herself. It continued to escalate as she began approaching (R5). On 03/25/24 at 03:05 PM, V1 (Administrator) stated facility staff started realizing that R4 had been getting close to R5, Last month. Mid-February. She was getting real close to (R5). She was whispering and began making sexual comments. She would say things like it's her right to have a boyfriend and 'We are adults. Leave us alone. We're in love.' We explained to (R4) that cognitively, (R5) doesn't understand and he cannot make this type of decision himself. I think she understands what It means for someone to be able to make decisions for themselves. (R4) tends to live in her own little world and was thinking she and (R5) were boyfriend and girlfriend. She also displays attention seeking behavior. She likes attention. She has been sneaky about this she'll look up to see if you're watching her. We had placed her on 15 minute checks after the 03/04/24 incident for 48 hours. We've never implemented one-on-one supervision, but definitely made sure she was in areas of high visibility. I think she has prompted (R5). I can totally see her manipulating the situation, especially with his impaired cognition. He does not grab at anyone else, so for his hands to be in contact with her, she's physically or verbally manipulated the situation somehow. V8's (Certified Nursing Assistant) witness statement noted in the facility's 03/04/24 incident investigation documents, (R4) sits in the lobby with her shirt up and no bra on and just sits there, and there are times family comes in to visit. I ask her to put her shirt down and she acts like she is doing nothing bad. On 03/26/24 at 09:50 AM, V8 verified her witness statement and stated the above occurred on 03/03/24, (R4's) shirt was up and I told her to stop and she said, 'Why? We're in love.' I told the nurse and she told me to separate them. I took (R5) in his room and transferred him into his recliner. All of this started in February. First (R4) was lifting up her shirt. She was sexually inappropriate and it seemed to progress to her constantly attempting to pursue (R5). You could move her to the other end of the lobby and she'd begin making her way back to him. This happened multiple times. Several staff would move (R4) away from (R5) and she would always seem to find her way back to him. I witnessed her with her shirt up twice on 03/03/24, and then again in the dining room about a week later. If (R5) physically had his hands on (R4) it is because she prompted him. (R5) will follow instruction, so I could see (R4) telling him to do things. (R5) does not grab at anyone. If that was the case, he'd be touching others as well. On 03/26/24 at 11:15 AM, V9 (Physical Therapy Assistant) stated she is the individual who witnessed the 03/04/24 incident between R4 and R5. V9 stated, I walked into the dining room and (R4) was talking to (R5). I knew they weren't supposed to be together and they were supposed to be separated. (R4) had been observed being sexually inappropriate with (R5) for a week or two prior to this day. I asked her what she was doing and she said 'nothing.' I told her to keep moving along and she did, but I continued observing. I overheard (R4) ask (R5) to put his hand in her pants, and I immediately intervened. I told her that was inappropriate and pushed her wheelchair to activities. I told (V3, Assistant Director of Nursing) about what had occurred and (V10, Social Service Director) called and spoke with me about the incident later that day, or the following day. On 03/27/24 at 10:30 AM, V11 (Certified Nursing Assistant) verified her witness statement noted on the facility's 03/04/24 incident investigation and stated, I usually work in the dementia unit. I was walking to the dining room for something and out of the corner of my eye I saw (R4) taking her shirt off. I went over and put her shirt back on and explained that she cannot be doing that in the lobby. I saw her doing it again when I was heading back the my unit, so I removed her from the area and pushed her wheelchair over by the CNA (Certified Nursing Assistant) that was working. I can't remember who was working that day. On 03/26/24 at 12:10 PM, (V10, Social Service Director) stated, I believe it was mid-February when (R4) started to approach (R5). She was getting in his personal space, and staff was instructed to separate them. She had been hypersexual and began pursuing him. (R5) is cognitively impaired and cannot consent. (R4) knows what she's doing. V10 verified that R4's care plan was updated on 02/29/24 after R4 was observed hypersexual and approaching R5 and, getting in his personal space. On 03/27/24 at 09:55 AM, V1 (Administrator) stated the 03/04/24 abuse allegation investigation regarding R4 and R5 was unsubstantiated, I did not feel like either one had the intent to be malicious. We initiated 15 minute checks on (R4) for 48 hours and placed her in areas of high visibility. I don't like doing one-on-one supervision as it can be upsetting and disruptive to the resident. We attempted to engage (R4) in more activities to redirect her focus. I would do one-on-one supervision if there were concerns about resident safety. This incident wasn't a safety concern. She (R4) wasn't going after all of the residents. (R4) and (R5) rooms are located on different hallways so we could keep them separated. The Immediate Jeopardy was identified on 04/01/24 at 07:45 AM to have begun on 02/29/24 when R4's care plan was updated for R4 displaying inappropriate behaviors of attempting to touch others. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 04/01/24 at 08:20 AM. The surveyor confirmed through interview, observation and record review that the facility took the following actions to remove the Immediate Jeopardy: On 04/03/24, V1 (Administrator) provided copies of the following In-Service/Meeting Attendance Forms completed on 04/01/24 and 04/02/24 with indication that this training was administered by V1 and V2 (Director of Nursing): Abuse/Neglect Policy/Procedure and Education; Abuse/Neglect In-Service; Abuse: Who to Report Abuse to/What is Abuse; Appropriate Seating for a Resident that Displays Inappropriate Touching and Redirection Tools to Divert Attention to Positive Outcome; and Monitoring Resident Behaviors for Signs and Symptoms of Abuse or Potential for Abuse. These attendance forms confirm all staff working on 04/01/24 and 04/02/24 received the required education. An In-Service Attendance Sheet for staff members not present at the in-services on 04/01/24 or 04/02/24 was also provided and these staff members were called and the education was administered via telephone conversation. On 04/03/24, the following staff members were interviewed and could speak in detail of the recent abuse training that they had received, including the facility's abuse prevention and reporting policy, including definitions of abuse and immediate actions needed, identification of sexual abuse and protection of residents, and increasing supervision for a sexually aggressive resident: V2 (Director of Nursing); V3 (Assistant Director of Nursing); V6, V8, V15, V18, V20 and V21 (Certified Nursing Assistants); V19 (Registered Nurse); V22 (Dietary Manager); V23 (Housekeeping/Laundry); V4 (Activity Director); and V24 (Maintenance). CNAs (Certified Nursing Assistants) and Licensed Nurses elaborated on the education administered regarding documenting resident behaviors and new behavior interventions. All staff interviewed were able to elaborate on behavioral interventions to utilize with a sexually aggressive resident. On 04/04/24 at 01:27 PM, R4 was lying in bed covered with a sheet. V5 (Certified Nursing Assistant) was sitting in a chair near the doorway to R4's room providing one-to-one supervision. On 04/03/24 at 10:05 AM, R4 was in her room lying in her bed, and V21 (Certified Nursing Assistant) was providing one-to-one supervision. V21 stated, She hasn't wanted to come out of her room much since she's been on one-to-ones. If she decides to go to the dining room for lunch today, she will be seated at a table with other female residents, but I am guessing she will want to eat in her room. R4 was observed eating lunch in her room on 04/03/24 at 12:16 PM. On 04/03/24, V1 (Administrator) provided a copy of the 1:1 Staffing Sheet for R4, which documents one-to-one supervision has been provided to R4 on 04/01/24 - 04/03/24. R4's Progress Note (dated 04/02/24) documents V10 (Social Service Director) contacted psychiatric services for notification of R4's recent behaviors, and an appointment was scheduled for R4 to be evaluated on 04/09/24. R5's Progress Note (dated 04/01/24) documents the following: (V10, Social Service Director) spent some time with (R5) today. No psycho-social distress noted. (R5) was relaxing in his recliner. On 04/03/24 at 11:19 AM, V10 verified the above progress note and stated she will continue monitoring R5 for psycho-social changes. R4 and R5's current care plans were revised on 04/02/24 to reflect the recent abuse concerns, and new behavioral interventions had also been implemented at that time. On 04/03/24, V1 (Administrator) provided copies of Focused Audit Tools, which document V10 (Social Service Director) interviewed five facility staff members and five residents regarding any concerns, or reports of resident abuse, with emphasis on inappropriate touching. V1 also provided a copy of a resident roster containing all residents in the facility with a Brief Interview for Mental Status score of 8 or above, and documents V10 conducted interviews with these residents for any abuse concerns. On 04/03/24, V1 provided a copy of an In-Service Education Attendance sheet with documentation that V26 (Director of Operations) met with the facility's department managers and education regarding their roles and responsibilities related to abuse/neglect prevention, reporting, investigation and follow-up was administered. On 04/03/24, V1 stated the facility has not had any allegations of abuse reported since the allegation involving R4 and R5 on 03/04/24. V1 spoke in detail regarding the following process: In the event of any future resident-to-resident allegation of sexual abuse, the alleged perpetrator resident will immediately be placed on one-to-one supervision until primary care, nursing, and psychiatric evaluations can be completed. The outcomes of these evaluations will be used to determine next steps and treatment which could include continue one-to-one supervision for the initiation of discharge planning to a facility with focus on behavior management. The Interdisciplinary Team will review the circumstances of the allegation to assess whether a root cause can be identified, such as a physiological change. The care plans of residents involved will be updated to reflect the next steps for treatment and staff will receive education on new interventions. On 04/03/24, V1 stated the facility has integrated the focus on abuse/neglect into the facility's QAPI (Quality Assurance and Performance Improvement) process and abuse and neglect will be discussed in detail at the facility's upcoming Quality Assurance meeting, scheduled for 04/18/24. V1 also confirmed V12 (R1's Primary Physician/Medical Director) was notified of all abuse concerns on 04/02/24, and V1 stated that V12 will attend the 04/18/24 meeting, and will continue to participate in the Quality Assurance process.

Based on observation, interview and record review, the facility failed to ensure an ambulatory resident with a history of known aggressive behaviors was monitored to prevent resident to resident verbal and physical abuse and failed to ensure residents were free of resident to resident verbal and physical abuse for three of four residents (R31, R34, R51) reviewed for abuse in the sample of 41. This failure resulted in R51 and R31 calling R34 a name using foul language, R34 wandering into R51's room and attempting to lift R51 out of R51's wheelchair resulting in R51 being fearful of R34. This failure also resulted in R34 wandering into R31's room, placing R34's hands on R31, attempting to pull R31 out of R31's room and then shoving R31 in the back. These failures resulted in an Immediate Jeopardy. While the Immediacy was removed on 4/14/22. The Facility remains out of compliance at a severity level II while the Facility continues to monitor the effectiveness of education and training on abuse prevention, reporting, and protecting a vulnerable population including conducting an investigation. Findings include: The facility's Abuse, Neglect, and Exploitation policy, revised, 6/8/20, states, Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subject to abuse by anyone, including, but not limited to: facility staff, other residents, consultants, contractors, volunteers or staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals. Definitions: 2. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful means the individual deliberately, not that the individual must have intended to inflict injury or harm. 3. Verbal abuse means the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance regardless of their age, ability to comprehend, or disability. 5. Physical Abuse includes but not limited to hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. R34's Facesheet documents R34 with diagnoses to include but not limited to: unspecified dementia with behavioral disturbance, cognitive communication deficit, anxiety disorder, and major depressive disorder. R34's Brief Interview for Mental Status documents R34 with severe cognitive impairment. R34's Wandering Risk Assessment, dated 12/2/21, documents R34 as a high risk for wandering. R34's current Care Plan, states, I wander with no rationale purpose, seemingly oblivious to needs or safety due to Dementia. Remove/redirect resident from other resident's rooms and/or unsafe situations or nonresident areas. This same Care Plan states, (R34) is/has potential to be verbally/physically aggressive r/t (related to) Anger, Dementia, Poor Impulse Control. R34's Nursing Notes on 3/17/22 documents R34 to be agitated and combative with staff. R34's Health Status Note on 4/1/22 at 12:14 P.M., states, (R34) becoming increasingly agitated. Took PRN (as needed) Xanax approx. (approximately) 20 min. (minutes ago). (R34) hit CNA (Certified Nursing Assistant) in the face when CNA attempting to redirect d/t (due to) resident frequently trying to go into other resident's rooms. R34's initial State Report form, (undated), provided by V1/Administrator on 4/7/22, documents on 3/19/22, R34 allegedly lifted another resident's chair (R51), scaring the resident and an investigation was initiated. R34's five-day follow-up report to the local state agency states, On 4/6/22, (V1/Administrator) informed by (V4/Director of Business Office Development) of possible incident between (R34) and (R51) that occurred on 3/19/22. Reported that (R34) lifted (R51's) wheelchair and scared (R51). This same report documents on 4/7/22 around 3:00 P.M., V23 (Resident Aide) telling V1 that on second shift (R34) was in (R51's) room and (R34) tried lifting (R51's) wheelchair while (R51) was sitting in it. (V23) also stated that (R34) laid on the floor of (R51's) room and (V23) had to get a nurse to come in and help get (R34) out of (R51's) room. (V1) spoke to (V24/Certified Nursing Assistant) on 4/7/22. (V24) stated (V24) does recall helping (V23) redirect (R34) out of (R51's) room. (R34) had entered (R51's) room through the joined bathroom. (R51) had stated that (R34) lifted (R51's) wheelchair. (V1) spoke to (R51) on 4/9/22. (R51) stated that (R34) raised (R51's) wheelchair while (R51) was in the wheelchair and it scared her. (R51) says she feels safe now that (R34) has been moved to another hallway. Disposition: On 4/9/22, the IDT (Interdisciplinary Team) discussed the altercation between (R34) and (R51) and implemented intervention of staffing 1:1 (one on one) and room change for (R34). R34's initial State Report form, (undated), provided by V1/Administrator on 4/7/22, documents on 3/19/22, R34 allegedly hit another resident (R31) and an investigation was initiated. R34's five day follow-up report to the local state agency states, On 4/6/22, (V1) informed by (V4) of possible incident between (R34) and (R31) that occurred on 3/19/22. Staff member (V23) stated that (R34) hit (R31) in the hallway. This same report states, (V1) spoke to (V23) by phone on 4/7/22 around 3:00 P.M., (V23) stated that (V23) observed (R34) hit (R31) on her back. On April 9, 2022, (V1) and (V2/Director of Nursing) watched the video footage of Hall 5 security camera from Saturday, March 19, 2022 .The camera showed that at 5:54 P.M., (R34) walks into (R31's) room, (R34) guides (R31) out of her room into the hallway, the guide was by (R31's) arms, then (R34) lightly shoves (R31's) back .There was no harm observed but the shove from (R34) was intentional. Disposition: On 4/9/22, the IDT (Interdisciplinary Team) discussed the altercation between (R34) and (R51) and implemented intervention of staffing 1:1 (one on one) and room change for (R34). On 4/6/22 at 8:32 A.M., R34 was observed in R34's room in R34's wheelchair, R34 entered the bathroom that is shared with R51. R34 then exited the bathroom on R51's side of the room and went into the hallway through R51's doorway. At this time, R51 stated, Get her away from me, she's trying to kill me. She scares me. No staff was present in the hallway at this time. On 4/6/22 at 9:11 A.M., R51 was sitting in R51's wheelchair. A test of the door alarms with R51's electronic wandering device was being conducted alongside V18 (Certified Nursing Assistant/CNA). R51 repeatedly asked about the whereabouts of R34 and why R34 acts the way R34 does. R51 stated, I shouldn't say that I know why she does that. It just scares me. Can't (R34) get out of here? On 4/6/22 at 9:15 A.M., V18 (Certified Nursing Assistant/CNA) stated, R34 and R51 do not get along. V18 stated there was an incident approximately one month ago when R34 came and tried to lift R51 out R51's chair. V18 stated, (R34) is strong and when she's mad, it's not good. V18 verified R34 is already on 15-minute checks. On 4/7/22 at 12:45 P.M., V4 (Director of Business Development) stated that when performing staff interviews about R34 lifting R51 out of R51's chair (on 3/19/22), V4 also found that staff reported to V4 that R34 hit R31 after R31 called R34 a b***h that same day (3/19/22). On 4/8/22 at 4:40 P.M., R7 stated, About a month ago, (R51) was sitting in her wheelchair in (R51's) room. (R34) came over there and grabbed a hold of (R51's) wheelchair (that R51 was sitting in) and started pulling and lifting it up. (R51) started yelling for help at that time. I would say it lasted about a minute. R7's Brief Interview for Mental Status, dated 1/20/22, documents R7 is cognitively intact without memory impairments. On 04/08/22 at 10:11 A.M., R51 stated, I was in my room listening to my music (on 3/19/22) and (R34) came into my room and lifted the back of my wheelchair up three times. I thought (R34) was going to kill me. I was so damn scared. I went and ate with (R36) because I was so scared. I didn't want to go to the dining room without someone or be alone in my room. (R34) shouldn't still be allowed to mingle around me. It hasn't happened again since. I keep my eye on (R34). I'm sure (R34) would like to get a hold of me again. (R34) wasn't always my neighbor. People have wrote stuff down about this before, no one has done anything. I'm so scared of her. They told me she was going to be leaving, but she never does. I wish she wasn't right next to me. On 4/8/22 at 12:48 P.M., V24 (Certified Nursing Assistant/CNA) stated, I was there on 3/19/22 when (R34) tried to pick (R51) out of the wheelchair. It was probably around 3:00 P.M. or 3:30 P.M., before supper. I was at the nursing station, and I heard some commotion. I was not assigned to that hallway. I helped get (R34) out of (R51's) room. (R51) was very mad. (R51) said she didn't want to deal with that anymore and that she shouldn't have to. I believe (V23/Resident Aide) told the nurse. I don't remember who the nurse was. I did not tell (V1/Administrator) but it should be reported right away. On 4/8/22 at 3:28 P.M., V23 (Resident Aide) stated, On second shift on the weekend, (3/19/22), I was keeping an eye on (R34). I was the 1:1 for (R31). I heard (R51) yell, 'Get this B***h out before I kill her.' (R34) was grabbing (R51's) wheelchair and trying to get (R51) out of the chair. (R34) then sat in (R51's) recliner chair in (R51's) room. (R51) asked (R34) to get out of the chair and (R34) said, 'I'm not going anywhere.' It took three of us to get (R34) out of (R51's) room. We went through the shared bathroom to get (R34) back into her own room. (R51) called (R34) a B-word and I think that is what triggered her. Once (R51) said the B-word is when (R34) got aggressive. (R31) also called (R34) a B-word and (R34) smacked (R31) that same day. (R51) is scared of (R34) now because of the way (R34) picked (R51) up. Every time I go in that hallway, (R51) asks me if (R34) is around. I reported all of this to (V1/Administrator) the next day. On 4/8/22 at 5:03 P.M., V1 (Administrator) stated, The staff should have called me right away. It says right on the outside of my door that I am the Abuse Coordinator and I even carry an abuse phone and the phone number is posted as well. We just in-serviced staff on who the abuse coordinator was and when to call in mid-February (2022). Waiting until the next day (to report potential abuse) is unacceptable. I would have come right in. I didn't know anything about this. We are going to discuss the best placement for (R34). We have to look at the census. (V4/Director of Business Development) first made me aware of this incident with (R34) the day before yesterday (4/6/22). (R34) wanders. Someone should always be with (R34). There should be some sort of documentation of (R34's) behavior in (R34's) medical record (about the 3/19/22 incident) and there is not. At this same time, V1 verified no new interventions or changes (after the 3/19/22 incident) have been put into place to keep other residents safe from R34. On 4/9/22 at 10:35 A.M., V31 (Certified Nursing Assistant/CNA) stated that R34 can be violent to anyone and everyone. On 4/9/22 at 3:30 P.M., After watching video surveillance, V1 verified on 3/19/22 that, R34 grabbed hold of the back of R51's wheelchair after wandering into R51's room, R34 wandered into R31's room, R34 shoved R31, and R34 then wandered again into R51's room. On 4/9/22 at 3:55 P.M., R36 stated, It's been several weeks ago now, but I was in my room about to go out the door. (R51's) room is right across from mine, so I can see everything. I believe (R34) came into (R51's) room from the bathroom door. (R34) was behind (R51) and lifted her chair a few times where (R51) slid just about out. (R34) does impulsive things. (R51) was yelling for help and saying 'stop, stop.' (R34) finally let (R51) go. The staff came and tried to get (R34) out of (R51's) room. (R51) was so scared. (R51) didn't want to be around her. (R51) was scared that (R34) would come through her bathroom door again. (R51) went to lunch (in the dining room) with me a couple times. I think because (R51) was too scared to stay there and see (R34). R36's Brief Interview for Mental Status, dated 2/23/22, documents R36 is cognitively intact without memory impairments. The Immediate Jeopardy was identified on 4/12/22. The Immediate Jeopardy began on 3/19/22 after R34 wandered into R51's room and placed R34's hands on R51's wheelchair while R51 was sitting in it and attempted to lift R51's chair. That same day, R34 then wandered into R31's room, pulled R31 out of R31's room and then R34 shoved R31 in the back. On 4/12/22 at 4:25 P.M. V1 (Administrator) was notified of the Immediate Jeopardy. On 4/14/22, the surveyor confirmed through observation, interview and record review the facility took the following actions to remove the Immediate Jeopardy: 1. On 4/9/22, R34 was moved to another hallway and placed on 1:1 (one to one) with staff. V1 (Administrator) and V2 (Director of Nursing) communicated altercation between R34 and R51 and R34 and R31 to floor staff and reason for implementation of 1:1 and room move. R34's Care Plan reviewed and updated with 1:1 supervision. 2. V6 (Social Service Director) V1 or designee will meet with R51 at least three times per week for four weeks to provide psychosocial support. 3. On 4/12/22, V1 was in-serviced by V22 (Vice President of Operations) on Resident Abuse Prevention and Reporting-Protecting a vulnerable population (including completion of pre/posttest) and Abuse, Neglect, Exploitation-Conducting an Investigation in a Skilled Nursing Facility (including completion of pre/posttest). 4. On 4/12/22, the facility began in-service with all staff on Resident Abuse Prevention and Reporting-Protecting a Vulnerable Population (including completion of pre/posttest). In-service completion date of 4/14/22. 5. On 4/13/22, all managers received in-service Resident Abuse Prevention and Reporting-Protecting a vulnerable population (including completion of pre/posttest) and Abuse, Neglect, Exploitation-Conducting an Investigation in a Skilled Nursing Facility (including completion of pre/posttest). 6. All abuse reports and investigations will be discussed with and reviewed by V4 prior to submission to the local state agency to ensure completion of Abuse Investigation Protocol Checklist.

Based on observation, interview and record review, the facility failed to immediately supervise a confused, wandering resident (R34) with a history of aggressive behaviors and implement new interventions after a resident to resident (R34 and R51) physical altercation occurred and failed to protect residents in the facility, including (R7, R31,R36, R46, R39, R51) who reside on the same hallway as R34, from further abuse and potential abuse during the course of an open investigation. This failure resulted in R34 having continued access to residents in the facility, including R31 who R34 physically pulled and shoved hours after R34's previous altercation with R51 on 3/19/22. This failure also resulted in R34 and R51 continuing to have bedrooms that were connected with a shared bathroom. R51 remained fearful of repeated abuse from R34. R34 continued to wander throughout the facility, including into R51's room. These failures resulted in an Immediate Jeopardy. While the Immediacy was removed on 4/14/22 the facility remains out of compliance at a severity level II while the Facility continues to monitor the effectiveness of education and training on abuse prevention, reporting, and protecting a vulnerable population including conducting an investigation. Findings include: The facility's Abuse, Neglect, and Exploitation policy, revised, 6/8/20, states, Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subject to abuse by anyone, including, but not limited to: facility staff, other residents, consultants, contractors, volunteers or staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals. Definitions: 2. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful means the individual deliberately, not that the individual must have intended to, inflict injury or harm. 3. Verbal abuse means the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance regardless of their age, ability to comprehend, or disability. 5. Physical Abuse includes but not limited to hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. Procedure: 5. Prevention of Abuse, Neglect and Exploitation-a. Train staff in appropriate interventions to deal with aggressive and/or catastrophic reactions by residents. b. Observe resident behavior and their reaction to other residents, roommates, tablemates. c. Place residents in accommodations and environments that help keep them calm. e. Respond to all allegations or questions of abuse by residents, family members, employees or visitors. f. Take appropriate actions when abuse, neglect, or exploitation is suspected. k. Assess, monitor and develop appropriate plans of care for residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, residents who have behaviors such as entering other resident's rooms, residents with self-injurious behaviors, residents with communication disorders and those that require heavy nursing care and/or are totally dependent on staff. 8. Resident Protection after Alleged Abuse, Neglect and Exploitation-The facility will make efforts to protect all residents after alleged abuse, neglect and/or exploitation. Examples of ways to protect a resident from harm during an investigation of abuse, neglect and exploitation may include, but are not limited to: a. Temporary (less than 24 hours) separation from other residents if a resident's behavior poses a threat of abuse or violence. b. Temporary or permanent room or roommate change, where incompatibility creates the potential for abuse. e. Temporary one on one supervision of a resident. f. Engage a resident in diversionary activities j. increased supervision of staff and residents 9. Response and Reporting of Abuse, Neglect and Exploitation: Anyone in the facility can report suspected abuse to the abuse agency hotline. When abuse, neglect or exploitation is suspected, the employee should: a. Respond to the needs of the resident and protect them from further incident (document). 14. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: c. Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in process. The facility's Compliance with Reporting Allegations of Abuse/Neglect/Exploitation policy, dated 1/1/20, states, Policy: It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes. Compliance Guidelines: The facility will provide resident, families and staff information on how and to whom they may report concerns, incidents, and grievances without the fear of retribution, and will provide feedback regarding the concerns that have been expressed. The facility will identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. 7. Protection: The facility will protect residents from harm during an investigation. R34's Facesheet documents R34 with diagnoses to include but not limited to: unspecified dementia with behavioral disturbance, cognitive communication deficit, anxiety disorder, and major depressive disorder. R34's Brief Interview for Mental Status documents R34 with severe cognitive impairment. R34's Wandering Risk Assessment, dated 12/2/21, documents R34 as a high risk for wandering. R34's current Care Plan, states, I wander with no rationale purpose, seemingly oblivious to needs or safety due to Dementia. Remove/redirect resident from other resident's rooms and/or unsafe situations or nonresident areas. This same Care Plan documents (R34) is/has the potential to be verbally/physically aggressive related to Anger, Dementia, Poor Impulse Control and on 11/23/21, 15-minute checks were initiated. R34's Nursing Notes on 3/17/22 documents R34 to be agitated and combative with staff. R34's Health Status Note on 4/1/22 at 12:14 P.M., states, (R34) becoming increasingly agitated. Took PRN (as needed) Xanax approx. (approximately) 20 min. (minutes ago). (R34) hit CNA (Certified Nursing Assistant) in the face when CNA attempting to redirect d/t (due to) resident frequently trying to go into other resident's rooms. R34's initial State Report form, (undated), provided by V1/Administrator on 4/7/22, documents on 3/19/22, R34 allegedly lifted another resident's chair (R51), scaring the resident and an investigation was initiated. R34's five-day follow-up report to the local state agency states, On 4/6/22, (V1/Administrator) informed by (V4/Director of Business Office Development) of possible incident between (R34) and (R51) that occurred on 3/19/22. Reported that (R34) lifted (R51's) wheelchair and scared (R51). This same report documents on 4/7/22 around 3:00 P.M., V23 (Resident Aide) telling V1 that on second shift (R34) was in (R51's) room and (R34) tried lifting (R51's) wheelchair while (R51) was sitting in it. (V23) also stated that (R34) laid on the floor of (R51's) room and (V23) had to get a nurse to coming and help get (R34) out of (R51's) room. (V1) spoke to (V24/Certified Nursing Assistant) on 4/7/22. (V24) stated (V24) does recall helping (V23) redirect (R34) out of (R51's) room. (R34) had entered (R51's) room through the joined bathroom. (R51) had stated that (R34) lifted (R51's) wheelchair. (V1) spoke to (R51) on 4/9/22. (R51) stated that (R34) raised (R51's) wheelchair while (R51) was in the wheelchair and it scared her. (R51) says she feels safe now that (R34) has been moved to another hallway. Disposition: On 4/9/22, the IDT (Interdisciplinary Team) discussed the altercation between (R34) and (R51) and implemented intervention of staffing 1:1 (one on one) and room change for (R34). R34's initial State Report form, (undated), provided by V1/Administrator on 4/7/22, documents on 3/19/22, R34 allegedly hit another resident (R31) and an investigation was initiated. R34's five-day follow-up report to the local state agency states, On 4/6/22, (V1) informed by (V4) of possible incident between (R34) and (R31) that occurred on 3/19/22. Staff member (V23) stated that (R34) hit (R31) in the hallway. This same report states, (V1) spoke to (V23) by phone on 4/7/22 around 3:00 P.M., (V23) stated that (V23) observed (R34) hit (R31) on her back. On April 9, 2022, (V1) and (V2/Director of Nursing) watched the video footage of Hall 5 security camera from Saturday, March 19, 2022 .The camera showed that at 5:54 P.M., (R34) walks into (R31's) room, (R34) guides (R31) out of her room into the hallway, the guide was by (R31's) arms, then (R34) lightly shoves (R31's) back .There was no harm observed but the shove from (R34) was intentional. Disposition: On 4/9/22, the IDT (Interdisciplinary Team) discussed the altercation between (R34) and (R51) and implemented intervention of staffing 1:1 (one on one) and room change for (R34). Throughout the days of 4/5/22-4/8/22, R34 and R51's room were connected by a shared bathroom. On 4/6/22 at 8:32 A.M., R34 was observed in R34's room in R34's wheelchair, R34 entered the bathroom that is shared with R51. R34 then exited the bathroom on R51's side of the room and went out into the hallway out R51's doorway. At this time, R51 stated, Get her away from me, she's trying to kill me. She scares me. No staff was present in the hallway at this time. On 4/6/22 at 9:11 A.M., R51 was sitting in R51's wheelchair. A test of the door alarms with R51's electronic wandering device was being conducted alongside V18 (Certified Nursing Assistant/CNA). R51 repeatedly asked about the whereabouts of R34 and why R34 acts the way R34 does. R51 stated, I shouldn't say that I know why she does that. It just scares me. Can't (R34) get out of here? On 4/6/22 at 9:15 A.M., V18 (Certified Nursing Assistant/CNA) stated, R34 and R51 do not get along. V18 stated there was an incident approximately one month ago when R34 came and tried to lift R51 out R51's chair. V18 stated, (R34) is strong and when she's mad, it's not good. V18 verified R34 is already on 15-minute checks. On 4/7/22 at 12:45 P.M., V4 (Director of Business Development) stated that when performing staff interviews about R34 lifting R51 out of R51's chair (on 3/19/22), V4 also found that staff reported to V4 that R34 hit R31 after R31 called R34 a b***h that same day (3/19/22). On 04/08/22 at 10:11 A.M., R51 stated, I was in my room listening to my music (on 3/19/22) and (R34) came into my room and lifted the back of my wheelchair up three times. I thought (R34) was going to kill me. I was so damn scared. I went and ate with (R36) because I was so scared. I didn't want to go to the dining room without someone or be alone in my room. (R34) shouldn't still be allowed to mingle around me. It hasn't happened again since. I keep my eye on (R34). I'm sure (R34) would like to get a hold of me again. (R34) wasn't always my neighbor. People have wrote stuff down about this before, no one has done anything. I'm so scared of her. They told me she was going to be leaving, but she never does. I wish she wasn't right next to me. On 4/8/22 at 12:48 P.M., V24 (Certified Nursing Assistant/CNA) stated, I was there on 3/19/22 when (R34) tried to pick (R51) out of the wheelchair. It was probably around 3:00 P.M. or 3:30 P.M., before supper. I was at the nursing station, and I heard some commotion. I was not assigned to that hallway. I helped get (R34) out of (R51's) room. (R51) was very mad. (R51) said she didn't want to deal with that anymore and that she shouldn't have to. I believe (V23/Resident Aide) told the nurse. I don't remember who the nurse was. I did not tell (V1/Administrator) but it should be reported right away. On 4/8/22 at 3:28 P.M., V23 (Resident Aide) stated, On second shift on the weekend, (3/19/22), I was keeping an eye on (R34). I was the 1:1 for (R31). I heard (R51) yell, 'Get this B***h out before I kill her.' (R34) was grabbing (R51's) wheelchair and trying to get (R51) out of the chair. (R34) then sat in (R51's) recliner chair in (R51's) room. (R51) asked (R34) to get out of the chair and (R51) said, 'I'm not going anywhere.' It took three of us to get (R34) out of (R51's) room. We went through the shared bathroom to get (R34) back into her own room. (R51) called (R34) a B-word and I think that is what triggered her. Once (R51) said the B-word is when (R34) got aggressive. (R31) also called (R34) a B-word and (R34) smacked (R31) that same day. (R51) is scared of (R34) now because of the way (R34) picked (R51) up. Every time I go in that hallway, (R51) asks me if (R34) is around. I reported all of this to (V1/Administrator) the next day. On 4/8/22 at 4:40 P.M., R7 stated, About a month ago, (R51) was sitting in her wheelchair in (R51's) room. (R34) came over there and grabbed a hold of (R51's) wheelchair (that R51 was sitting in) and started pulling and lifting it up. (R51) started yelling for help at that time. I would say it lasted about a minute. R7's Brief Interview for Mental Status, dated 1/20/22, documents R7 is cognitively intact without memory impairments. On 4/9/22 at 10:35 A.M., V31 (Certified Nursing Assistant/CNA) stated that R34 can be violent to anyone and everyone. On 4/8/22 at 5:03 P.M., V1 (Administrator) stated, The staff should have called me right away. It says right on the outside of my door that I am the Abuse Coordinator and I even carry an abuse phone and the phone number is posted as well. We just in-serviced staff on who the abuse coordinator was and when to call in mid-February (2022). Waiting until the next day (to report potential abuse) is unacceptable. I would have come right in. I didn't know anything about this. We are going to discuss the best placement for (R34). We have to look at the census. (V4/Director of Business Development) first made me aware of this incident with (R34) the day before yesterday (4/6/22). (R34) wanders. Someone should always be with (R34). There should be some sort of documentation of (R34's) behavior in (R34's) medical record (about the 3/19/22 incident) and there is not. At this same time, V1 verified no new interventions or increased supervision had been put into place to keep other residents safe from R34 and verified that R34 and R51's rooms remain connected with a shared bathroom. On 4/9/22 at 3:30 P.M., After watching video surveillance, V1 verified on 3/19/22 that, R34 grabbed hold of the back of R51's wheelchair after wandering into R51's room, R34 wandered into R31's room, R34 shoved R31, and R34 then wandered again into R51's room. As of 4/7/22 at 3:30 P.M., R31, R34, nor R51's medical record did not contain any documentation regarding any of the above altercations on 3/19/22 occurring or any added/increased interventions being implemented. On 4/9/22 at 10:13 A.M., V4 (Director of Business Development) stated in the evening of 4/8/22, R34 was placed on 1:1 (one on one) supervision and moved from the 500 hallway to the 200 hallway. On 4/9/22 at 12:26 P.M., V1 provided written resident interviews that V1 had obtained during the course of V1's investigation into the alleged abuse between R34 and R51 on 3/19/22. This form documents R51 was interviewed on 4/9/22 at 10:44 A.M. by V1 and documents R51 told V1 that R51 does not feel safe when R34 wanders into R51's room, R34 lifted up R51's wheelchair and it scared R51, and that R51 feels safe now that R34 has been moved. On 4/9/22 at 3:55 P.M., R36 stated, It's been several weeks ago now, but I was in my room about to go out the door. (R51's) room is right across from mine, so I can see everything. I believe (R34) came into (R51's) room from the bathroom door. (R34) was behind (R51) and lifted her chair a few times where (R51) slid just about out. (R34) does impulsive things. (R51) was yelling for help and saying 'stop, stop.' (R34) finally let (R51) go. The staff came and tried to get (R34) out of (R51's) room. (R51) was so scared. (R51) didn't want to be around her. (R51) was scared that (R34) would come through her bathroom door again. (R51) went to lunch (in the dining room) with me a couple times. I think because (R51) was too scared to stay there and see (R34). R36's Brief Interview for Mental Status, dated 2/23/22, documents R36 is cognitively intact without memory impairments. On 4/11/22 at 5:10 P.M., V1 stated had V1 first been notified of the altercation between R34 and R51, V1 does not think the altercation between R34 and R31 would have occurred. V1 would have immediately instructed the staff to separate the residents and keep R34 separated from others. V1 would have immediately come to the facility and would have looked into separating and moving rooms during the open investigation. On 4/14/22 at 1:28 P.M., R51 stated, (R51) is not next to me anymore. I haven't seen her since they moved her. I thought she was going to be moving facilities, but I guess (R51) being on the other side (of the facility) is good. I feel safe now that I know she isn't next door or even in my hallway anymore. I always was scared she would come through that bathroom door again. The Immediate Jeopardy was identified on 4/12/22. The Immediate Jeopardy began on 3/19/22 when R34 wandered into R31 and R51's room; placed R34's hands on R31 and R51; and staff did not immediately report the incident to V1, and no new interventions or increased supervision was immediately implemented to protect residents from further potential abuse. On 4/12/22 at 4:25 P.M. V1 (Administrator) was notified of the Immediate Jeopardy. On 4/14/22, the surveyor confirmed through observation, interview and record review the facility took the following actions to remove the Immediate Jeopardy: 1. On 4/9/22, R34 was moved to another hallway and placed on 1:1 (one to one) with staff. V1 (Administrator) and V2 (Director of Nursing) communicated altercation between R34 and R51 and R34 and R31 to floor staff and reason for implementation of 1:1 and room move. R34's Care Plan reviewed and updated with 1:1 intervention and providing redirection when approaching other residents. 2. On 4/12/22, V1 was in-serviced by V22 (Vice President of Operations) on Resident Abuse Prevention and Reporting-Protecting a vulnerable population (including completion of pre/posttest) and Abuse, Neglect, Exploitation-Conducting an Investigation in a Skilled Nursing Facility (including completion of pre/posttest). 3. On 4/12/22, the facility began in-service with all staff on Resident Abuse Prevention and Reporting-Protecting a Vulnerable Population (including completion of pre/posttest). In-service completion date of 4/14/22. 4. On 4/13/22, all managers received in-service Resident Abuse Prevention and Reporting-Protecting a vulnerable population (including completion of pre/posttest) and Abuse, Neglect, Exploitation-Conducting an Investigation in a Skilled Nursing Facility (including completion of pre/posttest). 5. All abuse reports and investigations will be discussed with and reviewed by V4 prior to submission to the local state agency to ensure completion of Abuse Investigation Protocol Checklist.