**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and physician and staff interviews, the facility neglected to protect the residents' right to be free from abuse when Resident #29 physically abused Residents #39 and #53. Resident #53 sustained injuries that required emergency room evaluation. This was for 1 of 1 resident (Resident #29) reviewed for resident-to-resident abuse. Immediate Jeopardy began on 11/08/21 when the facility failed to implement effective interventions to protect residents from the physical abuse of Resident #29 resulting in the resident placing Resident #53 in a headlock and pulling her to the floor. Immediate Jeopardy was removed on 1/30/22 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity of E (no actual harm with a potential for minimum harm that is not Immediate Jeopardy) to ensure the monitoring of the systems put into place and to complete facility employee and agency in-services, orientation and training. The findings included: Resident #29 was admitted to the facility on [DATE] and had diagnoses of dementia with behavioral disturbance. A nurse's note dated 9/20/21 revealed Resident #29 yelled at another resident for being in his room and told him if he did not get out, he was going to make him get out. An entry on Resident #29's care plan dated 9/20/21 revealed the resident had a behavior problem (yelling at another resident and being rude and cursing at staff). The goal was for the resident to not harm self or others through the review date (1/31/22). The interventions included to intervene as necessary to protect the rights and safety of others; approach/speak in a calm manner; divert attention and remove from the situation and take to an alternate location as needed. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 had severe cognitive impairment and verbal behavioral symptoms directed towards others on 1-3 days during the lookback period. The MDS noted the resident was independent with transfers and ambulation in his room, in the corridor and on the unit. A nurse's note completed by Nurse #6 dated 11/8/21 at 7:58 PM revealed Resident #29 displayed aggressive behavior against another resident this shift. Resident found standing over a female resident (Resident #53) with her in a headlock position and pulled her onto the floor. This writer separated the two residents and explained to him that it was not okay for him to do that. Resident's previous behaviors have shown no signs of this as a potential incident, seemingly unpredictable and unavoidable. Will continue to monitor resident for behaviors and will inform oncoming shift. (Resident #53's 10/13/21 MDS indicated her cognition was moderately impaired and she had verbal behaviors on 1 to 3 days during the review period.) On 2/1/22 at 9:52 AM an interview was conducted with Nurse #6 who stated on 11/8/21 she heard Resident #53 saying: Get off me. Nurse #6 further stated Resident #29 was behind Resident #53 and had his arm around her neck and pulled her to the floor. Nurse #6 stated another staff member helped her separate the two residents. Nurse #6 further stated there were no injuries for either resident. Nurse #6 stated she called the families of Resident #29 and Resident #53 and reported the incident to the previous Director of Nursing (DON). Nurse #6 stated she called the Medical Director who was the physician for Resident #53 and Physician #1 for Resident #29. An entry on the care plan dated 11/9/21 noted the resident was physically aggressive (putting a resident in a headlock) related to dementia. The interventions included monitor and document and report as needed any signs or symptoms of resident posing danger to self and others. Psychiatry consult as indicated and put stop sign on the outside of the resident's room to deter other residents from entering his room. A progress note completed by Nurse #3 dated 12/23/21 at 1:55 AM noted the nurse received report of a resident-to-resident situation occurring in the dining room with this resident (Resident #29) grabbing Resident #39 by the throat because he thought the resident was taking his food tray. Nurse #3 indicated this was communicated to her by the Med Aide on duty. Residents were noted to currently both be in bed with monitoring being done by staff. (Resident #39's 10/28/21 MDS indicated severely impaired cognition and no behavioral symptoms.) On 1/27/22 at 1:00 PM an interview was conducted with the Medication (Med) Aide #1 that was working on 12/23/21 when Resident #29 put his hands on the throat of Resident #39 in the dining room. Med Aide #1 stated she was setting up a supper tray for Resident #39 and Resident #29 thought the resident was getting his meal tray and he put both his hands around Resident #39's throat and she stopped him from going any further. Med Aide #1 stated that Resident #29 would get very upset if any of the residents started to go toward his room and would say that it was his room, and no one could go in there. On 2/2/22 at 9:08 AM a follow up interview was conducted with Med Aide #1. She stated on 12/23/21 when the incident occurred between Resident #29 and Resident #39 during the supper meal, she reported it to the nurse supervising her that evening. She was unable to recall who the nurse was or the time of the report. There were no new care plan interventions implemented after the 12/23/21 incident. A nurse's note completed by Nurse #1 dated 1/23/22 at 11:02 PM revealed Resident #53 was yelling help while in another resident's room. The Nursing Assistant (NA) found Resident #53 on the floor behind the door and Resident #29 was standing over Resident #53 attempting to hit her with a chair and kicked her. The assessment revealed Resident #53 had a knot on the left side of her head and a busted lip with a deep gash. 911 was called and Resident #53 was taken to the Emergency Department (ED) for evaluation. On 1/27/22 at 10:51 AM an interview was conducted with Nursing Assistant (NA) #1 who was working on the SCU on 1/23/22. NA #1 stated that Nurse #1 told her she would be back in a few minutes and left the unit and she was the only staff on the unit. NA #1 stated she was in a room where 2 residents were trying to get out of bed, and she was trying to keep them from falling. NA #1 further stated there were 2 male residents trying to get out of the door to the unit and then she heard someone saying, Help me. Help me. He's going to kill me. NA #1 stated she went to the room of Resident #29 and observed Resident #53 on the floor and there was blood on the floor. NA #1 stated she had no choice but to leave the room and went to the door to the unit and called down the hall to Nurse #2 that she needed help. NA #1 stated she and Nurse #2 went back to the room and she observed Resident #53 on the floor and Resident #29 was holding a wooden chair over her and she told him he better not do that and he dropped the chair and kicked Resident #53 in the head and stated to get this (racial slur) out of his room. NA #1 stated she and Nurse #2 got the resident up and sat her in a chair and cleaned her up. NA #1 further stated Resident #29 was very angry and she had never seen him like this. NA #1 stated they had one Med Aide or Nurse and one NA on the unit and this was not enough staff to monitor the residents on the SCU. On 1/27/22 at 5:01 PM an interview was conducted with Nurse #2 who responded to NA #1's call for help on the night of 1/23/22. Nurse #2 stated NA #1 came on the hall next to the SCU and was hollering for help and when she got to the room, Resident #53 was standing in the doorway arguing and saying to get her out of his room. Nurse #2 stated that Resident #3 (a resident that resided in the room across the hall from Resident #29) was in his wheelchair at the door to keep Resident #29 from getting back in his room and Resident #53 was on the floor crying and had blood on her clothing and on the floor. Nurse #2 further stated they tried to calm Resident #29 and directed him to the dining room to sit down but he sat down for a second and came back to the room and said to get her out of his room. Nurse #2 stated they were trying to get him back to the dining room and another resident was trying to get out of the door to the unit and she and NA #1 got Resident #53 up off the floor to sit in a chair. Nurse #2 stated NA #1 told her that Resident #29 hit Resident #53 with the chair and knocked her to the floor. Nurse #2 stated she called the Director of Nursing (DON) for extra hands, and they sent Resident #53 to the hospital. Nurse #2 further stated the DON told her to make sure to document what had happened and to call the family and the doctor. She stated by this time Nurse #1 had returned to the unit and stated she would call the doctor and the family. Nurse #2 was asked about the staffing on the SCU, and she stated there was one nurse or med aide and one NA and this was not enough staff for the unit. Nurse #2 further stated there had been issues with residents on the SCU getting out of the unit and onto the general population unit and that traffic control was the main issue. She explained that there were a few residents that got up all the time but were not steady and some residents would walk the hall at night and try to get out of the unit and some residents would wander into other resident's rooms which was what happened on the night of 1/23/22. On 1/27/22 at 11:23 AM an interview was conducted with the Interim Director of Nursing (DON) who stated she received a phone call on 1/23/22 around 9:00 PM from Nurse #2 who told her about a situation between Resident #29 and Resident #53. The DON stated she called the Administrator to let her know what was going on. The DON stated the Administrator told them to call the physician and the family. The DON further stated at that time she received a text that the police were on the way to the facility, and she called the Administrator back and was told to keep the residents separated and do 15-minute checks on the two residents and she (Administrator) would deal with it in the morning. The DON stated she did not work on Monday (1/24/22) so she did not know what action was taken the next morning. Review of the ED Record for Resident #53 dated 1/23/22 noted the resident was assaulted by another resident at the facility. Emergency Medical Technicians (EMT) reported resident was hit in the face with a wooden chair. The physical exam noted a lip laceration of the right upper lip and nasal swelling. Exam positive for neck pain at cervical back and laterally of the neck with signs of trauma and tenderness present. Pain with movement. Normal range or motion. A CAT (Computed Tomography) scan of the head was negative and showed a small Right Malar (cheek) contusion. A CAT scan of the cervical spine showed a small right malar (cheek) contusion. A CAT scan uses special x-ray equipment to help assess head injuries. Review of the police report dated 1/23/22 revealed a call was received regarding an assault on a female at the skilled nursing facility. The Nurse explained they would like the male resident (Resident #29) to be involuntarily committed. The report revealed that because of the resident's medical issues, the officer could not take the resident into custody. The female resident was picked up by EMS (Emergency Medical Services). The report indicated he advised the staff they could speak with the magistrate regarding the request for involuntary commitment orders. The case was closed. A Skin/Wound note completed by Nurse #5 dated 1/25/21 at 8:40 AM revealed Resident #53 had a bruise along the bridge of her nose that measured 4 centimeters (cm) by 3 cm along with an abrasion that was 2.3 cm by 0.1 cm. The resident was noted to be sniffling during the examination and the resident was asked if she had a cold and the resident stated: No, that man hit me across my nose. The right upper lip was swollen with abrasion 3.7 cm by 2.5 cm. An interview was conducted on 1/27/22 at 4:10 PM with the Medical Director (MD) who cared for Resident #53 in the facility. The MD stated he had been notified (on 1/25/22) of the incident between Resident #29 and Resident #53 and had not seen Resident #53 since the incident on 1/23/22. On 1/27/22 at 5:30 PM an interview was conducted with Physician #1 who cared for Resident #29 in the facility. The Physician stated Resident #29 had another resident (Resident #53) in a headlock several months ago and they were separated. Physician #1 stated he had not heard of any other issues with Resident #29 since that time and was not notified of an incident with this resident on 1/23/22. On 1/27/22 at 6:04 AM an interview was conducted with Nurse #3 who worked on the night shift in the Secure Care Unit (SCU). Nurse #3 stated if anyone went toward the room of Resident #29, he would get very upset. Nurse #3 further stated a Velcro STOP sign was put across his door and this had been somewhat effective but when Resident #29 came out of his room he would often forget to reattach the STOP sign in front of the door. On 1/28/22 at 9:20 AM an interview was conducted with Med Aide #2 who stated Resident #29 would get very upset if anyone went in his room and had been aggressive a number of times with other residents and she had expressed a concern to the previous Director of Nursing that Resident #29 was going to hurt someone. On 1/28/22 at 9:30 AM Nurse #17 stated in an interview that Resident #29's behaviors have escalated verbally and physically over the last couple of months. Nurse #17 further stated they have morning hall meetings, and the Administrator attended these meetings and the staff have expressed concerns during these meetings that Resident #29 was going to hurt somebody, and that he did not need to be on the SCU. Nurse #17 stated the staffing on the SCU was not adequate and the staff have expressed this concern to the Administrator but they were told that one Nurse or Med Aide and one NA was adequate staffing for the unit. On 1/27/22 at 11:58 AM an interview was conducted with the Administrator who stated Resident #53 had a fall on 1/22/22 and busted her lip and had an abrasion. The Administrator further stated the next day (1/23/22) Resident #29 and Resident #53 had an interaction and she was in the midst of that investigation now. The Administrator stated that NA #1 was in another room and heard someone needed help and found Resident #29 holding a chair and believed Resident #53 was hit with the chair. The Administrator further stated it seemed to her if he hit her with a chair, she would have had other injuries and the NA assumed the resident was hit with the chair. The Administrator stated Resident #29 was moved off the unit the next morning. The Administrator further stated she interviewed both residents after the 11/8/21 incident and one resident resided on one end of the hall and the other resident resided on the other end of the hall and when she interviewed them, neither of the residents had any recollection of the event on 11/8/21. The Administrator stated head to toe assessments were done, statements were obtained, and the Physician and the families had been notified and the Nurse Practitioner reviewed both residents. The Administrator stated she was not aware that Resident #29 had kicked Resident #53 in the head during the incident on 1/23/22. The Administrator stated the police were notified and the family did not choose to press charges. The Administrator stated the STOP sign on the door was an intervention as a result of the 11/8/21 incident. The Administrator stated there had been concerns from the staff about the staffing on the SCU and that she believed two staff members for 13 residents on the SCU was adequate. The Administrator stated when one of the staff took a meal break there was still one person on the unit and if there was an issue, they should call for additional help. The Administrator stated she thought the incident on 11/8/21 was an isolated incident and she was not aware of the incident on 12/23/21. The Administrator was notified of the Immediate Jeopardy at F600 on 1/28/22 at 1:32 PM. The facility provided a credible allegation of Immediate Jeopardy removal on 1/30/22. The allegation of Immediate Jeopardy removal indicated: Credible Allegation of Immediate Jeopardy Removal: Resident #29 displayed aggressive behaviors against Resident #53 on 11/8/2021. Resident #29 was found standing over Resident #53 with her in a headlock position and pulled her onto the floor. Nurse #6 separated the two residents and explained to Resident #29 that it was not okay for him to do that. Resident #53 did not have any injuries related to this incident. Resident #29's care plan was updated on 11/9/2021 and noted the resident was physically aggressive (putting a resident in a headlock) related to dementia. The physician was notified on 11/8/2021 of incident. Resident #29 and Resident #53 were evaluated by the Nurse Practitioner on 11/9/2021. Medication changes were made for Resident #29 due to his behavior change; therefore, a psychiatric evaluation was not obtained. The initial report was submitted to the State Survey Agency on 11/8/2021 and final investigation finding submitted on 11/12/2021. The police were not notified of this incident. The interventions included to monitor Resident #29, document and report as needed any signs or symptoms of resident posing danger to self and others. Additionally, facility to obtain as indicated and put stop sign on the outside of the resident's room to deter other residents from entering his room. Resident #29 displayed aggressive behavior on 12/23/2021 against Resident #39. Both residents were in the dining room when Resident #29 grabbed Resident #39 by the throat because he thought Resident #39 was taking his food tray. The residents were immediately separated by staff and increased monitoring (increase in frequency of being aware of his whereabouts, needs and behavior) was initiated and remained in place for the duration of the shift without further behaviors exhibited by the resident. A 24-hour reportable was not submitted to the State Survey Agency by the facility nor were the police notified at the time of the incident. For compliance purposes, a 24-hour report was sent to the State Survey Agency by the Regional Director of Operations on 1/29/2022 @ 3pm. Police were contacted on 1/29/2022 @ 10:30pm. Physician was notified of the incident on 1/28/2022 @ 1pm by the Administrator. The final investigation (5-day report) will be concluded and sent to the State Survey Agency. Resident #29 displayed aggressive behavior on 1/23/2022 against Resident #53. NA #1 stated that Nurse #1 told her she would be back in a few minutes and left the unit and she was the only staff on the floor. The NA stated she was in a room where 2 residents were trying to get out of bed, and she was trying to keep them from falling. The NA further stated there were 2 male residents trying to get out of the door to the unit and then she heard someone saying, Help me. Help me. He's going to kill me. The NA stated she went to the room of Resident #29 and observed Resident #53 on the floor and there was blood on the floor. The NA stated she had no choice but to leave the room and went to the door to the unit and called down the hall to Nurse #2 that she needed help. The NA stated she and Nurse #2 went back to the room and she observed Resident #53 on the floor and Resident #29 was holding a wooden chair over her and she told him he better not do that and he dropped the chair and kicked Resident #53 in the head and stated to get this (racial slur) out of his room. The police were immediately notified of the incident on 1/23/2022. The physician was made aware by the Social Worker on 1/25/2022. Resident #53 was sent to the emergency room for evaluation. The emergency room (ER) Record for Resident #53 dated 1/23/22 noted the resident was assaulted by another resident at the facility. The physical exam noted a lip laceration of the right upper lip and nasal swelling. Exam positive for neck pain at cervical back and laterally of the neck with signs of trauma and tenderness present. Pain with movement. Normal range or motion. A CAT scan of the head was negative and showed a small Right Malar (cheek) contusion. A CAT scan of the cervical spine showed a small right malar (cheek) contusion. Of note, Resident #53 had the above noted injuries when she arrived to the ER on [DATE]. These injuries were sustained from an unwitnessed fall on 1/22/22. According to the ER report dated 1/22/22, Resident #53 arrived to the ER after sustaining an unwitnessed fall. Resident #53 had her upper lip sutured by the ER Physician and she tolerated the procedure well. Administrator submitted 24-hour reportable to the State Survey Agency on 1/24/22 and initiated investigation; although, incident occurred 1/23/22. The police were immediately notified of the incident on 1/23/2022. Because all residents are at risk when the facility fails to protect residents from being physically abused by other residents, the following plan has been formulated to address this issue: On 1/23/2022 at approximately 9:30pm (21:30) Resident #29 was placed on 1:1 staff supervision until seen by Psychiatry and deemed safe to remove from 1:1 supervision. Further, a care conference was held on 1/28/2022 with the facility Interdisciplinary Team (IDT) to include the Administrator, Director of Nursing, Social Worker and Resident #29's Responsible Party. The Psychiatrist and Medical Director were notified of the care conference by the Social Worker but unable to attend. The purpose of the care conference was to discuss on-going medication management and alternate interventions to manage residents' aggressive behavior towards others. On 1/28/2022, the plan of care was reviewed and revised by the IDT for Resident #29 to protect all residents at risk. This plan of care includes the following: 1:1 supervision until seen by psychiatry and deemed safe to remove from 1:1 supervision; intervene to protect the safety of others; remove from situation and take to alternate location as needed; monitor behavior episodes and attempt to determine underlying cause with consideration of location, triggers, time of day, persons involved and situations; document behaviors, potential causes and what de-escalates the behavior, stop sign on door of Resident #29 room to deter other residents from wandering into Resident #29 room. On 1/28/2022, an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held by facility IDT (department heads), Regional Clinical Consultant and Regional Director of Operations on 1/28/2022 to review the behavioral management policy to ensure it included strategies to manage residents' behaviors toward others. Additionally, the committee discussed the incident(s) involving Resident #29 and developed an immediate action plan based upon root cause analysis to address and remove immediate and future risk potential. Based upon root cause analysis of each incident, Resident #29's primary trigger is individuals invading his personal space and his inability to make sound response decisions secondary to his cognition status and diagnosis of dementia. This was identified during the review of each incident with the involved residents and comments made by Resident #29. On 1/28/2022, the administrative staff which includes the Administrator, Director of Nursing were educated by the Regional Director of Operations and the Regional Director of Clinical Services on responding to emergency situations such as physical abuse. This education will include strategies for prevention of physical abuse and identifying the likelihood based upon resident assessments and any exhibited behaviors. Beginning 1/26/2022, current facility and agency staff on each shift, including Nursing, Activities, Social Work, Dietary, housekeeping and maintenance, will be re-educated by the Regional Director of Nursing and/or Administrator on F600 and the Prevention of Abuse or/and Neglect. The education will be communicated verbally and telephonically by the Director of Nursing. Written education will be available for review prior to the staff member working their assigned shift. Assistant Director of Nursing will utilize a master employee list to track completion of education. No staff will be allowed to work until education is completed. Education will also be included during orientation for newly hired staff. Beginning 1/28/2022, all staff will be educated by the Director of Nursing on the facility behavioral management policy to include managing resident behaviors and prevention of resident-to-resident altercations. This will include identifying contributing factors such as situational, physical environment, and organizational factors. An emphasis will be placed upon ensuring supervision of residents to aid in preventing physical assault between residents. If the resident is displaying aggressive behaviors towards others, the resident will be monitored closely which will include 1 to 1 observation if the resident continues to have behaviors. If the resident continues to have aggressive behaviors towards others despite facility interventions, the facility will transfer the resident (including Resident #29) to the hospital for an immediate psychological evaluation to protect risk to others. The education will be communicated verbally and telephonically by the Director of Nursing. Written education will be available for review prior to the staff member working their assigned shift. will utilize a master employee list to track completion of education. No staff will be allowed to work until education is completed. Education will also be included during orientation for newly hired staff. On 1/28/2022, the Administrator and Social Worker completed an audit for F600 via abuse questionnaire with cognitively intact residents and the Licensed Nurses completed body audits on cognitively impaired residents to ensure other residents are free from abuse, including resident-to-resident. No additional concerns identified. On 1/28/2022, the Administrator and Director of Nursing reviewed with the IDT, Licensed Nurses and Nurse Aides all residents on the secure unit with behaviors that could potentially affect the safety of other residents. Those identified as not currently having psychiatry services were referred to psychiatrist for consult and medication review. Effective 1/28/2022, the facility Administrator, Director of Nursing, Social Worker and Charge Nurse will perform facility tours (including off shifts and weekends) daily of the memory unit to observe for any residents with behaviors which would need additional interventions. Additionally, the Administrator and Director of Nursing will monitor staffing levels every shift (including coverage during breaks and lunches) on the memory care unit to ensure adequate staff to provide supervision to residents to prevent physical abuse. Effective 1/28/2022, the facility Administrator will conduct questionnaires weekly with Licensed Staff and Nurse Aides related to how to respond to residents with physical behaviors and interventions. Effective 1/28/2022, the Administrator and Director of Nursing will be ultimately responsible to ensure implementation of this immediate jeopardy removal for this alleged noncompliance. Alleged date of IJ Removal: 1/30/22 On 1/31/22 the Credible Allegation of Immediate Jeopardy removal was validated by onsite verification. Multiple interviews were conducted with regular staff as well as agency staff who stated they had received education on abuse and neglect and examples of each were included in the training. The staff stated the education included who to notify if abuse was suspected and the requirements of notification to the DON, Administrator, state agency and law enforcement. The staff stated the education also included prevention of resident-to-resident abuse. Verification of this education for staff was completed on 1/30/22 and the facility's Immediate Jeopardy removal date of 1/30/22 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #29 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance. The Quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #29's cognition was severely impaired. Resident #29 did not exhibit wandering behavior during the look back period. Resident #29 was independent with ambulation and used a walker as mobility device. A care plan updated 6/8/21 and currently in place revealed a focus of elopement risk related to disoriented to place, dementia with behavioral disturbances, and wandering. The goal was for Resident #29 will not leave facility unattended and his safety will be maintained through the review date. The interventions included: distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or book. Documentation of behavior observations, including wandering/pacing/exit seeking for Resident #29 were ordered by the physician for every shift on 10/21/21. Review of a behavior note dated 12/14/21 indicated that staff tried to redirect Resident #29 away from an exit door he opened setting off the alarm. Resident #29 became aggressive, swung at the staff member with his hand and then his walker. Resident #29 was moved from the secured memory care unit to a general hall on 1/24/22 after a resident-to-resident altercation per the medical record. There were no new interventions related to wandering implemented when he was moved to the unsecured unit. On 1/28/22 Resident #29 was placed on 1:1 monitoring after he became combative with staff. Review of a nursing note dated 1/29/22 at 8:26 AM by Nurse #9 revealed Resident #29 was noted to have walked out of the facility's front door after staff and redirected back inside. Physician #1, interim DON, responsible party (RP) and the Administrator were notified. A review of the weather conditions per Local Condition's website (www.localconditions.com) for Ahoskie's weather history indicated the temperature on 1/29/22 at 7:35 AM was 31 degrees Fahrenheit, 83% humidity and there was no precipitation. An interview was conducted with Nurse #1 on 1/31/22 at 2:50 PM, and she stated she was in the front lobby speaking to Receptionist #1 on the morning of 1/29/22 (time unknown). Receptionist #1 stated she was going to try to wait for the oncoming receptionist to relieve her from supervising Resident #29. Nurse #1 stated she did not agree that she would watch Resident #29 because the NA she was working with was pulled to another unit due to insufficient staffing. When Nurse #1 left the lobby to go back to her unit, Receptionist #1 and Resident #29 were in the lobby (time unknown). Receptionist #1 was interviewed on 1/31/22 at 2:46 PM, and she revealed she was asked to stay over Friday night (1/28/22) by the Administrator to monitor Resident #29 1 on 1 but was not instructed when to stay until or who was to relieve her. She stated Nurse #1 agreed to watch Resident #29 when she left the building at 6:30 AM. She stated that was the last time she saw him sitting in the front lobby. Nurse #10 was interviewed on 2/1/22 at 11:30 AM, and he revealed he worked the overnight shift on 1/28/22. He stated Resident #29 had been fighting with staff on the evening of 1/28/22 and was now on 1:1 monitoring. Nurse #10 further stated he last saw Resident #29 in the front lobby when he left the building at 7:30 AM on 1/29/22 and did not remember seeing Receptionist #1 with him. When Nurse #10 needed to leave the building without a receptionist present, he used the code to unlock the front door and pushed the door himself without using the automated release button. The front door was secured with a code. He stated he was certain there was no one behind him when he walked out because he stood out in front of the building when he left and took a picture of his schedule to send to his agency. Nurse #10 indicated his car was parked in front of the building. An interview was conducted with Nurse #9 on 1/31/22 at 11:21 AM, and she revealed after she received report for the morning shift of 1/29/22 and checked on her residents, which included #29, she walked toward the lobby to locate Resident #29. At that time, NA #5 was escorting him back into the building, and she did not know how long he was out of the building. Nurse #9 stated she performed a skin check on him but did not document the assessment. She contacted the Administrator immediately after Resident #29 returned (time unknown) and was told Receptionist #1 was assigned to monitor him 1:1. She stated Receptionist #1 had already left the facility, and she was unsure if the oncoming receptionist had arrived. During an interview with nurse aide (NA) #5 on 1/31/22 at 11:41 AM, she revealed she was late to work and arrived at the facility at 7:30 AM on 1/29/22. She stated she observed Resident #29 walking alone down the sidewalk in front of the building where cars park on the street just in front of the parking lot. He was walking towards the main road, and she met him while she was in her vehicle after recognizing him. NA #5 stated he was not wearing a jacket, but he was wearing long sleeves, pants, and shoes. She indicated it was cold outside and he appeared cold. He also seemed agitated when she instructed him to come inside, he slammed his walker down on the ground and that is when she called the facility's main number. No one answered the phone, so she contacted the Director of Nursing (DON) directly who came outside to help her. NA #5 was only with him a few minutes from the time she arrived to when Resident #29 was escorted back inside. NA #5 stated she was not sure how Resident #29 got out of the building, and the front door was always locked. During an interview with the DON on 1/31/at 12:58 PM, she revealed that she was made aware of Resident #29 needing 1:1 supervision indefinitely by the Administrator on 1/28/22 at 6:00 PM. She stated she arrived to work at 7:00 AM on 1/29/22 but forgot to clock in. When she used the punch clock in the lobby at 7:27 AM, she saw Resident #29 in the lobby. The interview continued on 1/31/22 at 6:17 PM, and the DON stated she did not see a 1:1 monitoring partner with him. Receptionist #1 was assigned to monitor Resident #29, but she left at 6:30 AM before the oncoming receptionist arrived. She further stated Receptionist #1 was supposed to stay with Resident #29 until someone relieved her, but she did not know who that person should have been. She then went back to her hall assignment to give Nurse #10 report and was contacted by NA #5 at 7:36 AM via telephone that Resident #29 was outside by himself. She then went to the front lobby and saw NA #5 and Resident #29 entering the front door. Nurse #9 was assigned to provide care for Resident #29, who was also present in the lobby at this time. An interview was conducted with the Administrator on 1/31/22 at 2:01 PM, and she revealed Resident #29 was placed on 1:1 monitoring Friday evening (1/28/22) at 6:00 PM. She stated Receptionist #1 accepted the supervision assignment and was willing to stay through the night until Resident #29 was handed off to the oncoming receptionist. The Administrator stated she was supposed to stay until she handed him off to the oncoming receptionist. The Administrator stated she was notified by Nurse #9 at 7:49 AM about Resident #29's elopement. She was told there were no nurse aides on duty on East Hall, the hall Resident #29 resided on, for the first shift which began at 7:00 AM. She stated she then called the DON at 7:56 AM. The Administrator stated Nurse #10 left the building after his shift ended and may have left the door open when Resident #29 got out. The Corporate Consultant was notified of immediate jeopardy on 1/31/22 at 7:08 PM. The facility provided the following Credible Allegation of immediate jeopardy removal. Beginning 2/1/22, the Director of Nursing and Regional Director of Nursing completed elopement education with all current facility and agency staff, including dietary, maintenance and housekeeping. Education included the Elopement Policy and providing effective supervision for cognitively impaired residents with wandering and exit seeking behaviors to prevent unsupervised exits from the facility. Education also included examples of effective techniques for resident redirection, effective monitoring of residents, supervision to ensure resident safety, response system in the event of a resident elopement, response system of a facility fire watch (15-minute door checks) and timely response to door alarms. Facility and agency staff will not be permitted to work until receiving education. On 2/1/22, the Director of Nursing and MDS Coordinator completed an audit of residents at risk of exiting the facility unsupervised who are cognitively impaired and exhibit exit seeking and wandering behaviors to ensure appropriate supervision and safety. For residents identified at risk for elopement, an updated Wandering Risk Assessment was completed by the licensed nurse and care plans updated to ensure appropriate interventions implemented based on resident risk. The Director of Nursing updated the Elopement Risk Binder to contain resident profiles, photographs, current Wandering Risk Assessment and care plan and placed binders at the nurse station and front lobby. Effective 2/1/22, all residents will be assessed for elopement risk by a Licensed Nurse upon admission, quarterly and with changes in resident condition. Residents identified at risk with exit seeking and wandering behaviors will have a care plan in place to ensure safety and profile, photo, Wandering Risk Assessment, and care plan will be placed in the Elopement Binder at the nurse station and front lobby. Residents with wanderguards will be monitored every shift for placement and every day for function by the licensed nurse. Effective 2/1/22, residents with exit seeking and wandering behaviors who have an increased need for monitoring including a change in room location from the secured unit to the unsecured unit will be reassessed by the licensed nurse and care plan revised as appropriate to ensure increased interventions are implemented to ensure resident safety. This may include, but is not limited to, the addition of a wanderguard, 15-minute checks or 1:1 observation as determined appropriate to ensure resident safety and supervision. Effective 2/1/22, the facility will ensure proper functioning and monitoring of the wanderguard system and facility doors and alarm system. The Maintenance Director, Maintenance Assistant or Administrator will perform and document door and alarm safety checks at least weekly. Effective 2/1/22, the facility will conduct elopement drills on all shifts monthly to ensure continued staff understanding of the facility process in the event of an elopement. Effective 2/1/22, newly hired Maintenance Directors, Assistance Maintenance Director and Administrators will receive education by the Administrator, Director of Nursing or Regional Director of Nursing on the wanderguard system, door security system and process for system malfunctions. Education to include wanderguard system and doors and alarm safety checks weekly and 24/7 continuous door monitoring shall be implemented and documented in the event of malfunction until system is fixed. Effective 2/1/22, the facility implemented a revised Safety Watch System to ensure continuous staff supervision for residents requiring 1:1 observation. The Administrator will ensure the 1:1 staff coverage is posted on the Safety Watch Schedule and assigned staff will utilize the Safety Watch Log to document coverage by signing and dating in and out times. During staff breaks and during change of shift, an alternate staff member will provide supervision and document on-coming and off-going coverage by signature and date on the Safety Check Log. In the event of call-outs or late arrivals, the current staff will notify the Administrator or Director of Nursing immediately and will remain with resident to ensure continuous supervision until alternate staff coverage is obtained. Staff who are assigned 1:1 resident observations will utilize interventions per resident plan of care to distract, redirect and intervene as appropriate. Any concerns with following the plan of care will be reported to the Physician and Administrator and/or Director of Nursing immediately and additional interventions implemented as necessary. Beginning 2/1/22, the Regional Director of Operations and Regional Director of Clinical Services will provide education to facility and agency staff on the Safety Watch System and the expectation of providing continuous 1:1 supervision as assigned and the process to follow to ensure resident safety without any disruptions in continuous coverage. Education will include the process of utilizing the Safety Watch Log to document coverage by signing and dating in and out times. During staff breaks and during change of shift, an alternate staff member will provide supervision and document on-coming and off-going coverage by signature and date on the Safety Check Log. In the event of call-outs or late arrivals, the current staff will notify the Administrator or Director of Nursing immediately and will remain with resident to ensure continuous supervision until alternate staff coverage is obtained. Staff who are assigned 1:1 resident observations will receive education on utilizing interventions per resident plan of care to distract, redirect and intervene as appropriate and reporting any concerns with following the plan of care and Safety Watch System to the Administrator and/or Director of Nursing immediately. Staff not educated by 2/1/22 will receive education prior to working on the floor. Effective 2/1/22, staff assigned to provide 1:1 resident supervision will not leave resident unattended at any time. During staff breaks and during change of shift, an alternate staff member will provide supervision and document on-coming and off-going coverage by signature and date on the Safety Check Log. In the event of call-outs or late arrivals, the current staff will notify the Administrator or Director of Nursing immediately and will remain with resident to ensure continuous supervision until alternate staff coverage is obtained. Effective 2/1/22, the Maintenance Director will audit the wanderguard system and door and alarm system weekly for proper function. This will be documented in the TELS system (electronic system used for maintenance tracking) Effective 2/1/2022, the facility Administrator or Director of Nursing will conduct weekly questionnaires with five (5) facility or agency staff to ensure proper understanding of providing effective supervision for cognitively impaired residents with wandering and exit seeking behaviors to prevent unsupervised exits from the facility. Effective 2/1/22, the Administrator, Director of Nursing or Manager on Duty will and will review the Safety Watch Log to ensure continuous supervision is being provided and documented for residents assigned 1:1 observation. Monitoring will be conducted daily. Effective 2/1/2022, the Administrator or Regional Director of Operations and Director of Nursing will be ultimately responsible to ensure implementation of this immediate jeopardy removal for this alleged noncompliance. The facility alleges the removal of Immediate Jeopardy on 2/2/22. The credible allegation of immediate Jeopardy removal was validated by onsite verification on 2/2/22 as evidenced by interviews with direct care, ancillary, and administrative staff, interviews with residents, record review and observations. Review of the 100% census verification and resident roll call was completed on 1/11/22 and Elopement drill on 1/12/22. Interviews conducted with nursing, housekeeping, dietary, therapy, medical record and other ancillary staff revealed they had attended training on the door alarm system, elopement education policy and procedures which included monitoring and managing residents with unsafe wandering and risk for elopement. The training included ways to modify behaviors and minimize risk associated hazards to prevent accidents and elopements. The education included tips for elopement prevention and that elopement risk were to be completed by licensed nurses upon admission, quarterly and with changes in condition. Staff education was also provided on 1:1 supervision and the process to follow to ensure resident safety without disruptions in continuous coverage, staff breaks, call outs or late arrivals. Reporting of issues to the Administrator or DON immediately. Inservice forms were reviewed and indicated the dates, topics discussed, and the trainer, and included attending staff signatures. No concerns were identified with these forms. Review of schedule for 1:1 revealed it was started for Resident #29 on 1/27/22 but was not in place at the time of his unsupervised exit. The schedule indicated 1:1 has since been consistently implemented as indicated. Review of a Wandering Audit revealed that on 2/1/22 a wandering audit was conducted of 100% of the residents. Review of the wander guard system monitoring was conducted. No issues were identified with these checks. An observation of the exit door and the locking mechanism was conducted, and the exit door alarmed when pushed but remained locked. After 15 seconds the locking mechanism released so that door was able to be opened. Resident #21 was observed on 2/2/22 at 11:00 AM in the dining room sitting at the table. A nurse aide was in the dining room and other residents were in the dining room. Resident #29 was observed on 2/2/22 at 11:23 AM in his room sitting up in the chair and a nurse aide was sitting in the room with Resident #29. An interview was conducted with the Director of Nursing (DON) on 2/2/22 at 1:50 PM. The DON stated that she was responsible for monitoring the 1:1 tracking tool. The facility's Immediate Jeopardy removal date of 2/2/22 was validated. Based on record review, staff interview and observation, the facility failed to provide supervision to prevent residents with severe cognitive impairment who displayed exit seeking behaviors from exiting the facility unsupervised for 2 of 2 residents (Resident #21, Resident #29) reviewed for wandering behavior. The facility also failed to implement 1 to 1 supervision for Resident #29. Immediate jeopardy began for Resident #21 on 1/11/22 when he exited the facility unsupervised and was observed by police near a local gas station approximately 0.75 miles from the facility at night. Immediate Jeopardy began for Resident #29 on 1/29/22 when he exited the facility unsupervised while he was supposed to be on 1 to 1 staff supervision. Immediate Jeopardy was removed on 2/2/22 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity of E (no actual harm with a potential for minimum harm that is not Immediate Jeopardy) to ensure the monitoring of the systems put into place and to complete facility employee and agency in-services, orientation, and training. The findings included: 1. Resident #21 was admitted to the facility on [DATE] with diagnoses that included vascular dementia with behavioral disturbance and difficulty in walking. The admission Minimum Data Set (MDS) dated [DATE] indicated Resident #21's cognition was severely impaired. Resident #21 exhibited wandering behavior 1 to 3 days of the 7 days look back period. Resident #21 required supervision with one person assist for ambulation. Resident #21 received antipsychotic medication 6 of the 7 days during the MDS look back period. Review of a behavior note dated 11/5/21 indicated that staff tried to redirect Resident #21 several times from going in other resident's rooms. Resident #21 became aggressive, grabbed staff arm, and scratched staff leaving open scratches to their arms. A care plan dated 11/5/21 revealed a focus of elopement risk/wanderer (vascular dementia) related to disorientation to place and attempts to leave facility unattended. The goal was for Resident #21 not to leave facility unattended through the review date. The interventions included: -Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. -Ensure that the area that resident wanders in is safe. -Report to MD changes in resident behavior. Review of the medical record revealed that Resident #21 was transferred to the facility from a sister facility due to his exit seeking behavior and need for a special care unit. Review of a nursing note dated 1/6/2022 revealed Resident #21 was transferred from the SCU (Special Care Unit) to the COVID unit on 1/6/22. Resident #21's care plan revealed no new interventions were implemented related to wandering/exit seeking when he was moved from the secured unit to the COVID unit. On 1/27/22 at 8:30 AM an observation was conducted of the COVID unit. The COVID unit had one closed door at the front of the unit that led to the general population units. This door at the front of the unit did not alarm when opened. The COVID unit had one exit door at the end of the unit that led to the exterior of the building. This door alarmed when pushed on and required a numerical code to be entered for the alarm to stop. An interview was conducted with NA #4 on 1/27/22 at 11:30 AM. NA #4 revealed that she had worked the 7:00 AM to 3:00 PM on 1/11/22. NA #4 stated she was aware of Resident #21's exit seeking behaviors when he was moved to the COVID unit. NA #4 stated Resident #21 regularly came out of his room and walked the hallway and was redirected back to his room. NA #4 stated that she would try to figure out what Resident #21 was looking for and would attempt to assist him. NA #4 stated Resident #21 could be easily redirected. She stated that Resident #21 had not displayed any aggressive behaviors towards her. NA #4 indicated there was malfunction on the exit door at the back of the unit on 1/11/22. She explained the door opened as soon as pushed and the alarm went off instead of waiting the normal 15 seconds before the door lock released and the door opened. NA #4 stated she was made aware of the issue with the doors locking by Nurse #8. An interview was conducted with Nurse #8 on 1/27/22 at 11:38 AM. Nurse #8 stated that she had worked with Resident #21 on 1/11/22 from 7:00 AM to 7:00 PM. Nurse #8 stated Resident #21 was up walking around the unit and stated he wanted to leave. Nurse #8 stated that she walked Resident #21 back to his room. Nurse #8 stated Resident #21 had opened the door at the front of the COVID unit (led to another unit in the facility and was not alarmed) and when she called his name he turned around and headed back inside the unit. Nurse #8 stated that she reported to Nurse #7 about Resident #21 trying to go out the COVID unit front door. Nurse #8 stated she was made aware of Resident #21's exit seeking behaviors when he was moved to the COVID unit. Nurse #8 stated the staff would redirect Resident #21 when he started walking in the hallway. Nurse #8 stated that she last saw Resident #21 at approximately 7:20 PM and he was on the bed in his room. Nurse #8 stated she was made aware that the lock on the exit door at the end of the COVID unit (that led to the exterior of the facility) was not working correctly during report with Nurse #7 on 1/11/22. Nurse #8 explained that the door would open as soon as pushed on and the alarm went off instead of waiting the normal 15 seconds before the door released and would open. An interview was conducted with NA #3 on 1/28/22 at 9:23 AM. NA #3 stated she was made aware that Resident #21 had exit seeking behaviors when he was moved to the COVID unit. She indicated staff would redirect Resident #21 to his room. NA #3 stated Resident #21 would wander up and down the hallway and try to push open the exit doors. She spoke about the COVID unit reporting that staff regularly used the door at the end of the unit to enter and exit the facility. She indicated the door alarmed when it was opened. She explained that the alarm system panel was in another area of the building and staff on the COVID unit could not view the panel to see which location alarm was sounding, but they could punch in a code at the COVID unit exit door to turn the alarm off. NA #3 stated that she was made aware by Nurse #8 that there was a malfunction with the exit doors on 1/11/22 causing the door to open and alarm as soon as it pushed on instead of waiting the 15 seconds before the door released and would open. NA #3 stated that she recalled seeing Resident #21 in his room after dinner on 1/11/22 because she picked up his tray. She stated Resident #21 was laying on his bed with a plaid shirt, pants, and socks on. The NA stated he had a pair of flip flops on the floor at the bedside. NA #3 stated Resident #21 had attempted to exit the COVID unit through the front door on 1/11/22 just before 7:00 PM. The NA stated that Nurse #8 assisted Resident #21 back to his room. NA #3 stated Nurse #7 came in at approximately 7:30 PM. She stated she heard an alarm when Nurse #7 came in and the nurse punched in the code to turn off the alarm. NA#3 stated at that time she was in the clean room (a room that is free of contamination) which was located 2 doors from the COVID unit exit door and did not see anyone pass the door during that time. NA#3 stated at approximately 7:40 PM Nurse #8 exited the building at the end of the COVID unit and the alarm did not go off. She revealed she did not report to anyone that the alarm didn't sound at when Nurse #8 left. NA #3 stated Nurse #7 left the facility through the COVID unit back door and stated she was going to get something to eat at approximately 7:45 PM and the alarm went off when she exited. NA #3 stated she after Nurse #7 left (approximately 7:45 PM) she was the only staff on the COVID unit until NA #5 came in. NA #3 reported that she heard the alarm go off for the COVID unit back door at approximately 8:00 PM when NA #5 came in. NA #3 stated that she and NA #5 were on the hall because Nurse #7 had not returned from getting her food. NA #3 stated she heard the COVID unit back door alarm at approximately 8:20 PM when Nurse #7 came back from getting her lunch. NA #3 stated Nurse #7 went back out the COVID unit back door to get her computer and a bag. She stated Nurse #7 brought her belongings in and went inside the clean room to place them down. NA #3 stated Nurse #7 returned to the door and punched in the code to turn off the alarm. NA #3 stated she went to lunch at approximately 8:30 PM. NA #3 stated she did not know that Resident #21 was not in the building. Review of the 911 Communications Report dated 1/11/22 at 8:04 PM revealed that Resident #21 was seen walking in the middle of the road wearing grey sweatpants and blue shirt. The report further revealed Resident #21 had exited the facility from the COVID unit at the back of facility. A review of the weather conditions per Local Condition's website (www.localconditions.com) for Ahoskie's weather history indicated the temperature on 1/11/22 at 7:35 PM was 24 degrees Fahrenheit, 69 % humidity and there was no precipitation. An interview was conducted with the receptionist on 1/28/22 at 9:32 AM. The receptionist revealed that she received a phone call from a local police officer on 1/11/22 at approximately 8:00 PM. She stated that the police officer asked her if the facility had a resident by Resident #21's name. The receptionist stated that she reviewed the resident census and stated that there was a resident that resided there with that name. The receptionist reported that the officer told her Resident #21 was out at a local service station. She stated the officer informed her that the precinct received a call about a suspicious person. The receptionist stated that she placed the officer on hold and called the COVID unit and spoke to Nurse #7. The receptionist stated that she asked Nurse #7 if Resident #21 was in his room. The nurse stated that she would look, and Resident #21 was not in his room. The receptionist stated that officer did not bring Resident #21 to the front door, so she did not see him when he returned. An interview was attempted with the local police officer who contacted the facility, but he was unable to be reached. An interview was conducted with Nurse #7 on 1/28/22 at 7:15 AM. Nurse #7 stated she received a call on 1/11/22 at approximately 8:30 PM to pick up the COVID unit cell phone. Nurse #7 stated that she spoke with someone, unable to recall who she spoke with, who told her they had Resident #21. Nurse #7 stated she did not know what time Resident #21 had gone out the door. Nurse #7 stated that when you hear an alarm sounding, there is no way to see which door the alarm is sounding for. Nurse #7 stated that she did not see anyone leave out the building and she parked in the back of the facility near the COVID exit door. Nurse #7 stated Resident #21 was wearing blue shirt and grey sweatpants when the police brought him back to the facility. She was unsure of whether Resident #21 had on a long sleeved or short sleeved shirt. Nurse #7 stated she was not sure if Resident #21 was wearing shoes. Nurse #7 stated that she was told that Resident #21 was found down by the gas station. Nurse #7 stated that the DON called her and informed her of what to do for Resident #21. A head-to-toe assessment was conducted, and Resident #21 had a scrape to his knee but no other injuries. Nurse #7 stated that he was placed on 15-minute watch for his safety. Review of a nursing note dated 1/12/22 at 7:11 AM revealed Resident #21 returned to the facility at 8:30 PM on 01/11/22. A full head to toe assessment was performed by Nurse #8 and Resident #21 was placed on 15-minute checks to ensure safety. Resident #21's vital signs were within normal limits. Resident #21's temperature was 97.4 and he had a small scrape to his left knee which was cleaned and required no dressing. Resident #21 remained on isolation for COVID. An interview was conducted with the DON on 1/27/22 at 9:40 AM. The DON stated that she was made aware of an issue with the locking of the exit doors on Sunday night 1/9/22. Staff reported that the alarm would sound when the door was pushed on and immediately opened instead of waiting the normal 15 seconds before you could open the exit door. The DON stated that the staff that work in the COVID unit were to use this exit to go in and out the unit. She indicated staff were trained to look to see who was at or around the door when the alarm sounded The DON stated that on 1/11/22 Receptionist #1 called her and stated the police had found Resident #21 and bought him back to the facility. The DON stated that she was not told where Resident #21 was when the police found him. The DON stated she was never notified that the COVID unit exit door opened without alarming at approximately 7:40 PM that evening (1/11/22) and indicated the staff should have reported any issues with the doors to maintenance and herself. The DON stated Resident #21was admitted to the special care unit (secured unit) because of his exit seeking behaviors. She revealed when he was transferred to the COVID unit (1/6/22) there no increase to the frequency of monitoring for Resident #21 was transferred. An interview was conducted on 1/26/22 at 4:11 PM with Maintenance Director. The Maintenance Director stated that the recent cold weather had caused the alarm system circuit board to burn up. He stated beginning on 1/9/22 the exit doors would continue to alarm but would open immediately instead of locking and waiting the 15 seconds for release per the egress code. The Maintenance Director stated that all staff including the DON and Administrator were made aware of the issue with the locking mechanism on the door. The staff were completing Firewatch every 30 minutes until the locking mechanism was fixed. The Maintenance Director stated the

Based on record review, observation, and physician and staff interviews, the facility failed to have sufficient staffing to prevent and protect Residents #53 and #39 from being physically abused by Resident #29 for 1 of 1 resident reviewed for resident-to-resident physical abuse (Resident #29) and to provide supervision to prevent residents with severe cognitive impairment (Resident #21 and Resident #29) from exiting the facility unsupervised for 2 of 2 residents reviewed for wandering. Immediate Jeopardy began on 11/08/21 when the facility failed to have sufficient staff to protect residents from physical abuse resulting in Resident #29 placing Resident #53 in a headlock and throwing the resident to the floor. Immediate Jeopardy was removed on 2/2/22 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity of E (no actual harm with a potential for minimum harm that is not Immediate Jeopardy) to ensure the monitoring of the systems put into place and to complete facility employee and agency in-services, orientation and training. The findings included: This is cross-referred to: F600: Based on record review and physician and staff interviews, the facility neglected to protect the residents' right to be free from abuse when Resident #29 physically abused Residents #39 and #53. Resident #53 sustained injuries that required emergency room evaluation. This was for 1 of 1 resident (Resident #29) reviewed for resident-to-resident abuse. F689: Based on record review, staff interview and observation, the facility failed to provide supervision to prevent residents with severe cognitive impairment who displayed exit seeking behaviors from exiting the facility unsupervised for 2 of 2 residents (Resident #21, Resident #29) reviewed for wandering behavior. The facility also failed to implement 1 to 1 supervision for Resident #29. On 1/27/22 at 10:10 AM an interview was conducted with Nursing Assistant (NA) #18 who stated she worked on the SCU (Secured Care Unit). NA #18 stated 14 residents were too much for one nurse and one NA to monitor. She indicated that there were multiple resident on the SCU who wandered. She explained if the nurse was passing medications and she was in a room providing care to a resident there was no one to monitor or supervise the residents who were wandering in the hall. On 1/27/22 at 11:42 AM an interview was conducted with the Staffing Scheduler who stated she scheduled one nurse or Medication Aide (Med Aide) and one NA on the SCU, and she would schedule 2 NAs if the census reached 13-14 residents, if she had the staff. The Scheduler further stated if there was not enough staff, then everyone helps out. The Staff Scheduler stated she used a computer program to do the staffing and the acuity of the unit was not taken into consideration when making out the schedule. The Scheduler stated none of the staff on the SCU have spoken with her about the staffing on the unit. The Interim Director of Nursing (DON) stated in an interview on 1/27/22 at 11:23 AM the staff on the SCU had told her there was not enough staff on the unit. The DON further stated they did not have the additional staff and if the agency staff did not pick up a shift they could not put more staff on the unit. The Administrator was notified of Immediate Jeopardy at F725 on 1/31/22 at 7:21 PM. The facility provided a credible allegation of Immediate Jeopardy removal on 2/1/22. The allegation of Immediate Jeopardy Removal indicated: Credible Allegation of Immediate Jeopardy Removal: The facility failed to have sufficient staffing to 1) Prevent and protect Residents #53 and #39 from being physically abused by Resident #29 and 2) to provide supervision to prevent two residents with severe cognitive impairment (Resident #21 and #29) from exiting the facility unsupervised. Because all residents are at risk when the facility fails to provide sufficient staffing to 1) prevent and protect residents from being physically abused by Resident #29 or other residents and 2) to provide supervision: to prevent residents with severe cognitive impairment (Resident #21 and #29) from exiting the facility unsupervised the following plan has been formulated to address this issue: On 2/1/2022, an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held by the Administrator, Director of Nursing, Regional Director of Clinical Services and Regional Director of Operations to discuss root cause analysis of the facilities failure to provide sufficient staffing levels to ensure supervision to keep residents free from physical abuse by other residents and to prevent unsupervised exits from the facility. The facility determined that administration and leadership failed to consider the number, acuity and diagnoses of the facility's resident population and to implement systems to ensure staffing schedules were adjusted accordingly, to include coverage during staff breaks, late arrivals with shift changes, to factor in the additional staff required to provide adequate supervision to keep residents safe from physical abuse by other residents and unsupervised exits from the facility. On 2/1/22, the Regional Director of Operations provided education to the Administrator and Director of Nursing on daily discussions of sufficient staff scheduling to ensure residents with behaviors towards others and residents exhibiting exit seeking or wandering behaviors are factored in when determining appropriate staffing levels to protect all residents from harm. Education included considering resident acuity and diagnoses and additional staff to assign to ensure sufficient staffing to provide adequate supervision to keep residents safe from physical abuse by other residents and unsupervised exits from the facility. Effective 2/1/22, the Administrator and Director of Nursing will discuss residents with behaviors towards others and residents exhibiting exit seeking or wandering behaviors daily to determine appropriate staffing levels to protect all residents from harm. The daily schedule will be adjusted to consider resident acuity and diagnoses and additional staff will be assigned to ensure sufficient staffing to provide adequate supervision to keep residents safe from physical abuse by other residents and unsupervised exits from the facility. Effective 2/1/22, the facility implemented a revised Safety Watch System to ensure continuous staff supervision for residents requiring 1:1 observation. The Administrator will ensure the 1:1 staff coverage is posted on the Safety Watch Schedule and assigned staff will utilize the Safety Watch Log to document coverage by signing and dating in and out times. During staff breaks and during change of shift, an alternate staff member will provide supervision and document on-coming and off-going coverage by signature and date on the Safety Check Log. In the event of call-outs or late arrivals, the current staff will notify the Administrator or Director of Nursing immediately and will remain with resident to ensure continuous supervision until alternate staff coverage is obtained. Staff who are assigned 1:1 resident observations will utilize interventions per resident plan of care to distract, redirect and intervene as appropriate. Any concerns with following the plan of care will be reported to the Physician and Administrator and/or Director of Nursing immediately and additional interventions implemented as necessary. Effective 2/1/22, the Regional Director of Operations and Regional Director of Clinical Services will provide education to facility and agency staff on the Safety Watch System and the expectation of providing continuous 1:1 supervision as assigned and the process to follow to ensure resident safety without any disruptions in continuous coverage. Education will include the process of utilizing the Safety Watch Log to document coverage by signing and dating in and out times. During staff breaks and during change of shift, an alternate staff member will provide supervision and document on-coming and off-going coverage by signature and date on the Safety Check Log. In the event of call-outs or late arrivals, the current staff will notify the Administrator or Director of Nursing immediately and will remain with resident to ensure continuous supervision until alternate staff coverage is obtained. Staff who are assigned 1:1 resident observations will receive education on utilizing interventions per resident plan of care to distract, redirect and intervene as appropriate and reporting any concerns with following the plan of care and Safety Watch System to the Administrator and/or Director of Nursing immediately. Effective 2/1/22, staff assigned to provide 1:1 resident supervision will not leave resident unattended at any time. During staff breaks and during change of shift, an alternate staff member will provide supervision and document on-coming and off-going coverage by signature and date on the Safety Check Log. In the event of call-outs or late arrivals, the current staff will notify the Administrator or Director of Nursing immediately and will remain with resident to ensure continuous supervision until alternate staff coverage is obtained. Effective 2/1/2022, the Administrator and Director of Nursing will make observational rounds to ensure adequate staffing levels are being provided based on acuity to prevent and protect residents from harm. Monitoring will be conducted at least weekly on 1) residents who exhibit exit seeking and wandering behaviors and 2) residents who have behaviors of aggression towards. Effective 2/1/22, the Administrator, Director of Nursing or Manager on Duty will and will review the Safety Watch Log to ensure continuous supervision is being provided and documented for residents assigned 1:1 observation. Monitoring will be conducted daily Effective 2/1/2022, the Administrator or Regional Director of Operations and Director of Nursing will be ultimately responsible to ensure implementation of this immediate jeopardy removal for this alleged noncompliance. Alleged Date of IJ Removal: 2/2/22. On 2/2/22 the Immediate Jeopardy removal plan was validated by onsite verification. Interviews were conducted with the DON and the Staffing Scheduler who stated they had been in-serviced to hold daily discussions to ensure sufficient staff were scheduled to ensure residents with behaviors towards others was factored in when determining appropriate staffing levels to provide adequate supervision to keep residents safe from physical abuse from other residents. The DON stated she had attended a QAPI meeting on 2/1/22 with the Regional Interim Administrator and discussed staff scheduling, neglect, abuse, reporting of abuse, behaviors. Immediate Jeopardy was removed on 2/2/22.

Based on record review, observation, and interviews with physician and staff, the facility Administration failed to provide oversight and leadership to 1) ensure the facility was free from abuse and to prevent and protect Resident #53 and #39 from being physically abused by Resident #29, 2) provide supervision to prevent residents with severe cognitive impairment from exiting the facility unsupervised (Residents #21 and #29); and 3) provide sufficient staffing to meet the needs of the residents. Immediate Jeopardy began on 11/08/21 when the facility leadership failed to implement interventions to maintain a safe and abuse free environment for the residents resulting in Resident #29 placing Resident #53 in a headlock and pulling her to the floor. Immediate Jeopardy was removed on 2/2/22 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity of E (no actual harm with a potential for minimum harm that is not Immediate Jeopardy) to ensure the monitoring of the systems put into place and to complete facility employee and agency in-services, orientation and training. The findings included: This tag is cross referenced to: F600: Based on record review and physician and staff interviews, the facility neglected to protect the residents' right to be free from abuse when Resident #29 physically abused Residents #39 and #53. Resident #53 sustained injuries that required emergency room evaluation. This was for 1 of 1 resident (Resident #29) reviewed for resident-to-resident abuse. F689: Based on record review, staff interview and observation, the facility failed to provide supervision to prevent residents with severe cognitive impairment who displayed exit seeking behaviors from exiting the facility unsupervised for 2 of 2 residents (Resident #21, Resident #29) reviewed for wandering behavior. The facility also failed to implement 1 to 1 supervision for Resident #29. F725: Based on record review, observation, and physician and staff interviews, the facility failed to have sufficient staffing to prevent and protect Residents #53 and #39 from being physically abused by Resident #29 for 1 of 1 resident reviewed for resident-to-resident physical abuse (Resident #29) and to provide supervision to prevent residents with severe cognitive impairment (Resident #21 and Resident #29) from exiting the facility unsupervised for 2 of 2 residents reviewed for wandering. The Administrator was notified of the Immediate Jeopardy at F835 on 1/31/22 at 7:21 PM. The facility provided a credible allegation of Immediate Jeopardy removal on 2/1/22. The allegation of Immediate Jeopardy removal indicated: Credible Allegation of Immediate Jeopardy Removal: The facility Administration failed to provide effective oversight and leadership to 1) ensure the facility was free from abuse and to prevent and protect Residents #53 and #39 from being physically abused by Resident #29, 2) provide supervision to prevent residents with severe cognitive impairment from exiting the facility unsupervised (Resident #21 and #29) and 3) provide sufficient staffing to meet the needs of the residents. On 2/1/2022, an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held by the Administrator, Director of Nursing, Regional Director of Clinical Services and Regional Director of Operations to discuss root cause analysis of the facilities failure to provide effective oversight and leadership to provide sufficient staffing to keep residents free from physical abuse by other residents and to prevent unsupervised exits from the facility. Root cause determined that the Administrator and Director of Nursing did not have clear understanding of acuity-based staffing. Additionally, administration failed to implement systems to ensure staffing schedules were adjusted to include coverage during staff breaks, late arrivals with shift changes, to factor in the additional staff required to provide adequate supervision to keep residents safe from physical abuse by other residents and unsupervised exits from the facility. On 2/1/22, an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held by the Administrator, Regional Director of Operations, Director of Nursing and Regional Director of Nursing on 2/1/22 to re-assess effective oversight and leadership to ensure 1)residents are protected from abuse, 2) that supervision is provided and interventions are implemented to prevent unsupervised exits from the facility and 3) sufficient staffing levels are provided based on resident acuity to ensure resident safety. On 2/1/22, the Regional Director of Operations provided education to the Administrator on effective administrative strategies and processes to ensure residents are protected from abuse, that supervision is provided and interventions are implemented to prevent unsupervised exits from the facility and that sufficient staffing levels are provided based on resident acuity to ensure resident safety. Education included review of company Abuse, Neglect and Exploitation Policy, Elopement and Wandering Residents Policy, a system to ensure staffing schedules are adjusted to include coverage during staff breaks, late arrivals with shift changes and the process for providing acuity-based staffing utilizing the ABS (acuity-based system) to provide adequate supervision to keep residents safe from physical abuse by other residents and unsupervised exits from the facility. Education of the ABS system included calculating staffing needs by adding the number of days at each RUG (Resident Utilization Grouper) level and case mix index divided by average daily census to determine number of staff needed. Newly hired Administrators will receive education upon hire during orientation. Effective 2/1/2022, the facility Administrator, Regional Director of Operations, Director of Nursing or Regional Director of Nursing will perform facility tours (including off shifts and weekends) daily to observe for any residents with behaviors which would need additional interventions. Additionally, the Administrator and Director of Nursing will monitor staffing levels every shift (including coverage during breaks and lunches) on the memory care unit based on resident acuity to ensure adequate staff to provide supervision to residents to prevent physical abuse. Effective 2/1/22, the Regional Director of Operations and/or the Regional Director of Clinical Services will be contacted by the Administrator and/or Director of Nursing when a resident-to-resident incident or unsupervised resident exit occurs to receive additional support and guidance and to ensure effective interventions to protect residents from harm. Effective 2/1/2022, the Regional Director of Operations and Regional Director of Clinical Services will meet at least bi-weekly with the Administrator and Director of Clinical Services in person or telephonically to discuss administrative oversight and leadership effectiveness in ensuring compliance with regulation F600, F689, and F725. Results of ongoing monitoring completed by the facility for F600, F689, F725 and F835 will be reviewed for completeness and effectiveness and additional support and interventions will be provided if necessary to maintain compliance. Effective 2/1/2022, the Administrator and Director of Nursing will be ultimately responsible to ensure implementation of this immediate jeopardy removal for this alleged noncompliance. Alleged Date of Immediate Jeopardy Removal: 2/2/22. On 2/2/22 the Credible Allegation was validated by onsite verification. Interviews were conducted with the DON and the staffing scheduler who stated they had been in-serviced to hold daily discussions to ensure sufficient staff were scheduled to ensure residents with behaviors towards others was factored in when determining appropriate staffing levels to provide adequate supervision to keep residents safe from physical abuse from other residents. The DON stated she had attended a QAPI meeting on 2/1/22 with the Regional Interim Administrator and discussed staff scheduling, resident elopement, neglect, abuse, reporting of abuse, behaviors and the use of the Safety Watch Log. Resident #29 was observed to be monitored 1:1 by facility staff and the Safety Watch Log was reviewed and the documentation revealed no gaps in monitoring from 1/28/22 (when the monitoring tool was implemented) until 2/2/22. The Immediate Jeopardy was removed on 2/2/22.