**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse and neglect for 3 of 24 residents (Residents #91, 81, and 92) reviewed for abuse/neglect. The facility failed to take sufficient protective measures after Resident #91 assaulted Resident #81 on 08/27/22 which resulted in Resident #91 assaulting and injuring Resident #92. On 11/30/22 at 5:30 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 12/04/22, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of physical and psychosocial injury, including serious injury or death. Findings included: Review of the undated face sheet for Resident #91 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of dementia of unspecified severity without behavioral disturbance, psychotic disturbance and anxiety. Review of the admission MDS for Resident #91 dated 07/28/22 reflected a BIMS score of 00, indicating a severe cognitive impairment and indicated no presence of aggressive behaviors. Review of the quarterly MDS for Resident #91 dated 11/14/22 reflected a BIMS score of 4, indicating a severe cognitive impairment. Record indicated the behavior of verbal aggression occurred one to three days of the 14-day lookback period, but not physical aggression. Review of the care plan for Resident #91 dated 08/30/22 reflected the following: The resident is/has potential to be physically agressive (sic) r/t Dementia 8/27/22- PUSHED ANOTHER RESIDENT INTO WALL CAUSING INJURY. The resident will not harm self or others through the review date. COMMUNICATION: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. Psychiatric/Psychogeriatric consult as indicated. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Review of the physician orders for Resident #91 on 11/30/22 at 2:31 p.m. reflected no new orders entered that day. Review of the progress notes for Resident #91 reflected the following: -08/27/22 documented by LVN N Late Entry: Note Text: Resident pushed another resident causing other resident to fall into wall and sustained small laceration to top of his head. Per witness, this resident pushed the other resident (Resident #81) Neither resident is able to recall incident. This resident family member was notified and informed she would need to come sit with resident. Family member verbalized agreement. (Family member) verbalize concern that was provoked and has never had this type of behavior. Advised family member to speak with admin on Monday. Family member verbalized agreement with changing resident room to provide separation. This resident room was changed from 115B to 116A. On call notified. Safety precautions in place. -11/30/22 documented by ADON A: Note Text: 0920am-Per CNA this resident (Resident #91) and another resident (Resident #81) had an altercation in the dining room. Went to assess (Resident #91) and no apparent injuries noted. VS 118/75, 76HR, 18R, 97.9, 96%RA. Asked patient what happened and patient states That guy had my jacket on, and I hit him. Patient unable to give this nurse any other description. Per staff, (Resident #91) walked up to (Resident #92) and thy began argue over (Resident #92)'s jacket. Then (Resident #91) punched (Resident #92) three times in the face. The staff pulled them both apart and separated them. Placed (Resident #91) on 1:1 for safety precautions. Police officer did come to evaluate situation. Notified DON, Administrator, NP, and RP. Review of an incident report completed for Resident #91 dated 08/27/22 reflected the following: Resident pushed another resident, causing other resident to fall into wall and sustained small laceration to top of his head. Per witness, this resident pushed the other resident after (roommate) pushed him. Neither resident is able to recall incident. This resident wife was notified and informed she would need to come sit with resident. (Family member) verbalized agreement. Verbalized concerned that her husband was provoked and has never had this type of behavior. Advised wife to speak with admin on Monday. Wife verbalized agreement with changing resident room to provide separation. The resident room was changed from 1:15 PM to 116. On-call notified. Safety precautions in place. Review of the undated face sheet for Resident #81 reflected a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. Review of readmission MDS for Resident #81 dated 09/01/22 reflected a BIMS score of 9, indicating a moderate cognitive impairment. Review of an incident report completed for Resident #81 dated 08/27/22 reflected the following: Aid assisted resident to nurse station. Resident has blood draining from his head down his left side of neck and back of head. Resident is unable to recall what happened. Per resident he was hit in the head and need to stop the bleeding. This nurse with assistance of other nurses cleaned blood from resident. Noted a gash - 1/2 inch long, superficial, no need for further assessment. Cleansed and applied bandage. Another resident visiting family member witnessed the incident. Per witness, roommate of resident pushed this resident after he shoved him. And this resident fell into the wall hitting his head. NP notified and aware resident is on Plavix. Per NP monitor closely and continue neurochecks. Family member's notified and verbalized concerned with the incident. ADON & DON notified. Review of undated face sheet for Resident #92 reflected an [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of dementia without behavioral disturbance. Review of quarterly MDS for Resident #92 dated 11/11/22 reflected a BIMS score of 3, indicating a severe cognitive impairment. Review of the care plan for Resident #92 dated 8/15/22 reflected the following: The resident exhibits behaviors of verbally & physically aggressive with agitation towards staff during attempts of providing care/redirecting. Review of hospital records for Resident #91 dated 07/17/22 immediately prior to admission to the facility and found uploaded to the resident's chart on the facility EMR reflected the following: Patient is walking the halls with his (family member) He is currently pleasantly confused. No further aggressive behavior as of yet. Has sitter at bedside. Still waiting on placement. This patient presents with altered mental status. Patient is a [AGE] year-old male brought to the emergency department for evaluation of aggressive behavior in dementia. Patient has no medical need to be admitted and should have been placed from ED but was unable to be. Patient is awake and alert. He is not oriented to time and place. Although his vital signs are stable his labs are mostly within normal limits. He does not have any significant past medical history other than dementia. This change of behavior is relatively new in the last two weeks and after today, he tried to choke his wife, and family are concerned and brought him here. Case management has tried to admit patient directly to a safe facility unfortunately, considering his aggression and being weekend, replacement has not been established yet. Neuro exam is limited, considering patient is not oriented and does not follow commands. Continue 1 to 1 sitter. CT of his head on 7/16 neck for any acute findings. Dispo: patient is at his baseline functional status. Wife refuses to take a patient home due to his violent behavior so still just waiting on a bed at Cross Creek or oceans. Patient is cleared to discharge on ce bed available. Plan discussed with patient and wife, nurse. Addendum: seen and examined on rounds. Wife and sitter at bedside. D/W PA. Patient gets aggressive when he's told what to do, and wife not comfortable taking him home. While I was in room, he refused to say seated and got up. Not aggressive, but clearly was not planning to listen to anyone. Still awaiting a facility that will take him. Reviewed PA findings and jointly created plan as above and agree. Review of physician progress note for Resident #91 dated 07/27/22 reflected the following : Patient was seen in collaboration with the supervising physician. Discussed POC with MD. Patient was admitted as a LTC resident due to dementia with behavioral issues. Admin history reason for admission for this day: the patient is a [AGE] year-old Caucasian male with a past medical history of dementia, who was brought to the emergency department for evaluation of aggressive behavior. Over the past four years, the patient's dementia has been slowly progressing to the point where his wife had to stay home with him for 24 hour care. Over the past three days prior to admission, patient's wife stated that he had been acting very aggressively. She stated that the morning of admission, he tried to choke her and hit their son several times when they tried to redirect him to eat, and to not wander outside . initially, we tried to place the patient into a psychiatric facility from the emergency room; however, we were unsuccessful as it was a weekend. As time progressed, the patient's wife did not want him placed in a psychiatric facility, and instead requested long-term care placement. Review of NP notes for Resident #91 dated 08/29/22 reflected the following: Patient was seen in the secure unit today. He is awake and alert, and oriented to his name only. He is ambulatory. Staff reported some behavioral issues where he had an altercation with another resident, which is unusual from his baseline since admission. Patient is afebrile, vital signs have been stable, will monitor closely. Assessment and plan. Dementia: dementia, aggressive behavior. Patient is awake and alert is not oriented shot time and place all the rest signs are stable. His labs are mostly within normal limits. He does not have any significant past medical history. Other than dementia. Neuro exam is limited considering patient is not oriented and does not follow commands. CT of his head on 7/16 negative for any acute findings. Patient will need a secure locked unit as he is at risk of wandering in elopement. Dementia continues to worsen and he is not oriented to place. Continue Namenda. Patient is back in the memory care unit due to exit seeking behavior. Staff reports that he had an altercation with another resident in the unit, able to redirect after the incident. Monitor closely. Interview on 11/30/22 at 11:25 a.m., the DON stated Resident #91 had punched Resident #92 in the dining room during breakfast that morning and as a result was on one-to-one supervision with a designated staff person. Observation and interview on 11/30/22 at 12:28 p.m. revealed CNA E seated in the hall adjacent to the dining area of the secure unit observing the area. She was 20 feet away from Resident #91 with three tables full of residents between them. She stated there were two CNAs assigned to the hall who were out in the main part of the facility retrieving their lunches. She stated she knew there had been an altercation between Resident #91 and #92, and she was made aware by the other CNAs. She said they told her Resident #91 was combative with another resident and to be wary of him. She stated the DON asked her to do one to one supervision of Resident #91. When asked what one to one supervision meant, she stated it meant to have him within her sight at all times. She stated there was not direction given about how close she needed to stand near the resident. She stated she had not communicated with the nurse who was currently on the hall about the incident or Resident #91's behavior. She stated LVN B told her about what happened. She stated LVN D was aware to keep eyes on everyone while on the secure unit. She stated technically, all the residents needed to be supervised, so Resident #91 did not need special supervision. She stated she was familiar with Resident #91 from when she picked up shifts, and she had never seen him exhibit any aggression. She stated she was not concerned about his behavior and that, besides some residents with high risks of falling, no one in the secure unit worried her for their safety or the safety of others. Observation and interview on 11/30/22 at 12:28 pm revealed Resident #91 seated at a table next to the back door of the secure unit dining area. Two female residents were seated at the table with him, and immediately behind him were three male residents seated at the neighboring table. There was a total of 24 residents sitting at tables in the dining area. Observation on 11/30/22 at 12:32 p.m. revealed LVN D standing at a medication cart in the nurse's station area adjacent to the dining room. The other two CNAs assigned to the hall returned with their lunch plates and went into a room off the nurse's station and closed the door. The CNAs were there for another ten minutes. Two visitors engaged CNA E in the nurse's station for a few minutes, and during this time, the residents in the dining room within, including Resident #91, were not in her line of sight. She also entered the room off the nurse's station where the other two CNAs were and closed the door behind her for a minute. Resident #91 did not have constant supervision during this period of time. Interview on 11/30/22 at 12:35 p.m., LVN D stated she had been back here about 30 minutes. She stated she had heard about an altercation, but she did not know offhand who the residents were, who were involved and had to look in her computer to determine them. She stated she was not given any instructions or guidance on what happened or what measures were in place. When asked if she knew of any measures, she stated her understanding was that the NP spoke to one of the ADONs, but she was not sure what the orders were. She looked in her computer and said no PRN anxiety medications were given for either resident. She said there was no one to one supervision currently needed or happening on the unit, to her knowledge. She said she had never seen Resident #91 be aggressive before, but she did not often work with him. She stated she usually found out about behaviors on a progress note or the 24-hour report. Interview on 11/30/22 at 12:48 p.m., CNA F stated she was present in the secure unit that morning (11/30/22) when Resident #91 assaulted Resident #92. She stated her back was turned helping two ladies eat, and she heard something, turned around, and saw them. She stated she worked with Resident #91 every day, and he had aggressive behaviors at times but was usually calm. When asked if she was aware of another incident of aggression by Resident #91, she first said no, but then when asked about the specific incident in August, she said she remembered. She stated it happened on the 2-10 p.m. shift, so she was not present when it occurred. She stated she believed that Resident #91 pushed Resident #81, and then Resident #91 was moved to a different room. She stated she did not think Resident #81 had any injuries after the incident. She stated she had not received any specific training or in-servicing after the incident. When asked what interventions she had been trained to use when Resident #91 exhibited aggressive behaviors toward another residents, she stated she would separate the residents. She could not think of any other interventions. When asked if she had access to view interventions in the resident care plan, she stated she did but could not remember how to access the care plans on her electronic documentation system. She stated she was updated on new incidents and resident behaviors each shift when they get a report from the outgoing CNAs or nurse. She stated she was not told that Resident #91 needed to be on one-to-one supervision after the incident with Resident #92 that morning, but she was keeping an eye on him. Interview on 11/30/22 at 12:55 p.m., CNA G stated she had been involved in the incident between Resident #91 and Resident #92 that morning. She stated they were eating breakfast and were just fine, and suddenly Resident #91 stood up and walked over to Resident #92 and began punching him. She stated it happened very quickly, but she got up immediately and got in between the two residents. She stated LVN B was also there and helped to intervene. She stated LVN B took Resident #91 down the hall, and they called the ADON to come assist. She stated Resident #92 was injured, and he was sent to the hospital, but she did not know the extent of his injuries. She stated no one had in-serviced her on the incident or what to do with Resident #91, but she and her colleagues knew to keep an eye on everyone. When asked about what to do when two residents had an altercation, she stated she was to separate them and call a nurse. Interview on 11/30/22 at 1:10 p.m., the SW stated Resident #91 had been aggressive in the facility (she had no further details), but not toward his family prior to admission. The SW stated she had just learned about his assault of Resident #92 a little while ago. The SW stated she usually goes to check on residents involved in such an incident, but she had been in care plan meetings that day. The SW stated she did not have a role in any care planning for aggression and that nursing handled that. Interview on 11/30/22 at 1:26 p.m., ADON A stated she had worked at the facility since October 2018. She stated she was in her office this morning around breakfast time, and the CNA came out and said Resident #91 and #92 got into it. She stated she went onto the secure unit and saw Resident #92's eye was bleeding. She stated the charge nurse for the unit, LVN B, was on a different hall, so ADON A stated she took care of it. She said she applied gauze and notified the NP, who wanted him sent to the hospital due to him being on Plavix. She stated she then talked to Resident #91, who was not able to tell her much. She stated staff told her that Resident #91 thought Resident #81 had his jacket on, and from there they started fighting. She stated the staff said the residents pushed each other, and Resident #91 initiated the punches. She stated they (she thought they was the DON) put him with a one-on-one staff, and she was not sure who they chose to do that job. She stated the definition of one-on-one supervision was the CNA should stay right by the resident. When asked how many feet there should be between the resident and the one-on-one supervisor, she stated the staff person should be able to see the resident at all times. She stated she did not know what the staff person assigned to provide one on one supervision was told about what that supervision should entail. She stated she told LVN B to assign someone back there to Resident #91. She stated she had heard of other times when Resident #91 was aggressive, but she had not seen him be aggressive. When asked what she knew about those events, she stated they moved him into another room after he was aggressive, and she believed it was aggression against Resident #81. She stated Resident #91 was not aggressive all the time but had his moments of aggression. She stated she was not aware of any history of aggression in Resident #91 before he came to the facility. She stated she was not sure what the interventions in place were to respond or react if Resident #91 exhibits aggression. She stated they were supposed to keep the residents safe, so separating them would be important. She stated she did conduct training and in-servicing for the staff if there was a particular problem they needed to address. She stated she had not trained staff about resident-to-resident abuse or aggressive behaviors. She stated the staff had computer-based training they were supposed to do, but she was not sure what all training had been offered to them related to aggression, behaviors, or Resident #91. Interview on 11/30/22 at 1:39 p.m., LVN B stated she was sitting in the corner of the dining room, heard a CNA yell stop and turned around and saw Resident #91 punch Resident #92 with a closed fist in the eye. She stated she and CNA G separated them. She stated she sat with Resident #91 until police showed up while ADON A assessed Resident #92. She stated once everything was calm, she was told by the DON to assign someone to one-on-one supervision, and Resident #91 had since been sitting in a chair in a dining area calm with residents. When asked what the definition of that one on one was, she stated the DON asked her to make sure the residents were safe and to keep an eye on Resident #91. She stated she assigned one on one supervision to CNA E, and her expectation was CNA E should have been right there with Resident #91. When asked if 20 feet away from the resident met the definition of one-on-one supervision, she stated, as long as Resident #91 did not appear agitated, the staff could be at a distance from him. When asked if Resident #91 was showing signs of agitation prior to assaulting Resident #92, she said he was not. She stated Resident #91 was eating his food one second and up the next. She stated the way they knew which residents had aggressive behaviors by looking at behavior notes and sometimes the 24-hour book. Interview on 11/30/22 at 1:46 pm, the DON stated a CNA came with ADON A to her that morning (11/30/22) during the breakfast hour and told her there had been an altercation. The DON said she went to the unit and saw Resident #92 with some redness around his eye, and the staff explained Resident #91 had hit him. The DON said she verified that the staff had told the ADM, who was the abuse coordinator, and she called the NP to make notification. The DON stated she stayed in the unit for 30 minutes and told LVN B to stay with Resident #91. The DON stated by the time EMS arrived, Resident #92 was walking around. The DON stated she told ADON A and LVN B to designate a third person in the secure unit so that someone could be assigned to Resident #91 to supervise one to one. The DON stated her expectation for one-to-one supervision was to have eyes on the resident the whole time. The DON said the staff should get up and follow the resident if s/he walked down that hall and stay with him or her. The DON stated one to one supervision could include being within reach of the resident, but close proximity was her expectation. The DON stated the NP decided to send Resident #92 to the hospital because he was on anti-platelet medication. The DON stated she did not know yet the extent of Resident #92's injury and was waiting to hear from the hospital. The DON stated for Resident #91, the NP just advised close monitoring. The DON stated she believed there was an order for CBC, TSH, CMP labs, but she did not know why the order had not been entered. The DON stated Resident #91 did not have any PRN medication for agitation, because he did not get agitated. She stated Resident #91 would be sitting and smiling one minute and then, all of a sudden, he was aggressive. The DON stated she learned the jacket Resident #92 was wearing looked similarly to one of Resident #91's favorite jacket, and she thought that triggered him. When asked if Resident #91 had ever assaulted anyone, DON stated she did not think he had but remembered the incident on 08/27/22 after checking the EMR. The DON stated she did not know that he had a history of aggression before being admitted to the facility. The DON looked at the hospital progress note and the MD's progress note after admission and stated she did not remember seeing that information . When asked how they ensure the admission referral was thoroughly read, DON stated she tried to read all the referrals. She stated the IDT was responsible for reading the entire admission packet, but she was not sure specifically who should be primarily responsible. The DON did not describe any formal process in place for reviewing admitting information. The DON stated Resident #91 was placed on the secure unit on admission, and that was because they assumed he would have some behaviors, but what they were aware of was wandering and exit seeking. The DON stated the secure unit has more staff supervising residents, and they have a lot of activities. The DON stated someone from activities was usually with them. The DON stated the first incident of aggression by Resident #91 was triggered when his roommate pushed him, and Resident #91 pushed back. The DON stated the roommate was injured. The DON stated in the immediate aftermath of this event, Resident #91's family member came to the facility and sat with him all day. She stated they did not put anything in place after the first incident except general closer monitoring. The DON stated they updated his care plan at that point, and she read the following interventions from his care plan, communication, cues, assisting verbalization, psych consult as indicated, when he becomes agitated intervene, engage calmly in conversation. The DON stated she thought they did not intervene more, because his roommate initiated the event. The DON stated he should have had a psych consult and did not know why that had not occurred. The DON stated it was the ADON's responsibility to oversee processes like that, but it was always also her responsibility. The DON stated there was no formal direction after the incident of that morning given by her to the staff. Interview on 11/30/22 at 2:05 p.m., the ADM stated he was aware of the incident of Resident #91 punching Resident #92. The ADM stated his understanding was that Resident #91 assumed the jacket Resident #92 was wearing was his own jacket. The ADM stated a CNA came to him and told him the incident had occurred. The ADM stated he went back there and saw that there was a bruise around Resident #92's eye. The ADM stated the NP sent Resident #92 out to the hospital to be assessed, and they put Resident #91 on one-on-one monitoring. The ADM stated the DON assigned the one-on-one supervision. The ADM stated at that point in the situation, there were four staff designated to the secure unit, and the one-on-one supervisor was a fifth. The ADM stated the one-on-one supervision was going to last until they deemed Resident #91 was not a danger to others. The ADM stated he could not presently say when that would be. The ADM stated they could deem him safe after constant supervision to see what his actions were. The ADM stated they could request the SW to speak with him to determine if he was safe, and they could get psychology involved. When asked what defines one on one supervision, ADM stated it depended on the situation. The ADM stated it would mean the one-on-one supervisor would stay in the general area of the resident. The ADM stated that on the secure unit, there was not a lot of room to maneuver, and they just had to have a straight line of sight of the resident being supervised. The ADM stated he did not know about Resident #91's history of aggressive behaviors. He was asked to read the hospital paperwork for Resident #91 in order to verify that the document included mention of recent aggressive behaviors, but he did not do so during the interview and did not remark on the content of this document or the facility physician progress note. The ADM stated he thought the incident on 08/27/22 to be an isolated incident. The ADM stated the facility procedure was to review the clinical information, and it was the job of the IDT to do so. The ADM stated they normally did not admit aggressive people or they had a plan to manage the behaviors. When asked what kind of plan they would enact, ADM stated they normally just would not admit anyone with a recent history of aggression. When asked if he would have admitted Resident #91 had they read the hospital referral paperwork, he stated it would depend and did not elaborate. Interview on 11/30/22 at 2:45 p.m., LVN N stated she vaguely remembered an incident when Resident #91 and Resident #81 had an altercation. LVN N stated Resident #81 was going through Resident #91's things and would not stay on his own side of the room. LVN N stated the witness who explained what happened was the family member of another resident, but she could not remember who was the aggressor in the situation. LVN N stated she did not recall what happened. She stated she did recall that Resident #91's family member came to the facility, and he changed rooms. LVN N stated she did not remember any in-servicing, directions from management, or new orders from that event. When asked what she should do if residents in her care had an altercation, LVN N stated she would split them up and get them each assessed. Review of facility policy dated September 2018 and titled Protection of Residents During Abuse Investigations reflected the following: Our facility will protect residents from harm during investigations of alleged abuse. During investigations of alleged abuse, residence will be protected from armed by the following measures: a. C. If the alleged abuse involves another resident, the accused residence representative and attending physician will be informed of the alleged abuse incident, and that there may be restrictions on the accused resident's ability to visit other residence, rooms, unattended. If necessary, the accused resident's family members may be required to help meet this requirement. This was determined to be an Immediate Jeopardy (IJ) on 11/30/22 at 5:30 p.m. The ADM was notified. The ADM was provided with the IJ template on 11/30/22 at 5:33 p.m. The following Plan of Removal submitted by the facility was accepted on 11/30/22 at 12:45 p.m.: Plan of Removal Issue: The facility failed to prevent Resident #91 from abuse, and neglect. The following plan of action outlines immediate interventions employed by the facility to remove any further concerns surrounding the issues: On 11/30/22 there were 26 Residents with the potential to be affected by Resident #91. On 11/30/22, the Director of Nursing placed Resident #91 on 1:1 monitoring with a facility staff member remaining within 6 feet of the member while outside of the resident's room. Beginning 11/30/22 and on-going, the DON / designee will assign a staff member to do 1:1 continuous observation on all shifts and provide training requirements to the staff for the resident at the time of assignment. Upon assignment, The DON / designee will in-service the assigned staff member(s), they must be between the resident and the entryway into the resident's room while in resident's room alone. Staff providing the 1:1 monitoring will sign in on the schedule binder to show the coverage day and hours. Resident #91 will remain on 1:1 monitoring until he is sent to a psychiatric facility to be evaluated. The DON / designee will be responsible for ensuring this is carried out. On 11/30/22, Resident's Primary care Physician gave an order for (psychology provider) Psychology to evaluate and treat. (Psychology provider) will follow Resident #91 while resident in this facility. The DON will be responsible to ensure Resident #91 continues to be treated by (Psychology provider). Beginning 12/1/22, The Regional Nurse Consultant will monitor that Resident #91 remains on services per physician's orders by verifying that visits are taking place, one time per week for four weeks, then two times per month for two months. The Director of Nursing re-educated the licensed nurses that were on shift at that time, on the indications of usage of PRN Antianxiety medication. The remainder of facility Nurses that were not working at that time, were re-educated prior to working their next shift and / or via telephone. All Licensed Nurses were re-educated by 12/2/22 by the DON / designee. Beginning 12/2/22 and on-going, The DON / designee will monitor all facili[TRUNCATED]