**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise the comprehensive person-centered care plan used to maintain the resident's highest practicable physical well-being for 1 (Resident #1) of 6 residents reviewed for care plans in that: - Resident #1 had 3 incidents of resident-to resident altercations. - On 12/01/2023, Resident #1 hit Resident #2 in the face which resulted in laceration to the lips - On 01/01/2023, Resident #1 hit Resident #3 in the face unprovoked. - On 01/15/2023, Resident #1 hit Reident #4 in the face twice unprovoked. - CNA A, CNA B, RN C and the DON all reported Resident #1's aggressive behaviors were unpredictable or unprovoked and difficult to prevent without continuous one-on-one supervision. - The facility failed to develop and implement interventions to prevent Resident #1's aggression and abuse of Residents #3 and #4. An Immediate Jeopardy (IJ) was identified on 03/15/2023 at 3:00PM. The IJ template was provided to the facility on [DATE] at 4:25PM, While the IJ was removed on 03/17/2023 at 2:00PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm as there is no evidence of actual harm and CMS has indicated IJ must be lowered to second level. These failures placed residents on the secured unit at risk of abuse, injuries and diminished quality of life. Findings included : Record review of Resident #1 was an [AGE] year-old male who was admitted into the facility on [DATE] and was diagnosed with cerebral infarction (disrupted blood flow to brain), Alzheimer's disease, dementia, and psychosis. Record review of Resident #1's MDS, dated [DATE], revealed the resident had a BIMS score of 3, indicating the resident's cognitions was severely impaired. It also reflected the resident was an independent walker while needing setup help for transferring . The MDS reflected no pertinent assessments on Resident #1's behaviors or mood. Record review of Resident #1's care plan, undated, reflected a focus on Resident #1's aggression initiated 01/02/2024 and revised on 01/16/2024. The focus revealed, .[Resident #1] was physically aggressive with a female resident on 1/1/2024 while on the unit when she unintentionally was ambulating within his path of ambulating on the unit as they passed each other. [Resident #1] does have a BIM score of 3 [severe impairment]. The goal was to have no other reports of injury to self or others due to aggressiveness through the next review target date, 03/27/2024. Interventions listed, included, . If [Resident #1] becomes combative, aggressive or refuse care, provide for safety, offer alternative time for care, back away, seek assistance as needed, notify Nurse of behaviors or refusal, assess reports of behaviors, assess for pain, change in mental status. Explain reason/need for care and risk due to refusal, why behavior is inappropriate. Implement appropriate interventions, document and Notify MD and RP if interventions are not effective . If [Resident #1] behaviors are affecting others, remove from area to quieter setting, and offer diversional activity as appropriate . The care plan had no consistent interventions in place to prevent future episodes of aggression, but only interventions to manage Resident #1 after an aggressive episode or an altercation had occurred. Record review of the resident roster , 03/13/2024, revealed Resident #1, #2, #3 and #4 all resided in hall 300, the secured unit. There were a total of 21 residents residing in the secured unit. Record review of Resident #2's face sheet revealed a [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with dementia, Alzheimer's disease and psychosis. Record review of Resident #2's MDS, dated [DATE], revealed the resident had a BIMS score of 4 indicating her cognition was severely impaired. The MDS reflected the resident's need for setup help to supervision for most ADLs . Record review of the facility's investigation report, dated 12/08/2023, revealed the investigation was conducted by Administrator A reflected that on 12/01/23, an unidentified resident reported witnessing Resident #1 hit Resident #2 while both residents were ambulating in the hallway. Resident #2 sustained a small laceration to here lips. It was documented that, .residents both suffer from dementia with noted cognitive deficits . Based on interviews with staff and lack of prior events, it is believed that [Resident #1] was startled as [Resident #2] passed him and he indistinctively swung at her. Even though we confirm this event did occur, there is no evidence that it was with intent to harm based on cognitive deficits presented; meaning no abuse occurred . There were no documented interventions placed after the incident to prevent aggressive behaviors by Resident #1. Record review of Resident #1's progress notes, dated 12/01/2023, revealed LVN D wrote, . staff instructed to keep [Resident #1] in constant supervision and away from other residents . Record review of Resident #3's face sheet revealed [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with bipolar disorder, depression and acute pain due to trauma. Record review of Resident #3's MDS, dated [DATE] revealed the resident had a BIMS score of 3 indicating her cognition was severely impaired and it also noted the resident's use of a walker to ambulate . Record review of the facility's investigation report, for incident dated 01/01/2024, revealed the investigation was conducted by Administrator B and reflected Resident #1 reached out and slapped Resident #3 while they were sitting close to each other in the TV room. No injury resulted from this incident. It was concluded in the investigation that, . the facility does not believe there was any intent for abuse and neglect. Both residents suffer from dementia and neither remember the incident . Record review of Resident #1's progress notes, dated 01/01/2024, revealed LVN E wrote, . [unidentified CNA] reported that this resident hit another resident in the face while the two of them was sitting on the sofa without being provoked. Resident unable to give explanation of what happened and why it happened due to cognition issues. Both residents were separated immediately. Resident sent to hospital for medical clearance and psych evaluation . Record review of Resident #1's care plan, undated reflected a focus on Resident #'1 aggression initiated 01/02/2024 and revised on 01/16/2024. It revealed, .[Resident #1] was physically aggressive with a female resident on 1/1/2024 while on the unit when she unintentionally was ambulating within his path of ambulating on the unit as they passed each other. [Resident #1] does have a BIM score of 3. The goal was to have no other reports of injury to self or others due to aggressiveness through the next review target date, 03/27/2024. Interventions listed, included, . If Resident #1 becomes combative, aggressive or refuse care, provide for safety, offer alternative time for care, back away, seek assistance as needed, notify Nurse of behaviors or refusal, assess reports of behaviors, assess for pain, change in mental status. Explain reason/need for care and risk due to refusal, why behavior is inappropriate. Implement appropriate interventions, document and Notify MD and RP if interventions are not effective . If [Resident #1] behaviors are affecting others, remove from area to quieter setting, and offer diversional activity as appropriate . The care plan had no consistent interventions in place to prevent future episodes of aggression, but only interventions to manage Resident #1 after an aggressive episode or an altercation had occurred. Record review of Resident #1's hospital records, dated 01/01/2024 - 01/02/2024 , revealed after being assessed for mental status, the resident was not given any new medication orders, but was instructed to follow up with mental health outpatient. Record review of Resident #1's progress notes, dated 01/05/2023, revealed he was assessed by the Psych NP who observed Resident #1 to very calm. The Psych NP recommended no med changes at the time and for, .staff to monitor closely and redirect other residents promptly and away from [sic] resident . Record review of Resident #4's face sheet revealed a [AGE] year-old male who was admitted into the facility on [DATE] and was diagnosed with dementia, type 2 diabetes and insomnia. Record review of Resident #4's MDS, dated [DATE], revealed the resident had a BIMS score of 2 indicating his cognition was severely impaired. The MDS reflected the resident's need for setup help to partial assistance for most ADLs . Record review of Resident #4's incident report , dated 01/15/2024, revealed Resident #1 was witnessed by an unidentified staff member to have been struck in the face twice by Resident #1 while sleeping and seated next to Resident #1. No injury resulted from this incident. Record review of Resident #1's incident report , dated 01/15/2024, reflected Resident #1 hit Resident ##4 twice in the face unprovoked. Resident #1 returned to his normal mood [NAME] after. As a result of the incident, immediate actions documented to be taken by staff included they separated the residents, performed assessments for injuries and aggressive moods, notified the Administrator, physician and responsible party, placed Resident #1 on one-on-one supervision by a CNA until the resident was picked up for transport to the ER. Record review of the facility's self-report, for an incident dated 01/15/2024, revealed the incident involved Residents #1 and #4 was conducted by Administrator B . Record review of Resident #1's hospital records, dated 01/15/2024 - 01/18/2024 , revealed it was documented the resident was to receive an in-patient consult with psychiatry but there was no documentation of a psych evaluation note on the patient. Records revealed the only new psych medication order by a physician was a PRN 50mg trazadone every 12 hours for up to 60 days. Record review of Resident #1's physician's orders, dated 03/14/2024, revealed the resident's only active psych med order was one daily 50mg tablet Trazodone at bedtime for insomnia and he had no medication changes since November 2023. In an interview with RN A on 03/13/2024 at 12:43PM, she reported she was only aware of two incidents in which Resident #1 hit Resident #2 and Resident #3. She stated she believed the resident tended to hit other residents who exhibited startling movements or residents who failed to respond to him while talking to them. She stated Resident #2 tended to have outbursts saying mean things like calling people stupid or saying, you stink, while Resident #3 swatted her arms in the air as if she was telling someone who was not there to get away. She stated Resident #1's actions were so unpredictable that she wouldn't know if he would exhibit the same aggressive behaviors today or not. When asked who Resident #1 was allowed to sit next to, she stated Resident #2 and Resident #3 were usually kept away from him. When asked if Resident #4 was also allowed to sit next to Resident #1 since their altercation, she asked, [Resident #4]? How many people did he hit? She stated Resident #1 did not have any medication changes following the evaluation at the hospital most likely because the resident was on his best behavior during his stay at the hospital When asked if she viewed Resident #1's actions as abuse, she stated it could be because he was not supposed to be hitting random people . In an interview with CNA A on 03/13/2024 at 12:58AM, she reported being aware of Resident #1's unpredictable aggressive behaviors and witnessed the incident on 01/01/24 but believed Resident #1's actions were not abuse because he was likely provoked in each situation, in that he was startled by the other person. She said she allowed Resident #1 to sit with another male resident for lunch today and Resident #2 usually sat by Resident #1 for mealtimes up until a month ago when a spot at the table reserved for women opened up. She stated she was not aware of all the residents Resident #1 had hit and she was not aware of a specific plan of care for Resident #1 regarding supervision to prevent future altercations. She stated at most, the charges nurses would verbally report to them which residents to keep separate from others depending on the residents' moods for that day. In an interview with CNA B 03/14/2024 at 10:35AM, she reported working in the secured unit for the past 6 months but not knowing of Resident #1's past incidents with other residents until yesterday on 03/13/24. She stated until then, she generally kept an eye on all residents in the secured unit but there was no specific plan of care regarding supervision for Resident #1. She stated she did not see Resident #1's actions as abuse because he had no intention behind it due to his dementia. She stated she did understand how other residents were at risk for experiencing abuse because his aggressive behaviors were unpredictable. In an interview with the DON on 03/14/2024 at 1:05PM, she stated she was aware of Resident #1's incidents in which he hit other residents. She stated Resident #1's episodes of aggression were unpredictable and attributed it to the resident being easily startled. She stated they could only try to separate the residents and redirect them to calm them down. She stated the altercations were like falls, for which they could put interventions in place but that's not to say that they won't fall again, but you can only prayerfully prevent an injury. She stated the only intervention they could impose was to separate the residents after the incident and send the aggressor to the hospital after the family was notified about the efforts made to safeguard the other residents. When asked if she believed that was an abuse concern, she stated they did all they can do to immediately respond after the incidents have occurred and Resident #1 did not intentionally abuse other residents due to his dementia nor did the staff know the incidents were going to happen. She said she did not know if a psych doctor had adjusted his medications as a result of the incidents. She said since the incident on 01/15/24, he had not had another incident of aggressive behavior. She stated he was not a candidate for one-on-one supervision at the moment because he had not had any other incidents since January . When asked how many incidents it would take for Resident #1 to be managed differently to prevent further incidents, she stated she could not put a number on that. She stated she did not know what else to say and that they could not prevent it because they did not know when the behaviors could start again. When asked if she believed the facility's abuse policy was followed, she stated the only thing they could do is put interventions in place which was done for all of Resident #1's incidents and that should suffice. In an interview with Administrator C on 03/14/2024 at 1:30PM, he reported it was his first day at the facility and based on the information he had learned about Resident #1, he said he would have discharged Resident #1 from the facility based on the established pattern of unpredictable episodes of aggression. He stated there would not have been a third incident by Resident #1 and the facility was not able to provide prolonged one-on-one supervision to prevent future incidents. He stated Resident #1 remaining at the facility could place residents at risks of unprovoked encounters with him. He stated there should have been an individualized training for staff on the resident's triggers which were difficult to determine considering he was unprovoked. He stated general knowledge of Resident #1's history and the need for increased monitoring would have been the most important things to educate staff on. Record review of facility's policy on Abuse Investigation and Reporting, not dated, reflected Administrator's duty to, .ensure any further potential abuse . is prevented. Record review of facility's policy on Care Plans, not dated, reflected, .The comprehensive, person-centered care plan will: a)include measureable objectives and timeframes b) describe the [NAME] that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being . An Immediate Jeopardy (IJ) was identified on 03/15/2024 at 3:00PM. On 03/15/2024 at 4:25PM the Administrator was notified of the IJ. The IJ template was left with the Administrator and a plan of removal (POR) was requested at that time. The POR was accepted on 03/16/2024 at 12:53PM. The POR reflected: PLAN OF REMOVAL OF IMMEDIATE JEOPARDY F 600 On 03/15/2024 at approximately 4:15 PM, [facility name] was notified by an HHSC employee the facility was in Immediate Jeopardy (IJ) with allegations of Abuse & Neglect (F600) noncompliance. On 03/15/2024, at approximately 4:22 PM, the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: F 600 - Alleging the facility failed to HHSC guidelines addressing Abuse and Neglect and an allegation of noncompliance. Resident #1 injured Resident # 2 causing a laceration of the lips and was observed to punch Residents #3 and #4 in the face. Due to pattern of aggressive behaviors and staff reporting the unpredictability of those events, it places all residents in the secured unit at risk for abuse. Action: o Charge nurse/ nurse managers Immediately assessed residents in the secure unit for possible abuse, no suspected abuse found at this time. oAdministrator/abuse coordinator Immediately in-service all staff 100% completion on Abuse & Neglect policy. oDirector of Nursing, Inservice all 100% of staff on current interventions in place for those residents with behavioral problems, 4 were identified in the secured unit care plans and interventions were updated and staff received the training of the current interventions. oResident #1 has been discharged to [behavioral hospital] on 3/14/24, care plan interventions updated . Monitoring : In-service record and policy titled, Preventing Resident-to-Resident Altercations in Nursing Homes, undated was reviewed. Policy used for staff training titled, Abuse Investigation and Reporting, dated July 2017, was reviewed. Record review of Resident #1's electronic health chart revealed the resident was discharged from the facility on 03/14/2024. Record review of care plans, undated, for Residents #5, #6, #7, #8 and #9 revealed updates of interventions to limit residents' aggressive behaviors were made on 03/16/2023. In an interview with CNA C and CNA D on 03/16/2024 at 2:04PM, they both correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Resident #8 on hall 200 as a resident to supervise closely and prevent episodes of aggression. In an interview with CNA E on 03/16/2024 at 2:12PM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Residents #1 and #9 on hall 300 as residents to supervise closely and prevent episodes of aggression. In an interview with CNA F and CNA G on 03/16/2024 at 2:34PM, they both correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Residents #5, #6 and #7 on hall 100 as a residents to supervise closely and prevent episodes of aggression. In an interview with CNA H on 03/16/2024 at 3:15PM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Residents #1 and #9 on hall 300 as residents to supervise closely and prevent episodes of aggression. In a phone interview with LVN C on 03/17/2024 at 10:50AM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Residents #1 and #9 on hall 300 as residents to supervise closely and prevent episodes of aggression. In a phone interview with CNA I on 03/17/2024 at 11:27AM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Resident #8 on hall 200 as residents to supervise closely and prevent episodes of aggression. In a phone interview with CNA J on 03/17/2024 at 12:03PM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, and identified who they would report incidents of resident-to-resident altercations to. In a phone interview with LVN B on 03/17/2024 at 12:59PM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to, and identified Residents #5, #6 and #7 on hall 100 as a residents to supervise closely and prevent episodes of aggression. In a phone interview with Administrator C on 03/17/2024 at 12:06PM, he stated the whole IDT was involved in reviewing incident reports, determining appropriate interventions for the resident, updating the care plan and educate staff on new plan of care. He stated residents with aggressive behaviors had been listed on the communication board for staff to reference and the facility would develop personal care plans and approaches with each resident to prevent abuse. He stated for the future when dealing with residents with unprovoked aggressive behaviors, he would resort to finding more appropriate placement for that resident to protect other residents. In a phone interview with the DON on 03/17/2024 at 12:16PM, she stated the IDT was responsible for care planning residents with aggressive behaviors. She stated residents with aggressive behaviors had been listed on the communication board for staff to reference and they would continue to education to staff to ensure proper interventions are in implemented. In a phone interview with the Social Worker on 03/17/2024 at 1:00PM, she stated the IDT and the doctor were responsible for updating plans of care for residents with aggressive behaviors. She stated to ensure prevention of aggressive behaviors, all residents would be kept safe, incident reports would be reviewed, staff would be in-serviced and the Ombudsman would be notified. In the case they could not ensure the safety of residents, her along with the IDT would look for alternative placement that would produce a more positive outcome for the resident identified as the aggressor. She stated they would also have the family and Ombudsman involved.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 4 for of 10 residents reviewed for abuse (Residents #1, #2, #3 and #4) were kept free form abuse, in that: - Resident #1 had 3 incidents of resident-to resident altercations. - On 12/01/2023, Resident #1 hit Resident #2 in the face which resulted in laceration to the lips - On 01/01/2023, Resident #1 hit Resident #3 in the face unprovoked. - On 01/15/2023, Resident #1 hit Reident #4 in the face twice unprovoked. - CNA A, CNA B, RN C and the DON all reported Resident #1's aggressive behaviors were unpredictable or unprovoked and difficult to prevent without continuous one-on-one supervision. An Immediate Jeopardy (IJ) was identified on 03/15/2023 at 3:00PM. The IJ template was provided to the facility on [DATE] at 4:25PM, While the IJ was removed on 03/17/2023 at 2:00PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm as there is no evidence of actual harm and CMS has indicated IJ must be lowered to second level. These failures placed residents on the secured unit at risk of abuse, injuries and diminished quality of life. Findings included : Record review of Resident #1 was an [AGE] year-old male who was admitted into the facility on [DATE] and was diagnosed with cerebral infarction (disrupted blood flow to brain), Alzheimer's disease, dementia, and psychosis. Record review of Resident #1's MDS, dated [DATE], revealed the resident had a BIMS score of 3, indicating the resident's cognitions was severely impaired. It also reflected the resident was an independent walker while needing setup help for transferring . The MDS reflected no pertinent assessments on Resident #1's behaviors or mood. Record review of Resident #1's care plan, undated, reflected a focus on Resident #1's aggression initiated 01/02/2024 and revised on 01/16/2024. The focus revealed, .[Resident #1] was physically aggressive with a female resident on 1/1/2024 while on the unit when she unintentionally was ambulating within his path of ambulating on the unit as they passed each other. [Resident #1] does have a BIM score of 3 [severe impairment]. The goal was to have no other reports of injury to self or others due to aggressiveness through the next review target date, 03/27/2024. Interventions listed, included, . If [Resident #1] becomes combative, aggressive or refuse care, provide for safety, offer alternative time for care, back away, seek assistance as needed, notify Nurse of behaviors or refusal, assess reports of behaviors, assess for pain, change in mental status. Explain reason/need for care and risk due to refusal, why behavior is inappropriate. Implement appropriate interventions, document and Notify MD and RP if interventions are not effective . If [Resident #1] behaviors are affecting others, remove from area to quieter setting, and offer diversional activity as appropriate . The care plan had no consistent interventions in place to prevent future episodes of aggression, but only interventions to manage Resident #1 after an aggressive episode or an altercation had occurred. Record review of the resident roster , 03/13/2024, revealed Resident #1, #2, #3 and #4 all resided in hall 300, the secured unit. There were a total of 21 residents residing in the secured unit. Record review of Resident #2's face sheet revealed a [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with dementia, Alzheimer's disease and psychosis. Record review of Resident #2's MDS, dated [DATE], revealed the resident had a BIMS score of 4 indicating her cognition was severely impaired. The MDS reflected the resident's need for setup help to supervision for most ADLs . Record review of the facility's investigation report, dated 12/08/2023, revealed the investigation was conducted by Administrator A reflected that on 12/01/23, an unidentified resident reported witnessing Resident #1 hit Resident #2 while both residents were ambulating in the hallway. Resident #2 sustained a small laceration to here lips. It was documented that, .residents both suffer from dementia with noted cognitive deficits . Based on interviews with staff and lack of prior events, it is believed that [Resident #1] was startled as [Resident #2] passed him and he indistinctively swung at her. Even though we confirm this event did occur, there is no evidence that it was with intent to harm based on cognitive deficits presented; meaning no abuse occurred . There were no documented interventions placed after the incident to prevent aggressive behaviors by Resident #1. Record review of Resident #1's progress notes, dated 12/01/2023, revealed LVN D wrote, . staff instructed to keep [Resident #1] in constant supervision and away from other residents . Record review of Resident #3's face sheet revealed [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with bipolar disorder, depression and acute pain due to trauma. Record review of Resident #3's MDS, dated [DATE] revealed the resident had a BIMS score of 3 indicating her cognition was severely impaired and it also noted the resident's use of a walker to ambulate . Record review of the facility's investigation report, for incident dated 01/01/2024, revealed the investigation was conducted by Administrator B and reflected Resident #1 reached out and slapped Resident #3 while they were sitting close to each other in the TV room. No injury resulted from this incident. It was concluded in the investigation that, . the facility does not believe there was any intent for abuse and neglect. Both residents suffer from dementia and neither remember the incident . Record review of Resident #1's progress notes, dated 01/01/2024, revealed LVN E wrote, . [unidentified CNA] reported that this resident hit another resident in the face while the two of them was sitting on the sofa without being provoked. Resident unable to give explanation of what happened and why it happened due to cognition issues. Both residents were separated immediately. Resident sent to hospital for medical clearance and psych evaluation . Record review of Resident #1's care plan, undated reflected a focus on Resident #'1 aggression initiated 01/02/2024 and revised on 01/16/2024. It revealed, .[Resident #1] was physically aggressive with a female resident on 1/1/2024 while on the unit when she unintentionally was ambulating within his path of ambulating on the unit as they passed each other. [Resident #1] does have a BIM score of 3. The goal was to have no other reports of injury to self or others due to aggressiveness through the next review target date, 03/27/2024. Interventions listed, included, . If Resident #1 becomes combative, aggressive or refuse care, provide for safety, offer alternative time for care, back away, seek assistance as needed, notify Nurse of behaviors or refusal, assess reports of behaviors, assess for pain, change in mental status. Explain reason/need for care and risk due to refusal, why behavior is inappropriate. Implement appropriate interventions, document and Notify MD and RP if interventions are not effective . If [Resident #1] behaviors are affecting others, remove from area to quieter setting, and offer diversional activity as appropriate . The care plan had no consistent interventions in place to prevent future episodes of aggression, but only interventions to manage Resident #1 after an aggressive episode or an altercation had occurred. Record review of Resident #1's hospital records, dated 01/01/2024 - 01/02/2024 , revealed after being assessed for mental status, the resident was not given any new medication orders, but was instructed to follow up with mental health outpatient. Record review of Resident #1's progress notes, dated 01/05/2023, revealed he was assessed by the Psych NP who observed Resident #1 to very calm. The Psych NP recommended no med changes at the time and for, .staff to monitor closely and redirect other residents promptly and away from [sic] resident . Record review of Resident #4's face sheet revealed a [AGE] year-old male who was admitted into the facility on [DATE] and was diagnosed with dementia, type 2 diabetes and insomnia. Record review of Resident #4's MDS, dated [DATE], revealed the resident had a BIMS score of 2 indicating his cognition was severely impaired. The MDS reflected the resident's need for setup help to partial assistance for most ADLs . Record review of Resident #4's incident report , dated 01/15/2024, revealed Resident #1 was witnessed by an unidentified staff member to have been struck in the face twice by Resident #1 while sleeping and seated next to Resident #1. No injury resulted from this incident. Record review of Resident #1's incident report , dated 01/15/2024, reflected Resident #1 hit Resident ##4 twice in the face unprovoked. Resident #1 returned to his normal mood [NAME] after. As a result of the incident, immediate actions documented to be taken by staff included they separated the residents, performed assessments for injuries and aggressive moods, notified the Administrator, physician and responsible party, placed Resident #1 on one-on-one supervision by a CNA until the resident was picked up for transport to the ER. Record review of the facility's self-report, for an incident dated 01/15/2024, revealed the incident involved Residents #1 and #4 was conducted by Administrator B . Record review of Resident #1's hospital records, dated 01/15/2024 - 01/18/2024 , revealed it was documented the resident was to receive an in-patient consult with psychiatry but there was no documentation of a psych evaluation note on the patient. Records revealed the only new psych medication order by a physician was a PRN 50mg trazadone every 12 hours for up to 60 days. Record review of Resident #1's physician's orders, dated 03/14/2024, revealed the resident's only active psych med order was one daily 50mg tablet Trazodone at bedtime for insomnia and he had no medication changes since November 2023. In an interview with RN A on 03/13/2024 at 12:43PM, she reported she was only aware of two incidents in which Resident #1 hit Resident #2 and Resident #3. She stated she believed the resident tended to hit other residents who exhibited startling movements or residents who failed to respond to him while talking to them. She stated Resident #2 tended to have outbursts saying mean things like calling people stupid or saying, you stink, while Resident #3 swatted her arms in the air as if she was telling someone who was not there to get away. She stated Resident #1's actions were so unpredictable that she wouldn't know if he would exhibit the same aggressive behaviors today or not. When asked who Resident #1 was allowed to sit next to, she stated Resident #2 and Resident #3 were usually kept away from him. When asked if Resident #4 was also allowed to sit next to Resident #1 since their altercation, she asked, [Resident #4]? How many people did he hit? She stated Resident #1 did not have any medication changes following the evaluation at the hospital most likely because the resident was on his best behavior during his stay at the hospital When asked if she viewed Resident #1's actions as abuse, she stated it could be because he was not supposed to be hitting random people . In an interview with CNA A on 03/13/2024 at 12:58AM, she reported being aware of Resident #1's unpredictable aggressive behaviors and witnessed the incident on 01/01/24 but believed Resident #1's actions were not abuse because he was likely provoked in each situation, in that he was startled by the other person. She said she allowed Resident #1 to sit with another male resident for lunch today and Resident #2 usually sat by Resident #1 for mealtimes up until a month ago when a spot at the table reserved for women opened up. She stated she was not aware of all the residents Resident #1 had hit and she was not aware of a specific plan of care for Resident #1 regarding supervision to prevent future altercations. She stated at most, the charges nurses would verbally report to them which residents to keep separate from others depending on the residents' moods for that day. In an interview with CNA B 03/14/2024 at 10:35AM, she reported working in the secured unit for the past 6 months but not knowing of Resident #1's past incidents with other residents until yesterday on 03/13/24. She stated until then, she generally kept an eye on all residents in the secured unit but there was no specific plan of care regarding supervision for Resident #1. She stated she did not see Resident #1's actions as abuse because he had no intention behind it due to his dementia. She stated she did understand how other residents were at risk for experiencing abuse because his aggressive behaviors were unpredictable. In an interview with the DON on 03/14/2024 at 1:05PM, she stated she was aware of Resident #1's incidents in which he hit other residents. She stated Resident #1's episodes of aggression were unpredictable and attributed it to the resident being easily startled. She stated they could only try to separate the residents and redirect them to calm them down. She stated the altercations were like falls, for which they could put interventions in place but that's not to say that they won't fall again, but you can only prayerfully prevent an injury. She stated the only intervention they could impose was to separate the residents after the incident and send the aggressor to the hospital after the family was notified about the efforts made to safeguard the other residents. When asked if she believed that was an abuse concern, she stated they did all they can do to immediately respond after the incidents have occurred and Resident #1 did not intentionally abuse other residents due to his dementia nor did the staff know the incidents were going to happen. She said she did not know if a psych doctor had adjusted his medications as a result of the incidents. She said since the incident on 01/15/24, he had not had another incident of aggressive behavior. She stated he was not a candidate for one-on-one supervision at the moment because he had not had any other incidents since January . When asked how many incidents it would take for Resident #1 to be managed differently to prevent further incidents, she stated she could not put a number on that. She stated she did not know what else to say and that they could not prevent it because they did not know when the behaviors could start again. When asked if she believed the facility's abuse policy was followed, she stated the only thing they could do is put interventions in place which was done for all of Resident #1's incidents and that should suffice. In an interview with Administrator C on 03/14/2024 at 1:30PM, he reported it was his first day at the facility and based on the information he had learned about Resident #1, he said he would have discharged Resident #1 from the facility based on the established pattern of unpredictable episodes of aggression. He stated there would not have been a third incident by Resident #1 and the facility was not able to provide prolonged one-on-one supervision to prevent future incidents. He stated Resident #1 remaining at the facility could place residents at risks of unprovoked encounters with him. He stated there should have been an individualized training for staff on the resident's triggers which were difficult to determine considering he was unprovoked. He stated general knowledge of Resident #1's history and the need for increased monitoring would have been the most important things to educate staff on. Record review of facility's policy on Abuse Investigation and Reporting reflected Administrator's duty to, .ensure any further potential abuse . is prevented. An Immediate Jeopardy (IJ) was identified on 03/15/2024 at 3:00PM. On 03/15/2024 at 4:25PM the Administrator was notified of the IJ. The IJ template was left with the Administrator and a plan of removal (POR) was requested at that time. The POR was accepted on 03/16/2024 at 12:53PM. The POR reflected: PLAN OF REMOVAL OF IMMEDIATE JEOPARDY F 600 On 03/15/2024 at approximately 4:15 PM, [facility name] was notified by an HHSC employee the facility was in Immediate Jeopardy (IJ) with allegations of Abuse & Neglect (F600) noncompliance. On 03/15/2024, at approximately 4:22 PM, the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: F 600 - Alleging the facility failed to HHSC guidelines addressing Abuse and Neglect and an allegation of noncompliance. Resident #1 injured Resident # 2 causing a laceration of the lips and was observed to punch Residents #3 and #4 in the face. Due to pattern of aggressive behaviors and staff reporting the unpredictability of those events, it places all residents in the secured unit at risk for abuse. Action: o Charge nurse/ nurse managers Immediately assessed residents in the secure unit for possible abuse, no suspected abuse found at this time. oAdministrator/abuse coordinator Immediately in-service all staff 100% completion on Abuse & Neglect policy. oDirector of Nursing, Inservice all 100% of staff on current interventions in place for those residents with behavioral problems, 4 were identified in the secured unit care plans and interventions were updated and staff received the training of the current interventions. oResident #1 has been discharged to [behavioral hospital] on 3/14/24, care plan interventions updated . Monitoring : In-service record and policy titled, Preventing Resident-to-Resident Altercations in Nursing Homes, undated was reviewed. Policy used for staff training titled, Abuse Investigation and Reporting, dated July 2017, was reviewed. Record review of Resident #1's electronic health chart revealed the resident was discharged from the facility on 03/14/2024. Record review of care plans, undated, for Residents #5, #6, #7, #8 and #9 revealed updates of interventions to limit residents' aggressive behaviors were made on 03/16/2023. In an interview with CNA C and CNA D on 03/16/2024 at 2:04PM, they both correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Resident #8 on hall 200 as a resident to supervise closely and prevent episodes of aggression. In an interview with CNA E on 03/16/2024 at 2:12PM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Residents #1 and #9 on hall 300 as residents to supervise closely and prevent episodes of aggression. In an interview with CNA F and CNA G on 03/16/2024 at 2:34PM, they both correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Residents #5, #6 and #7 on hall 100 as a residents to supervise closely and prevent episodes of aggression. In an interview with CNA H on 03/16/2024 at 3:15PM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Residents #1 and #9 on hall 300 as residents to supervise closely and prevent episodes of aggression. In a phone interview with LVN C on 03/17/2024 at 10:50AM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Residents #1 and #9 on hall 300 as residents to supervise closely and prevent episodes of aggression. In a phone interview with CNA I on 03/17/2024 at 11:27AM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Resident #8 on hall 200 as residents to supervise closely and prevent episodes of aggression. In a phone interview with CNA J on 03/17/2024 at 12:03PM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, and identified who they would report incidents of resident-to-resident altercations to. In a phone interview with LVN B on 03/17/2024 at 12:59PM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to, and identified Residents #5, #6 and #7 on hall 100 as a residents to supervise closely and prevent episodes of aggression. In a phone interview with Administrator C on 03/17/2024 at 12:06PM, he stated the whole IDT was involved in reviewing incident reports, determining appropriate interventions for the resident, updating the care plan and educate staff on new plan of care. He stated residents with aggressive behaviors had been listed on the communication board for staff to reference and the facility would develop personal care plans and approaches with each resident to prevent abuse. He stated for the future when dealing with residents with unprovoked aggressive behaviors, he would resort to finding more appropriate placement for that resident to protect other residents. In a phone interview with the DON on 03/17/2024 at 12:16PM, she stated the IDT was responsible for care planning residents with aggressive behaviors. She stated residents with aggressive behaviors had been listed on the communication board for staff to reference and they would continue to education to staff to ensure proper interventions are in implemented. In a phone interview with the Social Worker on 03/17/2024 at 1:00PM, she stated the IDT and the doctor were responsible for updating plans of care for residents with aggressive behaviors. She stated to ensure prevention of aggressive behaviors, all residents would be kept safe, incident reports would be reviewed, staff would be in-serviced and the Ombudsman would be notified. In the case they could not ensure the safety of residents, her along with the IDT would look for alternative placement that would produce a more positive outcome for the resident identified as the aggressor. She stated they would also have the family and Ombudsman involved.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the written policies and procedure to prevent abuse were implemented for 4 for of 10 residents reviewed for abuse (Residents #1, #2, #3 and #4), in that: - Resident #1 had 3 incidents of resident-to resident altercations. - On 12/01/2023, Resident #1 hit Resident #2 in the face which resulted in laceration to the lips - On 01/01/2023, Resident #1 hit Resident #3 in the face unprovoked. - On 01/15/2023, Resident #1 hit Reident #4 in the face twice unprovoked. - CNA A, CNA B, RN C and the DON all reported Resident #1's aggressive behaviors were unpredictable or unprovoked and difficult to prevent without continuous one-on-one supervision. - The facility failed to develop and implement interventions to prevent Resident #1's aggression and abuse of Residents #3 and #4. An Immediate Jeopardy (IJ) was identified on 03/15/2023 at 3:00PM. The IJ template was provided to the facility on [DATE] at 4:25PM, While the IJ was removed on 03/17/2023 at 2:00PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm as there is no evidence of actual harm and CMS has indicated IJ must be lowered to second level. These failures placed residents on the secured unit at risk of abuse, injuries and diminished quality of life. Findings included : Record review of Resident #1 was an [AGE] year-old male who was admitted into the facility on [DATE] and was diagnosed with cerebral infarction (disrupted blood flow to brain), Alzheimer's disease, dementia, and psychosis. Record review of Resident #1's MDS, dated [DATE], revealed the resident had a BIMS score of 3, indicating the resident's cognitions was severely impaired. It also reflected the resident was an independent walker while needing setup help for transferring . The MDS reflected no pertinent assessments on Resident #1's behaviors or mood. Record review of Resident #1's care plan, undated, reflected a focus on Resident #1's aggression initiated 01/02/2024 and revised on 01/16/2024. The focus revealed, .[Resident #1] was physically aggressive with a female resident on 1/1/2024 while on the unit when she unintentionally was ambulating within his path of ambulating on the unit as they passed each other. [Resident #1] does have a BIM score of 3 [severe impairment]. The goal was to have no other reports of injury to self or others due to aggressiveness through the next review target date, 03/27/2024. Interventions listed, included, . If [Resident #1] becomes combative, aggressive or refuse care, provide for safety, offer alternative time for care, back away, seek assistance as needed, notify Nurse of behaviors or refusal, assess reports of behaviors, assess for pain, change in mental status. Explain reason/need for care and risk due to refusal, why behavior is inappropriate. Implement appropriate interventions, document and Notify MD and RP if interventions are not effective . If [Resident #1] behaviors are affecting others, remove from area to quieter setting, and offer diversional activity as appropriate . The care plan had no consistent interventions in place to prevent future episodes of aggression, but only interventions to manage Resident #1 after an aggressive episode or an altercation had occurred. Record review of the resident roster , 03/13/2024, revealed Resident #1, #2, #3 and #4 all resided in hall 300, the secured unit. There were a total of 21 residents residing in the secured unit. Record review of Resident #2's face sheet revealed a [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with dementia, Alzheimer's disease and psychosis. Record review of Resident #2's MDS, dated [DATE], revealed the resident had a BIMS score of 4 indicating her cognition was severely impaired. The MDS reflected the resident's need for setup help to supervision for most ADLs . Record review of the facility's investigation report, dated 12/08/2023, revealed the investigation was conducted by Administrator A reflected that on 12/01/23, an unidentified resident reported witnessing Resident #1 hit Resident #2 while both residents were ambulating in the hallway. Resident #2 sustained a small laceration to here lips. It was documented that, .residents both suffer from dementia with noted cognitive deficits . Based on interviews with staff and lack of prior events, it is believed that [Resident #1] was startled as [Resident #2] passed him and he indistinctively swung at her. Even though we confirm this event did occur, there is no evidence that it was with intent to harm based on cognitive deficits presented; meaning no abuse occurred . There were no documented interventions placed after the incident to prevent aggressive behaviors by Resident #1. Record review of Resident #1's progress notes, dated 12/01/2023, revealed LVN D wrote, . staff instructed to keep [Resident #1] in constant supervision and away from other residents . Record review of Resident #3's face sheet revealed [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with bipolar disorder, depression and acute pain due to trauma. Record review of Resident #3's MDS, dated [DATE] revealed the resident had a BIMS score of 3 indicating her cognition was severely impaired and it also noted the resident's use of a walker to ambulate . Record review of the facility's investigation report, for incident dated 01/01/2024, revealed the investigation was conducted by Administrator B and reflected Resident #1 reached out and slapped Resident #3 while they were sitting close to each other in the TV room. No injury resulted from this incident. It was concluded in the investigation that, . the facility does not believe there was any intent for abuse and neglect. Both residents suffer from dementia and neither remember the incident . Record review of Resident #1's progress notes, dated 01/01/2024, revealed LVN E wrote, . [unidentified CNA] reported that this resident hit another resident in the face while the two of them was sitting on the sofa without being provoked. Resident unable to give explanation of what happened and why it happened due to cognition issues. Both residents were separated immediately. Resident sent to hospital for medical clearance and psych evaluation . Record review of Resident #1's care plan, undated reflected a focus on Resident #'1 aggression initiated 01/02/2024 and revised on 01/16/2024. It revealed, .[Resident #1] was physically aggressive with a female resident on 1/1/2024 while on the unit when she unintentionally was ambulating within his path of ambulating on the unit as they passed each other. [Resident #1] does have a BIM score of 3. The goal was to have no other reports of injury to self or others due to aggressiveness through the next review target date, 03/27/2024. Interventions listed, included, . If Resident #1 becomes combative, aggressive or refuse care, provide for safety, offer alternative time for care, back away, seek assistance as needed, notify Nurse of behaviors or refusal, assess reports of behaviors, assess for pain, change in mental status. Explain reason/need for care and risk due to refusal, why behavior is inappropriate. Implement appropriate interventions, document and Notify MD and RP if interventions are not effective . If [Resident #1] behaviors are affecting others, remove from area to quieter setting, and offer diversional activity as appropriate . The care plan had no consistent interventions in place to prevent future episodes of aggression, but only interventions to manage Resident #1 after an aggressive episode or an altercation had occurred. Record review of Resident #1's hospital records, dated 01/01/2024 - 01/02/2024 , revealed after being assessed for mental status, the resident was not given any new medication orders, but was instructed to follow up with mental health outpatient. Record review of Resident #1's progress notes, dated 01/05/2023, revealed he was assessed by the Psych NP who observed Resident #1 to very calm. The Psych NP recommended no med changes at the time and for, .staff to monitor closely and redirect other residents promptly and away from [sic] resident . Record review of Resident #4's face sheet revealed a [AGE] year-old male who was admitted into the facility on [DATE] and was diagnosed with dementia, type 2 diabetes and insomnia. Record review of Resident #4's MDS, dated [DATE], revealed the resident had a BIMS score of 2 indicating his cognition was severely impaired. The MDS reflected the resident's need for setup help to partial assistance for most ADLs . Record review of Resident #4's incident report , dated 01/15/2024, revealed Resident #1 was witnessed by an unidentified staff member to have been struck in the face twice by Resident #1 while sleeping and seated next to Resident #1. No injury resulted from this incident. Record review of Resident #1's incident report , dated 01/15/2024, reflected Resident #1 hit Resident ##4 twice in the face unprovoked. Resident #1 returned to his normal mood [NAME] after. As a result of the incident, immediate actions documented to be taken by staff included they separated the residents, performed assessments for injuries and aggressive moods, notified the Administrator, physician and responsible party, placed Resident #1 on one-on-one supervision by a CNA until the resident was picked up for transport to the ER. Record review of the facility's self-report, for an incident dated 01/15/2024, revealed the incident involved Residents #1 and #4 was conducted by Administrator B . Record review of Resident #1's hospital records, dated 01/15/2024 - 01/18/2024 , revealed it was documented the resident was to receive an in-patient consult with psychiatry but there was no documentation of a psych evaluation note on the patient. Records revealed the only new psych medication order by a physician was a PRN 50mg trazadone every 12 hours for up to 60 days. Record review of Resident #1's physician's orders, dated 03/14/2024, revealed the resident's only active psych med order was one daily 50mg tablet Trazodone at bedtime for insomnia and he had no medication changes since November 2023. In an interview with RN A on 03/13/2024 at 12:43PM, she reported she was only aware of two incidents in which Resident #1 hit Resident #2 and Resident #3. She stated she believed the resident tended to hit other residents who exhibited startling movements or residents who failed to respond to him while talking to them. She stated Resident #2 tended to have outbursts saying mean things like calling people stupid or saying, you stink, while Resident #3 swatted her arms in the air as if she was telling someone who was not there to get away. She stated Resident #1's actions were so unpredictable that she wouldn't know if he would exhibit the same aggressive behaviors today or not. When asked who Resident #1 was allowed to sit next to, she stated Resident #2 and Resident #3 were usually kept away from him. When asked if Resident #4 was also allowed to sit next to Resident #1 since their altercation, she asked, [Resident #4]? How many people did he hit? She stated Resident #1 did not have any medication changes following the evaluation at the hospital most likely because the resident was on his best behavior during his stay at the hospital When asked if she viewed Resident #1's actions as abuse, she stated it could be because he was not supposed to be hitting random people . In an interview with CNA A on 03/13/2024 at 12:58AM, she reported being aware of Resident #1's unpredictable aggressive behaviors and witnessed the incident on 01/01/24 but believed Resident #1's actions were not abuse because he was likely provoked in each situation, in that he was startled by the other person. She said she allowed Resident #1 to sit with another male resident for lunch today and Resident #2 usually sat by Resident #1 for mealtimes up until a month ago when a spot at the table reserved for women opened up. She stated she was not aware of all the residents Resident #1 had hit and she was not aware of a specific plan of care for Resident #1 regarding supervision to prevent future altercations. She stated at most, the charges nurses would verbally report to them which residents to keep separate from others depending on the residents' moods for that day. In an interview with CNA B 03/14/2024 at 10:35AM, she reported working in the secured unit for the past 6 months but not knowing of Resident #1's past incidents with other residents until yesterday on 03/13/24. She stated until then, she generally kept an eye on all residents in the secured unit but there was no specific plan of care regarding supervision for Resident #1. She stated she did not see Resident #1's actions as abuse because he had no intention behind it due to his dementia. She stated she did understand how other residents were at risk for experiencing abuse because his aggressive behaviors were unpredictable. In an interview with the DON on 03/14/2024 at 1:05PM, she stated she was aware of Resident #1's incidents in which he hit other residents. She stated Resident #1's episodes of aggression were unpredictable and attributed it to the resident being easily startled. She stated they could only try to separate the residents and redirect them to calm them down. She stated the altercations were like falls, for which they could put interventions in place but that's not to say that they won't fall again, but you can only prayerfully prevent an injury. She stated the only intervention they could impose was to separate the residents after the incident and send the aggressor to the hospital after the family was notified about the efforts made to safeguard the other residents. When asked if she believed that was an abuse concern, she stated they did all they can do to immediately respond after the incidents have occurred and Resident #1 did not intentionally abuse other residents due to his dementia nor did the staff know the incidents were going to happen. She said she did not know if a psych doctor had adjusted his medications as a result of the incidents. She said since the incident on 01/15/24, he had not had another incident of aggressive behavior. She stated he was not a candidate for one-on-one supervision at the moment because he had not had any other incidents since January . When asked how many incidents it would take for Resident #1 to be managed differently to prevent further incidents, she stated she could not put a number on that. She stated she did not know what else to say and that they could not prevent it because they did not know when the behaviors could start again. When asked if she believed the facility's abuse policy was followed, she stated the only thing they could do is put interventions in place which was done for all of Resident #1's incidents and that should suffice. In an interview with Administrator C on 03/14/2024 at 1:30PM, he reported it was his first day at the facility and based on the information he had learned about Resident #1, he said he would have discharged Resident #1 from the facility based on the established pattern of unpredictable episodes of aggression. He stated there would not have been a third incident by Resident #1 and the facility was not able to provide prolonged one-on-one supervision to prevent future incidents. He stated Resident #1 remaining at the facility could place residents at risks of unprovoked encounters with him. He stated there should have been an individualized training for staff on the resident's triggers which were difficult to determine considering he was unprovoked. He stated general knowledge of Resident #1's history and the need for increased monitoring would have been the most important things to educate staff on. Record review of facility's policy on Abuse Investigation and Reporting reflected Administrator's duty to, .ensure any further potential abuse . is prevented. An Immediate Jeopardy (IJ) was identified on 03/15/2024 at 3:00PM. On 03/15/2024 at 4:25PM the Administrator was notified of the IJ. The IJ template was left with the Administrator and a plan of removal (POR) was requested at that time. The POR was accepted on 03/16/2024 at 12:53PM. The POR reflected: PLAN OF REMOVAL OF IMMEDIATE JEOPARDY F 600 On 03/15/2024 at approximately 4:15 PM, [facility name] was notified by an HHSC employee the facility was in Immediate Jeopardy (IJ) with allegations of Abuse & Neglect (F600) noncompliance. On 03/15/2024, at approximately 4:22 PM, the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: F 600 - Alleging the facility failed to HHSC guidelines addressing Abuse and Neglect and an allegation of noncompliance. Resident #1 injured Resident # 2 causing a laceration of the lips and was observed to punch Residents #3 and #4 in the face. Due to pattern of aggressive behaviors and staff reporting the unpredictability of those events, it places all residents in the secured unit at risk for abuse. Action: o Charge nurse/ nurse managers Immediately assessed residents in the secure unit for possible abuse, no suspected abuse found at this time. oAdministrator/abuse coordinator Immediately in-service all staff 100% completion on Abuse & Neglect policy. oDirector of Nursing, Inservice all 100% of staff on current interventions in place for those residents with behavioral problems, 4 were identified in the secured unit care plans and interventions were updated and staff received the training of the current interventions. oResident #1 has been discharged to [behavioral hospital] on 3/14/24, care plan interventions updated . Monitoring : In-service record and policy titled, Preventing Resident-to-Resident Altercations in Nursing Homes, undated was reviewed. Policy used for staff training titled, Abuse Investigation and Reporting, dated July 2017, was reviewed. Record review of Resident #1's electronic health chart revealed the resident was discharged from the facility on 03/14/2024. Record review of care plans, undated, for Residents #5, #6, #7, #8 and #9 revealed updates of interventions to limit residents' aggressive behaviors were made on 03/16/2023. In an interview with CNA C and CNA D on 03/16/2024 at 2:04PM, they both correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Resident #8 on hall 200 as a resident to supervise closely and prevent episodes of aggression. In an interview with CNA E on 03/16/2024 at 2:12PM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Residents #1 and #9 on hall 300 as residents to supervise closely and prevent episodes of aggression. In an interview with CNA F and CNA G on 03/16/2024 at 2:34PM, they both correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Residents #5, #6 and #7 on hall 100 as a residents to supervise closely and prevent episodes of aggression. In an interview with CNA H on 03/16/2024 at 3:15PM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Residents #1 and #9 on hall 300 as residents to supervise closely and prevent episodes of aggression. In a phone interview with LVN C on 03/17/2024 at 10:50AM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Residents #1 and #9 on hall 300 as residents to supervise closely and prevent episodes of aggression. In a phone interview with CNA I on 03/17/2024 at 11:27AM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Resident #8 on hall 200 as residents to supervise closely and prevent episodes of aggression. In a phone interview with CNA J on 03/17/2024 at 12:03PM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, and identified who they would report incidents of resident-to-resident altercations to. In a phone interview with LVN B on 03/17/2024 at 12:59PM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to, and identified Residents #5, #6 and #7 on hall 100 as a residents to supervise closely and prevent episodes of aggression. In a phone interview with Administrator C on 03/17/2024 at 12:06PM, he stated the whole IDT was involved in reviewing incident reports, determining appropriate interventions for the resident, updating the care plan and educate staff on new plan of care. He stated residents with aggressive behaviors had been listed on the communication board for staff to reference and the facility would develop personal care plans and approaches with each resident to prevent abuse. He stated for the future when dealing with residents with unprovoked aggressive behaviors, he would resort to finding more appropriate placement for that resident to protect other residents. In a phone interview with the DON on 03/17/2024 at 12:16PM, she stated the IDT was responsible for care planning residents with aggressive behaviors. She stated residents with aggressive behaviors had been listed on the communication board for staff to reference and they would continue to education to staff to ensure proper interventions are in implemented. In a phone interview with the Social Worker on 03/17/2024 at 1:00PM, she stated the IDT and the doctor were responsible for updating plans of care for residents with aggressive behaviors. She stated to ensure prevention of aggressive behaviors, all residents would be kept safe, incident reports would be reviewed, staff would be in-serviced and the Ombudsman would be notified. In the case they could not ensure the safety of residents, her along with the IDT would look for alternative placement that would produce a more positive outcome for the resident identified as the aggressor. She stated they would also have the family and Ombudsman involved.