**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental or psychosocial status for 1 of 10 residents (Resident #1) reviewed for resident rights. The facility failed to ensure Resident #1's physician and psychiatrist were immediately notified after Resident #1 indicated he wanted to shoot or stab someone. An Immediate Jeopardy (IJ) situation was identified on 09/29/23 at 3:22 p.m. While the IJ was removed on 09/30/23 at 4:10 p.m., the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of a delay in medical intervention and decline in health or possible worsening of symptoms. Findings included: Record review Resident #1's face sheet, dated 09/27/23, indicated a [AGE] year old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), cerebral infarction (stroke), metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction), major depressive disorder (persistent feeling of sadness and loss of interest ), impulsiveness (tendency to act without thinking), and anxiety (a feeling of fear, dread, and uneasiness.) Record review of Resident #1's MDS assessment, dated 09/15/23, indicated Resident #1 was usually able to make himself understood and understand others, had severe cognitive impairment indicated by a BIMS score of 7. He had verbal behavior directed at others every 1-3 days. His behaviors were worse. He was mobile with a cane or wheelchair. Record review of Resident #1's care plan, dated 04/18/22, indicated Resident #1 had a neurocognitive disorder without behavioral disturbance (dementia). Interventions included remove Resident #1 from settings that seem to upset or exacerbate behaviors and psychiatric consult as ordered. Record review of Resident #1's care plan, dated 04/18/22, indicted Resident #1 had a history of behavioral symptoms of impulsiveness and temper outbursts. Interventions included remove from situation and allow time to calm down. Record review of Resident #1's care plan, dated 06/20/23, indicated Resident #1 had a verbal behavioral symptoms directed at others such as urinating on the bed, being naked in the hallways and cussing at others. Interventions included respond in a calm voice, maintain eye contact. Remove from area if Resident #1 was abusive to others. Record review of Resident #1's clinical file revealed there were no care plans available for review related to homicidal ideations. Record review of a clinical note dated 09/14/23, at 4:02 a.m., and completed by LVN A, indicated LVN A was walking down the hallway when she overheard Resident #1 tell CNA B I want to kill somebody so that I can go back to prison. I want to shoot or stab someone, probably both. The DON and administrator were notified. Q-15 minute monitoring set up for Resident #1. Resident #1 was lying in bed watching TV, no s/s of distress or mental status. Resident #1 appeared calm. Will continue to monitor Resident #1 and inform oncoming shift of behavior. There was no documentation of physician notification. Record review of a progress note, dated 09/18/23, completed by APRN L indicated she spoke with the nurse (she could not recall the name of the nurse) and the nurse indicated Resident #1 was being monitored after stating he wanted to stab his roommate. Resident #1 was lying in bed without acute distress. Resident #1 stated I don't want to hurt anyone. I just want to get out of here. I don't want to be here. Resident #1 said he did not have a plan to harm himself or anyone else. Resident #1 was in a pleasant mood without s/s of distress/anxiety/depression. APRN L included an order to refer for psychiatric services to evaluate Resident #1 for possible adjustment to medications. Resident #1 did not appear to be a harm to himself or anyone else. Record review of a psychiatric assessment, completed on 09/21/23, by FNP N, indicated Resident #1 was assessed due to agitation and expressing he wanted to hurt someone. Resident #1 refused to engage. Staff indicated Resident #1 was more agitated and said he wanted a knife to stab someone and to go back to prison. Resident #1 was uncooperative with the exam. Revisit in two weeks. Record review of a progress note, dated 09/25/23 completed by APRN L, indicated Resident #1 was lying in bed without acute distress. He was easy to wake. He said he did not want to hurt anyone. He wanted to get out of the facility. He did not want to be in the facility. He was instructed he could not make threats against others and verbalized understanding. He had no behaviors since last visit. Record review of clinical note dated 09/26/23 at 9:21 a.m., and completed by ADON C, indicated RP was notified regarding homicidal intentions and MD suggestions of sending to behavioral hospital to adjust medication and any possible treatment needed., RP agreed. Referral sent to behavior hospital. Record review of progress note, dated 09/26/23 at 10:31 p.m., completed by APRN L, indicated (late entry) spoke with nurse and Resident #1 was being monitored after stating he wanted to stab his roommate. Resident #1 was lying in bed without acute distress. Resident #1 stated I don't want to hurt anyone. I just want to get out of here. I don't want to be here. Resident #1 said he did not have a plan to harm himself or anyone else. Resident #1 was in a pleasant mood without s/s of distress/anxiety/depression. Order given to refer for psychiatric services to evaluate Resident #1 for possible adjustment to medications. Resident #1 did not appear to be a harm to himself or anyone else. During an interview on 09/26/23 at 4:55 a.m., LVN A said Resident #1 was on frequent monitoring with Q15 minute checks due to threats of harm to others. She said she overheard Resident #1 tell CNA B he wanted to kill someone, to shoot or stab them so he could go back to prison. She said she notified the DON and the administrator immediately. She said she did not notify the physician. She said she was not aware of Resident #1 making any previous threats to harm others. During an interview on 09/29/23 at 9:29 a.m., the DON said she was notified by LVN A on 09/14/23 of Resident #1's threat to shoot or stab someone. She said she did not remove him from the room or move his roommate because Resident #1 did not specify anyone he wanted to harm. She said he did not have an active plan. The DON said Resident #1 was mobile with a wheelchair. She said Resident #1 was placed on q15 minute checks. She said he was not placed on 1-1. She said the physician and psychiatric services were not notified at the time of the incident. During an interview on 09/29/23 at 10:00 a.m., the Administrator indicated she was not made aware of Resident #1's threats to harm others on 09/14/23. She said she was off due to her husband having surgery. She said Resident #1 was not placed on 1-1 and could have harmed his roommate or others. She said she would have placed Resident #1 on 1-1 until cleared by psychiatric services. She said she would have moved Resident #1 or his roommate. She said the police should have been notified. She said she did a counseling and coaching with the DON and LVN A on 09/26/23 related to notification and reporting. She said she notified MD K and completed an emergency QAPI on 09/26/23. She said staff were in-serviced on 09/26/23. During an interview on 09/29/23 at 1:56 p.m., APRN L said she was completing scheduled rounds in the facility on 09/21/23 and LVN A informed her of Resident #1's threat to harm his roommate. She said Resident #1 indicated he had no plan and no intention. She said she was not aware of any prior threats. APRN L said staff would continue to monitor Resident #1 until he was seen by psychiatric services. During an interview on 09/29/23 at 2:41 p.m., FNP N said she assessed Resident #1 on 09/21/23. She said he was not cooperative with the assessment. She said he made a threat to hurt someone with a knife so he could go to prison. She said she would have recommended Resident #1 be sent out to a behavioral unit if he was a threat. Record review of the facility's Physician Notification policy, updated March 2019, indicated The types of conditions which arise frequently are listed. This list is not inclusive. Altered Mental Status .It is the responsibility of the nursing staff to observe the change, make an assessment, and notify the physician as indicated based on the assessment. The physician; physician assistant; nurse practitioner; or clinical nurse specialist is to be promptly notified of the results of the radiology, lab and other diagnostic tests ordered. The nurse will: Recognize the condition change. Monitor the Patient and continue to assess the condition and changes. Notify the physician, patient and patient representative of any change in condition. This was determined to be an Immediate Jeopardy (IJ) on 09/29/23 at 3:22 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 09/29/22 at 3:44 p.m. The following Plan of Removal submitted by the facility was accepted on 09/29/23 at 4:10 p.m. Immediate Action: Systematic Approach: 1. Assessment - Resident #1 with homicidal ideation on 9/14/23 was placed on one-on-one on 9/26/23 at 9:02 AM until he was discharged to a Behavioral hospital on 9/27/23 at 2:00 PM.-The Executive Director notified the facility Medical Director of the Immediate Jeopardy on 09/29/22 at 4:20 PM. -An emergency QAPI meeting was held on 9/26/2023. -All residents will have a psychosocial assessment updated by the Director of Nurses, Assistant Director of Nurses and/or Patient Care Coordinator on 9/29/2023 to identify any current patients that are at imminent risk homicidal/suicidal ideation. The psychosocial assessments were completed on 9/29/23 by 6:00 PM. After completion of psychosocial assessments, no other residents were found to be at imminent risk of homicidal/suicidal ideation. The assessment includes the following information: The assessment is to determine if a resident is an imminent/suicidal risk for psychiatric needs. Who will be responsible: Director of Nursing/Nurse Managers Who Will monitor: Executive Director and RDCS -Beginning 9/29/2023, psychosocial assessments will be completed upon admission, condition change, and quarterly by the charge nurse and/or nurse managers, and for any resident that triggers an imminent risk for homicidal/suicidal ideation, the facility will initiate one-on-one supervision until further direction is provided. The abuse/neglect policy will be implemented immediately. The physician will be notified immediately of any homicidal ideation of any resident. The ED and DON will monitor for compliance daily by running an audit of the psychosocial assessments. Audits will be completed weekly for 3 months until 12/29/2023 and then monthly on an ongoing basis. Who will be responsible: Director of Nursing/Nurse Managers Who Will monitor: Executive Director/RDCS -Beginning 9/29/23, any resident who triggers an imminent risk of homicidal/suicidal ideation, will be placed on one-on-one supervision and will have notification to the staff caring for the resident, the attending physician, and psychiatric services referral will be made by the nurse manager and monitored by clinical staff. -ED will call family, police and notify physician to confirm notification of resident homicidal/suicidal ideation. -ED will implement the abuse/neglect policy immediately. -Any staff that is aware of a resident with homicidal/suicidal ideation will immediately inform the ED. -ED will notify HHSC of a homicidal/suicidal resident incident according to reporting protocols and following the abuse/neglect prohibition protocol. Who will be responsible: Director of Nursing/Nurse Managers Who Will monitor: Executive Director/RDCS All staff were educated to notify the Executive Director, DON or RDCS immediately upon verbalization of a resident wanting to harm someone or themselves. This education was provided on 9/29/2023. This education was provided by the Executive Director, DON and RDCS. Staff will not be allowed to begin their shift until the education has been completed. Until alternative and or safe living arrangements are made the resident will be placed on one-on-one supervision with facility staff. Resident care plans will also be updated to include any verbalizations of wanting to harm others including homicidal/suicidal ideations. The ED and/or RDCS will monitor weekly for compliance by completing an audit of the psychosocial assessments. Audits will be completed weekly for 3 months until 12/29/2023 and then monthly on an ongoing basis. Who will be responsible: Director of Nursing/Nurse Managers Who Will monitor: Executive Director/RDCS 2. In-Services All staff were in-serviced on resident homicidal/suicidal ideation and the abuse/neglect policy by the ED/RDCS/Director of Nursing and/or Nurse Managers. All new staff will receive the education as part of the onboarding orientation process prior to being assigned and providing care to residents. No staff member will be allowed to work in the facility until the above required in-services are completed. The in-service with all staff will be completed by 9/29/2023. All staff were in-serviced by 8:00 PM on 9/29/2023. Who will be responsible: DON/Nurse Managers Who Will monitor: Executive Director/RDCS Shift to Shift reporting process will be as follows: -As part of shift to shift report the charge nurse will notify the oncoming nurse of the one-on-one and homicidal/suicidal ideation. All nurses and CNAs will be in-serviced on the shift-to-shift report process by the Executive Director, Director of Nursing or Assistant Director of Nursing by 9/30/23 at 8:00 a.m. Who will be responsible: DON/Nurse Managers Who Will monitor: Executive Director/RDCS Each employee completed a post-test after their education was completed to ensure staff were able to identify abuse/neglect and reporting requirements. If the employee did not pass the test with at least 90% correctly answered the staff member was re-educated and re-tested until at least 90% pass rate was met. A staff roster was utilized to ensure 100% of licensed nursing staff were in-serviced and tested. In-services were deemed to be effective by the in-services post-test scores and verbalization of understanding by all facility staff (clinical, non-clinical and ancillary). All nurses, Executive Director and nurse managers were in-serviced on abuse and neglect on 9/29/23 by 8:00 PM. The Executive Director, DON and ADON were in-serviced by the RDCS on 9/29/23 by 4:00 PM. Who will be responsible: DON/Nurse Managers Who Will monitor: Executive Director/RDCS 3. Monitoring Starting 9/29/23 the Executive Director, Director of nursing and/or Nurse Managers will review all psychosocial assessments for any psychosocial needs including homicidal/suicidal ideation. The Regional Director of Clinical Services will review the documentation each week for compliance and will review any needs for reporting allegations to the state agency. Monitoring of the POR included the following: During interviews on 09/30/23 from 1:00 p.m. through 4:00 p.m. with LVN A 10 p.m. - 6 a.m., RN S (weekend shifts) CNA Q (6 a.m. -6 p.m.), LVN R (prn all shifts), CNA T (all shifts), LVN U 2 p.m. -10 p.m., LVN W 10 p.m. -6 a.m., LVN X 6 a.m. - 2 p.m., LVN Y 6 a.m. 2 p.m., CNA D 6 p.m.-6 a.m. and the ADON indicated staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the charge nurse or administrator and were able to give example of physical, verbal, sexual abuse, and immediate intervention procedures. All staff indicated they were educated to notify the Executive Director, DON or RDCS immediately if a resident threatened to harm someone or themselves. All staff indicated they would ensure any resident who threatened harm to themselves or others would be placed on 1-1 until cleared by their physician. They indicated resident care plans would be reviewed and updated to include any verbalizations of wanting to harm others which included homicidal/suicidal ideations. All staff indicated they were trained on resident homicidal/suicidal ideation and the abuse/neglect policy. They were able to give examples of appropriate actions to take in different situations involving abuse or threats of harm. The ADON and LVNs indicated they were to notify the physician of resident's change of condition and were able to give examples. During an interview on 09/30/23 at 3:45 p.m., the Administrator said she was in-serviced on 09/29/23 by the RDCS. She was able to verbalize the facility abuse, and neglect policy and they would conduct a thorough investigation of all incidents of resident threats of self harm or harm to others. She understood she was required to report incidents according to regulatory compliance, and reporting incidents of abuse or neglect that result in serious bodily injury/death. She said the physician would be notified immediately of any homicidal ideation of any resident. She and the DON would monitor for compliance daily by running an audit of the psychosocial assessments. She said this would be completed weekly for 3 months until 12/29/23 and then monthly on an ongoing basis. She said she and the DON would review the facility 24 Hour Report and Incident Reports in the morning clinical for any allegation or instances of abuse and/or neglect and physician notification. During an interview on 09/30/23 at 4:00 p.m., the DON said she was in-serviced on 09/29/23 by the RDCS. She was able to verbalize the facility abuse, and neglect policy and they would conduct a thorough investigation of all incidents of resident threats of self harm or harm to others. She understood she was required to report incidents according to regulatory compliance, and reporting incidents of abuse or neglect that resulted in serious bodily injury/death. The DON and Administrator would monitor for compliance daily by running an audit of the psychosocial assessments. The DON and Administrator would review the facility 24 Hour Report and Incident Reports in the morning clinical for any allegation or instances of abuse and/or neglect and physician notification. She said this would be completed weekly for 3 months until 12/29/23 and then monthly on an ongoing basis. Record review of all incidents from the previous 90 days indicated there were no additional incidents of threats of self harm or harm to others as of 09/30/23. Record review of resident abuse questionnaire, dated 09/29/23, indicated no residents were identified as reporting any abuse or being afraid of any residents or staff. Record review of training records indicated all staff (nursing and non-nursing) were in-serviced on 09/29/23 regarding the facility abuse and neglect policy, the procedure for reporting incidents of threats of harm with serious harm and/or death, suspected abuse/neglect, recognizing threats of harm (to self and others), and physician notification. Record review of quiz results, dated 09/29/23 and 09/30/23, indicated all staff passed the quiz regarding abuse, neglect, reporting, suicide threats, managing suicide ideations, comprehensive care plans, and physician notification. The Administrator and the DON were informed the Immediate Jeopardy was removed on 09/30/23 at 4:10 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 10 residents (Resident #1) reviewed for abuse and neglect. 1. The facility failed to place Resident #1 on 1-1 or move him to a private room after he threatened to shoot or stab someone. 2. The facility failed to implement their abuse policy when they failed to report allegations of abuse. An Immediate Jeopardy (IJ) situation was identified on 09/29/23 at 3:22 p.m. While the IJ was removed on 09/30/23 at 4:10 p.m., the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings include: Record review of Resident #1's face sheet, dated 09/27/23, indicated a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), cerebral infarction (stroke), metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction), major depressive disorder (persistent feeling of sadness and loss of interest ), impulsiveness (tendency to act without thinking), and anxiety (a feeling of fear, dread, and uneasiness.) Record review of an MDS assessment, dated 09/15/23, indicated Resident #1 was usually able to make himself understood and understand others, had severe cognitive impairment, indicated by a BIMS score of 7. He had verbal behavior directed at others every 1-3 days. His behaviors were worse. He was mobile with a cane or wheelchair. Record review of Resident #1's care plan, dated 04/18/22, indicated Resident #1 had a neurocognitive disorder without behavioral disturbance (dementia). Interventions included remove Resident #1 from settings that seem to upset or exacerbate behaviors and psychiatric consult as ordered. Record review of Resident #1's care plan, dated 04/18/22, indicted Resident #1 had a history of behavioral symptoms of impulsiveness and temper outbursts. Interventions included remove from situation and allow time to calm down. Record review of Resident #1's care plan, dated 06/20/23, indicated Resident #1 had a verbal behavioral symptom directed at others such as urinating on the bed, being naked in the hallways and cussing at others. Interventions included respond in a calm voice, maintain eye contact. Remove from area if Resident #1 was abusive to others. Record review of Resident #1's clinical record revealed there were no care plans available for review related to homicidal ideations. Record review of a clinical note dated 09/14/23 at 4:02 a.m., and completed by LVN A, indicated LVN A was walking down the hallway when she overheard Resident #1 tell CNA B I want to kill somebody so that I can go back to prison. I want to shoot or stab someone, probably both. The DON and administrator were notified. Q-15 minute monitoring set up for Resident #1. Resident #1 was lying in bed watching TV, no s/s of distress or mental status. Resident #1 appeared calm. Will continue to monitor Resident #1 and inform oncoming shift of behavior. There was no documentation of physician notification. Record review of a progress note, dated 09/18/23, completed by APRN L, indicated she spoke with the nurse (the nurse was not identified) and the nurse indicated Resident #1 was being monitored after stating he wanted to stab his roommate. Resident #1 was lying in bed without acute distress. Resident #1 stated I don't want to hurt anyone. I just want to get out of here. I don't want to be here. Resident #1 said he did not have a plan to harm himself or anyone else. Resident #1 was in a pleasant mood without s/s of distress/anxiety/depression. Order given to refer for psychiatric services to evaluate Resident #1 for possible adjustment to medications. Resident #1 did not appear to be a harm to himself or anyone else. Record review of a psychiatric assessment, completed on 09/21/23 by FNP N, indicated Resident #1 was assessed due to agitation and expressing he wanted to hurt someone. Resident #1 refused to engage. Staff indicated Resident #1 was more agitated and said he wanted a knife to stab someone and to go back to prison. Resident #1 was uncooperative with exam. Revisit in two weeks. Record review of a progress note, dated 09/25/23 completed by APRN L, indicated Resident #1 was lying in bed without acute distress. He was easy to wake. He said he did not want to hurt anyone. He wanted to get out of the facility. He did not want to be in the facility. He was instructed he could not make threats against others and verbalized understanding. He had no behaviors since last visit. Record review of clinical note, dated 09/26/23 at 9:21 a.m. and completed by ADON C, indicated RP was notified regarding homicidal intentions and MD suggestions of sending to the behavioral hospital to adjust medication and any possible treatment needed., RP agreed. Referral sent to behavior hospital. Record review of progress note, dated 09/26/23 at 10:31 p.m., completed by APRN L, indicated (late entry) spoke with nurse and Resident #1 was being monitored after stating he wanted to stab his roommate. Resident #1 was lying in bed without acute distress. Resident #1 stated I don't want to hurt anyone. I just want to get out of here. I don't want to be here. Resident #1 said he did not have a plan to harm himself or anyone else. Resident #1 was in a pleasant mood without s/s of distress/anxiety/depression. Order given to refer for psychiatric services to evaluate Resident #1 for possible adjustment to medications. Resident #1 did not appear to be a harm to himself or anyone else. Record review of Q-15 minute monitoring sheets indicated monitoring was completed from 09/14/23 through 09/26/23. Resident #1 was placed on 1-1 after the State Surveyor intervention (until Resident #1 was transferred to behavior hospital on [DATE]). During an observation on 09/26/23 at 4:50 a.m., Resident #1 was lying in bed watching TV in his room. Resident #1's roommate was asleep. Staff were assisting other residents with ADLS. There was no 1-1 staff or sitter observed. During an interview on 09/26/23 at 4:55 a.m., LVN A said Resident #1 was on frequent monitoring with Q15 minute checks due to threats of harm to others. She said she overheard Resident #1 tell CNA B he wanted to kill someone, to shoot or stab them so he could go back to prison. She said she notified the DON and the Administrator immediately. She said she did not notify the physician. She said she was not aware of Resident #1 making any previous threats to harm others. During an interview on 09/29/23 at 9:29 a.m., the DON said she was notified by LVN A of Resident #1's threat to shoot or stab someone. She said she did not remove him from the room or move his roommate because Resident #1 did not specify anyone he wanted to harm. She said he did not have an active plan. She said the room was not searched for a gun or a knife. The DON said Resident #1 was mobile with a wheelchair. She said Resident #1 was placed on q15 minute checks after he made a threat to shoot or stab someone. She said he was not placed on 1-1. She said she did not remove him from the room or move his roommate because Resident #1 did not specify anyone he wanted to harm. She said he did not have an active plan. She said she did not call the police. She said she did not report the incident to the State Survey Agency. She did not know Resident #1 threatening to harm others was a reportable event. She said she was trained on abuse and neglect. She said she did not think of reporting Resident #1's threat to harm others. She said other residents and staff were at risk of harm due to Resident #1's threat. During an interview on 09/29/23 at 10:00 a.m., the Administrator indicated she was not made aware of Resident #1's threats to harm others on 09/14/23. She said she was off due to her husband having surgery. She said Resident #1 was not placed on 1-1 and could have harmed his roommate or others. She said the DON was the designee and responsible to ensure polices were followed. She said she would have placed Resident #1 on 1-1 until cleared by psychiatric services. She said she would have moved Resident #1 or his roommate. She said she was not aware the incident was a reportable incident. She said she reported the incident to the State Survey Agency after the State Surveyor questioned the clinical note. She said the police should have been notified. She said she did a counseling and coaching with the DON and LVN A. She said she notified MD K and completed an emergency QAPI. She said staff were inserviced on 09/26/23. During an interview on 09/29/23 at 2:41 p.m., FNP N said she assessed Resident #1 on 09/21/23. She said he was not cooperative with the assessment. She said he made a threat to hurt someone with a knife so he could go to prison. She said she would have recommended Resident #1 be sent out to a behavioral unit if he was a threat. During an interview on 10/05/23 at 2:19 p.m., ADON C said Resident #1 should have been on 1-1 and put in a private room after he made threats to hurt others. She said psychiatric should have been contacted to assess Resident #1. She said Resident #1's threat to harm others was noted on the 24 hour report and would have been reviewed during the morning meeting. She said she did not recall if it was reviewed. Record review of the facility's Abuse Protocol, dated April 2019, indicated . 10. The abuse Prevention Coordinator will: a. Immediately (within 2 hours) report to (state agency) and other appropriate authorities incidents of Patient Abuse . Record review of the facility's Suicide Threats policy, dated 2001 (revised December 2007), indicated Resident suicide threats shall be taken seriously and addressed appropriately. 1. Staff shall report any resident threats of suicide immediately to the Nurse Supervisor /Charge Nurse. 2. The Nurse Supervisor /Charge Nurse shall immediately assess the situation and shall notify the Charge Nurse/Supervisor and /or Director of Nursing Services of such threats. 3. A staff member shall remain with the resident until the Nurse Supervisor/Charge Nurse arrives to evaluate the resident. 4. After assessing the resident in more detail, the Nurse Supervisor/Charge Nurse shall notify the resident's Attending Physician and responsible party, and shall seek further direction from the physician. 5. All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior immediately. 6. As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated. 7. If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly , until a physician has determined that a risk of suicide does not appear to be present. 8. Staff shall document details of the situation objectively in the resident's medical record. This was determined to be an Immediate Jeopardy (IJ) on 09/29/23 at 3:22 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 09/29/22 at 3:44 p.m. The following Plan of Removal submitted by the facility was accepted on 09/29/23 at 4:10 p.m. Immediate Action: Systematic Approach: 1. Assessment - Resident #1 with homicidal ideation on 9/14/23 was placed on one-on-one on 9/26/23 at 9:02 AM until he was discharged to a Behavioral hospital on 9/27/23 at 2:00 PM.-The Executive Director notified the facility Medical Director of the Immediate Jeopardy on 09/29/22 at 4:20 PM. -An emergency QAPI meeting was held on 9/26/2023. -All residents will have a psychosocial assessment updated by the Director of Nurses, Assistant Director of Nurses and/or Patient Care Coordinator on 9/29/2023 to identify any current patients that are at imminent risk homicidal/suicidal ideation. The psychosocial assessments were completed on 9/29/23 by 6:00 PM. After completion of psychosocial assessments, no other residents were found to be at imminent risk of homicidal/suicidal ideation. The assessment includes the following information: The assessment is to determine if a resident is an imminent/suicidal risk for psychiatric needs. Who will be responsible: Director of Nursing/Nurse Managers Who Will monitor: Executive Director and RDCS -Beginning 9/29/2023, psychosocial assessments will be completed upon admission, condition change, and quarterly by the charge nurse and/or nurse managers, and for any resident that triggers an imminent risk for homicidal/suicidal ideation, the facility will initiate one-on-one supervision until further direction is provided. The abuse/neglect policy will be implemented immediately. The physician will be notified immediately of any homicidal ideation of any resident. The ED and DON will monitor for compliance daily by running an audit of the psychosocial assessments. Audits will be completed weekly for 3 months until 12/29/2023 and then monthly on an ongoing basis. Who will be responsible: Director of Nursing/Nurse Managers Who Will monitor: Executive Director/RDCS -Beginning 9/29/23, any resident who triggers an imminent risk of homicidal/suicidal ideation, will be placed on one-on-one supervision and will have notification to the staff caring for the resident, the attending physician, and psychiatric services referral will be made by the nurse manager and monitored by clinical staff. -ED will call family, police and notify physician to confirm notification of resident homicidal/suicidal ideation. -ED will implement the abuse/neglect policy immediately. -Any staff that is aware of a resident with homicidal/suicidal ideation will immediately inform the ED. -ED will notify HHSC of a homicidal/suicidal resident incident according to reporting protocols and following the abuse/neglect prohibition protocol. Who will be responsible: Director of Nursing/Nurse Managers Who Will monitor: Executive Director/RDCS All staff were educated to notify the Executive Director, DON or RDCS immediately upon verbalization of a resident wanting to harm someone or themselves. This education was provided on 9/29/2023. This education was provided by the Executive Director, DON and RDCS. Staff will not be allowed to begin their shift until the education has been completed. Until alternative and or safe living arrangements are made the resident will be placed on one-on-one supervision with facility staff. Resident care plans will also be updated to include any verbalizations of wanting to harm others including homicidal/suicidal ideations. The ED and/or RDCS will monitor weekly for compliance by completing an audit of the psychosocial assessments. Audits will be completed weekly for 3 months until 12/29/2023 and then monthly on an ongoing basis. Who will be responsible: Director of Nursing/Nurse Managers Who Will monitor: Executive Director/RDCS 2. In-Services All staff were in-serviced on resident homicidal/suicidal ideation and the abuse/neglect policy by the ED/RDCS/Director of Nursing and/or Nurse Managers. All new staff will receive the education as part of the onboarding orientation process prior to being assigned and providing care to residents. No staff member will be allowed to work in the facility until the above required in-services are completed. The in-service with all staff will be completed by 9/29/2023. All staff were in-serviced by 8:00 PM on 9/29/2023. Who will be responsible: DON/Nurse Managers Who Will monitor: Executive Director/RDCS Shift to Shift reporting process will be as follows: -As part of shift to shift report the charge nurse will notify the oncoming nurse of the one-on-one and homicidal/suicidal ideation. All nurses and CNAs will be in-serviced on the shift-to-shift report process by the Executive Director, Director of Nursing or Assistant Director of Nursing by 9/30/23 at 8:00 a.m. Who will be responsible: DON/Nurse Managers Who Will monitor: Executive Director/RDCS Each employee completed a post-test after their education was completed to ensure staff were able to identify abuse/neglect and reporting requirements. If the employee did not pass the test with at least 90% correctly answered the staff member was re-educated and re-tested until at least 90% pass rate was met. A staff roster was utilized to ensure 100% of licensed nursing staff were in-serviced and tested. In-services were deemed to be effective by the in-services post-test scores and verbalization of understanding by all facility staff (clinical, non-clinical and ancillary). All nurses, Executive Director and nurse managers were in-serviced on abuse and neglect on 9/29/23 by 8:00 PM. The Executive Director, DON and ADON were in-serviced by the RDCS on 9/29/23 by 4:00 PM. Who will be responsible: DON/Nurse Managers Who Will monitor: Executive Director/RDCS 3. Monitoring Starting 9/29/23 the Executive Director, Director of nursing and/or Nurse Managers will review all psychosocial assessments for any psychosocial needs including homicidal/suicidal ideation. The Regional Director of Clinical Services will review the documentation each week for compliance and will review any needs for reporting allegations to the state agency. Monitoring of the POR included the following: During interviews on 09/30/23 from 1:00 p.m. through 4:00 p.m. with LVN A 10 p.m. - 6 a.m., RN S (weekend shifts) CNA Q 6 a.m. -6 p.m.), LVN R (prn all shifts), CNA T (all shifts), LVN U 2 p.m. -10 p.m., LVN W 10 p.m. -6 a.m., LVN X 6 a.m. - 2 p.m., LVN Y 6 a.m. 2 p.m., CNA D 6 p.m.-6 a.m. and the ADON indicated staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the charge nurse or administrator and were able to give example of physical, verbal, sexual abuse, and immediate intervention procedures. All staff indicated they were educated to notify the Executive Director, DON or RDCS immediately if a resident threatened to harm someone or themselves. All staff indicated they would ensure any resident who threatened harm to themselves or others would be placed on 1-1 until cleared by their physician. They indicated resident care plans would be reviewed and updated to include any verbalizations of wanting to harm others which included homicidal/suicidal ideations. All staff indicated they were trained on resident homicidal/suicidal ideation and the abuse/neglect policy. They were able to give examples of appropriate actions to take in different situations involving abuse or threats of harm. The ADON and LVNs indicated they were to notify the physician of resident's change of condition and were able to give examples. Interviews conducted with three alert residents on 09/30/23 from 1:00 p.m. through 4:00 p.m. indicated they would report abuse to the administrator or the DON. They were not afraid of any residents. During an interview on 09/30/23 at 3:45 p.m., the Administrator said she was in-serviced on 09/29/23 by the RDCS. She was able to verbalize the facility abuse, and neglect policy and they would conduct a thorough investigation of all incidents of resident threats of self harm or harm to others. She understood she was required to report incidents according to regulatory compliance, and reporting incidents of abuse or neglect that result in serious bodily injury/death. She said the physician would be notified immediately of any homicidal ideation of any resident. She and the DON would monitor for compliance daily by running an audit of the psychosocial assessments. She said this would be completed weekly for 3 months until 12/29/23 and then monthly on an ongoing basis. She said she and the DON would review the facility 24 Hour Report and Incident Reports in the morning clinical for any allegation or instances of abuse and/or neglect and physician notification. During an interview on 09/30/23 at 4:00 p.m., the DON said she was in-serviced on 09/29/23 by the RDCS. She was able to verbalize the facility abuse, and neglect policy and they would conduct a thorough investigation of all incidents of resident threats of self harm or harm to others. She understood she was required to report incidents according to regulatory compliance, and reporting incidents of abuse or neglect that resulted in serious bodily injury/death. The DON and Administrator would monitor for compliance daily by running an audit of the psychosocial assessments. The DON and Administrator would review the facility 24 Hour Report and Incident Reports in the morning clinical for any allegation or instances of abuse and/or neglect and physician notification. She said this would be completed weekly for 3 months until 12/29/23 and then monthly on an ongoing basis. Record review of all incidents from the previous 90 days indicated there were no additional incidents of threats of self harm or harm to others as of 09/30/23. Record review of resident abuse questionnaire, dated 09/29/23, indicated no residents were identified as reporting any abuse or being afraid of any residents or staff. Record review of training records indicated all staff (nursing and non-nursing) were in-serviced on 09/29/23 regarding the facility abuse and neglect policy, the procedure for reporting incidents of threats of harm with serious harm and/or death, suspected abuse/neglect, recognizing threats of harm (to self and others), and physician notification. Record review of quiz results, dated 09/29/23 and 09/30/23, indicated all staff passed the quiz regarding abuse, neglect, reporting, suicide threats, managing suicide ideations, comprehensive care plans, and physician notification. The Administrator and the DON were informed the Immediate Jeopardy was removed on 09/30/23 at 4:10 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 10 residents (Resident #1) reviewed for accidents and supervision. The facility failed to place Resident #1 on 1-1 supervision or move him to a private room after he threatened he wanted to shoot or stab someone. An Immediate Jeopardy (IJ) situation was identified on 09/29/23 at 3:22 p.m. While the IJ was removed on 09/30/23 at 4:10 p.m., the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of Resident #1's face sheet, dated 09/27/23, indicated a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), cerebral infarction (stroke), metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction), major depressive disorder (persistent feeling of sadness and loss of interest ), impulsiveness (tendency to act without thinking), and anxiety (a feeling of fear, dread, and uneasiness.) Record review of an MDS assessment, dated 09/15/23, indicated Resident #1 was usually able to make himself understood and understand others, had severe cognitive impairment, indicated by a BIMS score of 7. He had verbal behavior directed at others every 1-3 days. His behaviors were worse. He was mobile with a cane or wheelchair. Record review of Resident #1's care plan, dated 04/18/22, indicated Resident #1 had a neurocognitive disorder without behavioral disturbance (dementia). Interventions included remove Resident #1 from settings that seem to upset or exacerbate behaviors and psychiatric consult as ordered. Record review of Resident #1's care plan, dated 04/18/22, indicted Resident #1 had a history of behavioral symptoms of impulsiveness and temper outbursts. Interventions included remove from situation and allow time to calm down. Record review of Resident #1's care plan, dated 06/20/23, indicated Resident #1 had a verbal behavioral symptom directed at others such as urinating on the bed, being naked in the hallways and cussing at others. Interventions included respond in a calm voice, maintain eye contact. Remove from area if Resident #1 was abusive to others. Record review of Resident #1's clinical record revealed there were no care plans available for review related to homicidal ideations. Record review of a clinical note dated 09/14/23 at 4:02 a.m., and completed by LVN A, indicated LVN A was walking down the hallway when she overheard Resident #1 tell CNA B I want to kill somebody so that I can go back to prison. I want to shoot or stab someone, probably both. The DON and administrator were notified. Q-15 minute monitoring set up for Resident #1. Resident #1 was lying in bed watching TV, no s/s of distress or mental status. Resident #1 appeared calm. Will continue to monitor Resident #1 and inform oncoming shift of behavior. There was no documentation of physician notification. Record review of a progress note, dated 09/18/23, completed by APRN L, indicated she spoke with the nurse (the nurse was not identified) and the nurse indicated Resident #1 was being monitored after stating he wanted to stab his roommate. Resident #1 was lying in bed without acute distress. Resident #1 stated I don't want to hurt anyone. I just want to get out of here. I don't want to be here. Resident #1 said he did not have a plan to harm himself or anyone else. Resident #1 was in a pleasant mood without s/s of distress/anxiety/depression. Order given to refer for psychiatric services to evaluate Resident #1 for possible adjustment to medications. Resident #1 did not appear to be a harm to himself or anyone else. Record review of a psychiatric assessment, completed on 09/21/23 by FNP N, indicated Resident #1 was assessed due to agitation and expressing he wanted to hurt someone. Resident #1 refused to engage. Staff indicated Resident #1 was more agitated and said he wanted a knife to stab someone and to go back to prison. Resident #1 was uncooperative with exam. Revisit in two weeks. Record review of a progress note, dated 09/25/23 completed by APRN L, indicated Resident #1 was lying in bed without acute distress. He was easy to wake. He said he did not want to hurt anyone. He wanted to get out of the facility. He did not want to be in the facility. He was instructed he could not make threats against others and verbalized understanding. He had no behaviors since last visit. Record review of clinical note, dated 09/26/23 at 9:21 a.m. and completed by ADON C, indicated RP was notified regarding homicidal intentions and MD suggestions of sending to the behavioral hospital to adjust medication and any possible treatment needed., RP agreed. Referral sent to behavior hospital. Record review of progress note, dated 09/26/23 at 10:31 p.m., completed by APRN L, indicated (late entry) spoke with nurse and Resident #1 was being monitored after stating he wanted to stab his roommate. Resident #1 was lying in bed without acute distress. Resident #1 stated I don't want to hurt anyone. I just want to get out of here. I don't want to be here. Resident #1 said he did not have a plan to harm himself or anyone else. Resident #1 was in a pleasant mood without s/s of distress/anxiety/depression. Order given to refer for psychiatric services to evaluate Resident #1 for possible adjustment to medications. Resident #1 did not appear to be a harm to himself or anyone else. Record review of Q-15 minute monitoring sheets indicated monitoring was completed from 09/14/23 through 09/26/23. Resident #1 was placed on 1-1 after the State Surveyor intervention (until Resident #1 was transferred to behavior hospital on [DATE]). During an observation on 09/26/23 at 4:50 a.m., Resident #1 was lying in bed watching TV in his room. Resident #1's roommate was asleep. Staff were assisting other residents with ADLS. There was no 1-1 staff or sitter observed. During an interview on 09/26/23 at 4:55 a.m., LVN A said Resident #1 was on frequent monitoring with Q15 minute checks due to threats of harm to others. She said she overheard Resident #1 tell CNA B he wanted to kill someone, to shoot or stab them so he could go back to prison. She said she notified the DON and the Administrator immediately. She said she did not notify the physician. She said she was not aware of Resident #1 making any previous threats to harm others. During an interview on 09/29/23 at 9:29 a.m., the DON said she was notified by LVN A of Resident #1's threat to shoot or stab someone. She said she did not remove him from the room or move his roommate because Resident #1 did not specify anyone he wanted to harm. She said he did not have an active plan. She said the room was not searched for a gun or a knife. The DON said Resident #1 was mobile with a wheelchair. She said Resident #1 was placed on q15 minute checks. She said he was not placed on 1-1. She said she did not call the police. She said she did not report the incident to the state. She did not know Resident #1 threatening to harm others was a reportable event. She said she was trained on abuse and neglect. She said she did not think of reporting Resident #2's threat to harm others. She said other residents and staff were at risk of harm due to Resident #2's threat. She said Resident #1's care plan was not reviewed and updated to include threats of harm to others. During an interview on 09/29/23 at 4:39 p.m., APRN L said she was in the process of completing scheduled rounds in the facility on 09/21/23 and LVN A informed her of Resident #1's threat to harm his roommate. She said Resident #1 indicated he had no plan and no intention. She said she was not aware of any prior threats. APRN L said staff would continue to monitor Resident #1 until he was seen by psychiatric services. During an interview on 09/29/23 at 4:50 p.m., FNP N said she assessed Resident #1 on 09/21/23. She said he was not cooperative with assessment. She said he made a threat to hurt someone with a knife so he could go to prison. She said she would have recommended Resident #1 be sent out to a behavioral unit if he was a threat. During an interview on 09/29/23 at 10:00 a.m., the Administrator indicated she was not made aware of Resident #1's threats to harm others on 09/14/23. She said she was off due to her husband having surgery. She said Resident #1 was not placed on 1-1 and could have harmed his roommate or others. She said she would have placed Resident #1 on 1-1 until cleared by psychiatric services. She said she would have moved Resident #1 or his roommate. She said she was not aware the incident was a reportable incident. She said she reported the incident to the State Survey Agency after the State Surveyor questioned the clinical note. She said the police should have been notified. She said she did a counseling and coaching with the DON and LVN A. She said she notified MD K and completed an emergency QAPI. She said staff were inserviced on 09/26/23. During an interview on 10/05/23 at 2:19 p.m., ADON C said Resident #1 should have been on 1-1 and put in a private room after he made threats to hurt others. She said psychiatric should have been contacted to assess Resident #1. She said Resident #1's threat to harm others was noted on the 24 hour report and would have been reviewed during the morning meeting. She said she did not recall if it was reviewed. Record review of the facility's Safety and Supervision of Residents, dated 2001 (revised July 2017), indicated Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . 2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. 3. The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if there is a change in the resident's condition. This was determined to be an Immediate Jeopardy (IJ) on 09/29/23 at 3:22 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 09/29/22 at 3:44 p.m. The following Plan of Removal submitted by the facility was accepted on 09/29/23 at 4:10 p.m. Immediate Action: Systematic Approach: 1. Assessment - Resident #1 with homicidal ideation on 9/14/23 was placed on one-on-one on 9/26/23 at 9:02 AM until he was discharged to a Behavioral hospital on 9/27/23 at 2:00 PM.-The Executive Director notified the facility Medical Director of the Immediate Jeopardy on 09/29/22 at 4:20 PM. -An emergency QAPI meeting was held on 9/26/2023. -All residents will have a psychosocial assessment updated by the Director of Nurses, Assistant Director of Nurses and/or Patient Care Coordinator on 9/29/2023 to identify any current patients that are at imminent risk homicidal/suicidal ideation. The psychosocial assessments were completed on 9/29/23 by 6:00 PM. After completion of psychosocial assessments, no other residents were found to be at imminent risk of homicidal/suicidal ideation. The assessment includes the following information: The assessment is to determine if a resident is an imminent/suicidal risk for psychiatric needs. Who will be responsible: Director of Nursing/Nurse Managers Who Will monitor: Executive Director and RDCS -Beginning 9/29/2023, psychosocial assessments will be completed upon admission, condition change, and quarterly by the charge nurse and/or nurse managers, and for any resident that triggers an imminent risk for homicidal/suicidal ideation, the facility will initiate one-on-one supervision until further direction is provided. The abuse/neglect policy will be implemented immediately. The physician will be notified immediately of any homicidal ideation of any resident. The ED and DON will monitor for compliance daily by running an audit of the psychosocial assessments. Audits will be completed weekly for 3 months until 12/29/2023 and then monthly on an ongoing basis. Who will be responsible: Director of Nursing/Nurse Managers Who Will monitor: Executive Director/RDCS -Beginning 9/29/23, any resident who triggers an imminent risk of homicidal/suicidal ideation, will be placed on one-on-one supervision and will have notification to the staff caring for the resident, the attending physician, and psychiatric services referral will be made by the nurse manager and monitored by clinical staff. -ED will call family, police and notify physician to confirm notification of resident homicidal/suicidal ideation. -ED will implement the abuse/neglect policy immediately. -Any staff that is aware of a resident with homicidal/suicidal ideation will immediately inform the ED. -ED will notify HHSC of a homicidal/suicidal resident incident according to reporting protocols and following the abuse/neglect prohibition protocol. Who will be responsible: Director of Nursing/Nurse Managers Who Will monitor: Executive Director/RDCS All staff were educated to notify the Executive Director, DON or RDCS immediately upon verbalization of a resident wanting to harm someone or themselves. This education was provided on 9/29/2023. This education was provided by the Executive Director, DON and RDCS. Staff will not be allowed to begin their shift until the education has been completed. Until alternative and or safe living arrangements are made the resident will be placed on one-on-one supervision with facility staff. Resident care plans will also be updated to include any verbalizations of wanting to harm others including homicidal/suicidal ideations. The ED and/or RDCS will monitor weekly for compliance by completing an audit of the psychosocial assessments. Audits will be completed weekly for 3 months until 12/29/2023 and then monthly on an ongoing basis. Who will be responsible: Director of Nursing/Nurse Managers Who Will monitor: Executive Director/RDCS 2. In-Services All staff were in-serviced on resident homicidal/suicidal ideation and the abuse/neglect policy by the ED/RDCS/Director of Nursing and/or Nurse Managers. All new staff will receive the education as part of the onboarding orientation process prior to being assigned and providing care to residents. No staff member will be allowed to work in the facility until the above required in-services are completed. The in-service with all staff will be completed by 9/29/2023. All staff were in-serviced by 8:00 PM on 9/29/2023. Who will be responsible: DON/Nurse Managers Who Will monitor: Executive Director/RDCS Shift to Shift reporting process will be as follows: -As part of shift to shift report the charge nurse will notify the oncoming nurse of the one-on-one and homicidal/suicidal ideation. All nurses and CNAs will be in-serviced on the shift-to-shift report process by the Executive Director, Director of Nursing or Assistant Director of Nursing by 9/30/23 at 8:00 a.m. Who will be responsible: DON/Nurse Managers Who Will monitor: Executive Director/RDCS Each employee completed a post-test after their education was completed to ensure staff were able to identify abuse/neglect and reporting requirements. If the employee did not pass the test with at least 90% correctly answered the staff member was re-educated and re-tested until at least 90% pass rate was met. A staff roster was utilized to ensure 100% of licensed nursing staff were in-serviced and tested. In-services were deemed to be effective by the in-services post-test scores and verbalization of understanding by all facility staff (clinical, non-clinical and ancillary). All nurses, Executive Director and nurse managers were in-serviced on abuse and neglect on 9/29/23 by 8:00 PM. The Executive Director, DON and ADON were in-serviced by the RDCS on 9/29/23 by 4:00 PM. Who will be responsible: DON/Nurse Managers Who Will monitor: Executive Director/RDCS 3. Monitoring Starting 9/29/23 the Executive Director, Director of nursing and/or Nurse Managers will review all psychosocial assessments for any psychosocial needs including homicidal/suicidal ideation. The Regional Director of Clinical Services will review the documentation each week for compliance and will review any needs for reporting allegations to the state agency. Monitoring of the POR included the following: During interviews on 09/30/23 from 1:00 p.m. through 4:00 p.m. with LVN A 10 p.m. - 6 a.m., RN S (weekend shifts) CNA Q 6 a.m. -6 p.m.), LVN R (prn all shifts), CNA T (all shifts), LVN U 2 p.m. -10 p.m., LVN W 10 p.m. -6 a.m., LVN X 6 a.m. - 2 p.m., LVN Y 6 a.m. 2 p.m., CNA D 6 p.m.-6 a.m. and the ADON indicated staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the charge nurse or administrator and were able to give example of physical, verbal, sexual abuse, and immediate intervention procedures. All staff indicated they were educated to notify the Executive Director, DON or RDCS immediately if a resident threatened to harm someone or themselves. All staff indicated they would ensure any resident who threatened harm to themselves or others would be placed on 1-1 until cleared by their physician. They indicated resident care plans would be reviewed and updated to include any verbalizations of wanting to harm others which included homicidal/suicidal ideations. All staff indicated they were trained on resident homicidal/suicidal ideation and the abuse/neglect policy. They were able to give examples of appropriate actions to take in different situations involving abuse or threats of harm. The ADON and LVNs indicated they were to notify the physician of resident's change of condition and were able to give examples. Interviews conducted with three alert residents on 09/30/23 from 1:00 p.m. through 4:00 p.m. indicated they would report abuse to the administrator or the DON. They were not afraid of any residents. During an interview on 09/30/23 at 3:45 p.m., the Administrator said she was in-serviced on 09/29/23 by the RDCS. She was able to verbalize the facility abuse, and neglect policy and they would conduct a thorough investigation of all incidents of resident threats of self harm or harm to others. She understood she was required to report incidents according to regulatory compliance, and reporting incidents of abuse or neglect that result in serious bodily injury/death. She said the physician would be notified immediately of any homicidal ideation of any resident. She and the DON would monitor for compliance daily by running an audit of the psychosocial assessments. She said this would be completed weekly for 3 months until 12/29/23 and then monthly on an ongoing basis. She said she and the DON would review the facility 24 Hour Report and Incident Reports in the morning clinical for any allegation or instances of abuse and/or neglect and physician notification. During an interview on 09/30/23 at 4:00 p.m., the DON said she was in-serviced on 09/29/23 by the RDCS. She was able to verbalize the facility abuse, and neglect policy and they would conduct a thorough investigation of all incidents of resident threats of self harm or harm to others. She understood she was required to report incidents according to regulatory compliance, and reporting incidents of abuse or neglect that resulted in serious bodily injury/death. The DON and Administrator would monitor for compliance daily by running an audit of the psychosocial assessments. The DON and Administrator would review the facility 24 Hour Report and Incident Reports in the morning clinical for any allegation or instances of abuse and/or neglect and physician notification. She said this would be completed weekly for 3 months until 12/29/23 and then monthly on an ongoing basis. Record review of all incidents from the previous 90 days indicated there were no additional incidents of threats of self harm or harm to others as of 09/30/23. Record review of resident abuse questionnaire, dated 09/29/23, indicated no residents were identified as reporting any abuse or being afraid of any residents or staff. Record review of training records indicated all staff (nursing and non-nursing) were in-serviced on 09/29/23 regarding the facility abuse and neglect policy, the procedure for reporting incidents of threats of harm with serious harm and/or death, suspected abuse/neglect, recognizing threats of harm (to self and others), and physician notification. Record review of quiz results, dated 09/29/23 and 09/30/23, indicated all staff passed the quiz regarding abuse, neglect, reporting, suicide threats, managing suicide ideations, comprehensive care plans, and physician notification. The Administrator and the DON were informed the Immediate Jeopardy was removed on 09/30/23 at 4:10 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision to prevent elopement for 1 of 9 residents reviewed for elopement. (Resident #1) The facility did not prevent Resident #1, a resident who was cognitively impaired with increased exit seeking behaviors, from eloping from the facility. This failure could place the residents with exit seeking behaviors at risk for injury or death. This failure resulted in an identification of an Immediate Jeopardy (IJ) situation on 5/25/2023 at 4:55 p.m. While the IJ was removed on 5/26/2023 at 4:35 p.m., the facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Findings included: Record review of a face sheet dated 5/25/2023 indicated Resident #1 was admitted on [DATE], was [AGE] years old and had diagnoses of chronic obstructive pulmonary disorder (a group of lung diseases that block airflow and make it difficult to breathe), dementia (a group of thinking and social symptoms that interferes with daily functioning), and anxiety (intense, excessive, and persistent worry and fear about everyday situations). Resident #1 was discharged to a secure unit on 5/23/2023 Record review of a care plan with an effective date of 1/26/2023 - Present indicated Resident #1 had exhibited wandering behavior. The goal was for Resident #1 to maintain her current level of mobility within a secure environment over the next 90days. Interventions included to check Resident #1's location every 30 minutes on each shift (frequency three times daily starting 1/28/2023), redirect Resident #1 when wandering was observed, and use wander guard monitor daily. Record review of Resident #1's MDS dated [DATE] indicated Resident #1 had moderate cognitive impairment and had no history of wandering behaviors. She required supervision for most ADLs. Record review of Elopement Risk Assessments dated 1/28/2023 and 5/6/2023 indicated Resident #1 was a moderate risk for elopement on both assessments and same interventions. Patient is cognitively impaired AND Patient wanders aimlessly. Actions were to implement the elopement risk care plan and implement frequent monitoring form to determine elopement risk or until interdisciplinary team reviewed and made a recommendation. Record review of a clinical note dated 5/22/23 at 5:13 a.m., completed by LVN F, indicated Res. (#1) was up most of the night shift wandering the halls, res would go back to room and lay down but get back up 15 minutes later and wander again. Res. (Resident) At some point during this shift (10p.m. to 6 p.m.) took off her wander guard somehow nurse searched the room for it and how she got it off, but nothing was found even the missing Wander guard anklet. Nurse applied new Wander guard to resident's left ankle and explained to resident she has to keep it on. Nurse put in nurses report sheet to keep monitoring res. wander guard. Record review of a clinical noted dated 5/22/2023 at 9:14 p.m., completed by LVN E indicated while SN (skilled nurse) was charting at the nurses's station, family member informed nurse that she could not find her mother. Asked family member who was she visiting, and family member stated Resident #1. Immediately went to Resident room to check if Resident was in her restroom or any other restrooms located in the back of west wing. Nurse did not see patient in any bathrooms nor was the alarm system sounding d/t (due to) Resident has a wanderguard to right ankle and nurse checked for placement and function of wanderguard at the beginning of shift when Resident was sitting in chair across from nurse station with her former roommate. Immediately assigned all staff on west and east wing to check all bathrooms and closets d/t possible missing resident .At 6:22 p.m., informed by [facility] staff that resident was located. Nurse when to scene where resident was found along with police arriving to scen as well. Resident was located at the corner store next door in the woods. Nurse able to d a decent head to toe assessment and therapist at the scene along with CNAs. Resident was able to perfrom full [range of motion] and denied pain or discomfort. Resdient brought back to facility in wheelchair .Nurse checked resident vital signs 158/85 pulse 85 [respiratory rate] 20 [oxygen saturation] 96%. Small skin tear noted to right knee .1x.1 [cm] and very small scrathces on right ankle. Upon assessment nurse noted wanderguard was not on resident right ankle. Asked resident how did she remove her wanderguard/resident state she used scissors. Nurse asked resident where did she get scissors from/resident did not answer because a family member state she does not have to answer any of those questions and also state she is not to blame .Informed by supervisor per facility policy resident is to be sent to [emergency room] for evaluation .Resident sent to [emergency room] with [emergency medical personnel] .at approximately 7:20 p.m .When resident and family left/supervisor found wanderguard in former resident room across the hall in trash can which appears to be a clean cut removed from her ankle. Asked former roommate if we can use her scissors. Resident stated sure just make sure you return them. Long scissors with black and blue handle removed from resident room . Record review of a clinical note dated 5/22/2023 at 10:36 p.m., completed by LVN E, indicated Resident #1 was redirected often due to going to the front and back door several times, setting of the alarm . The LVN indicated to check for the wanderguard bracelet because she somehow removed the current one. Record review of Resident #1's records dated May 2023 indicated there was no documentation of Resident #1's location every 30 minutes on each shift. During an observation on 5/24/23 at 11:15 a.m., the Investigator observed highway where Resident #1 walked toward had a moderate amount of traffic. The speed limit in front of the facility was 45 mph. During an observation on 5/24/2023 at 12:12 p.m. of a facility video dated 5/22/2023 at 6:02 p.m., Resident #1 was observed walking out of the facility's back door on the west hall. She walked in the parking lot toward the front of the facility. When she got to the last parking spot closest to a busy highway in front of the facility, she turned left toward the gas station next to the facility. There was a small, tapered ditch, knee deep, she walked through. As Resident #1 reached the front of the store and stepped out of site (6:04 p.m.), her family pulled in the parking spot closest to the highway. During an observation on 5/24/2023 at 12:50 p.m. of a video of the gas station next to the facility, provided by Resident #1's family member, dated 5/22/2023 at 5:40 p.m., indicated Resident #1 was seen ambulating in the parking lot of the gas station. She was seen waving to an unknown female getting into a pickup. The Resident kept walking toward the tree line and disappeared. During an interview on 5/24/2023 at 10:20 a.m., the DON said Resident #1 had a wanderguard bracelet on her ankle due to wandering. She said on 5/22/2023, the day Resident #1 eloped she kept setting off the alarm by trying to sit in the front lobby by the window. She said the Resident was telling staff If you just cut this thing off (referring to the wanderguard bracelet on her ankle), I could go outside. The DON said the resident mostly stayed in the common areas during the day but ate her meals in her room. She said Resident #1 was not placed on 1:1 supervision. The DON said Resident #1 had her dinner tray picked up between 5:45 p.m. and 5:50 p.m. She knew it was around that time because the CNA's shift ended at 6:00 p.m. She said CNA C clocked out at 5:58 p.m. and went out the door near Resident #1's room. CNA C told the DON Resident #1 was in her room at that time. She said the Resident was on the other side of her bed near the window and did not notice if the Resident had the bracelet on her ankle. The DON said they determined Resident #1's ex-roommate gave her scissors to cut the bracelet off. The bracelet was found in the ex-roommate's garbage can. During an interview on 5/24/23 at 11:09 a.m., OT D said on 5/22/2023 she was told Resident #1 was missing and started looking outside. She said she followed the tree line behind the facility to the gas station next door. She said when she got just past the gas pumps she heard help me. She found Resident #1 sitting on the ground just behind the trees. She tried to get the Resident up, but the Resident was not able to stay standing. OT B said she had forgotten to grab her phone. She told Resident #1 to stay where she was while she went to get assistance. She said the family was already at the facility and assisted Resident #1 into the wheelchair and took her back to the facility. During an interview on 5/25/2023 at 8:39 a.m., the ED said staff had been educated on door checks, alert administration if there was a concern a resident might cut off their wanderguard bracelet. She said they were scheduled to have a QAPI meeting on 7/2/2023. RN A told the ED at that time she could do an emergency QAPI meeting to address the elopement issue. The ADON said, at that time, elopement risks were completed on admission, quarterly and significant change in condition. She said she completed an elopement risk assessment on Resident #1 the day (5/23/2023) she left the facility. The ADON said Resident #1's former roommate had scissors and they found the wanderguard bracelet in her trashcan on 5/22/2023, so they assumed that was how she got the bracelet off. During an interview on 5/25/2023 at 11:28 a.m., CNA B said she had not been told to increase monitoring of Resident #1. She was not aware she had taken her wanderguard bracelet off prior to the elopement on 5/22/2023. She said she knew Resident #1 would try to leave because she had been going to the door more. During an interview on 5/25/2023 at 11:58 a.m., the DON said she had not been aware of the increased exit seeking behaviors of Resident #1 until she read the clinical notes after the elopement. During an interview on 5/25/2023 at 12:27 p.m. LVN E said they had been monitoring Resident #1 because her Seroquel (used for behaviors) had been decreased. She said when they found Resident #1 on 5/22/2023, the Resident said she had cut off her bracelet with scissors. She said they found the wanderguard bracelet in her old roommate's trash on 5/22/2023. During an interview on 5/25/2023 at 12:41 p.m., CNA C said she was not told to increase monitoring of Resident #1 prior to her eloping. She said she clocked out at 5:58 p.m. and went out the back door by Resident #1's room. She said the Resident was sitting in her chair by the window and could not see her feet. She said she waved to the Resident and left. Record review of the facility's Patient Care Management System 3 Accidents/Incidents dated May 2016 indicated A Patient requiring the use of a Wandering Prevention Device must be assessed to ensure that the device is on the patient and working. The device must be tested using a Signaling Device Tester provided by the maker of the Wandering Prevention Device. The test will be documented daily, and visual verification that the device is in place on the Patient will be documented every shift. Record review of the facility's Wandering Patients policy revised February 2020 indicated Patients that are determined to be wanderers will receive the following interventions: Wandering behavior will be care planned with appropriate interventions documented, Wandering Patients will be counseled by intervening staff and redirected to appropriate Patient care areas . Record review of the facility's undated elopement protocol indicated ED or DON must be notified when a resident has increased behaviors. The ED and DON were notified of the IJ on 5/25/2023 at 4:55 p.m., the IJ template for Accident/Hazard and Supervision was given to the ED and DON. The findings were read to them and explained the process and a POR was requested. The following POR was submitted and accepted on 5/26/2023 at 10:31 a.m. Please accept this as a Plan of Removal for the alleged Immediate Jeopardy related to Accidents and Supervision called at 4:55 pm. The facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents. Residents that can be affected are those with imminent elopement risk assessments. At this time, the facility does not have any residents who could be affected. Systematic Approach: 1. Assessment -The Executive Director notified the facility Medical Director of the Immediate Jeopardy on 05/25/22 at 5:08 pm. -An emergency QAPI meeting was held on 5/25/2023. -All residents will have an elopement risk assessment updated by the Director of Nurses, Assistant Director of Nurses and/or Patient Care Coordinator on 5/25/2023 to identify any current patients that are at imminent risk for elopement. After completion of elopement assessments, no other residents were found to be at imminent risk of elopement. The assessment includes the following information: The assessment was to determine if a resident was an imminent risk for elopement. The resident will have to intentionally or unintentionally attempt to leave the community or verbalize a plan to elope the community to be documented in the elopement assessment as an imminent risk for elopement. Who will be responsible: Nurse Managers. Who Will monitor: Executive Director/Director of Nursing. -Beginning 5/25/2023, elopement assessments will be completed upon admission, condition change, and quarterly by the charge nurse and/or nurse managers, and for any resident that triggers an imminent risk for elopement, the elopement response protocol will be initiated. The ED and DON will monitor for compliance daily by running an audit of the elopement assessments. Audits will be completed weekly for 3 months until 8/25/2023 and then monthly on an ongoing basis. Who will be responsible: Nurse Managers Who Will monitor: Executive Director/Director of Nursing -Beginning 5/25/2023, wanderguard placement and working order will be checked for working order every shift by the charge nurse or nurse managers. The wanderguard placement and working orders will be documented in the EMR system. -Beginning 5/25/2023, the wanderguard system will be checked for working order every day by the maintenance director, Manager on Duty or Executive Director. The working order of the wanderguard system will be documented on the Daily Door Alarms, Wandering Systems and Storage Areas Log. -Beginning 5/25/23, any resident who triggers an imminent risk of elopement, meaning the resident intentionally or unintentionally attempts to leave the community or verbalize a plan to elope the community, will have notification placed in the elopement binder by the nurse manager and monitored by clinical staff in accordance with the elopement response protocol- - Facility staff will conduct thorough rounds of facility grounds. - If resident is not found within 15 minutes charge nurse will call the ED immediately. - ED will call family, police and notify physician. - ED will notify HHSC of incident. - Facility staff will continue to search for resident until found. - Once resident is found, a nurse will do a head-to-toe assessment and provide care accordingly. - In addition, the physician and responsible party will be notified of the results. Who will be responsible: Nurse Managers Who Will monitor: Executive Director/Director of Nursing All staff were educated to notify the Executive Director or nursing management immediately upon elopement or verbalization of an elopement plan of a resident. This education was provided on 5/25/2023. This education was provided by the Executive Director, Director of Nursing and Assistant Director of Nursing. Staff will not be allowed to begin their shift until the education has been completed. Until alternative and or safe living arrangements are made the resident will be placed on one-on-one supervision with facility staff. The resident's picture and face sheet will be placed in an elopement binder. Resident care plans will also be updated. The Director of Nursing and/or Nurse Managers will monitor weekly for compliance by completing an audit of the elopement assessments and the elopement binders. Audits will be completed weekly for 3 months until 8/25/2023 and then monthly on an ongoing basis. Who will be responsible: Nurse Managers Who Will monitor: Executive Director/Director of Nursing No items were found available that could assist residents at risk of wandering in removing their wanderguards on 5/25/2023. This search was conducted by the Executive Director and nursing managers. 2. In-Services - Clinical staff were in-serviced on the elopement by the Director of Nursing and/or Nurse Managers. All new clinical staff will receive the Elopement in service as part of the onboarding orientation process prior to being assigned and providing care to residents. No clinical staff member will be allowed to work in the facility until the above required in-services are completed. The in-service with all staff will be completed by 5/26/2023. All staff were in-serviced by 8am on 5/26/2023. Who will be responsible: Nurse Managers Who Will monitor: Executive Director/Director of Nursing - Shift to Shift reporting process will be as follows: 1. As part of shift to shift report the charge nurse will print the census to identify residents who are on leave and not in the facility. 2. At shift change, 6 a.m., 2 p.m., 10 p.m.- the oncoming nurse will conduct walking rounds with the outgoing nurse and will account for each patient on the census. 3. At shift change, 6 a.m., 6 p.m.- Certified Nurse Aides must conduct walking rounds and visually account for each resident. All new clinical staff will receive the elopement in service as part of the onboarding process prior to being assigned and providing care to residents on the floor by the Director of Nursing and/or Nurse Manager. All nurses and CNAs will be in-serviced on the shift-to-shift report process by the Executive Director, Director of Nursing or Assistant Director of Nursing by 5/26/23 at 8:00 a.m. Who will be responsible: Nurse Managers Who Will monitor: Executive Director/Director of Nursing - All staff in-service on changes in condition including increased wandering and elopement risk. Nurses will notify the Director of Nursing or nurse manager of changes in the condition of a resident. This in-service will be completed by 12 noon 5/25/2023 by the Director of Nursing and nurse managers. 3. Implementation of anti-elopement process - Beginning 5/25/2023 the Certified Nurse Aides and Nurses are performing every 2-hour body checks which means conduct walking rounds and visually account for each resident, every shift and notifying the Executive Director and Director of Nursing immediately within 15 minutes per elopement protocol if a resident cannot be located. - In-servicing will be completed with the charge nurses and CNAs by the Executive Director, Director of Nursing or Assistant Director of Nurses by 5/26/2023. All nurses and CNAs will be in-serviced on the shift-to-shift report process by 5/26/2023 at 8 a.m. Who will be responsible: Nurse Managers Who Will monitor: Executive Director/Director of Nursing 4. Monitoring - Starting 5/25/23 the Executive Director, Director of nursing and/or Nurse Managers will receive in hand, the resident monitoring/every 2- hour body check documentation at the end of each shift for the first 72 hours, each day for one week, then weekly for 4 weeks. This monitoring will include checking that each resident with a wander guard has the device in place and in working condition. The Regional Director of Clinical Services will review the documentation each week for compliance. - Beginning 5/25/2023 no clinical staff will be allowed to work until the required in servicing has been completed. 5. Quality - Starting 5/25/2023 and ongoing monthly all concerns regarding adequately supervising residents will be taken to the Quality Assurance Committee for analysis and recommendations with input from the Medical Director going forward. The Executive Director will monitor for compliance. - Starting 5/25/2023 and ongoing monthly all concerns regarding completing the elopement assessments and residents at risk of elopement will be taken to the Quality Assurance Committee for analysis and recommendations with input from the Medical Director going forward. The Executive Director will monitor for compliance. - Starting 5/25/2023 and ongoing monthly the Executive Director will monitor daily to ensure compliance for four weeks and will review at the next Quality assurance meeting. Monitoring of POR: On 5/26/2023 at 5:35 p.m., the surveyor confirmed the facility implemented their plan of removal sufficiently to lift the immediacy by: Record review of the in services dated 5/26/2023 related to elopement protocol, executive director notification, change of condition with focus on wandering and behaviors, room rounds every 2 hours, every 2 hours body checks for wanderguard bracelets, and walking rounds at shift change. During interviews of the ED, RN A, 4 LVNs, 6 CNAs, the DM, and the AD the retraining related to elopement protocol, executive director notification, change of condition with focus on wandering and behaviors, room rounds every 2 hours, every 2 hours body checks for wanderguard bracelets, and walking rounds at shift change was confirmed. During observations on 5/26/2023 from 2:25 p.m. to 4:00 p.m. indicated staff were making rounds and monitoring residents with wanderguard bracelets. The ED was informed the IJ was lifted on 5/26/2023 at 4:35 p.m., however, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. During an exit conference on 6/6/2023 at 3:00 p.m. the ED was asked for any additional information related to accidents/supervision. No additional information was provided.