Flatonia Healthcare Center

options.

The safety and protection of other residents is the facility's primary concern.

Resident to

jeopardy to resident health or occur:1.

The staff observing the incident will immediately separate the residents involved2.

The safety charge nurse will assess the victim to determine any injury3.

Physician and family of both victim and perpetrator will be notified of incident.4. An incident report will be completed for the perpetrator and

make the determination on what course of action needs to be taken with the perpetrator such as, but not limited to the following - immediate discharge from the facility due to potential for harm to other residents, can the behavior be controlled by location monitoring and need for referral to a psychologist/psychiatrist.

The family and physician of the perpetrator will be notified of the next step.7. If the perpetrator is placed on location monitoring, staff will be instructed on reason for monitoring and targeted behaviors being monitored.8. If the perpetrator is on a behavioral contract, facility staff will be in serviced accordingly, and the resident and family will be notified of consequences.9. If the perpetrator continues to exhibit inappropriate behaviors/or violates the behaviors identified on the behavioral contract, staff will immediately notify the Administrator /DON10.

The team will conduct an emergency review to determine further course of action such as immediate discharge11.

The victim will be seen by Social Services to determine further psychological support needed as well as follow up with physician/family12.

The Ombudsman will be notified of incident /allegations as appropriate.This was determined to be an Immediate Jeopardy (IJ) on 08/30/25 at 6:28 pm.

The Administrator was notified at 6:28 p.m.

The ADM was provided with the IJ template on 08/30/25 at 6:28 p.m.The following Plan of Removal submitted by the facility was accepted on 09/01/25 at 8:05 am. PLAN OF REMOVALPlan of RemovalOn 08/30/2025, an Immediate Jeopardy was identified at the facility due to a resident-to-resident abuse allegation.Action StepsThe following immediate actions were implemented Resident #1 was placed under 1:1 supervision immediately.

Resident's care plan updated to reflect changes in monitoring.

The 1:1 will remain in place until the IDT will be held on 9/2/2025, including physician, psychiatric input determines that it is safe to discontinue the cadence of supervision. If this is not deemed attainable, the facility will explore opportunities for discharging resident to an alternate setting. IDT meeting will be held weekly to discuss resident #1. Resident #1 was seen by psych services on 8/18, 8/26 and will continue with weekly visits until behaviors are improved.Residents 2 and 3 were assessed by DON for evidence of injury.Resident #2 was seen by the psych NP via telemedicine for evaluation of impact. A trauma informed assessment was completed on residents 1, 2 and 3.

Care Plans updated for resident 1, 2, and 3. No negative outcomes found in resident assessment.

Nursing Administration conducted resident record review, resident interviews to determine that no other residents were affected by the deficient practice.

Direct care staff are trained on resident care plans through a combination of orientation, ongoing in-service education, and real-time instruction from licensed nursing staff.

During orientation, staff receives instruction on individualized resident needs, the purpose of the care plan, and how their daily assignments connect to the plan of care.

Supervisors and charge nurses review care plan updates with staff as changes occur, and education is reinforced during shift huddles, staff inservicing, etc.

This ensures staff understand their role in implementing interventions outlined in each resident's care plan.

Each incident was reported to HHSC via self-report email template.

The incident for 8/11 was emailed on 8/30 @ 10:25PM.

The incident for 8/15 was emailed 8/31 at 7:57am.

The return emails from HHSC sending us the intake number has not been received yet. It typically takes 24-48 hours from time of submission.Start Date: 08/30/2025Completion Date:8/30/2025Responsible: Director of Nursing (DON), AdministratorFollowing the notification of immediacy, the Administrator and Director of Nursing received immediate elaborate retraining on abuse reporting requirements, the facility's abuse policy, and leadership responsibilities in responding to allegations. To validate that the retraining was effective and sustained, the Regional [TRUNCATED]

675445 09/02/2025

Flatonia Healthcare Center 624 N Converse St Flatonia, TX 78941