**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, to include corporal punishment, involuntary seclusion for one (Resident #1) of 7 residents reviewed for resident rights. Facility staff failed to provide necessary care and services for Resident #1 to avoid a preventable injury. CNA C was not competent of Resident #1's ADL limitations and supervision requirements. Resident #1 had diagnoses including one sided paralysis, unsteady gait and severe cognitive impairment with a history of documented falls at the facility. Resident #1 required extensive assistance with bathing and was left alone in the shower room to shower. The resident fell in the shower room when left alone and sustained a fracture of the distal femur requiring hospitalization for further evaluation and treatment. On 05/12/23 at 12:30 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 05/14/23, the facility remained out of compliance at a severity level of actual harm this is not immediate jeopardy and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk for not providing necessary care and services to prevent falls with injuries, which could result in severe harm, hospitalization or death. Findings included: Record review of the facility policy, Abuse: Prevention of and Prohibition Against, date revised 10/2022, revealed, neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility will act to protect and prevent abuse and neglect from occurring within the facility by: Assuring that residents are free from neglect by having the structures and processes to provide needed care and services to all residents, which include, but not limited to the completion of a Facility Assessment to determine what resources are necessary to care for its residents competently. Record review of Resident #1's Annual MDS Assessment, dated 03/09/23, revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: anemia, atrial fibrillation, hypertension, hyponatremia, hip fracture, aphasia, cerebrovascular accident, Non-Alzheimer's Dementia, and hemiplegia. Her BIMS score was a 3 out of 15, which meant the resident was severely cognitively impaired. Her functional status revealed her self-performance was total dependence and required one-person physical assistance with bathing. Record review of Resident #1's care plan, revised 05/10/23, revealed Has had an actual fall with no injury due to poor balance, unsteady gait on 08/28/21. Fall due to resident trying to get up without help on 11/12/21. Falls on 01/06/22 and 03/05/22 with no injuries. Unwitnessed fall without injury on 09/03/22. Unwitnessed fall with right hip pain and left upper extremity pain on 09/07/22. Unwitnessed fall with right hip pain without injury on 10/14/22. Unwitnessed fall with no known injuries on 12/26/22. Unwitnessed fall with no known injuries on 03/13/23. Unwitnessed fall with a fracture of the distal femur on 05/02/23. Her goal was to resume usual activities without further incident. Her interventions were evaluated in the emergency room on [DATE] and referral to therapy made upon her return. Her bed in lowest position. Continue interventions on the at-risk plan. Monitor/document /report to MD for signs and symptoms: pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. Neuro-checks as ordered. Her scoop mattress in place. Therapy consults for strength and mobility. 3/7/22 - Therapy consult s/p fall 3/5/22. Review of Resident #1's occupational therapy evaluation and plan of treatment, dated 04/11/23, reflected she required max assistance with bathing. Review of CNA C's trainings revealed she completed Alzheimer's disease and related disorders: behavior and ADL management on 04/13/23. She completed documentation of ADLs training on 04/15/23. She completed abuse, neglect, and exploitation training on 04/16/23. Review of Resident #1's occupation therapy Discharge summary, dated [DATE], revealed she was not provided services regarding bathing. Review of Resident #1's shower schedule, undated, reflected her shower days were Tuesday, Thursday, and Saturday during the 2:00 PM - 10:00 PM shift. CNA C was responsible for bathing Resident #1 on 05/02/23. Record review of Resident #1's Therapy Consultation/Screen, dated 05/02/23, revealed Patient triggered decline in locomotion on unit and off unit as documented in ADL significant change analysis report on 05/01/23. Patient was currently in physical therapy services under skilled maintenance program. Patient to increase duration of treatment to address decline. Record review of Resident #1's nursing notes, dated 05/02/23, written by LVN A revealed The nurse was called to the shower room by CNA. Upon entering room resident was observed to be lying on the floor in the shower stall in a supine position. Neuros within normal limits. Moves all extremities well. Denies pain. Resident assessed for injuries with no apparent injuries. DON and physician notified of fall. Left message with RP. No acute distress noted. Resident complained of pain in right knee. Right knee edema noted. Physician contacted and x-ray was ordered. Record review of Resident #1's nursing notes, dated 05/02/23 written by RN B, revealed X-ray competed and result shows acute fracture of the distal femur. Physician was notified and gave order to send resident to emergency room. RP was notified. Record review of Resident #1's right knee x-ray, dated 05/02/23, revealed she had a fracture of the distal femur. Record review of Resident #1's Change in Condition note, dated 05/03/23 written by RN B, revealed Fall with fracture to right distal femur. Record review of the facility's provider investigation report regarding Resident #1 revealed the facility identified the failure which caused Resident #1 to sustain a fall with fracture, and they reported the incident to HHSC on 05/03/23. The facility also identified measures to prevent a similar occurrence, including in-servicing staff on proper abuse and neglect protocols, update Resident #1's care plan, install new grip tape in shower rooms, the Director of rehab will update special instructions weekly according to current ADL assist status, and DON/designee will monitor proper shower procedures and documentation of ADLs on three residents weekly for 4 weeks. At the time of entry by the surveyor, the facility had not fully implemented these measures as evidenced by: - in-service staff on proper abuse and neglect protocols. - installed grip tape in all public shower rooms. - Director of rehab will update special instructions weekly according to current ADL assist status. - DON/designee will monitor proper shower procedures and documentation of ADLs on three residents weekly for 4 weeks. Interview with DON on 05/10/23 at 7:04 PM revealed CNA C left Resident #1 unattended in the shower room. She sated CNA C needed to remove Resident#1's bed linens. She stated Resident #1 was able to bathe herself but required supervision. She stated CNA's returned to the shower room and found Resident #1 on the ground. She stated Resident #1 was assessed by the nurse. She stated Resident #1 later complained of pain and received an x-ray. She stated the x-ray revealed a fracture of the distal femur. She stated the RP and physician were notified. She stated Resident #1 was sent to the hospital and will not be returning to the facility. She stated after the incident staff were in-serviced regarding residents' bathing needs. She stated CNA C received one-on-one coaching regarding where to find ADL information for residents. She stated she was unaware Resident #1's MDS assessment reflected she was total dependent and required one-person assist with bathing. She stated she refers to occupational therapy ADL notes to determine a resident's bathing needs. She stated she uses each resident's occupational therapy notes to complete the ADL forms. She stated the residents' ADL status was in their EMR dashboard. She stated CNAs were able to access residents' ADL status in the EMR dashboard. She stated the CNAs also had access to ADL forms regarding the residents' ADL status. She stated the CNAs were responsible for reviewing residents' EMR dashboard and ADL forms prior to providing service to the residents. She stated Resident #1's fall was preventable had she received adequate supervision by CNA C. She stated CNA C should have reviewed Resident #1's ADL status prior to providing care. Observation of shower rooms located in the public areas at the facility on 05/10/23 at 8:40 PM revealed a shower stall in shower room Bath 2 did not have grip strips. There was grip strips in shower rooms labeled Bath 1 and Bath 3. Record Review of CNA binder located at the nurse's station near the 100, 200, and 300 halls revealed the 100 hall ADL form for all residents was not in the binder. The ADL forms for the 200, 300, 400, and 500 halls were inaccurate; did not reflect ADL status for all residents at the facility. Interview with CNA C on 05/10/23 at 9:30 PM revealed she and CNA D provided Resident #1 with two-person assistance into a shower chair. She stated CNA D informed her Resident #1 could bath unsupervised in the shower room with the door cracked. She stated she did not have knowledge to check the ADL status in the EMR dashboard or CNA binder. She stated she knew residents were supposed to be supervised while bathing. She stated she was in-serviced during new hire orientation regarding accessing the EMR for resident ADL requirements. She stated she always supervised residents' bathing and did not know why she allowed Resident #1 to bath unsupervised. She stated residents' were supervised during bathing to prevent accidents from happening. She stated once Resident #1 was in the shower room set up help was provided. She stated the shower was turned on for the resident, soap provided, and a towel was provided. She stated she left Resident #1 unsupervised in a shower chair, in the public shower room. She stated she needed to change Resident #1's linens. She stated Resident #1's linens were changed on shower days. She stated when she went back to the shower room the resident was on the floor. She stated she informed LVN A and the resident was assessed. She stated Resident #1 did not complain of pain. She stated Resident #1 was transferred from the floor back to the shower chair and taken to her room. She stated she noticed Resident #1's knee was swollen while lying in bed. She stated she informed LVN A. Interview with CNA D on 05/11/23 at 6:50 AM revealed residents' ADL status was in the CNA binder at both nurse's station. She stated Resident #1 required assistance and supervision with bathing. She stated Resident #1 was not safe when she was left in the shower room unsupervised. She stated Resident #1 was only able to wash her hair and chest without CNA assistance. She stated all residents at the facility require supervision during bathing. She stated on 05/02/23 she assisted CNA C with transferring Resident #1 into a shower chair. She stated she and CNA C took Resident #1 to the shower room. She stated she turned the shower on, provided Resident #1 with soap, and towel. She stated she advised CNA C to stay in the shower room and supervise Resident #1 bathing. She stated she was in-serviced by the ADON regarding residents' ADL needs after the incident regarding Resident #1. She stated she had not previously been in-serviced regarding residents' bathing needs. Interview with Administrator 0n 05/11/23 at 9:07 AM revealed Resident #1 was found on the floor in the shower room by CNA C on 05/02/23. She stated LVN A and DON were immediately notified. She stated LVN A assessed the resident. She stated Resident #1 was transferred back to the shower chair and taken to her room. She stated there was no immediate harm. She stated the physician and RP were notified. She stated 20 minutes after the fall Resident #1 complained of pain and an x-ray was received. She stated the results were not received until 05/03/23. She stated the physician and RP were notified regarding the x-ray results. She stated Resident #1 was sent to the hospital. She stated Resident #1's care plan was updated. She stated after receiving the x-ray results, she investigated the incident to determine if there was immediate danger. She stated staff were in-serviced regarding abuse and neglect. She stated the DON provided one-on-one coaching to CNA C on where to locate ADL assistance information in EMR and the importance of checking ADL status even if familiar with the resident. She stated a shower book was created to include residents' ADL needs. She stated the DON educated staff how to access the special instructions and ADL sheets for the residents. She stated rounds were completed to ensure CNAs were following proper shower procedures. She stated a monitoring tool was created to check staff competency regarding proper shower procedures. She stated herself, DON, and Rehab Director review and updated the residents' special instructions regarding ADL assistance weekly in their EMR. She stated the facility ordered grip strips and placed them in the public showers labeled Bath 1, 2, and 3. She stated grip strips were not added to the private showers in residents' rooms. Interview with the Rehab Director on 05/11/23 at 10:05 AM revealed Resident #1 received occupational therapy from 04/11/23 to 05/03/23. She stated her occupational therapy evaluation revealed Resident #1 required max assistance with bathing. She stated she reviewed the residents' special instructions weekly for skilled residents and when there has been a change regarding non-skilled residents. Interview with Occupational Therapist on 05/11/23 at 11:19 AM revealed she provided occupational services to Resident #1 from 04/11/23 to 05/02/23. She stated Resident #1 needed assistance from staff with bathing. She stated Resident #1 should not have been left alone in the shower from to bathe herself. She stated Resident #1 had good sitting balance but not standing balance. She stated the fall with injury could have been prevented had staff provided adequate supervision to Resident #1. Interview with Maintenance supervisor on 05/11/23 at 11:39 AM revealed grip strips were ordered on 05/04/23. He stated he added the grip strips to the public shower stall floors as a fall protocol. Interview with CNA C on 05/11/23 at 2:15 PM revealed she had provided care to Resident #1 prior to the incident on 05/02/23. She did not specify the type of care provided to Resident #1 in the past. She stated 05/02/23 was the first time she provided bathing assistance to Resident #1. She stated she was in-serviced during new hire orientation regarding accessing the EMR for resident ADL requirements. She stated she was re-educated regarding accessing residents' ADL status using the CNA binder and supervising residents while bathing on 05/02/23. Interview with RP on 05/12/23 at 5:25 PM revealed Resident #1 had been in the hospital since 05/03/23 due to an injury acquired from a fall at the facility. He stated the hospital had not provided a discharge date for Resident #1. He stated the facility informed him she fell in the shower room. He stated Resident #1 informed him a staff member was helping her shower then left her alone in the shower room. He stated Resident #1's injuries could have been prevented had the staff member stayed in the shower room. He stated Resident #1 would not be safe at the facility and not returning to the facility after discharge from the hospital. Record review of the facility policy, Abuse: Prevention of and Prohibition Against, date revised 10/2022, revealed, It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This was determined to be an Immediate Jeopardy (IJ) on 05/12/23 at 12:30 PM. The Administrator was notified. The Administrator was provided with the IJ template on 09/28/22 at 12:42 PM. The Facility Plan of Removal was accepted on 05/14/23. The plan of removal reflected: The facility failed to ensure Resident #1 was free of accident hazards. The Resident was left in the shower room unsupervised, fell and sustained a fracture. The facility failed to implement corrective measure identified in the self-report to prevent recurrence. 1. Resident #1 was assessed by the nurse and transferred back to the shower chair. Medical Director was notified of the fall and complaint of pain to right knee. The x-ray showed a fracture to the right distal femur. Medical Director was notified and gave orders to transfer to the hospital. The resident's responsible party was notified, and the resident was sent to the hospital. The resident did not return to the facility as of 5/12/2023, per the family she will transferring from the hospital to another skilled nursing facility. 2. Post investigation the following measures were initiated and included on the self-report. o Self report made to HHSC o Staff training initiated on shower assistance levels, abuse/neglect. o Grip tape was ordered to place on the shower floors. o Documentation was created for the CNA binders for each unit that identifies the level of assistance needed for showers. o Director of Rehab to update special instructions weekly. 3. The Medical Director was notified of IJ on 5/12/2023 at 1:00pm. 4. Training and knowledge checks on abuse and neglect; ADL care in regard to shower assistance levels and supervision; and preventing accidents and hazards was initiated with all staff on 5/12/2023 and will be completed on 5/13/2023 by the DON; ADON; MDS; RN J; RN L; RN M; RN N; RN P; or RN O. The trainings included abuse & neglect; shower supervision / assistance levels; and preventing accidents and used facility policy on abuse and neglect; facility shower policy; and incident and accident policy. 5. This training and knowledge check may be in-person or over the phone with non-clinical staff, in person training will be completed with all nursing staff prior to starting their next shift. Nursing staff will not be allowed to work until they have completed the training and knowledge checks to ascertain competency with DON; ADON; MDS; RN N; RN P; or RN O. This training and knowledge check will also be included in the new hire orientation and will be included for agency/PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and knowledge check. The knowledge checks for non-clinical includes questions on abuse and neglect definitions, abuse coordinator, when should incidents be reported, examples of abuse and neglect. The clinical knowledge check includes questions on abuse and neglect definitions, abuse coordinator, when should incidents be reported, examples of abuse and neglect, shower assistance needed, CNA Binder. See attached check forms. 6. An ad hoc meeting regarding items in the IJ template was completed on 5/12/2023 at 2:15pm. Attendees included Administrator; DON; ADON; Medical Director; RN P; RN N. The Plan of removal items and interventions were developed, reviewed, and agreed upon. 7. The bath/shower policy was updated and implemented by DON on 5/3/2023 to include the addition of the CNA binder's documentation that includes shower assistance levels. The CNA Binders , which contains information on all residents, are made accessible to nursing staff on both nursing stations by DON and ADON. The policy was implemented 5/3/2023. Facility policy on abuse/neglect, incident and accidents and bath/showers were reviewed by DON ; Administrator and RN Clinical Resource on 5/12/2023, there were no changes at that time. 8. Grip tape installation was complete and verified on 5/12/2023. 9. All residents could have been affected by the alleged deficient practice. Currently there are 71 residents living in the facility. An audit of shower assistance levels was completed for all residents. The shower assistance sheets and OT evaluation documentation in EMR were compared by DON and Rehab Director. There were no additional residents identified, all were found to have the appropriate shower assistance levels documented in the CNA Binders. This information was added to the Care Profile and all care plans updated. Fall assessments were completed for all residents and their care plans updated as necessary. 10. DON; ADON; MDS or RN Clinical Resource will monitor 5 nursing staff weekly for shower assistance level knowledge. 11. Shower assistance levels are updated in the CNA binder by DON; ADON; or RN N twice weekly and with change in condition. Shower assistance levels were added to the resident Care Profile 5/12/2023 and will be reviewed during the weekly clinical meeting. 12. Residents at risk for falls and resident shower assistance levels will be reviewed during the weekly clinical meeting and the Medical Director will be consulted for any recommendations or suggestions as necessary. Knowledge checks will be completed with 10 staff weekly by DON; ADON; MDS or RN N; RN P; or RN O, beginning 5/12/2023 with initial knowledge check and again on 5/13/2023 and will be on-going throughout the Quality Assurance process, reported weekly to the QAPI committee meeting for 4 weeks or until substantial compliance is established and then monthly for 90 days. The knowledge checks for non-clinical includes questions on abuse and neglect definitions, abuse coordinator, when should incidents be reported, examples of abuse and neglect.The clinical knowledge checkincludes questions onabuse and neglect definitions,abuse coordinator, when should incidents be reported, examples of abuse and neglect,shower assistance needed, CNA Binder. If competency via the knowledge check form cannot be ascertained, the staff member will be removed from their work duties immediately and retrained and/or receive disciplinary action accordingly. 13. Daily review of incidents and accidents will be completed by DON; ADON; and Administrator, beginning 5/13/2023. This information will be reported to the weekly QAPI committee meeting for 4 weeks or until substantial compliance is established, then monthly for 90 days. 14. Administrator will monitor CNA shower binders weekly to ensure accurate levels of assistance are documented. This information will be reported to the weekly QAPI committee meeting for 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. 15. Weekly clinical meetings will include review of residents at risk of falls and shower assistance levels/CNA Binders and review of the Care Profile. Meeting attendees will include DON; ADON; MDS and Administrator. Meeting minutes will be reported to the weekly QAPI committee meeting for 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. 16. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. 17. Follow up on IJ Plan of Removal and monitoring will be verified by DON and Administrator by review of residents at risk of falls and shower assistance levels during the weekly clinical meeting, review of staff knowledge checks obtained throughout the week, and the weekly QAPI meeting. Monitoring of the Plan of Removal included the following: Record review of facility in-service training reports from 05/12/23 and 05/13/23 revealed CNA F, CNA G, CNA H, LVN I, RN k and staff across all three shifts, the weekend, PRN staff, and agency staff were in-serviced regarding incident prevention, abuse and neglect, incident/accident, and ADL care. Record review of facility competency test, undated, revealed CNA F, CNA G, CNA H, LVN I, RN k and staff across all three shifts, the weekend, PRN staff, and agency staff completed quizzes regarding incident prevention, abuse and neglect, incident/accident, and ADL care. Observation of the facility's public shower rooms on 05/13/23 at 3:32 PM revealed grip tape was placed in the showers located in Bath 1, 2, and 3. Record review of the CNA Binders located at the nurse's station for halls 100, 200, and 300 revealed shower ADLs had been updated for all residents. Record review of the CNA Binders located at the nurse's station for halls 400, 500, and 600 revealed shower ADLs had been updated for all residents. Interviews were conducted on 05/12/23 through 05/14/23 with CNA F, CNA G, CNA H, LVN I, and RN K across all three shifts, the weekend, PRN staff, and agency staff to ensure they had been properly in-serviced. All interviews revealed the staff were trained and completed a competency test regarding incident prevention, abuse and neglect, incident/accident, and ADL care. Interview with the Director of Rehab on 05/14/23 at 3:26 PM revealed her responsibilities regarding the plan of removal was the special instructions and ADL care instructions. She stated she did a review of all the charts. She stated she updated any instructions that needed to be updated. She stated she will complete weekly audits. Interview with the Director of Rehab on 05/14/23 at 3:30 PM revealed her responsibilities regarding the plan of removal were weekly knowledge checks, observing showers, following ADLs listed in CNA binder. She stated she must complete five observations a week and ten knowledge check a week. She stated if the staff do not pass the knowledge checks, they cannot work with the resident. Interview with RN J on 05/14/23 at 3:34 PM revealed her responsibilities regarding the plan of removal was providing education and in-servicing. She stated the task would be ongoing. She stated she did abuse, neglect, shower supervision, assistance levels, preventing accidents, and using facility policies in-servicing with staff. Interview with RN L on 05/14/23 at 3:45 PM revealed her responsibilities regarding the plan of removal was in-servicing staff. Interview with RN M on 05/14/23 at 3:47 PM revealed her responsibilities regarding the plan of removal was completing training with staff. She stated she was the companies educator. She stated training will continuously be done. Interview with RN N on 05/14/23 at 3:50 PM revealed her responsibilities regarding the plan of removal was education; abuse, neglect, incident/accident, showers/ADLs. He stated he educated non-clinical staff too. He stated training will be on-going. Interview with RN J on 05/14/23 at 4:08 PM revealed her responsibilities regarding the plan of removal was knowledge checks and will be ongoing. Interview with DON on 05/14/23 at 4:20 PM revealed her responsibilities regarding the plan of removal was to check CNA binders every new admission, every Monday, and Friday with the Rehab Director to see if any occupational therapy ADLs changed, ten knowledge checks, 5 visual checks a week to ensure competency, and continue to educate new agency staff. Interview with Administrator on 05/13/23 at 5:12 PM revealed the IJ occurred due to the information provided in the IJ template and per the plan of removal. She stated the acceptance of the plan of removal will prevent the reoccurrence of the IJ; such as completing trainings and knowledge checks with staff, ad hoc meeting regarding IJ templates with Medical Director, following the Medical Directors recommendations, keep ADL sheets updated, ensure ADL sheets were in the CNA binder, grip tape installed and verified in shower rooms, audit shower ADL sheets to ensure currency, DON/ADON/MDS nurse/Clinical Resource Nurse provide shower ADL knowledge to staff, review fall risk residents and ADLs weekly, daily review of the incident and accidents, weekly QAPI meetings, weekly clinical meetings, summary of IJ reviewed weekly by QAPI, herself and DON will follow up regarding Plan of removal weekly. She stated she supervises her staff to ensure policies/procedures are being followed. She stated she make sure she has staff to train them. She stated she made her number accessible for staff to report. She stated as the abuse coordinator she educated staff. She stated she would have the DON train staff regarding supervision and ADLs. She stated observations and interviews, resident council regarding grievances, reviewing incidents, and high-risk clinical meeting weekly. She stated the DON monitored their staff. She stated she monitored the [NAME] to ensure they had completed their tasks per plan of removal, incident and accident report monitored, overseeing the in-servicing and check offs, weekly QAPI updated, and made sure there were weekly meetings and daily meetings. Interview with the DON on 5/14/23 at 5:02 PM revealed, she supervised her staff by watching them complete the showers in person. She stated she was going to complete five random audits to ensure appropriate ADL levels were completed. She stated the IJ occurred due to the facility failing to ensure accurate safety measures for the dependent resident in the shower room. She stated the acceptance of the plan of removal will prevent the reoccurrence of the IJ; such as completing trainings and knowledge checks with staff, ad hoc meeting regarding IJ templates with Medical Director, following the Medical Directors recommendations, keep ADL sheets updated, ensure ADL sheets were in the CNA binder, grip tape installed and verified in shower rooms, audit shower ADL sheets to ensure currency, DON/ADON/MDS nurse/Clinical Resource Nurse provide shower ADL knowledge to staff, review fall risk residents and ADLs weekly, daily review of the incident and accidents, weekly QAPI meetings, weekly clinical meetings, summary of IJ reviewed weekly by QAPI, herself and DON will follow up regarding Plan of removal weekly. She stated she supervises her staff to ensure policies/procedures are being followed. She stated she make sure she has staff to train them. She stated she made her number accessible for staff to report. She stated as the abuse coordinator she educated staff. She stated she would have the DON train staff regarding supervision and ADLs. She stated observations and interviews, resident council regarding grievances, reviewing incidents, and high-risk clinical meeting weekly. Interview with Medical Director on 05/17/22 at 9:20 AM revealed, he was notified on 05/02/23 regarding Resident #1's fall and injury. He stated he was informed the facility received an IJ due to Resident #1 not being supervised in the shower, lack of training with staff, and Resident #1's needs were not communicated. He stated his expectation for staff was to be better trained and to communicate better with residents due to language barriers. He stated there would be more QAPI meetings. He stated the facility needed to train staff. The facility's Administrator was informed the Immediate

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for one (Resident #1) of seven residents reviewed for accidents and supervision. CNA A failed to provide supervision for Resident #1, who was identified in her MDS Assessment as being totally dependent upon staff with one person assist, while Resident #1 was in the shower. Resident #1 subsequently fell and was found alone on the floor in the shower room. X rays were completed and indicated Resident #1 sustained injury including a fracture of the distal femur(thighbone fracture). She was sent to the hospital for further evaluation and treatment; she did not return to the facility . On 05/12/23 at 12:30 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 05/14/23, the facility remained out of compliance at a severity level of actual harm this is not immediate jeopardy and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk for inadequate supervision and assistance from staff which may cause falls with injuries resulting in severe harm, hospitalization and/or death. Findings included: Record review of Resident #1's Annual MDS Assessment, dated 03/09/23, revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: anemia, atrial fibrillation, hypertension, hyponatremia, hip fracture, aphasia, cerebrovascular accident, Non-Alzheimer's Dementia, and hemiplegia. Her BIMS score was a 3 out of 15, which meant the resident was severely cognitively impaired. Her functional status revealed her self-performance was total dependance and required one-person physical assistance with bathing. Record review of Resident #1's care plan, revised 05/10/23, revealed Has had an actual fall with no injury due to poor balance, unsteady gait on 08/28/21. Fall due to resident trying to get up without help on 11/12/21. Falls on 01/06/22 and 03/05/22 with no injuries. Unwitnessed fall without injury on 09/03/22. Unwitnessed fall with right hip pain and left upper extremity pain on 09/07/22. Unwitnessed fall with right hip pain without injury on 10/14/22. Unwitnessed fall with no known injuries on 12/26/22. Unwitnessed fall with no known injuries on 03/13/23. Unwitnessed fall with a fracture of the distal femur on 05/02/23. Her goal was to resume usual activities without further incident. Her interventions were evaluation in the emergency room on [DATE] and referral to therapy made upon her return. Her bed in lowest position. Continue interventions on the at-risk plan. Monitor/document /report to MD for signs and symptoms: pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. Neuro-checks as ordered. Her scoop mattress in place. Therapy consults for strength and mobility. 3/7/22 - Therapy consult s/p fall 3/5/22. Review of Resident #1's occupational therapy evaluation and plan of treatment, dated 04/11/23, reflected she required max assistance with bathing. Review of CNA C's trainings revealed she completed Alzheimer's disease and related disorders: behavior and ADL management on 04/13/23. She completed documentation of ADLs training on 04/15/23. She completed abuse, neglect, and exploitation training on 04/16/23. Review of Resident #1's occupation therapy Discharge summary, dated [DATE], revealed she was not provided services regarding bathing. Review of Resident #1's shower schedule, undated, reflected her shower days were Tuesday, Thursday, and Saturday during the 2:00 PM - 10:00 PM shift. CNA C was responsible for bathing Resident #1 on 05/02/23. Record review of Resident #1's Therapy Consultation/Screen, dated 05/02/23, revealed Patient triggered decline in locomotion on unit and off unit as documented in ADL significant change analysis report on 05/01/23. Patient was currently in physical therapy services under skilled maintenance program. Patient to increase duration of treatment to address decline. Record review of Resident #1's nursing notes, dated 05/02/23, revealed The nurse was called to the shower room by CNA. Upon entering room resident was observed to be lying on the floor in the shower stall in a supine position. Neuros within normal limits. Moves all extremities well. Denies pain. Resident assessed for injuries with no apparent injuries. DON and physician notified of fall. Left message with RP. No acute distress noted. Resident complained of pain in right knee. Right knee edema noted. Physician contacted and x-ray was ordered. The nurse's note was written by LVN A. Record review of Resident #1's nursing notes, dated 05/02/23, revealed X-ray competed and result shows acute fracture of the distal femur. Physician was notified and gave order to send resident to emergency room. RP was notified. The nurse's note was written by RN B. Record review of Resident #1's right knee x-ray, dated 05/02/23, revealed she had a fracture of the distal femur. Record review of Resident #1's Change in Condition note, dated 05/03/23, revealed Fall with fracture to right distal femur. The nurse's note was written by RN B. Record review of the facility's provider investigation report regarding Resident #1 revealed the facility identified the failure which caused Resident #1 to sustain a fall with fracture, and they reported the incident to HHSC on 05/03/23. The facility also identified measures to prevent a similar occurrence, including in-servicing staff on proper abuse and neglect protocols, update Resident #1's care plan, install new grip tape in shower rooms, the Director of rehab will update special instructions weekly according to current ADL assist status, and DON/designee will monitor proper shower procedures and documentation of ADLs on three residents weekly for 4 weeks. At the time of entry by the surveyor, the facility had not fully implemented these measures as evidenced by: - in-service staff on proper abuse and neglect protocols. - installed grip tape in all public shower rooms. - Director of rehab will update special instructions weekly according to current ADL assist status. - DON/designee will monitor proper shower procedures and documentation of ADLs on three residents weekly for 4 weeks. Interview with DON on 05/10/23 at 7:04 PM revealed CNA C left Resident #1 unattended in the shower room. She sated CNA C needed to remove Resident#1's bed linens. She stated Resident #1 was able to bathe herself but required supervision. She stated CNA's returned to the shower room and found Resident #1 on the ground. She stated Resident #1 was assessed by the nurse. She stated Resident #1 later complained of pain and received an x-ray. She stated the x-ray revealed a fracture of the distal femur. She stated the RP and physician were notified. She stated Resident #1 was sent to the hospital and will not be returning to the facility. She stated after the incident staff were in-serviced regarding residents' bathing needs. She stated CNA C received one-on-one coaching regarding where to find ADL information for residents. She stated she was unaware Resident #1's MDS assessment reflected she was total dependent and required one-person assist with bathing. She stated she refers to occupational therapy ADL notes to determine a resident's bathing needs. She stated she uses each resident's occupational therapy notes to complete the ADL forms. She stated the residents' ADL status was in their EMR dashboard. She stated CNAs were able to access residents' ADL status in the EMR dashboard. She stated the CNAs also had access to ADL forms regarding the residents' ADL status. She stated the CNAs were responsible for reviewing residents' EMR dashboard and ADL forms prior to providing service to the residents. She stated Resident #1's fall was preventable had she received adequate supervision by CNA C. She stated CNA C should have reviewed Resident #1's ADL status prior to providing care. Observation of shower rooms located in the public areas at the facility on 05/10/23 at 8:40 PM revealed a shower stall in shower room Bath 2 did not have grip strips. Record Review of CNA binder located at the nurse's station near the 100, 200, and 300 halls revealed the 100 hall ADL form was not in the binder. The ADL forms for the 200, 300, 400, and 500 halls were inaccurate; did not reflect ADL status for all residents at the facility. Interview with CNA C on 05/10/23 at 9:30 PM revealed she and CNA D provided Resident #1 with two-person assistance into a shower chair. She stated CNA D informed her Resident #1 could bath unsupervised in the shower room with the door cracked. She stated she did not have knowledge to check the ADL status in the EMR dashboard or CNA binder. She stated she knew residents were supposed to be supervised while bathing. She stated she was in-serviced during new hire orientation regarding accessing the EMR for resident ADL requirements. She stated she always supervised residents' bathing and did not know why she allowed Resident #1 to bath unsupervised. She stated residents' were supervised during bathing to prevent accidents from happening. She stated once Resident #1 was in the shower room set up help was provided. She stated the shower was turned on for the resident, soap provided, and a towel was provided. She stated she left Resident #1 unsupervised in a shower chair, in the public shower room. She stated she needed to change Resident #1's linens. She stated Resident #1's linens were changed on shower days. She stated when she went back to the shower room the resident was on the floor. She stated she informed LVN A and the resident was assessed. She stated Resident #1 did not complain of pain. She stated Resident #1 was transferred from the floor back to the shower chair and taken to her room. She stated she noticed Resident #1's knee was swollen while lying in bed. She stated she informed LVN A. Interview with CNA D on 05/11/23 at 6:50 AM revealed residents' ADL status was in the CNA binder at both nurse's station. She stated Resident #1 required assistance and supervision with bathing. She stated Resident #1 was not safe when she was left in the shower room unsupervised. She stated Resident #1 was only able to wash her hair and chest without CNA assistance. She stated all residents at the facility require supervision during bathing. She stated on 05/02/23 she assisted CNA C with transferring Resident #1 into a shower chair. She stated she and CNA C took Resident #1 to the shower room. She stated she turned the shower on, provided Resident #1 with soap, and towel. She stated she advised CNA C to stay in the shower room and supervise Resident #1 bathing. She stated she was in-serviced by the ADON regarding residents' ADL needs after the incident regarding Resident #1. She stated she had not previously been in-serviced regarding residents' bathing needs. Interview with Administrator 0n 05/11/23 at 9:07 AM revealed Resident #1 was found on the ground in the shower room by CNA C on 05/02/23. She stated LVN A and DON were immediately notified. She stated LVN A assessed the resident. She stated Resident #1 was transferred back to the shower chair and taken to her room. She stated there was no immediate harm. She stated the physician and RP were notified. She stated 20 minutes after the fall Resident #1 complained of pain and an x-ray was received. She stated the results were not received until 05/03/23. She stated the physician were and RP were notified regarding the x-ray results. She stated Resident #1 was sent to the hospital. She stated Resident #1's care plan was updated. She stated after receiving the x-ray results, she investigated the incident to determine if there was immediate danger. She stated staff were in-serviced regarding abuse and neglect. She stated the DON provided one-on-one coaching to CNA C on where to locate ADL assistance information in EMR and the importance of checking ADL status even if familiar with the resident. She stated a shower book was created to include residents' ADL needs. She stated the DON educated staff how to access the special instructions and ADL sheets for the residents. She stated rounds were completed to ensure CNAs were following proper shower procedures. She stated a monitoring tool was created to check staff competency regarding proper shower procedures. She stated herself, DON, and Rehab Director review and updated the residents' special instructions regarding ADL assistance weekly in their EMR. She stated the facility ordered grip strips and placed them in the public showers labeled Bath 1, 2, and 3. She stated grip strips were not added to the private showers in residents' rooms. Interview with the Rehab Director on 05/11/23 at 10:05 AM revealed Resident #1 received occupational therapy from 04/11/23 to 05/03/23. She stated her occupational therapy evaluation revealed Resident #1 required max assistance with bathing. She stated she reviewed the residents' special instructions weekly for skilled residents and when there has been a change regarding non-skilled residents. Interview with Occupational Therapist on 05/11/23 at 11:19 AM revealed she provided occupational services to Resident #1 from 04/11/23 to 05/02/23. She stated Resident #1 needed assistance from staff with bathing. She stated Resident #1 should not have been left alone in the shower from to bathe herself. She stated Resident #1 had good sitting balance but not standing balance. She stated the fall with injury could have been prevented had staff provided adequate supervision to Resident #1. Interview with Maintenance supervisor on 05/11/23 at 11:39 AM revealed grip strips were ordered on 05/04/23. He stated he added the grip strips to the public shower stall floors as a fall protocol. Interview with CNA C on 05/11/23 at 2:15 PM revealed she had provided care to Resident #1 prior to the incident on 05/02/23. She did not specify the type of care provided to Resident #1 in the past. She stated 05/02/23 was the first time she provided bathing assistance to Resident #1. She stated she was in-serviced during new hire orientation regarding accessing the EMR for resident ADL requirements. She stated she was re-educated regarding accessing residents' ADL status using the CNA binder and supervising residents while bathing on 05/02/23. Interview with RP on 05/12/23 at 5:25 PM revealed Resident #1 had been in the hospital since 05/03/23 due to an injury acquired from a fall at the facility. He stated the hospital had not provided a discharge date for Resident #1. He stated the facility informed him she fell in the shower room. He stated Resident #1 informed him a staff member was helping her shower then left her alone in the shower room. He stated Resident #1's injuries could have been prevented had the staff member stayed in the shower room. He stated Resident #1 would not be safe at the facility and not returning to the facility after discharge from the hospital. Record review of the facility policy, Change of Condition Notification, dated 06/2020, revealed, To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner. The facility will promptly inform the resident, consult with the attending physician, and notify the resident's legal representative when the resident endures a significant change in their condition caused by, but not limited to: an injury/accident; a significant change in the resident's physical, cognitive, behavioral or functional status; a significant change in treatment; and/or a decision to transfer or discharge the resident from the facility. This was determined to be an Immediate Jeopardy (IJ) on 05/12/23 at 12:30 PM. The Administrator was notified. The Administrator was provided with the IJ template on 09/28/22 at 12:42 PM. The Facility Plan of Removal was accepted on 05/14/23. The plan of removal reflected: The facility failed to ensure Resident #1 was free of accident hazards. The Resident was left in the shower room unsupervised, fell and sustained a fracture. The facility failed to implement corrective measure identified in the self-report to prevent recurrence. 1. Resident #1 was assessed by the nurse and transferred back to the shower chair. Medical Director was notified of the fall and complaint of pain to right knee. The x-ray showed a fracture to the right distal femur. Medical Director was notified and gave orders to transfer to the hospital. The resident's responsible party was notified, and the resident was sent to the hospital. The resident did not return to the facility as of 5/12/2023, per the family she will transferring from the hospital to another skilled nursing facility. 2. Post investigation the following measures were initiated and included on the self-report. o Self report made to HHSC o Staff training initiated on shower assistance levels, abuse/neglect. o Grip tape was ordered to place on the shower floors. o Documentation was created for the CNA binders for each unit that identifies the level of assistance needed for showers. o Director of Rehab to update special instructions weekly. 3. The Medical Director was notified of IJ on 5/12/2023 at 1:00pm. 4. Training and knowledge checks on abuse and neglect; ADL care in regard to shower assistance levels and supervision; and preventing accidents and hazards was initiated with all staff on 5/12/2023 and will be completed on 5/13/2023 by the DON; ADON; MDS; RN J; RN L; RN M; RN N; RN P; or RN O. The trainings included abuse & neglect; shower supervision / assistance levels; and preventing accidents and used facility policy on abuse and neglect; facility shower policy; and incident and accident policy. 5. This training and knowledge check may be in-person or over the phone with non-clinical staff, in person training will be completed with all nursing staff prior to starting their next shift. Nursing staff will not be allowed to work until they have completed the training and knowledge checks to ascertain competency with DON; ADON; MDS; RN N; RN P; or RN O. This training and knowledge check will also be included in the new hire orientation and will be included for agency/PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and knowledge check. The knowledge checks for non-clinical includes questions on abuse and neglect definitions, abuse coordinator, when should incidents be reported, examples of abuse and neglect. The clinical knowledge check includes questions on abuse and neglect definitions, abuse coordinator, when should incidents be reported, examples of abuse and neglect, shower assistance needed, CNA Binder. See attached check forms. 6. An ad hoc meeting regarding items in the IJ template was completed on 5/12/2023 at 2:15pm. Attendees included Administrator; DON; ADON; Medical Director; RN P; RN N. The Plan of removal items and interventions were developed, reviewed, and agreed upon. 7. The bath/shower policy was updated and implemented by DON on 5/3/2023 to include the addition of the CNA binder's documentation that includes shower assistance levels. The CNA Binders , which contains information on all residents, are made accessible to nursing staff on both nursing stations by DON and ADON. The policy was implemented 5/3/2023. Facility policy on abuse/neglect, incident and accidents and bath/showers were reviewed by DON ; Administrator and RN Clinical Resource on 5/12/2023, there were no changes at that time. 8. Grip tape installation was complete and verified on 5/12/2023. 9. All residents could have been affected by the alleged deficient practice. Currently there are 71 residents living in the facility. An audit of shower assistance levels was completed for all residents. The shower assistance sheets and OT evaluation documentation in EMR were compared by DON and Rehab Director. There were no additional residents identified, all were found to have the appropriate shower assistance levels documented in the CNA Binders. This information was added to the Care Profile and all care plans updated. Fall assessments were completed for all residents and their care plans updated as necessary. 10. DON; ADON; MDS or RN Clinical Resource will monitor 5 nursing staff weekly for shower assistance level knowledge. 11. Shower assistance levels are updated in the CNA binder by DON; ADON; or RN N twice weekly and with change in condition. Shower assistance levels were added to the resident Care Profile 5/12/2023 and will be reviewed during the weekly clinical meeting. 12. Residents at risk for falls and resident shower assistance levels will be reviewed during the weekly clinical meeting and the Medical Director will be consulted for any recommendations or suggestions as necessary. Knowledge checks will be completed with 10 staff weekly by DON; ADON; MDS or RN N; RN P; or RN O, beginning 5/12/2023 with initial knowledge check and again on 5/13/2023 and will be on-going throughout the Quality Assurance process, reported weekly to the QAPI committee meeting for 4 weeks or until substantial compliance is established and then monthly for 90 days. The knowledge checks for non-clinical includes questions on abuse and neglect definitions, abuse coordinator, when should incidents be reported, examples of abuse and neglect. The clinical knowledge check includes questions on abuse and neglect definitions, abuse coordinator, when should incidents be reported, examples of abuse and neglect, shower assistance needed, CNA Binder. If competency via the knowledge check form cannot be ascertained, the staff member will be removed from their work duties immediately and retrained and/or receive disciplinary action accordingly. 13. Daily review of incidents and accidents will be completed by DON; ADON; and Administrator, beginning 5/13/2023. This information will be reported to the weekly QAPI committee meeting for 4 weeks or until substantial compliance is established, then monthly for 90 days. 14. Administrator will monitor CNA shower binders weekly to ensure accurate levels of assistance are documented. This information will be reported to the weekly QAPI committee meeting for 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. 15. Weekly clinical meetings will include review of residents at risk of falls and shower assistance levels/CNA Binders and review of the Care Profile. Meeting attendees will include DON; ADON; MDS and Administrator. Meeting minutes will be reported to the weekly QAPI committee meeting for 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. 16. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. 17. Follow up on IJ Plan of Removal and monitoring will be verified by DON and Administrator by review of residents at risk of falls and shower assistance levels during the weekly clinical meeting, review of staff knowledge checks obtained throughout the week, and the weekly QAPI meeting. Monitoring of the Plan of Removal included the following: Record review of facility in-service training reports from 05/12/23 and 05/13/23 revealed CNA F, CNA G, CNA H, LVN I, RN k and staff across all three shifts, the weekend, PRN staff, and agency staff were in-serviced regarding incident prevention, abuse and neglect, incident/accident, and ADL care. Record review of facility competency test, undated, revealed CNA F, CNA G, CNA H, LVN I, RN k and staff across all three shifts, the weekend, PRN staff, and agency staff completed quizzes regarding incident prevention, abuse and neglect, incident/accident, and ADL care. Observation of the facility's public shower rooms on 05/13/23 at 3:32 PM revealed grip tape was placed in the showers located in Bath 1, 2, and 3. Record review of the CNA Binders located at the nurse's station for halls 100, 200, and 300 revealed shower ADLs had been updated for all residents. Record review of the CNA Binders located at the nurse's station for halls 400, 500, and 600 revealed shower ADLs had been updated for all residents. Interview with the Director of Rehab on 05/14/23 at 3:26 PM revealed her responsibilities regarding the plan of removal was the special instructions and ADL care instructions. She stated she did a review of all the charts. She stated she updated any instructions that needed to be updated. She stated she will complete weekly audits. Interview with the Director of Rehab on 05/14/23 at 3:30 PM revealed her responsibilities regarding the plan of removal were weekly knowledge checks, observing showers, following ADLs listed in CNA binder. She stated she must complete five observations a week and ten knowledge check a week. She stated if the staff do not pass the knowledge checks, they cannot work with the resident. Interview with RN J on 05/14/23 at 3:34 PM revealed her responsibilities regarding the plan of removal was providing education and in-servicing. She stated the task would be ongoing. She stated she did abuse, neglect, shower supervision, assistance levels, preventing accidents, and using facility policies in-servicing with staff. Interview with RN L on 05/14/23 at 3:45 PM revealed her responsibilities regarding the plan of removal was in-servicing staff. She stated she did not know what the plan was going forward. Interview with RN M on 05/14/23 at 3:47 PM revealed her responsibilities regarding the plan of removal was completing training with staff. She stated she was the companies educator. She stated training will continuously be done. Interview with RN N on 05/14/23 at 3:50 PM revealed her responsibilities regarding the plan of removal was education; abuse, neglect, incident/accident, showers/ADLs. He stated he educated non-clinical staff too. He stated training will be on-going. Interview with RN J on 05/14/23 at 4:08 PM revealed her responsibilities regarding the plan of removal was knowledge checks and will be ongoing. Interview with DON on 05/14/23 at 4:20 PM revealed her responsibilities regarding the plan of removal was to check CNA binders every new admission, every Monday, and Friday with the Rehab Director to see if any occupational therapy ADLs changed, ten knowledge checks, 5 visual checks a week to ensure competency, and continue to educate new agency staff. Interview with Administrator on 05/13/23 at 5:12 PM revealed the IJ occurred due to the information provided in the IJ template per the plan of removal. She stated the acceptance of the plan of removal will prevent the reoccurrence of the IJ; such as completing trainings and knowledge checks with staff, ad hoc meeting regarding IJ templates with Medical Director, following the Medical Directors recommendations, keep ADL sheets updated, ensure ADL sheets were in the CNA binder, grip tape installed and verified in shower rooms, audit shower ADL sheets to ensure currency, DON/ADON/MDS nurse/Clinical Resource Nurse provide shower ADL knowledge to staff, review fall risk residents and ADLs weekly, daily review of the incident and accidents, weekly QAPI meetings, weekly clinical meetings, summary of IJ reviewed weekly by QAPI, herself and DON will follow up regarding Plan of removal weekly. She stated she supervises her staff to ensure policies/procedures are being followed. She stated she make sure she has staff to train them. She stated she made her number accessible for staff to report. She stated as the abuse coordinator she educated staff. She stated she would have the DON train staff regarding supervision and ADLs. She stated observations and interviews, resident council regarding grievances, reviewing incidents, and high-risk clinical meeting weekly. She stated the DON monitored their staff. She stated she monitored the [NAME] to ensure they had completed their tasks per plan of removal, incident and accident report monitored, overseeing the in-servicing and check offs, weekly QAPI updated, and made sure there were weekly meetings and daily meetings. Interview with the DON on 5/14/23 at 5:02 PM revealed, she supervised her staff by watching them complete the showers in person. She stated she was going to complete five random audits to ensure appropriate ADL levels were completed. She stated the IJ occurred due to the facility failing to ensure accurate safety measures for the dependent resident in the shower room. She stated the acceptance of the plan of removal will prevent the reoccurrence of the IJ; such as completing trainings and knowledge checks with staff, ad hoc meeting regarding IJ templates with Medical Director, following the Medical Directors recommendations, keep ADL sheets updated, ensure ADL sheets were in the CNA binder, grip tape installed and verified in shower rooms, audit shower ADL sheets to ensure currency, DON/ADON/MDS nurse/Clinical Resource Nurse provide shower ADL knowledge to staff, review fall risk residents and ADLs weekly, daily review of the incident and accidents, weekly QAPI meetings, weekly clinical meetings, summary of IJ reviewed weekly by QAPI, herself and DON will follow up regarding Plan of removal weekly. She stated she supervises her staff to ensure policies/procedures are being followed. She stated she make sure she has staff to train them. She stated she made her number accessible for staff to report. She stated as the abuse coordinator she educated staff. She stated she would have the DON train staff regarding supervision and ADLs. She stated observations and interviews, resident council regarding grievances, reviewing incidents, and high-risk clinical meeting weekly. Interview with Medical Director on 05/17/22 at 9:20 AM revealed, he was notified on 05/02/23 regarding Resident #1's fall and injury. He stated he was informed the facility received an IJ due to Resident #1 not being supervised in the shower, lack of training with staff, and Resident #1's needs were not communicated. He stated his expectation for staff was to be better trained and to communicate better with residents due to language barriers. He stated there would be more QAPI meetings. He stated the facility needed to train staff. The facility's Administrator was informed the Immediate Jeopardy was removed on 05/14/23 at 6:06 PM. The facility remained out of compliance at a severity level of actual harm this is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.