**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 2 of 3 residents (Residents #1 and #2) reviewed for accidents. 1. Driver A failed to secure Resident#1's wheelchair properly in the van, resulting in the resident hitting her head when the wheelchair tipped backwards during transport on 03/18/25. The resident was sent to the hospital but did not have any injuries. 2. Driver B failed to secure the safety strap on the lift when Resident #2 was being lowered. Driver B fell onto Resident #2 causing him to tip backwards in his wheelchair and hitting his head on the ground on 04/07/25. The resident was sent to the hospital where he was found to have an abrasion on his scalp but no serious injury. The noncompliance was identified as past noncompliance. The IJ began on 03/18/25 and ended on 04/07/25. The facility had corrected the noncompliance before the survey began. The failures placed residents who used the facility's transportation at risk for injury. Findings included: 1. Record review of Resident #1's undated admission Record, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. The admission Record reflected Resident #1 was her own RP and had diagnoses which included diabetes, heart failure, and vision loss. Record review of Resident #1's quarterly MDS, dated [DATE], reflected a BIMS score of 14 indicating she was cognitively intact. Her Functional Status assessment indicated she was independent in her ADLs. Record review of Resident #1's care plan, dated 02/26/25, reflected she had a history of headaches, and making false allegations. Record review of the facility's Provider Investigation Report, completed by the Administrator on 03/25/25, reflected the following incident occurred on 03/18/25 at 3:15 PM in the facility's van: .Description of Allegation: [Resident #1] stated [her] wheelchair was not secure in transport van, and that it tipped back a few inches and she hit her head on ramp behind her. Transport Driver [Driver A] stated that she secured [the] wheelchair, but discovered it was loose when she started to drive. Immediately pulled over and re-secured it. .Name and title of person who completed assessment: [RN D] Description of assessment including extent of injuries No sign of bump, bruising, or redness on head where resident states she hit it. Sent to ED for additional evaluation due to c/o head injury. .Provider Response .Driver [Driver A] suspended pending investigation. Resident [Resident #1] assessed by DON and sent to ED for CT scan due to hitting head - no bruising, laceration, or raised a red noted. CT at ED negative. Physician, ombudsman notified. Resident is RP. Investigation Summary .DON was notified by COTA (Therapy) that [Resident #1] refused therapy due to headache pain resulting from hitting head during transport the previous day. COTA .immediately report this incident to DON (was in office next to therapy gym) and provided written statement and report to Admin. Driver provided statement to Administrator that she did fail to completely secure [Resident #1's] wheelchair prior to driving. She noticed the wheelchair tip back 3-5 inches and immediately pulled off the road and properly secured [Resident #1's] wheelchair. [Resident #1] stated that she hit her head on the ramp in the van when she tipped back. Driver was talking about this incident at the nurse[s'] station upon return to the facility, and Administrator was at the nurse[s'] station at the same time. Driver assumed Admin was aware. Admin was conducting in-service/monitoring with another staff member at the time and did not hear the report of an incident in the van. Admin provided to [sic] coaching to driver regarding reporting any and all incidents or potential for incident or injury directly to him, not just when it could be heard. Investigation revealed driver [Driver A] had reported complaint of pain by resident [Resident #1] - upon return to facility - to resident's nurse. Nurse stated that she was unable to provide prn pain medication at that time due to caring for another resident and then forgot to get back to it. Nurse did assess resident for pain a few hours later and there was no c/o of pain or signs of distress. Resident does receive routine pain medications and has order for PRN, which she used most days. PRN order was changed to routine in AM with additional PRN available later in the day as needed. Admin identified all residents who had been on transport in last 30 days (from appointment calendar) and Social Worker completed safe survey assessments with each of them as well as safe survey pain assessments with several residents. No additional transport or pain issues were reported in surveys. Investigation showed that driver [Driver A] had been properly and completely trained on all policies and procedures for properly securing residents in transport van and properly transporting them. Driver [Driver A] failed to follow proper procedures. Driver [Driver A] failed to report complaint of injury during transport and failed to report failure to properly secure resident and wheelchair prior to transport. Driver [Driver A] resigned her position and employment. .Provider Action Taken Post-Investigation: All staff in-serviced on recognizing, preventing, and immediately reporting abuse and neglect directly to Abuse Coordinator. Nursing staff in-serviced on pain management policies and procedures. All drivers of van retrained on pre and post trip inspections as well as safety attestations to be completed prior to each trip. Record review of Driver A's written statement, dated 03/19/25, reflected: On Tuesday March 18, 2025 at approximately 1515 [3:15 PM] hrs. I, [Driver A], was transporting [Resident #1] from a doctor apt. She had complained about having a headache. I loaded [Resident #1] into [the] back of transport van and secured the chair using the straps and seat belt. I started driving and her chair tipped backwards about 4 inches. I immediately pulled over and re-secured the straps to her chair. She claimed she hit her head, but I am not positive she did. We got back to [the] facility where she asked the nurse for tylenol. It was mentioned in front of [the Administrator] about her hitting her head. Interview on 04/30/35 at 9:50 AM with Resident #1 revealed she was in the van on 03/19/25 in her wheelchair when her wheelchair tipped backwards 4-5 inches. Resident #1 stated when Driver A accelerated it caused her to hit her head on the lift of the van. The resident stated she had a headache, but she had a headache prior to the incident, so she did not have any injury. Resident #1 stated she was more startled than anything. Resident #1 stated she had not been in the van since, but she was not afraid to be transported again. Record review of Resident #1's nursing notes reflected the resident was sent to the ER via ambulance since she stated she had hit her head on a piece of metal. Nursing assessment revealed no obvious injury. The resident returned from the ER with no abnormal findings after examination and CT scan of her head. Record review of text communications, undated but timed 1:55 PM, with Driver A reflected: Can you please clarify for me exactly what process you did to secure [Resident #1]? I attached the ratchet straps to the frame of her chair in the back and front. When I re-secured the chair, I adjusted the positions of the straps to better secure the chair in place, ensuring it did not move again. I secured the seat belt across her lap to ensure she did not slip from the chair in case of an incident. The seat belt was placed prior to initially moving the van the first time. This belt was not needed to be adjusted after the incident. Record review of an Employee Disciplinary Report Action Request, dated 03/19/25, reflected Driver A had a written counseling and investigatory suspension due to an infraction that occurred involving Resident #1. This was signed by the Administrator on 03/19/25. Record review of a Coaching Form, dated 03/19/25, signed by both Driver A and the Administrator reflected: Situation: Incident in van. Wheelchair not properly secured. Resident claims wheelchair tipped back and she hit her head on the ramp (she was in position closest to ramp). Specific Coaching/Education given to the Employee: All residents must be properly secured prior to vehicle movement. Auto transport training to be completed prior to return to transport. All incidents must be reported immediately to Administrator. Record review of a Vehicle Inspection Report, dated 03/19/25, reflected the facility completed an inspection of the van's interior to include seat belts and wheelchair tie-downs, and there were no issues identified. Record review of Life Satisfaction Rounds forms, dated 03/20/25, reflected the facility conducted interviews with residents to determine if they felt safe at the facility and if there were any issues with transportation. These interviews revealed no concerns regarding transportation. Record review of an In Service Training Attendance Roster, dated 03/19/25, reflected facility staff received in-service training on the topic of Vehicle Training/Secure Passengers/Report Immediately. Record review of an In Service Training Attendance Roster, dated 03/21/25, reflected facility staff received in-service training on the topic of Safety Attestation presented by the Administrator. Record review of the Employee Auto Attestation Form, which was the topic of the in-service Training, reflected: I, ____________, attest that all of the following safety checks have been completed before taking ________(resident) to their appointment. 1. Before driving a company automobile, the driver must be satisfied that it is in safe operating condition. Any defects or unsafe conditions should be reported to appropriate individual(s) immediately. 2. All safety devices, including seat belts/restraint devices/wheelchair tie downs, will be used by anyone operating or riding in a vehicle. There shall be no more passengers in a vehicle than the number of seat belts available. Driver will check straps by attempting to move wheelchair on all 4 corners. 3. Driver will conduct a final visual inspection to ensure all residents have been safely secured [in] the vehicle before driving. Interview on 04/30/25 at 3:45 PM with the Administrator revealed Driver A had been the primary driver and Driver B was the back up driver who covered when Driver A was off. Driver B took over the primary driving responsibilities after Driver A had been terminated. The Administrator stated Driver A had also failed to call him or the DON from the scene, instead she waited until she returned from the transport. Driver A stated in her interview she had told the nurse and himself when she returned, she had assumed he heard her tell the nurse, but he stated he was speaking with another employee and did not hear Driver A report to the nurse. The Administrator stated Driver B had participated in the in-service and training on 03/20/25 and she did not follow procedures on 4/07/25, so she was terminated as well. The Administrator stated they now have two drivers on the van when transporting to improve safety and reduce the risk of procedure violation. He stated the facility did not have a policy covering transporting the residents, they relied on the company's driver training manual. Record review of Resident #1's hospital record reflected she was treated for abrasions after a fall. An attempt was made to interview Driver A via telephone on 04/30/25 at 1:15 PM. A voicemail message was left for Driver A; however, she did not return the call. Record review of Drivers A's driver training revealed Driver A had been initially trained for driving the van on 04/13/23 and her last re-training had been completed on 01/30/25. 2. Record review of Resident #2's undated admission Record, reflected the resident was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included kidney failure, diabetes, heart failure, and Parkinson's disease. Record review of Resident #2's quarterly MDS, dated [DATE], revealed he had a BIMS score of 15, indicating he was cognitively intact. His Functional Ability assessment reflected he required minimal assistance with his ADLs. Record review of Resident #2's care plan, dated 03/12/25, reflected he required the use of a wheelchair for mobility, he was on blood thinning medication, and he required assistance with transfers to and from his wheelchair. Record review of the facility's Provider Investigation Report, completed by the Administrator on 04/14/25, reflected the following incident occurred on 04/07/25 at 11:00 AM involving Resident #2 and Driver B: .Description of the Allegation: Driver [Driver B] was walking to take resident off of van, driver tripped and fell on resident causing the resident to flip backwards in wheelchair. Back ramp strap was not done. Resident complained of pain and was sent to ER [sic]. CT was negative and resident returned to facility. Driver suspended. .Description of assessment including extent of injuries Resident returning from doctors [sic] appt on facility van, Per the staff driver [Driver B] of the day, patient fell back while on the wheelchair. Resident [Resident #2] complained of head and neck pain. This LVN [LVN E] sent resident out EMS for eval. .Provider Response .Driver [Driver B] reported incident immediately, resident was assessed by nurse. All resident transports will require 2 staff members to be present to ensure resident safety. Investigation Summary .Driver [Driver B] immediately reported incident to DON (Admin Offsite) .per facility protocol. Resident was assessed by a nurse prior to being moved. Resident did not have any injuries but did complain of pain. Resident was transferred to ED for additional evaluation and treatment. CT negative for head and neck, resident returned to facility in stable condition. Driver was suspended pending investigation. It was determined that driver did fail to properly secure seatbelt on lift, and that driver stood on ramp with resident, both being failure to follow company policy and procedure. Driver [Driver B] had been fully trained and given additional training and in-services on van/transport protocols. Driver [Driver B] was terminated for failure to follow company policies. All drivers were re-trained on protocols and procedures prior to resuming transports. Facility has instructed all drivers that 2 staff members must be present for each transport to ensure safety. .Provider Action Taken Post-Investigation: Abuse and neglect in-service Van retraining completed for all drivers before van returns to driving. Record review of Resident #2's hospital records reflected he was treated on 04/07/25 for a fall and scalp abrasion. The hospital record reflected the resident did not sustain any serious injuries. Interview on 04/30/25 at 10:55 AM with Resident #2 revealed on 04/07/25 he was being unloaded from the facility's van. After he had been lowered to the ground on the lift, the driver fell onto him causing his wheelchair to roll backwards, and he tipped backwards. He stated he hit his head on the ground and had back pain. He denied losing consciousness. He was sent to the hospital via ambulance. He has been on the van three times a week since the incident for dialysis without incident. Interview on 04/30/25 at 11:05 AM with the Administrator revealed their investigation revealed Driver B failed to secure the safety strap at the back of the lift that is designed to prevent the resident from rolling off the back of the ramp. He stated Driver B had unlocked the wheelchair's locks, lost her balance, and fell onto the resident. The resident rolled backwards off the lift, at ground level, and tipped over backwards. Resident #2 was assessed by the nurse before being moved, he was found to have a minor abrasion to the back of his head and was sent to the hospital via ambulance. The Administrator stated Driver B was in-serviced on 03/20/25 on van transport procedures, after the incident with Resident #1, but still did not follow procedures with Resident #2. As a result she was terminated. The Administrator stated all six people authorized to drive the facility van were in-serviced again on 04/07/25, and all six were given the company's driving test again. The procedure had also been changed to have two drivers on the van for all transports in the future. Driver B was suspended on 04/07/25 and terminated on 04/08/25. Record review of the facility's in-services and training documents from 03/20/25 and 04/07/25 reflected six staff had been in-serviced by the regional trainer on transport procedures including loading and unloading the resident, and proper securement of the wheelchair in the van. All six staff had passed the company driving test administered by the regional trainer. Observation on 04/30/25 at 11:45 AM of van transport procedures, performed by Driver C, with Resident #3, revealed the resident was secured in his wheelchair with two straps to the front frame of the wheelchair, and two straps to the back frame of the wheelchair. A lap belt was placed and secured to the floor behind the wheelchair, and a chest strap was secured across the left shoulder to the lap belt, similar to a car seatbelt. The wheelchair locks were then secured. Unloading Resident #3 was accomplished by securing the safety strap across the back of the lift, rolling the wheelchair backwards onto the lift, securing the wheelchair breaks, and lowering the resident to ground level. The wheelchair locks were released before the safety strap was removed and the resident was rolled off the lift. Interview on 04/30/25 at 11:50 AM with Resident #3 revealed the procedure Driver C had performed for the transport was how all of his previous transports had been done. He stated he had no concerns with being transported via the facility van. Interview on 04/30/25 at 11:53 AM with Driver C revealed she had been re-trained on driving and transport procedures in March and April, and they now had two drivers present in the van to minimalize the risk for errors or injuries. Interviews on 04/30/25 from 12:00 PM-12:35 PM with four residents (Residents #3, #4, #5, and #6) that had been transported via the van on a regular basis for dialysis or other appointments revealed none had any concerns about how they were secured in the van, and all felt confident in the skills of the drivers. Interview on 04/30/25 at 4:23 PM with the Maintenance Director revealed his inspection of the van after both incidences revealed all equipment was in working order. An interview was attempted with Driver B via telephone; however, the attempt was unsuccessful. A voicemail message was left for Driver B, but Driver B did not return the call. Record review of Driver B's driver training revealed Driver B had initially been trained for driving the van on 05/17/23 and her last re-training was on 01/30/25. Record review of in-service training records reflected the facility provided Van Training to staff, who drove the facility van following the incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 1 of 10 residents (Resident #1) reviewed for care plans. The facility failed to develop and implement a care plan for Resident #1 to address him being at risk for constipation which he was at increased risk for due to his diagnosis of cerebral palsy. This failure resulted in the facility staff not being aware of these risk factors for constipation and not implementing interventions to prevent the resident from having a fecal impaction of the rectum with associated stercoral colitis, which is a rare inflammatory colitis that occurs when impacted fecal material leads to distention of the colon and eventually hardened stool formation. An Immediate Jeopardy was identified on 03/13/25 at 10:00 AM. While the Immediate Jeopardy was removed on 03/14/25, the facility remained at the severity level of noncompliance that results in no more than minimal physical, mental and/or psychosocial discomfort to the resident and/or has the potential (not yet realized) to compromise the resident's ability to maintain and/or reach his or her highest practicable physical, mental and/or psychosocial well-being as defined by an accurate and comprehensive resident assessment, plan of care, and provision of service and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure placed residents at risk of serious harm or death. Findings included: Record review of Resident #1's Nursing Home Comprehensive Item Set MDS Record dated, 01/15/25, reflected an initial admit date of 01/21/24 and readmission date of 01/30/25. Resident #1's diagnoses included: cerebral palsy (congenital disorder of movement, muscle tone, or posture), seizure disorder or epilepsy, sepsis (life-threatening complication of an infection), and dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage). Resident #1's MDS also reflected that Resident #1's cognition was intact with a BIMS score of 15. Resident #1's MDS reflected that Resident #1 was dependent (helper does all the effort) on staff for toileting. Resident #1's MDS also reflected that Resident #1 was not on a bowel toileting program. Resident #1's MDS reflected that the resident was always incontinent of bowel. The MDS also reflected that Resident #1 showed no constipation present. Record review of Resident #1's undated Care Plan reflected that Resident #1 had not been placed at Risk of Constipation. Record review of Resident #1's undated Discontinued Orders reflected resident received Baclofen Oral Tablet 20 MG 1 tablet by mouth four times daily. Resident #1 was also ordered and received Clonazepam .5 MG tablet by mouth twice daily. Resident #1 received Probiotic Oral Capsule daily as well. Resident #1 had a PRN (as needed) order for Bisacodyl Rectal Suppository insert 10 mg rectally as needed for constipation. Resident #1's orders also reflected he received 2 Hydrocodone-Acetaminophen Oral Table 5-325 three times daily. Resident #1 received 1 Cyclobenzaprine HCl Oral Tablet 10 MG twice daily. Record review of Resident #1's undated MAR reflected that Resident #1 did not receive a dosage of his order for Bisacodyl Rectal Suppository for constipation as needed ordered by his primary care physician during the month of February 2025. Record review of Resident #1's Bowel Movement ADL 30-day documentation chart reflected no bowel movements between the days of 02/11/25 through 02/20/25. The ADL record reflected the resident had one bowel movement on 02/21/25 but had no other bowel movements before he was transferred to the hospital on [DATE] at 12:00AM. Therefore, the ADL record reflected the resident had one bowel movement from 02/11/25 until discharge on [DATE]. Record review of Resident #1's Progress Notes dated 02/26/25 at 6:47 PM reflected LVN A transferred Resident #1 to the hospital due to a change in condition and family request on 02/26/25 at 12:00 AM after Resident #1 spoke with his Responsible Party on 02/25/25. Record review of Resident #1's Progress Notes dated 02/28/25 at 10:32 AM reflected the DON was made aware of allegations of neglect. This Progress Note by the DON reflected Administrator, Medical Director, Area Director of Operations, and the Area DON were notified. Record review of Resident #1's Hospital Record dated 02/26/25 at 10:16 PM reflected, Prominent fecal impaction of the rectum with associated stercoral colitis. There is constipation, without bowel obstruction. Record review of Resident #1's Hospital Record dated 02/28/25 at 9:23 AM reflected, Severe Constipation: on 02/27 Disimpaction severe and Mag Citrate, Lactulose, and Go Lytely. Record review of Resident #1's Hospital Record dated 03/02/25 at 11:44 AM reflected Resident #1's diagnoses of Severe constipation with fecal impaction: Improving. S/P (Status Post Docusate) docusate, lactulose, soapsuds enema, manual disimpaction. Had watery stool. Record review of Resident #1's Hospital Record dated 03/03/25 at 9:20 AM reflected Resident #1's diagnosis of Severe constipation, fecal impaction. The same hospital notenotes also reflected, Noted stercoral colitis on CT, Initiate docusate, lactulose, Soapsuds enema x 2, and No BM despite manual disimpaction. Will obtain CT/AP with p.o. contrast (Computed tomography of Abdomen and pelvis with oral contrast). Record review of the National Libraray of Medicine at www.ncbi.nlm.nih.gov/books/NBK560608, Stercoral Colitis, dated 07/10/23, reflected: Stercoral colitis is a rare inflammatory colitis that occurs when impacted fecal material leads to distention of the colon and eventually fecaloma [hardened stool] formation Interview on 03/11/25 at 9:53 AM with the Administrator revealed that a family member put on social media that Resident #1 was being neglected in the areas of showering, oral care, and monitoring of bowel movements. The Administrator also revealed that the resident did not return to the facility after discharge from the hospital. The Administrator said that Resident #1 went to a sister facility for long-term care. The Administrator revealed he was not aware Resident #1 had gone 11 days with no bowel movements. The Administrator stated that on 02/28/25, he in-serviced all staff on abuse/neglect, patient rounding, resident rights, bowel and bladder documentation, bowel incontinence care, bath, tub/shower, bed bath complete, teeth care/oral hygiene, resident/resident incidents, Immediately in-service on the definition of Immediate, accurate documentation of refusals, and physician's orders. Interview on 03/11/25 at 1:46 PM with Resident #1's Responsible Party revealed that a family member placed a negative comment about the facility on social media the morning that the resident went out to the hospital. The Responsible Party stated that he saw Resident #1 on the morning of 02/25/25, and he could tell that something was wrong. The Responsible Party stated that he called the facility and requested that his family member be sent out to the hospital. The Responsible Party confirmed that the hospital did not do surgery on Resident #1, and Resident #1 was now at another facility. Interview on 03/12/25 at 11:18 AM with the Medical Director revealed that Resident #1 had risk factors for constipation due to his diagnosis of cerebral palsy, which was a neurological condition which led to his immobility. The Medical Director stated that he provided the facility with standing orders for the treatment of constipation if a resident did not have a bowel movement after three days. The Medical Director said that he expected the facility's nurses to notify him if his prescribed interventions did not work for residents. The Medical Director stated that he did not recall if he was notified of a change in condition for Resident #1. The Medical Director concluded by stating that he could not remember everything about every resident. Interview on 03/13/25 at 10:11 AM with MDS U revealed that she had been in training as the MDS Coordinator for two weeks, andweeks and had been in-serviced regarding care plans and the risk of constipation. MDS U stated that as the MDS Coordinator, she was trained to look at the resident's medications, diagnoses, the resident's hospital records, the physician's orders, and communication from the resident such as their last bowel movement to aide in developing the care plan and specifically the risk of constipation. The MDS Coordinator added that the admitting nurse conducted a head-to-toe assessment including listening to bowel sounds and palpating the resident's stomach to determine the resident's risk of constipation. MDS U also said that Resident #1 had a standing order for a medication to be given if he experienced constipation as well as a medication ordered to be administered if the resident was constipated. MDS U revealed that all residents' care plans had been updated to reflect their risk of constipation. The MDS Coordinator also stated that new risks were communicated to her to add to a residents' care plans in the daily clinical meetings and as needed due to residents' changes in condition to continue to daily develop the care plans. MDS U said that that it was important that all staff had access to residents' care plans so that they can provide the specific care needed to each resident. On 03/13/25 at 11:30 AM, the Administrator was notified that an Immediate Jeopardy in the area of Comprehensive Resident Centered Care Plans. Interview on 03/13/25 at 6:41 PM with the Administrator revealed that upon admission the admitting nurse should complete a full assessment including bowel/bladder. The Administrator stated that the admitting nurse develops the care plan based on the risk of constipation due to diagnoses and medications and develop the goals and interventions. The Administrator revealed that if the resident was not assessed timely, then complications such as discomfort, loss of appetite, or potential infection could occur. Interview on 03/14/25 at 11:42 AM with the ADON revealed that Resident #1's care plan had now been updated to reflect the resident's risk of constipation. The ADON stated that upon admission, the charge nurse should complete a head-to-toe assessment and listen for bowel sounds. The ADON said that the admission assessment in addition to the resident's orders and medications would be used to determine if there was a risk of constipation. The ADON revealed that if there was a risk of constipation, the MDS coordinator would include it on the care plan as well as goals and interventions specific to each resident. The ADON stated that the care plan gave the staff the opportunity to view the residents' needs and changes as well as how to provide care to each resident. The ADON revealed that he and the DON monitored the care plans and verified residents' orders, medications, alerts, and necessary items involved in the care plans. The ADON stated that the care plans were reviewed quarterly in the care plan meetings and any changes that were needed could be made at that time or as needed prior to the care plan meeting by the MDS Coordinator. The ADON said that the interdisciplinary team (Administrator, the DON, the ADON, Social Worker, the Activities Director, the Therapy director, the Dietary manager) and the family as well as the resident attended the care plan meeting to review the risks (focus), goals, and interventions of residents. The ADON concluded by stating that the importance of timely documentation in care plans was to ensure continuity of care for residents. The DON was out due to illness during the days the surveyor was in the building 03/11/25-03/14/25. Interview on 03/13/25 at 2:30 PM with the Area DON revealed the facility began to in-service all staff on 03/13/25 after notification of the immediate jeopardy at 11:30 AM on 03/13/25. The Area DON stated that all staff were in-serviced on abuse and neglect by the ADON. Area DON also stated that all staff were in-serviced on documentation of bowel movements, reporting changes, and notifying the ADON and the DON of changes in bowel movements by the ADON. The Area DON revealed that she in-serviced the nursing staff on how to access clinical alerts in the facility's software. The Area DON also stated that the ADON in-serviced the nursing staff administering PRN (as needed) medication to residents with no bowel movement for three days. The Area DON said that the ADON in-serviced all nursing staff on bowel movement monitoring and dashboard alerts and monitoring. The Area DON stated that the ADON also in-serviced all nursing staff on recognizing a change of condition and the requirement to notify the resident's primary care physician. The Area DON revealed that she in-serviced the Administrator, the DON, Area Director of Operations, and the ADON on recognizing a change of condition and bowel movement changes. The Area DON revealed that the in-service was completed via a text service that went to all facility staff and copies were provided evidencing it. The Area DON also said that she and the ADON spoke with the staff about the in-service topics before they began their shifts in addition to the text that went out to all facility staff. The Area DON stated the DON or the ADON would review all new admissions in the stand-up meeting 5 times a week for six weeks and then as needed addressing alerts for no bowel movements and if the nurse accurately responded. The Area DON also revealed that the DON/and or the ADON would ask five nurses per week if anyone reported not having a bowel movement in the last three days and document the intervention and monitor for six weeks as needed. The Area DON stated that the DON/and or ADON would ask five CNAs per week if they reported a resident that did not have a bowel movement to their nurse and the nurse's response. Record review of in-services reflected: Abuse and Neglect completed on 02/28/25, Patient rounding completed on 02/28/25, Resident Rights completed on 02/28/25, Bowel and Bladder Documentation completed on 02/28/25, Bowel Incontinence Care completed on 02/28/25, Bath Tub/Shower completed on 02/28/25, Bed Bath Complete completed on 02/28/25, Teeth Care/Oral Hygiene completed on 02/28/25, Resident/Resident Incidents completed on 02/28/25, Immediate Notification completed on 02/28/25, Accurate Documentation of Refusals completed on 02/28/25, and Physician's Orders completed on 02/28/25. Record review of the facility's undated Comprehensive Care Planning Policy reflected: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident right that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment .Through the care planning process, facility staff will work with the resident and his/her representative, if applicable, to understand and meet the resident's preferences, choices and goals during their stay at the facility. The facility will establish, document and implement the care services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life .The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented. Record review of the facility's undated Physician's Orders policy reflected: To Monitor and ensure the accuracy and completeness of the medication orders, treatment orders, and ADL order for each resident. Record review of the facility's undated Documentation policy reflected: Documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident. It includes observations, investigations, and communications of the resident involving care and treatments. Record review of the facility's revised Abuse and Neglect Policy dated 9/9/24 reflected: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultant or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. .7. 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. An Immediate Jeopardy was identified on 03/13/25 at 10:00 AM. The Administrator was informed of the Immediate Jeopardy in the areas of Quality of Care and Resident Care Plans. The Immediate Jeopardy template was provided to the Administrator via email on 03/13/25 at 11:30 AM. The plan of removal was accepted on 03/13/25 at 3:11 PM and included: Plan of Removal Action: 03/13/25 1. Resident #1 no longer resides in the facility as of 03/13/25. 2. All residents in the facility were assessed on 03/13/25 for risk of constipation or other bowel issues, comprehensive care plans updated to include interventions and monitoring by the DON and/or the ADON and/or the Regional Compliance Nurse. No additional residents were identified with no bowel movement within three days. 3. The Compliance Nurse in-serviced the Administrator, the DON, and ADON 1:1 on the following topics below on 03/13/25: a. All residents who are at risk of constipation will have an active care plan with interventions and monitoring. b. Upon admission all residents will be assessed by a nurse on risk of constipation, history of constipation/fecal impaction, or other bowel related issues. c. Upon admission the nurse will be responsible for developing and implementing the care plan of risk of constipation based upon their assessment. d. The DON and/or the ADON/and/or the Designee will monitor care plans to ensure all resident care plans reflect their risk of constipation or other bowel issues. e. The DON and/or the ADON/and/or theDesignee will monitor admission assessment to ensure all resident care plans reflect their risk of constipation or other bowel issues. f. Upon admission, and as needed, all residents will be assessed for risk of constipation or other bowel issues. The care plan will reflect findings, interventions, and monitoring. g. InService on care plan location and how to access the care plan in software. 4. The DON, the ADON, and Regional Compliance Nurse in-serviced the licensed Nurses on the following topics on 03/13/25: a. All residents who are at risk of constipation will have an active care plan with interventions and monitoring. b. Upon admission all residents will be assessed by a nurse on risk of constipation, history of constipation/fecal impaction, or other bowel related issues. constipation based upon their assessment. d. The DON and/or the ADON and/or the Designee will monitor care plans to ensure all resident care plans reflect their risk of constipation or other bowel issues. e. ensure all resident care plans reflect their risk of constipation or other bowel issues. f. Upon admission, and as needed, all residents will be assessed for risk of constipation or other bowel issues. The care plan will reflect findings, interventions, and monitoring. g. InService on care plan location and how to access the care plan in facility software. 5. The DON, the ADON, and the Regional Compliance Nurse in-serviced the non-licensed staff on the following on 03/13/25: a. InService on care plan location and how to access the care plan in facility software. b. All residents who are at risk of constipation will have an active care plan with interventions and monitoring. 6. AD Hoc QAPI Contributors met and assessed all residents in the facility for the risk of constipation or other bowel movement issues, comprehensive care plans updated to include interventions and monitoring by the DON/ADON/Regional Compliance Nurse. No additional residents were identified with no Bowel movements within three days. Review of AD Hoc QAPI Completed on 03/13/25. 7. The QAPI committee will review findings and make changes as needed. Identified Residents at Risk: Only 1 resident was affected regarding this incident. The resident was treated with medication in the hospital. The resident did not require surgery. Systemic Changes: 1. Admitting nurse will assess all new residents for risk of constipation and/or bowel complications. 2. All residents at risk of bowel complications will have a care plan with interventions and goals developed upon admission. 3. The MDS Coordinator will review care plans with the interdisciplinary team at the resident's quarter care plan meetings and make necessary changes to the care plan. 4. Care Plans will be monitored by the DON and/or the ADON to ensure that changes are updated quarterly and as needed. 5. Licensed and Non-licensed staff know how to review residents' care plans in the facility software and will review resident's care plans for risk of constipation and monitor for risk of constipation. Responsibility: It is the Administrator, or designee, and the Director of Nursing, or designee's responsibility to follow the actions and the systematic changes listed above. The Administrator, or designee, and the Director of Nursing, or designee, will report their findings of the above actions and systematic changes through their QAPI [Quality Assessment Performance Improvement] Process. Monitoring interviews for the Immediate Jeopardy were started on 03/13/25 at 3:39 PM and continued through 03/14/25 at 11:15 AM with 20 nursing staff across all three shifts, including weekdays and weekends. The staff were interviewed about and abuse/neglect, the risk of constipation, assessing residents for the risk of constipation, developing care plans, monitoring admissions, care plan development and changes, and where care plans are located within the facility software. Record review of in-services reflected 32 staff attended the following in-services and all remaining staff were notified via cell phone text on the following in-services: Abuse/Neglect completed on 03/13/25, How to Access Clinical Alerts completed on 03/13/25, Care Plan/Assessment: Upon Admit Constipation or other bowel issues completed on 03/13/25, and Care Plans for all residents-Risk for Constipation completed on 03/13/25. Record review of facility monitoring tool reflected the DON and/or the ADON and/or the Designee and or the ADON and or the Designee will review all new admissions in stand-up meeting five times a week for six weeks, and then as needed completed 03/14/25 25 and reviewed 03/14/25. Record review of facility monitoring tool reflected the DON and/or the ADON and/or the Designee would review the 24-hour report and clinical alerts daily in stand-up meeting five times a week for five weeks, and then as needed completed 03/14/25 and reviewed 03/14/25. The following staff's in-service logs were reviewed, and they were interviewed during the monitoring time frame. They were able to articulate what they were taught including the correct protocols and procedures related to abuse/neglect, the risk of constipation, assessing residents for the risk of constipation, developing care plans, monitoring admissions, care plan development and changes, and where care plans are located within the facility software: LVN A, CNA B, CNA C, RN D, CNA E, CNA F, CNA G, CNA H, CNA I, MA J, LVN K, CNA L, LVN M, LVN N, Hospitality Aide O, LVN P, CNA Q, CNA R CNA S, RN T, Administrator, and the ADON. An Immediate Jeopardy was identified on 03/13/25 at 10:00 AM. While the Immediate Jeopardy was removed on 03/14/25, the facility remained at the severity level of noncompliance that results in no more than minimal physical, mental and/or psychosocial discomfort to the resident and/or has the potential (not yet realized) to compromise the resident's ability to maintain and/or reach his or her highest practicable physical, mental and/or psychosocial well-being as defined by an accurate and comprehensive resident assessment, plan of care, and provision of service and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that received residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices based on the comprehensive assessment of a resident for 1 of 10 residents (Resident #1) reviewed for quality of care. The facility failed ensure Resident #1, who was at increased risk for constipation due to having cerebral palsy, had measures in place to monitor his bowel activity and to ensure physician ordered interventions were implemented when the resident did not have a bowel movement within 72 hours. This failure resulted in the resident being diagnosed in the hospital with fecal impaction of the rectum with associated stercoral colitis, which is a rare inflammatory colitis that occurs when impacted fecal material leads to distention of the colon and eventually hardened stool formation. Prior to the hospitilization, the resident had only had one bowel movement between 02/11/25 and 02/26/25. An Immediate Jeopardy was identified on 03/13/25 at 10:00 AM. While the Immediate Jeopardy was removed on 03/14/25, the facility remained at the severity level of noncompliance that results in no more than minimal physical, mental and/or psychosocial discomfort to the resident and/or has the potential (not yet realized) to compromise the resident's ability to maintain and/or reach his or her highest practicable physical, mental and/or psychosocial well-being as defined by an accurate and comprehensive resident assessment, plan of care, and provision of service and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. The failure placed residents at risk of serious harm or death. Findings included: Record review of Resident #1's Nursing Home Comprehensive Item Set MDS Record dated, 01/15/25, reflected an initial admit date of 01/21/24 and readmission date of 01/30/25. Resident #1's diagnoses included: cerebral palsy (congenital disorder of movement, muscle tone, or posture), seizure disorder or epilepsy, sepsis (life-threatening complication of an infection), and dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage). Resident #1's MDS also reflected that Resident #1's cognition was intact with a BIMS of 15. Resident #1's MDS reflected that Resident #1 was dependent (helper does all the effort) on staff for toileting. Resident #1's MDS also reflected that Resident #1 was not on a bowel toileting program. Resident #1's MDS reflected that the resident was always incontinent of bowel. The MDS also reflected that Resident #1 showed no constipation present. Record review of Resident #1's undated Care Plan reflected that resident #1 was at risk for bowel incontinence. Resident #1's goal was to not have any complications relating to bowel incontinence. Resident #1's interventions included: apply barrier cream after every incontinent episode, check resident every two hours and assist with toileting as needed, provide peri care after each incontinent episode, report any skin change to the nurse immediately, see care plans on mobility, ADL, and cognitive deficit, Communication. Record review of Resident #1's undated Care Plan also reflected that resident #1 had an ADL Self Care Performance Deficit. Resident #1's goal was to maintain current level of function in bed mobility through the review date. Resident #1's interventions included: bathing-requires extensive assistance staff x 2 for assistance; bed mobility- requires extensive assistance staff x 2 for assistance; eating-requires staff x1; the resident requires a lift for all transfers; toilet use- requires extensive assistance staff x 2 for assistance; dressing-the resident requires (x2) staff participation to dress; the resident has contractures of the upper extremities. Record review of Resident #1's undated Discontinued Orders reflected resident received Baclofen Oral Tablet 20 MG 1 tablet by mouth four times daily. Resident #1 was also ordered and received Clonazepam .5 MG tablet by mouth twice daily. Resident #1 received Probiotic Oral Capsule daily as well. Resident #1 had a PRN (as needed) order for Bisacodyl Rectal Suppository insert 10 mg rectally as needed for constipation. Resident #1's orders also reflected he received 2 Hydrocodone-Acetaminophen Oral Table 5-325 three times daily. Resident #1 received 1 Cyclobenzaprine HCl Oral Tablet 10 MG twice daily. Record review of Resident #1's Progress Notes dated 02/26/25 at 6:47 PM reflected LVN A transferred Resident #1 to the hospital due to a change in condition and family request on 02/26/25 at 12:00 AM after Resident #1 spoke with his Responsible Party on 02/25/25. Record review of Resident #1's Progress Notes dated 02/28/25 at 10:32 AM reflected the DON was made aware of allegations of neglect. Progress Note by the DON reflected Administrator, Medical Director, Area Director of Operations, and Area DON notified. Record review of Resident #1's Bowel Movement ADL 30-day documentation chart reflected no bowel movements between the days of 02/11/25 through 02/20/25. The ADL record reflected the resident had one bowel movement on 02/21/25 but had no other bowel movements before he was transferred to the hospital on [DATE] at 12:00AM. Therefore, the ADL record reflected the resident had one bowel movement from 02/11/25 until discharge on [DATE]. Record review of Resident #1's undated MAR reflected that Resident #1 did not receive a dosage of his order for Bisacodyl Rectal Suppository for constipation as needed ordered by his primary care physician during the month of February 2025. Record review of Resident #1's Hospital Record dated 02/26/25 at 10:16 PM reflected, Prominent fecal impaction of the rectum with associated stercoral colitis (chronic constipation leading to stagnation of fecal matter). There is constipation, without bowel obstruction. Record review of Resident #1's Hospital Record dated 02/28/25 at 9:23 AM reflected, Severe Constipation: on 02/27 Disimpaction severe and Mag Citrate, Lactulose, and Go Lytely. Record review of Resident #1's Hospital Record dated 03/02/25 at 11:44 AM reflected Resident #1's diagnoses of Severe constipation with fecal impaction: Improving. S/P (Status Post Docusate) docusate, lactulose, soapsuds enema, manual disimpaction. Had watery stool. Record review of Resident #1's Hospital Record dated 03/03/25 at 9:20 AM reflected Resident #1's diagnosis of Severe constipation, fecal impaction. The same hospital progress notes also reflected, Noted stercoral colitis on CT, Initiate docusate, lactulose, Soapsuds enema x 2, and No BM despite manual disimpaction. Will obtain CT/AP with p.o. contrast [Computed tomography of Abdomen and pelvis with oral contrast]. Record review of the National Libraray of Medicine at www.ncbi.nlm.nih.gov/books/NBK560608, Stercoral Colitis, dated 07/10/23, reflected: Stercoral colitis is a rare inflammatory colitis that occurs when impacted fecal material leads to distention of the colon and eventually fecaloma [hardened stool] formation Interview on 03/11/25 at 9:53 AM with the Administrator revealed that a family member put on social media that Resident #1 was being neglected in the areas of showering, oral care, and monitoring of bowel movements. The Administrator also revealed that the resident did not return to the facility after discharge from the hospital. The Administrator said that Resident #1 went to a sister facility for long-term care. The Administrator revealed he was not aware Resident #1 had gone 11 days with no bowel movements. The Administrator stated that on 02/28/25 he in-serviced all staff on abuse/neglect, patient rounding, resident rights, bowel and bladder documentation, bowel incontinence care, bath, tub/shower, bed bath complete, teeth care/oral hygiene, resident/resident incidents, Immediately in-service, accurate documentation of refusals, and physician's orders. Interview on 03/11/25 at 10:42 AM with CNA B revealed that she worked three days on and four days off. CNA B stated that she documented the residents' activities of daily living in the facility kiosk. CNA B stated that she did not recall if Resident #1 had a bowel movement in the date range of 02/11/25-02/21/25 on the shifts that she worked. CNA B said that because the software system was supposed to trigger a warning if a resident went 72 hours without a bowel movement, she thought that the resident had a bowel movement on another aide's shift. CNA B revealed that she did not recall the resident having a bowel movement in the days prior to his discharge from the facility. CNA B stated she did not recall the system flagging a warning for Resident #1. CNA B revealed that she did not notify the nurse because she did not see a warning on her computer screen, though the resident had not had a bowel movement on her shift. CNA B stated that the resident did not complain of abdominal pain or have nausea and/or vomiting. However, CNA B revealed that Resident #1 had decreased appetite and intake prior to discharge. CNA B said that Resident #1 could communicate that he was in pain. CNA B also said that Resident #1's stomach did not appear distended. CNA B revealed that the facility's policy was that if a resident went more than 72 hours without a bowel movement, the CNA was supposed to report it to the charge nurse. The CNA stated that she did not report this because she never saw the software flag that the resident had gone 72 hours without a bowel movement. CNA B revealed that if a resident did not have a bowel movement within 72 hours, she was supposed to notify the nurse so that an as needed medication could be administered to the resident for constipation to prevent an obstruction which could lead to weight loss. Interview on 03/11/25 at 11:02 AM with CNA C revealed that she was also his regular aide. CNA C stated that his bowel movements were not regular. CNA C stated that Resident #1 was alert and would communicate if he had a bowel movement and needed assistance. CNA C said that she told a nurse at the nurses' station that Resident #1 had not had a bowel movement in 72 hours. However, CNA C could not recall which nurse she told. CNA revealed that the software system was supposed to flag the CNAs and the nurses if the resident had not had a bowel movement within 72 hours. CNA C stated the facility's policy was to tell the charge nurse if a resident did not have a bowel movement in 72 hours to prevent the resident from getting constipated which could lead to sepsis and other negative outcomes. Interview on 03/11/25 at 11:17 AM with LVN A revealed that she was one of Resident #1's charge nurses. LVN A stated that she was not told that Resident #1 did not have a bowel movement from 02/11/25-02/21/25 by any of the aides that provided care for Resident #1. LVN A said that Resident #1 could communicate, and the resident did not complain of pain or discomfort to her during that time. LVN A also revealed that the facility software system was supposed to flag the aides and nurses as a pop-up if a resident had not had a bowel movement within 72 hours. LVN A stated she never saw Resident #1's electronic health record flag the warning of no bowel movement for 72 hours. LVN A revealed that during her nursing assessments, in that time period, Resident #1's stomach was not distended. LVN A stated that she did not recall reviewing Resident #1's bowel movements in the electronic health record though he was a high risk for constipation due to his diagnoses and medications. Electronic Health Record reflected LVN A sent the resident out to the hospital on [DATE] because the resident was not talking, and the family wanted the resident sent out. LVN A revealed the importance of regular bowel movements was to prevent a bowel obstruction. LVN A stated that if a resident was at risk for constipation, she would encourage fluids. LVN also revealed that residents had standing orders for an as needed medication for constipation to be provided to the resident if the resident had not had a bowel movement within 72 hours. LVN A stated that it was everyone's responsibility to follow up with the CNAs to ensure that residents had a bowel movement within 72 hours after an as needed medication for constipation was administered. Interview on 03/11/25 at 11:45 AM with RN D revealed that Resident #1 was at high risk for constipation complications. RN D also revealed that Resident #1 did not have a bowel movement for 72 hours. RN D stated that the facility software should flag the nurses and aides if no bowel movement in 72 hours was documented. RN D said that the aides were pretty good at telling the nurses if a resident had not had a bowel movement in 72 hours. RN D stated that the software had a specific place that a nurse could go to review the resident's bowel movement history. RN D said that when she completed her assessments on Resident #1 during her daily shifts, she did not observe abdominal firmness, abdominal tenderness, nor distention. RN D stated that Resident #1 could communicate if he was in pain during an assessment. RN D revealed that 72 hours or greater without a bowel movement, put a resident at risk for bowel obstruction. RN D also revealed that she depended on the aides to tell her if the resident went 72 hours or longer without a bowel movement. The RN said that after an as needed medication for constipation was provided to the resident, she relied on the resident and the aides to communicate to her if the interventions were working. RN D also said that, during her daily assessments, she used her observations and nursing skills to determine if the interventions worked. RN D stated that it was the nurses' responsibility to ensure that a resident had a bowel movement and follow up with an assessment after an intervention was utilized. Interview on 03/11/25 at 1:46 PM with Resident #1's Responsible Party revealed that a family member placed a negative comment about the facility on social media the morning that the resident went out to the hospital. The Responsible Party stated that he saw Resident #1 on the morning of 02/25/25, and he could tell that something was wrong. The Responsible Party stated that he called the facility and requested that his family member be sent out to the hospital. The Responsible Party confirmed that the hospital did not do surgery on Resident #1, and, Resident #1 was now at another facility. Interview on 03/11/25 at 4:14 PM with the ADON revealed that he was unaware Resident #1 had no bowel movement from 02/11/25 to 02/21/25. The ADON stated that his expectation was that the aides report to their charge nurses if a resident had an abnormal bowel movement. The ADON said that the nurses should receive an alert on their software if a resident has gone 72 hours or longer without a bowel movement. The ADON also revealed that residents have a standing order for a medication to be administered if a resident is constipated and it has been 72 hours since the resident's last bowel movement. The ADON said that nurses should looks for signs of vomiting and distention as well as monitor for symptoms of constipation. The ADON revealed that constipation could lead to an obstruction which could further lead to other injuries such as a bowel perforation. Interview on 03/12/25 at 11:18 AM with the Medical Director revealed that Resident #1 had risk factors for constipation due to his diagnosis of cerebral palsy, which was a neurological condition which led to his immobility. The Medical Director stated that he provided the facility with standing orders for the treatment of constipation if a resident did not have a bowel movement after three days. The Medical Director said that he expected the facility's nurses to notify him if his prescribed interventions did not work for residents. The Medical Director stated that he did not recall if he was notified of a change in condition for Resident #1. The Medical Director concluded by stating that he could not remember everything about every resident. Interview on 03/12/25 at 1:25 PM with CNA E revealed that she provided care to Resident #1. CNA E stated that she could not recall if Resident #1 had a bowel movement from 02/11/25 to 02/21/25. CNA E said that the policy was to inform the nurse if a resident did not have a bowel movement within 72 hours. CNA E revealed her daily procedure when she worked was to review the resident's history. Then if the resident had missed a bowel movement within 48 hours and she arrived on the third day, she would report the abnormal bowel movement to the charge nurse verbally or write a note and hand it to them. CNA E stated that the importance of the policy was to ensure that a resident was provided their medication or treatment ordered by their physician for the constipation. CNA E confirmed that Resident #1 could communicate to her by using his tablet. CNA E said that Resident #1 did not complain pain. CNA E revealed that the resident's eating declined prior to discharge to the hospital. CNA E said that Resident #1 did not complain of vomiting, nausea, or stomach pain. CNA E stated that his stomach looked normal, without puffiness. Interview on 03/12/25 at 2:09 PM with CNA F revealed that Resident #1 was chronic for constipation. CNA F stated that Resident #1 had abnormal bowel movements, which was approximately once every two to four days. CNA F could not recall Resident #1's bowel movements for the month of February. CNA F stated that Resident #1 also had abnormal eating habits because he wanted to eat at night and not regular meals in the day. CNA F revealed that the resident did not complain of pain. CNA F stated that she did not observe distention of Resident #1's stomach. CNA F said that the documentation reviewed by her during the middle of shift depended on the individual she was working with. CNA F stated that she was not told that Resident #1 had not had a bowel movement in 72 hours when she last worked with the resident. CNA F said that she could not recall charting that the resident had no bowel movement during the time of 02/11/25 through 02/21/25 or if she had reported it to the nurse. CNA F stated that the standard protocol was that if a resident did not have a bowel movement within 72 hours, the nurse was supposed to be told by the aide. CNA F revealed that it was important to inform the nurse because the resident could be impacted or possibly have a bowel obstruction. Interview on 03/13/25 at 2:30 with Area DON revealed the facility began to in-service all staff on 03/13 after notification of the immediate jeopardy at 11:30 AM on 03/13/25. The Area DON stated that all staff were in-serviced on abuse and neglect by the ADON. The Area DON also stated that all staff were in-serviced on documentation of bowel movements, reporting changes, and notifying the ADON and DON of changes in bowel movements by the ADON. The Area DON revealed that she in-serviced the nursing staff on how to access clinical alerts in the facility software. The Area DON also stated that the ADON in-serviced the nursing staff administering PRN (as needed) medication to residents with no bowel movement for three days. The Area DON said that the ADON in-serviced all nursing staff on bowel movement monitoring and dashboard alerts and monitoring. The Area DON stated that the ADON also in-serviced all nursing staff on recognizing a change of condition and the requirement to notify the resident's primary care physician. The Area DON revealed that she in-serviced the Administrator, the DON, Area Director of Operations, and the ADON on recognizing a change of condition and bowel movement changes. The Area DON revealed that the in-service was completed via a text service that went to all facility staff and copies were provided evidencing it. The Area DON also said that she and the ADON spoke with the staff about the in-service topics before they began their shifts in addition to the text that went out to all facility staff. The Area DON stated the DON and/or the ADON will review all new admissions in the stand-up meeting 5 times a week for six weeks and then as needed addressing alerts for no bowel movements and if the nurse accurately responded. The Area DON also revealed that the DON and/or the ADON would ask five nurses per week if anyone reported not having a bowel movement in the last three days and document the intervention and monitor for six weeks as needed. The Area DON stated that the DON and/or the ADON would ask five CNAs per week if they reported a resident that did not have a bowel movement to their nurse and the nurse's response. The DON was out due to illness during the days the surveyor was in the building 03/11/25-03/14/25. Record review of the facility's undated Physician's Orders policy reflected: To Monitor and ensure the accuracy and completeness of the medication orders, treatment orders, and ADL order for each resident. Record review of the facility's undated Documentation policy reflected: Documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident. It includes observations, investigations, and communications of the resident involving care and treatments. Record review of the facility's Abuse and Neglect Policy dated 09/09/24 reflected: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultant or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. 7. 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. Record review of in-services reflected 32 staff attended the following in-services and all other staff were notified via cell phone text on the following in-services: Abuse/Neglect completed on 03/13/25, Documentation of Bowel Movements, Reporting Changes, Notify ADON/DON of Changes completed on 03/13/25, How to Access Clinical Alerts completed on 03/13/25, No Bowel Movement in 3 Days-Offer PRN (as needed) Intervention completed on 03/13/25, Bowel Movement and Monitoring/Dash Board Alerts and Monitoring completed 03/13/25, SBAR-Change of Condition/Notification to the Primary Care Physician completed 03/13/25, Change of Condition and Bowel Movements. Record review of in-services reflected 32 staff attended the following in-services and all other staff were notified via cell phone text on the following in-services:: Abuse/Neglect completed on 02/28/25, Patient rounding completed on 02/28/25, Resident Rights completed on 02/28/25, Bowel and Bladder Documentation completed on 02/28/25, Bowel Incontinence Care completed on 02/28/25, Bath Tub/Shower completed on 02/28/25, Bed Bath Complete completed on 02/28/25, Teeth Care/Oral Hygiene completed on 02/28/25, Resident/Resident Incidents completed on 02/28/25, Immediate Notification completed on 02/28/25, Accurate Documentation of Refusals completed on 02/28/25, and Physician's Orders completed on 02/28/25. Record review of facility monitoring tool that reflected the DON and/or the ADON would review the 24-hour report and clinical alerts daily in stand-up meeting five times a week for five weeks, and then as needed completed 03/14/25 and reviewed 03/14/25. Record review of the facility monitoring tool that reflected the DON and/or the ADON would ask five nurses per week if anyone reported a resident not having a bowel movement in the last three days, the nurses' response, and monitoring to continue for six weeks and as needed completed 03/14/25 and reviewed 03/14/25. Record review of the facility monitoring tool that reflected the DON and/or the ADON would ask five CNAs per week if anyone reported a resident not having a bowel movement in the last three days, the nurses' response, and monitoring to continue for six weeks and as needed completed 03/14/25 and reviewed 03/14/25. An Immediate Jeopardy was identified on 03/13/25 at 10:00 AM. The Administrator was informed of the Immediate Jeopardy in the areas of Quality of Care. The Immediate Jeopardy template was provided to the Administrator via email on 03/13/25 at 11:30 AM. The plan of removal was accepted on 03/13/25 at 3:11 PM and included: Plan of Removal Action: 03/13/25 1. Resident #1 no longer resides at the facility as of 03/13/25. 2. The Compliance Nurse in-serviced the Administrator, the DON, and the ADON 1:1 on the following topics below on 03/13/25: a. The use of the Dashboard in the facility software, labeled clinical alerts for no bowel movements in the past 72 hours, Nurses will document Interventions in the facility software. b. Promptly and correctly assessing a resident when a change of condition has been identified or reported. Assessing a resident's change in condition using a SBAR (Situation, Background, Assessment, Recommendations tool so that all necessary information is communicated to the physician or nurse practitioner. c. Abuse and /Neglect Policy. d. Reporting changes of condition to the physician or nurse practitioner based on interact's Acute change in condition file cards, e. Residents who have not had a bowel movement within three days will be assessed for constipation and offered PRN interventions. If not successful, MD will be notified for additional instructions. Resident will be monitored each shift until success bowel movement is reported. f. Potential complications of Bowel constipation. g. All residents who are at risk of constipation will have an active care plan with interventions and monitoring. h. If the nurse does not assess timely, the DON is to be notified. i. Accurate and timely documentation in the facility software, including resident bowel movement. 3. The DON, the ADON, and Regional Compliance Nurse in-serviced the licensed Nurses on the following topics on 03/13/25: a. Abuse/Neglect Policy. b. The use of the Dashboard in the facility software, labeled clinical alerts for no bowel movements in the past 72 hours, Nurses will document Interventions in the facility software. c. Promptly and correctly assessing a resident when a change of condition has been identified or reported. Assessing a resident's change in condition using a SBAR, so that all necessary information is communicated to the physician or nurse practitioner. d. Reporting changes of condition to the physician or nurse practitioner based on interact's Acute change in condition file cards. e. Residents who have not had a bowel movement within three days will be assessed for constipation and offered PRN interventions. If not successful, MD will be notified for additional instructions. Resident will be monitored each shift until success bowel movement is reported. f. Potential complications of Bowel constipation. g. All residents who are at risk of constipation will have an active care plan. 4. The DON, ADON, and Regional Compliance Nurse in-serviced the non-licensed staff on the following on 03/13/25: a. Abuse/Neglect Policy. b. Reporting changes in a resident's condition to a nurse immediately, including when a resident has not had a bowel c. If the nurse does not assess timely, the DON is to be notified. d. Accurate and timely documentation in the facility software, including resident bowel movements. 5. AD Hoc QAPI Contributors met and assessed all residents in the facility for the risk of constipation or other bowel movement issues, comprehensive care plans updated to include interventions and monitoring by the DON/ADON/Regional Compliance Nurse. No additional residents were identified with no Bowel movements within three days. Review of AD Hoc QAPI Completed on 03/13/25. 6. The QAPI committee will review findings and make changes as needed. Identified Residents at Risk: Only 1 resident was affected regarding this incident. The resident was treated with medication in the hospital. The resident did not require surgery. Systemic Changes: 1. Nursing Administration will monitor all residents at risk for bowel complications. 2. CNAs will monitor residents for no bowel movements and notify nurses and document it in the facility software. 3. Nurses will monitor the software dashboard for clinical alerts. 4. Nurses will contact the physician when a resident has a change in condition. 5. &nbs[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that residents are free of any significant medication errors for 1 of 10 residents (Resident #1) reviewed for medications. The facility failed ensure Resident #1, who was at increased risk for constipation due to having cerebral palsy, was administered his physician-ordered Bisacodyl Rectal Suppository when he had only one bowel movement between 02/11/25 and 02/26/25. This failure resulted in the resident being diagnosed in the hospital with fecal impaction of the rectum with associated stercoral colitis, which is a rare inflammatory colitis that occurs when impacted fecal material leads to distention of the colon and eventually hardened stool formation. Prior to the hospitilization, the resident had only had one bowel movement between 02/11/25 and 02/26/25. An Immediate Jeopardy was identified on 03/13/25 at 10:00 AM. While the Immediate Jeopardy was removed on 03/14/25, the facility remained at the severity level of noncompliance that results in no more than minimal physical, mental and/or psychosocial discomfort to the resident and/or has the potential (not yet realized) to compromise the resident's ability to maintain and/or reach his or her highest practicable physical, mental and/or psychosocial well-being as defined by an accurate and comprehensive resident assessment, plan of care, and provision of service and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. The failure placed residents at risk of serious harm or death. Findings included: Record review of Resident #1's Nursing Home Comprehensive Item Set MDS Record dated, 01/15/25, reflected an initial admit date of 01/21/24 and readmission date of 01/30/25. Resident #1's diagnoses included: cerebral palsy (congenital disorder of movement, muscle tone, or posture), seizure disorder or epilepsy, sepsis (life-threatening complication of an infection), and dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage). Resident #1's MDS also reflected that Resident #1's cognition was intact with a BIMS of 15. Resident #1's MDS reflected that Resident #1 was dependent (helper does all the effort) on staff for toileting. Resident #1's MDS also reflected that Resident #1 was not on a bowel toileting program. Resident #1's MDS reflected that the resident was always incontinent of bowel. The MDS also reflected that Resident #1 showed no constipation present. Record review of Resident #1's undated Care Plan reflected that resident #1 was at risk for bowel incontinence. Resident #1's goal was to not have any complications relating to bowel incontinence. Resident #1's interventions included: apply barrier cream after every incontinent episode, check resident every two hours and assist with toileting as needed, provide peri care after each incontinent episode, report any skin change to the nurse immediately, see care plans on mobility, ADL, and cognitive deficit, Communication. Record review of Resident #1's undated Care Plan also reflected that resident #1 had an ADL Self Care Performance Deficit. Resident #1's goal was to maintain current level of function in bed mobility through the review date. Resident #1's interventions included: bathing-requires extensive assistance staff x 2 for assistance; bed mobility- requires extensive assistance staff x 2 for assistance; eating-requires staff x1; the resident requires a lift for all transfers; toilet use- requires extensive assistance staff x 2 for assistance; dressing-the resident requires (x2) staff participation to dress; the resident has contractures of the upper extremities. Record review of Resident #1's undated Discontinued Orders reflected resident received Baclofen Oral Tablet 20 mg 1 tablet by mouth four times daily. Resident #1 was also ordered and received Clonazepam .5 mg tablet by mouth twice daily. Resident #1 received Probiotic Oral Capsule daily as well. Resident #1 had a PRN (as needed) order for Bisacodyl Rectal Suppository insert 10 mg rectally as needed for constipation. Resident #1's orders also reflected he received 2 Hydrocodone-Acetaminophen Oral Table 5-325 three times daily. Resident #1 received 1 Cyclobenzaprine HCl Oral Tablet 10 mg twice daily. Record review of Resident #1's Progress Notes dated 02/26/25 at 6:47 PM reflected LVN A transferred Resident #1 to the hospital due to a change in condition and family request on 02/26/25 at 12:00 AM after Resident #1 spoke with his Responsible Party on 02/25/25. Record review of Resident #1's Progress Notes dated 02/28/25 at 10:32 AM reflected the DON was made aware of allegations of neglect. Progress Note by the DON reflected Administrator, Medical Director, Area Director of Operations, and Area DON notified. Record review of Resident #1's Bowel Movement ADL 30-day documentation chart reflected no bowel movements between the days of 02/11/25 through 02/20/25. The ADL record reflected the resident had one bowel movement on 02/21/25 but had no other bowel movements before he was transferred to the hospital on [DATE] at 12:00AM. Therefore, the ADL record reflected the resident had one bowel movement from 02/11/25 until discharge on [DATE]. Record review of Resident #1's undated MAR reflected that Resident #1 did not receive a dosage of his order for Bisacodyl Rectal Suppository for constipation as needed ordered by his primary care physician during the month of February 2025. Record review of Resident #1's Hospital Record dated 02/26/25 at 10:16 PM reflected, Prominent fecal impaction of the rectum with associated stercoral colitis (chronic constipation leading to stagnation of fecal matter). There is constipation, without bowel obstruction. Record review of Resident #1's Hospital Record dated 02/28/25 at 9:23 AM reflected, Severe Constipation: on 02/27 Disimpaction severe and Mag Citrate, Lactulose, and Go Lytely. Record review of Resident #1's Hospital Record dated 03/02/25 at 11:44 AM reflected Resident #1's diagnoses of Severe constipation with fecal impaction: Improving. S/P docusate, lactulose, soapsuds enema, manual disimpaction. Had watery stool. Record review of Resident #1's Hospital Record dated 03/03/25 at 9:20 AM reflected Resident #1's diagnosis of Severe constipation, fecal impaction. The same hospital progress notes also reflected, Noted stercoral colitis on CT, Initiate docusate, lactulose, Soapsuds enema x 2, and No BM despite manual disimpaction. Will obtain CT/AP with p.o. contrast [Computed tomography of Abdomen and pelvis with oral contrast]. Record review of the National Libraray of Medicine at www.ncbi.nlm.nih.gov/books/NBK560608, Stercoral Colitis, dated 07/10/23, reflected: Stercoral colitis is a rare inflammatory colitis that occurs when impacted fecal material leads to distention of the colon and eventually fecaloma [hardened stool] formation Interview on 03/11/25 at 9:53 AM with the Administrator revealed that a family member put on social media that Resident #1 was being neglected in the areas of showering, oral care, and monitoring of bowel movements. The Administrator also revealed that the resident did not return to the facility after discharge from the hospital. The Administrator said that Resident #1 went to a sister facility for long-term care. The Administrator revealed he was not aware Resident #1 had gone 11 days with no bowel movements. The Administrator stated that on 02/28/25 he in-serviced all staff on abuse/neglect, patient rounding, resident rights, bowel and bladder documentation, bowel incontinence care, bath, tub/shower, bed bath complete, teeth care/oral hygiene, resident/resident incidents, Immediately in-service, accurate documentation of refusals, and physician's orders. Interview on 03/11/25 at 10:42 AM with CNA B revealed that she worked three days on and four days off. CNA B stated that she documented the residents' activities of daily living in the facility kiosk. CNA B stated that she did not recall if Resident #1 had a bowel movement in the date range of 02/11/25-02/21/25 on the shifts that she worked. CNA B said that because the software system was supposed to trigger a warning if a resident went 72 hours without a bowel movement, she thought that the resident had a bowel movement on another aide's shift. CNA B revealed that she did not recall the resident having a bowel movement in the days prior to his discharge from the facility. CNA B stated she did not recall the system flagging a warning for Resident #1. CNA B revealed that she did not notify the nurse because she did not see a warning on her computer screen, though the resident had not had a bowel movement on her shift. CNA B stated that the resident did not complain of abdominal pain or have nausea and/or vomiting. However, CNA B revealed that Resident #1 had decreased appetite and intake prior to discharge. CNA B said that Resident #1 could communicate that he was in pain. CNA B also said that Resident #1's stomach did not appear distended. CNA B revealed that the facility's policy was that if a resident went more than 72 hours without a bowel movement, the CNA was supposed to report it to the charge nurse. The CNA stated that she did not report this because she never saw the software flag that the resident had gone 72 hours without a bowel movement. CNA B revealed that if a resident did not have a bowel movement within 72 hours, she was supposed to notify the nurse so that an as needed medication could be administered to the resident for constipation to prevent an obstruction which could lead to weight loss. Interview on 03/11/25 at 11:02 AM with CNA C revealed that she was also his regular aide. CNA C stated that his bowel movements were not regular. CNA C stated that Resident #1 was alert and would communicate if he had a bowel movement and needed assistance. CNA C said that she told a nurse at the nurses' station that Resident #1 had not had a bowel movement in 72 hours. However, CNA C could not recall which nurse she told. CNA revealed that the software system was supposed to flag the CNAs and the nurses if the resident had not had a bowel movement within 72 hours. CNA C stated the facility's policy was to tell the charge nurse if a resident did not have a bowel movement in 72 hours to prevent the resident from getting constipated which could lead to sepsis and other negative outcomes. Interview on 03/11/25 at 11:17 AM with LVN A revealed that she was one of Resident #1's charge nurses. LVN A stated that she was not told that Resident #1 did not have a bowel movement from 02/11/25-02/21/25 by any of the aides that provided care for Resident #1. LVN A said that Resident #1 could communicate, and the resident did not complain of pain or discomfort to her during that time. LVN A also revealed that the facility software system was supposed to flag the aides and nurses as a pop-up if a resident had not had a bowel movement within 72 hours. LVN A stated she never saw Resident #1's electronic health record flag the warning of no bowel movement for 72 hours. LVN A revealed that during her nursing assessments, in that time period, Resident #1's stomach was not distended. LVN A stated that she did not recall reviewing Resident #1's bowel movements in the electronic health record though he was a high risk for constipation due to his diagnoses and medications. Electronic Health Record reflected LVN A sent the resident out to the hospital on [DATE] because the resident was not talking, and the family wanted the resident sent out. LVN A revealed the importance of regular bowel movements was to prevent a bowel obstruction. LVN A stated that if a resident was at risk for constipation, she would encourage fluids. LVN also revealed that residents had standing orders for an as needed medication for constipation to be provided to the resident if the resident had not had a bowel movement within 72 hours. LVN A stated that it was everyone's responsibility to follow up with the CNAs to ensure that residents had a bowel movement within 72 hours after an as needed medication for constipation was administered. Interview on 03/11/25 at 11:45 AM with RN D revealed that Resident #1 was at high risk for constipation complications. RN D also revealed that Resident #1 did not have a bowel movement for 72 hours. RN D stated that the facility software should flag the nurses and aides if no bowel movement in 72 hours was documented. RN D said that the aides were pretty good at telling the nurses if a resident had not had a bowel movement in 72 hours. RN D stated that the software had a specific place that a nurse could go to review the resident's bowel movement history. RN D said that when she completed her assessments on Resident #1 during her daily shifts, she did not observe abdominal firmness, abdominal tenderness, nor distention. RN D stated that Resident #1 could communicate if he was in pain during an assessment. RN D revealed that 72 hours or greater without a bowel movement, put a resident at risk for bowel obstruction. RN D also revealed that she depended on the aides to tell her if the resident went 72 hours or longer without a bowel movement. The RN said that after an as needed medication for constipation was provided to the resident, she relied on the resident and the aides to communicate to her if the interventions were working. RN D also said that, during her daily assessments, she used her observations and nursing skills to determine if the interventions worked. RN D stated that it was the nurses' responsibility to ensure that a resident had a bowel movement and follow up with an assessment after an intervention was utilized. Interview on 03/11/25 at 1:46 PM with Resident #1's Responsible Party revealed that a family member placed a negative comment about the facility on social media the morning that the resident went out to the hospital. The Responsible Party stated that he saw Resident #1 on the morning of 02/25/25, and he could tell that something was wrong. The Responsible Party stated that he called the facility and requested that his family member be sent out to the hospital. The Responsible Party confirmed that the hospital did not do surgery on Resident #1, and, Resident #1 was now at another facility. Interview on 03/11/25 at 4:14 PM with the ADON revealed that he was unaware Resident #1 had no bowel movement from 02/11/25 to 02/21/25. The ADON stated that his expectation was that the aides report to their charge nurses if a resident had an abnormal bowel movement. The ADON said that the nurses should receive an alert on their software if a resident has gone 72 hours or longer without a bowel movement. The ADON also revealed that residents have a standing order for a medication to be administered if a resident is constipated and it has been 72 hours since the resident's last bowel movement. The ADON said that nurses should looks for signs of vomiting and distention as well as monitor for symptoms of constipation. The ADON revealed that constipation could lead to an obstruction which could further lead to other injuries such as a bowel perforation. Interview on 03/12/25 at 11:18 AM with the Medical Director revealed that Resident #1 had risk factors for constipation due to his diagnosis of cerebral palsy, which was a neurological condition which led to his immobility. The Medical Director stated that he provided the facility with standing orders for the treatment of constipation if a resident did not have a bowel movement after three days. The Medical Director said that he expected the facility's nurses to notify him if his prescribed interventions did not work for residents. The Medical Director stated that he did not recall if he was notified of a change in condition for Resident #1. The Medical Director concluded by stating that he could not remember everything about every resident. Interview on 03/12/25 at 1:25 PM with CNA E revealed that she provided care to Resident #1. CNA E stated that she could not recall if Resident #1 had a bowel movement from 02/11/25 to 02/21/25. CNA E said that the policy was to inform the nurse if a resident did not have a bowel movement within 72 hours. CNA E revealed her daily procedure when she worked was to review the resident's history. Then if the resident had missed a bowel movement within 48 hours and she arrived on the third day, she would report the abnormal bowel movement to the charge nurse verbally or write a note and hand it to them. CNA E stated that the importance of the policy was to ensure that a resident was provided their medication or treatment ordered by their physician for the constipation. CNA E confirmed that Resident #1 could communicate to her by using his tablet. CNA E said that Resident #1 did not complain pain. CNA E revealed that the resident's eating declined prior to discharge to the hospital. CNA E said that Resident #1 did not complain of vomiting, nausea, or stomach pain. CNA E stated that his stomach looked normal, without puffiness. Interview on 03/12/25 at 2:09 PM with CNA F revealed that Resident #1 was chronic for constipation. CNA F stated that Resident #1 had abnormal bowel movements, which was approximately once every two to four days. CNA F could not recall Resident #1's bowel movements for the month of February. CNA F stated that Resident #1 also had abnormal eating habits because he wanted to eat at night and not regular meals in the day. CNA F revealed that the resident did not complain of pain. CNA F stated that she did not observe distention of Resident #1's stomach. CNA F said that the documentation reviewed by her during the middle of shift depended on the individual she was working with. CNA F stated that she was not told that Resident #1 had not had a bowel movement in 72 hours when she last worked with the resident. CNA F said that she could not recall charting that the resident had no bowel movement during the time of 02/11/25 through 02/21/25 or if she had reported it to the nurse. CNA F stated that the standard protocol was that if a resident did not have a bowel movement within 72 hours, the nurse was supposed to be told by the aide. CNA F revealed that it was important to inform the nurse because the resident could be impacted or possibly have a bowel obstruction. Interview on 03/13/25 at 2:30 with Area DON revealed the facility began to in-service all staff on 03/13 after notification of the immediate jeopardy at 11:30 AM on 03/13/25. The Area DON stated that all staff were in-serviced on abuse and neglect by the ADON. The Area DON also stated that all staff were in-serviced on documentation of bowel movements, reporting changes, and notifying the ADON and DON of changes in bowel movements by the ADON. The Area DON revealed that she in-serviced the nursing staff on how to access clinical alerts in the facility software. The Area DON also stated that the ADON in-serviced the nursing staff administering PRN (as needed) medication to residents with no bowel movement for three days. The Area DON said that the ADON in-serviced all nursing staff on bowel movement monitoring and dashboard alerts and monitoring. The Area DON stated that the ADON also in-serviced all nursing staff on recognizing a change of condition and the requirement to notify the resident's primary care physician. The Area DON revealed that she in-serviced the Administrator, the DON, Area Director of Operations, and the ADON on recognizing a change of condition and bowel movement changes. The Area DON revealed that the in-service was completed via a text service that went to all facility staff and copies were provided evidencing it. The Area DON also said that she and the ADON spoke with the staff about the in-service topics before they began their shifts in addition to the text that went out to all facility staff. The Area DON stated the DON and/or the ADON will review all new admissions in the stand-up meeting 5 times a week for six weeks and then as needed addressing alerts for no bowel movements and if the nurse accurately responded. The Area DON also revealed that the DON and/or the ADON would ask five nurses per week if anyone reported not having a bowel movement in the last three days and document the intervention and monitor for six weeks as needed. The Area DON stated that the DON and/or the ADON would ask five CNAs per week if they reported a resident that did not have a bowel movement to their nurse and the nurse's response. The DON was out due to illness during the days the surveyor was in the building 03/11/25-03/14/25. Record review of the facility's undated Physician's Orders policy reflected: To Monitor and ensure the accuracy and completeness of the medication orders, treatment orders, and ADL order for each resident. Record review of the facility's undated Documentation policy reflected: Documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident. It includes observations, investigations, and communications of the resident involving care and treatments. Record review of the facility's Abuse and Neglect Policy dated 09/09/24 reflected: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultant or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. 7. 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. Record review of in-services reflected 32 staff attended the following in-services and all other staff were notified via cell phone text on the following in-services: Abuse/Neglect completed on 03/13/25, Documentation of Bowel Movements, Reporting Changes, Notify ADON/DON of Changes completed on 03/13/25, How to Access Clinical Alerts completed on 03/13/25, No Bowel Movement in 3 Days-Offer PRN (as needed) Intervention completed on 03/13/25, Bowel Movement and Monitoring/Dash Board Alerts and Monitoring completed 03/13/25, SBAR-Change of Condition/Notification to the Primary Care Physician completed 03/13/25, Change of Condition and Bowel Movements. Record review of in-services reflected 32 staff attended the following in-services and all other staff were notified via cell phone text on the following in-services:: Abuse/Neglect completed on 02/28/25, Patient rounding completed on 02/28/25, Resident Rights completed on 02/28/25, Bowel and Bladder Documentation completed on 02/28/25, Bowel Incontinence Care completed on 02/28/25, Bath Tub/Shower completed on 02/28/25, Bed Bath Complete completed on 02/28/25, Teeth Care/Oral Hygiene completed on 02/28/25, Resident/Resident Incidents completed on 02/28/25, Immediate Notification completed on 02/28/25, Accurate Documentation of Refusals completed on 02/28/25, and Physician's Orders completed on 02/28/25. Record review of facility monitoring tool that reflected the DON and/or the ADON would review the 24-hour report and clinical alerts daily in stand-up meeting five times a week for five weeks, and then as needed completed 03/14/25 and reviewed 03/14/25. Record review of the facility monitoring tool that reflected the DON and/or the ADON would ask five nurses per week if anyone reported a resident not having a bowel movement in the last three days, the nurses' response, and monitoring to continue for six weeks and as needed completed 03/14/25 and reviewed 03/14/25. Record review of the facility monitoring tool that reflected the DON and/or the ADON would ask five CNAs per week if anyone reported a resident not having a bowel movement in the last three days, the nurses' response, and monitoring to continue for six weeks and as needed completed 03/14/25 and reviewed 03/14/25. An Immediate Jeopardy was identified on 03/13/25 at 10:00 AM. The Administrator was informed of the Immediate Jeopardy in the areas of Quality of Care. The Immediate Jeopardy template was provided to the Administrator via email on 03/13/25 at 11:30 AM. The plan of removal was accepted on 03/13/25 at 3:11 PM and included: Plan of Removal Action: 03/13/25 1. Resident #1 no longer resides at the facility as of 03/13/25. 2. The Compliance Nurse in-serviced the Administrator, the DON, and the ADON 1:1 on the following topics below on 03/13/25: a. The use of the Dashboard in the facility software, labeled clinical alerts for no bowel movements in the past 72 hours, Nurses will document Interventions in the facility software. b. Promptly and correctly assessing a resident when a change of condition has been identified or reported. Assessing a resident's change in condition using a SBAR (Situation, Background, Assessment, Recommendations tool so that all necessary information is communicated to the physician or nurse practitioner. c. Abuse and /Neglect Policy. d. Reporting changes of condition to the physician or nurse practitioner based on interact's Acute change in condition file cards, e. Residents who have not had a bowel movement within three days will be assessed for constipation and offered PRN interventions. If not successful, MD will be notified for additional instructions. Resident will be monitored each shift until success bowel movement is reported. f. Potential complications of Bowel constipation. g. All residents who are at risk of constipation will have an active care plan with interventions and monitoring. h. If the nurse does not assess timely, the DON is to be notified. i. Accurate and timely documentation in the facility software, including resident bowel movement. 3. The DON, the ADON, and Regional Compliance Nurse in-serviced the licensed Nurses on the following topics on 03/13/25: a. Abuse/Neglect Policy. b. The use of the Dashboard in the facility software, labeled clinical alerts for no bowel movements in the past 72 hours, Nurses will document Interventions in the facility software. c. Promptly and correctly assessing a resident when a change of condition has been identified or reported. Assessing a resident's change in condition using a SBAR, so that all necessary information is communicated to the physician or nurse practitioner. d. Reporting changes of condition to the physician or nurse practitioner based on interact's Acute change in condition file cards. e. Residents who have not had a bowel movement within three days will be assessed for constipation and offered PRN interventions. If not successful, MD will be notified for additional instructions. Resident will be monitored each shift until success bowel movement is reported. f. Potential complications of Bowel constipation. g. All residents who are at risk of constipation will have an active care plan. 4. The DON, ADON, and Regional Compliance Nurse in-serviced the non-licensed staff on the following on 03/13/25: a. Abuse/Neglect Policy. b. Reporting changes in a resident's condition to a nurse immediately, including when a resident has not had a bowel c. If the nurse does not assess timely, the DON is to be notified. d. Accurate and timely documentation in the facility software, including resident bowel movements. 5. AD Hoc QAPI Contributors met and assessed all residents in the facility for the risk of constipation or other bowel movement issues, comprehensive care plans updated to include interventions and monitoring by the DON/ADON/Regional Compliance Nurse. No additional residents were identified with no Bowel movements within three days. Review of AD Hoc QAPI Completed on 03/13/25. 6. The QAPI committee will review findings and make changes as needed. Identified Residents at Risk: Only 1 resident was affected regarding this incident. The resident was treated with medication in the hospital. The resident did not require surgery. Systemic Changes: 1. Nursing Administration will monitor all residents at risk for bowel complications. 2. CNAs will monitor residents for no bowel movements and notify nurses and document it in the facility software. 3. Nurses will monitor the software dashboard for clinical alerts. 4. Nurses will contact the physician when a resident has a change in condition. 5. Nurses will provide a resident with an intervention medication if the resident has not had a bowel movement in 72 hours. Responsibility: It is the Administrator, or designee, and the Director of Nursing, or design[TRUNCATED]