**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews, the facility failed to ensure that, based on the comprehensive assessment of a resident, the resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 4 residents (Resident #1) reviewed for receiving nursing services in that: 1. The facility failed to ensure the nurses reported that Resident #1 went without a BM for 72 hours as per facility's PCC alert system to the physician which resulted in a change of condition of abnormal vitals and vomiting. Resident #1 was sent to the ER and had emergency surgery that resulted in a colostomy. 2. The facility did not document in the nurses' notes from 04/10/23 to 04/12/23 and from 04/15/23 to 04/18/24 regarding the BM status for Resident #1. 3. The nurses did not report, to the physician, Resident #1's assessments. 4. The facility discontinued a physician's order dated from 08/15/18 to 10/30/22 to check for Resident's BM every day, if no BM give PRN laxative, and if no result notify MD or NP. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 04/27/2023 at 6:42 PM. While the IJ was removed on 04/30/2023, the facility remained out of compliance at actual harm that was not immediate jeopardy with a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its corrective systems. These failures could place residents at risk for health status decline and deny the physician opportunities to intervene on behalf of the resident(s). The findings were: Record review of Resident#1's face sheet, dated 9/18/21 and EMR revealed, the resident was admitted on [DATE] with diagnoses that included: cerebral infarction ( stroke), type 2 diabetes mellitus (sugar in the blood), spastic hemiplegia (muscle stiffness), ileus (lack of muscle contraction in the intestines) unspecified, and constipation unspecified. Resident was a Male; age [AGE]. Advanced Directive was Full Code. RP was listed as: a family member. [Resident #1 was not in the facility at the time of the investigation] Record review of Resident#1's MDS assessment, dated 07/25/22, revealed: o BIMS (brief interview of mental status) Score was not completed. o ADLs (activities of daily living): B/B (bowel and bladder): bowel was frequently incontinent; bladder was catheter. Transfer was extensive with 2-person assistance. Bed Mobility was extensive assistance 1 person assistance. ROM (range of motion) Record review of Resident# 1's Care Plan, dated 2/11/22, revealed goals and interventions did not include history of ileus or constipation. Record review of Resident#1's Physician' Orders, dated *8/15/18 revealed: Bisacodyl Suppository 10 MG, Suppository 10 MG, Insert 1 suppository rectally one time a day for constipation. *5/7/22-4/20/23 revealed: Sennosides Tablet 8.6 MG, give 2 tablets by mouth at bedtime related to ILEUS, UNSPECIFIED *5/7/22-4/20/23 revealed: Docusate Calcium Capsule 240 MG, give 1 capsule by mouth one time a day related to ILEUS, UNSPECIFIED *8/15/18- 10/30/2022, revealed: Bowel Management, check for BM Q Day, if no BM, give PRN laxative, if no result notify MD/NP, every shift for chronic distended colon. *10/30/2022-10/31/22, revealed: Bowel Management, check for BM Q Day, if no BM, give PRN laxative, if no result notify MD/NP, every shift for chronic distended colon. *4/21/22-4/30/22, revealed: Bowel Routine as per policy, check for BM Q Mon/Wed/Fri, if no BM, give PRN laxative, if no result notify MD/NP, every shift every Mon, Wed, Fri for bowel assessment. Record review of Resident#1's MAR (medication administration record), dated April 2023, revealed: *Bisacodyl Tablet Delayed Release 5 MG Give 1 tablet by mouth one time a day related to ILEUS, UNSPECIFIED was administered 4/1-4/21/23. *Docusate Calcium Capsule 240 MG, give 1 capsule by mouth one time a day related to ILEUS, UNSPECIFIED was administered 4/1-4/20/23 *Sennosides Tablet 8.6 MG, give 2 tablets by mouth at bedtime related to ILEUS, UNSPECIFIED was administered 4/1-4/20/23 Record review of Resident#1's MD Progress Notes revealed: *11/2/22: Constipation - Chronic: Chronic constipation controlled continue docusate, bisacodyl, sennosides and monitor. *3/15/23: Constipation - Chronic: Chronic constipation controlled continue docusate, bisacodyl, sennosides and monitor. *4/5/23: Constipation - Chronic: Chronic constipation controlled continue docusate, bisacodyl, sennosides and monitor. Record review of The Facility's Bowel Movement Log dated, 4/6/23 - 4/21/23, revealed Resident #1 did not have a bowel movement for over 72 hours on 4/16/2023 - 4/18/2023. Record review of Resident#1's Nurse Notes, dated 4/21/23, revealed Resident #1 was sent to ER via EMS due to Abdominal pain, Abnormal vital signs (Low/high BP, heart rate, respiratory rate, weight change), Nausea/Vomiting, Shortness of breath. Record review of Resident#1's hospital record, dated 4/21/23, revealed: *CC (Chief Complaint): Dyspnea (difficult of labored breathing), hypoxemia (low level of oxygen in the blood), vomiting, abdominal pain, and distention. *Assessment: Sigmoid Volvulus (portion of the intestine twists around its blood supply), Abdominal distention causing restrictive ventilation *Plan/Disposition: Surgery taking patient to the OR from ER, will admit. *Emergency surgery resulted in the resident getting a colostomy. Record review of Resident#1's CT, dated 4/21/23, revealed: *Sigmoid Volvulus (twisting of the intestines that causes necrotic tissues) During a telephone interview on 04/26/23 at 3:42 PM, the Complainant stated: same information detailed in the associated intake; however, Resident #1 was in the hospital status post colostomy surgery and possible sepsis. Community Nurse U informed the Complainant that the facility had a history of waiting until residents were severely sick before sending them to the hospital. During an interview on 04/27/23 at 2:20 PM, LVN A stated: Based on a PCC alert for Resident #1 (04/18/23) the resident should have been assessed, abdomen checked with all 4 quads; touched for firmness, and explored pain, done an SBAR, if applicable, and notified MD for further instructions; which could include can give a PRN laxative. LVN A stated, the facility had no explanation as to why the physician was not notified after the PCC alert of Resident #1 not having a BM on two occasions (04/10/23-04/12/23 and 04/15/23 to 04/18/23. LVN A stated the charge nurse was responsible (RN C) to respond to the PCC alerts. LVN A added there was no documentation that the nursing followed the BM protocol. LVN A further stated, the expected nursing practice was to check every day, take vitals if in a change of condition occurred, and check-off vitals in the PCC (point click care). According to LVN A, nursing management was not aware that the resident triggered for the 72 hour protocol on 4/18/23 (shifts are 6 AM-2 PM, 2 PM-10 PM, and 10 PM-6 AM). [the monitoring of Resident #1's BM was documented in PCC and not in a TAR]. During an interview on 04/27/23 at 3:51 PM, LVN B stated: .not aware that Resident (#1) had no BM from 4/15/23-4/18/23 .the floor nurse (RN C) should have contacted the MD [LVN B but did not know the facts around Resident #1's BM triggers] LVN B stated that the RP notified the facility on 04/21/23 that Resident #1 had an emergency placement of a colostomy. Community Nurse U showed up at the facility on 04/26/23 to gather information as to the events that lead to Resident #1 being sent to the ER on [DATE]. During an interview on 04/27/23 at 4:09 PM, the DON stated: there were no nursing notes in the clinical record for Resident #1 from 04/10/23 to 04/21.23. The DON stated: we chart by exception for custodial stable patients .we had enough opportunities to document on 3 shifts .we did not did chart or assess [Resident #1] .no one called the MD on [04/18/23] there were missed opportunities . after 7 shifts we should have taken action .it was on 4/25/23 that this (BM incident) came to my attention .the (Community Nurse U) told us [on 04/26/23] that the resident had emergency surgery resulting in an emergency colostomy .we failed to assess, we failed to document .we started training on 4/25/23 [abuse/neglect and BM protocol] .Resident (#1) was high risk .had ileus and constipation history . During an interview on 04/27/23 at 3:46 PM,. RN C stated: Resident #1 had to be monitored for constipation. RN C was not sure Resident #1 had a scheduled suppository on 04/10/23 to 04/12/23 and from 04/15/23 to 04/18/24. RN C was not aware that Resident #1 was not having BMs. RN C was aware of the 72-hour alert system in PCC for Resident #1 involving BM. RN C stated, if a resident did not have had a BM after 7 shifts (shifts are 8 hours long), nursing would assess bowel sounds, nausea and vomiting, palpitation to see if it (abdomen) felt hard and non-tender. Of course, if they had those signs, I would call the doctor for orders, for change in condition . RN C also stated, Yes, I am required to document no BM, notifications, interventions, medications in the MAR. [for] continuation of care we have 24 hours to document, q shift summaries (24-hour report/change in condition). If there is a change in condition, we are to notify the MD and document the change in condition RN C added that nursing needed to document interventions, MD notification and any response such as orders for medication or tests in a progress note. [RN C did not call the MD after the 72 PCC alert for Resident #1 because they (RN C) was not tracking the PCC alert system] During an interview on 04/27/23 at 3:51 PM, LVN M stated: they (LVN M) was not aware of the PCC alert on 04/15/23-04/18/23; but the charge nurse (RN C) was responsible to check on the PCC alert system. During an interview on 4/30/23 at 9:20 AM, MD K (Medical Director and Resident #1's primary physician) revealed the hospital records showed that there was no output into the colostomy, having a bowel movement every day is not the norm for everyone. Therapy was assessing Resident #1 every day, and there were no complaints of him not eating, vomiting, distended, grimacing, there was no complaints from therapy that there was a change in this resident. MD K stated Resident #1 went 3 days without a BM (04/15/23-4/18/23) [when asked by surveyors whether MD K was alerted by nursing staff that Resident #1 had no BM for a 72-hour period 04/15/23-04/18/23, MD K did not respond]. During an interview on 05/01/23 at 9:35 AM, Community Nurse U stated: visit was made to the facility on [DATE] to inform the facility that Resident #1 underwent emergency surgery for placement of a colostomy bag. Community Nurse U relayed to the facility the concerns involving Resident # 1 around: neglect due to resident not having a BM for over 72 hours, abdomen was extended, history of constipation and ileus, and according to Resident #1's clinical chart the resident did not have a BM for 3 days (4/10/23 to 4/12/23) and 4 days (from 4/15/23 to 4/18/23). Community Nurse U added that the physician was not notified about the latter days Resident #1 had no BM for 3 to 4 days. Neglect resulted, according to Community Nurse U, because the facility was not monitoring its PPC alert system and involving the MD in treatment of Resident #1's BM episodes. During an interview on 05/01/23 at 10:08 AM, the RP stated: they did not know why the Resident (#1) underwent emergency surgery. The facility called the RP and informed them that the Resident (#1) was under respiratory distress and had an extended abdomen and needed to go to the ER. The DON was given the IJ template and was notified of the Immediate Jeopardy {IJ} on 04/27/23 at 6:42 PM; and a plan of removal was requested. On 04/27/23, the facility provided a POR, and it was accepted on 04/28/23 at 3:36 PM It was documented as follows: Date 4/27/2023 PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it May Concern, Summary of details which leads to outcomes On 4/27/2023 an abbreviated survey was initiated at [facility], [address]. On 4/27/2023, a surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows: F684 Quality of Care The facility failed to provide quality of care for Resident #1 in that it did not follow its Bowel Movement policy which included: assessment, notifying MD, and documentation. Problem The Facility's Bowel Movement Log revealed Resident #1 did not have a bowel movement for over 72 hours on 4/16/2023 - 4/18/2023. Resident #1's Nursing Notes from 4/16/2023 - 4/20/2023 reviewed no documentation of assessments, interventions, MD notification, and any orders received for constipation. Immediate Corrections Implemented for Removal of Immediate Jeopardy. *Once the facility was made aware of the deficient practice, the Director of Nursing/ designee updated care plans for those residents identified at risk for digestive /constipation issues and updated as needed. *The facility Director of Nursing/designee completed a 100% audit of residents who trigger for having no BM or small BM in seven shifts by reviewing the ADL Documentation Report and Clinical Alert Report. This audit was completed on 4/25/2023. Residents who did not have a BM or small BM in seven shifts were assessed and attending physician notified. *Director of Nursing/Designee initiated education with all nursing staff on proper assessment, monitoring, and notifications to MD, for bowel protocol Identification of Others: *Residents identified at risk for constipation or with diagnosis of constipation have the potential to be impacted by the alleged deficient practice. *Director of nursing/designee completed review of all residents to validate if no BM in last 72 hours, physician has been notified, resident assessed, and appropriate interventions have been initiated. Systemic Changes *The Director of Nursing/ designee initiated immediate training with Clinical Alerts, Bowel Assessment, and Documentation to nursing staff on 4/25/2023 and Abuse and Neglect Policy with all staff on 4/27/2023. All educations are at 100% completions as of 4/28/2023. Staff who are on leave or off-site have been notified and provided education via phone call. *All education and training was started on 4/27/23 and will continue until all nursing staff have received training prior to the start of their work shift.? *The facility Director of Nursing, Corporate Clinical Director and Administrator met on 4/27/2023 to evaluate the facility policy and procedures regarding bowel movement resident examination and assessment. *The Director of nursing/designee will complete education and training with all licensed nurses and newly hired licensed nurses over facility bowel movement policy and procedure. The education will be provided by DON or designee with the necessary skill set related to assessments and documentation of resident bowel movement. The Resident Exam competency will be initiated on 4/27/2023 and completed by 4/29/2023. These competencies will be kept with the ADON. *The Administrator, DON, and designee will develop and ensure an ongoing long-term monitoring and oversight system is in place by 4/28/2023 to review and address concerns related to the deficient practices identified in F684. Monitoring will include a system to ensure deficient practice is prevented and residents are being monitored for bowel movements. The monitoring and oversight system will gather measurable data for review of patterns or trending. Concerns identified will be presented by the DON or designee to the QAPI committee monthly, for a minimum of 6 months, for the discussion of sustaining compliance or correction of concerns identified. Monitoring *The DON or designee will develop a short-term monitoring system for all areas of deficient practice identified for this deficiency. Monitoring will include a system to observe all residents especially those without a bowel movement within 72 hours. This monitoring system will begin 4/28/2023. Those who have triggered for no bowel within 72 hours will be assessed, MD notified, and intervention put in place to alleviate signs and symptoms. Data gathered will be measurable and monitoring will occur at least 3 times a week and include weekend days and alternate shifts over the next 6 months. All concerns identified during the monitoring process will be addressed timely and documented for correction. The monitoring process, findings, and corrections will be presented to the facility QAPI committee each month for a minimum of 6 months for this plan of correction. Administrator will be responsible for monitoring DON compliance with system weekly. System compliance will be documented and discussed. *The Administrator/ designee will develop or ensure an ongoing long-term monitoring and oversight system is in place by 4/28/2023 to review and address concerns related to the deficient practices identified in F684. *Clinical Director of Operations will in-service Admin and DON over Quality of Care Policy and Bowl Movement Policy and Procedure on 4/27/2023. Monitoring will be conducted weekly for 4 weeks to determine if compliance is being sustained. Sustained compliance or corrective actions will be discussed and documented in QAPI Meeting. *The QAPI committee will meet monthly, and facility interdisciplinary team will meet daily to review the ongoing status of the corrections for this deficiency with the purpose to identify, evaluate, plan, implement, and address concerns or deficient practices identified as it relates, or to determine if compliance is being sustained. All corrections or steps taken and identified by QAPI will be documented. *Ad Hoc QAPI meeting will be held on 4/28/23 with the Medical Director, Administrator, Director of Nursing, and Dietary Director to review and validate the plan of removal. Involvement of Medical Director The Director of Nursing notified the facility's Medical Director, [MD K], of the Immediate Jeopardy tag on 4/27/2023. The Administrator will be responsible for implementation of ensuring the adequate process regarding Bowel Movement Assessment and Evaluation. The new process/system were initiated on 4/27/2023. Please accept this letter as our plan of removal for determination of the alleged Immediate Jeopardy issued 4/27/2023. Validation of POR Interviews: During an interview on 4/28/23 at 9:40 AM, Administrator and DON revealed that Care Plans for residents on diuretics, dialysis, fluid restriction, stool softeners, those with history of CVA, and diagnosis of colostomy, pain, constipation, dementia, or other cognitive deficits were required as part of documentation. During an Interview on 04/28/23 at 11:20 AM, MD L revealed that they were not notified by nursing staff of the incidents of no BM for Resident #1 on 4/15/23-4/18/23. When asked by Nurse Surveyor how often they should have been assessing Resident #1 given his history, MD L stated, I would assume they were assessing daily, right. Nursing staff should have notified us, usually that is what happens, they let us know and we order a KUB to see if there is a blockage. I (MD L) knew he was in the hospital, but I was unaware he had a colostomy. During an interview on 04/28/23 at 2:48 PM, LVN G revealed Resident #1's abdomen was distended on 04/21/23 [date resident sent to ER]. During an interview on 4/28/23 at 3:11 PM, LVN H revealed: on 04/21/23 Resident #1 was sweating, labored breathing and placed on O2 per NC 6 liters. Resident #1's abdomen was distended, almost like he was pregnant . LVN H added the PCC system will alert nursing after 7 or 9 shifts of no BMs; when the nurses receive an alert, they will follow up with MD. LVN H added that they could not recall whether a PCC alert for Resident #1 occurred 4/10-4/12/23 and 4/15-4/18/23). Resident # 1 should have been assessed by nursing staff every 72 hours for BM change of condition. During an interview on 04/28/23 at 3:28 PM, MD K stated, they did not know whether they were notified of the incidents of no BMs on 4/10-4/12/23 and 4/15-4/18/23. During an interview on 04/29/23 at 10:23 PM, the DON stated: the CPs were updated and nursing staff who worked with the Residents #3, #4, and #5 were alerted to the updated CP's during the training on BM protocol. During an interview on 04/29/23 at 10:32 AM, the DON stated the MDs (MD K and MD S) were notified that an audit was done and only three residents (Resident #3, #4, and #5) had a history of constipation and were at risk for impaction. During telephone interview on 04/28/23 at 11:20 AM, MD L revealed: the facility failed to notify the MD L of the changes of condition involving Resident #1 on 04/18/23; but the facility is aware of the need to contact the MD when there is a change of condition involving no BMs for a period of 72 hours. During an interview on 04/29/23 at 10:50 AM, the DON stated: completed review of all residents to validate if no BM in last 72 hours, physician has been notified, resident assessed, and appropriate interventions have been initiated. During a joint interview on 04/29/23 at 11:58 AM, the DON stated: we clarified that the BM policy needed to be updated to reflect the MD needed to be notified during a change of condition involving constipation . maybe there was a failure of leadership to following up on documentation and routine to assessments and documents .and the CP were updated upon Resident #1's admission in 2020 .a systematic failure on documentation .on 4/25/23 the community VA nurse pointed out that there was a lack of assessments and failure to call the physician and it was not CP .I did not think it was reportable .because he said that it would be reported .I felt we had to fix our problem. The Administrator that: some documentation was missing for 72 hours constipation .do not know the reason the documentation missing from 4/16/23, 4/17/23, and 4/18/23 .the 4/25/23 I was not present .I am the abuse coordinator .I reported it to HHS once I was notified .4/27/28 intake #421083. During a joint interview on 04/30/23 at 9:50 AM, DON stated: clinical alert reports were run daily and discussed with nursing management when there is a documented alert. The monitoring system started 04/28/23. [POC: data collection for 6 months] During a joint interview on 04/30/23 at 9:59 AM, the Administrator and DON confirmed they received in-service over Quality of Care Policy and Bowl Movement Policy and Procedure on 4/27/2023. Joint interview on 4/30/23 at 10:01 AM, the DON stated an ad-hoc QAPI was held 04/28/23; attendees were Administrator, DON, ADON, and physicians by telephone MD K and MD S. The POR was discussed at the meeting. During interview on 04/30/23 at 9:20 AM, MD K[Resident #1's physician] revealed she was aware of the IJ. Confirmation of Training: Interview on 4/28/23 at 2:48 PM, LVN G (10pm-6am shift) revealed stated: Yes; LVN G stated they received training on Abuse, and Neglect, bowel assessment, documentation. Interview on 4/28/23 at 3:11 PM, LVN H (6am-2pm and 10pm-6am shift) revealed I received in-services, skill checks, GI assessment, full head to toe assessment, abuse and neglect, documentation, non-verbal resident, and PCC alerts. Interview on 4/28/23 at 3:32 PM with RN I (6am-2pm and 10pm-6am shift) revealed that: nursing staff did training on assessment, head to toe assessment, abuse and neglect, and documentation. Interview on 4/29/23 at 9:59 AM, LVN N (6am 10pm shift) stated: LVN N did receive training related to bowel protocol. LVN N commented that: Assess resident, auscultate all 4 quadrants, feel to see if the stomach is distended, if the abdomen is hard or soft. Ask when the last BM was, ask them how they feel. Check system to see when their last BM was, if they have not had a BM in 3 days, 2 days was monitoring and 3 days. LVN N added, I would see if they had a PRN ordered; if they do not, I would contact the physician to get an order, administer medication and monitor the resident and document. Depending on the orders the interventions might be different, so you have to keep following up with the doctor and the CNA . I tell the CNAs to tell me when they have had a BM so that I can check the consistency so that I can check the effectiveness of the interventions. If they are constipated, I would have to do a change in condition and include everything I have done in that assessment in the documentation . Interview on 4/29/23 at 10:07 AM with LVN B (8am-5pm and 10pm-6am shift) stated: I did receive training related to bowel protocol Initial assessment, speak with the individual to see what the symptoms are, residents with history of diarrhea, incontinence, IBS, pain with defecation, bloody stools, change in BM, and if they are taking any antidiarrheals and then we would assess vs, how many episodes and what type of diarrhea someone might be having, if there is change in LOC, signs of fecal impaction, or dehydration, the abdominal evaluation would be to palpate and auscultate all 4 quads for bowel sounds, long has the issue has been going on, how severe are the symptoms, diagnoses, labs, we would give prn if they need it and monitor . If there are not any PRNs we would contact the physician for orders, they usually order a KUB. LVN B remarked that an MD needed to be notified when the BM interventions were not effective; but when there was a PCC alert. Interview on 4/29/23 at 11:14 AM LVN R (8am-5pm shift) stated: I did receive training related to bowel protocol . VVN R added that a BM assessment included: bowel sounds, abdominal distention, hydration, eating, mobility, and other risk factors. LVN R stated that: notify a physician after 72 hours when a PPC alert occurred around a residents BM. Interview on 4/29/23 at 11:17 AM, LVN A (8am-5pm shift) stated: I did receive training related to bowel protocol We touch their tummy, watch for grimacing, listen to sounds in all four quadrants, see if there's abdominal distention, check if there are any triggers such as fluid restriction, thickened liquids, post stroke, dialysis LVN A stated, any resident with a constipation history was at risk at risk and a physician needed to be notified after the PCC alert for BM. Interview on 4/29/23 at 9:52 AM with CNA O (6AM -2PMshift), stated: I did receive training related to bowel protocol. Highlights of the training included: distended stomach, not wanting to eat, hard stool, decrease in BM; notify nursing staff. Interview on 4/29/23 at 9:54 AM, CMA P (6AM-2PM and 2PM-10PM shift) stated: I did receive training related to bowel protocol. The highlights of the training included: no BM in 2-3 days, nausea, not eating; notify nursing staff. Interview on 4/29/23 at 9:55 AM, CMA Q (2PM-10PM shift) stated: yes, I did receive training related to bowel protocol. The highlights of the training included reporting to nursing if a resident has not had a BM for 72 hours or they are not eating, have abdominal bloating, or back pain. Interview on 4/29/23 at 12:16 PM, CNA T (10PM-6AM shift) stated: I did receive training related to bowel protocol. It consisted of knowing they are having BMs, the type like if it is hard or soft or if they are having diarrhea. The highlights of the training also included: I document in the computer, and I let the nurses any concerns with the resident's BM episodes. Confirmation- Record Review Record review of Resident #3's, #4's, and #5's CP revealed: Nursing staff updated the CPs. Record review of facility's resident list revealed that a 100 % audit was done by nursing management from 04/25/23. Record review of Resident #3's BM report revealed she triggered for the 72-hour protocol and the MD was notified by nursing staff. Record review of Resident #3's April 2023 MAR revealed nursing staff gave resident a PRN Dulcolax depository on 04/27/23 and had a BM; physician notified. Record review of facility's training on Clinical Alerts, Bowel Assessment, and Documentation, and Abuse and Neglect Policy was completed on 04/28/23 (100%; total nursing staff was 64 on 04/29/23) (Clinical Alerts N=39 100%); Bowel Assessment N=39 100%; Documentation N=86 100%; and Abuse/Neglect N=96 100%) Record review of updated Facility Bowel policy undated read: Report an abnormal finding to the Physician. [policy was updated after surveyor entrance on 04/27/23] Record review of nursing competency assessments from 4/27/2023 and completed by 4/29/2023 skill set related to assessments and documentation of resident bowel movement were completed. Record review of QAPI sign-in sheet on 04/28/23 revealed signatures: Administrator, DON, ADON, and Regional Nurse. On 04/30/23 at 12:55 PM, the Administrator was informed that the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate and a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its Plan of Removal.