Every finding on record at Libby Care Center

Based on observations, interviews, and record reviews, the facility failed to ensure a resident's pain was managed in accordance with the resident's care plan and preferences for 1 (#57) of 23 sampled residents. This deficient practice resulted in resident #57 having moderate to severe pain from a fracture. This deficient practice increased the likelihood of other residents with pain not being managed. Findings include:During an observation and interview on 6/27/26 at 3:48 p.m., resident #57 was sitting in her recliner in her room. Resident #57 stated she was in pain due to a fractured elbow. Resident #57 rated her pain level as 6 out of 10 (moderate pain). Resident #57 stated the facility did not understand her pain management program, which her primary physician had set up before her admission to the facility. Resident #57 stated her pain was not being managed, and she was continuously in pain at 6 out of 10 or greater. Resident #57 grimaced and held her arm up to her chest during the interview. During an interview on 6/28/26 at 12:45 p.m., staff member E stated resident #57 had reported her pain as 8 out of 10 (severe pain) in her elbow. Staff member E stated resident #57 was given her scheduled oxycodone at approximately 6:30 a.m., and she was not able to give her any additional pain medication for eight hours. Staff member E stated she did not do anything more when resident #57 was reporting severe pain and had no additional pain medication available. Staff member E stated she had not offered resident #57 any non-pharmacological interventions to address her pain. Staff member E stated she had not contacted the physician for additional orders or treatment for the severe pain. During an interview on 6/28/26 at 1:03 p.m., resident #57 stated she was having pain at a 10 out of 10 (severe pain). Resident #57 was sitting in her recliner watching television, holding her arm. Resident #57 stated she tried to wear the arm sling provided by the facility, but it was very hot and did not make her arm feel any better. Resident #57 stated the staff told her she could not have any medication until mid-afternoon. Resident #57 stated that no other treatments or care were provided to ease her pain.During an interview on 6/28/26 at 3:15 p.m., staff member B stated resident #57 had an IV drug history, and this likely played a role in staff member E's reasoning for not reaching out to the physician for pain management. Staff member B stated she contacted the physician after this surveyor reported the pain management concerns for resident #57. Staff member B stated the physician did provide orders for a higher dose of pain medication and increased the frequency of the oxycodone upon request. Review of resident #57's, Care Plan, dated 6/28/26, showed:- . [Resident #57] has acute/chronic pain related to history of fracture of pelvis, and left elbow and right hand,- Interventions: . non-pharmacological interventions attempted prior to PRN pain medication administration. 1=Reposition; 2=Reduced stimuli; 3=Warm towel/ice; 4=Relaxation techniques; 5=Distraction; 6=Music; 7=Massage; 8=Other (document in progress notes) R=Refusal.- For Acute Pain: provide with reassurance that pain is time limited. Encourage attempts at different non-pharmacologic pain-relieving methods as well as timely use of ordered pain medications early in the recovery process. - For Chronic Pain: teach management of the stress response to pain, mind-body practices (yoga/tai chi), enjoyable activities, increase movement, determine effective non-pharmacological interventions to pain.- For Subacute Pain: teach inflammatory process is resolving and pain will resolve. Encourage exercise, non-pharmacologic interventions, and use of non-opioid medication therapy.Review of the facility's policy, Pain Assessment and Management, dated 9/2/25, showed:- . This facility is committed to recognizing and respecting each resident's right to be free from unnecessary pain and to receive timely, individualized pain management in accordance with professional standards of practice, the resident's comprehensive care plan, and personal preferences to help the resident attain or maintain his or her highest practicable level of well-being and to prevent or manage pain to the extent possible.

Based on observation, interview, and record review, the facility failed to ensure the washer area of the laundry room was clean and kept free of debris; and the facility staff failed to ensure proper glove use and hand hygiene during glucose testing process for 1 (#65) of 23 sampled residents. This failure had a likelihood of contaminating resident clothes and facility linens while being washed and transferred to the dryer and increased the risk of bloodborne pathogen contamination and/or infection for residents receiving care on the 100-hall unit. Findings include:1. During an observation and interview on 6/28/26 at 8:00 a.m., staff member F was preparing to check the blood sugar of resident #65. Staff member F pulled a bottle of test strips out of the medication cart, opened the bottle with gloves on, and put a strip into the glucose testing machine. Staff member F entered resident #65's room and used a lancet to draw blood from resident #65. Staff member F then stated she forgot to grab cotton balls and left the room with the gloves still intact on her hands. Staff member F then brought a handful of cotton balls in her gloved hands and placed the cotton balls in the community tray of supplies for glucose monitoring. Staff member F then pressed on the resident's finger to draw blood into the test strip. Staff member F reached into the community supply for a cotton ball to place on the resident's bleeding finger. At that time, it was observed that there was dried blood on the side of the bottle of the test strips. Staff member F then returned to her cart and placed the test strip bottle into the cart drawer. During the interview, staff member F stated she did not notice the dried blood on the bottle, and the blood appeared to her to be old. Staff member F then took an alcohol wipe and cleaned the blood off the bottle and placed the bottle back in the cart. Staff member F stated she did not realize she had touched the door handle and cart drawers with contaminated gloves or that she had reached into the cotton balls with a contaminated glove until she was interviewed, because she was focused on cleaning the glucometer. Staff member F stated that the bottle of test strips and the glucose testing tray were used for all residents requiring blood glucose testing on the 100-hall unit. During an interview on 6/28/26 at 12:24 p.m., staff member B stated staff member F should know better than to leave a resident's room with contaminated gloves. Staff member B stated the staff had received training on infection control practices, including hand hygiene, glove use, and blood-borne pathogens.Review of the facility's policy, Hand Hygiene, dated 9/15/26, showed:- . All healthcare workers should perform hand hygiene at critical moments during resident care, according to CDC guidelines. These moments include but are not limited to:- . f. After contact with blood, bodily fluids, or visibly contaminated surfaces. - g. Immediately after PPE removal (e.g., gloves, gown, eye protection, facemasks) .Review of the, CDC Clean Hands Clinical Safety: Hand Hygiene for Healthcare Workers, dated 2/27/24, found at https://www.cdc.gov/clean-hands/hcp/clinical-safety/#cdc_clinical_safety_best_practices_recomm-recommendations showed:- . When to change gloves and clean hands- . Before exiting a patient room. 2. During an observation on 6/29/26 at 7:46 a.m., there were several large white buckets of detergent on the floor with hoses through the holes on the lids. There were large gaps in the holes between the hoses and the lids. The detergent lids had lint and debris on them. The wall above the detergent, in between the washers, on top of the washers, and the door hinges of the washers had lint buildup. The washer doors were both open, and the seals at the opening had a buildup of white hard water patches and dark brown congealed substance around the edge. During an interview on 6/29/26 at 7:51 a.m., staff member H stated the washers had preset wash cycles that pulled from the buckets of detergent on the floor through the hoses. Staff member H stated she had asked the company that services the detergent for caps for the lids where the hoses go in three months prior, but they had not received any to date. Staff member H stated the lint was hard to keep under control and hard to reach on top of and around the washers. Review of the facility policy titled Laundry Services, dated 10/8/25, showed, This facility ensures laundry services are provided in a manner that maintains a clean and sufficient supply of linens to meet resident needs. Soiled laundry is managed to prevent accumulation and minimize infection risk, supporting a safe and functional environment.

Based on interview and record review, the facility failed to honor a resident's preference for three showers a week for 1 (#6) of 23 sampled residents. This deficient practice resulted in the resident frequently receiving only one shower a week. Findings include: During an interview on 6/27/26 at 3:47 p.m., resident #6 stated she had not been getting showers as often as she had wanted.During an interview on 6/28/26 at 2:33 p.m., resident #6 stated, My shower days are supposed to be Monday, Thursday, and Saturday. Most of the time I just get a shower on Monday. Resident #6 further stated last Thursday she had asked a CNA for a shower and the CNA told her, I can't give you one today.During an interview on 6/28/26 at 3:05 p.m., staff member D stated resident #6 wanted a shower three times a week.A review of resident #6's Care Plan in the resident's EHR, showed: Focus[Resident #6] has an ADL Self Care Performance Deficit r/t failed total right knee replacement and subsequent surgical repair. Date Initiated: 10/17/25 .Interventions/Tasks .Bathing (Shower/Bath) Monday/Thursday/Saturday day shift & PRN. Date Initiated: 1/05/26 Revision on: 5/29/26.A review of resident #6's bathing/shower task for May and June 2026 showed: Intervention/TaskBathing (Shower/Bath) Monday/Thursday/Saturday day shift & PRN.The document listed that a shower was done for resident #6 for May 2026, on 5/4, 5/11, 5/18, 5/25, and 5/30 (resident #6 received five showers for May, and there were 13 available shower days for that month)The document listed a shower was done for resident #6 for the month of June 2026, on 6/1, 6/8, 6/11, 6/13, 6/15, 6/22, and 6/27. (Resident #6 received seven showers for June, and there were 13 available shower days for that month)A review of a facility policy titled Resident Rights, with a revision date of 9/12/25, showed: Policy Residents will be cared for in a manner and in an environment that promotes maintenance or enhancement of each Resident's quality of life and is committed to assuring that the Resident's rights articulated under federal law are protected.Each resident has the right to exercise their rights as a resident of the facility and as a citizen or resident of the United States without interference, coercion, discrimination, and reprisal and be supported by the facility in the exercise of those rights.ProcedureThe facility will inform each resident, orally and in writing, of the following rights at the time of admission and periodically throughout their stay:1. The resident has a right to a dignified existence, self-determination .6. The resident has the right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care.19. The resident has the right to reside and receive services in the facility with reasonable accommodation of resident and preferences .25. The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessment, and plan of care.26. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. [sic]

Based on observations, interviews, and record review, the facility failed to honor the residents' rights to choose their attending physician for 1 (#57) of 23 sampled residents. This deficient practice affected all residents wanting to choose their primary physician and resulted in resident #57 feeling she could not use her primary physician she had built a relationship with and was comfortable using. Findings include:During an observation and interview on 6/27/26 at 3:40 p.m., resident #57 was sitting in a recliner in her room, watching television. Resident #57 was grimacing and stated she was in pain from a fractured elbow. Resident #57 stated she was not happy with the physician she was assigned to when she was admitted and wanted her own physician to manage her care. Resident #57 stated it took her a long time to find a physician she was comfortable with because of childhood trauma and she did not know this new physician and was feeling unsafe. Resident #57 stated her primary physician knew her medications and what would be needed to manage her pain. Resident #57 stated she was not given any options to choose her primary physician and was assigned the facility physician.During an interview on 6/28/26 at 12:24 p.m., staff member B stated she did not know how residents were assigned a primary physician on admissions.During an interview on 6/28/26 at 2:21 p.m., staff member G stated the residents were not given a choice in their primary physician while they were in the facility, unless their primary was already affiliated with the local [Hospital Name] physician group. Staff member G stated that residents who were admitted outside the hospital were assigned the medical director as their primary physician.During an interview on 6/28/26 at 2:40 p.m., staff member A stated she had understood the regulation to mean the resident had a choice of physicians who were already affiliated with the facility and did not include other outside physicians. Staff member A stated that after re-reading the regulation, she could understand the requirement to offer outside physicians who were willing to follow the contract as a primary physician for a resident requesting their services. Review of the facility's policy, Physician Services, dated 9/12/25, showed:- . 6. Resident Rights and Support- . c. Residents may choose their attending physician.- d. If a chosen physician cannot meet regulatory requirements, the facility will discuss alternatives and honor resident preferences whenever possible.- e. If a resident declines to designate a physician or the chosen physician fails to fulfil responsibilities, the Medical Director will consult with the attending physician before assigning an alternate provider.

Based on observations, interviews, and record review, the facility failed to ensure the interdisciplinary team assessed and determined residents were safe to self-administer medications prior to residents self-administering medications for 2 (#s 30 and 66) of 5 residents observed for medication administration. This deficient practice increased the likelihood of medication errors for all residents receiving medication in the facility, including failure to take clinically significant medications. Findings include:During an observation on 6/28/26 at 7:47 a.m., staff member F prepared medications for resident #30. Staff member F placed a multivitamin, Farxiga, Glimepiride, Januvia, metformin, Risperdal, and Rybelsus in a medication cup and took the medications to resident #30's room. Staff member F spoke to resident #30 and told her she had her medicine and placed the cup of pills on her bedside table. Resident #30 stated, Ok. Staff member F left the room without observing the medications being taken by resident #30. During an observation and interview on 6/28/26 at 7:59 a.m., staff member F prepared medications for resident #66. Staff member F placed Tylenol, aspirin, Entresto, meloxicam, metoprolol, and Farxiga in a medication cup. Staff member F prepared a half a cup of med pass liquid. Staff member F took the medication cup and cup of med pass liquid to resident #66's room. Staff member F told resident #66 she had his supplement drink and pills. Staff member F placed the medication cup of pills and med pass liquid on his bedside table. Resident #66 acknowledged staff member F and stated, Thank you. Staff member F left the room without observing resident #66 taking the medications or the med pass liquid. Staff member F stated she knew her residents would be fine to take their medications on their own. Staff member F stated she was not sure if the residents had an evaluation or orders for self-administration of medication. Staff member F stated she could not remember if she was trained on self-administration of medication procedures because she had been working at the facility for many years, but she stated she, probably did train on it at some point.Review of resident #30's and #66's EHRs, dated 6/28/26, did not reflect an evaluation for self-administration of medications, orders for self-administration of medications, or physician orders for self-administration of medications. During an interview on 6/28/26 at 12:24 p.m., staff member B stated the facility did not have self-administration set up for resident #30 or resident #66. Staff member B stated that resident #30 and #66 should not be self-administering medications and staff member F needed to be re-educated. During an interview on 6/28/26 at 12:45 p.m., resident #66 stated he did not know what the medications he was given were that morning, or what they were to treat. Resident #66 stated he took whatever medications were brought to him by the staff. Review of the facility's policy, Self-Administration of Medications, dated 9/16/25, showed:- . 1. When a resident expresses interest in self-administering medications, nursing staff will notify the resident's physician and initiate an interdisciplinary assessment. - 2. The assessment will evaluate the resident's:a. Physical ability to handle and take medicationsb. Cognitive understanding of medication purpose, timing, and side effectsc. Ability to follow instructions and recognize when to seek helpd. Capacity to store medications securely and prevent access by others- 3. If the team determines the resident can safely self-administer, the assessment will be documented in the Resident's medical record, a physician's order will be obtained, and the care plan will reflect the decision. [sic]

Based on observation, interview, and record review, the facility failed to prevent a resident elopement for 1 (#3) of 13 sampled residents. This failure resulted in resident #3 exiting the alarmed facility and walking four blocks, and facility staff returning him to the facility uninjured. The facility had corrected the deficient practice resulting in past non-compliance. Findings include:A review of a facility reported incident submitted to the State Survey Agency showed, on 1/25/26, a staff member was alerted to a door alarm that was going off at an exit door at the end of the hall on the [NAME] side of the building. There was a resident standing by the door who was wearing a Wanderguard. The staff member redirected the resident and checked outside the door and did not see any other residents outside the building. Resident #3 was noted to not be in his room. A search for resident #3 was initiated. During the search time, resident #3's family member, called the facility and reported resident #3 was at the laundry mat four blocks from the facility.During an interview on 6/2/26 at 11:04 a.m., staff member B stated when resident #3 set off the door alarm on 1/25/26, staff member D came to the hall the door was located to find resident #5 standing by the door. After staff member D disabled the alarm, she checked outside and did not see any other residents. Resident #5 was wearing a Wanderguard and had a history of setting off door alarms in the facility. Staff member B stated the resident was assessed for elopement on 1/20/25 and was determined to be an elopement risk. Interventions were initiated including a wanderguard placement on resident #3. Staff member B stated after resident #3 eloped his care plan was updated to include an actual elopement with interventions. Staff member B further stated that staff were educated on resident #3's elopement, other residents were assessed for elopement risk, and the QAPI committee reviewed the incident. POLICYIt is the policy of this facility to provide a safe environment, as free of accidents as possible, for all residents through appropriate assessment, interventions, and adequate supervision to prevent accidents related to unsafe wandering or elopement while maintaining the least restrictive manner for those at risk for elopement.A review of resident #3's care plan showed: Focus[Resident #3] is an elopement risk/wanderer r/t decreased cognition, decreased safety awareness, new admission/poor adjustment. Verbalization of wanting to leave. History of attempts to leave facility unattended. Date initiated: 1/20/26.Interventions/Task .Elopement on 1/25/26- Placed on Q 15 minute safety checks. Date initiated: 1/25/26.A review of a facility document titled, Resident Elopement Investigation and Conclusion, for resident #3, with a date of occurrence of 1/25/26 at 4:30 p.m., showed: Wandering/Elopement Evaluationsadmission Clinical Evaluation on 1/13/26: Not at risk for wandering or elopementWandering/Elopement evaluation on 1/20/26: Risk for elopement completed due to resident attempting to leave facility unattended to go to local hospital to 'find wife' who was actually in Kalispell, MT at hospital having a surgical procedure.Wandering/Elopement evaluation on 1/25/26: Risk for elopement 9completed post elopement) .Immediate Interventions: .Checked for injury, none noted, [Resident #3] interviewed and state he needed fresh air, he was bored and it was beautiful outside and wanted to be in the sunshine.Wandering/elopement evaluation completed and positive for ongoing risk for elopement.Wanderguard was checked for working condition, working condition noted.[Resident #3] was placed on 15 minute safety checks.Plan to prevent Reoccurrence: .Continue secure care bracelet to the left wrist with continued function and placement checks.Activity department to interview and address [Resident #3's] request and preferences of activities for outside activities. Activity staff to show resident and encourage to use inner courtyard for outdoor activities.[Resident #3] will continue 15 minute safety checks at this time and this will be discontinued with review of behaviors over the course of 72 hours.Continue to support [Resident #3] and his family with difficulty adjusting to nursing home placement.Education provided to staff to ensure that outside is checked and monitored with Wanderguard alarm, alarming. [sic]A review of the facility QAPI agenda dated 2/19/26, showed: . Elopements: 1[Resident #3] 1/25/26, no injury- discussed prior elopement, post elopement and interventions put into place, continue with other placement and family support along with activity evaluation to meet needs and family support.A review of a facility policy titled, Elopement, with a release date of 9/16/25, showed:During an observation on 6/2/26 at 11:15 a.m., the door on the west side of the facility was noted to have an armed delayed egress alarm.Resident #3 had no further elopements up to the date of his discharge from the facility on 2/13/26.

4. During an observation and interview on 6/28/25 at 2:50 p.m., the Team 2 medication room was found to have a variety of supplies and medications stacked in the corner and on the floor of the room which was an infection control concern. Staff member C said the room was too small for the amount of medication and supplies stored in the room. Staff member C said she asked administration for shelving to be able to provide more room for medication storage, but it had not been provided, so the items remained on the floor. During an observation and interview on 6/29/25 at 9:52 a.m., the Team 1 medication room had a variety of supplies covering the countertop. A used, personal cup, was in the sink. The counter was soiled and without a cleanable surface, and an infection control concern, due to the number of items stacked on the countertop. The area behind the sink, and the interior of the sink, contained unidentifiable debris adhered to the surface(s). The medication storage refrigerator contained wine boxes and wine spilled and pooled at the bottom of the refrigerator door. The shelves were covered with spilled food items and had not been cleaned. Staff member D said the refrigerator had not been cleaned, and nursing staff were responsible for keeping the medication refrigerator clean. 3. During an observation on 6/29/25 at 3:04 p.m., staff member E was preparing to do resident #38's dressing change. Staff member E donned gloves then a gown, pulling the gown over her head and smoothing down the back of her hair with her gloved hands in the process. Staff member E continued to gather wound supplies and prepare for the dressing change, until she was asked about changing gloves by another staff member. Review of the facility policy, Personal Protective Equipment (PPE) Donning and Doffing, with a revision date of 9/10/20, showed, . Here is a sequence for donning PPE: .3. Put on the isolation gown . 6. Put on gloves extending over the cuff of the gown . 7. C. change gloves when torn, heavily contaminated, or if touch personal face/hair/mask/eye protection . [sic] Based on observations, interviews, and record review, the facility staff failed to ensure proper hand hygiene and wear an infection control gown properly for 1 (#1) of 20 sampled residents; failed to follow infection control standards when donning PPE, for 1 (#38); failed to properly store refuge, sharps containers, supplies, and failed to clean showers between use by the residents; failed to clean and repair shower room floors, the hallway, and utility room; and failed to maintain a cleanable surface for medication or supply preparation. Findings include: 1. During an observational walk through, on 6/28/25 at 1:30 p.m., the following concerns were identified: - In the north dirty utility room: [NAME] substance smeared on the countertop, and non-cleanable floor surfaces. - A box of full sharps containers was located on the floor of the medication room, overflowing with sharps containers which were stacked more than a foot above the rim of the box. - North Common room: used tissue, used flossing stick, and empty pill cups were left and not removed from the table. - Three large black trash bags of refuge were on the floor of the hallway, by the North nursing station. - The North shower room had a strong mildew odor, there was a large stack of clean towels which were folded, stacked, and placed in the hand sink. There were briefs and wipes stored on the floor. - The clean linen, adjacent to the North shower, had trash, linen, and a brief on the floor. - The North nursing station counter top had many areas that were broken which were uncleanable surface areas. - In the South dirty utility room, there was a strong odor of feces and urine. There was feces all along the rim and outside of the hopper washer, and missing floor tiles in front of the door, entering the dirty utility room. - In the South shower room, there was an area that had missing or broken linoleum, measuring 3 inches by 2 inches. There was a bariatric chair, and on the chair there was a clean brief, clothing, and an orthopedic boot. There was an observed area approximately 5 feet by 3 feet of flooring missing in front of the walk-in shower which had wet and rotting wood. The shower was soiled, with visible mildew growth and rust on the bottom left side. There was a stack of clean clothes stored on the floor, outside the shower, and there was a clean bag of briefs on the floor, outside the shower, and feces smeared on the floor from the toilet to the shower. - The nutrition room had a cabinet under the sink with a large area, approximately 12 inches by 15 inches, missing laminate on the door. During an interview on 6/29/25 at 8:01 a.m., staff member I entered the North shower room. Staff member I stated there did not appear to be any spray cleaner available for staff to use when cleaning the shower, after resident use. During an interview on 6/29/25 at 8:11 a.m., when discussing resident safety related to the South shower room floor disrepair, staff member K stated, That's tricky, we just have to have CNAs put down towels to prevent the floor injuring the residents feet. During an interview on 6/29/25 at 10:01 a.m., staff member A stated there was asbestos in the shower tiles, and they had scheduled an abatement in September, so the remodel could be done for the South shower room. Staff member A stated the facility attempted patch repairs to the floor, but they did not hold. Staff member A stated the facility continued to use the South shower room due to the volume of showers to be completed for the resident census. During an interview on 6/29/25 at 10:43 a.m., staff member H entered the North shower room looking for the cleaner he stated was supposed to be used after each shower, and he stated he could not locate any cleaner. Staff member H stated the cleaner should be used after every shower was given, and he did not know why no one had obtained more from environmental services. During an interview on 6/29/25 at 12:32 p.m., staff member L stated environmental services delivered the linens to the units, then the CNAs moved the linens to the shower area. Staff member L stated, It's 100% the CNAs making the mess and creating the infection control issues. It makes me disgusted. It's not ok. During an interview on 6/29/25 at 12:45 p.m., staff member M stated the facility worked on the flooring and did not have a chance to finish. Staff member M stated the missing flooring is scheduled to be assessed next week, and the abatement for the South shower room was scheduled in September, so nothing more could be done with the South shower room until the abatement was completed. Review of Resident Council Minutes, dated 3/10/25, reflected: -1. Resident states the shower room floor is gross and it often smells like sewer. 2. During an interview on 6/28/25 at 5:10 p.m., resident #1 stated, This place is gross. It's no wonder my wounds are not healing and now I'm stuck on these IV antibiotics. During an observation on 6/29/25 at 8:17 a.m., staff member E prepared to start an IV, and then complete peri care and wound care. Staff member E completed hand hygiene, opened supplies to start the IV, picked up trash off the floor with her clean hands, then attached the IV to resident #1. Staff member E then started the IV pump. Staff member E, using her hands, began to search through the drawers looking for supplies again. She then removed resident #1's sock, washed her hands for six seconds. Staff member E re-searched the drawers with her hands to find a bottle of Calmoseptine and put the Calmoseptine on resident #1's ankle. Staff member E then completed hand washing for ten seconds, gloved, and re-searched the drawers for supplies. Staff member E cleaned the resident's wound and degloved. She then completed hand washing for less than five seconds, gloved, packed the wound on resident #1's left thigh with collagen dressing, stopped to open more dressings, and continued to pack the wound. The then degloved and completed hand washing for six seconds. Staff member E then gloved and began to provide the wound care on the left rear thigh. Staff member E cleansed the wound, completed six seconds of hand washing, gloved, picked up items she dropped on the floor to throw them away, then with her soiled hands opened the packages of wound supplies. She then placed the collagen powder and Triade cream into the wound, touching the opening of the Triade cream container repeatedly with her hands that had been in and touching the wound. She degloved, then completed hand washing for seven seconds. Staff member E did not complete proper hand hygiene throughout the care sessions. During an observation on 6/29/25 at 8:55 a.m., staff member E was preparing to remove the IV for resident #1. Staff member E put a PPE gown on but and did not tie the ties at the neck and waist. During the care session, staff member E repeatedly pulled at the gown and ties. She then tied the gown's ties when nearly finished with care. Staff member E stated the gown was annoying and in her way. Staff member E stated she should have tied the gown properly when beginning cares. During an interview on 6/29/25 at 2:02 p.m., staff member N stated the staff are trained on hand hygiene and should wash their hands with soap and water for 20-30 seconds, if visibly dirty, or use hand sanitizer. Review of the facility's policy, Hand Hygiene, dated 2/11/22, reflected: - 2. Rub hands together with vigorous friction for at least 20 seconds . Opportunities for hand hygiene: 3. Before assisting or performing any medical procedure, before inserting any invasive device .After contact with any objects in the immediate vicinity of the resident. Review of the facility's policy, Work Practices-Cleaning, dated 1/1/18, reflected: - . b. Multiple use resident care items are properly cleaned/disinfected between each resident use.

Based on interview and record review, the facility failed to record the temperatures for the medication storage refrigerator, in the team one medication storage room. The deficient practice increased the risk of medications being stored at incorrect temperatures, if the temperatures were not monitored by staff. Findings include: During an interview on 6/29/25 at 9:52 a.m., staff member D said refrigerator temperatures were to be monitored and recorded by staff daily, to be recorded at the beginning of each shift. Record review of a facility document, titled, Fridge Temperature Log, dated June 2025, showed temperature monitoring was recorded for the day shift 16 times over a 29-day period for the month of June 2025. No documentation was included on the form for the day or night shift freezer temperatures.

Based on observation, interviews, and record review, the facility failed to ensure advance directives were complete and matched the current EHR code status for 3 (#s 1, 29, and 65) of 20 sampled residents. Findings include: 1. During an interview on 6/29/25 at 8:17 a.m., resident #1 stated the physicians wanted her to have a catheter and PEG tube, and she did not ever want any tubes placed for care, including catheters, feeding tubes, or a PEG tube. Review of resident #1's EHR profile reflected resident #1 was a full code, with full treatment, and no artificial nutrition by tube. Review of resident #1's POLST form, dated 9/14/22, reflected resident #1 was a full code, with limited interventions, and had a defined trial period of artificial nutrition by tube to be determined at that time. Review of a POLST, provided by the facility, dated 6/24/25, reflected the resident was a full code, with full treatment to include intubation, advanced airway interventions, mechanical ventilation, cardioversion, and no artificial nutrition by tube. This POLST was not signed by the physician. This POLST was not on file in #1's EHR, and no verbal physician order was found in the EHR to approve the POLST. 2. Review of resident #29's POLST, dated 1/8/25, reflected resident #29's code status was, Do not resuscitate. Under the signature of patient or decision maker (required) showed the following: verbal w/ [decision maker]. 3. Review of resident #65's POLST, dated 10/16/25, reflected resident #65's code status was a Full code, with full treatment, and defined trial period to be determined at the time of need for artificial nutrition by tube. This POLST was signed by resident #65. Review of resident #65's EHR profile reflected resident #65's code status was do not resuscitate, comfort measures only, no artificial nutrition by tube. Under the signature of patient or decision maker (required): verbal w/son via phone and was not signed by the physician. No verbal physician order was found in the EHR for the resident's code status. During an interview on 6/29/25 at 2:02 p.m., staff member D stated the POLST forms were reviewed when the physician came in and would be signed at that time. Staff member D stated, They (nurses) jumped the gun putting them (unsigned POLSTS) in PCC (electronic medical record system) before they were signed. Review of the POLST instructions, dated 1/2024, reflected: - . Patient (or legal decision maker, if patient unable to make medical decisions), must sign to be valid. - Verbal orders are acceptable with follow-up signature by provider .

Based on observation, interview, and record review, the facility failed to ensure dignity was provided during peri care for 1 (#1) of 20 sampled residents. The resident specifically stated she did not want to be exposed. Findings include: During an observation and interview on 6/29/25 at 8:17 a.m., staff member D and E completed peri care and wound care for resident #1. Resident #1's bed was against the wall under the window. The blinds to the window were not lowered or closed. Staff member E raised the bed to the height of the windowsill when preparing for the care session. Staff member E removed resident #1's brief and rolled resident #1 towards the uncovered window. Resident #1's peri area was exposed throughout the peri care and wound care sessions, and the resident was facing the resident garden area from 8:17 a.m. to 8:40 a.m Resident #1 was then rolled to her left side and wound care was completed. Resident #1's buttocks were then exposed to the window from 8:40 a.m. to 8:51 a.m., and then a brief was placed on the resident. Resident #1 stated, I don't really want to be exposed out the window. During an interview on 8/29/25 at 8:54 a.m., staff member D stated they should have closed the blinds but did not think about it. Review of the facility policy, Resident Rights, dated 11/28/17, reflected: - 1. Facility staff treats each resident with dignity and respect.

Based on observation, interview, and record review, the facility failed to prevent the elopement of 3 (#s 4, 6, and 7) of 6 sampled residents for elopement; and failed to implement an effective elopement prevention and monitoring system for 6 (#s 4, 6, 7, 8, 9, and 10) of 6 sampled residents for elopement risk. This deficient practice increased the risk of an elopement or negative outcome for a resident who was at risk of eloping, due to the system failure. Findings include: Review of facility reported incident for elopements showed: 1. On 8/17/24, resident #6 had been out in the courtyard with another resident. The other resident went back into the building, and resident #6 was found wandering around the outside of the building, by a staff member on break. The resident had stated she got lost and did not know how to get back in the building. A wanderguard bracelet was placed for elopement risk. 2. On 1/1/25, resident #4 was found by an off-duty staff member, across town, by a local restaurant. They notified the facility, and staff picked resident #4 up and returned her to the facility. Resident #4 had a wanderguard bracelet and was on 15-minute checks due to behaviors at the time of the elopement. The facility did not identify how resident #4 eloped. Resident #4 was placed on continued 15-minute checks with a 1:1 monitor while out of her room. 3. On 1/11/25, the facility received a call from the [Hospital Name] stating resident #4 was at their facility. Resident #4 was brought back to the facility after several staff attempts to assist. Facility staff noted resident #4 had popped the screen out of her room window and had eloped through the window. The resident was wearing her wanderguard bracelet and placed on 1:1 (monitor) at all times. 4. On 3/17/25, resident #7 self-propelled out the north exit door, down the ramp, to the sidewalk. Another resident's family member was outside and went to alert facility staff. Resident #7 had a wanderguard bracelet on and it did not set off the system alerts. The bracelet was checked, had a low battery, and the bracelet was changed for a new wanderguard bracelet. During an interview on 3/25/25 at 10:22 a.m., staff member J stated she was on a smoke break when she saw resident #6 walking along the building outside. Resident #6 stated to staff member J she got lost trying to get back into the building after sitting in the courtyard with another resident. Staff member J stated she brought resident #6 back into the building and told the nurse. Staff member J stated resident #4 was difficult to handle because she was exit seeking, being combative, and had eloped. Staff member J stated the elopements happened on the evening and night shifts. Staff member J stated resident #4 had a wanderguard and frequent checks in place. It wasn't until after the elopements that resident #4 was on frequent checks. During an interview on 3/25/25 at 10:31 a.m., staff member G stated he checked all of the wanderguard doors weekly. A tablet was used to monitor the exit door's function, adjust the sensitivity to wanderguard bracelets, and lock/unlock the doors. Staff member G stated the exit with a ramp was currently locked at all times while the facility figured out a way to handle a recent elopement for resident #7. During an observation on 3/25/25 at 4:23 p.m., resident #10 was seen leaving the facility through the main entrance with a family member. When they exited the building alarms were set off. Staff member A walked out and asked to check the resident and found a wanderguard bracelet on him. Staff member A went into the building to grab scissors and had resident #10 sit on a bench outside so the bracelet could be cut off and he could leave. During an interview on 3/26/25 at 3:36 p.m., staff member E stated the nurses documented the wanderguard bracelet(s) functioning each shift, usually by the residents wandering by the doors to set them off. Staff member E stated there was a tool to check the bracelets but believed the housekeeping staff or maintenance had the tool to do that. During an interview on 3/26/25 at 3:58 p.m., staff member A stated the facility had not been tracking the resident's wanderguard 'activate by' dates to show when the battery would expire for any residents wearing the elopement bracelets. The facility did not currently keep a list of residents with wanderguards, to ensure staff were aware of who they were and to monitor them. Staff were to monitor the placement of the wanderguard bracelets, and that the skin was intact surrounding the bracelets. Maintenance checked the doors weekly. During an interview on 3/27/25 at 8:54 a.m., staff member I stated staff knew who to check for the wanderguard for when the task was on the TAR to document the check. Staff member I stated 15-minute checks were done, which meant every 15-minutes staff would visually check the resident and document the check on the hardcopy flow sheet. The 1:1 monitor was always within eight feet of the resident, visually watching them. The :1 was documented on the TAR. The elopements of the residents did not happen when she was working. Staff member I stated the nurses would check the wanderguard bracelets by the resident wandering near a door to set off the alarms, and then the nurse would document the check for their shift. Review of resident #4's nurse progress notes, from 12/3/24 through 2/23/25, showed after a hospital return, on 12/28/24 through 2/23/25, resident #4 exhibited multiple behaviors of calling 911, exit seeking, and elopements, among others. Review of a facility provided document titled, Wander Guard Procedure, not dated, showed it was not a formal policy, and the document did not specify how residents were to be monitored. Review of the facility provided list of residents who had wanderguard bracelets or were elopement risks showed resident #s 4, 6, 7, 8, 9, and the list did not show resident #10. Review of the facility wanderguard manual showed it was recommended to check the 'activate by' dates so the facility would know when the battery would expire. The manual had assessments and checklists for monitoring and testing the wanderguard system, identifying areas to address for wandering, and elopement risk residents.

Based on interview and record review, the facility failed to follow admission physician orders related to TED hose/antiembolism stockings for a post op patient for 1 (#2) of 3 rehab patients sampled. Findings include: During an interview on 3/25/25 at 9:30 a.m., NF1 stated resident #2 had a left total knee surgery on 2/25/25. Resident #2 was admitted on [DATE]. NF1 stated the first night after admitted , the facility staff took resident #2's TED hose stockings off and told her it was the facility policy to prevent skin breakdown. The next morning the stockings were still observed to be off. During an interview on 3/25/25 at 3:15 p.m., staff member D stated they had removed resident #2's TED hose stockings because it was facility policy to remove them at night to prevent skin ulcers. During an interview on 3/27/25 at 11:00 a.m., staff member F stated a physician's order related to TED hose would override a facility policy. Review of resident #2's admission orders, dated 2/26/25, showed, TED Hose on at all times. Review of the facility policy, Prevention and Treatment of Pressure Ulcers and Other Skin Alterations, with a revision date of 10/15/25, failed to show the removal of TED hose/antiembolism stockings at night for pressure ulcer prevention.

Based on interview and record review, the facility failed to ensure it provided behavioral health services to meet the needs of 1 (#4) of 6 sampled residents for behaviors. Findings include: During an interview on 3/25/25 at 3:49 p.m., staff member C stated the trauma informed care assessment was completed on admission, quarterly, and with significant changes. Resident #4 had not triggered on her trauma informed care assessment on admission, which would show if interventions were necessary. Staff member C stated the facility had a contract with a telehealth psychiatrist who was available to residents if they were willing to see the psychiatrist. Staff member C stated resident #4 had a noticeable mental and physical decline in mid-December which was after the initial course of antibiotics. Resident #4 had no involved family, POA, or guardian. The resident's next of kin was a son who lived across the state. Staff member C stated the goal was to discharge resident #4 back to the treatment center she had been at. After resident #4's hospitalization , she was not capable of attending mental health appointments, or signing advance directives. The treatment center resident #4 had been at would no longer take her back. During an interview on 3/26/25 at 4:28 p.m., staff member A stated resident #4's admission assessment showed no trauma, there was a low PHQ-9 score for depression, and high score in the Brief Interview of Mental Status assessment. After her decline, they did a Significant Change MDS in February 2025. The facility had their contracted psychiatrist review resident #4's chart to give suggestions to implement, but they did not work. Behavior monitoring was documented on the TAR. Staff member A stated resident #4 was given a 30-day discharge notice and was scheduled to discharge home, with her son, on 3/1/25, but she went to the hospital and passed away. Review of resident #4's nurse progress notes, from 12/3/24 through 2/23/25, showed after her hospital return, on 12/28/24 through 2/23/25, resident #4 exhibited multiple behaviors of calling 911, being combative to staff, offering sexual favors, attempting to take sanitizer dispensers off the walls, having vape supplies, alcohol, having non-prescribed medications in her room, exit seeking, and laying self on the floor, among others. Review of resident #4's 30-day discharge notice, dated 1/28/25, showed the reason as, Unable to manage addiction and mental health needs. The notice was given verbally to resident #4's son, with a note of sending referrals to other facilities, for a possible admission. Review of resident #4's Significant Change MDS, with an ARD of 2/19/25, showed resident #4 had a significant decline in her mental and physical health.

Based on interview and record review, the facility failed to have a process in place to ensure pill contents, contained in personal prescription medication bottles brought from resident homes, were verified before dispensing, for 1 (#2) of 3 rehab residents sampled. Findings include: Review of resident #2's admission orders showed he was admitted on [DATE], arriving around 4:00 p.m., for acute rehab, following a knee surgery on [DATE]. His additional diagnoses included Parkinson's. Review of resident #2's admission orders, dated [DATE], showed the following new medication orders: - Colace 100 mg twice daily, - Acetaminophen 1,000 mg three times daily, - Oxycodone 5 mg every 4 hours as needed for pain, and - Aspirin 81 mg twice daily. Below those medications were resident #2's home medications which the resident would continue taking, which were: - Carbidopa 25 mg-levodopa 100 mg three times daily, - Flomax 0.4 mg daily, - Clonazepam 2 mg at bedtime, - Meloxicam 15 mg daily, - Rivastigmine tartrate 1.5 mg twice daily, - Carbidopa ER 50 mg-levodopa 200 mg twice daily, and - Entacapone 200 mg three times daily. Review of resident #2's MAR, dated [DATE] - [DATE], showed he received all of these medications. During an interview on [DATE] at 9:30 a.m., NF1 stated they brought in some of resident #2's medication from home as they were not being covered by their insurance during the rehab stay. NF1 stated the prescription label on the bottle for resident #2's clonazepam showed to take 1 mg at night. Facility nursing staff who checked the medications in did not clarify this discrepancy with the physician order, which was for 2 mg at night. During an interview on [DATE] at 1:50 p.m., staff member C stated resident #2's admission was paid for by workers compensation, and they would only cover medications related to the post op of his knee. All other medications were to be supplied by the family. Staff member C stated resident medications brought from home had to be in their original prescription bottles and not expired. During an interview on [DATE] at 3:15 p.m., staff member D stated the pharmacy did not examine the pills in the bottles brought in by family members, and nursing reviewed the dosages on the labels, against the physician order. During an interview on [DATE] at 9:45 a.m., staff member E stated there were some family members that brought in medication from home, but the staff member was unsure on the process for reconciliation. During an interview on [DATE] at 11:14 a.m., NF2 stated the pharmacy had only filled orders for oxycodone, carbidopa, and tamsulosin for resident #2. These were delivered early the morning of [DATE]. During an interview on [DATE] at 11:20 a.m., NF3 stated they would refer to the facility policies and procedures regarding accepting medications brought in by family. During an interview on [DATE] at 8:50 a.m., staff member A stated there was a pill finder application in PCC that nurses could use if one of the pills in the bottles did not look correct. During an interview on [DATE] at 11:00 a.m., staff member F was unaware the resident family was bringing in personal medications to be dispensed by the facility, as this practice would not be allowed in a hospital setting. Review of the facility policy, Pharmacy Services, dated [DATE], showed, . 31. Medications that are received from the resident, family, responsible, party and/or significant other are not accepted because we are unable to reconcile the medication with the prescriber order and the requisitions for the medication .

Based on interview and record review, the facility failed to include a resident's history and risk of suicide on the baseline care plan for 1 (#76) of 2 sampled residents. Findings include: Review of resident #76's admission assessment dated [DATE], noted he was being admitted post hospitalization from an overdose. During an interview on 8/14/24 at 4:16 p.m., staff member E stated the nurses did not have any care plan or orders to monitor for suicide risk for resident #76. During an interview on 8/15/24 at 9:12 a.m., staff member C stated resident #76 had a suicide risk assessment and depression screening on admission. Staff member C said due to the assessment results, they determined suicide was not a current issue. Review of resident #76's hospice visits notes, dated on 7/18/24, showed resident #76 was noted to be a suicide risk due to his prior attempts and expressions of not wanting any contact with other humans, or not knowing why he is on earth. Review of resident #76's facility care plan, iniated on 7/9/24, had no information for suicide risk or history of attempts; how to identify, monitor, or support #76 if the signs of risk did occur.

Based on observation, interview and record review, the facility failed to coordinate care and communication with hospice, for 2 (#s 65 and 76) of 2 sampled residents for hospice. Findings include: During an interview on 8/14/24 at 11:24 a.m., NF2 stated hospice had its own documentation and care plan for resident #65 and #76. NF2 stated the hospice staff did not provide the care plan or visit notes to the facility; the documentation would have to come from the main office after they finished documenting their visits. NF2 stated hospice did their own care plan meeting every other week to go over their patients, so they did not attend the facility care conference meetings. During an observation and interview on 8/14/24 at 4:12 p.m., staff member E stated different hospice nurses came different days of the week. Staff member E stated she was not sure if there was a hospice care plan or if there were any copies of hospice visits for residents #65 and #76. Staff member E stated the hospice nurses would generally check in for medication order changes as there were a lot for both resident #65 and #76, especially for as needed medications. Staff member E stated the medications came in bottles, and the labels were not updated to reflect new physician orders. Staff member E showed a bottle of as needed Ativan that had new orders of either half tab or whole tab which did not match the original medication label. There were two tablets left. Staff member E stated she generally gave a whole tab of Ativan and could not tell what other nurses gave a half tab of Ativan did with the half not administered. Staff member E stated the medications usually came in bottles, but she had requested cards. Staff member E stated both residents had multiple as needed (medication) orders which would get confusing with the bottles and labels not being updated, as they were to continue using the bottles until they were empty. During an interview on 8/15/24 at 7:52 a.m., staff member A stated there was no documentation of who the designated facility staff member was to coordinate with hospice. Staff member A wrote on the survey request list it would be the 'Team Nurse' and explained it would be the nurse assigned to the unit each day, not a specific person at the facility. During an interview on 8/15/24 at 8:52 a.m., staff member C stated resident #76 did not have a current risk of suicide, so it was not on the care plan. Staff member C stated resident #76 had attempted suicide prior to his stay at the facility. Staff member C stated the facility would help with advance directives on admission and review at each care conference. Staff member C stated resident #65 only had a POLST with no other advance directives or plans to make any. Staff member C stated resident #65 had a friend for support and an estranged wife. Review of hospice social services notes, dated from 7/2/24 to 8/9/24, showed resident #65 had his wife as POA and managing his finances. Resident #65 wanted to switch to a friend because his wife was not paying his bills, causing him anxiety. Hospice social services noted they were helping resident #65 get his friend to be his POA. As of an 8/9/24 note, hospice was attempting to help resident #65 obtain conservatorship instead. Review of resident #76s pharmacy recommendation form, dated 7/15/24, showed: [Resident #76] receives potentially duplicate therapy of the following: 1. morphine concentrate 20 m/mL 0.75mL Q1H PRN 2. morphine concentrate 20 m/mL 0.25mL Q1H PRN 3. oxycodone 5mg Q4H PRN 4. oxycodone 15mg Q4H PRN Recommendation: Please reevaluate the need for both types of opioid orders indicated above. Due to multiple PRN analgesic orders, highly recommend adding pain scales to help staff differentiate when to use what medication (i.e. morphine concentrate if resident cannot swallow for moderate to severe pain) . Handwritten in on 7/18/24 declining any changes to the orders because of hospice. Resident #76 physician orders showed: - Oxycodone 5MG 1 tablet every 4 hours as needed for pain - Oxycodone 5MG 2 tablets every 4 hours as needed for pain - Oxycodone 5MG 3 tablets every 4 hours as needed for pain - Oxycodone 5MG 4 tablets every 4 hours as needed for pain -None of the oxycodone had specific ranges for when to use which dose or parameters if they could be used in conjunction with each or not in the ordered time ranges. Resident #65's physician orders showed: -Oxycodone 10mg 1 tab every 2 hours for moderate pain -Oxycodone 10mg 2 tabs every 2 hours for moderate pain -Oxycodone 5mg 1 tabs every 2 hours for mild pain -Oxycodone 5mg 2 tabs every 2 hours for mild pain -None of the oxycodone had specific ranges for when to use which dose or parameters if they could be used in conjunction with each or not in the ordered time ranges. Review of hospice visit records provided on 8/14/24 for resident #76, showed multiple notes of resident #76 discussing his suicide attempts, including a note on 7/18/24, which showed resident #76 was considered to be a suicide risk due to his prior attempts and expressions of not wanting any contact with other humans, or not knowing why he is on earth. Review of resident #76's Hospice delineation of services form, signed 7/10/24, showed: Hospice was responsible for: - Attending physician services. - Providing facility with copy of hospice plan of care and any revisions, hospice election form, hospice certification/recertification. - Hospice staff checks in with designated facility staff prior to and after providing care. - Hospice provides a copy of the daily visit note at the time of the visit. - Provide medical supplies related to terminal diagnosis. - DME related to terminal diagnosis. - Medications necessary for all palliation of pain and symptoms associated with the terminal illness and related conditions (list medications covered by hospice): [none listed] - Designate how hospice provided medications are ordered/delivered/renewed: [not specified] The facility was responsible for: - Hospice plan of care located in miscellaneous section of chart. - 24-hour room and board care, to meet the resident's personal care and nursing needs in coordination with hospice. - Designate facility IDT member to coordinate care with hospice. - Facility makes the resident's records available to the hospice professional for review of the patient needs related to the terminal diagnosis. - Medications not related to terminal diagnosis. Facility and hospice combined responsibility: - Facility staff and hospice communicate in person or by phone to ensure that the needs of the resident are addressed and met 24 hours a day and such communication to be documented in progress notes. - Provide medical direction and management of resident. - Counseling to include spiritual, dietary and bereavement. - Social work services. Review of both resident #65's and 76's electronic medical record, and the facility hardcopy charts on 8/12/24 and 8/13/24, showed no documentation of a hospice care plan or hospice visits from nurses, chaplain services, or social services, including the standard hospice contact and information sheet. The facility did not have any hospice care plan or visit records until requested by the survey team on 8/14/24.

Based on interview and record review, the facility failed to initiate interventions to prevent physical abuse for 2 (#s 67 and 237), resulting in 1 (#67) getting a broken nose, out of 2 sampled residents; and failed to complete an assessment after the altercation, for 1 (#237) out of 2 sampled residents, as well as not letting him return to the facility after the incident. Findings include: A facility reported incident, dated 6/9/23 at 3:35 p.m., showed: Incident Description: .(Resident #67) was found in his room with a bloody nose; he does have a diagnosis of dementia but states 'He just turned around and hit me.' The 'he' he was referring to was his roommate (Resident #237) who was no longer in the room. Staff immediately went out looking for (Resident #237) to find out he signed out and went to his significant others apartment . Plans were arranged with (Resident #237's) significant other to stay with her for the weekend; medications and belongings were provided for the weekend and (NF2) agreed to keep (Resident #237) in her care for the weekend until further arrangements can be made . (Resident #67) was evaluated by nursing staff .Full investigation to follow. Review of resident #237's nursing progress note, dated 5/26/23 showed, This am resident (#237) was in his room alone talking to himself. He then came out and told this nurse that his roommate (Resident #67) was calling him a child molester and they were not getting along at all. This nurse assured resident that no one was saying that about him and his roommate was down in the dining room having breakfast. Resident went back into his room and continued talking to himself. Staff is monitoring. Review of resident #237's nursing progress note, dated 5/26/23 showed, Resident (#237) has documented behaviors towards roommate (Resident #67). This nurse was at the north nurses station at the computer and residents roommate was standing talking to this nurse. Resident came up behind him and got very close to roommate and started accusing him of talking about him to the other residents and staff, resident was not able to be redirected by this nurse or aides. Escorted roommate to the dining room to separate. During an interview on 8/16/23 at 9:45 a.m., staff member H stated resident #237 always thought that resident #67 was talking behind his back. Resident #237 had auditory hallucinations, and he would often think resident #67 was saying things he was not. When resident #237 would become upset and accusatory of resident #67, staff would attempt to redirect resident #237, which would sometimes work. During an interview on 8/16/23 at 9:55 a.m., staff member I stated resident #237 and #67 had been roommates for at least two months prior to resident #237 leaving the facility. Staff member I stated resident #237 often accused resident #67 of talking about him, and accusing him of things. Staff member I stated staff would try to redirect resident #237, and stated there was not much else staff could do. Staff member I stated he was working at the facility and was on shift when resident #237 punched resident #67 in the nose. Staff member I stated he was walking down the hall and another resident said resident #67 was bleeding. Staff member I stated he entered the room and found resident #67 had a bunch of blood coming out of his nose. Staff member I stated his nose was completely crooked, and he asked resident #67 what happened, and he said resident #237 punched him in the nose. Resident #237 left the facility, and staff member I stated he did not think he had returned to the facility, or was assessed after the incident. Review of a facility document titled Resident to Resident Event Assessment, dated 6/9/23 showed: Description of Event: This nurse was walking to nurses station when another resident stated he (#67) was bleeding. The nurse went into his room and asked what happened. Resident #67 stated resident #237 'punched me.' The nurse immediately notified management and helped the resident stop the bleeding to his nose. Resident #237 immediately left the building. Resident #67, who was punched, was sent to the imaging center for a possible fracture of his nose. Review of resident #237's nursing progress note, dated 6/9/23 showed, This worker called and spoke with NF2 notifying her of incident between [Resident #237] and [Resident #67] .NF2 was notified the resident [#237] punched resident [#67] in the nose, left facility to walk to her apartment. NF2 was informed that the police had been notified and are on their way to her apartment as well. Resident was seen sitting at back door of [Name Apartment Complex]. NF2 brought resident into her apartment where she and resident are waiting for police officer to respond. NF2 was informed that it is unsafe for resident to return to facility .NF2 asked about resident's belongings. This worker informed NF2 that items can be boxed up for her to pick up During an interview on 8/16/23 at 10:37 a.m., staff member A stated after the physical altercation between resident #237 and #67, resident #237 did not return to the facility. Therefore, a post physical altercation assessment was not completed for resident #237. Review of resident #237's MDS 5-day scheduled assessment, with an ARD date of 5/1/23, showed resident #237 had a BIMS of 4, reflecting severe cognitive imparement. Review of resident #237's behavior documentation, dated April 2023 - June 2023, showed: - April 2023: On 4/25/23, accusing of others, anxious, cursing at others, and repetitive motions. There were no other documented behaviors that month. - May 2023: No behaviors were noted for the month. - June 2023: On 6/1/23, accusing of others. On 6/9/23, Abusive language, threatening of others, Entering Other Resident's Room/Personal Space, Hallucinations, Hitting others, and Physically Aggressive Towards Others, was documented. Review of resident #67's care plan did not show any Focus, Goals, or Interventions related to resident #237's behaviors towards him to keep him safe. There were not any interventions put in place to protect resident #67 from #237 prior to the physical altercation, despite multiple verbal indicators leading up to the incident. Review of the facility policy titled Abuse, with a revision date of 7/23/19, showed: 11. The facility identifies residents most at risk of neglect and abuse. Residents most at risk may include but is not limited to: . c. Residents who have psychosocial, interactive, and/or behavior disfunction, 1. Verbally aggressive behavior . 2. Physically aggressive behavior, such as hitting . 12. Residents identified at risk for abusing other residents, are identified through: c. Behavior monitoring logs .

Based on observation, interview, and record review, facility licensed nursing staff failed to thoroughly assess two residents for ensuring necessary transport services were provided when residents sustained fractures and head injuries during falls, and the residents were manually pushed in their wheelchairs by a nurse or CNA, to the ER, causing increased pain and risk of further injury due to inappropriate transports, for 2 (#s 238 and 239) of 3 sampled residents; and the ER later reported #238 had fractures in her back. Findings include: During an interview on 8/16/23 at 10:09 a.m., staff member I stated, when a resident needed to be transported to the ER, We try not to call EMS if we don't have to, we wheel them down in a wheelchair if it's safe to do so. During an interview on 8/17/23 at 7:21 a.m., staff member E stated, resident #239 was wheeled in a wheelchair, by a CNA, to the ER after her fall, we weren't sure if something was broken. Staff member E stated, It would depend on the severity of the resident's injury whether EMS would be called or staff would wheel them to the hospital. During an interview on 8/17/23 at 8:30 a.m., staff member B stated, the nurse assessment determined the mode of transporting the resident to the hospital by either wheelchair or EMS. Staff member B stated the sidewalks are kept clear year-round and had sufficient lighting. Staff member B stated the back entrance of the hospital ER was across the street. During an interview on 8/17/23 at 8:36 a.m., staff member B stated, she felt it was appropriate to transfer resident #239 in the Hoyer lift because they could stabilize her arms while folding them, crossed over her chest. Staff member B stated the Hoyer lift into a wheelchair was a better option than staff pulling the resident up off the ground and said it was no different than the scooper lift onto a stretcher by EMS. Staff member B stated EMS were volunteers, and the staff would have had to wait for EMS to get to the facility when a CNA or nurse could wheel the resident through the hospital's back door during the day, which was approximately 15 feet away. Staff member B stated resident #239 had no outward signs of a fracture, like bulging, even though the resident was screaming in pain when touched. Staff member B stated, resident #238 had pain in her back at the time of the fall, but the resident had chronic back pain. The primary reason for resident #238's transport was, the whack to the back of her head based on the nurse assessment. Staff member B stated it would be worse to take a resident back out of a wheelchair, if they complained of shoulder and pelvic pain. Review of resident #238's nurse progress notes on 3/20/23, showed, At 2300 (11:00 p.m.) . Res was laying on her back bleeding from contusion on back of head . On call MD notified and orders received/processed to send to ER.Res assessed for injury- no c/o pain until in wheelchair and going to the ER would c/o bumps hurting. ER reported Res to have a fracture to back S5, L4, L5 and would be admitted to hospital. [sic] Review of resident #239's nurse progress notes on 2/4/23, showed, Barely able to move her (L) arm and then screams out with pain whenever this nurse palpates her (L) shoulder . Three staff members assist resident up off the floor back into her w/c using a Hoyer lift. Resident crying out in pain whenever (L) shoulder or (L) arm is bumped or touched. Another note on 2/4/23 showed, Transferred to ER via w/c by CNA. [sic] Review of resident #238's nurse progress note dated 3/20/23, showed, At 2300 (11:00 p.m.) . Res was laying on her back bleeding from contusion on back of head . On call MD notified and orders received/processed to send to ER . Res assessed for injury- no c/o pain until in wheelchair and going to the ER would c/o bumps hurting. ER reported Res to have a fracture to back S5, L4, L5 and would be admitted to hospital. [sic] Review of resident #238's hospital discharge documents dated 3/21/23, showed, Concern for skull or cervical spine fracture along with intracranial hemorrhage . Patient presents with tailbone pain after backwards fall . CT of head, cervical spine, and pelvis were negative for acute abnormalities, however showed chronic nondisplaced fracture involving the ventral cortex of the S5 sacral segment, mild superior endplate L5 fracture likely acute and mild to moderate inferior endplate L4 fracture . posterior scalp laceration cleaned and repaired utilizing glue. The L5 and L4 fractures were determined to be chronic compression fractures, but having occurred since the last CT imaging on 3/16/21. Review of resident #239's, Post Fall Investigation, for a fall on 2/4/23 at 11:45 p.m., showed a pain level of 10/10 on a scale of 0-10 at the time of the fall. When resident #239 returned from the hospital, Upon return was assisted into recliner with legs elevated so she could not tip over out of her w/c. Advised to not lean forward when in her w/c to pick up something on the floor, to call for help instead. Review of resident #239's nurse progress notes showed on: - 2/4/23, she landed on her face, could not lift her legs, had back pain, leg pain, but not nearly as painful as her left shoulder. Barely able to move her (L) arm and then screams out with pain whenever this nurse palpates her (L) shoulder . Three staff members assist resident up off the floor back into her w/c using a Hoyer lift. Resident crying out in pain whenever (L) shoulder or (L) arm is bumped or touched. - 2/4/23, Transferred to ER via w/c by CNA. - 2/5/23, Resident returned from ER accompanied by ER nurse who reports resident's X-rays show (L) arm fracture at the proximal end of the humerus, CT scan of closed head injury did not show any acute findings, hemorrhage or mass defect. Review of the physician order on 2/4/23, for resident #239 showed, Transfer to ER for (L) shoulder/arm x-rays and evaluation by to R/O fracture. [sic] Review of the facility policy titled Fall Response and Management Policy, last revised on 5/17/21, did not show how a resident should be transferred or transported after a fall with injury, or how the treatment were to occur, only to get treatment if suspected injury. An emergent transport policy was requested and the facility policy, Managing Resident Appointments, dated 2/1/22, was provided, and showed for scheduled appointments, residents could be pushed to them in their wheelchair if they were close by. The interdisciplinary team would consider the resident's comfort level, staff, and transport availability. The policy did not cover transport related to events with injury, and emergent transport.

Based on interview and record review, the facility failed to act to identify a legal representative for a resident deemed not medically capable of understanding his rights and signing forms, resulting in a friend making his medical decisions, for 1 (#237) of 1 sampled resident. Findings include: During an interview on 8/16/23 at 10:37 a.m., staff member A stated resident #237 was not capable of making his own medical decisions so the doctor and NF2 decided it was best if she helped him make medical decisions. Staff member A stated resident #237 never had any documentation completed to make anyone his POA, or responsible party. During an interview on 8/16/23 at 11:17 a.m., staff member B stated resident #237 was unable to make medical decisions for himself. Staff member B stated NF2 was signing the resident's documents for him and managing his healthcare. Review of physician orders, dated 6/16/22, showed, Resident is not medically capable of understanding rights and signing forms. Review of resident #237's MDS 5-day scheduled assessment, with an ARD date of 5/1/23, showed resident #237 had a BIMS of 4. Review of a Quarterly Care Conference Progress note, dated 5/18/23, showed, .Verified advance directive, (Resident #237) is a DNR with POLST .No POA or living will. (NF2) continues with advance directive for COVID-19. Review of a social services progress note, dated 5/5/23, showed, This worker called and left voicemail for (NF2) informing her that resident is now covid recovered and discontinuing skilled care .Resident (#237) is not medically capable of understanding and/or signing forms.

Based on observation, interview and record review, the facility failed to cut a resident's toe nails, per her request, on a regular basis, for 1 (#31) of 1 sampled resident. Findings include: During an interview on 8/15/23 at 10:15 a.m., NF4 stated resident #31 had very thick, and hard to cut, toenails. She stated the facility does not keep them cut, and they are always long. During an observation and interview on 8/16/23 at 2:25 p.m., resident #31's toenails appeared very long. The second toenail on both her left and right foot was approximately a 1/4 of an inch long. Resident #31 stated the staff do not cut her toenails, and they were bugging her. Review of resident #31's current order dated 3/11/21 showed, LN to complete nail care on Thursdays per resident request. Every day shift every Thu for Nail Care. [sic]

Based on observation, interview, and record review, the facility failed to maintain a resident's right to privacy and dignity for 1 (#62) of 23 sampled residents. This caused harm to the resident and instilled fear, mistrust, increased anxiety and anger. Findings include: Resident #62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an observation and interview on 8/21/18 at 10:00 a.m., resident #62 was in bed with a sheet pulled over his head. Staff member M stated resident #62 covered his head often while he was in his room. The staff member said the act must help with his nightmares and anxiety. Review of resident #62's Admission MDS, with an ARD of 8/8/18, Section C0500, showed the resident had a summary score of 15, no cognitive impairment. The resident was his own guardian During an observation and an interview on 8/22/18 at 1:09 p.m., resident #62 stated staff confiscated items of his personal belongings, which the staff took from his black backpack. He said the items taken were now locked up at the facility and now I have to keep my bag with me at all times. He stated that after the items were taken, staff members A and B came to him during therapy and told him the staff went through his bag. Resident #62 said his belongings were still locked up, so they say. If they had asked me, I would have given the items to them. During an interview on 8/23/18 at 9:30 a.m., staff member I said staff member J reminded her that she had observed a vapor device by the bed. Staff member J asked staff member K to get staff member I to go to the room to remove the items from the resident's bag. The resident was in therapy at the time and not in his room. The items were placed in a plastic bag with his name and left in the medication room. Staff member I told staff member B that she had called the family and they were on their way to the facility. Staff member I said that was the last time she saw the items. Staff member I said she did not ask the resident's permission, prior to searching and confiscation his items. Staff member I stated if it had been her, she would have been pretty upset. During an interview on 8/22/18 at 3:05 p.m., staff member I said that on 8/10/18, staff member J and staff member K had gone into the resident's room and saw a vapor device on the floor. The resident was at therapy and out of his room. The staff member said the resident's bag was on his bed, and the items were in his bag. Staff member I said the bag was searched without the resident present and without his permission. Staff member I said it would have been better to do in the resident's presence. Staff member I said the items taken out of the resident's bag were placed in a plastic bag and given to a nurse. Staff member I said she had called the family before noon on 8/10/18. Staff member I said the resident had the right to have personal belongings. Staff member I said she knew the resident had been upset. The facility had not worked with resident to store his belongings prior to this event. During an interview on 8/23/18 at 10:00 a.m., resident #62 stated I was in therapy when this occurred. I was told that one of the workers found something and they went through my bag. I was not present when they went through my bag. I did not consent to allow them to go through my bag. Now, I keep my bag with me at all times. During an observation on 8/23/18 at 10:00 a.m., resident #62 had a black backpack hanging on his wheel chair, and the resident pulled a wallet out of his pocket. Resident #62 stated I have to sleep with my wallet now as I do not trust them. During an interview on 8/22/18 at 2:48 p.m., staff member B said resident #62 had drugs without a prescription. Staff member B said the resident had signed a smoking policy which included no vaping. Staff member B said she and staff member A spoke to the resident and his family members about the resident's items taken. Staff member B stated his belongings were still here and a family member was suppose to get them and had not picked them up, yet. Staff member B did not know if there was an inventory of the items that were taken from resident #62. Staff member B stated the resident should have been present when the staff went through his personal belongings. She said staff needed to be educated on going through a resident's personal items without the resident present. Staff member B thought the event occurred on 8/10/18. She said that staff member A had the items and reviewed with the resident. Family members asked staff member B to hold them until they could be picked up by the family. Staff member B thought there were pain medications, an antipsychotic, a blood pressure medication and some oils. Staff member B said the resident did not have an order for [REDACTED].>During an interview on 8/22/18 at 3:37 p.m., staff member A said he did not know who removed the items from the resident's bag. Staff member A said all the items were given to the family. Staff member A denied giving the items to another staff member. Staff member A stated he did not know if anyone's rights were violated. Staff member A said he did not know where the items were but staff member B should have an inventory. Staff member A stated he was not sure if residents could have property removed from their room if the resident was not aware of the removal. During an interview on 8/23/18 at 7:15 a.m., staff member B stated there was no investigation completed for the incident occurring on 8/10/18, pertaining to the infringement of rights for resident #62. During an interview on 8/23/18 at 7:23 a.m., staff member A stated there was no investigation done to his knowledge for the incident occurring on 8/10/18, pertaining to the infringement of rights for resident #62. Review of resident #62's Interdisciplinary Progress Note, dated 8/10/18, by social services, showed the resident was visited by staff, and the resident was observed to be Upset by raid of his medications that were in satchel in room. The resident felt he should have the right to keep some medications in room. The resident expressed high level of frustration/sorrow with medical condition and lack of control over the events in his life. Review of resident #62's Evaluation For Self-Administration of Medications, signed and dated on 8/2/18, showed the resident was approved for self-administration of medications. Review of resident #62's Inventory of Personal Effects, dated 8/3/18, did not show a black backpack, a wallet, or a list of medications. Review of resident #62's Physician's Evaluations of Resident's Capacity to Make Health Care Decisions or Provide Informed Consent, signed and dated 8/7/18, showed the resident was deemed to have the capacity to make health care decisions. The survey team requested to observe the items taken from the residents backpack on 8/10/18, and the facility did not provide the items, prior to the end of the survey, on 8/23/18.

Based on record review and interview, the facility failed to provide consistent pain management following a pathological [MEDICAL CONDITION] for 1 (#1), and provide consistent bowel management for 2 (#2 and 4) of 15 sampled residents. Findings include: 1. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of resident #1's nurses note, dated 6/1/17 and a radiology report dated 6/1/17, reflected an incident where the resident suffered a possible pathological [MEDICAL CONDITION], the night of 5/31/17. Review of resident #1's nursing note, dated 6/1/17 at 2:30 a.m., reflected the resident had left hip pain, and was given PRN pain medication with no effect. She was repositioned and massaged with no effect. There was no redness or bruising at the area of complaint. Review of resident #1's nursing note, dated 6/1/17 at 10:30 a.m., reflected the resident had complained of left sided hip and back pain in the morning. The nurse assessed the area, noting there was no bruising. The nurse wrote that the resident did not fall. She gave the resident another PRN pain pill as the resident requested before going to breakfast. The note reflected the resident was able to bear weight comfortably with assist of one and was transferred to the wheelchair. The resident ambulated herself in the wheelchair to the dining room and ate breakfast. It was at this time the family came to the facility and told the nurse the resident called them at 6:30 a.m. complaining of pain. The nurse called the doctor and awaited instructions. The family became frustrated of the time it was taking to get a return call from the doctor. At 10:30 a.m., the family decided to take the resident to the ER for an X-ray. The X-rays were inconclusive for [MEDICAL CONDITION], femur, or lumbar spine. Following a complaint by the family of the facility failing to treat resident #1's pain, the facility, on 6/2/17, initiated an investigation and plan of correction. Review of witness statements from the investigation reflected the nurse, working the night of the incident, stated that resident #1 was complaining of having Charlie horse type cramps in her left hip area while sitting on the commode around 11:00 p.m. on 5/31/17. The nurse assessed the resident, as was written in the nursing note on 5/31/17 at 2:30 a.m. The resident was assisted back to bed. The nurse placed pillows from the resident's shoulder to the lumbar area of the resident's back, to alleviate pressure on the left side. The resident still had complaints of pain one hour afterward. The nurse stated she massaged the resident's hip area per the resident's request. There were no other time tables mentioned in the witness statement. In a timeline of events provided by the facility, the initial pain medication was given at 11:00 p.m. on 5/31/17. This was confirmed by the narcotic count book. Incidentally, the wrong date was written for this administration of narcotic. It was written as 6/1/17 at 11:00 p.m., not 5/31/17. During an interview on 6/13/17 at 10:45 a.m., staff member D stated the date written in the narcotic book was a mistake. Review of the Medication Administration Record [REDACTED]. During an interview, on 6/13/17 at 10:45 a.m., staff member D stated the med aides were responsible for change over of the Medication Administration Record, [REDACTED] Review of the timeline provided by the facility, reflected at 12:00 a.m. the resident was reassessed by the nurse. The area was massaged, and pillows placed for comfort. On 6/1/17 at 2:30 a.m., the resident requested more pain medication. The nurse told the resident she could not give any more because it had not been six hours since the last dose. Other staff reported the resident was initially uncomfortable at rest, and pain was more significant during routine incontinence care and repositioning. Record review showed a fax was sent to the doctor sometime between 2:30 a.m. and 6:00 a.m. on 6/1/17. The fax was not marked with the time it was sent. The fax reflected the same information as the nursing note on 6/1/17 at 2:30 a.m., but showed the resident stated she related her pain to feeling as if something was broken. During an interview, on 6/13/17 at 3:25 p.m., staff member D stated the resident told her it felt like it was broken, at the end of her shift, before she sent the fax to the doctor. During an interview, on 6/13/17 at 3:10 p.m., staff member C stated the resident should not have been left in pain, it shouldn't have happened. The staff member stated the other administrative nurses agreed staff member D should have called the doctor at 2:30 a.m. 2. Review of resident #2's Skilled Daily Nurses Notes, dated 4/6/17, showed the resident was placed on comfort care, and had [DIAGNOSES REDACTED]. The resident was discharged to a local hospital on [DATE], and was readmitted [DATE]. Review of the resident's Admit MDS, with an ARD of 4/16/17, showed the resident was cognitively impaired and unable to make her needs known. The resident required extensive assist with toileting and cares. Review of the resident's Skilled Daily Nurses Notes, dated 4/8/17, showed the resident was unable to make her needs known, and the resident had stool digitally removed from rectum, anxiety restlessness, PRN [MEDICATION NAME] and [MEDICATION NAME] given. There was no documentation on the follow up on the removal of the stool. Review of resident #2's Order Summary Report, dated 1/1/17 - 5/31/17, showed the resident had orders, dated 4/8/17, [MEDICATION NAME], 0.125 ml up to 1 ml every 1 hour as needed for pain. The resident had orders for laxative of choice qd PRN for constipation as a standing order, dated 4/3/17. Review of the facility's BM Communication Log, March 2017, and the CNA - ADL Tracking form, dated 3/17, showed the resident did not have a bowel movement documented from 3/27/17 until she went to the hospital on [DATE]. Review of the facility's BM Communication Log, April 2017, and the CNA - ADL Tracking form, dated 4/17, showed the resident did not have a bowel movement documented 4/23/17 until 4/28/17. Review of the facility's BM Communication Log, May 2017 and June 2017, and the CNA - ADL Tracking form, dated May 2017 and June 2017, showed the resident did not have a bowel movement documented from 5/26/17 until 6/9/17. Review of resident #2's MAR, dated 3/1/17 - 3/31/17 and 4/1/17 - 4/30/17, showed the resident had a physician prn order, dated 3/11/17, for [MEDICATION NAME] capsule 100 mg, two capsules, two times a day. Documentation showed the resident recieved the medication 32 out of 47 opportunities. The order was discontinued on 4/7/17. Review of resident #2's MAR, dated 3/1/17 - 3/31/17, 4/1/17 - 4/30/17, and 5/1/17 - 5/31/17, showed: - An order, dated 3/21/17, for [MEDICATION NAME], 5 mg, 1-2 tablets if no bowel movement in two days. - An order, dated 3/21/17 for [MEDICATION NAME], 17 gm, dissolved in 4/8 oz. of water, by mouth, if no bowel movement in three days. - If the resident had no bowel movement on the fourth day, a suppository, as needed, had been ordered, on 3/27/17, related to constipation. Review of resident #2's MAR, dated 3/1/17 - 3/31/17, showed a nurse had signed off for giving resident #2 a laxative of choice, PRN, for constipation, on 3/15/17. There was no other documentation showing the resident had received any of the ordered PRN medications in March, April, or May 2017. Review of resident #2's care plan, with a date of 6/29/16, showed the problem of the resident's decreased fluid or PO intake. Approaches and interventions included to encourage fluid intake at meal times and between meals. Comfort measures included offering fluids as tolerated. Constipation concerns were identified as a problem under weight loss but there was no documentation showing approaches and interventions the facility staff should use. Review of resident #2's physician visit, dated 5/1/17, showed the resident was getting more forgetful, and less obsessed with her bowel movements than she had been. During an interview on 6/14/17 at 9:06 a.m., staff member A stated if a resident had no bowel movement in three days, she would give a laxative. The staff member stated she was made aware of a resident's bowel movements by looking at the BM sheets at the nurse station. The staff member also stated she would ask the resident if he/she had a bowel movement. During an interview on 6/14/17 at 9:53 a.m., staff member B stated she would give a resident a suppository if he/she had not had a bowel movement in three days. The staff member stated she reviewed the CNAs' BM charting, daily. 3. Review of resident #4's medical records showed the resident had a [DIAGNOSES REDACTED]. Review of the facility's BM Communication Log, March 2017, and the CNA - ADL Tracking form, dated March 2017, showed the resident did not have a bowel movement documented from 3/8/17 until 3/11/17. Review of the facility's BM Communication Log, April 2017, and the CNA - ADL Tracking form, dated April 2017, showed the resident did not have a bowel movement documented 4/5/17 until 4/8/17. There was no documentation of a concern with the resident not having regular bowel movements. Review of resident #4's physician progress notes [REDACTED]. The physician's assessment showed slow transit constipation. The treatment included: - Increase the resident's dose of [MEDICATION NAME] to 15 ml, twice a day. - Ordered an enema 7-19 GW118 ml, as directed, as needed for not having a BM in three days. - [MEDICATION NAME] powder, 48.57 percent, one dose daily. - Increase in Senna S tablet to 8.6-50 mg, two tablets, every eight hours as needed for no BM times one day. Review of the facility's BM Communication Log, dated May 2017 and the CNA - ADL Tracking form, dated May 2017, and June 2017, showed the resident did not have a bowel movement documented from 5/7/17 until 5/12/17 and from 5/22/17 until 5/29/17. Review of the facility's CNA - ADL Tracking form, dated 6/17, showed the resident did not have a bowel movement documented from 6/1/17 until 6/13/17. The BM Communication Logs, and the CNA - ADL Tracking forms, for resident #4, were inconsistent. During an interview, on 6/14/17 at 10:30 a.m., NF1 stated the resident had a bowel problem. The physician had increased the resident's order for a laxative daily. NF1 stated she kept the resident's BM marked on a calendar, in the resident's room, and told the CNAs to mark when the resident had a BM. NF1 stated she would go tell the nurses if the resident hadn't had a BM for a while and then they give him something. Review of the Policies and Procedures form, with a subject of Bowel Movement Assessment, and an effective date of 11/30/14, showed the policy provided a format to use as a working tool to record and monitor each resident's bowel movement to prevent impactions. The procedure was for the CNAs to fill out the Bowel Movement Worksheet or the ADL sheet each shift, for each resident. The sheets were to remain at the nursing desk. The CNAs were directed not to leave a blank space and to mark either the size of the BM or that no BM occurred. When a suppository or enema was given, the nurse was to mark the space for the resident. The Nurse was to check the BM worksheet or the ADL sheet for the date of the resident's last BM and identify the need for additional interventions. If the resident does not have a BM by the third day, the nurse would give a laxative or suppository, depending upon the circumstances and physician orders.