**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide the necessary care and services for 6 of 24 sampled residents by failing to: 1. Check Resident 268's blood glucose level (amount of sugar in the blood stream, the normal value between 70 milligrams [mg, unit of measurement] per (/) deciliter [dL, unit of measurement] and 100 mg/dL) prior to administering Insulin Glulisine (a fast-acting medication to lower high blood sugar). 2. Accurately transcribe (copy from one place to another) Resident 268's discharge medication order for Insulin Glargine (a long-acting medication to lower high blood sugar) when readmitted to the facility on [DATE] from a long-term acute care hospital (LTACH). 3. Administer Milk of Magnesia (medication to treat constipation) to Resident 3 who did not have a bowel movement for three days and then for five days. 4. Turn and reposition Resident 30 and Resident 32, both of whom had existing pressure injuries (injury to skin and underlying tissue resulting from prolonged pressure on the skin). 5. Ensure the nasal cannula (a tube with two prongs for the nostrils connected to, and to deliver oxygen to a person with difficulty breathing) was not applied too tightly causing an indentation on the cheeks for two of eight sampled residents (Resident 56 and Resident 94) receiving oxygen therapy. 6. The oxygen nasal cannula was applied in Resident 94 nostrils (external opening of the nose) to supply the amount of oxygen as ordered by the physician. These failures resulted in Resident 268 being administered Insulin Glulisine instead of Insulin Glargine without blood glucose monitoring prior to administration on 10/26/2023 and 10/27/2023. This failure led to Resident 268 having a hypoglycemic (low blood glucose level, below 70 mg/dL) episode, altered mental status (AMS, changes in cognition [process of thinking], mood behavior, and/or arousal) and being transferred on 10/27/2023 to the general acute care hospital (GACH). These failures also resulted in the delay of bowel treatment for Resident 3 and transfer to the general acute care hospital (GACH) and had the potential for the formation of new or worsening of already existing pressure injuries. These failures also had the potential to cause skin breakdown, and the potential for the residents to develop respiratory distress. Findings: 1. During a review of Resident 268's admission Record (Face Sheet), the admission Record indicated Resident 268 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included but not limited to metabolic encephalopathy (problem in the brain caused by a chemical imbalance of the blood), sepsis (serious condition resulting from the presence of harmful microorganisms in the blood or other tissues), type 2 diabetes mellitus (condition that results in too much sugar circulating in the blood), anemia (problem of not having enough healthy red blood cells to carry oxygen to the body's tissues), dementia (a condition characterized by progressive or persistent loss of intellectual functioning), and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). During a review of Resident 268's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 8/25/2023, the MDS indicated Resident 268's cognition was severely impaired (ability to think and reason). The MDS indicated Resident 268 did not have the ability to understand and be understood by others. The MDS indicated Resident 268 was totally dependent on staff and required one- person physical assistance for bed mobility, dressing, eating, toilet use, personal hygiene, and bathing. The MDS indicated Resident 268 was receiving insulin. During a review of Resident 268's Order Summary Review, dated 10/27/2023, the Order Summary Review indicated the following orders: 1. Enteral feeding (food delivered through a feeding tube) of Glucerna 1.2 (name of enteral feeding) infused on a feeding pump at 35 milliliters (mL, unit of measurement) per hour for 20 hours. 2. Insulin Glulisine Injection Solution, inject 10 unit (unit of measurement) subcutaneously (injection into the fatty tissue, just under the skin) one time a day, at 9 a.m., for diabetes mellitus management. 3. Insulin Lispro Injection Solution (a fast-acting medication to control high blood sugar), inject per sliding scale (administration of pre-meal insulin dose based on the blood glucose level before the meal) subcutaneously before meals at 6:30 a.m., 11:30 a.m., and 4:30 p.m. and at bedtime, at 9 p.m., for diabetes mellitus management. During a review of Resident 268's Medication Administration Record (MAR), for the month of October 2023, the MAR indicated on 10/27/2023 at 6:30 a.m., Resident 268 had a blood glucose level of 310 mg/dL and was administered 12 units of Insulin Lispro. The MAR indicated Resident 268 was administered Insulin Glulisine 10 units subcutaneously on 10/26/2023 and 10/27/2023 at 9 a.m. During a review of Resident 268's Change in Condition Evaluation (COC), dated 10/27/2023, the COC indicated at 12:20 p.m. on 10/27/2023, Resident 268 had a blood glucose level of 45 mg/dL and sluggish eyes with no eye contact. The COC indicated a code blue was announced and Resident 268 received 1mg of Glucagon (medication to increase blood glucose level) intramuscularly (IM, injection deep in the muscle). The COC indicated paramedics were called and arrived at the facility, and Resident 268 was transferred to the GACH. During a review of the paramedic's Responsive Report, dated 10/27/2023, the Responsive Report indicated Resident 268's chief complaint (statement describing the symptoms, problem, or condition of an individual) was hypoglycemia. The Responsive Report indicated at 12:38 p.m., on 10/27/2023, Resident 268 was administered 125 mL of Dextrose 10% (D10, liquid solution with concentrated level of sugar) intravenously (in the vein). The Responsive Report indicated at 12:39 p.m., Resident 268 had a blood glucose level of 43 mg/dL then at 12:51 p.m., Resident 268 had a blood glucose level of 128 mg/dL. During a review of Resident 268's Emergency Department (ED) Note, dated 10/27/2023, the ED Noted indicated Resident 268 was brought to the ED due to altered mental status and hypoglycemia. The ED Note indicated after Resident 268 arrived in the ED, she was administered 250 mL of D10 intravenously. The ED Note indicated at 1:43 p.m., Resident 268's blood glucose level was 150 mg/dL. The ED Note indicated Resident 268 was admitted to the intensive care unit (ICU, unit in the hospital that provides specialized treatment to patients who require critical medical care) for hypoglycemia, concern for sepsis (a life-threatening complication of an infection), hypothermia (a significant and potentially dangerous drop in body temperature), hydrocephalus (a condition in which fluid builds up in the brain), and possible left-side basilar pneumonia (lung inflammation of the lower left side of the lungs caused by bacteria or viral infection). During an interview on 10/27/2023 at 12:46 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she had gone into Resident 268's room around 12:15 p.m. on 10/27/2023 to check the resident's blood glucose and noticed the resident was foaming at the mouth. When LVN 1 checked Resident 268's blood glucose level it was 45 mg/dL. LVN 1 stated she placed the pulse oximeter (device to check the oxygen level in the blood) on Resident 268's finger and when there was no reading, so LVN 1 announced a code blue. LVN 1 stated once staff arrived to assist, Glucagon was administered. LVN 1 stated Resident 268's blood glucose level was checked after five minutes, and it resulted as 35 mg/dL. LVN 1 stated she last saw Resident 268 at 11 a.m. (on 10/27/2023) before the incident and the resident was okay. During a concurrent interview and record review on 10/27/2023 at 2:39 p.m. with LVN 1, Resident 268's MAR, for the month of October 2023, was reviewed. The MAR indicated Resident 268 had a blood glucose level of 310 mg/dL and was administered 12 units of Insulin Lispro on 10/27/2023 at 6:30 a.m. LVN 1 stated Insulin Lispro was administered during the prior shift, and LVN 1 administered Insulin Glulisine within an hour after the Insulin Lispro was administered. LVN 1 stated Insulin Glulisine was a fast-acting insulin and could decrease the resident's blood glucose level within 30 minutes. LVN 1 stated Resident 268's blood glucose was checked during the prior shift and LVN 1 felt okay giving Insulin Glulisine. LVN 1 stated blood glucose levels should be checked prior to insulin administration. LVN 1 stated Resident 268's enteral feeding was turned off at 9 a.m. per the physician's order. LVN 1 stated after administrating insulin, food was usually given to the resident. LVN 1 stated not checking the blood glucose level prior to insulin administration could cause hypoglycemia that could cause the resident to become nonresponsive or lead to death. LVN 1 stated the combination of the administration of Insulin Lispro, Insulin Glulisine, and the discontinuation of the enteral feeding may have caused Resident 268's hypoglycemic episode. During an interview on 10/27/2023 at 3:30 p.m. with Registered Nurse (RN) 1, RN 1 stated residents who received a rapid-acting insulin needed to have their blood glucose level checked before administration. RN 1 stated Insulin Lispro and Insulin Glulisine were both rapid-acting insulins. RN 1 stated due to the rapid action of both insulins, it was important to check the blood glucose level because the blood glucose level could decrease quickly. RN 1 stated she (RN 1) would have clarified the order for the lack of blood glucose monitoring and the actual order for Insulin Glulisine due to the fact Resident 268 was already receiving Insulin Lispro. RN 1 stated the combination of insulins had the possibility to drop Resident 268's blood glucose level significantly. During an interview on 10/27/2023 at 4:25 p.m. with the Director of Nursing (DON), the DON stated the purpose of administering insulin was to treat hyperglycemia (high blood sugar level) by decreasing the blood glucose level, and the blood glucose level should be checked before administering insulin. The DON stated checking the blood glucose level was important because if the blood glucose level was within the normal range and insulin was administered, that could cause hypoglycemia. The DON stated on10/27/2023, Resident 268 was hard to arouse, had her eyes closed, and did not respond to stimuli (anything that can trigger a physical or behavioral change). The DON stated if staff had not intervened during Resident 268's hypoglycemic episode, the resident could have gotten worse, became more nonresponsive, and had the potential to drift away. 2. During a concurrent interview and record review on 10/27/2023 at 3:40 p.m. with RN 1, Resident 268's LTACH Discharge Medications, dated 10/25/2023, were reviewed. The LTACH Discharge Medications indicated to continue Insulin Glargine, 10 units, subcutaneous injection, daily. RN 1 stated Insulin Glulisine was not on the discharge paperwork from the LTACH. RN 1 stated the action type between Insulin Glulisine and Insulin Glargine were different and had different effects on blood glucose levels. RN 1 stated the RN who admitted Resident 268 to the facility was responsible for transcribing the medication order correctly from the LTACH. RN 1 stated there was a mix up when Resident 268's discharge medications were transcribed incorrectly. During an interview on 10/27/2023 at 3:50 p.m. with Physician 1, Physician 1 stated the normal process was to continue the discharge medications from the LTACH. Physician 1 stated he had not placed the order for Insulin Glulisine. Physician 1 stated the blood glucose level should always be checked prior to administering insulin. Physician 1 stated Resident 268 should not have had two rapid-acting insulins ordered together as this caused Resident 268's hypoglycemic episode. Physician 1 stated there was an error in the discharge medication transcription and the facility should have followed the orders from the LTACH. During an interview on 10/27/2023 at 4:30 p.m. with the DON, the DON stated the normal process was to review the discharge medications from the discharging facility and to input those orders into the system. The DON stated there was a transcription error because Resident 268 was receiving Insulin Glargine at the LTACH and was supposed to be continued at the facility. The DON stated Insulin Glulisine should not have been ordered and Resident 268 should not have received the medication. The DON stated this was a medication error and this affected the resident where her blood glucose level dropped quickly. During a review of the facility's policy and procedure (P&P) titled, Consulting Physician/Practitioner Orders, dated 12/19/2022, the P&P indicated for consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will call the attending physician to verify the order . [and] follow the facility procedures for verbal or telephone orders including: noting the order, submitting to pharmacy, and transcribing to medical or treatment administration record, when appropriate. 3. During a review of Resident 3's admission Record (Face Sheet), the admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included but not limited to Parkinson's disease (disorder of the nerves in the body affecting movement of the body), dementia, and type 2 diabetes mellitus. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognition was severely impaired. The MDS indicated Resident 3 was totally dependent on staff and required one-person assist when toileting. The MDS indicated Resident 3 had bowel incontinence (inability to control bowel movements that result in involuntary soiling). During a review of Resident 3's Order Summary Report, dated 10/18/2023, the Order Summary Report indicated to administer Milk of Magnesia Oral Suspension (liquid medication to treat constipation) 30 milliliters (ml, unit of measurement) by mouth as needed for constipation, if no bowel movement in two days. During a review of Resident 3's MAR, for the month of October 2023, the MAR indicated Resident 3 received Milk of Magnesia Oral Suspension on 10/12/2023. During an interview on 10/26/2023 at 10:30 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated the CNAs were responsible to chart whether a resident had a bowel movement or not. CNA 1 stated at the end of the shift, she would also report that information to the LVN. During an interview on 10/26/2023 at 10:43 a.m. with LVN 2, LVN 2 stated the licensed nurses were responsible to assess residents' bowel function. LVN 2 stated if a resident was unable to remember their last bowel movement, she would check the resident's electronic health record. LVN 2 stated, in the event a resident did not have any recent bowel movements, she would then look at the resident's orders and see if there are any medications ordered to treat constipation. During a concurrent interview and record review on 10/26/2023 at 10:50 a.m. with LVN 2, Resident 3's Documentation Survey Report (Bowel Elimination), for the month of October 2023 was reviewed. The Documentation Survey Report indicated Resident 3 did not have a bowel movement on 10/3/2023 to 10/5/2023 and 10/7/2023 to 10/11/2023. LVN 2 stated Resident 3 did not have a bowel movement for 3 days on 10/5/2023 and based on her medication orders, she should have been administered the Milk of Magnesia. LVN 2 stated Resident 3 had a bowel movement on 10/6/2023, however did not have a bowel movement for five days afterwards. LVN 2 stated the Milk of Magnesia should have been given to Resident 3 after not having a bowel movement for two days. LVN 2 stated not having a bowel movement could cause discomfort for the resident and there was delay in Resident 3's care. LVN 2 stated Resident 3's lack of bowel movement could have caused the fecal impaction (hardened fecal matter that cannot be pushed out) on 10/18/2023. During an interview on 10/26/2023 at 12:25 p.m. with RN 1, RN 1 stated if a resident did have not a bowel movement in three days, she would assess the resident for abdominal distention (bloating and swelling of the stomach area) and check to see if any medications for constipation could be administered. During a concurrent interview and record review on 10/26/2023 at 12:30 p.m. with RN 1, Resident 3's MAR, for the month of October 2023 was reviewed. The MAR indicated Resident 3 was routinely receiving Docusate Sodium Tablet (stool softener) 100 milligrams (mg, unit of measurement) twice a day and Lactulose Solution (medication to treat constipation) 10 grams per 15mL twice a day for bowel management. RN 1 stated Resident 3 was already on scheduled bowel management medication, it was concerning that she had not a bowel movement for three days and then for five days. RN 1 stated when a resident does not have a bowel movement, this could cause fecal impaction. RN 1 stated although Resident 3 had bowel movements after the administration of Milk of Magnesia, it was possible that the fecal impaction was already present. RN 1 stated there was a delay in Resident 3's care because there were multiple opportunities for her to receive the Milk of Magnesia. During an interview on 10/26/2023 at 12:48 p.m. with the DON, the DON stated she expected her licensed nurses to follow the physician's orders and in Resident 3's situation, to administer the Milk of Magnesia when she did not have a bowel movement after two days. The DON stated, Resident 3 was found to have fecal impaction and not having a bowel movement for multiple days were proof of why she had a fecal impaction. The DON stated Resident 3 was very constipated and had abdominal distention. The DON stated this could have potentially caused Resident 3 to have a bowel obstruction (digested material is prevented from passing normally through the bowel). The DON stated, the possibility of a bowel obstruction could have affected the resident's quality of life negatively. During a review of the facility's P&P titled, PRN Medications, dated 12/19/2023, the P&P indicated 'PRN medication' refers to a medication that is taken 'as needed' for a specific situation. It is not provided routinely, and requires assessment for need and effectiveness . PRN medications are administered by staff who are legally authorized to do so through certification or licensure, in accordance with a physician's order. 4a. During a review of Resident 30's admission Record, the admission Record indicated Resident 30 was admitted to the facility 12/25/2018 and had diagnoses of a fracture of the left hip joint (broken hip bone), intervertebral disc (part of the spine that provides cushioning of the bones of the spine) disorders, low back pain, history of falling and chronic pain. During a review of Resident 30's MDS, dated [DATE], the MDS indicated Resident 30's cognition was intact and required extensive assistance with bed mobility, transfers, getting dressed, toileting and maintaining personal hygiene. During an interview, on 10/24/2023, at 9:43 a.m., with Resident 30, Resident 30 stated he had not been repositioned every two hours and needed help to reposition himself. During an interview on 10/24/2023, at 3:20 p.m., with the Treatment Nurse (TN 2), TN 2 stated Resident 30 received treatments for a deep tissue injury and stated he expected Resident 30 to be repositioned every two hours to prevent further skin break down. During an observation, on 10/26/2023, from 7:30 a.m. to 9:30 a.m., Resident 30 was observed positioned on his back side. During an interview, on 10/26/2023, at 9:35 a.m., with Resident 30, Resident 30 stated, They did not turn me yesterday, all day. During a concurrent review and interview on 10/26/2023, at 9:47 a.m., with CNA 8, the charting section titled, Repositioning, was reviewed. CNA 8 was unable to present documentation of repositioning the resident before 4 p.m. on 10/25/2023. CNA 8 stated if it was not charted, it was not done. CNA 8 stated, If we are not repositioning the resident, then the resident has the potential to develop a pressure ulcer. During an interview, on 10/26/2023, at 9:50 a.m. with the Director of Staff Development (DSD), the DSD stated, We do not have a system of charting the repositioning of our residents available for the nurses. We just do a validation method between the LVNs, CNAs and department managers. The DSD stated there was a potential to not know or track how often the residents are turning and stated there was a lack of documentation to prove how often the nurses have repositioned the residents. During an interview with the DON, on 10/26/2023, at 10:20 a.m., the DON stated there was always a potential for residents to develop pressure ulcers. The DON stated there was a lack of documentation to prove that the repositioning was performed and stated there was a possibility that if it was not documented, it may not have been done. During a review of Resident 30's care plan, titled, At risk for pain or discomfort, revised 9/6/2023, the care plan indicated the facility was to reposition Resident 30 every two hours for comfort. 4b. During a review of Resident 32's admission Record, the admission Record indicated, Resident 32 was admitted to the facility on [DATE] with diagnoses that included but not limited to acute respiratory failure (condition in which not enough oxygen passes from the lungs into the blood), type 2 diabetes mellitus, and dementia. During a review of Resident 32's MDS, dated [DATE], the MDS indicated Resident 32's cognition was severely impaired. The MDS indicated Resident 32 required extensive assistance in bed mobility and required two-person assist. The MDS indicated Resident 32 has a stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle). During a review of Resident 32's care plan titled, At risk for re-hospitalization, initiated on 6/22/2023, the care plan indicated to turn and reposition every two hours and as needed for circulation and comfort. During a review of Resident 32's Surgical Consult, dated 9/11/2023, the Surgical Consult indicated to continue offloading (relieving pressure on parts of the body) and turn per facility protocol. During an observation on 10/25/2023 at 9:15 a.m., in Resident 32's room, Resident 32 was observed positioned on her right side after her wound care treatment. During an observation on 10/25/2023 at 10:25 a.m., in Resident 32's room, Resident 32 was observed laying on her right side. During an observation on 10/25/2023 at 11:35 a.m., in Resident 32's room, Resident 32 was observed laying on her right side. During a concurrent observation and interview on 10/25/2023 at 11:45 a.m. with TN 1, Resident 32 was observed laying on her right side. TN 1 stated they finished Resident 32's wound treatment at 9:15 a.m. and the resident was placed on her right side. TN 1 stated Resident 32 was in the same position she was in after her treatment. TN 1 stated Resident 32 was supposed to be turned and repositioned every two hours. TN 1 stated residents were turned to promote circulation, prevent skin breakdown, and prevent new pressure injuries from forming. TN 1 stated although Resident 32 was on a specialty mattress, the resident still needed to be turned and repositioned. TN 1 stated residents with existing pressure injuries were prone to developing new ones because they were already compromised. During an interview on 10/25/2023 at 12:45 p.m. with CNA 1, CNA 1 stated residents with pressure injuries and/or bed bound needed to be turned and repositioned to prevent new skin breakdown and to make sure they did not get worse. CNA 1 stated Resident 32 was on her side for two and a half hours and that is too long to be on one side. During an interview on 10/25/2023 at 2:34 p.m. with LVN 8, LVN 8 stated residents in bed were supposed to be turned every two hours or as needed. LVN 8 stated two and a half hours on one side would put a resident at risk for development of a pressure injury. During an interview on 10/26/2023 at 8:36 a.m. with the RN 1, RN 1 stated residents in bed were supposed to be turned every two hours to prevent further pressure injury and other skin issues. During an interview on 10/26/2023 at 8:47 a.m. with the DON stated the normal practice was to turn the residents in bed every two hours. The DON stated when a resident had a pressure injury, the resident would be positioned off that certain area. The DON stated if a resident was left in the same position for a long period of time, there could be the potential that future skin break down could develop. During a review of the facilities P&P titled, Turning and Repositioning, dated 9/12/2023, the P&P indicated residents at risk of, or with existing pressure injuries will be turned and repositioned, unless it is contraindicated due to medical condition. 5. During a review of Residents 56's admission Records, the admission record indicated Resident 56 was admitted to the facility on [DATE]. Resident 56's diagnoses included respiratory failure, anemia (a low number of red blood cells) and anxiety disorder (persistent and excessive worry that interferes with daily activities). During a review of Resident 56's MDS, dated [DATE], the MDS indicated Resident 56 was unable to complete brief interview for mental status. The MDS indicated Resident 56 required an extensive assistance with two-person physical assist with bed mobility, transfer and one-person physical assist on toilet use, and personal hygiene. The MDS Section O, for Special treatment procedures and program under respiratory treatment indicated Resident 56 was receiving oxygen. During a record review of Resident 56's Oder Summary Report date ordered 5/15/2023, the order summary report indicated oxygen at 2 liters per minute, may titrate (adjust) oxygen to maintain oxygen saturation (concentration of oxygen in the body) greater than 95 percent (%) as needed for shortness of breath. During an interview on 10/24/2023 at 8:19 a.m., in Resident 56's room with CNA 7, CNA 7 stated Resident 56's nasal cannula as being too tight creating an indentation on the resident's face. CNA 7 stated the nasal cannula should have foam protection to prevent pressure injury (localized damage to the skin as well as the underlying soft tissue). During concurrent observation and interview on 10/26/2023 at 8:56 a.m., in Resident 56's room with CNA 9, CNA 9 verified Resident 56 cheeks had indentation markings from the oxygen nasal canula being too tight. CNA 9 further stated when the nasal canula was applied too tight, it would cause pressure injury, redness, possible pain, and discomfort to Resident 56. CNA 9 stated the oxygen needed to be administered properly. CNA 9 stated the nasal canula prongs should be in both nostrils to get the proper amount of oxygen the resident needed. CNA 9 stated the oxygen tubing should not be too tight to protect the residents from skin injury. 6a. During a review of Residents 94's admission Records, the admission records indicated Resident 94 was admitted to the facility on [DATE]. Resident 94's diagnoses included difficulty in walking, muscle weakness, and obstructive sleep apnea (intermittent airflow blockage during sleep). During a review of Resident 94's MDS, dated [DATE], the MDS indicated Resident 94 had intact cognition for daily decision making. The MDS indicated Resident 94 required an extensive assistance with one-person physical assist with bed mobility, transfer, toilet use, and personal hygiene. The MDS Section O, Special treatment, procedures, and program under respiratory treatment, indicated Resident 94 was receiving oxygen. During a record review of Resident 94's Oder Summary Report date ordered 11/27/2022, the order summary report indicated oxygen at 2 liters per minute continuously via nasal cannula for shortness of breath. During a record review of Resident 94's care plan, initiated 3/14/2023, the care plan indicated oxygen via nasal cannula per MD (medical doctor) order. During a concurrent observation and interview on 10/24/2023 at 8:30 a.m. in Resident 94's room with LVN 3, LVN 3 stated Resident 94's oxygen nasal cannula was too tight, that created an indentation on Resident 94's both cheeks LVN 3 further stated if the canula is applied too tight, there's a possible risk for skin break down. 6b. During concurrent observation and interview on 10/24/2023 at 8:30 a.m. in Resident 94's room with LVN 3, LVN 3 stated Resident 94's nasal canula was not applied properly. One of the nasal canula prong was on the right nares and there was no nasal canula prong on the left nares. LVN 3 further stated both nasal canula prongs should be on both nares to administer the right amount of oxygen Resident 94 needs. During interview on 10/27/2023 at 10:19 a.m., with the Administrator (ADMN), the ADMN stated it was important to administer oxygen according to the physician's order. If the nasal canula was not applied properly, the residents will not get the right amount of oxygen they needed. The nasal cannula should not be too tight, it was a potential for skin beak down if not applied properly. During interview on 10/27/2023 at 10:57 a.m., with the DON, the DON stated oxygen nasal cannula prongs must be on both nostrils (right and left) for the resident to get the right amount of oxygen the resident's needs. The nasal cannula tubing was not supposed to be too tight. If too tight, it could possibly cause redness or skin breakdown. During a review of the facility's P&P titled, Oxygen Administration, revised date 6/5/2023, indicated oxygen is administered to residents who needs it, consistent with professional standards of practice, the comprehensive person -centered care plans, and the resident 's goals and preference. The P&P indicated the equipment needed for oxygen administration will depend on the type of delivery system ordered. Types of delivery system include a nasal cannula - Oxygen was administered through plastic cannula in the nostrils.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was admitted to the facility with no pressure ulcers and/or injuries (damaged skin caused by staying in one position for too long), was turned and repositioned every 2 hours to prevent the development of an unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough [yellow/white material consisting of dead cells that accumulate in the wound, contributing to delayed wound healing or eschar [collection of dry, dead tissue within a wound]). This failure resulted in Resident 1 developing an unstageable pressure ulcer on the sacrococcygeal (tail bone) area. Findings: During a review of Residents 1's admission Records, the admission records indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included difficulty in walking, anemia (lack of healthy red blood cells), and pulmonary hypertension (a type of high blood pressure that affects the arteries in the lungs and the right side of the heart). During a review of Resident 1's Minimum Data Set (MDS, standardized care and screening tool), dated 9/18/2023, the MDS indicated Resident 1 was severely impaired with cognitive skills for daily decision making (ability to think and reason). The MDS indicated Resident 1 required an extensive assistance and one-person physical assist with bed mobility, transfer, personal hygiene, and a two-person physical assist with toilet use. Section M0100S of the MDS indicated Resident 1 was at risk for pressure ulcers and the resident had no skin conditions and/or pressure ulcers upon admission. During a review of Resident 1's Braden Scale for Predicting Pressure Ulcer Risk (tool commonly used in health care to assess and document a resident's risk for developing pressure ulcers), dated 9/13/2023 at 3:28 p.m., the Braden Scale indicated Resident 1 was bedbound and had very limited mobility making position changes to the body or extremities (arms/legs) independently as factors for pressure ulcer development. The Braden Scale indicated Resident 1 had a score of 14, indicating the resident was at moderate risk for developing pressure ulcers. During a review of Resident 1's Braden Scale for Predicting Pressure Ulcer Risk, dated 9/19/2023 at 4:37 p.m., the Braden Scale indicated Resident 1 had a score of 15, indicating moderate risk. During a concurrent interview and record review on 10/7/2023 at 12:52 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 1's Medication Administration Record (MAR), for the month of September 2023, was reviewed. The MAR indicated Resident 1 was not repositioned every 2 hours from 9/11/2023 to 9/24/2023. LVN 1 stated Resident 1 was bed bound upon admission. LVN 1 stated from 9/11/2023 to 9/24/2023, there was no documentation indicating Resident 1 was being repositioned every 2 hours. LVN 1 further stated, If it was not documented, it was not done. During an interview with Family Member 1 (FM 1), on 10/7/2023 at 11:40 a.m., in Resident 1's room, FM 1 stated Resident 1 was not being turned, repositioned every 2 hours upon admission. FM 1 stated the facility started repositioning Resident 1 after the resident acquired an unstageable pressure ulcer on 9/22/2023. During a concurrent observation and interview with Treatment Nurse 1 (TN 1), on 10/7/2023 at 12:40 p.m., in Resident 1's room, Resident 1's unstageable pressure ulcer to the sacrococcygeal was observed. The unstageable pressure ulcer measured 9.0 centimeters (cm, unit of measurement) in length, 6.5 cm in width, and 0.4 cm in depth. The wound bed was observed with 100% slough. TN 1 stated residents that were high risk for pressure ulcer development were to be repositioned every 2 hours. During a concurrent interview and record review with TN 1, on 10/7/2023 at 1:26 p.m., Resident 1's care plans were reviewed. TN 1 stated there was no care plan upon Resident 1's admission addressing the resident's skin integrity. TN 1 stated Resident 1's care plan should have been initiated upon admission. TN 1 stated Resident 1 was unable to reposition herself upon admission and the resident's skin was intact from 9/11/2023 to 9/21/2023. During a record review of Resident 1's document titled Skin Evaluation, the document indicated the following: • 9/22/2023 - Resident 1 had an unstageable pressure ulcer to the sacrococcygeal area, measuring 8.0 cm in length, 6.1 cm in width, 80 percent (%) undetermined eschar, and 20 % yellow slough noted to the wound bed. • 9/25/2023 -Unstageable pressure ulcer to the sacrococcygeal area measuring 9.0 cm in length, 7.5 cm in width, and 100% necrotic tissue (premature death of cells or tissue from disease or injury) noted to the wound bed. • 10/02/2023 - Unstageable pressure ulcer measuring 9.0 cm in length, 6.5 cm in width, 0.4 cm in depth, and 100% yellow slough noted to the wound bed. During a concurrent interview and record review with TN 1, on 10/7/2023 at 6:24 p.m., Resident 1's medical records titled, Physical Therapy (PT) Notes, dated 9/12/2023, was reviewed. The notes indicated Resident 1's bed mobility was maximum assist. TN 1 stated maximum assist meant Resident 1 was unable to move. TN 1 stated if Resident 1 was repositioned every 2 hours there was a possibility Resident 1 would not have developed an unstageable pressure ulcer. TN 1 stated the facility failed to prevent Resident 1's pressure ulcer development. During a concurrent interview and record review with the Administrator, on 10/7/2023 at 7 p.m., Resident 1's MAR for the month of September 2023, the MDS dated [DATE], care plans, Braden Scale dated 9/13/2023 and 9/19/2023, and PT notes dated 9/12/2023 were reviewed. The Administrator verified the following: • The MAR indicated the resident was not turned and repositioned every (Q) 2hrs, from 9/11/2023 to 9/24/2023. • The MDS indicated Resident 1 was at risk for pressure ulcer development. • There was no initial care plan regarding Resident 1's skin integrity and risk for skin breakdown initiated upon admission. • A Braden Scale was not initiated until 9/13/2023, and a second Braden Scale dated 9/19/2023, indicated a score of 15 indicating the resident was now at moderate risk for pressure ulcer development. • The PT notes indicated Resident 1's baseline was maximum assist with bed mobility. The Administrator stated the facility failed to prevent the development of Resident 1's unstageable pressure ulcer by not repositioning Resident 1 every 2 hours and by not initiating a care plan for skin integrity upon admission. During a record review of the facility's Policy and Procedure (P&P) titled, Pressure injury prevention, revised date 10/2022, the P&P indicated the facility was committed to the prevention of avoidable pressure injuries, unless clinically unavoidable and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcer/injuries. Under Policy Explanation and compliance Guidelines: indicated: 3. Assessment of Pressure Injury Risk a. License nurse would conduct a pressure injury assessment using the Braden scale for predicting pressure ulcer risk, on all residents upon admission /re-admission, weekly times 3 more weeks, then quarterly or when ever the resident's condition changes significantly. b. The tool would be used in conjunction with the other risk factor not captured by the risk assessment tool. Example of risk factors indicated impaired/ decreased mobility and decreased functional ability, cognitive impairment, and exposure of the skin to urine and fecal incontinence (inability to control). 4. Interventions for prevention and to promote healing. a. After completing a thorough assessment/ evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. During a record review of the facility's P&P titled, Turning and Repositioning, revised date 9/12/2023, the P&P indicated it was the facility's policy to implement turning and repositioning as part of our systemic approach to pressure injury prevention and management. This policy establishes responsibilities and protocols for turning and repositioning. Under Policy Explanation and compliance guidelines: 1. Resident at risk of, or with existing pressure injuries, will be turned and repositioned , unless it is contraindicated due to medical condition. In this case, small shifts in repositioning will be employed. 2. Turning and repositioning is a primary responsibility of nursing assistant. However, nursing staff are expected to assist with turning and repositioning. 3. The facility has established routine turning and repositioning schedules consisting of every 2-4 hours, on the even hours, a maximum of thirty minutes before of after the schedule time will be allotted for the compliance with the schedule. 4. The frequency of turning and repositioning will be determined by the resident's: a. Tissue tolerance b. Level of activity and mobility c. Skin condition d. Overall medical condition e. Treatment goal f. Type of pressure distribution support in use(turning and repositioning is still required on specialty surface, but frequency may be reduced) g. Comfort levels

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident, who was receiving Zyprexa (an antipsychotic [a medication that works by altering brain chemistry to help reduce psychotic symptoms [including delusions (false beliefs) and hallucinations (seeing or hearing things that others do not see or hear)]medication that can treat several mental health conditions including schizophrenia), received care and services to prevent and manage constipation (condition when stools remain in the colon (large intestine) for too long, and the colon absorbs too much water from the stool, causing them to become hard and dry) as one of Zyprexa side effects for one of two sampled residents (Resident 1). (Cross referenced to F 758) The facility failed to: 1. Ensure the nursing staff monitored Resident 1 for signs and symptoms of constipation in accordance with the care plan titled Risk for constipation related to decreased mobility, use/side effects of medication, and psychoactive medication (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior). 2. Ensure the licensed nurses administered to Resident 1 prescribed Milk of Magnesia ([MOM] a laxative that works by drawing water into the intestines to induce bowel movement), fleets enema (works by increasing water in the intestine to hydrate and soften the stool to help produce a bowel movement) and Dulcolax suppository (inserted into the rectum [the opening at the far end of the digestive tract through which stool leaves the body] stimulates a bowel movement and softens stools to treat constipation) as ordered by the physician to prevent and treat constipation. These deficient practices resulted in Resident 1 experiencing constipation, requiring a transfer to a general acute care hospital (GACH) and diagnosed with a fecal impaction and bowel obstruction. Resident 1 underwent a digital dis-impaction (the use of fingers to manually remove stool from the rectum) and multiple enemas (medication injections of fluid used to cleanse or stimulate the emptying of the intestines). Findings: During a review of Resident 1's admission Record (AR), the AR indicated the resident was originally admitted to the facility on [DATE] with the diagnosis including schizophrenia (a mental disorder characterized by disruptions in thought process, perceptions, and social interactions). During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 12/26/2022, the MDS indicated Resident 1 had severely impaired cognitive skills (thought process) for daily decision-making and required extensive to total assistance with activities of daily living (ADLs). During a review of Resident 1's physician's orders (PO), the orders indicated the following prescribed medications: 1. Zyprexa (Olanzapine) 5 milligrams ([mg] unit of measurement) give one tablet by mouth two times a day for schizophrenia manifested by hallucinations [(m/b) a sensory experience of something that does not actually exist, delusions (false belief) and/or verbal aggression] ordered on 10/26/2022. Monitor side effects associated with Zyprexa including common-sedation, drowsiness, dry mouth, constipation, and blurred vision. 3. Fleet enema [an over-the-counter saline laxative that is administered rectally (the last several inches of the large intestine closest to the anus) softens and lubricates stools, making them easier to pass) 7-19 gram (gm)/118 milliliters (ml) (sodium phosphate) insert one enema application rectally as needed for constipation, if no results from suppository, dated 6/28/2022. 4. Dulcolax Suppository ([Bisacodyl] medication which stimulates a bowel movement and softens stools inserted into the rectum]) 10 mg, insert rectally as needed for constipation, if no results from Milk of Magnesia daily, dated 6/28/2022. 5. Milk of Magnesia (medication which increases water in the intestines to stimulate bowel movements) suspension 400mg/5ml, to give 30 ml by mouth as needed for constipation daily, if no bowel movement in four days, dated 6/28/2022. A review of the website DailyMed the common side effects of Zyprexa included lack of energy, dry mouth, increased appetite, sleepiness, tremor (shaking), having hard or infrequent stools, dizziness, changes in behavior, and/or restlessness https://dailymed.nlm.nih.gov/dailymed/ During a review of Resident 1's care plan (CP) dated 3/15/2019, titled Use of psychotropic medications related to (r/t) diagnosis of schizophrenia m/b hallucinations/delusions/verbal, the goal for Resident 1 was to remain free of psychotropic (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) drug related complications including constipation, and fecal impaction. According to this CP, the nursing staff had to observed Resident 1 Zyprexa side effects every shift. During a review of Resident 1's CP revised on 5/22/2022 tiled Risk for constipation related to decreased mobility, use/side effects of medication, and psychoactive medication, the CP indicated a goal for Resident 1 was to have a normal bowel movement. The CP also indicated the nursing staff interventions included monitoring Resident 1 for constipation as medication side effects, keeping the physician informed of any problems, and observe Resident 1 for sign and symptoms of complications related to constipation including small loose stools and fecal smearing. During a review of Resident 1's Intervention/Task flowsheet for December 2022, the flowsheet indicated Resident 1's bowel elimination from 12/10/2022 to 12/26/2022, documented as follows: 1. On 12/10/2022, the resident had one bowel movement which was medium in amount and constipated/hard in consistency. 2. From 12/11/2022 to12/16/2022, a total of six days, the resident had no bowel movements. 3. On 12/17/2022, the resident had two bowel movements, one which was small and putty-like in consistency and the second one was medium in amount and formed/normal in consistency. 4. On 12/18/2022, the resident had one bowel movement which was large and loose/diarrhea (a condition in which feces are discharged from the bowels frequently and in a liquid form) in consistency. 5. On 12/19/2022, the resident had no bowel movement. 6. On 12/20/2022, the resident had one bowel movement which was medium in amount and formed/normal in consistency. 7. From 12/21/2022 to 12/23/2022, a total of three days, the resident had no bowel movement. 8. On 12/24/2022, the resident had one bowel movement which was medium in amount and putty like in consistency. 9. On 12/25/2022, the resident had two bowel movements, one was large and loose/diarrhea in consistency and the second one was medium in size and putty like in consistency. During a review of Resident 1's Change of Condition (COC) progress note dated 12/26/2022, the COC indicated Resident 1 was transferred to the GACH for shortness of breath. During a review of Resident 1's GACH history and physical (H/P), dated 12/26/2022, the H/P indicated Resident 1 was diagnosed with a fecal impaction with and possible bowel obstruction requiring an admission to the GACH for further evaluation and treatment. During a review of Resident 1's GACH Radiology [(X-ray) a photographic or digital image of the internal composition of body part or internal organ] report, dated 12/30/2022, the X-ray report indicated Resident 1 had a large fecal material impacted in the dilated rectum (abnormally enlarged intestine) causing partial colonic [(colon) the longest part of the large intestine (a tube-like organ connected to the small intestine at one end and the anus (the opening at the far end of the digestive tract through which stool leaves the body) at the other end] obstruction. During a review of Resident 1's GACH's progress notes, dated 12/30/2022 and timed at 9:35 p.m., the progress notes indicated digital (finger) dis-impaction was performed and multiple hard stool pieces were removed. During a review of Resident 1's GACH Medication Administration Record (MAR) for the month of 12/2022, the MAR indicated Resident 1 received a fleet mineral oil enema on 12/26/2022, 12/31/2022, and 1/3/2023. During a review of Resident 1's physician orders, dated 1/3/2023, the physician orders indicated Resident 1 was re-admitted to the facility. During an interview on 2/9/2023 at 11:55 a.m. with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated putty-like bowel movement was not a normal consistency stool and must be reported to the charge nurse. During an interview on 2/9/2023 at 12:22 p.m. with the Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated putty-like consistency for bowel movements could mean the resident was constipated. During a review of Resident 1's MAR for the month of 12/2022, the MAR's documentation indicated from 12/10/2022 to 12/26/2022, a total of 17 days, Resident 1 did not exhibit any side effects of Zyprexa such as constipation [sic]. During a concurrent interview and record review on 2/9/2023 at 12:27 p.m. of Resident 1's MAR for the month of 12/2022 with the Director of Nurses (DON), the DON confirmed the MAR indicated from 12/10/2022 to 12/26/2022, a total of 17 days, the resident did not receive any doses of Dulcolax suppository, fleet enemas, and/or Milk of Magnesia. The DON stated putty-like bowel movement consistency was not normal. The DON stated Resident 1's bowel pattern should have been evaluated to determine what was normal for the resident. After the DON reviewed Resident 1's Intervention/Task flowsheet specific to the resident's bowel elimination for the month of 12/2022, the DON stated Resident 1's bowel pattern was not normal, and the licensed staff failed to monitor and identify signs and symptoms of constipation and provide interventions to prevent constipation and inform the physician. The DON could not provide any documentation the licensed staff had informed the physician regarding Resident 1's abnormal bowel movements pattern. The DON confirmed the facility's failure to monitor and provide interventions for Resident 1's constipation resulted in the resident's fecal impaction. The DON could not provide a policy regarding the facility's bowel management program. On the same day at 2:50 p.m., in a subsequent interview, the DON confirmed Resident 1 was receiving Zyprexa which have the side effect of constipation. During an interview on 2/10/2023 at 11:03 a.m. with the Registered Pharmacist (RPH), the RPH confirmed constipation was a side effect of Zyprexa and should be monitored. The RPH stated if a resident was already experiencing constipation, continued use of Zyprexa could worsen the constipation. During a review of the facility's policy and procedure (P/P) dated 9/2022 and titled, Provision of Quality of Care, the P/P indicated based on comprehensive assessments, the facility will ensure residents receive treatment and care by a qualified persons based on professional standards of practice and the comprehensive person-centered care plans. According to the P/P each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident, who was receiving the psychotropic drugs (any drug that affects brain activities associated with mental processes and behavior) Zyprexa (medication used to treat certain mental/mood conditions including schizophrenia [a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions]) was monitored for medication side effects for one of two sampled residents (Resident 1). The facility failed to: 1. Ensure the licensed nurses monitored Resident 1 for constipation (less than three bowel movements a week) related to intake of Zyprexa as indicated in the plan of care titled Use of psychotropic medications related to (r/t) diagnosis of schizophrenia m/b hallucinations/delusions/verbal and a care plan titled Resident at risk for constipation related to use/side effects of medication, and psychoactive medication (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior). 2. Ensure the licensed nurses administered to Resident 1 Dulcolax suppository (used to produce bowel movements in a short time), Fleet enemas (used to relieve constipation and cleanse the colon) and Milk of Magnesia (treatment for constipation) as prescribed by the physician whenever necessary (PRN) for constipation. 3. Ensure the licensed nurses notified Resident 1's physician that the resident was not having consistent bowel movements as per the resident's plan of care titled Resident at risk for constipation related to decreased mobility, use/side effects of medication, and psychoactive medication, and the facility's policy and procedure titled Use of Psychotropic Medication. These deficient practices resulted in Resident 1 experiencing constipation, requiring a transfer to a general acute care hospital (GACH) and diagnosed with a fecal impaction (a mass of dry, hard stool that cannot pass out of the colon (large intestine [long tube like organ connected to the small intestine at one end and the anus {the opening where stool comes out at the other}) and bowel obstruction (a partial or complete block of the small or large intestine that keeps food, liquid, gas, and stool from moving through the intestines in a normal way). Resident 1 underwent a digital disimpaction (the use of fingers to manually remove stool from the rectum) and multiple enemas (medication injections of fluid used to cleanse or stimulate the emptying of the intestines). Findings: During a review of Resident 1's admission Record (AR), the AR indicated the resident was originally admitted to the facility on [DATE] with the diagnosis including schizophrenia (a mental disorder characterized by disruptions in thought process, perceptions, and social interactions). During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 12/26/2022, the MDS indicated Resident 1 had severely impaired cognitive skills (thought process) for daily decision-making and required extensive to total assistance with activities of daily living (ADLs). During a review of Resident 1's physician's orders (PO), the orders indicated the following prescribed medications: 1. Zyprexa (Olanzapine) 5 milligrams ([mg] unit of measurement) give one tablet by mouth two times a day for schizophrenia manifested by hallucinations [(m/b) a sensory experience of something that does not actually exist, delusions (false belief) and/or verbal aggression] ordered on 10/26/2022. Monitor side effects associated with Zyprexa including common-sedation, drowsiness, dry mouth, constipation, and blurred vision. 3. Fleet enema [an over-the-counter saline laxative that is administered rectally (the last several inches of the large intestine closest to the anus) softens and lubricates stools, making them easier to pass) 7-19 gram (gm)/118 milliliters (ml) of Sodium Phosphate solution (a saline laxative that is thought to work by increasing fluid in the small intestine), insert one enema application rectally as needed for constipation, if no results from suppository, dated 6/28/2022. 4. Dulcolax Suppository ([Bisacodyl] medication which stimulates a bowel movement and softens stools inserted into the rectum]) 10 mg, insert rectally as needed for constipation, if no results from Milk of Magnesia daily, dated 6/28/2022. 5. Milk of Magnesia (medication which increases water in the intestines to stimulate bowel movements) suspension 400mg/5ml, to give 30 ml by mouth as needed for constipation daily, if no bowel movement in four days, dated 6/28/2022. According to website DailyMed the common side effects of Zyprexa included lack of energy, dry mouth, increased appetite, sleepiness, tremor (shaking), having hard or infrequent stools, dizziness, changes in behavior, and/or restlessness https://dailymed.nlm.nih.gov/dailymed/ During a review of Resident 1's care plan (CP) dated 3/15/2019, titled Use of psychotropic medications related to (r/t) diagnosis of schizophrenia m/b hallucinations/delusions/verbal, the goal for Resident 1 was to remain free of psychotropic (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) drug related complications including constipation, and fecal impaction. According to this CP, the nursing staff have to observed Resident 1 Zyprexa side effects every shift. During a review of Resident 1's CP revised on 5/22/2022 titled Resident at risk for constipation related to decreased mobility, use/side effects of medication, and psychoactive medication, the CP indicated a goal for Resident 1 was for the resident to have a normal bowel movement at least once every three days through the review date. The CP also indicated staff interventions included monitoring the resident for medication side effects of constipation and keeping the physician informed of any problems and observe sign and symptoms of complications related to constipation which include small loose stools and fecal smearing. During a review of Resident 1's Intervention/Task flowsheet for December 2022, the flowsheet indicated Resident 1's bowel elimination from 12/10/2022 to 12/26/2022, documented as follows: 1. On 12/10/2022, the resident had one bowel movement which was medium in amount and constipated/hard in consistency. 2. From 12/11/2022 to12/16/2022, a total of six days, the resident had no bowel movements. 3. On 12/17/2022, the resident had two bowel movements, one which was small and putty-like in consistency and the second one was medium in amount and formed/normal in consistency. 4. On 12/18/2022, the resident had one bowel movement which was large and loose/diarrhea (a condition in which feces are discharged from the bowels frequently and in a liquid form) in consistency. 5. On 12/19/2022, the resident had no bowel movement. 6. On 12/20/2022, the resident had one bowel movement which was medium in amount and formed/normal in consistency. 7. From 12/21/2022 to 12/23/2022, a total of three days, the resident had no bowel movement. 8. On 12/24/2022, the resident had one bowel movement which was medium in amount and putty like in consistency. 9. On 12/25/2022, the resident had two bowel movements, one was large and loose/diarrhea in consistency and the second one was medium in size and putty like in consistency. During a review of Resident 1's change of condition (COC) progress note dated 12/26/2022, the progress note indicated Resident 1 was transferred to the GACH for shortness of breath. During a review of Resident 1's GACH history and physical (H/P), dated 12/26/2022, the H/P indicated Resident 1 was found to have fecal impaction with possible bowel obstruction requiring an admission to the GACH for further evaluation and treatment. During a review of Resident 1's GACH Radiology report, dated 12/30/2022, the report indicated Resident 1 had a large fecal material impacted in the dilated rectum (abnormally enlarged intestine) causing partial colonic obstruction. During a review of Resident 1's GACH progress note, dated 12/30/2022 and timed at 9:35 p.m., the note indicated digital dis-impaction was performed and multiple hard stool pieces were removed. During a review of Resident 1's GACH Medication Administration Record (MAR), the MAR indicated Resident 1 received a fleet mineral oil enema (a medication which lubricates and softens the stool to produce a bowel movement) on 12/26/2022, 12/31/2022, and 1/3/2023. During a review of Resident 1's physician orders, dated 1/3/2023, the physician orders indicated Resident 1 was re-admitted to the facility. During an interview on 2/9/2023 at 11:55 a.m. with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated putty like bowel movement was not a normal consistency and must be reported to the charge nurse. During an interview on 2/9/2023 at 12:22 p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated putty like consistency for bowel movements could mean the resident was constipated. During a review of Resident 1's MAR for the month of 12/2022, the MAR's documentation indicated from 12/10/2022-12/26/2022 (17 days) Resident 1 did not exhibit any side effects of Zyprexa such as constipation. During a concurrent interview and record review on 2/9/2022 at 12:27 p.m. of Resident 1's MAR for the month of 12/2022 with the DON, the DON confirmed the MAR indicated from 12/10/2022-12/26/2022 (17 days), the resident did not receive any doses of Dulcolax suppository (medication which stimulates a bowel movement and softens stools), fleet enemas, and/or milk of magnesia (medication which increases water in the intestines in order to induce bowel movements). During an interview on 2/9/2023 at 12:27 p.m. with the Director of Nursing (DON), the DON stated putty-like consistency bowel movements was not normal, but it could depend on the resident's bowel pattern. After the DON reviewed Resident 1's intervention/task flowsheet specific to bowel elimination, dated 12/2022, the DON stated Resident 1's bowel [NAME] was not normal and the licensed staff failed to monitor Resident 1 and identify signs and symptoms of constipation, provide interventions to prevent constipation, and inform the physician. The DON could not provide any documentation the licensed staff had informed the physician regarding Resident 1's abnormal bowel movements or pattern. The DON confirmed the facility's failure to monitor and provide interventions for constipation lead to the resident experiencing fecal impaction. During an interview on 2/9/2023 at 2:50 p.m. with the DON, the DON confirmed Resident 1's MAR from 12/10/2022-12/26/2022 (17 days) indicated the licensed staff documented Resident 1 did not exhibit the side effects of Zyprexa such as constipation. In a subsequent interview at 2:50 p.m., the DON confirmed Resident 1 was receiving Zyprexa which has the side effect of constipation and agreed Zyprexa could be the reason why Resident 1 was experiencing constipation. During an interview on 2/10/2023 at 11:03 a.m. with the Registered Pharmacist (RPH), the RPH confirmed constipation was a side effect of Zyprexa and should be monitored closely. The RPH stated if a resident was already experiencing constipation, the continued use of Zyprexa can worsen the constipation. During a review of the facility's policy and procedure (P/P), dated 9/2/2022 and titled, Use of Psychotropic Medication, the policy indicated the effects of the psychotropic medication on a resident's physical, mental and psychosocial well-being will be evaluated on an ongoing basis including nursing assessments and medication monitoring parameters.