**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review , the facility failed to ensure 67 out of 67 residents (residents who received Levaquin [a brand name for levofloxacin, a type of antibiotic known as fluoroquinolone used to treat bacterial infections] and Metformin [a medication that helps control the amount of glucose (sugar) in the blood]) (Residents 392, 389, 122, 130, 127, 124, 383, 393, 132, 83, 126, 391, 125, 129, 388, 68, 7, 10, 82, 52, 41, 394, 123, 390, 70, 384, 21, 387, 133, 93, 74, 385, 326, 381, 103, 47, 377, 222, 89, 49, 46, 106, 131, 323, 16, 22, 33, 63, 50, 23, 386, 128, 111, 322, 4, 71, 80, 99, 15, 382, 2, 64, 26, 17, 380, 90, and 65) were free from unnecessary medications when there was inadequate monitoring and systemic failure in management of residents on medications with black box warning (BBW, is the strongest warning the Food and Drug Administration [FDA-it is a federal agency responsible for protecting and promoting public health by regulating and supervising food safety, medications, medical devices, cosmetics, and other products] gives for prescription drugs. It highlights serious or life-threatening risks associated with a medication, signaling to healthcare professionals and patients that they should be aware of potential dangers and use the drug with caution) like Levaquin and Metformin. They are as follows: 1. During a record review of the pharmacy list of residents who had Levaquin from January 2025 to June 2025, it revealed the following: 1a. 54 out of 54 residents (Residents 392, 389, 122, 130, 127, 124, 383, 393, 132, 83, 126, 391, 125, 129, 388, 68, 7, 10, 82, 52, 41, 394, 123, 390, 70, 384, 21, 387, 133, 93, 74, 385, 326, 381, 103, 47, 377, 222, 89, 49, 46, 106, 131, 323, 16, 22, 33, 63, 50, 23, 386, 128, 111, and 322) who received Levaquin, did not have documentation that the BBW was being monitored related to Levaquin use; 1b. 54 out of 54 residents (Residents 392, 389, 122, 130, 127, 124, 383, 393, 132, 83, 126, 391, 125, 129, 388, 68, 7, 10, 82, 52, 41, 394, 123, 390, 70, 384, 21, 387, 133, 93, 74, 385, 326, 381, 103, 47, 377, 222, 89, 49, 46, 106, 131, 323, 16, 22, 33, 63, 50, 23, 386, 128, 111, and 322) who received Levaquin, did not have a care plan developed related to Levaquin's BBW; and 1c. 30 out of 54 residents (Residents 392, 389, 122, 130, 127, 383, 391, 125, 129, 7, 394, 123, 390, 70, 384, 387, 133, 93, 103, 122, 89, 49, 106, 16, 50, 23, 386, 74, 128, and 385) who received Levaquin did not have an appropriate indication or diagnosis (specific and accurate identification of a disease, condition, or injury based on a patient's signs, symptoms, and medical history. 2. During a record review of the facility's list of residents who received Metformin from June 1, 2025, to June 17, 2025, it revealed the following: 2a. 19 out of 19 residents (Residents 4, 71, 80, 99, 15, 47, 222, 382, 83, 2, 64, 26, 17, 7, 10, 82, (380, 90, and 65) who received Metformin did not have documentation that the BBW was being monitored related to Metformin use; and 2b. 19 out of 19 residents (Residents 4, 71, 80, 99, 15, 47, 222, 382, 83, 2, 64, 26, 17, 7, 10, 82, 380, 90, and 65) who received Metformin did not have a care plan developed related to Metformin's BBW. 3. Six out of six residents (Residents 47, 222, 83, 7, 10, and 82) received both Levaquin and Metformin without proper documentation of the medications BBW monitoring and had no care plan developed related to the medications' BBW. 4. The facility's Infection Preventionist (IP) failed to identify and report the facility's irregularities related to frequent prescription and Levaquin use, missed BBW monitoring, inappropriate diagnosis of antibiotic use and no care plans for Levaquin use with BBW; . 5. The facility's Consultant Pharmacist (CP) failed to identify and report the facility's irregularities related to frequent prescription and Levaquin use, missed BBW monitoring, inappropriate diagnosis of antibiotic use and no care plans for Levaquin use with BBW during the medication regimen review (MRR) for 67 out of 67 residents. Due to these systemic failures (as stated above) with potential to affect all residents who received or still receiving Levaquin and Metformin medications, the facility needed to take immediate action to correct the noncompliance. On 6/18/2025 at 2:56 p.m., an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified and declared, in the presence of the facility's Administrator (ADM) and director of nursing (DON) related to above failures. On 6/23/2025 at 3:56 p.m., the IJ was removed after the ADM submitted an acceptable IJ Removal Plan (IJRP, a plan with interventions to immediately correct the deficient practices), and after the survey team verified and confirmed the corrective actions while onsite. The failures had the potential for residents to suffer a serious adverse effect on: A. Levaquin use including tendinitis (the inflammation or irritation of a tendon, [the fibrous tissue that connects muscles to bones]), tendon rupture (a tear in a tendon, it can result in significant pain, swelling, and inability to move the affected joint), numbness or tingling or pricking sensation pins and needles in arms or legs, muscle weakness, muscle pain, joint pain, joint swelling, anxiety, depression, hallucinations, suicidal thoughts, confusion, worsening of myasthenia gravis (a chronic autoimmune disorder in which antibodies destroy the communication between nerves and muscles, resulting in weakness of the skeletal muscles), and abnormal, rapid or strong heartbeat; and B. Metformin use including lactic acidosis (a condition where too much lactic acid [a chemical your body produces when your cells break down carbohydrates for energy] builds up in the body, causing the blood to become too acidic) especially on residents with impaired kidney function, heart failure, or other conditions that can reduce oxygen supply to tissues. Findings: 1a. During a concurrent interview with the IP and document review of the facility's Infection Prevention and Control Surveillance Log on 6/12/2025 at 1:23 p.m., the IP confirmed Resident 68 and Resident 89 received Levaquin, and both residents did not have any documentation of BBW monitoring. During an interview with the director of nursing (DON) on 6/13/2025 at 3:10 p.m., DON stated staff used the Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) to document the medication's black box warning. DON further stated, the nurse would click on the black box beside the medication and the BBW would show up and nurses should document their monitoring in the progress notes. During a concurrent interview with both DON and IP and record review of Resident 68 and Resident 89's e-MAR (electronic MAR) on 6/13/2025 at 3:45 p.m., IP stated whenever nurses would administer the Levaquin to the resident, the BBW would pop up in their system and nurses would document in the resident's progress note if they monitored the BBW. IP further stated nurses from three different shifts (Days, Evening, and Night shift) monitored Resident 68 and Resident 89 related to Levaquin's BBW. During an interview on 6/13/25 at 3:50 p.m. with licensed vocational nurse L (LVN L) she was asked about her understanding of the BBW for the medication Levaquin. She responded that Levaquin has a rare side effect of tendonitis, it is very painful, can be excruciating pain in a tendon. This must be addressed right away. The doctor should be called right away if the resident experiences this side effect. LVN L also stated in the MAR, the medication will have a black box that nurses will click on prior to administering the medication which will show what precautions to observe for. During an interview with registered nurse I (RN I) on 6/13/2025 at 3:51 p.m., RN I stated they monitored Levaquin's adverse side effects, but she was not sure about the BBW. During an interview with licensed vocational nurse J (LVN J) on 6/13/2025 at 3:57 p.m., LVN J stated the BBW warning should be documented in the progress notes. LVN J confirmed only day shift licensed nurses would be alerted about the Levaquin's BBW because they were the ones who administered the medication. LVN J stated evening and night shift nurses would not be alerted to monitor the BBW because they did not administer the medication. During an interview with licensed vocational nurse K (LVN K) on 6/16/2025 at 10:02 a.m., LVN K confirmed the BBW for Levaquin use would show up before the medication administration and nurses should document that the Levaquin's BBW were monitored. LVN K stated evening and night shift nurses would not be able to document because the BBW would not pop up in their electronic documentation. During an interview with medical director (MD) on 6/18/2025 at 9:45 a.m., MD confirmed she was aware that Levaquin was being prescribed especially by old, schooled doctor, and we talked about this before. MD stated when a medication with BBW was ordered, she expected licensed nurses (LN) to monitor residents on medication with BBW and to communicate with the doctors and pharmacists. During a review of the facility's policy and procedure titled, Black Box Warning Medication Policy, date revised 2/5/2025, indicated, Purpose: To ensure the safe use, monitoring, and documentation of medications that carry an FDA Black Box Warning, which indicates a serious or life-threatening risk associated with the drug. Policy: All medications with a Black Box warning must be reviewed for clinical appropriateness and administered with careful monitoring .4. Documentation: Nursing progress notes must reflect monitoring and resident response. Due to the inconsistencies with staff statements and the above policy and procedure review, the survey team reviewed all residents who received Levaquin from January 2025 to June 17, 2025. For Resident 21: Review of Resident 21's clinical record titled, admission Record, indicated she was admitted on [DATE] with diagnoses including infection and inflammatory reaction (the body's immune system's response to injury or infection, characterized by redness, swelling, heat, pain, and sometimes loss of function) due to internal left hip prosthesis (artificial hip joint), aortic valve stenosis (narrowing of the valve in the large vessel branching off the heart {aorta} and hypertension (high blood pressure). Review of Resident 21's physician order, dated 2/21/25, indicated Levaquin 750 mg once daily for wound infection until 3/5/25. Review of Resident 21's 2/2025 and 3/2025 MAR , indicated Resident 21 received Levaquin 750 mg daily at 8 p.m. from 2/21/25 until 3/5/25. Review of Resident 21's nursing progress notes dated 2/21 - 3/10/2025, indicated there was no documented monitoring by licensed staff related to the BBW potential serious adverse effects for the use of Levaquin. For Resident 33: Review of Resident 33's clinical record titled, admission Record, indicated she was admitted on [DATE] with diagnoses including fracture right pubis (a break in the pubic bone, part of the pelvis), osteoarthritis (degenerative joint disease , a condition where the protective cartilage within joints gradually wears down, leading to pain, stiffness, and reduced range of motion) and hypertension (high blood pressure). Review of Resident 33's physician order, dated 5/4/25, indicated Levaquin 500 mg one time only for suspected UTI (Urinary Tract Infection , a bacterial infection that affects any part of the urinary system, including the kidneys, bladder, ureters, and urethra). An additional physician order, dated 5/6/25, indicated Levaquin 500 mg STAT (immediately) for UTI. An additional physician order dated 5/7/25 indicated Levaquin 500 mg one time a day for UTI for 2 days. Review of Resident 33's 5/2025 MAR indicated Resident 33 received Levaquin 500 mg on 5/4/25 at 5:05 p.m., 500 mg at 5:31 p.m. on 5/6/25, and 500 mg at 9:00 a.m. on 5/7/25 and 5/8/25. Review of Resident 33's nursing progress notes dated 5/4 - 5/15/2025, indicated there was no documented monitoring by licensed staff related to the BBW potential serious adverse effects for the use of Levaquin. For Resident 74: Review of Resident 74's clinical record titled, admission Record, indicated she was admitted on [DATE] with diagnoses including acute kidney failure, rhabdomyolysis (breakdown of muscle tissue that releases damaging protein into the blood) and hypertension (high blood pressure). Review of Resident 74's physician order, dated 1/5/25, indicated Levaquin 500 mg daily for infection for 5 days. An additional physician order, dated 2/10/25, indicated Levaquin 500 mg daily for suspected URI (upper respiratory infection , a common illness caused by viruses or bacteria that infect the nose, throat, and sinuses) for 6 days. An additional physician order, dated 4/26/25, indicated Levaquin 250 mg two tablets STAT for suspected UTI. Review of Resident 74's 1/2025, 2/2025 and 4/2025 MAR indicated Resident 74 received Levaquin 500 mg at 1:00 p.m. from 1/5/25 through 1/9/25, 500 mg at 9:00 a.m. from 2/10/25 through 2/16/25, and 500 mg at 7:53 p.m. on 4/26/25. Review of Resident 74's 1/2025, 2/2025 and 4/2025 nursing progress notes indicated there was no documented monitoring by licensed staff related to the BBW potential serious adverse effects for the use of Levaquin. For Resident 93: Review of Resident 93's clinical record titled, admission Record, indicated he was admitted on [DATE] with diagnoses including chronic peripheral venous insufficiency (veins have problems sending blood from the legs back to the heart), idiopathic peripheral autonomic neuropathy (damage to the nerves that control automatic body functions) and hypertension (high blood pressure). Review of Resident 93's physician order, dated 2/2/25, indicated Levaquin 500 mg one time only for possible UTI. An additional physician order, dated 2/6/25, indicated Levaquin 500 mg daily for suspected UTI for 6 days. An additional physician order, dated 3/5/25, indicated Levaquin 500 mg one time only for UTI. An additional physician order, dated 3/7/25, indicated Levaquin 500 mg daily for UTI for 7 days. Review of Resident 93's 2/2025 and 3/2025 MAR indicated Resident 93 received Levaquin 500 mg at 7:51 p.m. on 2/2/25, 500 mg at 9:00 a.m. from 2/6/25 through 2/11/25, 500 mg at 5:12 p.m. on 3/5/25, and 500 mg at 9:00 a.m. from 3/8/25 through 3/14/25. Review of Resident 93's 2/2025 and 3/2025 nursing progress notes indicated there was no documented monitoring by licensed staff related to the BBW potential serious adverse effects for the use of Levaquin. For Resident 122: Review of Resident 122's clinical record titled, admission Record, indicated he was admitted on [DATE] with diagnoses including intracardiac thrombosis (formation of clots within the chambers of the heart), chronic kidney disease, chronic embolism (a blockage in your blood vessel usually from a blood clot) and thrombosis of deep vein of lower extremity Blood clot present in deep vein of leg for an extended period of time), long term use of anticoagulants (medication to prevent or treat blood clots). Review of Resident 122's physician order, dated 3/3/25, indicated Levaquin 500 mg STAT for suspected UTI. An additional physician order, dated 3/13/25, indicated Levaquin 500 mg one time only for UTI. An additional physician order, dated 3/14/25, indicated Levaquin 500 mg one time only daily for UTI for 6 days. An additional physician order dated 4/13/25 indicated Levaquin 500 mg daily for suspected UTI for 2 days. Review of Resident 122's 3/2025 and 4/2025 MAR indicated Resident 122 received Levaquin 500 mg at 8:37 a.m. on 3/3/25, 500 mg at 11:04 p.m. on 3/13/25, 500 mg at 9:00 a.m. from 3/14/25 through 3/19/25, 500 mg at 5:12 p.m. on 3/5/25, 500 mg at 9:00 a.m. from 3/8/25 through 3/14/25, 500 mg at 2:38 p.m. on 4/13/25, and 500 mg at 9:00 a.m. on 4/14/25. Review of Resident 122's 3/2025 and 4/2025 nursing progress notes indicated there was no documented monitoring by licensed staff related to the BBW potential serious adverse effects for the use of Levaquin. For Resident 123: Review of Resident 123's clinical record titled, admission Record, indicated she was admitted on [DATE] with diagnoses including pneumonia (an infection of the lungs that causes inflammation of the air sacs [alveoli]), diabetes mellitus (blood sugar levels are too high), congestive heart failure (heart does not pump the blood efficiently), chronic pain syndrome, and obesity. Review of Resident 123's physician order, dated 1/4/25, indicated Levaquin 500 mg daily for infection for 5 days. An additional physician order, dated 2/18/25, indicated Levaquin 500 mg daily for bronchitis for 5 days. Review of Resident 123's 1/2025 and 2/2025 MAR indicated Resident 123 received Levaquin 500 mg at 9:00 a.m. from 1/4/25 through 1/8/25, and 500 mg at 9:00 a.m. from 2/18/25 through 2/22/25. Review of Resident 123's 1/2025 and 2/2025 nursing progress notes indicated there was no documented monitoring by licensed staff related to the BBW potential serious adverse effects for the use of Levaquin. For Resident 124: Review of Resident 124's clinical record titled, admission Record, indicated he was admitted on [DATE] with diagnoses including infection and inflammatory reaction due to internal prosthetic devices (an artificial device or implant that is surgically placed inside the body to replace a missing or damaged internal body part or function), polyneuropathy, (nerves in different parts of the body are damaged), diabetes mellitus (blood sugar levels are too high), Chronic Obstructive Pulmonary Disease (COPD, progressive lung disease that makes it hard to breathe), end stage renal disease (ESRD, irreversible kidney failure), dependance on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). Review of Resident 124's physician order, dated 1/8/25, indicated Levaquin 500 mg daily every 2 days for Acute UTI for 6 administrations. Review of Resident 124's 1/2025 MAR indicated Resident 21 received Levaquin 500 mg daily at 8:00 p.m. on 1/8/25, 1/10/25, 1/12/25, 1/14/25, 1/16/25, and 1/18/25. Review of Resident 124's nursing progress notes dated 1/8 -1/25/25, indicated there was no documented monitoring by licensed staff related to the BBW potential serious adverse effects for the use of Levaquin. For Resident 125: Review of Resident 125's clinical record titled, admission Record, indicated he was admitted on [DATE] with diagnoses including acute kidney failure, disease of the pancreas (a gland located in the abdomen, behind the stomach. It plays a crucial role in digestion, and blood sugar regulation), chronic viral hepatitis C (infection caused by a virus that attacks the liver) Review of Resident 125's physician order, dated 1/16/25, indicated Levaquin 500 mg one time only for suspected infection. Review of Resident 125's 1/2025 MAR indicated Resident 125 received Levaquin 500 mg daily one time only at 12:47 p.m. on 1/16/25. Review of Resident 125's nursing progress notes dated 1/16 -1/25/2025, indicated there was no documented monitoring by licensed staff related to the BBW potential serious adverse effects for the use of Levaquin. For Resident 126: Review of Resident 126's clinical record titled, admission Record, indicated he was admitted on [DATE] with diagnoses including pneumonia (inflammation or infection in the lungs), diabetes mellitus (blood sugar levels are too high), hypertension (high blood pressure), pulmonary embolism (arteries in the lungs become blocked by a blood clot). Review of Resident 126's physician order, dated 1/6/25, indicated Levaquin 500 mg daily for pneumonia for 6 days. Review of Resident 126's 1/2025 MAR , indicated Resident 126 received Levaquin 500 mg daily at 9:00 a.m. from 1/7/25 through 1/10/25. Review of Resident 126's nursing progress notes dated 1/7 - 1/15/2025, indicated there was no documented monitoring by licensed staff related to the BBW potential serious adverse effects for the use of Levaquin. For Resident 388: Review of Resident 388's clinical record titled, admission Record, indicated she was admitted on [DATE] with diagnoses including chronic kidney disease, hypertensive heart disease (heart problems that develop with chronic high blood pressure), atherosclerosis of aorta (build-up of plaque (a localized, abnormal patch or deposit on a body part or surface, often composed of accumulated substances) in the aorta {main artery of the heart}, pleural effusion ((build-up of fluid around the lungs). Review of Resident 388's physician order, dated 1/15/25, indicated Levaquin 750 mg one time only for pneumonia. Review of Resident 388's 1/2025 MAR indicated Resident 388 received Levaquin 750 mg daily at 9:58 p.m. on 1/14/25. Review of Resident 388's nursing progress notes dated 1/14 - 1/20/2025, indicated there was no documented monitoring by licensed staff related to the BBW potential serious adverse effects for the use of Levaquin. During an interview and concurrent record review on 6/18/25 at 10:00 a.m. with registered nurse H (RN H), she reviewed the records for Residents 21, 33, 74, 93, 122, 123, 124, 125, 126, and 388. RN H confirmed there was no monitoring documented on the MAR or in the licensed nurse progress notes related to the BBW potential serious adverse effects for the use of Levaquin for the above - mentioned residents. RN H stated the nurses progress notes do identify the residents are receiving an antibiotic but there is no specific mention of Levaquin's BBW. For Resident 10: Review of Resident 10's face sheet (FS: a document that gives resident's information at a quick glance) indicated Resident 10 was admitted to facility on 4/8/2019. Review of Resident 10's diagnoses included diabetes type 2 (a chronic condition that happens with persistent high blood sugar levels) and psoriasis (a condition in which skin cells build up and form scales and itchy, dry patches). Review of Resident 10's physician orders dated 2/7/2025 indicated Levaquin 500 milligram (mg: a unit of mass equal to one-thousandth of a gram) one time a day for 6 days for respiratory infection. Review of Resident 10's electronic medication administration record (EMAR: digital system for documenting medication administration) for February/2025 indicated Resident 10 received Levaquin from 2/7/2025 to 2/13/2025 at 9:00 a.m. Review of Resident 10's nursing progress notes for February/2025 indicated there was no documented evidence that nursing staff monitored and documented BBW serious adverse reactions every shift for Levaquin use. Resident 377: Review of Resident 377's FS indicated Resident 377 was admitted to facility on 4/10/2025. Review of Resident 377's diagnoses included diverticulosis (when small, bulging pouches [called diverticula] form in the lining of your intestine, usually the colon) of large intestine (part of body organ responsible for processing indigestible food materials) and infection (inflamed and infected lining of the large intestine) and inflammatory reaction (complication following knee surgery with infection inflammation) due to internal right knee prothesis (an artificial device that replaces a missing or impaired part of the body). Review of Resident 377's order summary report, date ordered 5/20/2025, indicated an order of Levaquin 500 mg one time a day for 5 days for respiratory infection. Review of Resident 377's EMAR for May/2025 indicated Resident 377 received Levaquin from 5/20/2025 to5/25/2025 at 9:00 a.m. Review of Resident 377's nursing progress notes for May/2025 and June/2025 till 6/14/2025 indicated there was no documented evidence that nursing staff monitored and documented BBW serious adverse reactions every shift for Levaquin use. Resident 222: Review of Resident 222's FS indicated Resident 222 was admitted to facility on 5/22/2025. Review of Resident 222's diagnoses included cellulitis of right lower limb (a skin infection of right leg). Review of Resident 222's order summary report, date ordered 5/22/2025, it indicated an order of Levofloxacin 750 mg one time a day until 5/25/2025 for cellulitis. Review of Resident 222's EMAR for May/2025 indicated Resident 222 received Levofloxacin from 5/23/2025 to 5/25/2025 every day at 9:00 a.m. Review of Resident 222's nursing progress notes for May/2025 and June/2025 till 6/14/2025 indicated there was no documented evidence that nursing staff monitored and documented BBW serious adverse reactions every shift for Levaquin use. Resident 49: Review of Resident 49's FS indicated Resident 49 was admitted to facility on 2/5/2025. Review of Resident 49's diagnoses included urinary tract infection (an infection of system of body organs that makes urine) and unspecified Escherichia coli (common bacteria found in human gut, commonly harmless. However, certain strains cause infections and illnesses). Review of Resident 49's order summary report, date ordered 5/29/2025, it indicated an order of Levaquin 500 mg one time for infection for 1 day. Review of Resident 49's EMAR for May/2025 indicated Resident 49 received Levaquin on 5/29/2025 (one dose) at 7:23 p.m. Review of Resident 49's nursing progress notes for May/2025 and June/2025 till 6/14/2025 indicated there was no documented evidence that nursing staff monitored and documented BBW serious adverse reactions every shift for Levaquin use. Resident 106: Review of Resident 106's FS indicated Resident 106 was admitted to facility on 2/26/2025. Review of Resident 106's diagnoses included diabetes type 2 and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to arms and legs). Review of Resident 106's order listing report date ordered 5/28/2025, it indicated an order of Levaquin 500 mg one time a day for infection until 6/24/2025. Review of Resident 106's EMAR for May/2025 indicated Resident 106 received Levaquin on 5/28/2025 till 5/31/2025 at 9:00 a.m. Review of EMAR for June/2025 indicated Resident 106 currently receiving Levaquin every day at 9:00 a.m. Review of Resident 106's nursing progress notes for May/2025 and June/2025 till 6/14/2025 indicated there was no documented evidence that nursing staff monitored and documented BBW serious adverse reactions every shift for use of Levaquin. Resident 323: Review of Resident 323's FS indicated Resident 323 was admitted to facility on 2/7/2025 and discharged home on 5/18/2025. Review of Resident 323's diagnoses included diabetes type 2 and pseudomonas as the cause of diseases (type of bacteria common cause of infections from mild skin rashes to severe, life-threatening illnesses). Review of Resident 323's order summary report, date ordered 5/15/2025, it indicated an order of Levaquin 500 mg one time a day for right thigh wound infection for 14 days, and this order had been discontinued on 5/18/2025. Review of Resident 323's EMAR for May/2025 indicated Resident 323 received Levaquin on 5/16/2025 and 5/17/2025 at 5:00 p.m., (2 doses). Review of Resident 323's nursing progress notes for May/2025 and June/2025 till 6/14/2025 indicated there was no documented evidence that nursing staff monitored and documented BBW serious adverse reactions every shift for Levaquin use. Resident 16: Review of Resident 16's FS indicated Resident 16 was admitted to facility on 3/1/2025 and discharged from facility on 6/6/2025. Review of Resident 16's diagnoses included diabetes type 2 and aftercare following neoplasm surgery (monitoring healing, managing potential complications and ensuring overall well-being during recovery after tumor [abnormal tissue growth] surgery). Review of Resident 16's order listing report, date ordered 5/21/2025, it indicated an order of Levofloxacin 500 mg stat (immediately or at once) for cough. Review of Resident 16's EMAR for May/2025 indicated Resident 16 received Levofloxacin on 5/21/2025 at 12:06 pm., (one dose). Review of Resident 16's nursing progress notes for May/2025 and June/2025 till 6/6/2025 indicated there was no documented evidence that nursing staff monitored and documented BBW serious adverse reactions every shift for Levofloxacin use. For Resident 22: Review of Resident 22's FS indicated Resident 22 was admitted to facility on 1/30/2023. Review of Resident 22's diagnoses included congestive heart failure (chronic condition where the heart muscle is unable to pump enough blood to meet body's needs) and disorder of urinary system (a condition impacts the body's ability to filter and pass urine). Review of Resident 22's order listing report, date ordered 5/8/2025, it indicated an order of Levaquin 250 mg one time a day for respiratory infection for 7 days. Review of Resident 22's EMAR for May/2025 indicated Resident 22 received Levaquin from 5/8/2025 till 5/14/2025 at 9:00 a.m. Review of Resident 22's nursing progress notes for May/2025 and June/2025 indicated there was no documented evidence that nursing staff monitored and documented BBW serious adverse reactions every shift for use of Levaquin. Resident 63: Review of Resident 63's FS indicated Resident 63 was admitted to facility on 3/1/2025. Review of Resident 63's diagnoses included hypertension (a condition in which the force of the blood against the artery [a blood vessel that carries blood from heart to tissues and organs in the body] walls is too high). Review of Resident 63's order summary report, date ordered 5/15/2025, it indicated an order of Levaquin 500 mg one time only for PNA (pneumonia: inflammation and fluid in lungs [a pair of spongy. Pinkish-gray organs essential for breathing and gas exchange] caused by infection) and this order had been extended for 6 more days till 5/21/2025. Review of Resident 63's EMAR for May/2025 indicated Resident 63 received Levaquin from 5/15/2025 till 5/21/2025 (7 doses) at 9:00 a.m. Review of Resident 63's nursing progress notes for May/2025 and June/2025 till 6/14/2025 indicated there was no documented evidence that nursing staff monitored and documented BBW serious adverse reactions every shift for use of Levaquin. For Resident 322: Review of Resident 322's FS indicated Resident 322 was admitted to facility on 11/4/2024 and discharged from facility on 2/7/2025. Review of Resident 322's diagnoses included diabetes type 2 and chronic kidney (kidney: body organ that filters waste and excess fluid from blood) disease (progressive damage and loss of function in the kidneys). Review of Resident 322's order listing report, date ordered 12/28/2024, it indicated an order of Levaquin 500 mg one time a day for respiratory infection for 6 days. Review of Resident 322's EMAR for December/2024 and January/2025 indicated Resident 322 received Levaquin on 12/29/2024 to 1/3/2025(6 doses) at 9:00 a.m. Review of Resident 322's nursing progress notes for December/2024 and January/2025 indicated there was no documented evidence that nursing staff monitored and documented BBW serious adverse reactions every shift for use of Levaquin. During an interview with RN O on 6/16/2025 at 4:00 pm, RN O stated medications' severe allergic reaction was different from BBW serious adverse reactions . RN O also stated there was no monitoring of BBW serious adverse reactions for residents on medications with BBW. RN O further stated nursing staff should have[TRUNCATED]