**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews, and facility policies, the facility failed to ensure two of 19 residents (R) (R6 and R15) weren't provided with nursing care and services to ensure their medical needs were met related to pain management for R6 and R15; administering medication without a physicians order for R15; and a pest infestation of gnats that were on the R6 left leg wound. Further, harm was identified to have occurred when R15 was administered Fluoxetine (Prozac) for forty-eight weeks after it was discontinued on 6/29/2023, resulting in increasing unusual behavior, a low-grade temperature, swelling in bilateral knees, and going from ambulating independently to not being able to ambulate. Findings included: A review of the facility policy titled Administering Medications dated April 2019 that medications are administered in a safe and timely manner, and as prescribed; only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so; the Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions; medications are administered in accordance with prescriber orders, including any required time frame; if a dosage is believed to be inappropriate or excessive for a resident, or medication has been identified as having potentially adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns; and the individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. A review of the facility policy titled Pain Assessment and Pain Management dated October 2022 revealed that the purposes of this procedure are to help the staff identify pain in the resident and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. Pain management is a multidisciplinary care process that includes the following: a. Assessing the potential for pain; b. Recognizing the presence of pain; d. Addressing the underlying causes of the pain. Review the resident's clinical record to identify conditions or situations that may predispose the resident to pain, including: a. musculoskeletal conditions: (1) degenerative joint disease; (2) rheumatoid arthritis. Contact the prescriber immediately if the resident's pain or medication side effects are not adequately controlled. A review of the facility policy titled Pressure Ulcer/Skin Breakdown, with a revision date of April 2018, revealed that the physician will assist the staff in identifying the type (for example, arterial or stasis ulcer) and characteristics (presence of necrotic tissue, status of wound bed, etc.) of an ulcer. The physician will help identify and define any complications. A review of the facility policy titled Pest Control dated May 2008 revealed that the facility shall maintain an effective pest control program. Policy Interpretation and Implementation. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. 1. A review of the admission Record for R15 revealed she was admitted to the facility on [DATE] and diagnoses of, but not limited to major depressive disorder, osteoarthritis, thyrotoxicosis, and unspecified dementia, severe, with other behavioral disturbances. A review of the resident's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was assessed as 00 which indicated severe cognitive impairment; no mood or behavior exhibited; that R15 required supervision/touching assistance with Activities of Daily Living (ADL) care; was independent with mobility requiring no mobility device; was receiving a scheduled pain medication; and not receiving any PRN (as needed) pain medication. A review of the care plan updated 6/4/2024 revealed that R15 is care planned for pain related to left knee diagnosis of osteoarthritis and low back pain. Interventions to be implemented included administering medications for the lower back and left knee as ordered. Monitor and document effectiveness every shift. An observation on 6/18/2024 at 11:25 am revealed R15 lying in bed with the covers bunched up around her waist. The resident was gripping the covers and grimacing. The resident's bilateral knees were observed to be swollen and the resident appeared to be in pain and discomfort. During the observation, the Licensed Practical Nurse (LPN) NN and a family member entered the room. The family member stated that both of R15's knees were swollen on the previous day as well (6/17/2024) and that R15 would not allow the family to touch her knees. The family was observed to ask R15 if she could touch her knees and promised to be gentle and R15 gave permission. The family stated that R15's left knee was warm to the touch. The LPN asked R15 if she would like something for pain and the resident nodded her head up and down. The LPN stated that R15 did not have an as-needed oral pain medication and would call the Nurse Practitioner (NP) regarding R15's pain. During an interview on 6/18/2024 at 11:40 am, LPN NN stated the NP gave an order for Tylenol for R15. The LPN explained to R15 that she had something for the pain. LPN NN was observed to administer two tablets of Tylenol 325 mg (milligrams) to R15 by mouth (PO). The resident took the medication without any problems. During the reconciliation of the medication pass, there was no physician order for Tylenol 325 mg, two tablets. A phone interview on 6/18/2024 at 10:33 am with the family of R15 stated they have filed several grievances with the facility regarding R15's care and services. The family expressed that their most recent concern when they visited R15 on 6/17/2024 was that R15 looked weak, sick, and was moaning and crying. The family stated something was going on with R15 because R15 was usually up walking without any type of assistive device and was usually attending activities. The family stated that R15 had been complaining of knee pain and this was reported to the charge nurse. The family stated the nurse applied Diclofenac Sodium ointment to both knees. The family stated the ointment is routine, the pain in the knees is different and no one bothered to notify the physician asking for something else for pain. The family stated the facility is quick to notify the family when R15 is combative and refusing medication, but no one notified the family that R15 had been in the bed lethargic, with a low-grade temperature (99.0 Fahrenheit), unable to stand or walk, and not her usual self. The family stated the nurse or Certified Nursing Assistant (CNA) should have taken notes, assessed R15, and notified the physician, NP, and/or psychiatrist of R15's change. The family stated there was a meeting with the Social Worker, Unit Manager (UM), and the Psychiatrist but could not give the exact date of the meeting. She stated that the Psychiatrist explained that he would discontinue the Citalopram (Celexa) and start Escitalopram (Lexapro). The family stated he gave the UM instructions during the phone conference to have the nurses document and notify him of any adverse reactions (i.e. overly sedated). The family stated they noticed a change in R15 after the most recent medication change was made by the psychiatrist. She stated that on 6/17/2024 the family visited and R15 appeared to be overly sedated, but the psychiatrist was not notified. The family stated she understood that R15 has dementia but what was going on with her was different and not related to the diagnosis of dementia. An interview on 6/18/2024 at 11:20 am with CNA DDD stated that R15 was usually up, dressed, and attending the facility's activities. She stated that today, R15 was limping when assisted with ADL care. She stated that R15 complained of knee pain. The CNA stated that she did let the charge nurse know that R15 complained of pain but did not give a reason why she did not inform the nurse. An observation of R15's medication administration on 6/20/2024 at 10:19 am with LPN NN the following medications were administered to R15: Amlodipine Besylate (Norvasc) 5 mg 1 Aspirin 81 mg 1 over-the-counter (OTC) Depakote sprinkle 125 mg 1 (placed in water) Diclofenac Sodium External Gel (applied to the right and left knee) Escitalopram (Lexapro) 5mg/5 milliliters (ml) Fluoxetine (Prozac) 10 mg 1 Metformin 500 mg 1 Methimazole 5 mg 1 Metoprolol Succinate Extended Release (ER) 50 mg 1 Multiple Vitamins 1 OTC Omeprazole 20 mg 1 Potassium Chloride ER 10 milliequivalent 1 Prednisone 10 mg 1 The resident looked inside the medication cup before taking the medications and shook her head to the left and right. The nurse explained what was in the cup and with multiple prompts the resident took the medication and drank two 8-ounce glasses of water. During the reconciliation of the medication pass, there was no physician order for Fluoxetine (Prozac) 10 mg. A review of the care plan updated 6/4/2024 revealed that R15 is care planned for depression and insomnia with intervention to administer antidepressant medications as ordered; monitor for a decline in ADL self-care and gait changes; and to notify the physician of the findings. A review of the Physician Order dated 6/29/2023 revealed discontinuation of Fluoxetine (Prozac) 10 mg. Discontinue Order ePrescription sent successfully 6/29/2023 3:25 pm to pharmacy. Ordered signed by the Medical Director. An interview on 6/20/2024 at 2:35 pm with LPN NN confirmed that the Fluoxetine (Prozac) 10 mg capsule is a medication that is in R15's strip pack. The LPN stated on the days that she works Fluoxetine (Prozac) is administered to R15. The LPN, with the assistance of the Assistant Director of Health Services, could not locate a physician order for the medication. The LPN checked the remaining strip packs on the cart and the Fluoxetine (Prozac) is one of the medications in the individual strip packs. The LPN stated she would talk to her Director of Health Services (DHS) immediately. A phone interview on 6/20/2024 at 3:35 pm with the Psychiatrist EEE regarding R15's medication. The Psychiatrist stated it is dangerous to give a person two selective serotonin reuptake inhibitors (SSRIs) due to it causing serotonin syndrome. He stated it can cause insomnia, poor appetite, agitation, or restlessness. He stated that he was called in on consult 6/28/2023 to see R15. He stated that Prozac was discontinued due to being a potentially harmful drug in the elderly. He stated that R15 was started on Escitalopram (Lexapro) on 6/28/2023. He stated because the resident continued to have a decline, he discontinued Escitalopram (Lexapro) and started Citalopram (Celexa). He stated a few weeks ago he had a conference call with the UM and family. He stated the family expressed that R15 was continuing to decline. He stated he discontinued the Citalopram (Celexa) and restarted the Escitalopram (Lexapro). He stated the UM was instructed at that time to notify him of any changes or behaviors R15 may have. The Psychiatrist stated if the Prozac was never stopped that would explain the resident's continued decline. He stated that receiving two SSRIs (Fluoxetine (Prozac) and Escitalopram (Lexapro) is not good. An interview on 6/21/2024 at 12:36 pm with the Pharmacist stated pharmacy has been dispensing a daily dose of Fluoxetine (Prozac) 10 mg from 7/28/2023-6/20/2024. The Pharmacist stated the first time they received an order to discontinue the medicine was on 6/20/2024. The pharmacist confirmed that the Fluoxetine (Prozac) was not on the resident's profile although it is being dispensed. She stated that the pharmacy has started pulling the resident's medication profile and comparing it with the framework of the APP machine that automatically dispenses the medications. She stated that currently, the pharmacy reconciles each patient's profile in the Electronic Medical Record system. She stated the pharmacy department is willing to go to the facility and do a complete cart audit. She stated what happened was not purposely done, it was an accident. An interview on 6/25/2024 at 4:58 pm with UM JJ stated the pharmacy delivers a strip pack of medications approximately every seven days. She stated the medications arrive on the 11: 00 pm to 7:00 am shift. The UM stated it is the responsibility of the nurse to verify the medications in the strip packs with the resident's Medication Administration Record (MAR) before the strip packs of medication are placed on the cart. She stated the physician should be notified for clarification if there are any discrepancies. The UM stated if a medication is in the strip pack and not on the resident's MAR the medication should not be given. She stated the physician should be notified for clarification. An interview on 6/25/2024 with the DHS stated that she expects the nurses to administer medication safely as prescribed by the physician. She stated she has started a skills check-off on medication administration for all the nurses. She stated the nursing staff has also started a facility-wide cart audit. 2. An observation and interview on 5/2/2024 at 11:30 am of R6 who was lying flat in the bed (B), the room was dark. The resident's mood was blunted, affect was sad. An observation of R6's right hand, left hand and fingers has a deformity. The resident had a white sheet covering his waist down to the upper part of his left leg. An observation of black gnats flying around and lying on the left leg. The Resident had a dressing on the left leg from the knee to the ankle dated 5/1/2024. The dressing was covered with a large amount of reddish-brown drainage. The resident was pleasant and agreed to speak with the surveyor. The resident stated he has bad Rheumatoid Arthritis in his fingers and shoulders that are painful. The resident stated he has never been seen by therapy for any type of braces on his hands or fingers. The resident stated he must ask for his pain medication because it is not a regularly scheduled medication. The resident stated the physician or nurse practitioner had never asked if he needed his oral pain medicine scheduled. During the interview, R6 stated he has had a vascular wound on his left leg for a long time. The resident stated gnats have always been a problem in the room. An observation on 5/3/2024, 5/7/2024, and 5/8/2024 of black gnats flying around and lying on R6's left leg. The Resident had a dressing on the left leg from the knee to the ankle the dressing was saturated with a large amount of reddish-brown drainage. A review of R6 admission Record revealed an admission date of 3/25/2021 with multiple diagnoses of, but not limited to, chronic pain, gout, and rheumatoid arthritis (RA). A review of the quarterly MDS assessment dated [DATE] revealed R6 presented with a BIMS score of fifteen, which indicated R6 was cognitively intact. The assessment further indicated the resident had a regularly scheduled pain medication and an as-needed pain medication. A review of the care plan updated 10/31/2024 revealed that R6 was care planned for rheumatoid arthritis. Interventions to be implemented included monitoring, documenting, and reporting to the physician as needed signs and symptoms or complications related to arthritis: joint pain, joint stiffness, contracture formation, and joint shape changes. A review of the Order Summary Report revealed an order for Oxycodone 10 mg every six hours as needed for pain related to chronic pain on 8/1/2023. A review of the Order Summary Report revealed an order for Tylenol 325 mg two every six hours as needed for chronic pain syndrome on 8/1/2023. A review of the Order Summary Report revealed an order for Diclofenac Sodium External Gel 1%. Apply half inch to shoulders topically four times a day, for seropositive rheumatoid arthritis on 3/27/2024. A review of the MAR for 4/1/2024 to 4/30/2024 revealed that R6 had a documented pain level of seven to nine on fifteen occasions. The resident requested and was given Oxycodone 10 mg 57 times. There was no documentation that the physician was notified of the frequency of the pain and administration of the as-needed medication. A review of the MAR for 5/1/2024 to 5/3/2024 revealed that R6 had a documented pain level of five to eight. The resident requested and was given Oxycodone 10 mg five times out of three days. There was no documentation that the physician was notified of the frequency of the pain and administration of the as-needed medication. During an interview on 5/7/2024 at 10:48 am, the Occupational Therapist (OT) stated the therapy department has never had R6 on caseload for hand braces. The OT explained that R6's right hand metacarpophalangeal (MCP) joint, also known as the knuckle, hyper flex, the proximal interphalangeal joint (PIP) that bends and extends the fingers is hyperextended, the distal interphalangeal (DIP) close to the fingernail is hyper flexed. The left-hand MCP is hyper-flexed, the PIP is flexed, and the DIP is hyper-flexed. The Therapist stated that R6 hands/fingers have a lot of inflammation that can be painful and cause discomfort. During an interview and observation on 5/8/2024 at 10:20 am of R6's wound, the Wound Care Physician confirmed the gnats on the resident's left leg dressing and the drainage. He stated the wound had a lot of moisture and that was attracting the gnats to the left leg. The Wound Care Physician stated he had seen gnats in the room on previous visits. During an interview on 5/9/2024 at 11:50 am, LPN OO stated that for the last two years, the facility had been having problems with gnats. LPN OO stated she had never reported the gnats to anyone, and she did not realize they were in R6's room that bad until the surveyor brought it to her attention. During an interview on 5/9/2024 at 11:54 am, UM JJ stated she was not aware of the gnat problem until the surveyor brought it to her attention on 5/2/2024 and 5/3/2024 and that she immediately reported the gnats to the Maintenance Department. During an interview on 5/15/2024, the DHS stated that she expects the nurses to assess the residents and notify the physician as needed. She stated that R6 was more relaxed since his pain medication had been adjusted. A review of the MAR for 4/1/2024 to 4/30/2024 revealed that R6 had a documented pain level of seven to nine on fifteen occasions. The resident requested and was given Oxycodone 10 mg 57 times. There was no documentation that the physician was notified of the frequency of the pain and administration of the as-needed medication. A review of the MAR for 5/1/2024 to 5/3/2024 revealed that R6 had a documented pain level of five to eight. The resident requested and was given Oxycodone 10 mg five times out of three days. There was no documentation that the physician was notified of the frequency of the pain and administration of the as-needed medication. During an interview on 5/7/2024 at 10:48 am, the Occupational Therapist (OT) stated the therapy department has never had R6 on caseload for hand braces. The OT explained that R6's right hand metacarpophalangeal (MCP) joint, also known as the knuckle, hyper flex, the proximal interphalangeal joint (PIP) that bends and extends the fingers is hyperextended, the distal interphalangeal (DIP) close to the fingernail is hyper flexed. The left-hand MCP is hyper-flexed, the PIP is flexed, and the DIP is hyper-flexed. The Therapist stated that R6 hands/fingers have a lot of inflammation that can be painful and cause discomfort. During an interview and observation on 5/8/2024 at 10:20 am of R6's wound, the Wound Care Physician confirmed the gnats on the resident's left leg dressing and the drainage. He stated the wound had a lot of moisture and that was attracting the gnats to the left leg. The Wound Care Physician stated he had seen gnats in the room on previous visits. During an interview on 5/9/2024 at 11:50 am, LPN OO stated that for the last two years, the facility had been having problems with gnats. LPN OO stated she had never reported the gnats to anyone, and she did not realize they were in R6's room that bad until the surveyor brought it to her attention. During an interview on 5/9/2024 at 11:54 am, UM JJ stated she was not aware of the gnat problem until the surveyor brought it to her attention on 5/2/2024 and 5/3/2024 and that she immediately reported the gnats to the Maintenance Department. During an interview on 5/15/2024, the DHS stated that she expects the nurses to assess the residents and notify the physician as needed. She stated that R6 was more relaxed since his pain medication had been adjusted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interviews, and the facility policy Administering Medications the facility failed to ensure one of forty-three sampled residents (R) (R15) was receiving medications as prescribed by the psychiatrist. The pharmacy continued to dispense Fluoxetine (Prozac) to R15 after it was discontinued on 6/29/2023 by the psychiatrist. Harm was identified to have occurred when R15 was administered Fluoxetine (Prozac) for forty-eight weeks after it was discontinued on 6/29/2023, resulting in increasing unusual behavior, a low-grade temperature, swelling in bilateral knees, and going from ambulating independently to not being able to ambulate. Findings included: A review of the facility policy titled Administering Medications dated April 2019 revealed that medications are administered in a safe and timely manner, and as prescribed. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. The Director of Nursing Services (DNS) supervises and directs all personnel who administer medications and/or have related functions. Medications are administered in accordance with prescriber orders, including any required time frame. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. During an observation of R15's medication administration on 6/20/2024 at 10:19 am with a Licensed Practical Nurse (LPN) NN, the following medications were observed to be administered to R15: Amlodipine Besylate (Norvasc) 5 milligrams (mg) 1 Aspirin 81 mg 1 over-the-counter (OTC) Depakote sprinkle 125 mg 1 (placed in water) Diclofenac Sodium External Gel (applied to the right and left knee) Escitalopram (Lexapro) 5mg/5 milliliters (ml) Fluoxetine (Prozac) 10 mg 1 Metformin 500 mg 1 Methimazole 5 mg 1 Metoprolol Succinate Extended Release (ER) 50 mg 1 Multiple Vitamins 1 (OTC) Omeprazole 20 mg 1 Potassium Chloride ER 10 milliequivalent 1 Prednisone 10 mg 1 During the reconciliation of the medication pass, there was no physician order for Fluoxetine (Prozac) 10 mg. A review of the admission Record for R15 revealed she was admitted to the facility on [DATE] with diagnoses of, but not limited to, major depressive disorder, osteoarthritis, thyrotoxicosis, and unspecified dementia, severe, with other behavioral disturbances. A review of the Psychiatrist Progress Note dated 6/28/2023 revealed that R15 was seen for initial psych evaluation and ongoing management of symptoms related to cognitive impairment/behaviors. Coordination of Care: Discussed with nursing, discussed with social services, reviewed medications, reviewed chart, discussion of medication side effects. Psychotropic medication (include dosage, frequency): Prozac 10mg by mouth (PO) every am for depression, Trazodone 50mg PO every night for sleep, Melatonin 3 mg PO every night for sleep, Depakote DR 125mg PO twice a day for mood/agitation. Recommendations for Primary Care Physician/Facility Staff: will stop Prozac and start R15 on Lexapro solution 10 mg PO every morning for agitated dysphoria. A review of the Physician Order dated 6/29/2023 revealed discontinuation of Fluoxetine (Prozac) 10 mg. Discontinue Order ePrescription Sent Successfully 6/29/2023 3:25 pm to the pharmacy. The order was signed by the Medical Director. A review of the Pharmacy Medication Regimen Review for July 2023 through May 2024 revealed the pharmacist conducted monthly reviews. There were no pharmacy recommendations for R15 and/or Fluoxetine (Prozac). A review of the Pharmacy Med Room, Med Cart & Nursing Station Inspection Report conducted by the Pharmacy Nurse Consultant from 9/8/2023 to 6/3/2024 revealed the nurse consultant conducted monthly medication cart audits twice a month. There was no documentation of a medication cart audit for R15. During an interview on 6/25/2024 at 1:00 pm, the Executive Director stated in August 2023 the facility was transitioning from one pharmacy to the current pharmacy. She stated that the current pharmacy physically picked up all the resident physician orders on or around 6/23/2023. She stated that the nursing staff were educated to fax all orders after 6/23/2023 to both pharmacies. She stated that R15 order to discontinue the Fluoxetine (Prozac) was on 6/29/2024 and should have been faxed to both pharmacies. The Executive Director stated the pharmacy did not reconcile R15's medication orders. She stated that the facility has started a medication cart audit, and the pharmacy is in the process of also completing a facility-wide medication cart audit. The medication cart audit is to ensure that residents are getting the medications as ordered by the physician. A post-survey telephone interview on 6/27/2024 at 1:00 pm with the Pharmacy Nurse Consultant stated onsite visits to the facility are conducted twice a month. She stated she is responsible for medication cart audits. The Nurse Consultant stated during her visits to the facility she does not audit every resident medication cart. She stated the medication cart audit is randomly selected. She is aware that the pharmacy continued to dispense a medication for R15 that had been discontinued. The Nurse Consultant stated she has not completed a medication cart audit on R15. She stated that the pharmacy has planned to come in on Friday 6/28/2024 and complete a facility-wide medication cart audit on the residents that are currently in the facility. Cross-refer to F-Tag 684 and 757

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of facility policy titled Administering Medications, the facility failed to ensure one of two residents (R) (R15) was free from unnecessary psychotropic medications. Resident (R15) was administered Fluoxetine (Prozac) during a medication observation. Harm was identified to have occurred when R15 was administered Fluoxetine (Prozac) for forty-eight weeks after it was discontinued on 6/29/2023, resulting in increasing unusual behavior, a low-grade temperature, swelling in bilateral knees, and going from ambulating independently to not being able to ambulate. Findings included: A review of the admission Record for R15 revealed she was admitted to the facility on [DATE] with diagnoses of, but not limited to, major depressive disorder, osteoarthritis, thyrotoxicosis, and unspecified dementia, severe, with other behavioral disturbances. A review of the resident's most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was assessed as 00 which indicated severe cognitive impairment. Section N R15 was assessed as receiving antidepressants in this assessment period. An observation of R15's medication administration on 6/20/2024 at 10:19 am with Licensed Practical Nurse (LPN) NN the following medications were administered to R15: Amlodipine Besylate (Norvasc) 5 milligrams (mg) 1 Aspirin 81 mg 1 (over the counter OTC) Depakote sprinkle 125 mg 1 (placed in water) Diclofenac Sodium External Gel (applied to the right and left knee) Escitalopram (Lexapro) 5mg/5 milliliters (ml) Fluoxetine (Prozac) 10 mg 1 Metformin 500 mg 1 Methimazole 5 mg 1 Metoprolol Succinate Extended Release (ER) 50 mg 1 Multiple Vitamins 1 (OTC) Omeprazole 20 mg 1 Potassium Chloride ER 10 milliequivalent 1 Prednisone 10 mg 1 During the reconciliation of the medication pass, there was no physician order for Fluoxetine (Prozac) 10 mg. A review of the Order Summary Report revealed a physician order dated 1/17/2024 Observe closely for side effects of Antipsychotic medication including dry mouth, constipation, blurred vision, disorientation or confusion, difficulty urinating, hypotension, dark urine, yellow skin, nausea or vomiting, lethargy, drooling, EPS symptoms (tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or tongue) every shift Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and progress note findings. An interview on 6/20/2024 at 2:35 pm with LPN NN confirmed that the Fluoxetine (Prozac) 10 mg capsule is a medication that is in R15's strip pack. The LPN stated on the days that she works Fluoxetine (Prozac) is administered to R15. She confirmed that the Fluoxetine (Prozac) was not listed on R15's Medication Administration Record (MAR). An interview on 6/25/2024 at 10:40 am with LPN NN stated she just started in the role as a nurse in February 2024. The LPN stated all her education/in-services have been provided by the staff in the facility. The LPN stated the facility does provide resources (i.e. Drug Handbooks) on each medication cart. She stated in the future she will make sure she is checking the MAR and the medication in the strip packs for accuracy. She stated if it is a question about the residents medication, she will notify the physician or Nurse Practitioner. The LPN expressed she is open and willing to learn. An interview on 6/25/2024 at 11:00 am with the Director of Health Services (DHS) stated that LPN NN was hired in 2/2024 and has not had a Medication Pass completed. She stated she would schedule a medication pass with the Pharmacy Nurse Consultant for LPN NN. She stated she would also do random medication passes with the nurses in the facility. She stated the staff will be in-service on medication passes and assess residents who are administered psychotropic medication. She stated the facility is in does not have a Staff Educator and is in the process of hiring someone. A post-survey telephone interview on 6/27/2024 at 1:00 pm with the Pharmacy Nurse Consultant stated onsite visits to the facility are conducted twice a month. She stated she is responsible for medication passes with the nursing staff. She stated She will conduct a medication pass with the nursing staff that are working during the time she is in the facility. The Pharmacy Nurse Consultant stated she has not done a medication pass with LPN NN. She stated she and the DHS would arrange to conduct a medication pass with LPN NN. A review of the facility policy titled Administering Medications dated April 2019 revealed that medications are administered in a safe and timely manner, and as prescribed. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. The Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions. Medications are administered in accordance with prescriber orders, including any required time frame. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Cross Refer to F-tag 684 and 755