**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on open and closed medical record reviews, interviews with staff, review of side effects for Paxlovid (an antiviral medication), review of interaction warning for Paxlovid medication, review of fact sheet on Paxlovid, review of hospital records, and facility policy review, the facility failed to adequately monitor residents for signs and symptoms of bleeding while taking an anticoagulant medication. This resulted in Immediate Jeopardy and serious life-threatening harm on [DATE] when Resident #56 was prescribed Paxlovid (an antiviral medication) twice daily for five days to treat COVID-19 infection while also taking Rivaroxaban (generic brand for Xarelto), an anticoagulant medication. The facility failed to monitor Resident #56 for signs of bleeding and the resident subsequently exhibited signs of internal bleeding on [DATE] without facility intervention including notification of the medical practitioner. The Immediate Jeopardy continued [DATE] when Resident #56 again had signs of internal bleeding and was noted to have a moderate amount of blood in her stool and complained of abdominal pain. Resident #56 became lethargic, pale, and difficult to arouse, was sent to the emergency room for evaluation and treatment where she passed away from a brain bleed and a gastrointestinal (GI) bleed. In addition, concerns that did not rise to the level of Immediate Jeopardy were identified when six additional residents (Resident #9, #15, #30, #42, #48, and #109) reviewed for anticoagulant medication administration were identified without a care plan and/or adequate monitoring for signs and symptoms of side effects (including bleeding) from the anticoagulant medications. This affected seven residents (Resident #9, #15, #30, #42, #48, #56, and #109) of eight residents reviewed for anticoagulant medications. The facility census was 59. On [DATE] at 3:41 P.M. the Director of Nursing (DON) and Unit Manager (UM) #101 were notified Immediate Jeopardy began on [DATE] when Resident #56 was prescribed Paxlovid (a medication to treat COVID-19) while concurrently being administered the anticoagulant medication, Xarelto without any increased monitoring for any signs and symptoms of bleeding or bruising despite the warning that the two medications could have a severe interaction causing increased bleeding. On [DATE], Resident #56 was noted to have reddish colored urine but staff failed to notify Certified Nurse Practitioner (CNP) #192 of the change in condition and failed to complete any additional monitoring for signs and symptoms of bleeding or bruising. On [DATE] at 2:19 P.M., Resident #56 was noted to have a moderate amount of blood in her stool and complained of abdominal pain. On [DATE] at 3:24 P.M., Resident #56 was lethargic, pale, and difficult to arouse. The resident was sent to the emergency room. On [DATE] at 9:43 P.M., the facility was notified by Resident #56's family the resident had passed away as a result of a brain bleed and a gastrointestinal (GI) bleed. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: • On [DATE] by 3:00 P.M. care plans for each resident who was receiving anticoagulant therapy were reviewed and updated to address anticoagulant therapy by Minimum Data Set (MDS) Nurse #128 with documentation on the care plan. This includes all potentially affected residents, Resident #8, #15, #258, #109, #30, #3, #50, #42, #37, #12, #9, #29, #6, #48, #44, #5, #41, #13, and #20. • On [DATE] by 3:00 P.M. each nurse (nine registered nurses and 12 licensed practical nurses) and 30 Nursing Assistantswere educated in person or telephonically regarding monitoring for adverse effects of anticoagulant therapy by DON, Unit Manager #149, Unit Manager #l01. • On [DATE] at 4:30 P.M. a discussion with Pharmacy Manager #220, Facility Pharmacist #221, Pharmacist #190, and Pharmacist #195 regarding drug interactions, process for contacting facility based on the level of severity of the interaction (mild/moderate/severe) and agreement was made for the pharmacy to call the facility for all severe interactions was held. Drug interactions will be assessed by the pharmacy. Their dispensing system will flag drug interactions as they verify the order and physician will be notified of potential interaction by facility. Pharmacist will not dispense medication and contact facility by phone. If there is a potential interaction, the pharmacy will not dispense medication until receiving verification from physician. The consulting pharmacist also completes a monthly review, the consulting pharmacist reviews the patient's current active medications every month and provides recommendations for nursing and medical staff follow-up. • On [DATE] by 5:00 P.M. all residents receiving anticoagulant therapy including Residents #15, #8, #258, #109, #30, #3, #50, #42, # 37, # 12, # 9, #29, #6, #48, #44, #5, #41, #13 and #20 had skin assessments completed by nurse weekly. The skin assessment monitors for any new areas on the skin including signs of adverse effects of anticoagulant. These residents were assessed by the nurse with no adverse effects found. • On [DATE] at 6:00 P.M. information was provided to the facility Quality Assessment and Performance Improvement (QAPI) Committee for review and additional guidance. The Medical Director provided input and approved the facility's abatement plan on 03/l 7/23 at 6:00 P.M. • On [DATE] by 7:00 P.M. each nurse was educated in person or telephonically regarding the process for handing potential drug interactions by the DON, Unit Manager #149, or Unit Manager #101. Drug interactions will be assessed by the pharmacy. Their dispensing system will flag drug interactions as they verify the order and physician will be notified of potential interaction by facility. If the drug is flagged for an interaction, the pharmacy will not dispense medication until receiving verification from physician. • On [DATE] by 8:00 P.M. a whole house audit for residents receiving anticoagulants was completed by the Director of Nursing (DON) or designee. No residents were noted to have adverse side effects from anticoagulants. Orders were verified to be in place and updated to monitor for adverse effects of anticoagulant therapy and if noted to report to the physician as clinically indicated for all residents who have orders for it. This was completed on [DATE] at 2:36 P.M. by Nurse Unit Manager #101. • On [DATE] by 8:00 P.M. all 30 State Tested Nursing Assistants (STNAs) were educated to report any signs of bleeding or bruising to the nurse and to ensure that the nurse visualized the concern by the DON, Unit Manager #149, or Unit Manager #101. • On [DATE] by 8:00 P.M. the DON, Unit Manager #149, or Unit Manager # 101 completed an audit on all residents receiving anticoagulation therapy to include physician orders and care plans for monitoring adverse effects i.e.: bruising and bleeding. Residents #8, #15, #42, #258, #109, #30, #3, #37, #12, #9, #44, #5, and# 41 had care plans with anticoagulant monitoring. These care plans were reviewed and updated as necessary with documentation of the additions. The audit showed that Residents #50, #29, # 6, #48, #13, and #20 did not have care plans that addressed monitoring for adverse effects of anticoagulants. Appropriate interventions were added by the MDS Nurse #128 by 6:00 P.M. on [DATE]. • On [DATE] by 8:00 P.M. the DON developed a monitoring tool and implemented monitoring tool and process of adverse effects of anticoagulant medications. This was implemented on [DATE] by 12:00 P.M. Monitoring tool will include list of residents on anticoagulant therapy and verification that monitoring was completed as ordered. This monitoring will be completed by DON, Unit Manager #149, or Unit Manager #101 that was trained on [DATE] by 8:00 P.M. • On [DATE] by 12:00 P.M. the facility implemented a plan for audits to be conducted twice a week for two weeks and then weekly for a month by the DON, Unit Manager #149, or Unit Manager #101 to check for orders and care plans for monitoring of adverse effects of anticoagulant medications for all resident who have received them. • On [DATE] at 12:00 P.M. the facility implemented a plan for audits on drug interactions and ensuring appropriate follow-up were completed and will be reviewed weekly by the QAPI Committee for two weeks. QAPI team will provide further guidance and monitoring as needed. • On [DATE] at 3:00 P.M. the DON implemented an audit tool to monitor for appropriate follow up on each drug interaction and MMR made by the pharmacy. Audits will be conducted twice a week for 2 weeks and then weekly for a month by DON or designee. • On [DATE] at 5:00 P.M. each nurse (12 LPNs and 9 RNs) were educated in person or via telephone regarding the process for handling potential drug interactions by the DON, Unit Manager #149, or Unit Manager #101. • On [DATE] at 9:18 A.M. interviews with RN #152, STNA #160 and STNA #167 revealed all staff interviewed had received facility education related to anticoagulant medication use, drug interactions and/or monitoring for signs/symptoms of bleeding/bruising. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings Include: 1.Review of the closed medical record for Resident #56 revealed an admission date on [DATE] and a discharge date due to death on [DATE]. Medical diagnoses included major depressive disorder, anxiety disorder, gastrostomy status, tracheostomy status, unspecified psychosis, hypertension (HTN), malignant neoplasm of unspecified female breast, unspecified open wound of unspecified part of head, unspecified fractures of lower left femur, neck, multiple ribs on left side, and shaft of left clavicle, and displaced fracture of sixth cervical vertebra. Review of a hospital discharge record dated [DATE] (prior to admission to the facility) revealed Resident #56 sustained multiple fractures from a motor vehicle accident. Resident #56 was prescribed the anticoagulant medication, Xarelto for a diagnosis of coagulopathy (a condition in which the blood's ability to form clots is impaired). Resident #56 received surgical intervention to repair injuries to her left leg. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #56 had impaired cognition with a Brief Interview for Mental Status (BIMS) score of three out of 15. The assessment revealed Resident #56 required extensive assistance to total dependence from one to two staff to complete activities of daily living (ADLs). The assessment did not indicate Resident #56 had received an anticoagulant medication daily. The assessment was incorrect as the resident had received an anticoagulant daily. Review of the physician's orders revealed Resident #56 had a medication order, dated [DATE] for Rivaroxaban (generic for Xarelto) 20 milligrams (mg) via peg tube one time daily for prevention. The medication was ordered by Physician #200. On [DATE] the resident had an order for Paxlovid (300/100) oral tablet therapy pack twenty X 150 milligrams (mg) and ten X 100 mg with instructions to give 300 mg via peg-tube two times daily for COVID-19 for five days and give 100 mg via peg tube two times a day for COVID-19 for five days. The medication was ordered by Certified Nurse Practitioner (CNP) #192. There was not a physician order to monitor for side effects or signs and symptoms of bleeding in place. Review of the Paxlovid order, dated [DATE] at 3:59 P.M. revealed the medication had an ALERT! Drug Interaction. The alert was located on the right-hand side in the electronic medical record when the physician order was clicked on to be viewed. Review of the Drug-to-Drug Interaction Details, viewed when the medication alert was clicked on in the electronic medical record, revealed there was a severe interaction with Rivaroxaban (Xarelto) medication which stated, Coadministration of rivaroxaban with combined Paxlovid should be avoided according to official package labeling in the United States. Review of an electronic Medication Administration Record (eMAR) note, titled Orders-Administration Note in the progress notes section of the electronic medical record, dated [DATE] at 4:01 P.M. revealed the system had identified a possible drug interaction with a severity of severe with Rivaroxaban with plasma concentrations and pharmacologic effects of Rivaroxaban may be increased in combination with Paxlovid. Coadministration of Rivaroxaban with Paxlovid should be avoided according to official package labeling in the United States. Review of the resident's care plan revealed the plan of care did not address anticoagulant medication or monitoring for signs and symptoms of bleeding or bruising. Review of a progress note from Certified Nurse Practitioner (CNP) #192 dated [DATE] revealed Resident #56 was seen for follow up due to COVID-19 diagnosis. Resident #56's medications were reviewed and reconciled. Care included to start COVID-19 protocol, Paxlovid 150/100 therapy pack twice daily for five days due to Resident #56's COVID-19 positive diagnosis. There was no mention of a possible interaction with Xarelto medication. Review of a progress note from CNP #203 dated [DATE] revealed Resident #56 was seen for follow up related to COVID-19 diagnosis. The resident's medications were reviewed and reconciled, and the resident would continue medications, including Paxlovid 300 mg twice daily. There was no mention of a possible interaction with Xarelto medication. Review of the Medication Administration Record (MAR) dated [DATE] revealed Resident #56 received Rivaroxaban daily as ordered and Paxlovid twice a day for five days (a total of ten doses) from [DATE] to [DATE] as ordered. Review of progress notes dated from [DATE] through [DATE] revealed on [DATE] at 6:40 A.M., an unidentified State Tested Nursing Assistant (STNA) reported to Licensed Practical Nurse (LPN) #107 that Resident #56's urine color appeared reddish. Resident #56's vital signs were within normal limits and the resident denied any pain. The morning shift nurse (unidentified) was notified. There was no evidence the CNP or physician were notified of the change in condition. On [DATE] at 2:19 P.M., a progress note entered by Registered Nurse (RN) #152 revealed an unidentified STNA called the nurse to Resident #56's room. The resident had a moderate amount of blood in stool and Resident #56 complained of pain to abdomen. The resident's blood pressure was 112/60. CNP #205 was notified and new orders for an abdominal x-ray, complete blood count (CBC), and complete metabolic panel (CMP) were provided. On [DATE] at 3:24 P.M. (approximately one hour later), a progress note entered by RN #152 revealed Resident #56 was lethargic, pale, and difficult to arouse. Resident #56's temperature was 100.3 degrees Fahrenheit and blood pressure was 141/97. CNP #205 was notified and a new order to send Resident #56 to the emergency room was given. On [DATE] at 9:43 P.M., a progress note entered by RN #156 revealed Resident #56's family called to notify the facility that Resident #56 had passed away as a result of a brain bleed and a gastrointestinal (GI) bleed. Review of hospital records, dated [DATE] at 4:02 P.M. revealed Resident #56 had a history of deep vein thrombosis and was on Xarelto medication. The resident presented to the hospital for an evaluation of unresponsiveness. The records noted staff checked on Resident #56 at 1:00 P.M. and she had complained of abdominal pain and when checked again at 3:30 P.M., the resident was unresponsive. At 5:20 P.M., the radiologist reported Resident #56 had a large intraparenchymal hemorrhage of the right frontal lobe with mass-effect and vasogenic edema (a brain bleed). KCentra (a medication to reverse effects of anticoagulant) and Vitamin K were ordered. The family reported Resident #56 had dark stools and there was concern for GI bleeding. A rectal exam was performed and was positive for bloody stool. Troponin levels were elevated likely due to blood loss and hemoglobin was 7.1. Resident #56 was admitted to the Intensive Care Unit (ICU) for further critical care treatment. Resident #56 was pronounced deceased on [DATE] at 9:30 P.M. at the hospital. Interview on [DATE] at 2:51 P.M. with the Director of Nursing (DON) revealed Resident #56 was fine and was not on the radar for any concerns except weight gain prior to [DATE]. The DON stated she was notified on [DATE] of Resident #56's bloody stool. The DON was not aware and had not been notified of reddish colored urine on [DATE]. The DON confirmed Resident #56 was on an anticoagulant medication, Xarelto, and reddish colored urine would be a potential sign of bleeding. The DON stated she would have expected the CNP to be notified by the staff, additional monitoring for any other possible signs or side effects, a urine sample to be obtained and sent out for testing, and possibly additional lab work to be ordered. Interview on [DATE] at 3:57 P.M. with CNP #192 revealed she had not been notified that Resident #56 had reddish colored urine on [DATE]. CNP #192 stated she was not aware of any signs or symptoms of bleeding prior to [DATE]. CNP #192 confirmed Resident #56 was on Xarelto, an anticoagulant. CNP #192 stated staff noted resident concerns in a binder that she reviewed when she was on-site at the facility. CNP #192 confirmed the binder did not note any reddish colored urine for Resident #56. CNP #192 stated had she been notified of the change, she would have requested a more detailed description of the urine, ordered labs, and would have wanted the staff to continue monitoring for any signs or symptoms of bleeding (including blood in urine, blood in stool, or any increased bruising). Interview on [DATE] at 4:36 P.M. with CNP #192 revealed drug interactions between medications occur constantly and she would only consider stopping an anticoagulant if the interaction was a severe interaction. CNP #192 stated she assessed the benefits versus the risks of continued administration of Paxlovid and Xarelto together and felt the benefits outweighed the risks at that time to treat COVID-19 infection. CNP #192 confirmed she was aware of the possible severe interaction between the two medications and confirmed administering Paxlovid with Xarelto may increase bleeding. CNP #192 confirmed she should have been notified of Resident #56's reddish colored urine on [DATE] and would have expected staff to be monitoring Resident #56 of any signs or symptoms of bleeding while on the anticoagulant medication. Interview via telephone on [DATE] at 9:53 A. M. with Pharmacist #190 revealed she was a new consulting pharmacist who conducted monthly medication reviews at the facility since [DATE]. Pharmacist #190 stated a national software was used to identify drug interactions. If a severe interaction was identified, Pharmacist #190 notified the physician/DON/nurse manager directly due to the need for immediate attention as well as write a pharmacy recommendation. The pharmacist revealed it was the prescriber of the medication who made the final decision whether to continue administering the medications. Pharmacist #190 stated Paxlovid was a new medication and interacted with several medications. Pharmacist #190 confirmed Paxlovid administered with Xarelto could increase bleeding. Interview via telephone on [DATE] at 11:06 A.M. with Pharmacist #195 revealed he was a pharmacist with Complete Pharmacy Solutions, the pharmacy used to fill the facility's medication prescriptions. Pharmacist #195 stated medication orders were received via fax, electronically, or verbally but the bulk of the facility's orders were received by fax. Pharmacist #195 confirmed he checked for medication interactions with new prescriptions to ensure it was clinically safe to administer the medications prior to filling the prescription. If a severe interaction was identified, Pharmacist #195 stated he contacted the floor nurse who cared for the resident of the possible interaction. Pharmacist #195 confirmed there was risk for increased bleeding when Paxlovid and Xarelto were administered together. Pharmacist #195 stated a risk assessment would be completed with the floor nurse to review the benefits versus the risks of continuing administration of the medications together. Pharmacist #195 confirmed Paxlovid and Xarelto administered together would be a more major drug interaction with an increased risk of increased bleeding. Pharmacist #195 stated the resident should be monitored for signs and symptoms of increased bleeding. Pharmacist #195 confirmed Paxlovid was dispensed to the facility on [DATE] and confirmed Resident #56 was also on Xarelto for a long time. Pharmacist #195 stated the order was called in to the pharmacy by Nurse #207 and the same nurse would have been notified of the possible severe drug interaction. Interview via telephone on [DATE] at 4:50 P.M. with Physician #200 revealed he was aware Resident #56 was taking Paxlovid and Xarelto together to treat COVID-19 infection. Physician #200 revealed he felt the benefits outweighed the risks of administering the medications together at the time. However, Physician #200 confirmed the facility staff absolutely should have notified himself and/or the CNP of any signs or symptoms of bleeding for Resident #56. Physician #200 confirmed he was not notified of Resident #56's reddish colored urine on [DATE]. Physician #200 stated had he been notified of the reddish colored urine on [DATE], increased monitoring would have been initiated in an attempt to identify the cause of the reddish colored urine. Review of Paxlovid: What Prescribers and Pharmacists Need to Know, dated [DATE], revealed, there is uncertainty about effect magnitude in target populations and high certainty for harm with Paxlovid if drug interactions are not mitigated. Additionally, the fact sheet showed the recommendation if a resident was on Rivaroxaban (Xarelto) was do not coadminister, hold and restart two days after completing Paxlovid, and significant questions in drug concentrations expected. Do not coadminister due to risk of serious toxicity. If possible, use alternative COVID-19 agent. If not possible, then: low risk of clot: hold rivaroxaban. 24 hours after the last dose of rivaroxaban, start Paxlovid AND aspirin 81 mg daily. Finish Aspirin one day after completing Paxlovid. Restart Rivaroxaban two days after completing Paxlovid. High Risk of clot: hold rivaroxaban. 24 hours after the last dose of rivaroxaban, start Paxlovid AND therapeutic dosing of a subcutaneous low molecular weight heparin (LMWH). Finish LMWH one day after completing Paxlovid. Restart Rivaroxaban two days after completing Paxlovid. Review of Paxlovid Side Effects Center, dated [DATE], revealed Paxlovid had an established significant drug interaction with Rivaroxaban. Clinical comments included, Increased bleeding risk with Rivaroxaban. Avoid concomitant use. Review of the facility policy titled, Anticoagulation-Clinical Protocol, revised 11/2018, revealed the policy stated, as part of the initial assessment, the physician and staff will identify individuals who are currently anticoagulated. Assess for any signs or symptoms related to adverse drug reactions due to the medication alone or in combination with other medications. Assess for evidence of effects related to the subtherapeutic or greater than therapeutic drug level related to that particular drug (for example, a resident with an above therapeutic level of an anticoagulation medications should be assessed for bleeding.) The physician will prescribe anticoagulation therapy appropriately, consistent with recognized guidelines. The physician will collaborate with the consultant pharmacist and nursing staff to identify potentially serious medication interactions with anticoagulants. The physician should adjust the anticoagulant dose or stop, taper, or change medications that interact with the anticoagulant. If an individual on anticoagulation therapy shows signs and symptoms or evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant as indicated. Review of the undated facility policy, Medications and Treatment Orders, revealed: • If a medication triggers with a severe interaction when putting it in resident's orders, physician will be notified, and pharmacy will verify medication· with the provider. This will also be documented in resident's chart. • When there is a medication which triggers with severe interactions and physician or NP chooses to continue with this medication therapy rational will be documented in a resident's record. • Medications which have the potential for adverse reactions or side effects including anticoagulants, antibiotics etc . will have increased monitoring to meet assessment heeds. If any adverse reactions or side effects are noted, physician or NP will be notified immediately. 2. Review of Resident #9's medical record revealed an initial admission date of [DATE] and readmission date on [DATE]. Medical diagnoses included dementia with other behavioral disturbance, unspecified atrial fibrillation, presence of cardiac pacemaker, chronic kidney disease Stage 3, and metabolic encephalopathy. Review of the care plan dated [DATE] revealed Resident #9's care plan addressed the resident taking an anticoagulant medication with interventions to monitor for signs and symptoms of bleeding. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #9 had impaired cognition and scored a six out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #9 required supervision from staff to complete Activities of Daily Living (ADLs). Resident #9 was administered anticoagulant medication daily. Review of the physician's orders for [DATE] revealed Resident #9 had an order for Eliquis (an anticoagulant medication) 5 milligrams (mg) with instructions to give one tablet by mouth twice daily for atrial fibrillation. The order had a start date of [DATE]. There were not any orders to monitor for side effects or signs and symptoms of bleeding until [DATE] when an order was added (after surveyor intervention). Review of the Medication Administration Records (MARs) and Treatment Administration Records (TARs) dated [DATE], February 2023, and [DATE] revealed Resident #9 received Eliquis medication twice daily as ordered unless the resident refused the medication. There was no evidence of any monitoring for side effects or bleeding noted on the MAR or the TAR for any of the three months. Review of progress notes dated from [DATE] through [DATE] revealed there was no evidence Resident #9 was monitored for any signs or symptoms of bleeding or side effects of anticoagulant medication. Interview on [DATE] at 3:49 P.M. with the Director of Nursing (DON) confirmed there was no evidence Resident #9 was being monitored for side effects or signs and symptoms of bleeding while being administered an anticoagulant medication. 3. Review of Resident #30's medical record revealed an original admission date on [DATE] and a readmission date on [DATE]. Medical diagnoses included chronic obstructive pulmonary disease (COPD), orthostatic hypotension, end stage renal disease, paroxysmal atrial fibrillation, and Type II Diabetes Mellitus. Review of the plan of care dated [DATE] revealed Resident #30 had a history of deep vein thrombosis (blood clots). Interventions included to monitor/document/report as needed any signs or symptoms of blood clots including abnormal bleeding, bruising, or petechiae (related to anticoagulant use). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #30 had intact cognition and scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #30 required extensive assistance to total dependence from one to two staff to complete Activities of Daily Living (ADLs). Resident #30 received daily anticoagulant medication. Review of physician's orders dated [DATE] revealed Resident #30 had an order for Eliquis (an anticoagulant medication) 2.5 milligrams (mg) with instructions to give one tablet twice daily for deep vein thrombosis (blood clot) prophylaxis. This order was dated [DATE] and the medication started [DATE]. There were no additional orders to monitor for side effects or signs and symptoms of bleeding until [DATE] when an order was added (following surveyor intervention). Review of the Medication Administration Records (MARs) and Treatment Administration Records (TARs) dated [DATE], February 2023, and [DATE] revealed Resident #30 received anticoagulant medication twice daily as ordered. There was no evidence in the MARs or TARs Resident #30 was monitored for any side effects or signs and symptoms of bleeding while taking the anticoagulant medication. Review of the progress notes dated from [DATE] to [DATE] revealed there was not any evidence Resident #30 was monitored for side effects or signs and symptoms of bleeding. Interview on [DATE] at 3:49 P.M. with the Director of Nursing (DON) confirmed there was no evidence Resident #30 was being monitored for side effects or signs and symptoms of bleeding while being administered an anticoagulant medication. Review of the facility policy, Anticoagulation-Clinical Protocol, revised 11/2018, revealed the policy stated, the physician will order appropriate lab testing to monitor anticoagulant therapy and potential complications: for example, periodically checking hemoglobin/hematocrit, platelets, PT/INR, and stool for occult blood. The staff and the physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems. If an individual on anticoagulation therapy shows signs and symptoms or evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant as indicated. 4. Review of Resident #15's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included acute respiratory failure with hypoxia, pneumonia, acute myocardial infarction, hemiplegia, metabolic encephalopathy, diabetes, acute kidney failure and heart failure. Review of Resident #15's physician orders dated [DATE] revealed an order for L[TRUNCATED]