Health inspection·September 9, 2025

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 1 (Resident #1) of 8 residents reviewed for unnecessary drugs.The facility failed to discontinue 4 medications (mirtazapine, escitalopram, tizanidine, and tramadol) as documented in the physician orders in Resident #1's hospital discharge records dated 08/01/25.This failure could place residents at risk of harm due to medication side effects and/or medication interactions.Findings Included:Record review of Resident #1's admission record dated 09/09/25 revealed a [AGE] year-old female admitted to the facility on [DATE] from an acute care hospital. She had diagnoses that included, but were not limited to, metabolic encephalopathy (problems in the brain from chemicals in the blood), acute pancreatitis (sudden inflammation of the pancreas resulting in severe abdominal pain), acute kidney failure (sudden episode of kidney failure that happens in hours or days), and unspecified depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).Record review of Resident #1's admission MDS completed on 08/14/25 revealed a BIMS score of 00 which indicated severely impaired cognition. Section N Medications of the MDS revealed Resident #1 was receiving antidepressant and opioid medication.Record review of Resident #1's care plan initiated on 08/02/25 revealed she had impaired cognitive function due to her diagnosis of metabolic encephalopathy and was at risk for depression. She was noted to be receiving escitalopram and mirtazapine to address this risk. One of the interventions was to Administer medications as ordered. Resident #1 was noted to have chronic pain. Tramadol and tizanidine were listed as the medications to address her pain.Record review of Resident #1's discontinued, struck out, and completed orders revealed mirtazapine, escitalopram, tizanidine, and tramadol were all discontinued on 08/25/25.Record review of Resident #1's active order summary revealed the following orders with corresponding start dates:08/25/25 Acetaminophen Oral Tablet 500 MG (Acetaminophen) Give 2 tablet by mouth every 8 hours as needed for Severe Pain .08/25/25 Sertraline HCI Oral Tablet 25 MG (Sertraline HCI) Give 1 tablet by mouth one time a day related to DEPRESSION, UNSPECIFIED .Record review of Resident #1's MAR for August 2025 revealed she had the following orders: . tiZANidine HCl Oral Tablet 2 MG (Tizanidine HCl) Give 2 mg by mouth every 8 hours as needed for pain related to OTHER CHRONIC PAIN (G89.29) -Order Date- 08/01/2025 1410 -D/C Date- 08/25/2025 0508 .Mirtazapine Tablet 45 MG Give 1 tablet by mouth at bedtime related to DEPRESSION, UNSPECIFIED (F32.A) -Order Date- 08/01/2025 1410 (02:10 PM) -D/C Date- 08/25/2025 0506 .Escitalopram Oxalate Tablet 10 MG Give 1 tablet by mouth one time a day for Depression related to DEPRESSION, UNSPECIFIED (F32.A) -Order Date- 08/01/2025 1410 -D/C Date-08/25/2025 0510 .traMADol HCl Oral Tablet 50 MG (Tramadol HCl) Give 50 mg by mouth every 8 hours as needed for pain related to OTHER CHRONIC PAIN (G89.29) -Order Date- 08/01/2025 1410 -D/C Date- 08/25/2025 0509 .The MAR for August 2025 further revealed Resident #1 did not receive tizanidine during the month of August 2025. She received mirtazapine 45 mg tablet every day from 08/01/25 to 08/24/25. Resident #1 received escitalopram 10 mg tablet every Residents Affected - Some Page 1 of 3 676010 676010 09/09/2025 Legacy Rehabilitation and Living 4033 W 51st Ave Amarillo, TX 79109

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some day from 08/03/25 to 08/24/25. She received tramadol 50 mg tablet 16 total times from 08/01/25 to 08/24/25. Resident #1 received tramadol on the following dates: 08/01/25, 08/02/25, 08/05/25, 08/07/25, 08/11/25 (Resident #1 received tramadol twice on this date), 08/13/25, 08/14/25, 08/15/25, 08/16/25, 08/18/25, 08/19/25, 08/21/25, 08/22/25, 08/23/25, and 08/24/25.Record review of Resident #1's hospital records in her EHR revealed an AFTER VISIT SUMMARY dated 08/01/25 with the following instructions: . Your medications have changed START taking: . sertraline ([brand name of sertraline]) Start taking on: August 2, 2025. STOP taking: escitalopram 10 mg tablet ([brand name of escitalopram]) mirtazapine 45 mg tablet ([brand name of mirtazapine]) tiZANidine 2 mg tablet ([brand name of tizanidine]) tramadol 50 mg tablet ([brand name of tramadol]) .Record review of a progress note with date of service of 08/21/25 and signed by NP A on 08/24/25 revealed under the Admit History section Resident #1 was on mirtazapine and escitalopram, but they were discontinued and replaced with sertraline per psych. The note further indicated due to her (Resident #1's) AMS tizanidine and tramadol were discontinued.Record review of a progress note with date of service of 08/25/25 and signed by NP A on 08/26/25 revealed under the Admit History section Resident #1 was on mirtazapine and escitalopram, but they were discontinued and replaced with sertraline per psych. The note further indicated due to her (Resident #1's) AMS tizanidine and tramadol were discontinued. NP A noted she spoke with Resident #1's family member and explained to [Resident #1's family member] the Tramadol, Tizanidine, Mirtazapine, and escitalopram. NP A explained to Resident #1's family member sertraline was started and was for Resident #1's mood.During an interview on 09/09/25 at 09:58 AM DON stated charge nurses, and MDS nurses were responsible to enter orders into the EHR when a new resident was admitted to the facility. She stated the two ADONs used to help with admissions, but both of them quit last week. DON stated the MDS nurses checked back over the admissions to ensure accuracy.During an observation and interview on 09/09/25 at 11:18 AM Resident #1 stated she had no concerns with the medications she had been receiving since her admission to the facility.During an interview on 09/09/25 at 01:56 AM MDS RN stated MDS LVN entered diagnoses codes for new admissions, and she (MDS RN) entered orders, medications, diets, code status, allergies, and completed the baseline care plan. She looked at Resident #1's admission and stated ADON was the one who entered orders for Resident #1. MDS RN stated a resident could be negatively affected if given medications that were supposed to be discontinued. She stated it would depend on the type of medication. MDS RN stated it can have serious negative outcomes. She gave an example of a resident continuing to receive a blood thinner when it was supposed to be discontinued. She stated in that case the resident would be at risk of bleeding out. When asked about antidepressant and pain medications she stated psychotropic medications sometimes had the opposite effect than expected. MDS RN stated Resident #1's diagnosis of kidney disease could lead to AMS.During an interview on 09/09/25 at 01:58 PM MDS LVN stated Resident #1's diagnosis of metabolic encephalopathy could lead to AMS.During an interview on 09/09/25 at 03:01 PM NP B stated she started working for the facility last week. She stated she did not know about Resident #1 receiving medications that were supposed to be discontinued. Regarding a possible negative outcome to Resident #1, NP B stated, I feel like it is hard for me to say because I don't know what her baseline was before.During an interview on 09/09/25 at 03:07 PM NP A stated she was on vacation at the beginning of August 2025 and her first day back in the facility was 08/11/25. She stated she saw Resident #1 on 08/11/25 and that evening she noticed the medications were not discontinued. NP A stated, I reviewed all the records and found she (Resident #1) was supposed to be off those 4 meds tramadol, tizanidine, mirtazapine and escitalopram. NP A stated she called to let staff know the medications should be discontinued. She stated she made the call on 08/24/25. She stated she did not know which staff member she talked 676010 Page 2 of 3 676010 09/09/2025 Legacy Rehabilitation and Living 4033 W 51st Ave Amarillo, TX 79109

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to. She explained the delay from the time she found the medications had not been discontinued to the time she notified facility staff by saying she was behind in her charting and was playing catch up from her vacation. NP A stated she did not think Resident #1 would have been negatively impacted by taking the discontinued medications for 24 days because it was just a transcription error. NP A said, I dug and dug to try to find out why they (hospital) discontinued them (the four medications in question). NP A stated she could not find the reason the medications were discontinued.During an interview on 09/09/25 at 03:30 PM LVN C stated a resident could be negatively impacted by taking medications that were supposed to be discontinued. She stated, I mean surely a doctor said discontinue this for a reason.During an interview on 09/09/25 at 03:46 PM Resident #1's family member stated when NP A called to speak to her about Resident #1's care she (NP A) mentioned four medications were not discontinued as they were supposed to have been. She stated, It was a short conversation, she (NP A) didn't go into it. Resident #1's family member stated Resident #1 was taking mirtazapine and escitalopram prior to entering the hospital on [DATE].During an interview on 09/09/25 at 04:08 PM DON stated a resident could be negatively impacted by receiving medications that were supposed to be discontinued. She stated the negative impact would depend on the medication. DON stated she asked for a different NP than NP A due to concerns about NP A not getting her charting into the EHR timely. When asked why she though ADON did not catch the fact the four medications were to be discontinued, she stated she demoted ADON to a floor nurse when it became evident she did not have the necessary skills to be an ADON. DON did not answer what a specific negative outcome could be for taking discontinued antidepressant and/or pain medications. DON was asked for an unnecessary medication policy during this interview.During an interview on 09/09/25 at 04:16 PM RN D stated a resident could be negatively impacted if they received a medication that was supposed to be discontinued. She stated, If they no longer need it and it was discontinued at the hospital it can put the patient at risk.During an interview on 09/10/25 at 01:20 PM ADON stated she did not remember entering orders for Resident #1. She stated she did not remember Resident #1. ADON stated she only worked for the facility for a short time, and she entered admission orders for one, maybe two residents the whole time I was there. She stated she had an admission checklist and when she was finished the other ADON, DON, or MDS RN would look over her work and sign off on it to indicate it was correct.Record review of facility policy titled Care and Treatment Psychotropic Drug Use revealed the following: . 2. On admission, the admitting nurses will review the transfer orders for any psychotropic medications. Any information obtained will be documented in the resident's clinical record.Record review of facility policy titled Pharmacy Services Physician Orders revealed the following: . it is the policy of this facility that drugs shall be administered only upon the written order of a person duly licensed and authorized to prescribe such drugs.Record review of the facility policy titled Continuum of Care Admission, General revealed no mention of transcribing orders from the hospital into the facilities EHR.An unnecessary medication policy was not provided. 676010 Page 3 of 3