**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure 13 out of 40 sampled residents (Residents 10, 19, 38, 39, 47, 53, 60, 67, 72, 93, 104, 111, and 121) were free from unnecessary medications when there was inadequate monitoring and systemic failure in the management of antihypertensive (medication to manage high blood pressure) and antiarrhythmic (medication to manage arrhythmia [abnormal or irregular heartbeats]) medications, and lack of monitoring for signs and symptoms related to the use of anticoagulants (medication to prevent blood clots). They are as follows: 1. During a medication pass observation, Licensed Vocational Nurse C (LVN C) failed to measure Resident 47's blood pressure (BP) before administering an antihypertensive medication, losartan 50 milligrams (mg, unit of measurement), to Resident 47. 2a. For Resident 104: - Nursing staff did not carry out the physician's order for daily BP monitoring. - He had a routine order for metoprolol (medication to lower BP and heart rate [HR]) with the direction to hold the medication if SBP less than (<)100 milliliters of mercury (mmHg, unit of measurement) and HR <60 beats per minute (bpm) order but the staff did not check the BP and HR daily before its administration. (Normal HR: 60 - 100 bpm) - He received daily amiodarone (a potent antiarrhythmic agent - medication to treat/prevent irregular or abnormal heart rhythms) without consistent and daily BP and HR monitoring, and without a comprehensive care plan. - He received four routine antihypertensive medications without daily BP monitoring: Metoprolol, Entresto (a combination medication for hypertension and heart failure [a condition when the heart cannot pump enough blood to meet the body's needs]), furosemide (a diuretic, or water pill, to remove excess salt and water, and thereby lowering BP), and spironolactone (a diuretic to manage hypertension). The nursing staff did not code the Medication Administration Record (MAR, official document where staff record medication administration and related monitoring) correctly to require the input of the required BP and HR before administration of these medications. The record review indicated there was a period where BP and HR were not checked for as long as 14 days, as follows: - Resident 104's BP was not checked for 14 days from 1/11/25 to 1/26/25; for 3 days from 1/26/25 to 1/30/25; for 7 days from 2/1/25 to 2/8/25; for 2 days from 2/9/25 to 2/12/25; for 5 days from 2/13/25 to 2/18/25; and for 6 days from 2/19/25 to 2/26/25. - Resident 104's HR measurement was not obtained for 14 days from 1/11/25 to 1/26/25; for 4 days from 1/26/25 to 1/30/25; for 11 days from 2/1/25 to 2/13/25, and for 8 days from 2/19/25 to 2/27/25. 2b. For six residents (Residents 10, 38, 54, 111, 121, and 287) receiving digoxin (an antiarrhythmic agent to treat heart failure and AF) - Resident 38 received digoxin 6 times when HR was outside of the prescribed parameter in January and February 2025 - Resident 111 had no HR obtained on 2/26/24, but digoxin was given - Resident 111 received digoxin daily since admission in June 2024 without monitoring for digoxin blood level (to monitor if the medication is within therapeutic range and to avoid toxicity) - Resident 10 had a physician's order to obtain digoxin level every 3 months since 4/1/24. There was no digoxin level done in July 2024, October 2024, and January 2025. - Six out of six residents did not have comprehensive care plan developed related to digoxin use (see F 656). 2c. The facility's consultant pharmacist (CP) failed to identify and report to the facility irregularities related to the above findings for above residents (Residents 10, 38, 54, 104, 111, 121, and 287) (See F 756) 2d. For eight residents (Residents 19, 38, 60, 67, 72, 93, 104, and 121) receiving amiodarone: - Eight out of eight residents had no documentation of BBW monitoring related to amiodarone - Eight out of eight residents had no documentation of BP and HR checks prior to administration of amiodarone until 2/28/2025 (day of survey); - Resident 72 received amiodarone on 2/28/2025 at 9:00 a.m. with BP of 95/87 when it was supposed to be held and the physician to be notified. - Seven out of eight residents did not have comprehensive care plan developed related to amiodarone use (see F 656). 2e. The competency checks for five licensed nurses (LNs) revealed one out of five LNs did not have nursing care competency and medication administration training (see F 726). The facility's noncompliance related to lack of monitoring of BP and HR prior to antihypertensive and antiarrhythmic medication administration and as ordered; hold parameters not being followed; lack of laboratory monitoring for digoxin level; lack of BBW monitoring for amiodarone; lack of hold parameters for these medications; inaccurate coding of the MAR; lack of comprehensive care planning; and lack of CP's recommendations or identification of irregularities related to these deficient practices had the potential for the residents to suffer adverse effects from severe hypotension or low BP (such as dizziness or lightheadedness, weakness, fatigue, confusion, blurred vision, nausea and vomiting) and worsening arrhythmias (such as chest pain, fainting, rapid or pounding heartbeats, sweating, collapse, and sudden cardiac arrest [heart stop beating suddenly]). Resident 104 had low BP readings on 1/7/25, 1/30/25, 2/1/25, 2/8/25, 2/13/25, and 2/19/25. Due to these systemic failures (as stated above) with the potential to affect all residents receiving antihypertensive and antiarrhythmic medications, the facility needed to take immediate action to correct the noncompliance. On 2/28/25 at 5:45 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, the Director of Nursing (DON), and the Regional Director of Clinical Services (RDCS) related to lack of BP and HR monitoring prior to antihypertensive and antiarrhythmic medication administration and as ordered; lack of laboratory monitoring for digoxin; lack of BP, HR, and BBW monitoring for amiodarone; lack of hold parameters for these medications; lack of comprehensive care planning; and lack of CP's recommendations or identification of irregularities related to these medication use. On 3/3/25, at 1:48 p.m., the IJ was removed after the Administrator 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 acceptable IJRP included the following corrective actions: A. The facility identified residents whose BP and HR need to be monitored. All 59 residents with antihypertensive and antiarrhythmic medications have their updated orders for BP and/or HR check prior to administration, hold parameters, BBW monitoring, digoxin level (when applicable), and developed comprehensive care plan. B. The DON or RDCS in-serviced/trained 7 out of 8 clinical leadership members, and 34 out of 38 licensed nurses (LNs) on ensuring that residents with anti-hypertensive and antiarrhythmic medications have orders for BP and/or HR check prior to administration, hold parameters, BBW monitoring order, digoxin level (when applicable) is carried out, and care plan is developed for use of those medications. LNs who are on vacation or leave and any new registry licensed nurses will be provided in-service/competency training before they work on the floor. C. The CP was provided an in-service by his supervisor on reviewing and identifying medication irregularities during monthly medication regimen review on 3/1/2025. The CP performed an audit of all residents on anti-hypertensive and antiarrhythmic medications for any inconsistencies on BP and/or HR checks prior to medication administration and on applicable lab test recommendations for those medications. This audit was completed by 3/2/2025. D. The interdisciplinary team (IDT, team composed of members from different departments involved in a resident's care) will continue to conduct a daily review of new admissions orders and any new orders for anti-hypertensive and antiarrhythmic medications and verify that those required components are present and being followed. E. The clinical leadership team started with random observation of several LNs during medication pass on 3/1/2025 to ensure that BP and/or HR are checked prior to giving medication(s) and hold parameters are followed. F. The Medical Director ([NAME]) has been actively consulted and involved by the clinical leadership team on ensuring that all residents receiving medications have appropriate vital signs (measure of basic functions: body temperature, HR, respiratory rate, BP) monitoring and checks, have hold parameters, and applicable lab orders for use of medications. G. The Medical Records Director (MRD) or designee will continue to perform compliance audits to ensure that residents with anti-hypertensive and antiarrhythmic medications have orders for BP and/or HR check prior to administration, hold parameters, black box monitoring, digoxin level (when applicable), and care plan. H. Corrective Action Plan will be reviewed at QAPI [Quality Assessment and Performance Improvement] Committee Meeting for 6 months using pertinent compliance audit information and resolutions from March 2025 through the end of August 2025 or until the desired outcome of 100% compliance is achieved and sustained for at least six consecutive months. 3. Resident 47 received daily losartan with a hold parameter without the nursing staff monitoring the BP prior to its administration. 4. Resident 104 received amiodarone on 2/28/2025 at 9:00 a.m. with BP of 98/66 when it was supposed to be held and the physician to be notified, after the concerns had been raised with facility leadership staff. 5. Resident 39 received Xarelto (an anticoagulant to prevent blood clots) without evidence of staff monitoring for signs and symptoms related to its use. 6. For Resident 53, the nursing staff did not consistently monitor the signs and symptoms related to the use of Eliquis (an anticoagulant). The failures had the potential for residents to suffer adverse effects of the medications including undetected severe hypotension, worsening of arrythmias, and anticoagulant-related symptoms such as bleeding, bruising, discolored urine, black, tarry stools, lethargy, sudden changes in mental status or vital signs, shortness of breath, or nosebleeds, and untimely interventions for the residents. Findings: The BP is measured in millimeters of mercury (mmHg, unit of measurement) and in two numbers. The upper number is the systolic BP, or SBP, indicating the pressure in the arteries when the heart beats and pumps blood through the body; the lower number is the diastolic BP, or DBP, is the pressure in the arteries when the heart rests between beats. According to the American Heart Association, normal BP is less than 120/80 mmHg; and low BP is a reading lower than 90/60 mmHg (www.heart.org; accessed 3/6/25) 1. During a medication pass observation on 2/24/25 at 9:33 a.m., LVN C was observed preparing and administering 8 medications, including a tablet of losartan 50 mg, to Resident 47. During the concurrent interview and record review on 2/24/25 at 9:52 a.m., when asked about Resident 47's BP for the administration of losartan, LVN C stated a certified nursing assistant (CNA) had already taken it earlier that day. She reviewed Resident 47's BP in the clinical record which indicated the latest BP was obtained the day prior, on 2/23/25 at 16:08 (4:08 p.m.). LVN C stated she did not check the resident's BP earlier that morning. On 2/24/25 at 9:54 a.m., she was observed returning to Resident 47's bedside and obtained her BP. It was 156/70 mmHg. After returning to the medication cart, LVN C stated, It was a mistake and she should have checked the BP before giving the losartan. A review of Resident 47's clinical record indicated a physician's order, dated 5/21/24, for losartan 50 mg, give 1 tablet one time a day for hypertension hold for systolic [BP] <110 [mmHg]. 2a. A review of Resident 104's admission record indicated he was admitted to the facility with diagnoses including pleural effusion (condition where excess fluid accumulates in the pleural space, the thin cavity between the lungs and the chest wall), heart failure, pulmonary edema (condition where excess fluid accumulates in the lungs, causing difficulty breathing), and unspecified peripheral vascular disease (slow and progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel). A review of the cardiologist's (physician specialized in heart medical conditions) After Visit Summary, dated 9/9/24, indicated the resident was assessed with bruit (abnormal sound in an artery caused by turbulent blood flow). A review of Resident 104's Minimum Data Set (MDS, a care area assessment and screening tool), dated 12/17/24, indicated he had a BIMS (Brief Interview for Mental Status, a test given by medical professionals that helps determine a patient's cognitive understanding, scored from 1 to 15) score of 11, which indicated his cognitive condition was moderately impaired. On 2/27/25, a review of Resident 104's physician's orders, and January and February 2025 Medication Administration Records (MARs), indicated the following orders and administration times: A. Four routine antihypertensive medications: - Valsartan (treat high blood pressure and heart failure) 40 mg 1 tablet twice daily for hypertension, dated 4/12/24. On 1/30/25, valsartan was discontinued and switched to Entresto (combination of valsartan and sacubitril, another antihypertensive medication) 24-26 mg twice daily. One 2/4/25, Entresto was reduced to one time a day for hypertension. Part of its order indicated to Check BP without specified frequency. Each of these medications was scheduled to be administered daily at 10 a.m. - Furosemide 20 mg, give 1.5 tablets (30 mg) one time a day for edema (swelling caused by a buildup of fluid in body tissues) and hypertension, dated 8/23/24. It was scheduled to be administered daily at 9 a.m. - Spironolactone 25 mg, give 1 tablet one time day for fluid retention, dated 12/26/24. It was scheduled to be administered daily at 9 a.m. - Metoprolol extended release (ER) 25 mg one time a day for hypertension, hold for systolic BP < [less than] 100 [mmHg], [HR] <60 [bpm], dated 4/12/24. It was scheduled to be administered daily at 10 a.m. (Normal HR is between 60 - 100 bpm). B. Amiodarone 200 mg, 1 tablet by mouth one time a day for arrhythmia, dated 4/12/24. It was scheduled to be administered daily at 10 a.m. C. Check BP Q [every] day one time a day 'call clinic if SBP is less than 100 [mmHg] consistently, dated 1/30/25. It was scheduled daily at 9 a.m. A review of the Package Insert (PI, document included in the package of a medication that provides information about that drug and its use) for amiodarone, revised 10/2018, indicated it an antiarrhythmic medication to treat ventricular arrhythmias (life-threatening heart rhythm disturbance where the ventricles [lower chambers of the heart] quiver instead of contracting normally) and atrial fibrillation (an irregular heart rhythm that begins in your heart's upper chambers [atria]). The PI also indicated to monitor the patient's cardiac [heart] rhythm and blood pressure, and, if bradycardia [low HR] ensues, a ß-adrenergic agonist [a type of medication to increase HR] or a pacemaker may be used . The review of the PI for amiodarone also indicates it has a Black Box Warning (BBW, strongest warning put in the labeling of a prescription drug by the Food and Drug Administration [FDA] to indicate the drug carries a significant risk of serious or life-threatening adverse effects) indicating it has potential to cause life-threatening liver toxicity, pulmonary [lung] toxicity, and worsening arrhythmia. (https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm, accessed 2/28/25) A review of Resident 104's January and February 2025 MARs indicated the nursing staff placed their initials and a check mark on in the entry for the Check BP one time a day with no corresponding BP readings. There were no corresponding BP readings for the administration of furosemide, valsartan or Entresto, and spironolactone. Similarly, there was no documentation of corresponding BP and HR for the administration of metoprolol despite the physician's order to hold for SBP <100 mmHg and HR <60 bpm. Furthermore, there was no hold parameters for or corresponding measurement of BP and HR for the use of amiodarone. Further review of Resident 104's BP and HR summary indicated: - Resident 104's BP was not checked for 14 days from 1/11/25 to 1/26/25; for 3 days from 1/26/25 to 1/30/25; for 7 days from 2/1/25 to 2/8/25; for 2 days from 2/9/25 to 2/12/25; for 5 days from 2/13/25 to 2/18/25; and for 6 days from 2/19/25 to 2/26/25. - Resident 104's HR measurement was not obtained for 14 days from 1/11/25 to 1/26/25; for 4 days from 1/26/25 to 1/30/25; for 11 days from 2/1/25 to 2/13/25, and for 8 days from 2/19/25 to 2/27/25. A review of Resident 104's clinical record also indicated there was no comprehensive care plan that included the diagnosis, goals/outcomes, monitoring parameters and interventions for Resident 104's arrhythmia or the monitoring of the BBW related to amiodarone use. During a concurrent interview and record review with the Director of Nursing (DON), the Infection Control Preventionist (IP), and Nurse Supervisor D (NS D) on 2/27/25 at 1:45 p.m., they reviewed Resident 104's clinical record and acknowledged the resident's BP and HR were not checked on a daily basis as per physician's order, and before administration of metoprolol; no BP checks done before the administration of Entresto, spironolactone, and furosemide; no hold parameters and no BP and HR check for amiodarone; and no comprehensive care plan for Residentn104's arrhythmia and amiodarone use. The IP and NS D stated the BP and HR should be checked at least daily, and the care plan should have been developed. The staff present also verified there were gaps of multiple days (as stated above) where BP and HR were not checked daily and acknowledged the potential for resident to suffer from undetected severe hypotension and arrhythmias (such as too slow HR) During an interview with Resident 104 on 2/27/25 at 2:09 p.m., when asked how often the staff obtained his HR, he stated, Here and there. About the BP measurement, Resident 104 stated, They get it when they come in, sometimes 2 to 3 times per day. It depends. During a telephone interview with the CP on 2/27/25 at 3:30 p.m., he stated residents receiving amiodarone should receive routine HR monitoring, and Resident 104 receiving four antihypertensive medications had a risk of hypotension. When asked whether he had identified and made a recommendation for the nursing staff to include HR and BP monitoring for the use of his antihypertensive and antiarrhythmic medications for Resident 104, the CP stated he did not. During an interview with the DON on 2/27/25 at 4:33 p.m., she stated, The blood pressure and pulse were not consistently done . The MAR was not coded right so it's not on the MAR. She explained the MAR should be coded to require an input of the BP and/or HR with BP and cardiac (heart) medications. When asked whether the BP and HR measurements were documented somewhere else, the DON stated no and that she checked the CNA's logs, and it's not there. On 2/28/25 at 9:26 a.m. in the presence of the Assistant Director of Staff Development (ADSD), a review of Resident 104's February 2025 MAR was conducted with LVN G. She confirmed she administered the metoprolol with the prescribed hold parameters, and documented she checked the BP on 2/5 and 2/6/25; however, there was no BP and HR measurement in the clinical record for both days. Both LVN G and the ADSD stated the nursing staff check BP and HR before giving BP and cardiac medications. The ADSD also reviewed the clinical record and stated, I am not sure what to say. During a concurrent interview and record review with LVN H on 2/28/25 at 9:42 a.m., she reviewed Resident 104's February 2025 MAR and confirmed she documented the administration of metoprolol with ordered hold parameters, and did the daily BP on 2/25/26; however, there were no BP and HR measurement on 2/25/26 in Resident 104's clinical record. She stated, If the MAR doesn't say then I don't put in there unless I put in the progress notes. When asked to look up the progress notes, LVN H stated, I know I did not. During a concurrent interview and record review with LVN I on 2/28/25 at 9:55 a.m., a review of Resident 104's February 2025 MAR with LVN I indicated she documented she administered the metoprolol and did the daily BP check on 2/10, 2/11, 2/15, and 2/21/25 during which there were no documentation of daily BP and HR measurement. She stated, I checked them but not entered into the system because it didn't have entry to enter, but I always check them. In a concurrent interview and record review with Registered Nurse (RN) J on 2/28/25 at 10:11 a.m., a review of Resident 104's February 2025 MAR with RN J indicated she administered the BP medications, including the metoprolol; and the daily BP check, on 2/3, 2/4, 2/14, 2/22, 2/23, and 2/26/25 during which there were no BP and HR measurement in the clinical record. RN J acknowledged there were BP and HR missing in the MAR and stated, I understand what you are saying. There's no excuse for it. She also acknowledged Resident 104 was receiving four BP medications which had the potential for severe hypotension if not checked. She stated the nurses can change the order when the MAR did not have entries to input BP and HR, but acknowledged they were not done prior to being brought up by the survey team (on 2/27/25). A request was made for an interview with Resident 104's physician (Physician A) on 2/28/25. During an interview on 2/28/25 at 10:55 a.m., Nursing Supervisor D (NS D) stated she just received a telephone call from Physician A who said she is not available for interview as she was in a conference. NS D stated Physician A wanted her to relay the message to the surveyor that Resident 104 was being followed by the cardiologist. NS D also stated that Physician A said she has had concerns about the care in the facility and that is the reason why she would not admit new patients to this facility until things are fixed. On 2/28/25 at 11:35 a.m., a telephone interview was conducted with the Medical Director ([NAME]). When asked about the expectation of staff obtaining and documenting the BP and HR for antihypertensive and cardiac medications, he stated, If there's a standing order, it should be documented. Ideally. During a concurrent interview and record review with NS D on 2/28/25 at 11:47 a.m., a review of Resident 104's BP summary in the electronic record indicated he had low BP readings (see below). NS D stated she could not tell if the BP readings were before or after metoprolol administration on 2/1, 2/8, and 2/13/25. She was asked to provide the exact timing of the metoprolol administration for those days. Date and time BP readings in mmHg - 1/7/25 at 1:40 a.m. 108/58 - 1/30/25 at 10:23 a.m. 101/50 - 2/1/25 at 10:20 a.m. 93/54 - 2/8/25 at 9:10 a.m. 91/56 - 2/13/25 at 8:52 a.m. 96/54 - 2/19/25 at 1:02 a.m. 95/54 During a follow-up interview with NS D on 3/1/25 at 4:07 p.m., she stated the electronic system only allowed a 14-day look back of medication administration times, so she could not provide the exact time the metoprolol was administered on those days. A review of an online article from the National Heart, Lung, and Blood Institute titled Low Blood Pressure, updated 3/14/22, indicated hypotension symptoms included: Confusion, dizziness or lightheadedness, fainting, feeling tired or weak, blurry vision, headache, neck or back pain, nausea, and heart palpitations. (https://www.nhlbi.nih.gov/health/low-blood-pressure, accessed 2/28/25) A review of the online publication titled Symptoms, Diagnosis and Monitoring of Arrhythmia dated 10/10/24, by the American Heart Association (www.heart.org), severe arrhythmia symptoms include: Fatigue or weakness, dizziness or lightheadedness, fainting or near-fainting spells, shortness of breath, chest pain, alternating fast and slow heart rate, sweating, and in extreme cases, collapse and sudden cardiac arrest. 2b. A review of the PI for digoxin, dated 2015, indicated Digoxin has a narrow therapeutic index [medication in which the therapeutic dose is very close to the toxic dose], increased monitoring of serum digoxin concentrations and for potential signs and symptoms of clinical toxicity is necessary when initiating, adjusting, or discontinuing drugs that may interact with digoxin . Monitor for signs and symptoms of digoxin toxicity and clinical response. Adjust dose based on toxicity, efficacy, and blood levels. On 2/28/25 starting at 2:30 p.m., a concurrent interview and review of the clinical records residents receiving digoxin was conducted with Minimum Data Set Coordinator B (MDSC) B. The following was identified: A. On 2/28/25 starting at 2:32 p.m., a review of Resident 38's clinical record with MDSC B indicated the resident had a physician's order for Digoxin Tablet 250 MCG [micrograms, unit of measurement], Give 1 tablet by mouth one time a day for heart failure check apical heart rate [or apical pulse or AP; heartbeat that is felt or heard at the apex (bottom) of the heart, typically on the left side of the chest] prior to each dose. Hold dose if heart rate is less than 60 and notify MD [medical doctor], dated 1/5/25. A review of Resident 38's January and February 2025 MARs indicated the nursing staff did not hold the resident's digoxin when he had the documented pulse (HR) of less than 60 bpm on: 1/20 (HR: 58); 1/26 (HR: 53); on 2/3 (HR: 59), on 2/5 (HR: 53), 2/7 (HR: 55), and 2/18/25 (HR: 59). MDSC B also reviewed the progress notes and stated there was no physician's notification on those days. She confirmed the physician's order was not followed. Furthermore, there was no comprehensive care plan developed for the resident's heart failure or digoxin use. MDSC B stated it should have been care planned. B. On 2/28/25 at 2:40 p.m., a review of Resident 111's clinical record with MDSC B indicated Resident 111 had a physician's order for Digoxin Oral Tablet 125 MCG . Give 1 tablet by mouth one time a day for Antiarrhythmic Hold if APICAL pulse <60 [bpm], dated 6/28/24. A review of Resident 111's February 2025 MAR indicated digoxin was documented as administered to the resident on 2/26/25, but there was no documented AP on that day. MDSC B verified this finding. She also confirmed there was no care plan developed for the use of digoxin, and stated there should have been a care plan developed. Also, the review of Resident 111's clinical record with MDSC B indicated no digoxin level since admission and ordered date of 6/28/24 (a period of 8 months). C. On 2/28/25 at 2:42 p.m., a concurrent interview and record review of Resident 287's clinical record with MDSC B indicated a physician's order for Digoxin Tablet 125 MCG Give 1 tablet by mouth one time a day for heart failure hold if pulse less than 70, dated 2/14/2025. MDSC B stated she could not find any care plan for the resident's heart failure or digoxin use. She confirmed there should have been a care plan developed. D. On 2/28/25 at 2:44 p.m., a review of Resident 10's clinical record indicated he had been receiving Digoxin Tablet 125 MCG Give 1 tablet by mouth one time a day for heart failure Hold dose if AP less than 60, since 4/24/2021. He also had a physician's order, dated 4/1/24, for laboratory blood tests including the digoxin level every 3 months, scheduled January, April, July, and October each year. MDSC B reviewed Resident 10's clinical record and the contracted laboratory website and stated she could only found one laboratory report conducted on 4/1/24. She confirmed there was no digoxin level done in July 2024, October 2024, or in January 2025. Also, MDSC B stated she could not find any care plan for the use of digoxin. She acknowledged the physician's order was not carried out and there should be a care plan for the resident's heart failure. E. On 2/28/25 at 3:40 p.m., a review of Resident 54's clinical record with MDSC B indicated a physician's order for Digoxin tablet 125 MCG Give 1 tablet by mouth one time a day for AFib [atrial fibrillation] hold if less than 60 [bpm] and notify M.D as needed, dated 9/6/2023. MDSC B stated she could not find the comprehensive care plan for AF or digoxin use. She confirmed there should have been a care plan developed. F. On 2/28/25 at 3:57 p.m., a concurrent interview and record review of Resident 121's clinical record with MDSC B indicated a physician's order for digoxin 125 mcg 1 tablet one time a day for AF, dated 10/18/24. MDSC B stated there was no care plan for Resident 121's AF or digoxin use. 2c. During a telephone interview with the CP on 2/28/25 at 4:12 p.m., the CP stated digoxin level should be monitored routinely, and he would make a recommendation for it every 6 months. When asked whether he had made a recommendation to draw a digoxin level for Resident 111 since she was admitted in June 2024, the CP stated he did not, and confirmed he should have. Regarding the review for the care plans related to medication use in the residents' clinical record, the CP stated, Sometimes I do but not too much. After reviewing his own record, the CP stated he did not make recommendation on care plans during the monthly medication regimen review for Residents 10, 38, 54, 111, 121, and 287. 2d. A concurrent interview and record review of seven additional residents (Residents 19, 38, 60, 67, 72, 93, and 121) receiving amiodarone indicated: A. Review of Resident 121's clinical record titled, admission Record, dated 2/28/25, indicated Resident 121 was admitted to the facility with diagnoses including hypertensive heart and chronic kidney disease (refers to a condition where high blood pressure damages both the heart and kidneys) with heart failure and stage 1 through stage 4 chronic kidney disease (occurs when kidneys work harder to filter blood and may stop working altogether), paroxysmal atrial fibrillation (a fast, irregular heartbeat that only lasts a few hours or days), and cardiomyopathy (a disease that affects the heart muscle, making it difficult for the heart to pump blood). Review of Resident 121's physician order, dated 12/20/24, indicated, Amiodarone . 100 MG Give 1 tablet by mouth one time a day for CHF [chronic heart failure, a condition where the heart can't pump enough blood to meet the body's needs]. Amiodarone was scheduled to be given daily at 9:00 a.m. During a concurrent interview with the Assistant Director of Staff Development (ADSD) and record review on 2/28/25 at 3:35 p.m., the ADSD reviewed Resident 121's physician's order and the February 2025 MAR, and confirmed there was no documentation from nursing that the amiodarone's BBW was being monitored. The ADSD further confirmed there was no documented BP and HR readings in the MAR from 2/1 to 2/27/25 prior to administration of amiodarone. ADSD also confirmed there was no care plan developed