**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff, hospital staff, physician and resident responsible party interviews, the facility failed to provide appropriate wound care, by competent nursing staff, consistent with professional standards of nursing practice, to promote healing, prevent infection and worsening of a pressure ulcer for 1 of 2 resident records reviewed with pressure ulcers (Resident #1). The facility reported a census of 46 residents. Findings include: The Minimum Data Set (MDS) Assessment tool dated [DATE] revealed the resident admitted to the facility [DATE] with diagnoses that included diabetes, pneumonitis due to aspiration and muscle weakness, severe cognitive impairment with symptoms of delirium present, sometimes able to make herself understood and usually able to understand others, and required extensive assistance, sometimes total dependence on staff to reposition in bed, transfer to and from bed and chair, dressing, eating, toileting, bathing and personal hygiene, non-ambulatory, always incontinent of bladder, usually incontinent of bowel, and a Stage 1 pressure sore (PS) present (defined as observable, pressure-related alteration of intact skin with non-blanchable redness of a localized area usually over a bony prominence). Physician Orders directed the following skin treatments and wound care: [DATE] Apply Calmoseptine Ointment to coccyx topically twice daily. [DATE] Fibracol to coccyx area and cover with foam dressing every 3 days, discontinued [DATE]. [DATE] Fibracol to coccyx area and cover with foam dressing daily, discontinued [DATE]. [DATE] Cleanse sacral ulcer with Dakins solution, apply Hydrofera Blue to coccyx wound, cover with foam external pad dressing daily. A Pressure related Injury to Skin Problem initiated on the Nursing Care Plan [DATE], with goal the pressure injury would show signs of healing and remain free from infection by the next review date, directed staff to: 1. Utilize pressure relieving/reducing device on bed/chair, initiated [DATE] 2. Monitor for pain related to pressure injury, initiated [DATE] 3. Monitor/document/report any changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size (length, width and depth), stage, initiated [DATE] Facility wound assessments of the sacral PS, completed by the Assistant Director of Nursing (ADON), identified as the wound nurse, revealed: [DATE], Stage 1 PS, present on admission, measured 8.6 centimeters (cm) by 5.7 cm, surrounding skin normal colored, intervention in place. [DATE], Stage 1 PS, 8.6 cm by 5.7 cm, surrounding skin normal colored, cleansed with wound cleanser, incontinence management implemented, intervention in place. [DATE], Stage 1 PS, 1.6 cm by 1.2 cm, scabbed area without drainage, surrounding skin fragile and at risk for breakdown, cleansed with soap and water, treated with Calmoseptine (a barrier cream applied to skin). [DATE], Stage 1 PS, 2.5 cm by 0.5 cm, surrounding skin fragile and at risk for breakdown, without induration or swelling, cleansed with soap and water, treated with Calmoseptine, stable. [DATE], Stage 1 PS, 10.4 cm by 0.9 cm, depth recorded as not applicable, wound bed described as granulation tissue without drainage, surrounding skin normal colored without induration or swelling, cleansed with soap and water, treated with Calmoseptine, stable. [DATE], Stage 1 PS, 2.6 cm by 1.0 cm, depth not applicable, light serosanguinous drainage (yellow-pink colored), without indication of infection, surrounding skin fragile and at risk for breakdown, without induration or swelling, cleansed with Wound Cleanser, new order for Fibracol and foam patch applied daily and as needed (PRN), stable. [DATE], Stage 1 PS, 4.8 cm by 2.1 cm, depth not applicable, slough tissue in wound bed, light serosanguinous drainage, faint odor, no indications of infection, surrounding skin normal colored, without induration or swelling, rolled wound edges, wound cleansed with Dakins,Hydroera blue applied to wound bed, cover with foam dressing, changed daily and PRN, stable. A physician progress note dated [DATE] described the resident's sacral PS as a Stage 2 PS (Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising. May also present as an intact or open/ruptured blister.) The physician directed staff to cleanse the wound with Wound Cleanser, apply Fibracol to the wound bed, cover with a foam dressing changed every 3 days and as needed. A physician progress note dated [DATE] described the resident's sacral PS as a Stage 2 PS that measured 1 cm by 0.8 cm and 0.8 cm by 3 cm, wound bed epithelial cells and 50 percent slough tissue, and directed staff to continue cleansing wound with Wound Cleanser, apply Fibracol to the wound bed, cover with a foam dressing changed every 3 days and as needed. A facility wound photo of the resident's sacral PS, dated [DATE], revealed wound depth estimated at 1 cm based on resident anatomy in the photo, slough tissue in the wound bed, and reddened skin surrounded the wound opening and extended at least 1 cm from the wound edges that surrounded the wound opening. The wound in the photo appeared as a Stage 3 PS (full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue). The resident's January, 2023 Treatment Administration Records (TAR's) revealed facility Certified Medication Aides (CMA's) documented they completed the resident's sacral PS wound care and dressing changes on the following dates: [DATE] Staff D, CMA/Certified Nursing Assistant (CNA) [DATE] Staff D [DATE] Staff P, CMA/CNA [DATE] Staff E, CMA/CNA [DATE] Staff E Nursing Progress Notes revealed the following entries: [DATE] at 9:53 a.m. Patient noted to be more sleepy today, difficult to arouse. Patient will open eyes, but no verbal/mumbling noted. Skin pale, warm and dry. Two blisters to right lower extremity, calf area noted to be intact. No redness, swelling, signs or symptoms of infection noted to area, no edema noted to bilateral lower extremities. Dressing to coccyx noted to be dry and intact. Respirations even/unlabored. Lungs clear to auscultation, abdomen soft, bowel sounds present, No symptoms of pain noted. Involuntary muscle twitching to bilateral upper extremities. This RN unable to obtain vital signs after several attempts. [DATE] at 1:23 p.m. Rests in bed, no verbal response, unable to obtain vitals, fingers with some mottling, lungs diminished, bowel sounds present, no cough or dyspnea, no nausea or vomiting, TLC given, no distress noted. [DATE] at 1:39 p.m. This RN called and spoke with POA regarding change in condition. POA requesting that patient gets sent out to ER where 'people know more'. This RN attempted to provide education on assessment and status of patient but POA declined education and repeated that they wanted patient sent out to be seen by a doctor who has a 'higher level of education'. This RN verbalized understanding. The resident's record lacked any documentation of sacral pressure sore condition descriptions, type of drainage and amount, symptoms of infection present and other wound conditions as required, between [DATE] and [DATE]. Shower care documented as completed in the resident's record, completed by Staff B, Certified Nursing Assistant (CNA) who worked as a Bath Aide included: [DATE], [DATE], [DATE], [DATE] and [DATE] One other shower was documented as completed [DATE] by Staff E, CNA The facility's Certified Medication Aide (CMA) Job Duties/Job Description policy, dated effective [DATE] directed: 1. According to the description of the scope of practice pertaining to CMA's described in Iowa Chapter 58.21(6), CMA's can administer nonparenteral medications if they have taken an approved class and passed a challenge examination. (Parenteral medications are administered via routes other than the digestive tract, such as injection or infusion). 2. There are no limitations on the type of oral solid medications that can be administered. 3. Per Iowa Code 58.19(2)(a), CMA's may not administer injectable medication. The Iowa Board of Nursing regulates practices that Registered Nurses (RN's) and Licensed Practical Nurses (LPN's) may delegate to an unlicensed assistive personnel (UAP) by: 1. Ensuring the UAP has the appropriate education and training and has demonstrated competency to perform the delegated task. 2. Ensuring the task does not require assessment, interpretation, and independent nursing judgment or nursing decision during the performance or completion of the task. 3. Verifying that, in the professional judgment of the delegating nurse, the task poses minimal risk to the patient. 4. Communicating directions and expectations for completion of the delegated activity and receiving confirmation of the communication from the UAP. 5. Supervising the UAP and evaluating the patient outcomes of the delegated task. Results of the resident's laboratory blood work obtained in the hospital ER on [DATE] revealed: White Blood Cell (WBC) count of 18.8 K/mm3, high value, normal range 4.5 - 11.0 K/mm3. BUN (Blood Urea Nitrogen) 151 mg/dL, high value, normal range 6 to 24 mg/dL. Creatinine 8.96 mg/dL, high value, normal range 0.59 to 1.04 mg/dL. Glomerular Filtration Rate (GFR) 5 ml/min 1.73 m2, low value, normal range 90 to 120 mL/min/1.73 m2. Potassium 5.5 mMole/Liter, high value, normal range 3.6 to 5.2 mmol/L. Sodium 151 mEq/L, high value, normal range 135 to 145 mEq/L. Blood Glucose 424 mg/dL, a high value, critical result value, normal range 99 mg/dL or lower for fasting result. The results indicated the resident's septic condition (severe infection that involves the blood), severe dehydration and acute renal failure (kidney shutdown). The resident's Death Certificate, signed by the County Medical Examiner [DATE], stated the resident died [DATE] at 9:26 a.m. as a result of Sepsis from a pressure ulcer on the sacral region. The resident's responsible party/Power of Attorney (POA) interviews revealed: POA#1, interviewed [DATE] at 3:02 p.m., stated the facility notified them she had a bed sore (pressure sore), but not that there was any concern over it, that it was something minor that was being treated, and never once said it was serious, or had gotten worse, or infected. POA #2, interviewed [DATE] at 3:27 p.m., stated one day while visiting they saw the soiled dressing in the resident's trash-can in her room, there was a foul odor and what looked like pus and blood on the dressing, when they asked staff if the bedsore was infected, they wouldn't answer them. Staff interviews revealed: Staff A, Registered Nurse (RN), interviewed [DATE] at 12:45 p.m., stated she didn't care for the resident very often, had changed her PS dressing, on [DATE] she notified the physician of wound changes that included yellow-green drainage with foul odor via fax (facsimile), couldn't remember any depth to the wound, the surrounding skin was reddened but blancheable. Staff B, Certified Nursing Assistant (CNA), interviewed [DATE] at 9:50 a.m. stated she worked as a Bath Aide, she showered the resident with her dressing on her sacral area, and the nurse never came in the shower room to remove the dressing after it was saturated from the shower, or to apply a new dressing. Staff C, RN, interviewed [DATE] at 10:20 a.m., stated when she completed a dressing change, she documented that on the TAR, and no need for any other documentation unless the wound looked different, then would chart that in the progress notes. She changed the resident's dressing a couple of times. When asked to describe the wound the last time she changed the dressing ([DATE]), she stated there was about a quarter-sized dark spot, but could not provide a color or further description of the area, the dark spot hadn't opened yet, there was no drainage and no odor. When instructed that the last time she documented she changed the dressing, [DATE], was after yellow-green drainage with odor was noted and the physician informed of that on [DATE], Staff C stated she'd had a runny nose, wore a mask, couldn't smell anything, and didn't remember if the wound was opened or not. If she noticed any wound changes she would notify the physician, take a photo of the wound, and would notify family. The facility's Assistant Director of Nursing (ADON), a Licensed Practical Nurse (LPN) interviewed [DATE] at 12:22 p.m., stated she was the facility wound nurse, had special training through Relias (computer based education program for health professionals) and was certified as a wound nurse through the Relias program. The ADON stated nursing should document what they see when they change a wound dressing, and document the treatment was completed in the TAR. If anything abnormal was noted staff should document that in the nursing progress notes. The last time she saw the resident's sacral pressure sore ([DATE]) there was an area that was dark, no depth to the wound but it was open, had light amount of serous drainage, a faint odor that the provider had been updated on. The provider changed the orders to cleanse it with Dakins solution, apply Hydrofera blue to the wound and cover with a foam dressing daily. The ADON stated nurses were expected to complete dressing changes, the CMA's can complete dressing changes if supervised by a nurse, whatever their company policy said. When asked what their company policy directed, the ADON stated she wasn't sure what it said. The ADON's Certificates of Attendance for wound care education revealed: 1.25 contact hours of continuing education credit for completion of Wound Care for Arterial Ulcers on [DATE] 1.0 contact hours of continuing education credit for completion of Wound Dressings: Making the Right Choice on [DATE] The facility Director of Nursing (DON), interviewed [DATE] at 12:55 p.m., stated CMA's could complete dressing changes if the nurse there delegated it to them. Both RN's and LPN's could delegate things to the CMA's if they were there. The DON stated she would have to address how the treatments were signed off on the TAR's by the CMA's and was not aware that CMA's completed pressure sore wound care. Staff D, CMA/CNA, interviewed [DATE] at 1:04 p.m., stated she had taken care of the resident, she did whatever the nurse delegated to her as far as the resident's sacral PS wound care, and when asked specifically what wound care she provided, or what actions she completed, Staff D abruptly ended the interview and stated she would call the surveyor back in 10 minutes. Staff E, CMA/CNA interviewed [DATE] at 11:48 a.m. stated she did whatever the nurse delegated to her when asked if she had provided wound care for the resident's sacral PS. Staff E was advised that was not an acceptable response, she needed to specify what activities the nurse delegated to her, what actions she had taken for the resident's wound care, then Staff E stated she didn't remember what the nurse delegated to her, but the nurse was present. When asked if she had handled the wound care supplies, or what she did with the supplies, Staff E stated she handed the supplies to the nurse when she needed them, she opened the package of Fibracol for the nurse, removed the Hydrofera blue from the package and handed it to the nurse, the nurse cut the Hydrofera blue with scissors, and helped to keep the resident positioned on her side during the care. Staff F, RN, interviewed [DATE] at 3:29 p.m. stated she hadn't seen the resident's PS as the dressing change was scheduled on the day shift, dressing changes were something the nurse should do and not appropriate for the CMA's, she would never delegate that to a CMA to do. If she thought she saw wound changes, she would communicate with the doctor immediately, document it in the progress notes, inform the wound nurse and would let the family know. Staff G, LPN, interviewed [DATE] at 2:26 p.m., stated she had not seen the resident's sacral PS until the day she was sent to the hospital ([DATE]), it was an opened area, nickel to quarter sized, depth approximately 1 cm, there was serosanguinous drainage, she couldn't tell if there was an odor, the resident was acting differently that day, she thought she was transitioning. She would report any wound changes to the doctor on call and record the changes on the skin sheets. Soiled dressings removed are supposed to go in a red bag and taken to the appropriate container in the soiled utility room, staff should not put a soiled dressing in the resident's trash in their room. Staff J, RN, agency nurse interviewed [DATE] at 12:08 p.m. stated she worked the day shift on [DATE] and [DATE] and was the nurse who sent the resident to the hospital. On [DATE] she felt the resident was transitioning and shutting down, when she assessed the resident at the request of her family she couldn't get a blood pressure reading or pulse oxymetry result, and she had not notified the physician of those findings. She provided her wound care and really couldn't recall what the wound looked like or if there was depth when she changed the dressing on [DATE] as that was so long ago. When asked if a CMA provided her wound care, Staff J stated that wasn't something a CMA could do, that was a nursing responsibility. On [DATE] she notified the resident's POA by phone that she wasn't doing well, the POA was upset and demanded that she call the doctor and send the resident to the hospital where she would get the care she needed from staff that were more knowledgeable. Staff J notified the doctor, requested an ambulance for transport, the resident was non-responsive at the time she left the facility. Staff H, hospital emergency room (ER) physician (MD), interviewed [DATE] at 10:13 a.m., stated she assessed the resident in the ER on [DATE], the resident was in critical condition, septic from a wound infection of the sacral pressure sore, the sacral pressure sore was at least grapefruit sized, open, deep, infected and looked horrible. The resident had recently acquired burns on her leg, an unstageable pressure sore on her ear, she was in pain and required Morphine (a strong narcotic opiate analgesic) for pain control. Upon the Resident's presentation to the ER that included a non-responsive state, her hair was matted, very dirty and unkempt. Nursing home staff reported to ER staff that the resident had been up for breakfast and ate some, but she thought that couldn't have been possible given the resident's critical and unresponsive condition when she arrived early in the afternoon to the ER. Staff I, hospital RN, interviewed [DATE] at 2:22 p.m., stated on [DATE], the resident's sacral pressure sore measured 10 cm by 10 cm, wound bed described as black eschar, no recorded depth of the wound, scant serosanguinous drainage, surrounding skin red and indurated. The resident required Morphine administration several times for pain control before her death 3 days later on [DATE]. Her primary diagnosis was sepsis from wound infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and facility policy review, the facility failed to notify the physician of changes in condition and/or the need to alter treatment for two (Resident #311 and Resident #209) of six residents reviewed for medication administration. Specifically, the facility failed to notify the physician when Resident #311 tested positive for COVID-19, which resulted in a delay in obtaining treatment orders for the resident, who subsequently expired; Resident #311's blood sugars were out of prescribed parameters; Resident #311's medications were unavailable for administration and Resident #209 did not receive medications as ordered. The facility identified a census of 53 current residents. Findings include: 1. A review of an admission Record revealed Resident #311 had diagnoses which included chronic obstructive pulmonary disease (COPD), chronic viral hepatitis C, diabetes, multiple sclerosis, congestive heart failure (CHF), hypertension, cirrhosis of the liver, and chronic kidney disease. Further review of the admission record revealed the resident expired at the facility on [DATE]. A review of the admission Minimum Data Set (MDS), dated [DATE], indicated Resident #311 scored 12 on a Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. The resident required limited to extensive assistance of two people for activities of daily living (ADLs). The MDS indicated the resident received insulin injections on six out of seven days during the lookback period. A review of a care plan, dated as initiated on [DATE], revealed Resident #311's goal was to transition back to the community. The facility developed an intervention for the resident to transition home with goals met. 1. a) A review of the facility's policy titled, Lab and Diagnostic Test Results - Clinical Protocol, revised [DATE], indicated, The physician will identify, and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility. When test results are report to the facility, a nurse will first review the results. The policy also indicated the following: - A nurse will identity the urgency of communicating with the attending physician based on the physician's request, the seriousness of any abnormality, and the individual's current condition. - A physician can be notified by phone, fax, voicemail, e-mail, mail, pager or a telephone message to another person acting as the physician's agent (for example, office staff). a. Facility staff should document information about when, how, and to whom the information was provided and the response. This should be done in the Progress Notes section of the medical record and not on the lab results report, because test results should be correlated with other relevant information such as the individual's overall situation, current symptoms, advance directives, prognosis, etc. [et cetera]. b. Direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification, especially when the resident's clinical status is unstable or current treatment needs review or clarification. Review of a facility policy titled, COVID-19 Testing Policy, revised [DATE], revealed, Documentation of Testing. Facilities must demonstrate compliance with the testing requirements. To do so, facilities should do the following: For symptomatic residents and staff, document the date(s) and time(s) of the identification of signs or symptoms, when testing was conducted, when results were obtained, and the actions the facility took based on the results. A review of Progress Notes revealed a COVID-19 Testing note was entered on [DATE] at 5:55 PM, which indicated Resident #311 had a positive COVID-19 test. The note did not indicate the physician was notified of the positive results. A review of Progress Notes dated [DATE] at 12:21 AM and [DATE] at 12:47 PM, revealed Resident #311 had no signs or symptoms of COVID-19 after testing positive. A review of Progress Notes dated [DATE] at 12:24 AM, revealed Resident #311's oxygen saturation was 86% on room air. Oxygen was applied, and the resident's oxygen saturation came up to 91% with the oxygen at 2 liters per minute via nasal cannula. There was no indication the physician was notified. A review of a focused evaluation Progress Note, dated [DATE] at 12:30 AM, indicated Resident #311 had an occasional non-productive cough with oxygen in place. The note indicated the resident had no other signs and symptoms and remained in isolation for a recent diagnosis of COVID-19. A review of Doctor's Orders and Progress Notes, dated [DATE] at 12:30 PM, revealed, Apparently, [Resident #311] tested positive for COVID-19 on Friday night [[DATE]]. No provider was notified. Labs and medications were ordered at this time. A review of a Social Service Note, dated [DATE] at 12:59 PM, indicated Resident #311 expired that morning. A review of the Death Record, dated [DATE], indicated Resident #311's time of death was [DATE] at 7:28 AM, and the cause of death was COVID-19 pneumonia. During an interview on [DATE] at 2:32 PM, Staff T, Nurse Practitioner (NP), stated she was the primary provider for Resident #311. She stated Resident #311 tested positive for COVID-19 on a Friday and she was not notified until she came into the facility to do rounds on the following Tuesday ([DATE]). She stated the night shift nurse had left a note in her folder requesting an order for oxygen because the resident's oxygen saturation had dropped during the night. She stated she was going to see the resident, and that was when she was told the resident was on the COVID unit. She stated the resident went five days before any COVID treatment was ordered, then died the next day. On [DATE] at 8:42 AM, the surveyor attempted to call Staff U, the nurse caring for Resident #311 on [DATE] when the physician orders were written. Staff U did not answer, and the surveyor left a message. Staff U did not respond by the end of the survey. During an interview on [DATE] at 2:37 PM, Staff H, a Licensed Practical Nurse (LPN), stated whenever a resident tested positive for COVID-19, they were put into quarantine and notifications were made to the physician and families and should be documented in the progress notes. She stated the facility did not have standing orders for how to treat COVID-19. After reviewing Resident #311's record, Staff H stated she was unable to find documentation of the provider being notified when the resident tested positive for COVID-19. During an interview on [DATE] at 3:20 PM, the Director of Nursing (DON) stated whenever a positive COVID-19 test result was obtained, the facility would put the resident in isolation and notify the physician, family, state, and medical director. She stated those notifications should be documented in the progress notes. She stated the facility did not have standing orders for positive COVID-19 residents, but the physician should be updated, and they would provide orders as needed. The DON stated she could not recall the details of Resident #311's death. During an interview on [DATE] at 4:53 PM, the Administrator, she stated when a positive COVID-19 case was identified the resident was moved to the isolation area and the physician and family should be notified. She stated it should be documented in a progress note. 1. b) A review of the facility's policy titled, Diabetes, revised [DATE], indicated, The physician and staff will establish notification parameters related to diabetes monitoring. Based on individualized notification parameters, the staff will inform the practitioner about the status of each patient's glucose control, depending on the situation, goals, and other associated symptoms or conditions. A review of Resident #311's physician orders and February 2022 Medication Administration Record (MAR) indicated physician orders to check the resident's blood sugar before meals and at bedtime. The order indicated the facility was required to contact the resident's primary care provider (PCP) if Resident #311's blood sugar was over 300 or less than 70. A review of the February 2022 MAR revealed Resident #311's blood sugar was greater than 300 on 58 occasions out of the 112 times it was checked. On fourteen of those occasions, it was greater than 400; on sixteen occasions, it was greater than 500; and on one occasion, it was greater than 600. A review of Resident #311's Progress Notes for February 2022 revealed the resident's PCP was notified on five of the 58 occasions that the resident's blood sugar was greater than 300. On [DATE] at 8:42 AM, the surveyor attempted to contact Staff T, Resident #311's PCP, for an interview regarding Resident #311's blood sugars. The surveyor left a message requesting a callback. Staff T did not respond by the end of the survey. During an interview on [DATE] at 9:05 AM, Staff V, a Certified Medication Aide (CMA), stated the licensed nurses dealt with residents' blood sugars and notifying the physician if the results were out of parameters. During an interview on [DATE] at 10:33 AM, Staff W, a CMA, stated the physician should always be notified as ordered if a resident's blood sugar was out of parameters, because the physician may want to make changes to the resident's medications. During an interview on [DATE] at 2:37 AM, Staff H, a Licensed Practical Nurse (LPN), stated staff should document in a progress note or in the MAR notes when a resident's blood sugar was out of physician-ordered parameters and the provider was notified. After reviewing Resident #311's record, she was not able to find documentation that the resident's blood sugars were reported to the physician as ordered, but she stated they should have been. She stated it was important to let the provider know, because they may adjust the resident's medications or diet. During an interview on [DATE] at 3:20 PM, the Director of Nursing (DON) stated any resident with physician orders to check blood sugars should have parameters ordered as to when to notify the physician, and the nurse should document in the computer progress note when the physician was notified. The DON stated notifying the physician when a resident's blood sugar was not within physician-ordered parameters was important, so the physician could make changes if needed. During an interview on [DATE] at 4:53 PM, the Administrator stated if a resident's blood sugars were out of physician-ordered parameters, the physician and DON should be notified, and it should be documented in a progress note. 1. c) A review of the facility's policy Pharmacy and Therapeutics Oversight, revised [DATE], revealed Medications will be ordered, administered, and monitored appropriately and safely. According to the policy, The medical director will advise the facility on prescribing, handling, dispensing, storing, prescribing, and monitoring medications, including the following: a. Appropriate indications, selection, and prescribing of medications for the facility's resident/patient population. b. Safe procurement, storage, distribution, use and disposal of drugs and biologicals . d. Contents of emergency and interim medication kits . i. Monitoring for, identifying, correcting, and preventing medication-related problems including adverse consequences. A review of the Physician Orders and the February 2022 Medication Administration Record (MAR) indicated Resident #311 had orders which included: - Flomax (used of urinary incontinence) 0.4 milligrams (mg) give one tablet by mouth one time a day. - Fluconazole (used for yeast infections) 50 mg give one tablet by mouth one time a day every three days. - Ranolazine (used for chest pain) 1,000 mg give one tablet by mouth two times a day. - Isosorbide Mononitrate (used for chest pain) 50 mg give 50 mg by mouth two times a day. - Prednisone (used for multiple sclerosis) 20 mg give three tablets by mouth one time a day. - Ropinirole (used for restless leg syndrome) 2 mg give one tablet by mouth one time a day. Further review of the February 2022 MAR revealed the resident did not receive the following medications due to not being available from the pharmacy for administration: - Flomax 0.4 mg on [DATE], [DATE], [DATE], and [DATE] - Fluconazole 50 mg on [DATE], [DATE], and [DATE] - Prednisone 60 mg on [DATE], [DATE], and [DATE] - Ranolazine 1,000 mg on [DATE], [DATE], [DATE], [DATE] AM and PM dose, [DATE] AM and PM dose, and [DATE] AM and PM dose - Isosorbide 50 mg on [DATE], [DATE], [DATE], and [DATE] - Ropinirole 2 mg on [DATE] and [DATE] A review of the Orders-Administration Notes for the above medications indicated the medications were either not available or were on order. A review of Resident #311's record revealed no documentation that the primary care provider (PCP) was notified of the resident not receiving the above medications. During an interview on [DATE] at 2:32 PM with Staff T, Nurse Practitioner (NP), she stated she could not recall if the facility had notified her of Resident #311 missing medications. She stated she expected to be notified whenever the nurse held a medication so that if the resident ended up having an adverse reaction to not getting the medications, then she would know the reason and it would affect how she would treat the resident. She stated having the staff fail to notify her when a medication was being held or not given had been an issue in the past. During an interview on [DATE] at 9:05 AM with Staff V, Certified Medication Aide (CMA), she stated if a medication was not available during the medication pass, then she would tell the nurse and document that it was not available. She stated she was unsure if the physician was notified but thought the nurse did that. During an interview on [DATE] at 10:33 AM with Staff W, CMA, she stated if a medication was not available, she would tell the charge nurse and document it was not available. She stated the charge nurse should notify the physician. During an interview on [DATE] at 2:37 PM with Staff H, Licensed Practical Nurse (LPN), she stated if a medication was not available during the medication pass, the physician was notified by fax but admitted it was not done every time. During an interview on [DATE] at 3:20 PM, the Director of Nursing (DON) stated if a medication was not available during the medication pass, the physician should be notified sometime during the day, and depending on the type of medication, maybe sooner. She stated if a medication was unavailable for multiple days, the physician, pharmacy, and DON should be notified. The DON stated the physician should be contacted for clarification whenever a medication was not available to see how the physician wanted to proceed. During an interview on [DATE] at 4:53 PM, the Administrator stated if a medication was not available during the medication pass, the pharmacy and physician should be contacted along with the DON. 2. A review of Resident #209's admission Record, revealed the facility admitted the resident on [DATE] with diagnoses that included dementia without behavioral disturbance, major depressive disorder, and Parkinson's disease. A review of Resident #209's admission Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severely impaired cognitive skills. A review of Resident #209's Order Summary Report revealed the resident was admitted with orders for pramipexole dihydrochloride tablet 0.25 milligram (mg). The order was to give one tablet by mouth twice a day related to Parkinson's disease. The order start date was the day of admission, [DATE]. A review of the pharmacy receipt revealed Resident #209's pramipexole dihydrochloride tablets were delivered to the facility on [DATE]. A review of the resident's [DATE] and [DATE] Medication Administration Record [MAR] revealed the pramipexole dihydrochloride tablet 0.25 mg was not administered the evening of [DATE] or the mornings of [DATE], [DATE], or [DATE]. A review of the resident's Progress Notes, dated [DATE], [DATE], [DATE], and [DATE] revealed the medication was not available for morning administration and no note indicated the physician was called regarding the missing medication. During a telephone interview with Staff R, a Certified Medication Assistant (CMA), on [DATE] at 1:33 PM, she stated she was able to pass medications as of [DATE] and had worked at the facility for four years as a CNA. She stated if the medication was in stock it was administered. She stated if the medication was not available, she would inform the charge nurse and they would see what was going on. If a medication was not given, it should be documented on the MAR and in a nursing note. She stated she could not find the Parkinson medication for Resident #209 the morning of [DATE]. She stated the medication cards were not in the cart that morning and she notified Staff F, a Licensed Practical Nurse (LPN) and charge nurse, who double checked and could not find the medication card either. An interview with Staff F on [DATE] at 2:28 PM revealed if a medication needed to be given but was not available, she would call the pharmacy to see when it could be delivered. She stated the pharmacy for the facility could be very slow when delivering medications. She stated she was not passing medications on [DATE] and did not recall getting any reports from the CMAs about missing medications. During an interview with the Director of Nursing (DON) on [DATE] at 2:30 PM, she stated ideally if the medication was not available the nurse would call the pharmacy and check the E-kit (emergency kit; emergency medication box). If the medication was determined to not be sent from the pharmacy, it should be reordered. She stated the physician should be notified the same day when a medication was not available for administration and kept up to date about when the medication could be given. She stated if the medication had not arrived in a few days, the nurses should be following up with pharmacy. She stated there was a card issue with Resident #209's medication and the doses not given in the morning should have been reported to the physician. During an interview on [DATE] at 2:37 PM with Staff H, a Licensed Practical Nurse, she stated she was not sure if the physician was notified that Resident #209's medications were not given. During an interview with the Administrator on [DATE] at 4:04 PM, she stated the physician, the pharmacy, and the DON should be notified if a medication was not available at medication pass time. She stated the CMAs should report to the nurse if medications were not available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview, the facility failed to ensure three (Resident #311, Resident #29, and Resident #209) of six sampled residents reviewed for medication administration received care and treatment in accordance with professional standards of practice. Specifically, the facility failed to ensure Resident #311's physician was notified of a positive COVID-19 test on [DATE]. Once the provider was aware the resident had COVID-19 on [DATE], the facility failed to ensure physician-ordered medications were provided and tests were obtained as ordered on [DATE]. In addition, the facility failed to monitor Resident #311's vital signs for approximately 23 hours prior to the resident's death. Resident #311 expired on [DATE] due to COVID-19 pneumonia; failed to notify the physician when blood sugar levels were out of parameters (too high and/or too low) and failed to conduct and document follow-up blood sugar results and assessments after obtaining abnormal blood sugars for Resident #311 and Resident #29; and failed to administer medications as ordered and/or inform the physician when medications were missed or unavailable for Resident #29 and Resident #209. The facility identified a census of 53 current residents. Findings include: 1. A review of an admission Record revealed Resident #311 had diagnoses which included chronic obstructive pulmonary disease (COPD), chronic viral hepatitis C, diabetes, multiple sclerosis, congestive heart failure (CHF), hypertension, cirrhosis of the liver, and chronic kidney disease. Further review of the admission record revealed the resident expired at the facility on [DATE]. A review of the admission Minimum Data Set (MDS), dated [DATE], indicated Resident #311 scored 12 on a Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. The resident required limited to extensive assistance of two people for activities of daily living (ADLs). The MDS indicated the resident received insulin injections on six out of seven days during the lookback period. A review of a care plan, dated as initiated on [DATE], revealed Resident #311's goal was to transition back to the community. The facility developed an intervention for the resident to transition home with goals met. 1. a) A review of the facility's policy titled, Lab and Diagnostic Test Results - Clinical Protocol, revised [DATE], indicated, The physician will identify, and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility. When test results are report to the facility, a nurse will first review the results. The policy also indicated the following: - A nurse will identity the urgency of communicating with the attending physician based on the physician's request, the seriousness of any abnormality, and the individual's current condition. - A physician can be notified by phone, fax, voicemail, e-mail, mail, pager or a telephone message to another person acting as the physician's agent (for example, office staff). a. Facility staff should document information about when, how, and to whom the information was provided and the response. This should be done in the Progress Notes section of the medical record and not on the lab results report, because test results should be correlated with other relevant information such as the individual's overall situation, current symptoms, advance directives, prognosis, etc. [et cetera]. b. Direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification, especially when the resident's clinical status is unstable or current treatment needs review or clarification. Review of a facility policy titled, COVID-19 Testing Policy, revised [DATE], revealed, Documentation of Testing. Facilities must demonstrate compliance with the testing requirements. To do so, facilities should do the following: For symptomatic residents and staff, document the date(s) and time(s) of the identification of signs or symptoms, when testing was conducted, when results were obtained, and the actions the facility took based on the results. A review of Progress Notes revealed a COVID-19 Testing note was entered on [DATE] at 5:55 PM, which indicated Resident #311 had a positive COVID-19 test. The note did not indicate whether the physician was notified of the positive results. A review of Progress Notes dated [DATE] at 12:21 AM and [DATE] at 12:47 PM, revealed Resident #311 had no signs or symptoms of COVID-19 after testing positive. A review of Progress Notes dated [DATE] at 12:24 AM, revealed Resident #311's oxygen saturation was 86% on room air. Oxygen was applied, and the resident's oxygen saturation came up to 91% with the oxygen at 2 liters per minute via nasal cannula. A review of a focused evaluation Progress Note, dated [DATE] at 12:30 AM, indicated Resident #311 had an occasional non-productive cough with oxygen in place. The note indicated the resident had no other signs and symptoms and remained in isolation for a recent diagnosis of COVID-19. A review of Doctor's Orders and Progress Notes, dated [DATE] at 12:30 PM, indicated Resident #311 tested positive for COVID-19 on [DATE] and no provider was notified. Further review revealed the provider ordered a Z-pak (antibiotic), Dexamethasone (a steroid medication) six milligrams (mg) by mouth daily for 10 days, Tessalon pearls (for cough) 200 mg one by mouth four times a day for 72 hours and then as needed (PRN), Robitussin DM 2 teaspoons every six hours as needed for cough, and oxygen to keep saturations greater than 90%. The provider also ordered a chest x-ray, a complete blood count (or CBC, a laboratory test to detect anemia and/or infection), a basic metabolic profile (BMP, a blood test to check for hydration and kidney function), and a d-dimer (test used to rule out blood clots). The ordered labs were to be completed today [[DATE]]. There was also an order to test the resident for influenza (flu) A and B if the test had not already been completed. The notes also indicated the facility would be contacted to set up a monoclonal antibody infusion (treatment for COVID-19) for Resident #311. A review of a Social Service Note, dated [DATE] at 12:59 PM, indicated Resident #311 expired that morning. A review of Resident #311's physician order reports revealed the physician orders for medications and laboratory tests from [DATE] were not entered into the computer until [DATE] and were not implemented prior to the resident's death on [DATE] at 7:28 AM, approximately 19 hours after the orders were written. A review of Resident #311's Progress Notes, dated [DATE] at 2:08 PM, indicated the resident had a non-productive cough but the lungs were clear to auscultation, and respirations were even and unlabored. The note indicated the resident's oxygen saturation was 96% on room air on [DATE] at 6:11 AM, approximately eight hours earlier. According to the notes, Resident #311's other vital signs, including temperature (98.5 degrees Fahrenheit), blood pressure (137/56 millimeters of mercury), pulse (71 beats per minute), and respirations (16 breaths per minute) were also obtained at 6:11 AM, approximately eight hours earlier. A review of Progress Notes, dated [DATE] at 4:16 AM, indicated Resident #311 did not show any signs or symptoms of COVID-19. The resident's lungs were clear to auscultation and respirations were even and unlabored. Further review of the note revealed the same vital signs obtained on [DATE] at 6:11 AM (the previous day) were also documented on the [DATE] note, oxygen saturation-96%, temperature-98.5 degrees Fahrenheit, blood pressure-137/56 millimeters of mercury, pulse-71 beats per minutes, and respirations-16 breaths per minute. There were no current vital signs documented. A review of Resident #311's physician orders from the facility's electronic medical records system revealed the resident's current vitals were last obtained on [DATE] at 6:11 AM. A review of the Death Record, dated [DATE], indicated Resident #311's time of death was [DATE] at 7:28 AM, and the cause of death was COVID-19 pneumonia. Continued review of Resident #311's Progress Notes revealed no documentation of the circumstances surrounding the death of Resident #311 and no documented evidence the facility checked the resident's vital signs, including the oxygen saturation level, for approximately 23 hours before the resident's death. During an interview on [DATE] at 2:32 PM, Staff T, Nurse Practitioner (NP), stated she was the primary provider for Resident #311. She stated Resident #311 tested positive for COVID-19 on a Friday and she was not notified until she came into the facility to do rounds on the following Tuesday ([DATE]). She stated the night shift nurse had left a note in her folder requesting an order for oxygen because the resident's oxygen saturation had dropped during the night. She stated she was going to see the resident, and that was when she was told the resident was on the COVID unit. She stated the resident went five days before any COVID treatment was ordered, then died the next day. On [DATE] at 8:42 AM, the surveyor attempted to call Staff U, the nurse caring for Resident #311 on [DATE] when the physician orders were written. Staff U did not answer, and the surveyor left a message. Staff U did not respond by the end of the survey. On [DATE] at 11:28 AM, the surveyor attempted to contact Staff C, the nurse who input the orders on [DATE] after the resident expired. Staff C did not answer, and the surveyor left a message. Staff C did not respond by the end of the survey. During an interview on [DATE] at 2:37 PM, Staff H, a Licensed Practical Nurse (LPN), stated whenever a resident tested positive for COVID-19, they were put into quarantine and notifications were made to the physician and families and should be documented in the progress notes. She stated the facility did not have standing orders for how to treat COVID-19. After reviewing Resident #311's record, Staff H stated she was unable to find documentation of the provider being notified when the resident tested positive for COVID-19. She stated when a physician did rounds, they would provide the progress notes at the time of the visit and then the note should go into the resident's chart. Staff H stated the provider would write any new orders on the progress note. She stated she was unable to say why Resident #311's orders were not put into place the day they were ordered. During an interview on [DATE] at 3:20 PM, the Director of Nursing (DON) stated whenever a positive COVID-19 test result was obtained, the facility would put the resident in isolation and notify the physician, family, state, and medical director. She stated those notifications should be documented in the progress notes. She stated the facility did not have standing orders for positive COVID-19 residents, but the physician should be updated, and they would provide orders as needed. She stated when a provider completed a visit at the facility, the progress notes would be put in the resident's file to be uploaded into the computer. She stated the providers would write any new orders on the progress notes. She stated she expected the orders to be put into the computer right away. After reviewing Resident #311's provider progress note dated [DATE], she stated the orders should have been put in right away and initiated. The DON stated she could not recall the details of Resident #311's death. During an interview on [DATE] at 4:53 PM, the Administrator, she stated when a positive COVID-19 case was identified the resident was moved to the isolation area and the physician and family should be notified. She stated it should be documented in a progress note. The Administrator stated when a physician did a visit and wrote orders, the staff should be putting those orders in when they were received and followed. The Administrator stated Resident #311's orders should have been put in the same day and started and did not know why there was a delay. 1.b) A review of the facility's policy titled, Diabetes, revised [DATE], indicated, The physician and staff will establish notification parameters related to diabetes monitoring. Based on individualized notification parameters, the staff will inform the practitioner about the status of each patient's glucose control, depending on the situation, goals, and other associated symptoms or conditions. A review of Resident #311's physician orders and February 2022 Medication Administration Record (MAR) indicated physician orders to check the resident's blood sugar before meals and at bedtime. The order indicated the facility was required to contact the resident's Primary Care Provider (PCP) if Resident #311's blood sugar was over 300 or less than 70. A review of the February 2022 MAR revealed Resident #311's blood sugar was greater than 300 on 58 occasions out of the 112 times it was checked. On fourteen of those occasions, it was greater than 400; on sixteen occasions, it was greater than 500; and on one occasion, it was greater than 600. A review of Resident #311's Progress Notes for February 2022 revealed documentation that the resident's PCP was notified on five of the 58 occasions that the resident's blood sugar was greater than 300. On [DATE] at 8:42 AM, the surveyor attempted to contact Staff T, Resident #311's PCP, for an interview regarding Resident #311's blood sugars. The surveyor left a message requesting a callback. Staff T did not respond by the end of the survey. During an interview on [DATE] at 9:05 AM, Staff V, a Certified Medication Aide (CMA), stated the licensed nurses dealt with residents' blood sugars and notifying the physician if the results were out of parameters. During an interview on [DATE] at 10:33 AM, Staff W, a CMA, stated the physician should always be notified as ordered if a resident's blood sugar was out of parameters, because the physician may want to make changes to the resident's medications. During an interview on [DATE] at 2:37 AM, Staff H, a Licensed Practical Nurse (LPN), stated staff should document in a progress note or in the MAR notes when a resident's blood sugar was out of physician-ordered parameters and the provider was notified. After reviewing Resident #311's record, she was not able to find documentation that the resident's blood sugars were reported to the physician as ordered, but she stated they should have been. She stated it was important to let the provider know, because they may adjust the resident's medications or diet. During an interview on [DATE] at 3:20 PM, the Director of Nursing (DON) stated any resident with physician orders to check blood sugars should have parameters ordered as to when to notify the physician, and the nurse should document in the computer progress note when the physician was notified. The DON stated notifying the physician when a resident's blood sugar was not within physician-ordered parameters was important, so the physician could make changes if needed. During an interview on [DATE] at 4:53 PM, the Administrator stated if a resident's blood sugars were out of physician-ordered parameters, the physician and DON should be notified, and it should be documented in a progress note. 2. A review of the admission Record indicated Resident #29 had diagnoses which included diabetes. A review of the quarterly Minimum Data Set (MDS) indicated Resident #29 had moderate cognitive impairment, with a Brief Interview for Mental Status (BIMS) score of 12. The resident required extensive to total assistance of two people for activities of daily living (ADLs). The MDS indicated the resident received insulin injections seven out of seven days during the look back period. 2. a) A review of the facility's policy titled, Diabetes, revised [DATE] indicated, The physician and staff will establish notification parameters related to diabetes monitoring. Based on individualized notification parameters, the staff will inform the practitioner about the status of each patient's glucose control, depending on the situation, goals, and other associated symptoms or conditions. A review of the physician orders indicated Resident #29 had orders for accuchecks (blood sugar checks) to be completed two times a day and to notify the primary care provider (PCP) if the resident's blood sugar was greater than 300 or less than 70. A review of the physician orders and [DATE] Medication Administration Record (MAR) revealed the resident also had an order (initiated on [DATE]) for glucagon (a medication used to treat low blood sugar) one milligram (mg)/0.2 milliliter (ml). The directions were to inject one mg subcutaneously as needed and update the PCP if the resident's blood sugar was over 300 or less than 70. A review of the [DATE] MAR revealed Resident #29 had a blood sugar below 70 on eleven occasions, with three blood sugar results below 60. There was no documentation the PCP was notified, no documentation that glucagon was administered, nor of any follow-up assessments/checks of the resident's blood sugar. A review of the [DATE] MAR revealed nine occasions when the resident's blood sugars were below 70, two of which were less than 60. Further review revealed Resident #29's blood sugar was above 300 on occasions. There was no documented evidence the resident's PCP was notified. In addition, there was no documentation that glucagon was administered when the resident's blood sugar was below 70, nor of any follow-up/assessments of the resident's blood sugar. A review of all progress notes dated from [DATE] through [DATE] revealed no documentation Resident #311's PCP was notified as ordered when Resident #29's blood sugars were out of physician-ordered parameters (below 70 or greater than 300). There was also no documentation of the low blood sugars being treated or monitored. On [DATE] at 8:42 AM, the surveyor attempted to contact Staff T, Resident #29's primary care provider, for an interview regarding the resident's blood sugars. The surveyor left a message requesting a return call. Staff T did not respond by the end of the survey. During an interview on [DATE] at 9:05 AM, Staff V, a Certified Medication Aide (CMA), stated the nurses dealt with residents' blood sugars and physician notification if results were out of parameters. During an interview on [DATE] at 10:33 AM, Staff W, a CMA, stated the physician should always be notified if blood sugars were out of physician-ordered parameters, because the physician may want to make changes to the resident's medications. During an interview on [DATE] at 2:37 AM, Staff H, a Licensed Practical Nurse (LPN), stated staff should document in a progress note or on the MAR notes when a resident's blood sugar was out of physician-ordered parameters and the provider was notified. After reviewing Resident #311's record, she was not able to find documentation that the resident's blood sugars were reported to the physician as ordered, but she stated they should have been. She stated it was important to let the provider know, because they may adjust the resident's medications or diet. During an interview on [DATE] at 3:20 PM, the Director of Nursing (DON) stated any resident with physician orders to check blood sugars should have ordered parameters for when to notify the physician, and the nurse should document in the computer progress notes when the physician was notified. The DON stated notifying the physician when a resident's blood sugar was not within physician-ordered parameters was important, so the physician could make changes if needed. During an interview on [DATE] at 4:53 PM, the Administrator stated if a resident's blood sugars were out of physician-ordered parameters, the physician and DON should be notified, and it should be documented in a progress note. 2.b) A review of the facility's policy Pharmacy and Therapeutics Oversight, revised [DATE], revealed Medications will be ordered, administered, and monitored appropriately and safely. According to the policy, The medical director will advise the facility on prescribing, handling, dispensing, storing, prescribing, and monitoring medications, including the following: a. Appropriate indications, selection, and prescribing of medications for the facility's resident/patient population. b. Safe procurement, storage, distribution, use and disposal of drugs and biologicals . d. Contents of emergency and interim medication kits . i. Monitoring for, identifying, correcting, and preventing medication-related problems including adverse consequences. A review of Progress Notes, dated [DATE], indicated Resident #29 was congested and tested positive for COVID-19 twice. The note indicated the provider was notified and new orders were obtained. A review of Resident #29's Physician Orders indicated an order was received on [DATE] for dexamethasone six milligrams (mg) give one tablet by mouth one time a day for COVID-19 for seven days, scheduled to start on [DATE]. A review of Resident #29's [DATE] Medication Administration Record (MAR) revealed on [DATE] and [DATE], dexamethasone was coded 9, indicating to see the progress notes. A review of Progress Notes, dated [DATE] at 3:08 PM and [DATE] at 7:59 AM, revealed the dexamethasone was not available to be administered. The [DATE] note indicated the medication was ordered. Further review of the MAR revealed dexamethasone was only administered for five days, [DATE] through [DATE], instead of the physician-ordered seven days. A review of the Ekit (Emergency medication kit) Contents indicated twelve dexamethasone one mg tablets were available in the e-kit. During an interview on [DATE] at 2:32 PM, Staff T, the Physician Assistant who was Resident #29's primary care provider, stated she expected to be notified if a medication was held. She stated she needed to be aware in case the resident had an adverse reaction due to not receiving the medication. She stated not being notified by facility staff when a medication was held or not given had been an issue in the past. During an interview on [DATE] at 9:05 AM, Staff V, a Certified Medication Aide (CMA), stated if a medication was not available during the medication pass, she would notify the nurse and document that it was not available. She stated she was unsure if the physician was notified. During an interview on [DATE] at 10:33 AM, Staff W, a CMA, stated if a medication was not available, she would tell the charge nurse and document it was not available. She stated the charge nurse should notify the physician. She stated if the medication was available in the e-kit, then it should be given. She stated she was unsure why dexamethasone for Resident #29 was not pulled out of the e-kit. She stated the medication should have been given as ordered for seven days, even if it was not available the first two days. During an interview on [DATE] at 2:37 PM, Staff H, a Licensed Practical Nurse (LPN), stated if a medication was not available during medication pass, the nurse or CMA should check the e-kit to see if it was available there. She stated if the medication was available at the same dose but was with medications ordered at a different time, it could be pulled from those medications and the pharmacy should be notified so the dose could be replaced. She stated if a medication was not available at all, staff should notify the pharmacy. She stated the physician should be notified by fax, but admitted it was not done every time. After reviewing Resident #29's record, she stated the dexamethasone should have been pulled from the e-kit the first two days until it was provided by the pharmacy. Staff H stated Resident #29's dexamethasone should have been given for the full seven days as ordered. During an interview on [DATE] at 3:20 PM, the Director of Nursing (DON) stated if a medication was not available during the medication pass, the cart and the medication room should be double-checked and then the e-kit should be checked to see if the medication was available. The DON stated the pharmacy needed to be called to find out when it was sent and when it would be available. She stated sometimes they could get the pharmacy to deliver medications the same day, even though the pharmacy was hours away. The DON stated the physician should be notified that day, and depending on the type of medication, maybe sooner. She stated if a medication was unavailable for multiple days, the physician, pharmacy, and DON should be notified. She stated dexamethasone was available in the e-kit and could have been used. The DON stated the physician should be contacted for clarification whenever a medication was not available, to see how the physician wanted to proceed. During an interview on [DATE] at 4:53 PM, the Administrator, stated if a medication was not available, the pharmacy, physician, and DON should be contacted. 3. A review of Resident #209's admission Record, dated [DATE], revealed the facility admitted the resident on [DATE] with diagnoses including dementia without behavioral disturbance and Parkinson's disease. A review of the admission MDS, dated [DATE], revealed the resident scored 3 on a BIMS, which indicated the resident had severely impaired cognitive skills. A review of the computerized physician's orders, dated [DATE], revealed the facility admitted the resident with physician orders for pramipexole dihydrochloride tablet 0.25 milligram (mg). The directions were to give one tablet by mouth twice a day related to Parkinson's disease. A review of a pharmacy receipt revealed Resident #209's pramipexole dihydrochloride tablets were delivered to the facility on [DATE]. A review of the [DATE] and [DATE] Medication Administration Records (MARs) revealed the pramipexole dihydrochloride tablet was not administered the evening of [DATE], nor the mornings of [DATE], [DATE], and [DATE]. During a telephone interview on [DATE] at 1:33 PM, Staff R, a Certified Medication Assistant (CMA), stated she was able to pass medications as of [DATE] and had worked at the facility for four years as a Certified Nursing Assistant (CNA). She stated she had passed medications twice on her own. She stated if the medication was in stock, then it was administered. She stated if a medication was not available, she would inform the charge nurse and the charge nurse would see what was going on. If a medication was not given, that information should be documented on the MAR and in a nursing note. She stated she could not find the pramipexole dihydrochloride for Resident #209 the morning of [DATE]. She stated the medication cards (pharmacy provided the facility's medications on blister cards) were not in the cart that morning, and she notified Staff F, Licensed Practical Nurse (LPN) charge nurse, who double-checked and could not find the morning medication card either. She stated the medication was available the previous two evenings ([DATE] and [DATE]) and she administered it. During an interview on [DATE] at 2:28 PM, Staff F revealed if a medication needed to be given but was not available, she would call the pharmacy to see when it could be delivered. She stated the pharmacy for the facility could be slow when delivering medications. She stated she was not covering the medication cart on [DATE] and did not recall getting any reports from the CMAs about medications missing. During an interview with the Director of Nursing (DON) on [DATE] at 2:30 PM, she stated, ideally, if a medication was not available, the nurse would call the pharmacy and check the emergency-medication-kit. If the medication was determined to not be sent from the pharmacy, it should be reordered. She stated the physician should be notified the same day when a medication was not available for administration and kept up to date about when the medication could be given. She stated if the medication had not arrived in a few days, the nurses should be following up with the pharmacy. She stated there was a card issue with Resident #209's medication, and the doses not given in the morning should have been reported to the physician. During an interview on [DATE] at 2:37 PM, Staff H, Licensed Practical Nurse, revealed she was not sure if the physician was notified that Resident #209's medication was not given as ordered. During an interview with the Administrator on [DATE] at 4:04 PM, she stated the physician, the pharmacy, and DON should be notified if a medication was not available at medication pass time. She stated the medication assistants should report to the nurse if medications were not available. She stated staff members should have been administering the medication from the medication cards regardless of whether they were AM or PM medication cards.