**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and physician interviews, the facility failed to provide incontinence care safely to a dependent resident for 1 of 1 residents reviewed for falls. Resident #307 fell out of bed during incontinence care provided by Nursing Assistant (NA) #1 resulting in an upper lip laceration which required to 7 sutures, a laceration to the left side of the head that required 12 staples and a small laceration to the 2nd digit on the left foot. Findings included: Resident #307 was admitted to the facility on [DATE] with medical diagnosis which included in part: stroke with hemiparesis, vascular dementia, contractures of left wrist and hand and right hand, aphasia, and epilepsy. Review of Resident #307's 11/23/22 annual Minimum Data Set (MDS) assessment revealed resident had severe cognitive impairment with no behaviors. Resident #307 required total assistance of 2 people with bed mobility and toileting. Resident #307 had impaired range of motion on both sides of the upper extremities and impairment on 1 side of her lower extremities. Resident #307's height was 61 inches, and her weight was 172 pounds. Resident #307 did not receive an anticoagulant during the lookback period. Resident #307's care plan updated on 12/1/22 revealed a plan of care for activities of daily living (ADLs) personal care. The care plan interventions indicated Resident #307 was dependent for bathing and personal hygiene and required 2-person assist with bed mobility. Resident #307's undated care guide indicated 2-person assist was required with bed mobility. Review of Resident #307's electronic medical record revealed a nursing health status note written by Nurse # 1 on 1/22/23 at 11:21 PM. The note read in part called to room by aide, found resident on the floor face down with a large amount of blood. The note further indicated Emergency Medical Service (EMS) was alerted and Resident #307 was transported to the hospital. Review of an incident report completed by Nurse #1 on 1/22/23 at 11:30 PM revealed she was called to the room by NA #1. The note stated that Resident #307 was observed lying face down with blood noted around the head area. The note indicated that Nurse #1 could not tell where the blood was coming from. Emergency Medical Service (EMS) was called, and Resident #307 was transferred to the hospital. Review of a 1/23/23 statement completed by NA #1 indicated she was assigned to Resident #307 on the evening shift on 1/22/23. The statement indicated at approximately 7:15 -7:30 PM NA #1 provided incontinence care to Resident #307. NA #1 indicated Resident #307 was positioned in bed. NA #1 indicated following incontinence care she pushed the resident onto the left side with her left hand. NA #1 then placed her right hand on resident's right side and turned to reach for a clean brief when Resident #307 rolled off the bed onto the floor. NA #1 stated Resident #307 hit the nightstand with her head and landed face down on the floor. NA #1 immediately notified Nurse #1 that Resident #307 was on the floor. Attempts were made 3 times by phone and text message to contact NA # 1 on 8/23/23 and 8/24/23 without success. An interview was conducted on 8/22/23 at 3:55 PM with Nurse # 1. Nurse # 1 revealed she was assigned to Resident #307 on 1/22/23. Nurse # 1 stated NA #1 turned Resident #307 away from her while providing incontinence care. Nurse # 1stated Resident #307 was too close to the edge of the bed and rolled off. An interview was conducted on 8/23/23 at 1:25 PM with Nurse #3. Nurse #3 revealed she was working the night of 1/22/23 and responded to the room following Resident #307's fall. Nurse #3 observed Resident #307 lying face down on the floor by the bed and there was a large amount of blood. Review of the hospital records revealed an emergency department provider note dated 1/22/23 which indicated Resident #307 presented to the emergency department with profuse bleeding from a scalp and a lip laceration after a fall while staff were attending to her. Physical exam indicated Resident #307 had a 3.5 centimeter left posterior scalp laceration and a 2-centimeter upper lip laceration. Resident #307 received 7 sutures to the upper lip and 12 staples to the scalp. The note further indicated Resident #307 underwent a CT scan which revealed no cranial hemorrhage. Resident #307 returned to the facility on 1/23/23. An interview was conducted on 8/23/23 04:35 PM with the Assistant Director of Nursing (ADON). The ADON revealed she completed the investigation of Resident #307's 1/22/23 fall. The ADON stated that as part of the investigation, NA #1 demonstrated what happened when Resident #307 fell. The ADON stated NA #1 demonstrated she turned Resident #307 away from her while providing incontinence care. The root cause analysis of the fall was improper turning and repositioning. The ADON stated if NA #1 had turned the resident toward her during care the fall could have been prevented. The ADON further stated the care guide indicated Resident #307 required 2-person assistance with mobility. The ADON stated NA # 1was trained on how to provide incontinence care to a dependent resident when she was hired. The ADON stated all nurses and NAs were retrained after this incident on how to properly turn and reposition a resident and were required to complete return demonstrations. The ADON stated NA #1 was retrained and was not allowed to provide patient care until she completed the retraining and demonstrated that she knew how to safely provide care. An interview was conducted with the Administrator on 8/24/23 at 7:15 AM. The Administrator revealed that a full investigation of the incident was completed, and a Plan of Correction was completed after the fall. The Administrator stated that the Plan of Correction consisted of audits and in service education with all nurses, NAs and Medication Aides regarding turning and repositioning. Interview on 8/24/23 at 2:35 PM with the Physician revealed due to Resident #307's dependent status with history of stroke with hemiparesis, the NA should not have turned the resident away from her during care. An interview was conducted on 8/24/23 at 4:00 with the Nursing Supervisor. The Nursing Supervisor revealed Resident #307 required total care, was nonverbal and required 2 person assist with mobility. The Nursing Supervisor stated that all nurses and NAs received in service training regarding safe handling following Resident #307's fall on 1/22/23. An interview on 8/25/23 at 9:56 AM with the Director of Nursing (DON) revealed safe handling was the root cause of the incident with Resident #307 on1/22/23. Root cause analysis was investigated and training and in services were provided to all nurses and NAs following the incident. The facility provided the following Corrective Action Plan with a completion date of 2/15/23: 1. On 1/22/23 approximately 7:15-7:30 PM Resident #307 was in bed receiving incontinence care by one Nursing Assistant (NA). Resident #307 was positioned with the head of bed elevated with her hips in the center of the bed and legs slightly to the left. NA lowered the head of the bed, raised the bed to the height of about 2.5 to 3 feet and began to provide incontinence care. Upon interviewing the NA, she stated following incontinence care, she pushed the resident onto the left side with her left hand while raising resident's right leg up and over the left leg resulting in the resident being positioned along the edge of the bed on the left side. The NA stated when reaching for a brief, the resident continued to take a forward motion to the left side of the bed. The NA was unable to stop the forward motion of the resident and she rolled off the bed onto the floor. The assigned nurse on duty and another nurse assessed the resident, observed a large amount of blood on the floor around resident's head and determined the resident would be sent to the emergency room for evaluation. Emergency Medical Services (EMS) arrived at the facility and transported resident to the hospital for evaluation. Resident underwent a CT scan of the head which revealed no cranial hemorrhage. Resident received 7 sutures to the upper lip laceration and 12 staples to the scalp laceration. Resident remained in the emergency room overnight and returned to the facility on 1/23/23. 2. The Nurse Aide involved was not permitted to provide resident care pending investigation and education regarding safe handling and turning and repositioning. The Nursing Assistant was also asked to do a return demonstration of the incident. The Assistant Director of Nursing met with the Nursing Assistant on 1/23/23, written statement was received, and education was provided. The Nursing Assistant provided demonstration of the incident and following education completed a demonstration of proper handling and turning and repositioning. 3. Reeducation to the nursing staff to include Nursing Assistants, nurses and Medication Aides was initiated on 1/23/23 by the Assistant Director of Nursing (ADON) and nursing supervisor. Education included proper turning and positioning procedure, safe handling and following the resident care guide. All nursing staff will receive education prior to next scheduled shift. Education is congoing for new hired staff. The Director of Nursing (DON) initiated an in service with all nurses, Nursing Assistants and Medication Aides regarding positioning in bed with emphasis on the providing care in bed to the dependent resident, safe handling and utilizing the care guide. 100% audit of all resident positioning needs in bed. 100% audit utilizing a questionnaire with all cognitively intact residents regarding any concerns related to turning and positioning during care. 100% audit of all falls in the prior 30 days 100% audit of resident care plans and care guides to ensure correct information in place and updated as needed. Staff Development Coordinator and/or Nursing Supervisor will complete 5 random weekly observations of staff providing bed mobility and proper positioning during care for 4 weeks. 4. Results of the 5 random weekly observations will be discussed at the monthly Quality Assurance and Performance Improvement (QAPI) meeting for one month to determine trends or issues that may require further interventions or monitoring to sustain substantial compliance. 5. Allegation of Compliance Date: 2/15/23. The Corrective Action Plan was validated on 8/24/23 and concluded the facility implemented an acceptable corrective action plan on 2/15/23. Interviews with nursing staff revealed the facility had provided education and training on proper turning and repositioning and safe handling. Staff interviewed verbalized they received in service training including return demonstration of competency prior to starting their next shift. Review of the facility audit tools revealed 100% audit of resident positioning needs in bed was completed. Audit records further revealed questionnaires were completed with all cognitively intact residents regarding turning and positioning during care. 100 % of the falls in the prior 30 days were reviewed. No concerns were identified as a result of the audits. Review of the monitoring tools of safe handling and turning and repositioning that began on 1/24/23 were completed weekly as outlined in the corrective action plan with no concerns identified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2). Resident #31 was admitted to the facility on [DATE] with medical diagnosis which included insomnia. Resident #31's medical record revealed a physician order dated 6/14/23 for temazepam (antianxiety medication) oral capsule 15 milligrams. Give 1 capsule by mouth at bedtime for insomnia. Resident #31's August 2023 medication administration record (MAR) revealed that on 8/15/23, 8/16/23, 8/17/23 and 8/18/23 the documentation for temazepam was charted as 10 which indicated that the medication was not administered due to not available. Interview with Resident #31 on 8/21/23 at 12:45 PM revealed she did not receive her sleep medication for several nights due to it was not available in the facility. Resident #31 stated she was upset the nights she did not receive the medication because she could not sleep and feared she was going to have withdrawals. Review of the Controlled Substance Count Record for Resident #31 revealed a count sheet dated 8/18/23 for temazepam 15 milligrams. The count sheet indicated 30 tablets sent by pharmacy on 8/18/23. Interview on 8/23/23/ at 1:00 PM with Nurse #1 revealed she was assigned to Resident #31 on the evening of 8/16/23 until 11:00 PM. Nurse #1 indicated documentation of 10 on the MAR meant that the medication temazepam was unavailable. Nurse #1 stated that the medication temazepam was not in the medication cart on 8/16/23 and was not in the facility, so she did not administer it and documented 10 on the MAR. Nurse #1 revealed that she did not inform the physician that the medication was unavailable and did not attempt to obtain the medication. Nurse #1 stated she had worked at the facility for several years and knew she was supposed to obtain the medication or inform the physician it was unavailable, but she did not do so. Interview with Nurse #2 on 8/23/23 at 1:18 PM revealed that if the supply of a medication was getting low the nurse was to call the pharmacy, order the medication on the computer or fax the refill request to the pharmacy. Nurse #2 indicated she thought temazepam was refilled without a new prescription, but she was not sure. Nurse #2 indicated the pharmacy delivered the medication that night if ordered before 4 PM. If it was requested after 4 PM, the medication was received the next night. Nurse #2 indicated the facility had an emergency kit that contained some medications, including pain medication. Nurse #2 stated temazepam was not included in the emergency kit. Nurse #3 stated that if a medication was not available, she did not give it. Nurse #2 sometimes it was recorded on the report sheet if a medication was not available for someone to follow up. Nurse #2 recalled that Resident #31 was out of the medication temazepam recently, but she did not know why or how that happened. Nurse #2 stated that documentation of 10 on the MAR indicated the medication was not administered due to it was not available. Interview on 8/23/23 at 4:14 PM with MDS Nurse #2 revealed she was assigned to Resident #31 on the 3:00 PM -11:00 PM shift on 8/18/23. MDS Nurse #2 indicated she did not usually work the medication cart and when she did, she worked different assignments. MDS Nurse #2 stated she was not familiar with Resident #31's usual sleep patterns. MDS Nurse stated if any of the nurses noticed that a medication was running low, they could request a refill from the pharmacy. MDS Nurse #2 stated she documented a 10 on Resident #31's MAR on the evening of 8/18/23 indicating the medication was not available and she did not give it. MDS Nurse #2 stated she did not know why the medication was not available, she had not attempted to obtain it and had not notified the physician. MDS Nurse #2 revealed medication aides worked the medication carts and they don't check when refills are needed. MDS Nurse #2 stated no one was assigned to audit the medication carts for refills. MDS Nurse #2 stated she did not recall if Resident #31 was upset on 8/18/23 about not receiving her scheduled temazepam. Interview on 8/24/23 at 5:20 AM with Nurse #3 indicated she was assigned to Resident #31 on 8/15/23 and 8/17/23 from 7:00 PM to 7:00 AM. Nurse #3 revealed some medications required a prescription for refills. Nurse #3 stated all the nurses were supposed to send requests to the provider to obtain a prescription for refills. No one was assigned to check when refills were needed or to send the requests for refill prescriptions. Nurse #3 stated when she was assigned to Resident #31 on 8/15/23 and 8/17/23, she charted 10 on the MAR for temazepam which indicated the medication was not available in the facility and she did not give it. Nurse #3 stated she should have attempted to obtain the medication and notified the physician, but she did not do so. Nurse #3 stated she did not know why she had not done these things. Interview on 8/24/23 at 1:00 PM with Regional Pharmacy Services Manager revealed that some residents experience insomnia and nervousness or restlessness from missing a dose of temazepam. During a follow up interview on 8/24/23 at 1:45 PM with the Regional Pharmacy Services Manager he revealed that the last prescription for temazepam was dispensed for Resident #31 on 7/14/23 for 30 tablets. On 8/18/23 a new prescription of 30 tablets of temazepam was dispensed for Resident #31. There was no refill request received from the facility prior to 8/18/23. The pharmacy received an electronic prescription on 8/18/23 for Resident #31 for temazepam 15 milligrams give one tablet at bedtime for sleep. An interview on 8/24/23 at 2:45 PM with the Physician revealed she was not informed that Resident #31 did not receive the ordered temazepam on 8/15/23, 8/16/23, 8/17/23 and 8/18/23 due to it was not available. The physician stated that it may not have affected Resident #31 to miss the scheduled doses of temazepam, but it should have been reported and the refill should have been requested before the resident ran out of medication. The physician stated the omission of a medication for insomnia for several nights could be a significant issue. An interview was conducted on 8/24/23 at 3:49 PM with the Nursing Supervisor. The Nursing Supervisor revealed the nurses sometimes told her and she contacted the doctor's office to request a refill for a controlled substance. The Nursing Supervisor stated that on 8/18/23 she was told the refill was needed for Resident #31's temazepam and she requested the refill from the physician. The Nursing Supervisor stated there was no one assigned to check the medications on the medication cart to be sure the residents had their ordered medications. The Nursing Supervisor further stated that she was not informed until 8/18/23 that Resident #31 required a refill of her ordered temazepam. An interview was conducted on 8/25/23 at 10:14 AM with the Director of Nursing. The DON stated the physician was to be notified in a timely manner that a new prescription was needed for a refill of a controlled substance. The DON stated the nurses should have notified the physician when they determined the medication was unavailable to determine if there was a substitute. The DON stated the Nursing Supervisor usually handled contacting the physician when refills were needed. The DON stated she did not know why the refill request was not sent prior to the medication running out. 4. Resident #62 was admitted to the facility on [DATE] with diagnoses of dementia and anxiety. A physician's order for Resident #62 dated 5/8/22 was for buspirone (a medication to treat anxiety) 5 milligram (mg) 1 tablet by mouth one time a day for anxiety. A review of Resident #62's January 2023 Medication Administration Record (MAR) revealed documentation he was administered buspirone 5 mg 1 tablet by mouth one time a day for anxiety from 1/1/23 through 1/31/23. A review of a New Prescription Summary for Resident #62 dated 1/23/23 provided by the Regional Pharmacy Services Manager on 8/24/23 revealed buspirone 10 mg take 1 tablet by mouth every morning for vascular dementia related anxiety. The effective date was 1/23/23. A Consultant Pharmacist's Medication Regime Review for Resident #62 dated 2/16/23 revealed in part an electronic prescription had been sent to the pharmacy and Resident #62's buspirone dose was changed on 1/23/23. The pharmacy faxed this change to the facility, but this change didn't appear to have been carried out. Staff were charting the 5 mg dose as given. The follow-through documented on the form by the Director of Nursing (DON) revealed she observed staff giving one half tablet of the medication which was the correct dose of 5 mg per Resident #62's MAR. The follow through documentation by the DON was not dated. A physician's order entered into Resident #62's medical record by the Assistant Director of Nursing (ADON) dated 2/22/23 was for buspirone 5 mg 2 tablets by mouth one time a day for anxiety (2 tablets equaled 10 mg new order dated 2/21/23). A review of Resident #62's February 2023 MAR revealed documentation he received buspirone 5 mg 1 tablet by mouth one time a day for anxiety from 2/1/23 through 2/22/23. It further revealed documentation he received buspirone 5 mg 2 tablets by mouth one time a day for anxiety (2 tablets equaled 10 mg new order 2/21/23) from 2/23/23 through 2/28/23. A review of Resident #62's quarterly Minimum Data Set (MDS) dated [DATE] revealed he was severely cognitively impaired. He had no hallucinations, delusions, or behaviors. He did not reject care. He received antipsychotic, antianxiety and antidepressant medication on 7 of 7 look-back period days. Antipsychotic medication was received only on a routine basis. The physician documented a gradual dose reduction as clinically contraindicated on 7/27/23. A review of Resident #62's current comprehensive care plan revealed a focus area last revised on 5/10/23 of psychotropic drug use. The goal was for Resident #62 to have no side effects of medication through the next review. An intervention was to administer medications per the physician's order. On 8/24/23 at 9:24 AM a telephone interview with the facility Regional Pharmacy Services Manager indicated the pharmacy received an electronic prescription for Resident #62 on 1/23/23 for buspirone 10 mg take 1 tablet by mouth every morning for vascular dementia related anxiety. He stated when an electronic prescription came directly to the pharmacy, the pharmacy faxed this information to the facility so the facility could enter it into their order system as the pharmacy did not have that capability. He went on to say the pharmacy sent 10 mg buspirone tablets to the facility for Resident #62 on 1/23/23. He further indicated buspirone was not a medication that would cause harm to Resident #62 if administered after being cut in half. On 8/24/23 at 10:09 AM an interview with the DON indicated she conducted an observation of Resident #62's medication administration in response to the Consultant Pharmacist's Medication Regime Review for Resident #62 dated 2/16/23. She stated she did not recall the date of this observation. She further indicated Resident #62's MAR at the time of the observation reflected the most current physician's order the facility had in his record for buspirone 5 mg daily. She went on to say the buspirone dose available for Resident #62 at the time of her observation was 10 mg tablets. The DON stated she observed the staff member cut the 10 mg buspirone tablet in half and administer one half tablet equaling 5 mg to Resident #62. She went on to say she did not question why the pharmacy sent Resident #62 10 mg tablets of buspirone when the current physician's order was for one 5 mg tablet. She stated usually the form of the medication sent by the pharmacy would match the order. She further indicated she did not recall her thought process at the time. The DON stated normally if the pharmacy did not have the form of a medication ordered by the physician and needed to send a substitute there would be a label on the medication indicating this. She went on to say she did not recall this being the case for Resident #62 at that time. She further indicated the process when a physician sent an electronic prescription directly to the pharmacy was the pharmacy would then fax a copy of the prescription to the facility. The DON stated this fax usually went to the fax machine in the Nursing Supervisor's office. She went on to say the Nursing Supervisor would then put the order into the resident's medical record for display on the MAR because pharmacy did not have the capacity to do this. She stated she did not know why this had not occurred with the physician's order for Resident #62 to increase his buspirone dose to 10 mg daily dated 1/23/23. The DON went on to say the risk to Resident #62 from not receiving the ordered dose of his buspirone was experiencing increased anxiety. She stated she was not aware of any behaviors demonstrating increased anxiety by Resident #62 during that period. On 8/24/23 at 10:55 AM an interview with the ADON indicated she would have entered the buspirone 5 mg 2 tablets by mouth one time a day for anxiety (2 tablets equaled 10 mg new order dated 2/21/23) immediately after she received it from the Nursing Supervisor. She stated the process for electronic prescriptions sent directly to the pharmacy was that the pharmacy would then fax a copy over to the facility and it would be entered in the resident's medical record. She further indicated this system was not fool proof. The ADON stated after she entered the order into Resident 62's medical record, she would have given it back to the Nursing Supervisor. On 8/24/23 at 10:58 AM an interview with the Nursing Supervisor confirmed the facility process for electronic prescriptions sent directly to the pharmacy by a physician. She stated she did not know what happened to the New Prescription Summary for Resident #62 dated 1/23/23 for buspirone 10 mg take 1 tablet by mouth every morning for vascular dementia related anxiety. She confirmed it was not in Resident #62's medical record. She stated she did not recall ever receiving the fax from the pharmacy. The ADON went on to say there were 5 fax machines in the facility and the fax could have gone anywhere. She stated she probably got a physician's order for Resident #62 on 2/22/23 for buspirone 5 mg 2 tablets by mouth one time a day for anxiety (2 tablets equaled 10 mg new order dated 2/21/23) and gave it to the ADON to enter in Resident #62's medical record but she did not remember. She went on to say she could not find this either. On 8/24/23 at 2:49 PM a telephone interview with Physician #1 indicated she did not really know what the facility process was for electronic prescriptions sent to the pharmacy. She stated she was familiar with Resident #62. She stated she did not think Resident #62 suffered any adverse consequences from not receiving the ordered dose of his buspirone. She stated she had not seen much change in Resident #62's behaviors in the 2 years she had been caring for him. Based on observations, record review, staff, Regional Pharmacy Manager, and Physician interviews the facility failed to: 1) administer 25 doses of a controlled substance hypnotic medication (Ambien) as prescribed for the treatment of insomnia resulting in decreased sleep, restlessness, and anxiety (Resident #84, and Resident #6); 2) administer 4 doses of a controlled substance antianxiety medication (Temazepam) as prescribed for the treatment of insomnia resulting in decreased sleep and fear of withdrawal (Resident #31); 3) ensure the correct dose of a controlled substance medication (Dronabinol) was administered as prescribed for an appetite stimulant (Resident#256); and 4) ensure the correct dose of antianxiety medication was administered in accordance with the physician's order (Resident #62) for 5 of 5 residents reviewed for medication administration. Findings included. 1a) Resident #84 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Heart Failure, and Insomnia. A physicians order dated 03/06/23 for Resident #84 revealed an order for Ambien 10 milligram (mg) tablets. Administer one tablet by mouth at bedtime for Insomnia. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #84 was cognitively intact. She required supervision with bed mobility, transfers, and activities of daily living (ADLs). She received scheduled hypnotics on 4 of 7 days during the assessment period. A care plan dated 03/15/23 revealed Resident #84 received psychotropic and hypnotic medications. The interventions included in part; to administer medications per the physicians order. Review of Resident #84's March 2023 Medication Administration Record (MAR) revealed on 3/10, 3/17, 3/18, 3/19, 3/22, 3/24, 3/26, 3/28, and 3/30, Ambien 10 mg tablets were documented on the MAR as not available for administration. Review of Resident #84's April 2023 Medication Administration Record (MAR) revealed on 4/19, 4/20, 4/21, and 4/23, the Ambien 10 mg tablets were documented on the MAR as not available for administration. Review of the Controlled Substance Count Record for Resident #84 for March 2023 and April 2023 revealed the entries made by staff were not legible and it could not be determined if the dose was signed out on the declining count record. Review of the nursing progress notes dated 03/10/23 through 04/23/23 revealed no documentation as to why the Ambien 10 mg tablets were not available and were not administered to Resident #84. During an interview on 08/23/23 03:03 PM Resident #84 was observed lying in bed in her room. She was alert and oriented. She stated she needed the Ambien each night for sleep and stated she went for a period of time a few months ago when the medication was not available, but she could not recall a specific date or time. She stated she was only told the medication was not available from the pharmacy. She stated when she didn't take the nightly dose of Ambien, she had trouble sleeping. She stated she did not get good sleep when she didn't take the medication and during that time, she would eventually fall asleep late around 2:00 -3:00 AM and then she would wake up several times during the night which caused her to be tired the following day. She stated it would also cause her to be anxious from not getting sleep, but stated she did not take medication for anxiety. She stated she didn't feel great most days and without taking Ambien and getting sleep it made her feel worse and it made her not want to get out of bed. During a phone interview on 08/24/23 at 01:53 PM the Regional Pharmacy Services Manager stated the pharmacy was not aware of any issue with Resident #84's Ambien until they were notified by the facility on 04/21/23. He stated upon investigation their records showed that thirty Ambien 10 mg tablets were dispensed to the facility for Resident #84 on 03/13/23, and thirty tablets were dispensed to the facility on [DATE], and thirty tablets were dispensed to the facility on [DATE]. He stated the facility should have had the medication on hand and available for Resident #84 on the specified dates. Review of the Monthly Consultant Pharmacist reports revealed no documentation regarding Resident #84's Ambien. The Pharmacy Consultant that conducted the monthly review was not available for interview during the survey period. b.) Resident #6 was admitted to the facility on [DATE] with diagnoses including Heart Failure, Diabetes, and Insomnia. A care plan dated 11/21/22 revealed Resident #6 received psychotropic and hypnotic medications. The interventions included in part; to administer medications per the physicians order. A physicians order for Resident #6 dated 12/05/22 revealed Zolpidem Tartrate (Ambien) Oral Tablet 10 mgs. Give 10 mgs by mouth at bedtime for insomnia. Review of Resident #6's March 2023 Medication Administration Record (MAR) revealed on 3/3, ¾, 3/5, 3/6, 3/8, 3/10, 3/13, and 3/16, Ambien 10 mg tablets were documented on the MAR as not available for administration. Review of Resident #6's April 2023 Medication Administration Record (MAR) revealed on 4/2, 4/19, 4/20, 4/21, Ambien 10 mg tablets were documented on the MAR as not available for administration. Review of the Controlled Substance Count Record for Resident #6 for March 2023 and April 2023 revealed the entries made by staff were not legible and it could not be determined if the dose was signed out on the declining count record. A progress noted dated 04/02/23 at 8:00 PM documented by Nurse #6 revealed Ambien was not available. Resident was made aware and admitted that chronic pain kept her awake at night and will take her available Tramadol for back pain, (pain scale) 5 out of 10 which will also help her to sleep with pain relief. During the investigation an attempt was made to contact Nurse #6 on 08/25/23 with no response. Further review of the nursing progress notes dated 03/03/23 through 04/21/23 revealed no documentation as to why the Ambien 10 mg tablets were not available and were not administered to Resident #6. The Minimum Data Set (MDS) most recent quarterly assessment dated [DATE] revealed Resident #6 was cognitively intact. She required extensive one-to-two-person assistance with bed mobility, transfers, and activities of daily living (ADLs). She received hypnotics during the assessment period. During an interview on 08/23/23 at 3:00 PM Resident #6 was observed lying in bed in her room. She was alert and oriented. She stated there was a period of time a few months ago when she was not receiving her nightly dose of Ambien. She stated she was only told the medication was not available from pharmacy. She stated not getting the Ambien each night caused her to not fall asleep, or if she dozed off, she would not stay asleep. She stated she was up all hours of the night during that time and would have to watch TV during the night at 3 or 4:00 AM just to try to go to sleep. She stated she took Tramadol as needed for pain and had to take pain medication on some of those nights to relax enough to help her get to sleep. She stated she stayed in bed most of the time regardless of her medications but stated on the nights she wasn't sleeping due to not getting the Ambien, it made her feel more tired and restless during the day. During a phone interview on 08/24/23 at 01:53 PM the Regional Pharmacy Services Manager stated the pharmacy was not aware of any issue with Resident #6's Ambien until they were notified by the facility on 04/21/23. He stated upon investigation their records showed that on 01/20/23 the pharmacy dispensed to the facility thirty tablets of Ambien 10 mgs. On 03/17/23 the pharmacy dispensed thirty tablets of Ambien 10 mgs. On 03/29/23 the pharmacy dispensed five tablets of Ambien 10 mgs, then on 04/03/23 the pharmacy dispensed thirty Ambien 10 mg tablets. He stated the facility should have had the medication on hand and available for Resident #6 on the specified dates. Review of the Monthly Consultant Pharmacist reports revealed no documentation regarding Resident #6's Ambien. The Pharmacy Consultant that conducted the monthly review was not available for interview during the survey period. During an interview on 08/24/23 at 07:21 AM the Administrator stated that on 04/21/23 the Nursing Supervisor was responsible for the medication cart that contained Resident #84 and Resident #6's medications due to a staff member not showing up for work that morning. She stated the Nursing Supervisor thought the narcotic count sheet didn't look right and she reported this to her. She stated they immediately started an investigation and determined the Ambien for Resident #84 and Resident #6 was missing. She stated a full investigation was completed. She contacted the pharmacy and obtained dispensing records and determined that no Ambien was returned to the pharmacy for Resident #84 or Resident #6. She stated she and the Nursing Supervisor were unaware until that time that Resident #84 or Resident #6 was not getting the nightly dose of Ambien. During an interview on 08/24/23 at 11:42 AM the Nursing Supervisor stated on 04/21/23 a Medication Aide was assigned to Resident #84 and Resident #6's medication cart due to a staff member not showing up for work that morning. She indicated she could not recall which Medication Aide was on the cart that morning. She stated the medication aide on duty put the declining inventory sheet (Controlled Substance Count Record)in her box at the nurses station that morning. When she looked at the declining inventory sheet it was not legible and didn't look right and she immediately reported this to the Administrator. She stated she checked the medication cart at that time and there was no Ambien available on the cart for Resident #84 or Resident #6. She stated they conducted a full investigation and determined the medication was missing because it had been dispensed from pharmacy and should have been on hand. She stated that was why Resident #84 and Resident #6 did not receive the nightly dose of Ambien on the dates specified. She stated the medication ordering process included that if a medication was not available for administration the nurse could reorder through the electronic medical record if there were refills available. She stated if no refills were available the nurse would complete a handwritten order form, and give it to her, and she would call the physician to get a new order. She stated for controlled medications the physician's office would send the order directly to the pharmacy. She stated no staff had reported to her during that time from 03/10/23 through 04/23/23 that this medication was not available and that was why they didn't catch the discrepancy sooner. She stated the nurses should not continue to document on the MAR that a medication was not available without following up on the medication order with the pharmacy or by notifying her so that she could get the medication sent to the facility. She stated staff needed to get better with follow-up when medications were not available for administration. She stated she did not recall getting any reports from Resident #84 or Resident #6 or from staff regarding any adverse effects from not receiving the medications but stated she believed Resident #84 and Resident #6 would have trouble sleeping without getting the nightly dose of Ambien. During an interview on 08/24/23 at 12:30 PM the Director of Nursing (DON) indicated the Nursing Supervisor was responsible for reordering medications. She stated an investigation was conducted regarding Resident #84 and Resident #6's Ambien. She indicated the Nursing Supervisor could provide the details regarding the Residents not receiving the Ambien. During an interview on 08/24/23 at 4:00 PM Nurse #1 stated she typically worked the day and evening shift and was assigned to Resident #84 and Resident #6 routinely. She stated there was an issue in April 2023 that was investigated by the facility regarding missing Ambien for both Residents. She stated that if she documented on the MAR that the medication was unavailable that meant it was not on the medication cart when it was scheduled to be given. She stated typically when a medication was not available, she would either reorder through the electronic medical record or complete an order form and send it to the Nursing Supervisor who would get it ordered. She stated she could not recall if or when she notified the Nursing Supervisor that Resident #84's or Resident #6's Ambien was not available. She indicated unfortunately Resident #84, and Resident #6 did go for a while without getting the nightly dose of Ambien. She indicated she was not aware if Resident #84 or Resident #6 had any adverse effects such as not sleeping or increased anxiety on the nights that they didn't get the medication. During a phone interview on 08/25/23 at 1:00 PM Medication Aide #1 stated she typically worked the evening shift and was routinely assigned to Resident #84 and Resident #6. She stated she recalled a period of time when both Residents did not have Ambien available. She stated an investigation was done by the facility. She stated if she documented on the MAR that the medication was unavailable that meant it was not on the medication cart at that time. She stated medications could be reordered through the electronic medical record or she would notify the Nursing Supervisor. She stated sometimes she would just notify the Nursing Supervisor verbally that a medication was out and needed to be reordered. She stated she could not recall if or when she notified the Nursing Supervisor of Resident #84 or Resident #6 not having Ambien available. She stated she did not recall if Resident #84 or Resident #6 reported any adverse effects of not receiving the medication. During an interview on 08/25/23 at 3:30 PM Medication Aide #2 stated she typically worked the evening or night shift. She stated she was aware that Resident #84 and Resident #6 missed getting the nightly Ambien dose for a period of time. She stated she recalled an investigation being conducted regarding the medication. She stated if she documented on the MAR that the medication was unavailable that meant it was not on the medication cart and was not given. She stated she could not recall if she notified the Nursing Supervisor during that time that the medication was unavailable. She indicated she was not aware of any adverse effects it had on Resident #84 or Resident #6 when they didn't get the medication. During an interview on 08/25/23 at 4:00 PM Nurse #4 stated he routinely worked the evening and night shift and was familiar with Resident #84 and Resident #6. He stated he could not recall the details regarding the missing Ambien. He stated if he documented the medication was not available on the MAR then it was not on the medication cart at that time and was not administered. During a phone interview on 08/25/23 at 4:30 PM Nurse #5 stated she only worked as needed and could not recall any details regarding Resident #84 or Residents #6's Ambien. She stated if she documented on the MAR that the medication was not available that meant it was not on the medication cart at that time and it was not given. During a phone interview on 08/25/23 at 5:00 PM Physician #1 stated she did not recall the details of Resident #84's or Resident #6's missing Ambien. She stated the facility most likely made her aware of the issue regarding the Ambien but stated she knew they had resolved the concern. She stated Resident #84 or Resident #6 not getting the nightly dose of Ambien would cause difficulty sleeping. She stated she did not recall any reported concerns made by staff of increased anxiety or restlessness regarding Resident #84 or Resident #6 but they most likely were not sleeping well during that time. During an interview on 08/25/23 at 5:00 PM the Administrator stated during the time that staff were documenting the Ambien medication was unavailable that staff should have followed up sooner with the Nursing Supervisor. She stated Resident #84 or Resident #6 should not have gone for that length of time without follow up and without receiving the medication. She indicated Resident #84, and Resident #6 most likely did experience lack of sleep during that time since the Ambien was not administered. She stated education would be provided to all nursing staff regarding medication administration. 3). Resident #256 was admitted to the facility on [DATE] with medical diagnosis that included anorexia and moderate protein-calorie malnutrition. Review of an admission MDS assessment for Resident #256 documented he had moderately impaired cognition. He received a mechanically altered, therapeutic diet and weighed 133 pounds. He was independent with eating and required set up help only. The initial care plan for Resident #256 was in progress beginning on 08/11/23 and included guidance for activities of daily living and personal care. Review of Resident #256 ' s weights revealed an admission weight on 08/11/23 of 132.6 pounds. On 08/23/23 he weighed 130.6 pounds