**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review the facility failed to provide pharmacy services, have safeguards and systems in place for the control, accountability, and reconciliation of controlled medications by failing to: 1. Reconcile and account for the use of Methadone (a Schedule II controlled substance [medications with a high potential for abuse]) among licensed nurses prior to the start/end of their working shift to conduct the narcotic counts (a physical inventory of all controlled medications, including the emergency supply, is conducted by two licensed nurses) and document on the facility's controlled medication accountability record for one resident (Residents 25) in 22 sampled residents on controlled drugs to prevent diversion [stealing prescription medicines or controlled substances such as opioids for their own use] or accidental misuse and exposure of the controlled drug medication in accordance with the facility's policy. 2. Create a Controlled Drugs Count sheet (medication accountability record or an inventory log for controlled substances [CS] -medications which had a potential for abuse that may also lead to physical or psychological dependence) when receiving the CS Methadone liquid bottles (medication packaging system that contains individual doses of medication per bottle) dispensed by the Methadone Clinic Dispensing Pharmacy every Fridays since November 2020, for Resident 25 in one of two inspected Medication Carts. 3. Ensure the dosage in Resident 25's Methadone liquid's pharmacy label was checked for the correct dosage as indicated in the physician's order and the Medication Administration Record (MAR) prior to administration, for one of 22 sampled residents on controlled drugs (Resident 25) to prevent underdosing or overdosing of the medication. 4. Accurately document the medication administration of Resident 25's Methadone liquid in the facility and at the Methadone Clinic for one of one sampled resident (Resident 25) who receives medication dispensed outside the facility's own pharmacy to ensure proper dosage of medication is being given to the resident in accordance with the physician's order. 5. Resident 251's Percocet (medication is used to help relieve moderate to severe pain) tablet was discarded in the medication disposal container inside the facility's Medication Room. 6. Resident 251's PRN Percocet was not consistently documented on the Medication Administration Record after drug administration. 7. Resident 299's Bupren-Nalox (medicine used to treat opioid addiction) was discarded in the facility's medication room. 8. Failed to verify the identity of Resident 3 prior to administering the medication. These deficient practices had the potential to impact all 22 residents in the facility receiving controlled drug medications with the increased risk for drug diversion, misuse, and had the potential for residents to not receive the dosage amount of controlled drug as ordered by the physician. On 7/14/2021 at 7:40 pm, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's administrator (ADM), director of nursing (DON), and quality assurance (QA) nurse regarding the facility's failure to provide pharmacy services and have safeguards and systems in place for the control, accountability, and reconciliation of controlled medications. On 7/16/2021 at 1:29 PM, the IJ was lifted after the ADM and the DON submitted an acceptable Plan of Action (POA, interventions to correct the deficient practices). The surveyor verified and confirmed the implementations of the POA while onsite by observation, interview, and record review. The IJ was removed in the presence of the ADM and DON. The acceptable POA included the following actions: 1. The DON created a Controlled Drugs Count sheet for Resident 25's Methadone liquid 110 mg once a day and reconciled the current amount on hand. 2. The administrator requested the methadone liquid bottles to be dispensed in a sealed, tamper-evident seal to permit a chain of custody system (disposition of materials). 3. The administrator informed the Methadone Clinic that an escort will accompany the resident to ensure clinician to staff member endorsement of the six bottles of Methadone for each week's administration along with the corresponding dispensing log. 4. The DON conducted an audit of the Methadone Clinic's dispensing logs against Resident 25's MAR to ensure 100% reconciliation. 5. The Facility's Consultant Pharmacist conducted an in-service total of 9 licensed staff present during that time regarding methadone administration at the facility, medication administration competency skills check, how to properly document and utilize Controlled Drugs Count sheets and when it is needed. 6. The licensed nurse would check for any new medications changes such as increase or decrease in dosage and ensure that medications are accounted and reconciled upon returning from the Methadone Clinic. Any new orders will be clarified with the attending physician and transcribed accurately in the MAR. 7. The Consultant Pharmacist will include Resident 25's Methadone treatment in the monthly Medication Regimen Review conducted onsite. 8. The licensed nurses will conduct every shift counting of Controlled Medications - including methadone from an outside source - per standard controlled medication chain of custody system. 9. The facility will request weekly documentation of dispensing logs from the methadone clinic to confirm Resident 25's status and methadone order including other residents on Methadone to ensure accurate accounting of medications. Cross Reference to F760 Findings: 1. A review of Resident 25's admission Record indicated an admission to the facility on 8/17/2020 with diagnoses that included other symptoms and signs involving the musculoskeletal system (a general term which relates to the muscles and the skeleton of the body), anxiety (a mental condition characterized by excessive apprehensiveness and worries ), Hepatitis C (a viral infection contracted only through direct contact with the blood of a person infected with the Hepatitis C virus), and long-term use of opiate analgesic (highly addictive narcotic medication used to relieve pain from a variety of conditions). A review of Resident 25's Minimum Data Set (MDS; a care area screening tool and assessment) dated 2/12/21, indicated the resident's cognition (the process of thinking) was intact, and required supervision (oversight, encouragement or cueing) during activities of daily living (walking, dressing, bed mobility, dressing, eating). A review of Resident 25's History and Physical dated 7/12/21, indicated the resident had the capacity to understand and make decisions. A review of Resident 25's Physician Orders recapped (summarized) for the months of December 2020, January 2021, February 2021, March 2021, April 2021, May 2021, June 2021, and July 2021 indicated an order dated 11/25/2020 for the resident to receive Methadone 120 mg, 1 bottle liquid by mouth every day for opioid (synthetic narcotics that provides pain relief and can be highly addictive) abuse. A review of Resident 25's Medication Administration Record for the months of November 2020 (from 11/25/2020 to 11/30/2020), December 2020, January 2021, February 2021, March 2021, April 2021, May 2021, June 2021, and July 2021 indicated signature initials for the Methadone 120 mg, from the facility's licensed nurses every day, including Fridays except for 6/4/21 (Friday). The Nurses Medication Notes found at the back of the June 2021 MAR indicated that on 6/4/21 timed at 6 AM, the Methadone liquid was not available, and Resident 25 would be picking up the medications. A review of Resident 25's Care Plan Description dated 11/25/2020, indicated the resident had a history of substance abuse and had been taking Methadone since admission [DATE]). The care plan goal indicated the resident would exhibit acceptable behavior as evidenced by not having alcohol/drugs hidden in room. The interventions included for nursing to administer medications as ordered and monitor for side effects of Methadone 120 mg daily for opioid use. The interventions also indicated Resident 25 would go to the Methadone Clinic for counselling (no dates indicated) and that the Methadone Clinic would be providing the medication that will be kept in a lock box and to be kept by the facility in the narcotic drawer. The care plan did not indicate that the facility's licensed nurses would only administer the Methadone liquid at the facility from Saturday to Thursday and the Methadone Clinic would administer the last dose every Friday. On 7/14/21 at 11:05 AM, during an inspection of Station 1's Medication Cart A's narcotic drawer with Licensed Vocational Nurse (LVN) 1, an unlabeled cloth handbag with an attached lock and key was found inside the narcotic drawer. Inside the handbag were six 3.5-inch, opaque plastic bottles. One out of the six plastic bottles contained a quarter-full of pink liquid medication and the remaining five bottles were observed empty. The label on the six bottles indicated Resident 25's name and the medication name and dose of, 110 milligrams (mg), Methadone (physician's order is for 120mg). During a concurrent interview, LVN 1 stated Resident 25 brings the liquid Methadone into the facility from an outside dispensing clinic and the licensed nurses in the facility administers the medication to the resident. On 7/14/21 at 11:30 AM, during an interview, LVN 1 stated the facility did not keep a controlled medication accountability record of Resident 25's Methadone liquid since 11/2020. LVN 1 stated Resident 25 goes to the Methadone Clinic every Friday and picks up six bottles of Methadone for the facility staff to administer to the resident. LVN 1 stated the facility did not keep a controlled medication accountability record of Resident 25's Methadone liquid because the medications were not dispensed from the facility's own pharmacy. LVN 1 stated the licensed nurses signs out the Methadone liquid administration in Resident 25's MAR as administered. LVN 1 stated without a controlled medication accountability record, the licensed nurses would not be able reconcile the controlled drug in the narcotic counts that is typically conducted every shift change. LVN 1 further stated that without a controlled medication accountability record, the facility would not be able to account for any controlled medications that may be missing. During the same interview, on 7/14/21 at 11:30 AM, LVN 1 stated the licensed nurses administers the Methadone liquid to Resident 25 every day during the nightshift at 6 AM except Fridays. LVN 1 stated the facility receives only six bottles of Methadone liquid because Resident 25 would receive the 7th dose at the Methadone Clinic on Fridays. On 7/14/21 at 1:57 PM, during an interview, the DON stated since 11/2020, the Methadone Clinic dispensed Resident 25's Methadone liquid, while the facility staff administered the medication. The DON stated the licensed nurses had been administering the Methadone liquid to Resident 25, the same way (From Saturday to Thursday) since 11/2020. The DON stated that Resident 25's Methadone liquid should be accounted for in the facility's-controlled medication accountability record. A concurrent review and interview with the DON and Resident 25's medical record and controlled accountability records binder indicated no documented evidence the resident's Methadone liquid had been accounted for and reconciled since 11/2020 up to July 14, 2021. The DON stated that Resident 25's Methadone medication should have been counted as part of the narcotics-controlled medication count per facility policy because Methadone is a controlled substance. On 7/14/21 at 3 PM, during an interview, LVN 3 stated Methadone was not included as part of the controlled drugs count. LVN 3 stated she only counted and checked the narcotics that was indicated in the facility's Narcotic binder, where the facility put all controlled drugs count sheets. LVN 3 stated the licensed nurses had to go through each narcotic medication located inside the narcotic drawer and compare it with the count sheets with another nurse at the beginning and end of work shift to account for all the residents narcotics. On 7/14/21 at 3:47 PM, during an interview, Resident 25 stated, I'm always in pain. Resident 25 stated he receives two pain medications in the facility (Dilaudid [narcotic medication] and Methadone). Resident 25 stated he goes to the Methadone clinic every Fridays unaccompanied by facility staff. Resident 25 stated a driver from a transport van takes him to the Methadone Clinic. On 7/14/21 at 3:55 PM, during an interview, the Director of Staff Development (DSD) stated the Methadone clinic used to provide the facility with the dispensing logs and the nurse would sign the logs each day to account for the use of Resident 25's Methadone liquid. DSD stated he could not recall when the Methadone Clinic had stopped providing the dispensing logs. The DSD stated the facility could not find documented evidence of the dispensing logs from the Methadone clinic that was provided to the facility several months ago because the facility did not keep copies of the dispensing logs. On 7/14/21 at 4 PM, during a concurrent observation and interview, the DON opened the Methadone bottle containing the quarter-full pink colored liquid medication. The DON verified the Methadone bottles were not sealed and there were no level markings on all 6 of the Methadone bottles for accountability during physical inventory (narcotics count) as required for every shift. The DON stated that Resident 25's Methadone was administered in the facility by the night shift licensed nurses from Saturday through Thursday at 6 AM. The DON stated Resident 25 received the 7th dose in the Methadone clinic every Friday. On 7/14/21 at 4:05 PM during a concurrent interview and review of Resident 25's MAR, the DON stated Resident 25's July MAR indicated the order for Methadone 120 mg and Methadone bottle label indicated 110 mg. The DON stated and confirmed the facility's licensed nurses' signature initials on Resident 25's MAR for the administration of Methadone every day (Saturday through Friday). The MAR indicated the facility's licensed nurses was also signing the MAR as administered on Fridays (7/2/21 and 7/9/21). The DON stated the licensed nurses should not be signing the MAR for the Methadone administration on Fridays because it was not administered by the facility's licensed nurses in the facility. The DON was unable to give an explanation as to why the licensed nurses were signing off as administering the medication on Fridays when it should have been administered at the Methadone clinic. On 7/14/21 at 4:12 PM, during a telephone interview, the facility's Pharmacy Consultant (PC) 1 stated she was not aware that Resident 25 was bringing Methadone into the facility that was being dispensed from a Methadone Clinic. PC 1 stated, The facility should have a recorded controlled count sheet like any other controlled medication. The facility should be keeping a record even if Resident 25 was getting his medication dispensed at the Methadone clinic, either by requesting one from the clinic or by creating their own. On 7/15/21 at 7:07 AM, during a concurrent interview and review of Resident 25's July 2021 MAR, LVN 4 stated she signed the resident's MAR for Methadone administration on Fridays from 7/2/21 and 7/9/21, even if she did not administer the Methadone. LVN 4 was unable to explain as to why she signed off administering the medication to the resident when she did not administer it. LVN 4 stated she was used to signing for the Methadone administration every day, even Fridays. LVN 4 stated there were no instruction or clear directions on how to handle and account for Resident 25's Methadone medication. On 7/16/21 at 10:31 AM, during an interview, the administrator stated the facility did not know when the Methadone medication order was changed from 120 mg to 110 mg by the Methadone Clinic physician (Physician 2). The administrator stated the Methadone 120 mg dose was ordered by Resident 25's attending physician (Physician 1) based on the dispensing logs that the facility used to receive from the Methadone Clinic. The administrator stated the Methadone Clinic did not notify the facility that the dose of the Methadone was changed from 120 mg to 110 mg. The administrator stated the Methadone Clinic stopped providing the facility the medication dispensing logs, since the start of November 2020 where it indicated the number of Methadone liquid bottles and corresponding doses dispensed to Resident 25. The administrator could not provide documented evidence that the facility had followed up and coordinated with the Methadone clinic when it stopped providing the Methadone dispensing logs to the facility. On 7/16/21 at 11:05 AM, during an interview, LVN 1 stated that before a licensed nurse administers a medication, the licensed nurse should check the physician's order in the MAR and compare it with the medication label as to the name of the resident, the route, the dosage and the time. LVN 1 stated if all information were accurate, the licensed nurse can give the medication. During a concurrent review of Resident 25's MAR and a copy of the pharmacy label on the resident's Methadone liquid bottle, LVN 1 stated she would not give Resident 25 the Methadone because the label on the bottle did not match the order in the MAR. LVN 1 stated she would not administer the medication and would call the Methadone Clinic to clarify the medication order. During the same interview, on 7/16/21 at 11:05 AM, LVN 1 stated that on Fridays LVN 1 would receive the Methadone liquid bottles inside a bag from Resident 25. LVN 1 stated that Resident 25 would give LVN 1 the unlabeled cloth bag. LVN 1 stated she would count if there were (6) six bottles inside the bag, but LVN 1 did not check and review the methadone pharmacy labels to reconcile the medications for any changes in dosing. LVN 1 stated she did not document how many methadone liquid bottles were received on Fridays. LVN 1 stated she did not know when the medication dose was changed from 120 mg to 110 mg. A review of a document titled Patient Orders provided by Resident 25's Methadone Clinic to the facility via fax on 7/16/21 timed at 1:07 PM, indicated a change of Methadone dose on 2/21/2021 from 120 mg to 110 mg. The order was signed by Physician 2 from the Methadone Clinic. The Patient Order indicated the reason for the dose change was due to Patient requesting to lower dosage due to drowsiness. A review of the facility's policy and procedure titled Medication Storage in the Facility; Controlled Medication Storage, dated 8/1/2010, indicated medications included in the Drug Enforcement (DEA) classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations. The policy indicated a controlled medication accountability record is prepared by the facility for all Scheduled II, III, IV, and V (III, IV, and V are drugs with an abuse risk less than Schedule II) medications The following information should be completed: 1. Name of resident, if applicable 2. Prescription number, if applicable 3. Name, strength, and dosage form of medication 4. Date Received 5. Quantity received 6. Name of person receiving medication supply. The policy indicated, At each shift change, a physical inventory of all controlled medications, including the emergency supply, is conducted by two licensed nurses and is documented on the controlled medication accountability record. The policy indicated that any discrepancy in controlled substance medication counts is reported to the director of nursing immediately. The policy indicated that current controlled medication accountability records are kept in medication books and upon completion would be kept on file for five years. 2. During an observation of the facility's medication room, in the presence of the Director of Nurses (DON) on 7/14/21 at 9:16 AM, a rectangular dark gray bin covered with a lid labeled Discontinued Medications was observed placed on the floor beside a white circular covered container labeled for incineration only Upon uncovering the white, circular container, a clear pouch with a manufacturing label 'Silent Knight' (pill crusher pouch) indicating, Resident 251's room and bed number, Percocet (controlled medication) half tablet. Inside of the clear pouch half of a white colored tab and two yellow capsules that were still intact, were observed. During an interview, on 7/14/21 at 9:18 AM, the DON stated discontinued medications were discarded in the discontinued medications bin before removing from the packaging and then discarded into the pharmaceutical waste bin during destruction of discontinued non-controlled medications. The DON stated that only non-controlled medications (medication considered not to be of risk) were discarded in the medication room in the presence of a licensed nurse (LN) to witness. The DON stated that controlled medications (medications that can create mental and physical addiction or dependency) were given to the DON and kept in a locked drawer, inside the DON's office while awaiting destruction. The DON stated that all controlled medications were discarded by the DON and the facility's pharmacist. The DON stated that Percocet should not be discarded in the pharmaceutical waste bin inside the Medication Room since it was a controlled medication. During an interview on 7/14/21 at 1:02 PM, the director of staff development (DSD) stated non- controlled medications should be placed in the dark gray, rectangular bin located in the Medication Room. The DSD stated that another licensed nurse must witness the wasting of a medication. The DSD stated that wasting of medication should be documented on the Medication Discretion Form for non-controlled medications. The DSD stated that controlled medication should be given to the DON with the narcotic inventory form. A review of Resident 251's Face Sheet indicated an admission to the facility on 7/12/21 with diagnoses that included quadriplegia (paralysis of all four limbs), schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), and alcohol abuse. A review of Resident 251's July 2021 Recapped Physician's Order indicated an order for Percocet 7.5-325 mg tablet one tablet via gastrostomy tube (g-tube- a tube inserted through the belly that brings nutrition directly to the stomach) as needed every four hours for severe pain (8-9). A review of Resident 251's recapped Physician Orders for July 2021 indicated Percocet (medication is used to help relieve moderate to severe pain; Percocet is a scheduled II controlled substance [exposes users to the risks of addiction, abuse, and misuse]) 7.5-325 milligrams (mg) tablet one tablet via gastrostomy tube (g-tube: a tube placed directly to the stomach for nutrients and medication administration) as needed every four hours for severe pain (8-9). A review of Resident 251's Narcotic and Hypnotic Record indicated on 7/19/2021 at 8 AM, Percocet 7.5-325mg tablet, was the last dose administered to Resident 251. The Narcotic and Hypnotic Record indicated a total of 21 doses of Percocet was administered to Resident 251 since 7/14/2021. A review of Resident 251's Pain Assessment Flowsheet indicated 7/19/2021 at 2 AM was the last administration and efficacy of medication documented. A review of Resident 251's Medication Administration Record (MAR) for July 2021 indicated a total of 18 doses of Percocet administered to Resident 251. 3. During an interview and concurrent record review on 7/14/21 at 1:45 PM, the Medication Destruction form dated 4/3/21 for non-controlled medication, the DON validated the signatures indicated at the bottom of the form was the DON and licensed vocational nurse (LVN) 2. During concurrent record review the DON stated she could not identify any controlled medications on the form. The form indicated a total quantity of 5 Bupren-Nalox (maintenance treatment of opioid dependence; Scheduled III controlled substance [a potential for abuse less than substances in Schedules I or II and abuse may lead to moderate or low physical dependence or high psychological dependence.]) 2- 0.5 milligrams (mg) sublingual (under the tongue) wasted for Resident 299 due to medication discontinuation. The DON did not know if Bupren-Nalox was a controlled medication. During a concurrent interview and record review on 7/14/21 at 3:45 PM, LVN 2 stated that controlled medications are only discarded by the DON and the pharmacist. LVN 2 stated Bupren-nalox destruction with the DON and the pharmacist. A review of Resident 299's Face Sheet indicated an admission to the facility on 2/25/21 with diagnoses that included of osteomyelitis (bone infection), psychoactive substance abuse, and hepatitis C (an infection caused by a virus that attacks the liver and leads to inflammation). A review of Resident 299's Minimum Data Set (MDS- a care area screening and assessment tool) dated 3/4/21, indicated intact cognition and required extensive assistance (staff provide weight bearing support) with one person physical assist, for bed mobility, walk in room, dressing, and toilet use. Resident 299 required limited assistance (non - bearing weight assistance) with one person physical assist for transfers. Resident 299 required supervision with set up only for eating and personal hygiene. A review of Resident 299's March 2021 Medication Administration Record (MAR) indicated Suboxone 2mg/0.5mg, give two tablets (4mg) sublingual every 8 hours for opioid use. The MAR indicated a discontinued date of 3/28/2021. 4. During an interview and concurrent review of Resident 251's Narcotic and Hypnotic Record and MAR on 7/19/2021 at 11:08 AM, LVN 1 stated Resident 251 had an order to receive Percocet 7.5-325mg tablet every four hours. LVN 1 validated that Percocet administration indicated on the Narcotic and Hypnotic Record and the MAR dose administration did not match. LVN 1 stated that the two forms, Narcotic and Hypnotic Record and the MAR must always match as an indicator for medication that has been administered During an interview on 7/19/2021 at 12:11 PM, the Director of Nursing (DON) stated the facility practices on medication administration was that the licensed nurses (LN) follow the pour, pass and sign when administering medications. The DON stated medications must be documented immediately after a medication is administered to the residents. The DON stated that the LN must not continue with administering medication to another resident without signing the MAR for the medication that was just administered. The DON stated that documenting the administration of medication was part of the medication rights when administering medication to aid in the prevention of errors. The DON stated the MAR and the Narcotic and Hypnotic Record must always match so that all medications were accounted for. A review of the facility's Policy and Procedure, titled Medication storage in the Facility, dated 8/1/10, indicated controlled medications remaining in the facility after the order has been discontinued are destroyed by the facility's DON and consultant pharmacist. A review of the facility's policy and procedure titled Disposal of Medication and Medication-Related Supplies for Medication Destruction, dated 8/1/10, indicated controlled substances are retained in a securely locked area with restricted access by the facility DON and/or pharmacist consultant and/or administrator. The policy indicated for non-controlled medication destruction occurs only in the presence of two licensed nurses. A review of the facility's policy tiled Disposal of Medication and Medication- Related Supplies for Controlled Medication Disposal, dated 8/1/10, indicated the DON and the facility's pharmacist consultant are responsible for the facility's compliance with federal and state laws and regulations in the handling of controlled medication. The policy indicated unused partial tablets and unused portions of single does ampules are destroyed in the presence of two licensed nurses, and the disposal is documented on the accountability record on the line representing that dose. The policy indicated Schedule II medications remaining in the facility after a resident has been discharged , or the order discontinued, are disposed by the director of nursing and pharmacist consultant. Schedule III, IV, and V controlled substance are disposed at the facility and signed off by the DON and Pharmacist Consultant. A review of the facility's Policy and Procedure (P&P) titled Medication Administration with a revision date of 1/1/2012 , indicated the licensed nurse will chart the drug, time administered, and initial his/her name with each medication and sign full name and title on each page of the MAR. The P&P indicated the time and dose of the drug or treatment administered to the patient will be recorded in the patient's individual medication record by the person who administers the drug or treatment. The P&P indicated for as needed (PRN) medication documentation, the medication should be documented on the MAR and the LN would indicate the reason given, the reason for the drug, route of administration, date, and time. The result of the PRN medication will be charted by the responsible nurse on the back. 5. A review of Resident 3's admission Record indicated an admission to the facility on 3/26/2017 with a diagnosis of hemiplegia (paralysis of right limbs), Peripheral Vascular Disease, Essential Hypertension. A review of Resident 3's recapped Physician Orders for June 2021 indicated an order for Gabapentin (drug used for nerve pain) 600 mg one tablet by mouth every eight hours for Neuropathy hold if RR less than 12 or sleepy monitor prior giving med. During medication administration observation on 7/14/21 at 1:30 p.m., the LVN 1 was observed giving the medication to Resident 3's without checking identifying the resident wristband and resident name before administration of the medication. During an interview on 7/14/21 at 1:54 p.m., the LVN 1 stated she knew the resident for a long time and the resident was alert and oriented. The LVN 1 stated she did not verify Resident 1 identity by checking his name and last name or check the wristband before administering the medication and the resident has no wristband. During an interview and record review of the facility policy for Medication Administration on 7/14/21 at 2:00 p.m., the LVN 1 stated she should have verified Resident 3's identification prior to administration of medication. During an interview on 7/14/21 at 3:15 p.m., the DON stated, licensed nurses must verify the resident identity based on facility policy prior to administrating the mediation. The DON stated the licensed nurses must follow the seven rights of medication administration. A review of the facility's Policy and Procedure titled Medication Administration with a revision date of 1/1/2012, indicated the Licensed Nurse will verify the resident's identity before administering the medication. The Licensed Nurse will follow the seven rights of medication administration which includes as fallowing: The right medication, the right amount, The right resident, The right time, The right route, Resident has right to know what the medication does, Resident has the right to refuse the medication (unless court ordered).