**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #66 was admitted to the facility on [DATE] with diagnoses that included multiple myeloma, chronic pain, and osteoarthritis (OA). A therapy screen form dated 3/30/22 indicated Resident #66 was screened by physical therapy and was appropriate for the use of a total body lift with 2 person staff assistance due to decrease range of motion (ROM) of the bilateral upper extremities (BUE) and OA of bilateral knees. A quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #66 was cognitively intact and required total dependence of 2 staff for transfers. An incident report dated 6/2/22 at 2:37 PM written by MDS Nurse #1 revealed Resident #66 experienced a fall in the bathroom. The incident report indicated a Nurse Aide (NA) #21 transferred Resident #66 from the commode using a sit to stand lift when her knees buckled, and Resident #66 slid out of the lift pad and onto the floor. An interview on 8/23/22 at 2:40 PM with MDS Nurse #1 revealed she attended the huddle immediately, (facility meeting to discuss a resident fall or incident) following Resident #66's fall on 6/2/22. MDS Nurse #1 indicated she assisted in completing the incident report; however, she only entered data related to the details of the fall. An interview with NA #21 on 8/24/22 at 1:58 PM revealed she was the NA assigned to Resident #66 on 6/2/22 and verified she and another agency NA, whom she could not recall the NA's name, transferred Resident #66 to the commode using a sit to stand lift after Resident #66 requested to go to the toilet. NA #21 stated she was new to the facility at that time and was not familiar with Resident #66 so when Resident #66 requested to go to the commode using the sit to stand lift she did not verify what transfer status she was assigned through the use of the [NAME] or the EMR (electronic medical record), but instead asked the Medication Aide assigned to her hall who told her if Resident #66 requested to go to the bathroom with the lift to take her. She could not recall the MA's name whom she had asked. NA #21 stated when she and another agency NA used the sit to stand lift to transfer Resident #66 from the commode, Resident #66's knees buckled and she let go of the lift with her hands causing her to fall out of the bottom of the lift sling and to the floor landing on her right side and bumping her head on the floor. NA #21 explained when Resident #66 fell she put a pillow under her head and went to the resident's door to summon other staff for assistance. NA #21 indicated multiple staff came to the room to assist and examine Resident #66 while she was in the floor before she was transferred back to her bed using the Hoyer lift. NA #21 stated she recalled Resident #66 complaining of her head hurting after she fell but did not recall any open area or bleeding. NA #21 said she thought the straps had been placed on the correct position. NA #21 stated she had never been shown how to use the sit to stand lift and she could not recall being asked to write or give a verbal account of what occurred following the huddle meeting. An interview with NA #20 on 8/24/22 at 1:42 PM revealed she was not assigned to Resident #66 on the 6/2/22, the date of the fall; however, was assigned to Resident #66's hall. NA #20 stated when she arrived at the time of the fall, Resident #66 was lying in the floor on her right side with her head in the direction of the toilet. NA #20 stated she assisted Resident #66 to be transferred from the floor to the resident's bed with the use of a Hoyer lift after her fall. NA # 20 stated she was aware in the past Resident #66 would request to go to the bathroom and wanted to use the sit to stand lift, but Resident #66's correct transfer status was a Hoyer lift for safety. An interview on 8/23/22 at 3:19 PM with Nurse #8 revealed she attended the huddle immediately following the fall and assessed Resident #66 for injuries. She indicated Medication Aide #1 (MA #1) was assigned to the hall on the date of the fall; however, MAs were unable to assess and she took over the care for Resident #66. Nurse #8 verified Nurse Practitioner (NP) #1 assessed Resident #66 and gave authorization to assisting her back to bed. A progress note dated 6/2/22 written by NP #1 revealed Resident #66 experienced a fall. The note indicated NP #1 was summoned to the room of Resident #66 where she was found to be in the bathroom floor lying on her right side. Resident #66 and staff had reported the fall occurred when Resident #66 fell from the sit to stand lift in the bathroom and had reported the only pain she had at the time was in the back of the head. At the time of the fall on 6/2/22, NP #1 indicated there was no visible swelling or open areas on the head nor loss of consciousness immediately post fall to the floor. An interview with NP #1 on 8/24/22 at 9:55 AM revealed she was summoned to the room of Resident #66 on the date of her fall (6/2/22). NP #1 verified she assessed the resident for injuries after she fell in the bathroom because NA #21 transferred Resident #66 to the toilet with a sit to stand lift despite her need for a total body lift which was her assigned transfer status. NP #1 verified Resident #66 complained of head pain, but upon exam, there were no open areas or visible swelling. A progress note dated 6/3/22, with no time of note, written by NP #1 revealed Resident #66 was up in her wheelchair and complained of right upper extremity pain with movement. The note indicated during the examination, family entered the room and agreed to allow for an x-ray of the right shoulder and elbow to be performed. A physician's order dated 6/3/22 revealed Resident #66 had an order which requested a right shoulder and elbow x-ray STAT. An x-ray report of the right shoulder and elbow dated 6/4/22 indicated Resident #66 had a no acute injury to the right elbow; however, she had a right anterior dislocation of the glenohumeral (shoulder) joint and no acute fracture present. A nurse progress note dated 6/6/22 at 2:20 PM indicated Resident #66's x-ray reports had been received by the facility and indicated a right shoulder dislocation and the NP was notified. The note further explained the NP ordered Resident #66 to be referred to orthopedic for follow-up care for the acute right shoulder dislocation. The note referenced attempts to make an appointment for Resident #66 with an orthopedic office and they refused to see Resident #66 without an emergency room examination. Resident #66's responsible party was contacted and agreed to transfer to the emergency room and was transported via emergency medical services (EMS) on 6/6/22 at 4:20 PM. An emergency room report dated 6/6/22 indicated Resident #66 was examined for a fall from a sit to stand lift 4 days prior and x-rays of the right and left shoulder were ordered and obtained. Upon examination, Resident #66 vocalized a pain level of a #7 of 10 to the right shoulder. The report further indicated an x-ray of the right shoulder indicated there was no dislocation of the glenohumeral found; however, the joint space as not well demonstrated. An interview with the former DON #3 on 8/24/22 at 3:55 PM revealed she was the DON at the time of Resident #66's fall, but vaguely recalled hearing about the incident. She indicated she could not recall if any investigation was completed by herself; however, stated if she had been involved, she would have obtained statements from the resident and staff involved, determined the root cause of the incident, and provided education to staff to prevent further incidents from occurring. She indicated to her knowledge, NA #21 should have been trained by her agency prior to working in the facility and she was unable to verify if any additional education had been provided to NA #21 regarding the proper use of the lifts and how to identify the assigned transfer status for each resident. She stated all NAs in the facility should follow the proper transfer status for each resident for safety. An interview with the Interim Director of Nursing and Administrator on 8/25/22 at 4:39 PM revealed all NAs should transfer residents using the designated transfer status assigned to each resident to ensure safety. The Interim DON verified Resident #66's transfer status was a total body lift at the time of the incident. Based on observations, record review, staff, family, and Nurse Practitioner (NP) interviews the facility failed to have a working call bell for the resident to use to call for help and the resident attempted to get up and fell into the floor and then the facility failed to investigate the fall out of bed which required the resident to be sent to the emergency room (ER) and was diagnosed with an acute nondisplaced nasal fracture (Resident #156). Resident #156 fell from his bed during the night and was transferred off the floor back to bed and developed a nosebleed and had to be transferred to the ER where he was diagnosed with a nondisplaced nasal fracture and required silver nitrate (used to burn the skin to stop bleeding). The facility also failed to transfer a resident using the correct mechanical lift which resulted in the resident falling from the lift (Resident #66) for 2 of 3 residents reviewed for accidents. The finding included: 1. Resident #156 was admitted to the facility on [DATE] with diagnoses that included: End Stage Renal Disease, right above knee amputation, and others. Review of physician orders dated 06/17/22 included the following medications: Aspirin 81 milligrams (mg) by mouth every day, Eliquis (blood thinner) 5 mg by mouth every day, and Plavix (blood thinner) 75 mg by mouth every day. Review of the admission Minimum Data Set (MDS) dated [DATE] indicated that Resident #156 was moderately cognitively impaired and required extensive assistance of two staff members for bed mobility and transfers. The MDS further indicated that Resident #156 had a fall history prior to admission but had no falls since admission to the facility. Review of Resident #156's medical record revealed no documentation of a fall occurring. Review of a Skilled Nursing Facility (SNF) to Hospital transfer form dated 06/26/22 at 9:13 AM read in part; Reason for transfer: Fall. The form indicated that Resident #156 was capable of decision making and ambulated independently and the family and NP were made aware of the transfer. The form was signed by Nurse #2. Resident #156's family member was interviewed on 08/23/22 at 5:01 PM. The family member stated that he came to the facility on [DATE] between 10:00 AM and 11:00 AM and when he walked into the room, he noted a bloody towel laying on the bed. The son stated a staff member whom he did not know stated that Resident #156 had a nosebleed, and they were trying to get it stopped. The staff member also informed him that Resident #156 had fallen out of bed on the previous shift, but no one had reported it to them except Resident #156. He added that Nurse Aide (NA) #18 was also trying to get the bleeding stopped. The family member stated that he stayed with Resident #156 until breakfast came and after breakfast, he began to shave Resident #156 and during that time he kept having to stop because Resident #156's nose kept dripping with blood and it kept dripping then became a steady stream of blood. The family member stated he went to the staff and stated that he was concerned that Resident #156's nose kept bleeding and he was on a blood thinner and did not want him to bleed out. The staff member returned about 15 minutes later and stated she had gotten authorization to transfer him to the ER and Resident #156 was transferred to the ER where they discovered he had a nasal fracture. Resident #156 was discharged to the hospital on [DATE]. Review of an ER to Hospital admission dated 06/26/22 read in part, Fall: right epistaxis (nosebleed) improved. Management of epistaxis included the use of silver nitrate which stopped the bleeding. Nondisplaced nasal fracture. Review of the facility schedule for 06/25/22 revealed that Nurse #4 was assigned to the unit where Resident #156 resided from 7:00 PM to 7:00 AM, Nurse #5 was schedule on a unit next to where Resident #156 resided from 7:00 PM to 7:00 AM, Nurse #6 and Nurse #7 were scheduled on the other side of the facility from 7:00 PM to 7:00 AM. Review of the facility schedule for 06/26/22 revealed that Nurse #2 was assigned to the unit where Resident #156 resided from 7:00 AM to 7:00 PM and NA #18 was assigned to care for Resident #156 from 7:00 AM to 11:00 PM. NA #18 was interviewed on 08/24/22 at 12:33 PM and confirmed that she had worked with Resident #156 on 06/26/22 at 7:00 AM until he was transferred to the hospital. She stated she had not received any report that morning because she was running late to work. NA #18 stated when she got to work, she went to check on Resident #156 and he stated he had fallen out of bed during the night and laid in the floor for 2 hours and then when the staff came in, they were stern with him about not using his call bell, which he stated did not work. NA #18 stated that while she was in the room with Resident #156 his nose started bleeding and she applied pressure and immediately went and got Nurse #2 who immediately came to the room and tried to get the bleeding stopped by applying pressure, but his nose kept dripping then became a steady stream. She stated that Resident #156 told Nurse #2 the same story about falling out of bed during the night, but the fall never got reported to Nurse #2 from the previous shift. NA #18 stated that NA #17 had cared for Resident #156 through the night and added Resident #156 would not be able to get himself up if he fell out of bed. NA #18 stated that while she was in the room with Resident #156 his family came in and when they saw the nosebleed, they requested him to be sent to the ER for evaluation and so Nurse #2 arranged the transfer. NA #18 stated she saw no other injuries except the nosebleed. NA #17 was interviewed on 08/24/22 at 5:36 PM and confirmed that she was working with Resident #156 on 06/25/22 at 7:00 PM to 7:00 AM on 06/26/22. NA #17 stated that when she arrived for her shift at 7:00 PM she had made a round and Resident #156 was resting in bed, and she stated she again checked on him between 11:00 PM to 12:00 AM and again was resting in bed. She stated that when she made her third round between 2:00 AM and 3:00 AM she found Resident #156 on the floor. NA #17 stated she asked Resident #156 why he had not turned on his call light if he needed something and Resident #156 indicated that he had turned the call light on, and it was not working. NA #17 stated she pressed the call light to test it out and it was in fact not working. NA #17 stated she went and got a nurse but did not know who the nurse was. She stated that they picked Resident #156 up off the floor and placed him back in the bed, but she did not see any injuries, no bleeding or bruising and no knots on his head. NA #17 stated that once Resident #156 was back in the bed she left the room while the nurse remained at bedside. She stated she did not get any vital signs nor was she asked to get vital signs. NA #17 stated she did not do anything with the call bell but did let the nurse know that it was not working. NA #17 was informed that Nurse #4 was scheduled to be on the unit where Resident #156 resided, and she stated she was certain the nurse was not Nurse #4 but did not know who the nurse was that assisted her in getting Resident #156 out of the floor that night. Nurse #5 was interviewed on 08/24/22 at 5:51 PM and stated she had no knowledge of Resident #156 falling out of bed. She stated if a resident fell, she would have to complete all the required paperwork in addition to the head-to-toe assessment and notify the provider/family but again she stated she knew nothing about Resident #156 falling out of bed nor did she assist in getting him back in the bed. Nurse #7 was interviewed on 08/24/22 at 6:02 PM and confirmed that she worked at the facility through an agency. She stated she had no recollection of Resident #156 and had no knowledge of a fall or transfer to the hospital. Nurse #4 was interviewed on 08/24/22 at 6:07 PM and stated that had no knowledge of Resident #156 falling out of bed or being transferred to the hospital. She stated if a resident fell during her shift she would immediately complete a head-to-toe assessment including range of motion, administer any first aide that was needed, notify the provider/family, and document the fall in the medical record. Nurse #6 was interviewed on 08/24/22 at 6:29 PM and confirmed that she worked at the facility through an agency. She stated she had no recollection of Resident #156 or any fall out of bed or transfer to the hospital. Attempts to speak to Nurse #2 were made on 08/23/22, 08/24/22, and 08/25/22 without success. The interim Director of Nursing (DON) was interviewed on 08/24/22 at 3:52 PM and confirmed that she had worked at the facility since March 2022 but had only been the interim DON since 08/23/22. She stated she recalled discussing Resident #156 in the clinical stand-up meeting because he had gone out to the hospital because he stated he fell and wanted to go to the hospital. The interim DON stated she did not believe he fell and knew nothing about a nosebleed and knew nothing about how or why he fell. She added she knew that staff were interviewed by one of the previous DON's but there was no documentation of those interviews. The Interim DON stated she had no incident report, no investigation, no documentation that she could find regarding a fall for Resident #156. The former DON was interviewed on 08/25/22 at 7:14 PM who confirmed that she was the DON during the time Resident #156 was in the building. She stated she vaguely recalled the event. She stated that when Resident #156 went to the hospital he reported a fall, and we had no record of the fall, and she was very confused because he could not have gotten himself up. The former DON stated she believed that they had interviewed the staff that worked that night and she had placed the interviews in a folder and left them in the facility. She stated that the current DON should be able to locate them. The NP was interviewed on 08/25/22 at 3:42 PM and stated that sometime on the morning of 06/26/22 someone from the facility had called her but she could not recall who and stated that Resident #156 reported he fell out of bed and wanted to go to the ER to be evaluated. She stated that she agreed, and he was transferred to the ER. The NP stated to her knowledge there was no injuries, and she was not aware of any nosebleed. The NP stated that after she arrived at work that morning there was discussion in the morning meeting about it and she was told that they had talked to the staff that worked and no one saw him fall so she did not believe that there was a fall. The Administrator was interviewed on 08/25/22 at 5:18 PM and stated she had been at the facility for three months. She stated that she recalled Resident #156 reporting that he fell during the night and discussing that he would not have been able to put himself back into bed because of his recent amputation. The Administrator stated that from what she could remember Resident #156 had a nosebleed and the family wanted him transferred to the ER. She stated that when a resident fell, she expected the staff to report the fall, complete the required head to toe assessment and a full investigation should have been conducted by the former DON.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and resident, staff, pharmacy, and Nurse Practitioners (NP) interviews, the facility failed to manage a resident's pain when she was provided the incorrect dosage of a narcotic pain medication for 1 of 1 resident reviewed for pain management (Resident #38). Findings included: Resident #38 was admitted to the facility on [DATE] with diagnosis that included mononeuropathy with unspecified lower limb (damage to the nerves). A review of Resident #38's physician orders revealed an order for Norco (Hydrocodone/Acetaminophen- a narcotic pain medication used to treat moderate to severe pain). The order read as follows: An order dated 3/25/21 for Norco 10/325mg (milligram)- give 1 tablet by mouth every 6 hours PRN (as needed) for pain. A review of Resident #38's physician's orders revealed the following additional pain management orders: An order dated 8/19/21 for Gabapentin 100 mg- give 1 capsule twice daily for neuropathy pain. An order dated 4/6/22 for Cyclobenzaprine 5mg- give 1 tablet twice daily for back pain. A Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #38 was cognitively intact and had no episodes of refusals of care. The assessment further indicated she received scheduled pain medications, received PRN (as needed) pain medications, had occasionally experienced pain over the last 5 days and had received 7 days of opioid medications during the reference period of 7 days. A review of Resident #38's physician orders revealed an additional order for Norco. The order read as follows: An order dated 7/4/22 for Norco 5/325mg now x 1 dose due to medication not available from pharmacy. A progress note dated 7/5/22 written by Nurse Practitioner #2 revealed Resident #38 had polyosteoarthritis which she had a current medication regimen that included Norco 10-325 mg every 6 hours as needed for pain - and the recommendations was to continue the same medication regimen for pain. A review of Resident #38's July 2022 medication administration record (MAR) indicated Norco 5/325mg was administered on 7/4/22 at 5:35 AM. It also indicated Norco 10/325mg was administered 7/1, 7/4, 7/5, 7/6, 7/7, 7/8, 7/9, 7/10, 7/11, 7/12, 7/13, 7/14, 7/15, 7/17, 7/18, 7/19, 7/20, 7/21, 7/22, 7/23, 7/24, 7/25, 7/26, 7/27, 7/28, 7/29, 7/30, and 7/31. The July MAR also revealed Resident #38's pain level had reached a level #7 on 7/28 and a #8 on 7/29. According to a Controlled Medication Utilization Record dispensed from the pharmacy on 7/25/22 indicated Resident #38 was administered Norco 5/325 mg on 7/26, 7/27, 7/28, 7/29, 7/30, and 7/31. According to pain documentation for July 2022 in addition to the levels listed on the July MAR, Resident #38 had a pain level that reached a level #7 on 7/26/22. A comparison of the Medication Administration Record to the Control Medication Utilization Record was performed which revealed Resident #38 received Norco 5/325 mg without a physician's order for the dosage on 14 separate occasions during the date range of 7/26/22 through 7/31/22. However, the MAR indicated Resident #38 had received the dosage of Norco 10/325 mg which was the prescribed dosage. A review of Resident #38's August 2022 MAR indicated Norco 10/325 mg was administered on 8/1, 8/3, 8/4, 8/6, 8/7, 8/8/, 8/9, 8/10, 8/11, 8/12, 8/13, 8/14, 8/15, 8/16, 8/17, 8/18, 8/19, 8/20, 8/21, 8/22, 8/23, and 8/24. It also revealed Resident #38's pain level had reached a level #8 on 8/3, #6 on 8/4, #7 on 8/6, #8 on 8/7. According to a Controlled Medication Utilization Record dispensed from the pharmacy on 7/25/22 indicated Resident #38 was administered Norco 5/325 mg on 8/1, 8/2, 8/3, 8/4, 8/5, 8/6, and 8/7. According to pain documentation for August 2022, in addition to the levels listed on the August MAR, Resident #38 had a pain level that reached a level #8 on 8/2/22. A comparison of the Medication Administration Record to the Control Medication Utilization Record was performed which revealed Resident #38 received Norco 5/325 mg without a physician's order for the dosage on 10 separate occasions during the date range of 8/1/22 through 78/7/22. However, the MAR indicated Resident #38 had received the dosage of Norco 10/325 mg which was the prescribed dosage. A progress note dated 8/2/22 written by Nurse Practitioner #2 revealed Resident #38 had polyosteoarthritis which she had a current medication regimen that included Norco 10-325 mg (milligram) every 6 hours as needed for pain - and the recommendations was to continue the same medication regimen for pain. An observation and interview with Resident #38 on 8/22/22 at 1:39 PM revealed she was sitting in her recliner and voiced she had concerns that her pain was not controlled during July and part of August 2022. Resident #38 stated, at times, her pain had reached a level #10 and she indicated she was unsure if she was being administered her pain medication because her pain was not being controlled like it had previously been when she received her pain medication consistently. Resident #38 vocalized she was aware there had been some concerns with the facility not having her Norco available from the pharmacy and she had to go without it at times. Resident #38 was unable to identify specific dates, but clarified her pain was unmanaged for periods during July and August. She vocalized, my pain has been so bad at times, I almost think I wasn't given anything but Acetaminophen. A follow-up interview with Resident #38 on 8/24/22 at 9:34 AM revealed that during parts of July and August 2022 she had experienced pain in her lower back and legs which she described as achy with frequent cramps that went down the backs of both legs. She indicated she had made staff administering medications, the DON, and her NP that she was having pain and did not feel like her pain was being managed correctly but was not provided a solution and could not recall the dates she spoke with individuals. A telephone interview with the dispensing pharmacy on 8/24/22 at 8:00 AM revealed they had record of Resident #38 receiving Norco 10/325 mg since admission; however, after a telephone conversation with the facility about dispensing concerns, the pharmacy received a faxed prescription written by NP #2 on 7/25/22 which read Norco 5/325 mg: give one tablet every 6 hours PRN for pain with a quantity written for #120; therefore, the pharmacy filled the order despite not receiving notification through the electronic medical record the order had been received by the facility. An interview with Nurse Practitioner #2 on 8/24/22 at 8:53 AM revealed she had taken over the primary care of Resident #38 and was aware she had chronic pain. Nurse Practitioner #2 stated she had been made aware early in July 2022 that the facility was experiencing difficulty obtaining Resident #38's narcotic pain medications and new scripts had to be written frequently and sent in order for the pharmacy to be able to dispense small quantities at a time. She stated Resident #38 had been consistently receiving Norco 10/325 mg which was effective in managing her pain. She indicated NP #1, the Director of Nursing (DON), the pharmacy, and herself had a telephone conference call. After concluding the call, she faxed a prescription into the pharmacy which read Norco 5/325 mg give 1 every 6 hours as needed for pain. NP #2 stated she did not verify the current order before writing the script and inadvertently had written the prescription for the incorrect dosage. She stated this was discovered within a couple days of writing the prescription because she notified the facility Resident #38 had been complaining of pain after Resident #38 had approached her with pain management concerns. She indicated she spoke with the DON and notified her the resident should be receiving Norco 10/325 mg every 6 hours PRN for pain and that the Norco 5/325 mg was a one-time order and she had inadvertently faxed the pharmacy a script that included the incorrect dosage. The DON indicated she would correct the concern. NP #2 stated she had not heard anything else from the DON or staff and was not aware Resident #38 continued to receive the incorrect dose of Norco 5/325 mg until 8/7/22. An interview with the Interim Director of Nursing, Administrator, and Corporate Nurse Consultant on 8/24/22 at 9:00 AM revealed they had no knowledge Resident #38 had received the incorrect dosage of a controlled opioid during July and August 2022. An interview with NP #1 on 8/24/22 at 9:55 AM revealed she had assisted in managing the care of Resident #38 in the absence of NP #2 being in the building and recalled that Resident #38 had approached her during July 2022 and indicated her pain was not being managed well. NP #1 stated that she, NP #2, and the DON had a telephone conference call with the pharmacy related to the dispensing of Resident #38's opioid medication. NP #1 stated there had been difficulty obtaining her medication when requested and had to write a new script every 3 days or so because the pharmacy was not dispensing more than 12 at a time. NP #1 stated she was aware NP #2 had faxed in a new script to the pharmacy for Resident #38's medication; however, had never been notified the incorrect dose had been written on the script faxed nor that Resident #38 was receiving the dosage of Norco 5/325 mg without a physician's order and had not been notified of any plans of changes in Resident #38's physician's pain management regimen to decrease the dosage from Norco 10/325 mg to Norco 5/325 mg every 6 hours PRN pain. A telephone interview with the DON on 8/24/22 at 1:08 PM revealed she was not longer employed at the facility; however, she recalled the telephone conference call between herself, the two facility NP's, and the pharmacy related to concerns with the dispensing of Resident #38's ordered medication: Norco 10/325 mg and the need for the providers being asked to write a new prescription every few days due to the pharmacy only dispensing a very small quantity at a time. She could not recall the exact date of the conference call; however, stated she thought NP #2 was going to fax in a new script to the pharmacy following the call. The DON did indicate NP #2 had spoken with her regarding the incorrect dosage being dispensed from the pharmacy and to her recollection, the concern had been corrected. She did not know Resident #38 had continued to receive the incorrect dosage until 8/7/22. A follow-up interview with the Interim Director of Nursing and the Administrator on 8/25/22 at 4:39 PM revealed the Interim DON stated all staff administering medications should compare the order written in the electronic medical record to the controlled medication utilization record as well as to the card dispensed from pharmacy before administering any medication to any resident. All staff administering medications should follow the 6 Rights: right resident, right medication, right dose, right time, right route, and right documentation. The Interim DON indicated the Norco 5/325 should not have been administered except on 7/4/22 when the one-time order was obtained from the provider when the medication was unavailable from pharmacy. She stated Resident #38 should have received Norco 10/325mg every 6 hours PRN pain and that the staff should not have signed they provided a medication that was not available in the facility.