**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to properly account for 34 tablets of hydromorphone (a controlled narcotic pain medication) for 1 of 3 residents (R1) reviewed for controlled medications. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE] indicated diagnoses of infection of multiple sites of the spine, septicemia (infection in the blood) and low back pain. The MDS also indicated R 1 had recent spinal surgery and she had received scheduled and as needed pain medication. R1's care plan dated 9/17/24 indicated she had pain related to diagnosis of lumbar fusion (spinal surgical procedure) and complaints of back pain. R1's hospital discharge orders included an order for hydromorphone (a narcotic pain medication) 2 milligrams (mg) every 3 hours as needed for severe pain. R1 was discharged from the hospital on 9/17/24. R1's September 2024 medication administration record (MAR) indicated she received hydromorphone 2 mg on 9/17/24 and 9/19/24. On 10/15/24, nurse practitioner (NP)-A wrote an order to discontinue hydromorphone 2 mg. On 10/16/24 at 9:36 a.m. a progress note indicated R1 discharged to home at 9:00 a.m. On 11/5/24 at 9:45 a.m., the director of nursing (DON) stated R1 was discharged home from the facility on 10/16/24, and the hydromorphone was not sent home with R1. On 11/5/24 at 10:47 a.m., R1 stated she did not take the hydromorphone often while at the facility, as she did not have the need for it. She also stated she did not take the hydromorphone home with her when she discharged on 10/16/24. On 11/5/24 at 11:27 a.m., licensed practical nurse (LPN)-A stated she and LPN-B discovered R1's hydromorphone was missing on 10/21/24 around 7:00 p.m., when they conducted their narcotic count at the change of shift. When the medication was discovered to be missing, she sent an email to the DON to notify her of the discrepancy. On 11/5/24 at 1:19 p.m., LPN-B stated she remembered seeing R1's hydromorphone the morning of 10/18/24. She stated when she came to work on 10/21/24 at 7:00 p.m. she completed her narcotic count with LPN-A, and they discovered R1's hydromorphone was missing. LPN-A sent an email to the DON. On 11/5/24 at 2:34 p.m., the DON stated she would have expected the nurses to have called her immediately upon discovering any discrepancies with narcotic counts. She did receive an email regarding R1's missing hydromorphone. On 11/5/24 at 3:44 p.m., LPN-C stated he recalled seeing R1's hydromorphone on 10/18/24. He did not follow policy and did not verify the narcotics were physically present in the medication cart. It was, Kind of a trusting situation. He knew the process of viewing each actual medication and looking at the count sheet to verify the actual number of medications, and this was an essential step to the process of narcotic counting. On 11/5/24 at 4:31 p.m., the assistant director of nursing (ADON) stated narcotic counts should be completed anytime a new staff person worked on a medication cart. The oncoming nurse should be counting the bin/locked box of medication. The nurse who was leaving should be reviewing the book to verify the quantity. If there was any discrepancy, they were to notify the DON immediately. The ADON also stated discontinued medications should be destroyed timely with two nurses. On 11/6/24 at 9:22 a.m., the pharmacist stated all medications were destroyed on site. The pharmacy no longer accepted returned medications. Best practice was to destroy a medication as soon as it was discontinued. R1's Narcotic Record indicated 36 tablets were received on 9/17/24. 1 tablet was removed from the card on 9/17/24, and another tablet was removed on 9/19/24, leaving 34 tablets. The facility policy Narcotic Count dated 7/19 directed the count is done by having one nurse look at the index and corresponding sign out page. A second nurse confirms the quantity remaining in the medication card, box, or bottle. Both staff sign the count notebook to indicate the count was current. a) if the count is not correct, notify the nursing supervisor promptly and search for the missing medication(s). b) if missing medication(s) cannot be accounted for, notify DON (or designee) who will determine the appropriate course of action The facility policy Medication Disposition dated 2/23 directed controlled medications: 1. When a scheduled II-V medication is discontinued, upon resident death, or upon discharge of a resident when a schedule II-V medications are not sent with resident upon discharge these medication must be destroyed by DON (or designee) and a second nurse. 2. Medications are to remain locked in the locked narcotic box on the medication cart and will be counted per the narcotic count policy until they are removed for destruction. 3. As soon as practical after discontinuance, death or discharge the following should occur: Narcotic medications are destroyed via state and federally acceptable practices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Interview and document review, the facility failed to ensure resident families and/or representatives were updated timely for a change in condition related to a fall for 1 of 2 residents (R34) reviewed for falls. Findings include R34's quarterly Minimum Data Set (MDS) dated [DATE], included severed cognitive deficit with diagnosis of Alzheimer's disease. R34's care plan listed problem of cognition/mood dated 10/10/22, indicated R34, Relies on family to assist with major decision making prn [as needed], and directed staff to, Encourage family support and involvement. When interviewed on 10/31/22, at 12:14 p.m. R34's responsible family member (FM)-A stated, R34 had a fall on 9/30/22, at around 1:00 a.m. The facility did not notify him until 9/30/22 around 3:30 p.m. He was traveling for work that day. He would have chosen not to travel if he had know R34 required family assistance. It should have been more timely, if not at the time of occurrence, at least way before 3:30 p.m. R34's fall event report indicated a fall on 9/30/22, at 12:56 a.m. and FM-A was notified at 3:51 p.m. R34's progress note dated 9/30/22, at 12:56 a.m. identified, Resident found on the floor, lying on right side facing the bed. He was screaming for help. Wheelchair within reach. Denies pain, denies hitting his head. ROM [range of motion] intact. Wearing white whites. He reports he was trying to get up to go to the bathroom and slipped out of bed. Assisted off the floor with assist of Nurse and aide. Aide assisted to the bathroom. Skin check completed, no discoloration noted. R34's progress note dated 9/30/22, at 3:31 p.m. identified, Updated [FM-A] this afternoon regarding fall that happened during previous shift. Was upset that he wasn't updated sooner than later. Said he was on the road and was 10 hours away and wouldn't have been able to get here had anything serious transpired. Was reassured that resident was stable and sustained no injuries from fall. [FM-A] said he would be contacting management regarding timely communication. When interviewed on 11/3/22, at 1:20 PM registered nurse (RN)-C stated, with any resident fall or incident, facility protocol is to notify resident's primary care provider, family or representative and nurse managers. RN-C stated if a resident had a fall that did not result in an injury on an overnight shift facility protocol was for the incoming day shift nurse to make those notifications. When interviewed on 11/3/22, at 2:36 p.m. RN-A stated, [FM-A] had not made a complaint to any management staff that she was aware of therefore no grievance had been initiated. RN-A stated nurse managers normally reviewed all facility progress notes and any noted concerns should have been brought forward to the interdisciplinary team. RN-B stated she had spoken to FM-A on 9/30/22, regarding another matter and he had expressed no concern regarding lack of notification. RN-B stated normally if there is no resident injury or transfer to the emergency room, the day shift staff would make notifications of any incidents on overnights. RN-B stated she did follow-up with FM-A today (11/3/22) to discuss his concern. RN-B stated FM-B had agreed to a care plan change for R34 instructing staff to notify family no matter what the time of day. The facility policy titled, Notification of Physician and Resident Representative, dated 5/4/22, included, Primary physicians, residents, and the resident representative, consistent with their authority, will be updated with all resident condition changes as soon as possible. The names of those contacted will be documented in the progress note.