LPN #1 was covering medication duties for another nurse who had gone on break when Resident #2 complained of a headache around 2:30 PM.
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"This has been going on for over three months." She had finally threatened to report the facility if conditions didn't improve.
CNA #3, who was operating the van, told inspectors she had not received training for the safe use of the securement system.
The resident at Hartley Nursing and Rehab was sent to an apartment on December 3rd.
The licensed practical nurse, identified as LPN #5 in inspection records, pulled 0.25ml doses from a morphine solution between August 15 and August 24.
She said she thought the resident had discharged to his family member's house as planned.
The citation centered on problems with a concrete ramp in the facility's 200 hall that residents use to enter and exit the building for smoking breaks.
The incident occurred during the CNA's final rounds on October 23, when he found the resident had soiled herself with a large bowel movement.
CNA A had moved the resident at 10:15 AM but failed to reposition the drainage bag properly.
The resident hit her head and tore skin on her right elbow during the January 7 fall at Village at Victory Lakes.
His September cognitive assessment showed a score of 8 out of 15, indicating moderately impaired mental function.
The specialist prescribed gabapentin, a seizure medication commonly used to treat nerve pain, at 100 milligrams daily.