Based on record review and interviews with the resident and staff, the facility failed to follow their abuse policy for protection after Resident #52 reported on 12/28/23 that Nurse Aide (NA) #1 had been providing her with methamphetamine and syringes. The facility failed to suspend NA #1 and allowed her to work her scheduled shift on 12/28/23 from 7:00 PM to 7:00 AM on 12/29/23. This deficient practice had the high likelihood of serious adverse outcome for 10 residents with history of substance abuse which included Resident #52. Immediate jeopardy started on 12/28/23 when the facility failed to follow their abuse policy and protect all residents with a history of substance abuse including Resident #52 by not suspending NA #1 after Resident #52 alleged that NA #1 had been supplying her with methamphetamine and syringes at the facility. Immediate jeopardy was removed on 1/12/24 when the facility implemented an acceptable credible allegation on immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put in place are effective. The findings included: Review of the facility's Abuse, Neglect, Exploitation & Misappropriation Policies and Procedures revised on 11/16/22 indicated under Protection: Any suspect(s), who is an employee or contract service provider, once he/she has (have) been identified, will be suspended pending the investigation. A review of the Facility-Reported Incident dated 12/28/23 indicated an original allegation regarding a staff member allegedly brought syringes and/or drugs to Resident #52 sometime on or before 12/28/23. An interview with Resident #52 on 1/8/23 at 10:09 AM revealed while she received a shower on 12/28/23, they went through her bags and found the methamphetamine and the syringes. She told NA #4 on 12/28/23 after she received her shower that NA #1 had been bringing her methamphetamine and syringes whenever she worked. Review of NA #1's time sheet for 12/28/23 indicated NA #1 clocked in at 7:26 PM on 12/28/23 and clocked out at 7:23 AM on 12/29/23. Multiple attempts were made to contact NA #1 during the investigation, but they were all unsuccessful. An interview with NA #4 on 1/11/24 at 9:01 AM revealed on 12/28/23, Resident #52 told her while she was getting her dressed that she had some needles, syringes and a vape in the pouch. Resident #52 later told her around 5:00 PM that she also had some methamphetamine in the pouch which were brought in to her by NA #1. NA #4 stated she reported this information to the Unit Manager. A written signed statement dated 12/29/23 by the Unit Manager (UM) revealed: Another nurse aide came to the DON's office and stated that Resident #52 told her, while getting her shower, that NA #1, the night shift nurse aide, had been supplying needles and methamphetamine to her when she was working. During an interview with the Unit Manager (UM) on 1/11/24 at 12:15 PM, she stated that Resident #52 told NA #4 after she gave her a shower on 12/28/23 that NA #1 had been bringing her methamphetamine. The UM indicated she learned about this information from Nurse #6. Nurse #6 told the UM that NA #4 did not want to report it directly to the UM because she was scared that she would get in trouble with Resident #52 if she learned that NA #4 was the one who reported it. After hearing about this information, the UM talked to NA #4 in the DON's office on 12/28/23 and confirmed this story from NA #4. Attempts were made to contact Nurse #6 but they were unsuccessful. An interview with the Director of Nursing (DON) on 1/12/24 at 1:13 PM revealed that she was aware of Resident #52's allegation about NA #1 bringing her drugs on 12/28/23 but their only evidence at that time were the syringes with clear and red liquids. She stated that NA #1 should not have worked on the night of 12/28/23 and they should have suspended her that night. The DON remembered calling NA #1 on 12/29/23 to let her know that she was going to be suspended due to Resident #52's allegations. An interview with the Administrator on 1/10/24 at 3:05 PM revealed that he believed the nurses and the nurse aides discovered the syringes in a bag when it fell over while she was getting a shower on 12/28/23. He and the DON talked to Resident #52, and she admitted to them that NA #1 gave her the syringes and the methamphetamine. Review of a credible allegation of immediate jeopardy removal plan dated 1/11/24 revealed there were currently 10 residents with a history of substance abuse including Resident #52. During a follow-up interview with the Administrator on 1/12/24 at 2:14 PM, he stated that NA #1 should not have worked on the night of 12/28/23 and they should have suspended her immediately when they became aware of Resident #52's allegation on 12/28/23. The Administrator was notified of immediate jeopardy (IJ) on 1/10/24 at 4:16 PM. The facility provided the following credible allegation of IJ removal. * Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Resident #52 has a history of drug abuse. On 12/28/23 a bag with approximately 10-20 insulin syringes, some with clear liquid and some with red liquid, was found in the Resident #52's room. Items were removed and placed in the Director of Nursing office. Resident #52 reported Nurse Aide #1 had been providing her with methamphetamine and syringes. The center failed to suspend Nursing Assistant #1 until 12/29/23 and Nursing Assistant #1 worked 7p-7a on 12/28/23. The center failed to provide protection to Resident #52 by not suspending Nurse Aide #1 on 12/28/23. Current residents in the facility have the potential to be affected by the deficient practice. * Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 1/11/24 the [NAME] President of Clinical Services provided education to the Executive Director, Director of Nursing and Nurse Manger about Abuse, Neglect, Exploitation and Misappropriation. Education included implementing effective systems or processes to protect residents with a history of substance abuse. The [NAME] President of Clinical Services also educated the Executive Director, Director of Nursing and Nurse Manger on the importance of immediate suspension of any suspect in an abuse allegation to ensure the protection of all residents until the investigation is completed. Starting on 1/11/24 all current staff, including contract employees, will be educated by the Director of Nursing, Assistant Director of Nursing and/or the Unit Managers on Abuse Policy including the immediate suspension of any suspect until the investigation is completed. Staff members not educated on 1/11/2024 will not work their next shift until their education has been provided. On 1/11/24 the Director of Nursing, Assistant Director of Nursing and/or the Unit Managers will track who has received and not received education daily by using the facility employee roster. The Director of Nursing, Assistant Director of Nursing and the Unit Managers have been notified of this responsibility. On 1/12/24, the Director of Nursing, Assistant Director of Nursing and/or the Unit Managers will continue to provide abuse education to all current employees including contract employees. Education will include the following: the immediate suspension of any suspect until the investigation is completed. Education will continue throughout the night shifts and weekend by Director of Nursing, Assistant Director of Nursing and/or the Unit Managers until current staff have been completed. This will include calling staff who are not on the schedule and are not scheduled to work. The Director of Nursing, Assistant Director of Nursing and the Unit Managers were notified of this responsibility on 1/11/2024. Newly Hired staff will be educated during the Orientation process by the Director of Nursing going forward. The Director of Nursing was notified of this responsibility on 1/11/24. The alleged date of IJ removal is 1/12/24. On 1/16/24, the facility's credible allegation of immediate jeopardy removal was validated by review of documentation regarding staff training on the systems and interventions to protect residents from abuse and the importance of immediate suspension of any suspect in an abuse allegation. Staff interviews revealed receipt of training regarding abuse including immediate suspension of any suspect until the investigation is completed. The facility's date of immediate jeopardy removal of 1/12/24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews with resident, staff, Nurse Practitioner, Medical Director and Police Officer, the facility failed to discuss with Resident #52 the presence of many needles found in her possession at the hospital, monitor for illegal substances in her room and supervise Resident #52 for triggers of illegal substance abuse for a resident with a known history of substance abuse. Resident #52 was found with many needles in her room while in the hospital on 9/22/23. On 10/5/23, Resident #52 was sent to the hospital after a sudden onset of lethargy, low oxygen saturation and increased heart rate. Hospital staff documented suspicion of illicit drug use. Staff observed drug paraphernalia in her room including vape pens (a handheld device consisting of a battery attached to a cartridge filled with a concentrate), syringes (some used with old blood in the syringe and some with medication residual), medicine cups with medication residual, and flushes. The facility failed to notify law enforcement and obtain Resident #52's consent to search her room to remove any additional illegal drugs or drug paraphernalia. On 12/28/23, a bag with approximately 10-20 insulin syringes with clear and red liquid and another bag with lighters and a vape pen were found in Resident #52's room. Upon investigation on 12/29/23, a folded-up piece of paper with crystals was discovered in one of the bags. Police were notified and identified the crystals as methamphetamine. The facility failed to obtain consent to search Resident #52's room for any additional illegal drugs or drug paraphernalia. This was for 1 of 3 residents reviewed for supervision to prevent accidents. Immediate jeopardy started on 10/5/23 when Resident #52 had a change of condition and staff found drug paraphernalia in her room. Immediate jeopardy was removed on 1/12/24 when the facility implemented an acceptable credible allegation on immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put in place are effective. The findings included: Resident #52 was admitted to the facility on [DATE] with diagnoses that included quadriplegia (form of paralysis that affects all four limbs and torso), C1-C4 incomplete, respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions), chronic osteomyelitis (bone infection), bipolar disorder, intraspinal abscess, anxiety disorder, chronic pain, opioid dependence with other opioid-induced disorder, obstructive hepatitis, and neuromuscular dysfunction of bladder. Resident #52's care plan initiated on 8/22/23 indicated Resident #52 had chronic pain. Interventions included to administer analgesia as per orders and to give a half hour before treatments or care, evaluate the effectiveness of pain interventions, monitor/document for side effects of pain medication and notify physician if interventions were unsuccessful or if current complaint was a significant change from resident's past experience of pain. Resident #52 did not have a care plan to address her history of substance use disorder. The hospital records for Resident #52's hospital stay from 9/15/23 through 9/28/23 indicated Resident #52 who had a history of intravenous drug abuse-related cervical spine infection was transferred from the facility to the hospital on 9/15/23 due to worsening of a known pressure ulcer. She was noted to have purulent (containing or consisting of pus) drainage. She was on Hydromorphone for chronic pain due to her sacral wounds. The History & Physical dated 9/16/23 indicated she reported to the Emergency Department (ED) doctor that she had used alcohol and methamphetamine in the past with her last use approximately a year ago. A hospital physician note dated 9/22/23 indicated many needles and contraband were found in her room last night. Urine drug screen was not helpful as she had been getting opioids at the hospital although she tested positive for cannabis. She told the doctor that her last intravenous drug use was several months ago in her facility. The urine drug screen done on 9/22/23 indicated Resident #52 was positive for benzodiazepine, cannabinoid, opiate and tricyclic antidepressant. PICC (peripherally inserted central catheter) line was placed on 9/26/23 for intravenous antibiotics. Resident #52 was discharged back to the facility on 9/28/23 with an order for intravenous antibiotics every 6 hours. The Nurse Practitioner's progress note dated 9/29/23 indicated under history of present illness: The hospital discharge summary reports contraband was found in Resident #52's room on the night of 9/22/23 but she stated that her last intravenous drug abuse was prior to coming to the facility. Left upper extremity had an occlusive superficial vein thrombosis (inflammation of the superficial vein) in the basilic and cephalic veins but no deep vein thrombosis. Plan included to continue (antibiotic medication) via PICC line every 6 hours scheduled until 11/2/23 and current pain regimen included Hydromorphone (opioid medication used to treat moderate to severe pain), Oxycodone (opioid medication used to treat moderate to severe pain), Pregabalin (nerve pain medication), Acetaminophen (analgesic used to treat mild to moderate pain) and Tizanidine (muscle relaxant). An interview with the Nurse Practitioner (NP) on 1/12/24 at 9:02 AM revealed she did not remember asking Resident #52 about the contraband that was found while she was in the hospital in September. The NP stated she might have reviewed the hospital discharge summary after she had already seen Resident #52 and was doing her documentation at the end of the day. The NP stated she did not call the hospital to get more information regarding this incident about Resident #52. She also did not remember if she had talked to the nursing staff about Resident #52 having been found with contraband in the hospital. An interview with the Director of Nursing (DON) on 1/12/24 at 9:42 AM revealed she did not know anything about Resident #52 having been found with contraband and testing positive for cannabinoid while she was at the hospital in September. The DON stated she started working as the DON in the middle of August 2023 but had to take a medical leave for two weeks and then worked a few hours from home and then a few hours at the facility afterwards in September 2023. The DON stated they had an interim Administrator at that time, but she did not find any investigation regarding this incident with Resident #52. A review of Resident #52's Medication Administration Record for September 2023 indicated she received the following medications: * Hydromorphone 8 milligrams (mg) oral tablet 1 tablet by mouth every 8 hours scheduled for chronic pain * Alprazolam 0.5 mg oral tablet 1 tablet by mouth every 8 hours as needed for anxiety * Pregabalin 200 mg oral capsule 1 capsule by mouth three times a day for nerve pain * Oxycodone 10 mg oral tablet 1 tablet by mouth every 6 hours as needed for pain * Tizanidine 6 mg oral capsule 1 capsule by mouth three times a day and 2 mg 1 tablet by mouth every 8 hours as needed for muscle spasms The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #52 was cognitively intact, had no behaviors and had range of motion impairment on both sides of the upper and lower extremities. She required set-up or clean-up assistance with eating and oral hygiene but was totally dependent on staff assistance with other activities of daily living. The MDS further indicated Resident #52 received scheduled and as needed pain medication regimen and complained of frequent pain at a level of 6 (moderately stronger pain). Frequent pain rarely or not at all affected Resident #52's sleep at night and rarely or not at all interfered with her day-to-day activities. Resident #52 had one stage 4 pressure ulcer present upon admission. She received antipsychotic, antianxiety, antidepressant, antibiotic, opioid and hypoglycemic medications. She also received intravenous medications and had an intravenous access while a resident at the facility. The Nurse Practitioner's progress note dated 10/5/23 indicated Resident #52 was seen for concerns of hypovolemia. Recurrent fever of 102.0 (normal body temperature is around 98.6 degrees). The NP ordered intravenous fluids and laboratory studies this morning. Nursing reported Resident #52 had been non-compliant with the intravenous antibiotics and had skipped two doses. Upon initial assessment, she was awake and appropriate. Color pale but last hemoglobin was 8.5 (normal hemoglobin level for females is 12 to 16). Lips dry and urine dark. At that point, the NP was going to continue intravenous fluids and obtain blood cultures. Approximately two hours later, nursing requested reassessment. She was very pale, oxygen saturation 40s (normal level of oxygen is usually 95% or higher), lethargic, with heart rate 120-130s (normal resting heart rate for adults ranges from 60 to 100 beats per minute) and systolic blood pressure 80 (normal blood pressure for most adults is systolic pressure of less than 120 and a diastolic pressure of less than 80). She appeared to be intoxicated. 911 was called for transfer to the emergency room (ER). She was placed on non-rebreather with oxygen saturation up to the 90s. She was more alert and talking. She did receive Hydromorphone scheduled, Oxycodone for breakthrough, and Alprazolam 0.5 mg every 8 hours as needed. She had been given one (dose of Alprazolam) around 12 PM which was two hours prior. Found paraphernalia in her room including vape pens, cigarettes, syringes (some used with old blood in the syringe and some with medication residual), medicine cups with medication residual, and flushes. When questioned she denied using any of the supplies found in her room. She became very tearful. The NP called and discussed with her (family member). Plan included due to fever, tachycardia (fast heart rate) and hypoxia to send to ER for evaluation and treatment. Concerned for possible endocarditis (inflammation of the heart valve). The hospital records for Resident #52's hospital stay from 10/5/23 through 10/25/23 indicated Resident #52 was sent to the ER on [DATE] for decreased responsiveness and hypoxia. Resident #52 appeared to be poor historian and was in severe distress with pain and crying during the encounter. She reported that the staff at the facility was not able to wake her up and she was very low on oxygen and was transferred to the hospital. Per ED report, Resident #52's oxygen saturation dropped down to 50% and she was put on 15 liters with a non-rebreather when (her oxygen saturation came up to) around 90%. The urine drug screen dated 10/5/23 indicated Resident #52 was positive for benzodiazepine, cannabinoid, opiate, oxycodone and tricyclic antidepressant. ED note also mentioned concern that Resident #52 might have been crushing up her pain medications and injecting them into her PICC line and possibly also having benzodiazepines snuck into the facility. Toxicology screen on admission was positive for benzodiazepines, cannabinoids, opiates, and tricyclics (although she was prescribed many of these medications chronically). The Infectious Disease (ID) Consultation note dated 10/6/23 indicated the ID doctor recorded that he thought Resident #52 was illicitly injecting/using drugs and this was likely what caused her hypoxia/unresponsiveness/current presentation/readmission rather than a new infection, although they had not ruled this out yet. (She could have a PICC-related bacteremia [presence of bacteria in the bloodstream] or fungemia [presence of fungi or yeasts in the blood] especially if she was using the line illicitly). The ID doctor was also concerned about the possibility of endocarditis given evidence suggesting pulmonary and splenic emboli (sudden blocking of an artery) and recent bacteremia with enterococcus and Klebsiella, but she had been on Ampicillin/Sulbactam covering both of these organisms so he doubted even if she had endocarditis that it would explain this readmission. She was nearly ready to discharge back to the facility on [DATE] when she had recurrent fever to 102.0 and she reported chills, so they requested ID to re-evaluate her to see if any changes were needed. At this point, she had completed four weeks of Ampicillin/Sulbactam and it seemed unlikely that (antibiotic) failure was the cause of her fevers, so ID stopped antibiotics in favor of monitoring fever curve/vitals. Resident #52 had a PICC line that was removed on 10/16/23 and a right-sided internal jugular central venous line was placed. She was transitioned to oral medications and was determined to be stable for discharge on [DATE]. An interview with Resident #52 on 1/10/24 at 1:08 PM revealed the syringes including the vape pens that were found in her room in October 2023 originally came in with her when she was first admitted to the facility. Resident #52 stated she did not feel comfortable answering more questions because she was trying to transfer to another facility which was closer to her family. She said that if she divulged more information, she felt that this might jeopardize her chances of moving to another facility. An interview with Nurse #2 on 1/10/24 at 9:09 AM revealed she usually took care of Resident #52, but she did not work with Resident #52 on 10/5/23 when she was found non-responsive. Nurse #2 stated that she heard Resident #52 was just checked by the Nurse Practitioner (NP), and she was fine initially. She also heard that they observed paraphernalia in her room including vape pens, cigarettes, syringes, medicine cups with medication residual, and flushes. She heard there was a box of insulin syringes. Nurse #2 stated she had asked Resident #52 later on whether she had used the syringes and she denied having used them. She also asked Resident #52 where she obtained the box of insulin syringes and she stated to her that she had brought them from home before she was admitted to the facility. Nurse #2 stated Resident #52 had no visitors because her family lived six hours away and she had no friends. Nurse #2 stated she could have only gotten the vape pens from staff. Nurse #2 further stated that she remembered Resident #52 having a dresser in her room that she kept locked up so that might have been where she was hiding the paraphernalia found in her room. Nurse #2 also shared that when Resident #52 came back to the facility from her hospitalization in October 2023, they started crushing her medications and putting them in applesauce to make sure that she swallowed her pills. Nurse #2 stated that they thought she might have been cheeking (pretending to swallow medications but actually hiding the pills in the part of the mouth between the gum and the cheek) her pills, crushing them later and then injecting them directly into her PICC line. An interview with the Unit Manager (UM) on 1/8/24 at 3:27 PM revealed she was aware of Resident #52's history of drug use and remembered sometime in October 2023 when she was sick and was receiving intravenous antibiotics through a PICC line. The UM stated all of a sudden she became very lethargic and was not responding. The UM stated they found a box of insulin syringes in her room and then Resident #52 was sent to the hospital. While at the hospital, they ran a drug panel which showed positive for a bunch of substances but then she also received a lot of medications. They kept her at the hospital for a long time before she came back to the facility. Back in October 2023, Resident #52 denied having used any intravenous medications, but the staff speculated that she might have been crushing her oral pills and injecting them directly into her PICC line. The UM stated she remembered one of the ports in Resident #52's PICC line being clogged all the time. When Resident #52 came back to the facility, they started crushing all of her medications and placing them in applesauce to make sure she swallowed her pills. During a follow-up interview with the UM on 1/11/24 at 12:15 PM, she stated that she remembered Resident #52 being non-responsive on 10/5/23 and she reported this to the NP and the Director of Nursing. The UM stated she remembered seeing at least three vape pens in addition to the box of insulin syringes at Resident #52's bedside. The UM stated they suspected Resident #52 of cheeking her oral pills, crushing them and then injecting them directly into her PICC line. After they removed everything they found at Resident #52's bedside, they discarded everything. She remembered trying to find out what kind of vape pens they were, but they thought one was for sure a weed pen. The police were not notified, and they did not come to the facility that day. An interview with the Nurse Practitioner (NP) on 1/10/24 at 9:24 AM revealed she had assessed Resident #52 on 10/5/23 and she was fine but two hours later, she was unresponsive. When she went into her room, they found all kinds of drug paraphernalia including vape pens, syringes, and medicine cups with medication residual. The NP stated there was blood in some of the syringes, so she suspected Resident #52 of not swallowing her pills, crushing them later and then injecting them directly into her skin and into her vein. The NP stated she did not see any marks on Resident #52's skin that day and when she asked her about the syringes in her room, she just cried and denied everything. The NP stated that she told Resident #52 on 10/5/23 that injecting drugs to herself could kill her. The NP also stated that she called Resident #52's family member that day but all she told her was that this was her history and that she had done this before. The NP stated she discussed with Resident #52's family member what actions to take but there was nothing they could do when there were no facilities that would take her. The NP stated that Resident #52 required a facility that offered drug rehabilitation as well as skilled nursing services and this facility was not ideal for her. She shared that when Resident #52 came back to the facility from the hospital in October 2023, she was switched to oral antibiotics, and they decided to crush all her medications. She also shared that Resident #52 was manipulative and tried to trick some of the nurses, so she gave them an order to crush all of her medications. While discussing the drug tests at the hospital, the NP stated that Resident #52 tested positive for cannabinoid which was probably from the vape pens which were found in her room. Her Oxycodone was changed to Hydromorphone while she was at the hospital because it was the medication that was controlling her pain the best. The NP shared she was also hesitant about prescribing Hydromorphone because it was ten times more potent than Oxycodone and was also not ideal with her history of drug abuse. The NP stated Resident #52 was ordering the syringes online. An interview with the Social Worker (SW) on 1/10/24 at 8:74 AM revealed after Resident #52 was re-admitted to the facility from the hospital in October 2023, she knew that the nurses had started crushing up her medications whenever they gave them, and she was instructed to open any package together with Resident #52. The SW stated she had been doing this for the last few months and she made sure that there were no suspicious materials or drug paraphernalia such syringes or illegal drugs. An interview with the Director of Nursing (DON) on 1/9/24 at 2:31 PM revealed Resident #52 always had make-up size bags and one fell out into the floor in October 2023. There were insulin syringes and saline flushes with no needles attached with white residue inside. Resident #52 never admitted to doing anything in October 2023, but they thought she had figured out a way to cheat with her medications. The DON stated they thought she was self-injecting her oral pain medications into her PICC line so when she came back to the facility, they started crushing all her medications. The DON also shared that Resident #52 had two different stories regarding how she obtained the insulin syringes: one was that she ordered them online and one was that she had brought them in to the facility when she was first admitted . During a follow-up interview with the DON on 1/11/24 at 11:06 AM, she stated that they were more concerned about sending Resident #52 out to the hospital after she was found unresponsive on 10/5/23 and when she left, she thought she was no longer in danger. The DON stated she didn't know why they didn't call the police to search her room, but they didn't think there were drugs in the vape pens. She stated she thought the vapes were cigarette pens. An interview with the Administrator on 1/10/24 at 3:05 PM revealed he didn't know anything about the incident on 10/5/23 when Resident #52 was unresponsive and was observed with paraphernalia in her room. The Administrator stated there was an interim Administrator at that time, but he hadn't seen any investigation into the incident. A review of the Facility-Reported Incident dated 12/28/23 indicated an original allegation regarding a staff member allegedly brought syringes and/or drugs to Resident #52 sometime on or before 12/28/23. The accused individual's employment was terminated on 1/4/24 and the termination was related to the allegation. Summary of Facility Investigation: Discovery was made by day shift nurse of several used needles in Resident #52's room in a bag near her bed. The Unit Manager verified the same, confiscated the items and kept until police picked them up. Interviews with Resident #52 by the Social Worker, the Administrator and the Director of Nursing verified that Nurse Aide (NA) #1 was supplying Resident #52 with methamphetamine and syringes/needles. Interviews conducted with alert and oriented residents turned up with no further evidence. Skin checks with those residents who were not alert and oriented were completed with no further evidence. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #52 was cognitively intact, had no behaviors and had range of motion impairment on both sides of the upper and lower extremities. She required set-up or clean-up assistance with eating and oral hygiene but was totally dependent on staff assistance with other activities of daily living. The MDS further indicated Resident #52 received scheduled and as needed pain medication regimen and was in almost constant pain at a level of 10 (most severe pain). Frequent pain made it hard for Resident #52 to sleep at night and occasionally limited her day-to-day activities. Resident #52 had one stage 4 pressure ulcer present upon admission. She received antipsychotic, antianxiety, antidepressant, opioid and antiplatelet medications. Resident #52's care plan last reviewed on 12/20/23 indicated Resident #52 had chronic pain. Interventions included to administer analgesia as per orders and to give a half hour before treatments or care, evaluate the effectiveness of pain interventions, monitor/document for side effects of pain medication and notify physician if interventions were unsuccessful or if current complaint was a significant change from resident's past experience of pain. An interview with Resident #52 on 1/8/24 at 10:09 AM revealed she had been completely paralyzed but she was now able to move both arms and could lift her left leg a little. She stated she couldn't sit up on her own. Resident #52 stated NA #1 had been bringing her drugs whenever she worked on the night shift. She shared that this got started after she talked to NA #1 about how she ended up with her medical issues which was from doing intravenous drugs. Resident #52 stated that NA #1 mentioned to her that she did them as well, so they started talking about it and NA #1 offered to bring her some drugs. Resident #52 stated she was still in the beginning of her recovery phase of her drug addiction, and this was not something she should have been exposed to, but it was hard for her to say no. Resident #52 stated NA #1 was bringing methamphetamine to her for free but that this didn't help with her goal of trying to get closer to her family. Resident #52 shared that she didn't have a family member close by and they lived six hours away. The interview further revealed that Resident #52 received the methamphetamine in crystal form, dissolved it with water and shoot it with a syringe. Resident #52 stated she had been doing this for about two months a couple of times a day. Resident #52 denied having experienced any withdrawal symptoms after her drugs were removed from her room. She shared that the methamphetamine gave her more energy and that she was not using it often enough to make her experience withdrawal symptoms. Resident #52 explained that when she went to take a shower, the staff went through her bags and found the drugs, but nobody said anything to her right away. Resident #52 stated nobody talked to her for five days except for Nurse #2 who told her that she could get in trouble for it, and she could get arrested. They called her family member and told her that they were worried because the drugs came from an employee. Resident #52 denied having gone through any drug test or talking to the police about the drugs. Resident #52 explained that some of the liquid in the syringes were red due to blood, but the clear liquid was diluted methamphetamine in water. A follow-up interview with Resident #52 on 1/10/24 at 1:08 PM revealed she didn't remember any of the nurses doing full head-to-toe skin assessments on her. Resident #52 stated that she was re-using the syringes that were discovered and that NA #1 was also supplying her those. Resident #52 shared that she injected the methamphetamine straight into whatever vein she could find on her hands and arms. They sometimes left a bump on her skin but no bruising. During the interview, Resident #52 was wearing long sleeves and kept both hands under her bed sheet. When she occasionally pulled out her hands from under her sheet, no marks were observed on her hands. Resident #52 added that she didn't really time the two doses of methamphetamine injection and she just did them whenever she wanted to. Resident #52 stated that her privacy screen was always pulled up around her bed because staff wanted her door open all the time. She reiterated that she never paid for the methamphetamine and that she didn't have enough money to pay for them. She also shared that the vape that was discovered recently was a vape that she kept with her when she went to the hospital back in October 2023 and she didn't need to refill the cartridge because she didn't use it that often. Multiple attempts were made to contact NA #1 during the investigation, but they were all unsuccessful. A written signed statement dated 12/29/23 by Nurse #2 revealed: On 12/28/23, Resident #52 got up for her shower. Nurse #2 went to wipe Resident #52's bed down with bleach wipes, moved her red and black blanket and her cheetah print bag fell over on the bed. In the bag were needles (several), tissue with blood on them, vapes. Nurse #2 took bag to DON. Resident #52 was upset and crying. Nurse #2 informed Resident #52 that her bag was with the DON. An interview with Nurse #2 on 1/8/24 at 11:59 AM revealed she was wiping Resident #52's bed and sanitizing it while she was getting a shower in the shower room on 12/28/23 when her bag fell over after she moved her blanket. The contents of the bag spilled onto Resident #52's bed and revealed some bloody tissues in the bag, and several insulin syringes. Nurse #2 stated she was not sure whether all the insulin syringes were used but some of them had red liquid, and some had a clear substance. Nurse #2 stated she didn't look at all the contents of the bag because Resident #52 had a bloodborne illness, and she didn't want to touch the used syringes without gloves. Nurse #2 stated they later discovered that there was a folded piece of paper in a perfect square and inside was crystal methamphetamine after the police officer identified it the next day. Nurse #2 stated she did not ask Resident #52 about the contents of her bag because she was already upset and crying. She later found out that Resident #52 said that NA #1 had been bringing the drugs to her for free, but she stated that she did not believe that she was getting them for free. Nurse #2 stated she brought Resident #52's bag to the DON's office and they kept it. A follow-up interview with Nurse #2 on 1/10/24 at 9:09 AM revealed she had been doing skin assessments on Resident #52 and did not notice any marks on Resident #52's arms and hands. Nurse #2 stated Resident #52's arms had always looked gray, and she did not notice anything unusual with her skin or her behavior. An interview with NA #3 on 1/9/24 at 12:41 PM revealed she got Resident #52 up out of the bed because she was scheduled to receive a shower. NA #4 along with another nurse aide were assigned to do showers on 12/28/23. NA #3 helped Nurse #2 wipe Resident #52's bed when her cheetah print bag fell over on her bed and some of the needles/syringes fell out of the bed. NA #3 stated she didn't look much inside the bag but the syringes she saw had caps and she was unsure if they had been used. Nurse #2 took the bag to the DON's office. NA #3 stated that while Resident #52 was receiving a shower in the shower room, she must have known that they were going to discover her bag because she sent NA #4 to retrieve her bag, but they had already given it to the DON. When they put Resident #52 back into bed, she must have realized that her bag was gone because she started screaming and yelling about the bag. She kept crying and told them that she had some needles and vape in there. Resident #52 told her that the nurse gave her the vape but she didn't think that was right and she thought that Resident #52 was just making up that statement. Resident #52 also told her that she had brought in the syringes from when she was admitted to the facility. An interview with NA #4 on 1/11/24 at 9:01 AM revealed while assisting Resident #52 with her shower on 12/28/23, she sent her back into her room to get her pouch from her bed. When she went into Resident #52's room, staff had already gotten her bag, so she went back to tell Resident #52 that she didn't see it. NA #4 stated after she put Resident #52 back into bed, she was crying and said that she was mad about the pouch being gone. Resident #52 told her while she was getting her dressed that she had some needles, syringes and a vape in the pouch. Resident #52 later told her around 5:00 PM that she also had some methamphetamine in the pouch which was brought in to her by NA #1. NA #4 stated she reported this information to the Unit Manager. A written signed statement dated 12/29/23 by the Unit Manager (UM) revealed: On 12/28/23, NA #3 brought her two bags and stated while Resident #52 was getting a shower she was making up her bed and cleaning her room up when she noted these two bags on her bedside table. One bag was green and blue, and the other was leopard print. NA #3 told the UM to look in the bags. Upon observation, the UM noted several needles both used and full of clear or red substances. This was in the green and blue bag. In the leopard print bag, there were lighters and a weed vape. The DON, the Administrator and the Social Worker were informed. Another nurse aide came to the DON's office and stated that Resident #52 told her, while getting her shower, that NA #1, the night shift nurse aide, had been supplying needles and methamphetamine to her when she was working. An interview with the Unit Manager on 1/8/24 at 3:27 PM revealed NA #3 brought to her the two bags that were in Resident #52's room while she was in the shower room. The UM stated she remembered because NA #3 had asked for some bleach wipes to sanitize Resident #52's bed while she was in the shower. The UM looked inside the green and blue bag and saw some needles and syringes which some had clear liquid, and some had red liquid. In the leopard print bag were a vape and lighters. Both bags were placed in a plastic bag and locked up in the DON's office. The next day, a police [TRUNCATED]

Based on record review, observation, and interviews with resident, staff, Nurse Practitioner, Medical Director and Police Officer, the facility failed to provide effective leadership and implement effective systems to manage and supervise a resident with a history of substance abuse after syringes were found in Resident #52's room and protect all residents after Resident #52 reported Nurse Aide #1 was providing her with methamphetamine and syringes. This failure had a high likelihood of affecting other facility residents. Immediate jeopardy started on 10/5/23 when after observing drug paraphernalia in Resident #52's room the facility's administrative team failed to identify the seriousness of the situation and put effective systems in place. Immediate jeopardy was removed on 1/12/24 when the facility implemented an acceptable credible allegation on immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put in place are effective. The findings included: This tag is cross-referenced to: F607 - Based on record review and interviews with the resident and staff, the facility failed to follow their abuse policy for protection after Resident #52 reported on 12/28/23 that Nurse Aide (NA) #1 had been providing her with methamphetamine and syringes. The facility failed to suspend NA #1 and allowed her to work her scheduled shift on 12/28/23 from 7:00 PM to 7:00 AM on 12/29/23. There were a total of 10 residents with a history of substance abuse. This deficient practice affected 1 of 3 residents reviewed with a history of substance abuse. F689 - Based on record review, observations, and interviews with resident, staff, Nurse Practitioner, Medical Director and Police Officer, the facility failed to discuss with Resident #52 the presence of many needles found in her possession at the hospital, monitor for illegal substances in her room and supervise Resident #52 for triggers of illegal substance abuse for a resident with a known history of substance abuse. Resident #52 was found with many needles in her room while in the hospital on 9/22/23. On 10/5/23, Resident #52 was sent to the hospital after a sudden onset of lethargy, low oxygen saturation and increased heart rate. Hospital staff documented suspicion of illicit drug use. Staff observed drug paraphernalia in her room including vape pens (a handheld device consisting of a battery attached to a cartridge filled with a concentrate), syringes (some used with old blood in the syringe and some with medication residual), medicine cups with medication residual, and flushes. The facility failed to notify law enforcement and obtain Resident #52's consent to search her room to remove any additional illegal drugs or drug paraphernalia. On 12/28/23, a bag with approximately 10-20 insulin syringes with clear and red liquid and another bag with lighters and a vape pen were found in Resident #52's room. Upon investigation on 12/29/23, a folded-up piece of paper with crystals was discovered in one of the bags. Police were notified and identified the crystals as methamphetamine. The facility failed to obtain consent to search Resident #52's room for any additional illegal drugs or drug paraphernalia. This was for 1 of 3 residents reviewed for supervision to prevent accidents. An interview with the Administrator on 1/10/24 at 3:05 PM revealed when staff found the syringes in Resident #52's bag on 12/28/23, they did not know what were in the syringes and at that point, he did not suspect her of any drug abuse. He acknowledged that he waited another 12 hours before notifying the police, but this was after he discovered the folded-up piece of paper with crystals that was tucked in a pocket of the bag. The Administrator stated he wanted to be sure that there were illegal drugs before notifying the police. He stated that corporate staff advised him on the steps to take in reporting and monitoring regarding Resident #52 after she alleged that Nurse Aide (NA) #1 had been bringing her methamphetamine and syringes to the facility. He further stated that they instructed him on how to do a 4-point plan of correction. He added that once Nurse Aide #1 was terminated on 1/4/24 for not cooperating with the investigation, he didn't see anything else happening to Resident #52. He started talking about having done an ad hoc QAPI (Quality Assurance and Performance Improvement) meeting related to this incident but after he looked at his QAPI folder, he realized that there wasn't one done. The Administrator stated the administrative staff started monitoring Resident #52's room daily through rounds and looking for any obvious signs of illegal drugs in the room. The nurses also monitored Resident #52 for changes in behavior. They also did in-services to all staff regarding abuse and their abuse policy. The Administrator added that after he talked to Resident #52, she promised him that she would not engage in illicit drug use anymore while she was at the facility. The Administrator was notified of immediate jeopardy (IJ) on 1/11/24 at 1:37 PM. The facility provided the following credible allegation IJ Removal. * Identify those recipients who have suffered, or are likely to suffer a serious adverse outcome as a result of the noncompliance. The facility failed to provide leadership and effective systems related to a resident with a history of drug abuse not being protected from illegal substances. The facility failed to provide leadership and effective systems related to the protection of all residents after an abuse allegation was made. * Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring and when the action will be complete. The Regional [NAME] President of Operations (RVPO) educated the Executive Director (ED) on 1/11/24 in regard to implementing effective systems or processes to protect residents with a history of substance abuse. The RVPO also educated the ED on the importance of immediate suspension of any suspect in an abuse allegation to ensure the protection of all residents until the investigation is completed. The Regional Director of Clinical Services and the [NAME] President of Clinical Services provided education to the Director of Nursing and Nurse Mangers on the Abuse Policy including the immediate suspension of any suspect until the investigation is completed. The Nurse Managers educated the Department Heads of this process. The ED understands that law enforcement is to be notified at the time of the identification of any suspicion or evidence of any illegal substance abuse. During the facility stand up and stand down meeting residents' with a history of substance abuse will be discussed and reviewed for any signs of substance abuse. The Director of Nursing/Nurse Manager will report to the Executive Director daily during stand up/stand down meetings if any residents have exhibited signs of substance abuse. Upon any receipt of an allegation of abuse, the ED will notify both the RVPO and the Regional Director of Clinical Services (RDCS). Upon notification, the RVPO and/or RDCS will provide additional guidance as needed related to any investigation. The RDCS will provide additional oversight to the center leadership team on implementation of policies to ensure the center has effective systems. As stated in the Employee Handbook, possession of illegal drugs on company property is a Level 2 violation and is grounds for immediate termination. The alleged date of IJ removal is 1/12/24. On 1/12/24, the facility's credible allegation of immediate jeopardy removal was validated by an interview with the Administrator. He stated that he received education by the Regional [NAME] President of Operations regarding processes related to substance abuse which included immediately suspending any suspect and calling the police if they suspected any resident with drug abuse. As the abuse coordinator, he was responsible for conducting the investigation and doing interviews with residents and staff. The facility's date of immediate jeopardy removal of 1/12/24 was validated.