**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, hospital record review, death certificate review, investigation review, drug information review, interview and policy review the facility failed to ensure staff belongings were properly secured to prevent access to Resident #11 and failed to ensure a condition change was timely reported to medical practitioners resulting in resident neglect. This resulted in Immediate Jeopardy and Actual Harm/subsequent death on [DATE] between 5:00 A.M. and 6:00 A.M. when Resident #11, who resided on a secured behavior unit and had a history of drug use and drug seeking behavior, accessed Certified Nurse Assistant (CNA) #120's purse (which was located at an unsecured nursing station) and obtained the prescription medication, Adipex (a stimulant). Resident #11 then ingested up to 20 37.5 milligram (mg) tablets that had been in the bottle without staff knowledge. At 7:40 A.M. Resident #11 was noted to be not acting right and at 8:56 A.M. Resident #11 developed a rapid pulse and confusion. Resident #11 (who was normally ambulatory) was unable to stand alone and was unable to walk with staff assistance. Physician Assistant (PA) #805 was notified and indicated she would be in to see Resident #11. At 11:17 A.M. PA #805 was notified Resident #11 was hypertensive (high blood pressure), required oxygen and an order was received to transfer the resident to the emergency room (ER) for evaluation of respiratory distress. While in the ER, Resident #11 required cardiopulmonary resuscitation (CPR) and intubation and was admitted to the intensive care unit (ICU) with amphetamines (stimulants) in her urine and pneumonia. The resident expired on [DATE] at a palliative care facility. A situation of neglect that did not rise to Immediate Jeopardy was identified when the facility failed to obtain and provide basic care, services and necessary equipment to meet the total care needs of Resident #70. This affected two residents (#11 and #70) of four residents reviewed for abuse/neglect. The facility census was 77. On [DATE] at 10:00 A.M. the Administrator (LNHA), Director of Nursing (DON), and Regional Director of Clinical Services (RDCS) #704 were notified Immediate Jeopardy began on [DATE] between 5:00 A.M. to 6:00 A.M. when Resident #11 accessed CNA #120's unsecured purse behind the nurses' station and ingested up to 20 37.5 mg tablets of Adipex (stimulant medication used for weight loss) resulting in a condition change that began at 7:40 A.M. The resident had confusion, hypertension, the inability to stand/walk, and rapid pulse before the resident was evaluated by the PA. The resident was not transferred to the ER until 11:37 A.M. for evaluation where she required CPR, intubation and was admitted to the ICU. The resident was comatose and never regained consciousness, subsequently expiring on [DATE]. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrections: • On [DATE] at 11:37 A.M., Resident #11 was transported to the emergency room by Emergency Medical Services (EMS) for evaluation. The resident was admitted to the hospital on [DATE] at 3:35 P.M. • On [DATE] at 11:42 A.M. the Nurse Registered Nurse (RN) #500 attempted to notify Resident #11's guardian regarding the resident's condition and transport to the ER; however, there was no answer, and the nurse was unable to leave a voicemail. The resident's Emergency Contact #2 was notified and stated she would inform the resident's guardian. • On [DATE] at 11:01 A.M. Certified Nurse Assistant (CNA) #120 notified the Administrator, via phone, that a bottle of her prescription medication (Adipex) and a lighter were missing from her purse. • On [DATE] at 11:05 A.M. Resident #11's room was searched by Unit Manager #508 and an empty medication bottle labeled phentermine (Adipex) with CNA #120's name on it, a lighter and a bottle of esomeprazole (no name on the bottle) were found. The facility denied knowledge of how the resident obtained the bottle of esomeprazole. • On [DATE] at 11:29 A.M. the Unit Manager #508 notified an unidentified Intensive Care Unit nurse at the hospital of the empty Adipex bottle being found in Resident #11's room. • On [DATE] at 11:30 A.M. the Administrator and Regional Director of Operations #811 spoke with CNA #120. The employee reported that her medication and lighter were missing from her purse, but she could not remember if her purse was closed. The CNA #120 was suspended at approximately 11:35 A.M. • On [DATE] at 11:30 A.M. the Unit Managers #529 and #508 completed an observation of all four nursing stations to ensure that no personal items were kept there, unsecured. Employees on duty Registered Nurse (RN) #500, CNA #507, CNA #511, CNA #515, CNA #527, CNA #513, Licensed Practical Nurse (LPN) #540, CNA #541, CNA #560, CNA #604, CNA #620, and LPN #806 were instructed on where personal items were to be stored. Items must be stored on the units in the nurse aide rooms. • On [DATE] at 11:45 A.M. Regional Director of Operations #811 completed another environmental observation of Resident #11's room to ensure that no loose pills were in the room or that no items that could harm the resident were in the room. • On [DATE] at 11:54 A.M. the Unit Manager #508 spoke with CNA #120 and obtained a verbal statement. The employee reported she left her bag at the nurses' station and later noticed that her prescription pill bottle and lighter were missing. • On [DATE] at 12:00 P.M. the Management team including Unit Manager #508, Dietary Manager #517, Unit Manager #529, Director of Social Service #538, Minimum Data Set Nurse #543, Business Office Manager #556, Receptionist/Admin Assistant #591, and Admissions/Marketing #619 completed an environmental observation of 74 resident rooms to ensure there were no medications or items that could harm the residents. • On [DATE] at 12:00 P.M. Regional Nurse #704 began a medical record review that consisted of physician orders and notes, care plan, any behaviors, cognitive level and history with diagnosis for Resident #11. • On [DATE] at 12:30 P.M. Minimum Data Set (MDS) Nurse #543 reviewed Resident's #11's care plan. • On [DATE] at 1:30 P.M. Unit Managers #508 and #529 completed an observation of all residents in the facility (73) to ensure they displayed no change in condition. Observations were completed by 3:30 P.M. All resident progress notes were reviewed for condition changes not reported or addressed and all residents with a Brief Interview Mental Status (BIMS) score of eight to 15. In addition, Residents #3, #4, #5, #6, #8, #10, #12, #13, #14, #15, #16, #17, #18, #19, #22, #23, #24, #26, #27, #28, #29, #32, #34, #35, #37, #38, #39, #42, #43, #44, #45, #46, #48,#49, #50, #51, #52, #53, #54, #55, #58, #59, #61, #62, #63, #64, #65,#66, #67, #68, #69, #74, #76, #129, and #230 were interviewed related to care. • On [DATE] at 2:00 P.M. Regional Nurse #704 reviewed two additional resident records who were identified with a history of self-harm behaviors (Resident #16 and Resident #72) and one resident, (Resident #10) for drug seeking behaviors. No other residents were identified to meet the review criteria. • On [DATE] at 2:00 P.M. all (133) employees (2 activities, 1 Admissions director, 1 Business office, 1 Wellness Director, 20 LPNs, 7 RN'S, 60 CNA'S, 12 DIETARY, 9 Housekeepers, 7 Laundry, 1 HR/payroll, 1 PT, 2 PTAs, 1 OT, 4 OTA, 1 SLP, 2 Maintenance and 1 Medical Records) were educated on where they were to store their personal belongings, Residents' right to live in a safe environment, Abuse, Neglect and misappropriation policies. Education provided to all licensed nurses (20 LPNs and 7RNs), included medication storage and reporting changes in condition with emphasis on residents' behaviors and level of consciousness. Education was provided by the Administrator/designee in person or via phone. Any scheduled agency staff would be required to review the information in the Agency binder and sign that the information was reviewed before their scheduled shift. New hires would be educated during orientation by Human Resources Manager #512. • On [DATE] at 2:15 P.M. in person or via telephone education was provided by Unit Managers 3508 and #529 to (27) Nurses; staff were educated on the change in condition and documentation in the medical records policies. • On [DATE] at 2:25 P.M. the Administrator interviewed the nurse on duty, RN #500, related to resident's change in condition. RN #500 received education provided by the Administrator (the behavior unit) about documenting timely in the medical record including changes in condition. The education was provided verbally and in person. • On [DATE] at 2:30 P.M. the Administrator or designee began interviewing staff to determine if staff observed any changes in the resident's condition or were aware of any medications in her room. • On [DATE] at 2:30 P.M. Maintenance staff changed the lock to the designated area for staff to keep their belongings on Cherry Grove (the behavior unit) to a keypad. All 133 staff were provided with the code. • On [DATE] at 2:40 P.M. the Administrator initiated a self-reported incident (SRI) tracking number 258954 related to an allegation of neglect involving Resident #11. • On [DATE] at 5:05 P.M. an ad hoc Quality Assurance Performance Improvement meeting (QAPI) including Unit Manager #508, Unit Manager #529, Administrator, Director of Social Services #538, Receptionist #591, Regional Nurse #704, and Physician #812. QAPI was held to review the incident and the plan to prevent recurrence, Physician #812 attended via phone. The plan included interventions and system changes identified in this removal plan. • On [DATE] at 9:30 A.M. Maintenance Director #540 changed the gate to a half door. The mechanism to open the door was located on the inside of the door and not the outside which decreased access behind the nurses' station to like residents. • On [DATE] at 1:30 P.M. the Interdisciplinary Team (Unit Manager #508, Dietician #520, Unit Manager #529, Administrator # 537, Director of Social Services #538, MDS Nurse #543, Receptionist #591, and Regional Nurse #704) reviewed the incident in the facility's scheduled weekly risk meeting. • Beginning [DATE], the Administrator or designee would complete daily observations for five days then weekly for three weeks at varying times/shifts to verify that no employees' personal items were stored at the nurses' station or in areas accessible to residents. • Beginning [DATE] the DON or designee would complete an observation/assessment daily of each resident for changes in condition outside of their baseline and to ensure that changes in condition were documented in the resident's medical records. Reviews were to be completed daily for five days then weekly for four weeks. • Beginning [DATE], Ambassadors (Activity Director #506, Unit Manager #508, Maintenance #509, Human Resources Manager #512, Dietary Manager #517, Schedular #522, Unit Manager #529, Director of Social Services #538, Director of Maintenance #540, MDS Nurse #543, Activity Assistant #544, Business Office Manager #556, Receptionist #591, Medical Records #593, and Admissions/Marketing #619) or designee were to complete room checks at varying times/shifts to ensure no medications were stored in the residents' room and that the room does not have any unsafe items in them. Observations were to be conducted daily for five days in all resident rooms then weekly for four weeks. • Beginning [DATE], the Administrator or designee would complete an observation of the gate/door across the entrance to the nurses' station daily for five days, then weekly, for three weeks of the nursing station on Cherry Grove to ensure it was properly secured. • Beginning [DATE], the Administrator would review the audits weekly for four weeks to ensure they were completed, and any concerns would be addressed. Results of audits would be forwarded to the facility QAPI committee for further review and recommendations monthly for three months. The first review was completed [DATE]. Although the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at a Severity Level 2 (no actual harm with potential for more than minimum harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective action plan and monitoring to ensure on-going compliance Findings include: 1.Review of the closed medical record for Resident #11 revealed the resident was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses including dementia, schizophrenia, borderline personality disorder, obsessive compulsive disorder, bipolar, anxiety, schizoaffective, auditory hallucination, major depressive disorder, dependent personality disorder, post-traumatic stress disorder, chronic kidney disease Stage 3, mild protein calorie malnutrition, drug use and viral hepatitis. Review of the medical record revealed behavior notes dated [DATE], [DATE], [DATE], and [DATE] indicating Resident #11 ambulated independently on the secured behavior unit. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #11 had severe cognitive impairment. The MDS revealed Resident #11 wandered one to three days during the assessment period. The wandering placed Resident #11 at significant risk of getting to a potentially dangerous place. The assessment revealed Resident #11 required supervision or touch assistance to ambulate. Review of a care plan dated [DATE] revealed Resident #11 had impaired cognitive process for daily decision making and was at risk for further decline in cognitive status. Interventions included to administer medications as ordered and observe for side effects (of medications). Review of a care plan dated [DATE] revealed Resident #11 would remain safe in the present environment, would adjust to the nursing home placement, would have opportunities for freedom of expression and movement in a safe environment, and would maintain her normal living patterns. Interventions included to allow Resident #11 to wander in acceptable areas and assist with ambulation as needed. Review of a care plan dated [DATE] revealed Resident #11 required secured unit placement related to a secondary diagnosis of elopement risk, bipolar disorder, dementia, psychosis, and schizophrenia. Interventions included to take the resident on walks or allow the resident to walk ad lib in the enclosed unit. Further review of the medical record revealed a general progress note dated [DATE] at 7:40 A.M. and authored by Registered Nurse (RN) #500 (created on [DATE] at 4:11 P.M. as a late entry) that revealed a CNA (unidentified) reported Resident #11 was not acting right. Resident #11 had a pulse of 104 beats per minute (bpm) (normal 60-90 bpm), a blood pressure was 129/89 millimeters of mercury (mmHg) (normal 120/80 mmHg) and oxygen saturation (the amount of oxygen in your blood with the normal level being greater than 92 percent) of 95 percent on room air. Resident #11 was alert with confusion. Resident #11 was unable to stand by herself and was unable to walk with staff (assistance). PA # 805 was notified and stated she would be in soon to see Resident #11. Review of a general progress note dated [DATE] at 10:11 A.M. and authored by RN #500 (created on [DATE] at 4:17 P.M. as a late entry) revealed a CNA (unidentified) reported Resident #11 only ate a couple bites of breakfast and was not able to feed herself. Resident #11's pulse was 102 bpm, blood pressure was 136/72 mmHg, and oxygen saturation was 93% on room air. Resident #11 was not able to sit up in a chair and the CNA put Resident #11 in bed. Review of a general progress note dated [DATE] at 11:17 A.M. and authored by RN #500 (created on [DATE] at 4:31 P.M. as a late entry) revealed a CNA (unidentified) reported Resident #11 was short of breath and unable to stand or sit upright. Resident #11's pulse was 103 bpm, blood pressure was 159/108 mmHg, temperature of 99.5 degrees Fahrenheit (F), and oxygen saturation was 89 percent. PA #805 was called and stated she was in the building and on her way to evaluate Resident #11. Oxygen was placed on Resident #11 at two liters and oxygen saturation increased to 94 percent. New orders were received to send Resident #11 to the hospital for respiratory distress. 911 was called and an ambulance arrived within eight minutes to transport Resident #11 to the hospital. Resident #11 left the facility at 11:37 A.M. Further review of the medical record revealed a Situation, Background, Assessment, Recommendation (SBAR) Communication Form dated [DATE] and authored by RN #500 that revealed Resident #11 had abnormal vital signs, altered mental status, fever, functional decline, hypertension, and shortness of breath. The form indicated symptoms started on [DATE] and had gotten worse. Resident #11 had an altered level of consciousness, increased confusion or disorientation, memory loss, decreased mobility, more assistance needed for activities of daily living, and weakness. Resident #11 had labored/rapid breathing and shortness of breath, a resting pulse greater than 100 (bpm), distended abdomen, and Resident #11 reported no pain. There was no further documentation or assessment regarding the resident's labored/rapid breathing or her distended abdomen. Review of the transfer form dated [DATE] at 11:30 A.M. revealed Resident #11 usually ambulated independently and could follow simple instructions. Resident #11 was a full code (required life saving measures/CPR in the event of respiratory or cardiac arrest) and reported no pain. Review of a general progress note dated [DATE] at 3:35 P.M. and authored by RN #500 (created on [DATE] at 4:36 P.M. as a late entry) revealed Resident #11 had coded (required cardiopulmonary resuscitation) at the hospital and would be going to the intensive care unit (ICU) once all testing was completed. Review of emergency department documentation dated [DATE] at 4:19 P.M. revealed Resident #11 had no complaints. The Emergency Medical Service (EMS) stated Resident #11 had abdomen pain and (her) abdomen was distended. Resident #11 had a chest and abdominal computed tomography (CT) and had been on the monitor per nursing about 15 minutes prior to it being discovered that all of Resident #11's leads (heart monitor leads) were off and Resident #11 was unresponsive. Resident #11 did not have a pulse and cardiopulmonary resuscitation (CPR) was started. Nursing stated when Resident #11 was put back on the monitor the initial rhythm was bradycardic (heart rate less than 60 bpm) and in the range around 18 to 20 beats per minute. A resultant pulse was obtained, and Resident #11's pupils were eight (8)-millimeters (in diameter) and not responsive. The CT of the chest showed pneumonia and Resident #11 was ordered antibiotics. Resident #11's family was aware of the concern for hypoxic brain injury (lack of oxygen to the brain) and pneumonia. An addendum revealed the nursing facility staff reported Resident #11 pointed to her abdomen stating her belly hurt. When asked if abdomen hurt, Resident #11 stated yes and reported being short of breath. Resident #11 had generalized weakness along with hypoxia. Resident #11 was saturating at 88 percent at the nursing home and Resident #11 was placed on two liters and transported to the hospital. Resident #11 was able to get around on her own normally; however, the nursing staff were unable to get Resident #11 out of bed this morning. Review of the hospital record revealed a toxicology report dated [DATE] at 4:23 P.M. that revealed Resident #11 was positive for amphetamines (stimulants). All other toxicology results were negative. Emergency Department (ED) documentation on [DATE] at 6:44 P.M. revealed Resident #11's family stated Resident #11 was sneaky with drugs at the nursing facility and wondered if there were any drugs in Resident #11's system. The family were told a drug screen could be ordered and the family would be notified of the results. The history and physical from the hospital dated [DATE] revealed EMS reported Resident #11 had abdominal pain and her abdomen was distended. Resident #11 had been transported to the ED for evaluation. Resident #11's family was notified by the nursing facility that patient was not her usual self. Upon arrival at the ED, Resident #11's temperature was 98.9 degrees F, heart rate was 88 bpm, blood pressure was 156/110 mmHg, and oxygen saturation was 94 % on two (2) liters (of oxygen) While on telemetry, Resident #11 was noted to become bradycardic into the 20's and unresponsive with subsequent pulseless electrical activity (PEA) for which CPR was initiated and Resident #11 was intubated. There was a question as to the length of downtime, with initial report of eight minutes of downtime; however, per review of telemetry monitor, downtime may have been as long as 15 minutes. The return of spontaneous circulation (ROSC) was reportedly achieved after five minutes. Resident #11 had decerebrate posturing (an involuntary, abnormal body posture characterized by rigid extension of the arms and legs, with toes pointed down, and the head and neck arched back. It is a strong indicator of severe brain damage) and non-purposeful movements. Resident #11 did open her eyes to sternal rub. Initially, pupils were reactive and brisk, but pupils were currently nonreactive. The urine drug screen was positive for amphetamines. A hospital progress note dated [DATE] revealed Resident #11's pulseless electrical activity arrest (PEA) arrest may be related to an overdose of Adipex. The history and physical from the hospital dated [DATE] revealed Resident #11's family requested to transition the resident to a Do Not Resuscitate Comfort Care (DNRCC) and to stop all interventions with terminal liberation from the ventilator (the process of withdrawing a patient from mechanical ventilation when they are no longer expected to recover). A hospital consultation note dated [DATE] revealed Resident #11 was a [AGE] year-old female with past medical history of mental illness including schizoaffective disorder, depression, anxiety, history of seizures, history of drug abuse, hypothyroidism, and hyperlipidemia. Resident #11 was not acting herself the morning of [DATE] and was running a fever. Resident #11 was transported to the emergency room. Resident #11 had bradycardia and thought to have pneumonia. Resident #11's urine was positive for amphetamines. Resident #11 developed PEA arrest resulting in anoxic brain injury, and at some point, had taken off her oxygen and cardiac monitor and required resuscitation with possibly five to eight minutes of downtime. Resident #11 was intubated and placed on hypothermic protocol and transferred to the ICU. Resident #11 was seen by neurology and had an abnormal electroencephalography (EEG), to record spontaneous electrical activity of the brain, with generalized periodic epileptiform discharges (abnormal electrical patterns). Resident #11 remained comatose, but did have a corneal and gag reflex. Resident #11's overall prognosis was significantly poor, and this was discussed with her family. Resident #11 was ultimately removed from the ventilator and transferred to the regular floor with palliative care to assist with end-of-life. Hospital discharge documents dated [DATE] revealed Resident #11 was admitted [DATE] and discharged on [DATE] to the compassionate care center. Resident #11 presented to the emergency department from skilled nursing facility (SNF) due to a fever and not acting herself. In the ED, Resident #11 became bradycardic into the 20's and unresponsive with subsequent PEA and CPR was initiated. ROSC was achieved after five minutes. Resident #11 was found to have multifocal pneumonia and cystitis. An EEG showed generalized periodic epileptiform discharges and Resident #11 was started on Keppra. Resident #11 remained comatose despite an interruption of sedation. Resident #11's poor prognosis was discussed with Resident #11's family, and they decided on comfort care. Resident #11 was ultimately removed from the ventilator and transferred to the regular floor. Comfort medications were started, palliative care was consulted for discharge planning, and Resident #11 was discharged to the inpatient hospice unit. Review of a self-reported incident (SRI) Tracking Number 258954, created on [DATE] at 1:43 P.M. revealed a resident had a change in condition with an empty medication bottle found in the resident's room. On [DATE] CNA #120 called the Administrator to alert her that she was missing a prescription medication bottle from her purse and asked if the staff would look for it on the unit she was assigned [DATE]. Due to the call, the Administrator and nursing directors searched the behavior unit CNA #120 was working on during her [DATE] shift and searched all resident rooms. The empty medication bottle was found in the room of Resident #11. According to CNA #120, the bottle should have had 20 pills remaining in the bottle. The Administrator contacted the hospital where Resident #11 was located and alerted them Resident #11 could possibly have taken this medication, causing her condition change. The facility also alerted the guardian and physician. CNA #120 was suspended pending investigation. The SRI included Resident 311 had a history of psychiatric behaviors and resided on the behavioral unit (Cherry Grove) within the facility. Review of the facility investigation dated [DATE] revealed the following statements: Former Assistant Director of Nursing (ADON) #806 shared a nurse asked for assistance. Resident #11 was lying back in a wheelchair. PA #805 was assessing Resident #11. Resident #11's oxygen saturation was 88 percent on room air. ADON #806 applied oxygen at two liters to Resident #11. Resident #11's oxygen saturation increased to 97 percent and Resident #11 was sent to the hospital for evaluation. A statement by former CNA #544 revealed on [DATE] around 8:30 A.M. she said good morning to Resident #11. Resident #11 seemed different, and CNA #511 stated nursing staff was monitoring Resident #11. Resident #11 seemed weak and was not ambulating. Resident #11 was sent to the hospital. A statement by CNA #511 revealed Resident #11 was not acting right. The nurse checked Resident #11 and requested that staff monitor Resident #11. Resident #11 continued to fall asleep on and off. A statement by Unit Manager #508 revealed CNA #120 reported prescription medication and a lighter were missing from CNA #120's purse. An empty (prescription) bottle and lighter were found in Resident #11's room. Review of Resident #11's death certificate with a date of death [DATE] revealed the cause of death was anoxic brain injury after cardiac arrest and pneumonia. Interview on [DATE] at 12:34 P.M., with CNA #511 revealed CNA #120 reported Resident #11 was up (moving around) on [DATE] around 5:30 A.M. CNA #511 went into Resident #11's room around 6:00 A.M. and Resident #11 was not standing properly. CNA #511 notified RN #500. Resident #11's vitals were okay. Resident #11 was brought into the common area so Resident #11 could be watched because something was not right. CNA #511 stated the nurse had to help get Resident #11 to the toilet and then about 45 minutes later, Resident #11 was slurring her words and her blood pressure, and heart rate were up. Resident #11 was sent to the hospital. CNA #511 stated she did not see a prescription bottle in Resident #11's room. Further interview with CNA #511 revealed CNA #120 reported, the next day ([DATE]), that her prescribed medication was missing. CNA #511 reported the prescription bottle was found in Resident #11's room. Interview on [DATE] at 5:43 P.M. with CNA #120 revealed she was an as needed employee and worked until 6:00 A.M. on [DATE]. CNA #120 stated she took Adipex, a prescribed medication for weight loss every morning at 5:00 A.M. before doing the last checks on the residents. CNA #120 stated she took the medication the morning of [DATE] and then put the bottle of pills back in the zipper part of her purse. CNA #120 stated she came out of a room near Resident #11's room and saw Resident #11 walking around. Further interview revealed she worked again on [DATE] beginning at 2:00 A.M. and saw Resident #11 had been transferred to the hospital for mental status change. While at work on [DATE], a resident asked to smoke and CNA #120 looked in her purse for a lighter, but she could not find the lighter and had to get a lighter from someone else. CNA #120 shared that on [DATE] around 5:00 A.M. several call lights were on so she did not take her medication at that time, and she went home and took a short nap after her shift. When she woke up, she looked in her purse for her weight loss medication but could not find it. CNA #120 called the facility on [DATE] between 11:00 A.M. to 12:00 P.M. and talked to RN #508 to see if anyone had found her prescription bottle but nothing had been reported at that time. RN #508 called about an hour later and asked if CNA #120 would write a statement about her medication. CNA #120 stated she would after she got off work at another place of employment. CNA #120 stated RN #508 and the Administrator called her back around 4:30 P.M. or 5:00 P.M. and the Administrator told her she was terminated because she had left a controlled medication unsupervised and the empty prescription bottle was found in a drawer in Resident #11's room. CNA #120 stated her purse was on the desk behind the nurse's station, next to the printer and there was a baby type gate that was hard to close, to keep residents from going behind the nurse's station. CNA #120 stated she was scheduled to work on another unit that night but had been moved to the behavioral unit due to a call off. CNA #120 shared there was nowhere to leave her belongings on the behavioral unit. On the unit there was a locked door indicating a medication room, and another locked door that had a sign that stated not to enter unless they were getting something for a resident. CNA #120 verified she did not have the codes to the doors, and she would not have asked for the code to the medication room because she was not a nurse. CNA #120 shared that she was the only staff member on the behavioral unit that night and if she cal[TRUNCATED]