**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents' right to be free from abuse for one resident (Resident #1) of ten residents reviewed for abuse. -The facility failed to ensure that Resident #1 was free from physical abuse when he alleged he received methadone from a staff member, was found unresponsive, required Narcan, and tested positive for Methadone for which he did not have an order for. Resident #1 was transported to the local hospital on 4/30/25 and diagnosed with hypoxia (low oxygen) likely due to acute-on-chronic systolic heart failure. An Immediate Jeopardy (IJ) was identified on 5/07/25 at 1:56 PM and an IJ Template was provided to the Administrator at 3:00 PM. While the IJ was removed on 5/08/25, the facility remained out of compliance at a scope of isolated with the severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for abuse. Findings included: Record review of Resident #1's face sheet, dated 5/08/25, reflected a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: acute systolic (congestive) heart failure, unspecified sequelae of cerebral infarction (stroke), major depressive disorder (mood disorder), and hx of cocaine and alcohol abuse. Record review of Resident #1's quarterly MDS assessment, dated 04/21/25, reflected his BIMS score was 12, which indicated moderate cognitive impairment. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #1 required moderate to maximal assistance with most ADLs and used a motorized wheelchair. The MDS Assessment under Section N-Medications, reflected Resident #1 was prescribed medication under the high-risk drug class that included and opioid. Record review of Resident #1's care plan, revised 5/05/25, reflected the resident required pain management r/t to generalized pain that included Gabapentin and Norco. Interventions included: administering analgesia (pain reliever) as ordered, anticipating the resident's need for pain relief immediately to any complaint of pain, monitoring/recording/reporting to nurse any s/sx of non-verbal pain, monitoring/recording/reporting to nurse loss of appetite, refusal to eat, and weight loss, monitoring/recording/reporting to nurse complaints of pain or requests for pain treatment, and observing and reporting changes in usual routine. Further review of this document reflected it was revised on 5/05/25 to reflect that Resident #1 had a history of drug abuse prior to admission to facility. Resident #1 had gone out to hospital and noted to have non prescribed narcotic medication in his system. Interventions included: Drug abuse policy was given to resident with education and signature, Narcan (medication to reverse opioid/narcotic overdose) provided PRN, psychiatric medication management NP to see resident, referral to psychiatric services, resident was offered rehabilitation services and declined, and resident was seen by psychologist. Record review of Resident #1's active consolidated physician orders, dated 5/08/25, reflected in part the following: -HYDROcodone-Acetaminophen oral tablet 5-325 MG (for pain relief) - give 1 tablet by mouth every 6 hours as needed for pain. Hold medication if drowsy and notify MD. -Gabapentin oral capsule 300 MG (for pain relief) - give 1 capsule by mouth three times a day for pain. Hold medication if drowsy and notify MD. Further review of this document revealed there was not an order for Methadone. Record review of Resident #1's hospital records, dated 4/30/25, reflected in part the following: HPI: 64 [sic] y.o. male with a past medical history of GERD, hyperlipidemia, hypertension, diabetes mellitus stroke, seizure disorder who was brought into ER from nursing home because of respiratory distress. During my encounter [Resident #1] was on BiPAP and poor historian so history is taken from ER notes. As per ER [Resident #1] is on opioid outpatient in likely took more than dysuria of narcotics and later on was found to be short of breath and drowsy for which EMS was called. On arrival to ER [Resident #1] was found to be drowsy and was given Narcan, [Resident #1] responded very well to Narcan however got very anxious for which morphine was administer after my suspicion of an opioid withdrawal. ABGs: PH 7.25 (normal range 7.35-7.45), pC02 58.7 (normal range 32.0-45.0 mmHg), P02 98 (normal range 83.0-108.0 mmHg). [Resident #1] was on non-rebreather mask initially and was later on placed on BiPAP. CTA chest negative for PE or pleural effusions. Troponin 122 (normal range 38.73-80.22 ng/L), BNP 125 (normal range less than 100 pg/mL). [Resident #1] was given Lasix 100 mg IV once and breathing treatment as well. Review of system is limited as [Resident #1] is on BiPAP and lethargic during my encounter. . Labs: Specimen: Clean Catch; Urine Methadone- Positive Opiate- Positive . Hospital Course/Long LOS Summary: [Resident #1] is a [AGE] year-old male with past medical history of systolic heart failure, diabetes, hypertension, sleep apnea, and chronic pain who presented to the emergency room for altered mental status and shortness of breath. [Resident #1] was admitted for acute hypoxic respiratory failure requiring supplemental O2 and BiPAP to maintain O2 saturation >92%. Likely related to acute on chronic systolic heart failure versus community acquired or aspiration pneumonia. [Resident #1] was started on IV Lasix (water pill) with good urine output. Discharge plan pending clinical improvement. . Record review of Resident #1's progress note, dated 4/30/25 at 9:30 AM by LVN A, reflected the following: [Resident #1] not alert and SOB noted. [Resident #1] responsive only to sternal rub. b/p 142/90 p137 r22 o2 sat 47% on RA. Applied o2 via mask rebreather at 15l. o2 sat 92%. EMS called and [Resident #1] transferred to [name] ED. Record review of a document titled Resident Out on Pass Log, dated 4/20/25-5/07/25, reflected Resident #1 had not signed out to leave the facility. Record review of Resident #1's EHR reflected the resident was seen by a psychologist to address his s/sx of depression on 5/05/25. The recommendations reflected the following: -Psychological consultation is recommended to assist staff in developing and implementing behavior plans to reduce [Resident 1's] affective and/or cognitive symptoms. -Individual therapy to reduce [Resident 1's] affective and/or cognitive symptoms. -Referral for medication evaluation. Record review of an in-service titled Abuse and Neglect, dated 5/01/25, reflected all staff were educated on the facility's policy on recognizing and reporting abuse and neglect. Record review of an in-service titled Resident Drug and Alcohol Abuse, dated 5/05/25, reflected all staff were educated on the facility's policy on drugs and alcohol. Record review of an in-service titled Intoxicated Residents, dated 5/05/25, reflected all staff were educated on recognizing s/sx of an intoxicated resident and who to notify. Record review of an in-service titled Naloxone Administration, dated 5/06/25, reflected all nurses were educated on the protocol for administering Naloxone to a resident suspected of an overdose. In an interview and observation on 5/06/25 at 11:42 AM, Resident #1 was sitting in his wheelchair in his room. He was dressed and well-groomed with no s/sx of distress. Observation of the room revealed it was clean with no evidence of drugs, alcohol, or paraphernalia. Resident #1 immediately asked if I was from social services and if he was in trouble. This state investigator stated No and asked Resident #1 about his recent hospital stay. Resident #1 stated he was transported to the hospital for what he thought was another stroke. Resident #1 stated he could not recall what happened but was told that he was found unresponsive in his room. Resident #1 looked concerned, then proceeded to state that he did not want to be in trouble or get anyone else in trouble; however, he became sick after taking Methadone that he received from a staff member. Resident #1 refused to identify the staff. He stated he must have taken too much, and it caused him to pass out. Resident #1 did not recall exactly when he took the drug or how much he consumed. Resident #1 stated he was sad about his mother, who was sick at a different nursing facility, and he needed something to take his mind off it. Resident #1 refused to provide any additional information. In an interview on 5/06/25 at 12:20 PM, LVN A stated she worked at the facility for about 6 months. She stated she worked with Resident #1 on 4/30/25 when he was transported to the ER. LVN A stated she entered Resident #1's room to check his blood sugar at approximately 7:30 AM and found the resident less responsive than usual and exhibited respiratory distress. LVN A stated she immediately called for help while checking Resident #1's vitals. She stated she was unable to get an O2 reading and put the resident on oxygen. LVN A stated EMTs had already been called and arrived at the facility to transfer Resident #1 to the local hospital. LVN A stated initially she was unsure what caused Resident #1's change in condition, but later found it appeared to be from a drug overdose based on clinical records. LVN A stated she was aware Resident #1 had a hx of drug use. She stated she had not ever seen the resident have possession of nonprescription drugs or use them at the facility. LVN A stated she had never seen any staff members or other residents with nonprescription drugs. She stated the staff were in-serviced on the facility's drug policy on 5/05/25. In an interview on 5/06/25 at 1:10 PM, RN B stated she worked at the facility since 2019. She stated she worked with Resident #1 during the incident on 4/30/25. RN B stated the nurses were checking blood sugars on the hall when LVN A called for her help in Resident #1's room. RN B stated LVN A informed that she was unable to obtain an O2 reading from Resident #1, and he was unresponsive. RN B stated when she entered the room, she found that Resident #1 was breathing but was not responding normally. She stated after calling his name loudly a few times, Resident #1 opened his eyes and said Yes then went back to sleep. RN B stated Resident #1 needed constant engagement to stay alert. RN B stated she remained in the room with Resident #1 until EMTs arrived. In an interview on 5/06/25 at 1:54 PM with the DON and Administrator, the DON stated on 04/30/25 she was alerted by LVN A that Resident #1 was in respiratory distress and needed to be sent out to the hospital. This state investigator informed them that Resident #1 admitted he received the Methadone from a staff member that he refused to identify. The DON stated Resident #1 returned to the facility during the weekend on 5/3/25 and the clinicals showed that Methadone was found in his system. The DON stated the MD and pain management team was notified. The DON stated a care plan meeting with Resident #1 was held on 5/05/25 and during an interview with the resident he denied using any drugs and did not report receiving any drug from staff. The DON stated Resident #1 only stated he was depressed about his mother. The DON stated a referral was sent for psychiatric services and Resident #1 was able to talk with a psychologist on 5/05/25. The Administrator stated staff were in-serviced on the facility's drug policy, s/sx of intoxicated residents, and abuse and neglect. He also stated a Resident Council meeting was scheduled to discuss the facility's drug policy and to see if there were any concerns. The Administrator and DON stated this was new information and they would need to consult with regional managers on how to move forward. In a further interview on 5/06/25 at 3:00 PM with the DON and Administrator, the Administrator stated the Regional Managers advised them to submit a self-report to the state agency and start a provider investigation regarding the alleged abuse. In an interview on 5/07/25 at 9:42 AM with the DON and Administrator, the Administrator stated the facility submitted a self-report to the stated agency and started the provider investigation. The Administrator stated Resident #1 was interviewed again and still denied any drug use and getting drugs from a staff member. The Administrator stated the police were called out and Resident #1 also denied everything to them. In a further interview on 5/07/25 at 11:50 AM with the DON and Administrator, The DON stated she received and reviewed Resident #1's hospital records on 5/02/25, prior to the resident discharging from the hospital, when it was found that Methadone was in the resident's system. The DON stated Resident #1 did not have an order to take Methadone at the facility and was not receiving any outpatient treatment where he would receive Methadone. The Administrator stated the incident had just happened and they were still gathering information to determine what happened, which is why a self-report was not submitted prior to the state investigator entering the facility. In an interview on 05/07/25 at 3:45 PM with the Regional Nurse Consultant and Regional Director of Operations, the Regional Nurse Consultant stated she was informed by the DON on 5/02/25 that Resident #1's hospital records indicated there was Methadone found in his system and she advised the DON to start an investigation. The Regional Director of Operations stated the facility began reviewing the resident sign-out logs, in-servicing staff, auditing medications in the facility to check for Methadone/narcotics and medication errors, and conducting safe surveys with staff and residents. The Regional Director of Operations stated the investigation continued over the weekend, with the DON doing pop-up visits to check the facility for drugs. Both Regional managers stated they were not sure why the DON and Administrator did not provide this information prior to the Immediate Jeopardy being called. This state investigator informed that the only evidence that was provided prior to the Immediate Jeopardy being called were the staff in-services, Resident #1's psychology assessment note, Resident #1's care plan conference notes, and a scheduled Resident Council Meeting to discuss the facility's drug policy. There was no evidence of medications audits, safe surveys, interviews, IDT notification, or a report to the state agency provided. Review of the facility's policy titled Abuse Prevention and Prohibition Program, revised 08/2020, reflected in part the following: Purpose: To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. Policy: I. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property. A. Definitions for the meaning of key terms used in this policy. II. The Facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors. This policy statement also includes deprivation by any individual, including a caretaker, of goods, services or rights that are necessary for a resident to attain or maintain physical, mental, and psychosocial wellbeing. III. The Administrator is responsible for coordinating and implementing the Facility's abuse prevention policies, procedures, training programs, and systems. IV. This policy also identifies Special Considerations regarding the investigation of injuries of unknown origin, the reporting of suspected rape, and resident-to-resident abuse. Procedure: . IV Prevention A. Staff, residents and families will be able to report concerns, incidents and grievances without fear of retribution or retaliation. B. Supervisors shall immediately intervene, correct, and report identified situations where abuse, neglect or misappropriation of resident property is at risk for occurring. . VII Investigation A. The Facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, injuries of an unknown source, or criminal acts. . IX. Reporting/Response A. Facility Staff are Mandatory Reporters i. Facility owners, operators, employees, managers, agents, and contractors are obligated by the Elder Justice Act and any state specific regulations to report known or suspected instances of abuse of elder or dependent adults. . Review of the facility's policy titled Resident Drug and Alcohol Abuse, revised 08/2020, reflected in part the following: Purpose: To provide a safe and drug-free environment for residents while at the Facility. Policy Statement: I. The Facility will admit a resident who has a history of drug and alcohol abuse as long as their primary diagnosis is suitable for skilled care at this Facility. II. The Facility has a zero-tolerance policy for the use or possession of illegal drugs (including marijuana) or any type of drug apparatus in the Facility or on the grounds of the Facility. All illegal drugs and/or drug paraphernalia will be confiscated from the resident and /or their room. B. The only drugs permissible at the Facility and/or on Facility grounds are those for which there is an Attending Physician order. IV.Any resident found in violation of this policy will be discharged to a more appropriate setting for care (See Policy Transfer and Discharge). . The Administrator and DON were notified of an Immediate Jeopardy (IJ) on 5/07/25 at 2:57 PM, due to the above failures and the IJ Template was provided at 3:00 PM. The facility's Plan of Removal (POR) was accepted on 5/08/25 at 12:30 PM and included: Date: 5/7/25 PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it may concern, Summary of Details which lead to outcomes. F600 Free from Abuse On 5/6/25, during a complaint survey at [Nursing Facility]. The facility failed to ensure Resident #1 was free from abuse when he suffered respiratory distress after taking methadone that the resident reported was provided by a staff member. The notification of the alleged immediate jeopardy states as follows: Resident #1 is a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included: hx of stroke, major depressive disorder, and hx of alcohol and cocaine abuse. On 4/29/25 [sic], Resident# l was found to be in respiratory distress and less aroused than usual. He was sent out to the local hospital where he was diagnosed with hypoxia (low oxygen) likely due to acute-on-chronic systolic heart failure with labs that were positive for methadone. Identify residents who could be affected: All Residents have the potential to be affected by this deficiency Identify responsible staff/ what action taken: 1. Alleged employee suspended pending investigation. Last day employee worked was 4/27/25 2. Attending Physicians was notified of the incident involving the resident on 5/2/25 3. Trauma screen was completed on 5/6/25. 4. Police notified on 5/6/25. 5. Resident referred to Deer OAKS for psychological assessment on 5/5/25 6. Care plans updated on 5/5/25 7. Reviewed out on pass for 5/2/25 8. Reviewed advance entry for visitors on 5/2/25 9. Reviewed facility medications for use of methadone 5/2/25 10. Completed care plan conference with residents on 5/5/25 11. Resident seen by psychologist on 5/5/25 12. Drug abuse contract and policy discussed with residents and signed 5/5/25 13. Staff in-service on facility drug policy, identifying intoxicated residents, Narcan administration on 5/7/25, and will be completed on 5/8/25. All staff in-services will be ongoing to ensure all PRN, new staff, and any staff who are not in-serviced for any reason will receive it before the start of the shift. 14. Abuse and neglect in-service started on 5/7 /25 and will be completed on 5/8/25. All staff inservices will be ongoing to ensure all PRN, new staff, and any staff not in-serviced for any reason receive them before the start of the shift. In-service will be conducted by the Administrator/DON or Designee. 15. 1:1 in-service conducted for DON and Administrator on Abuse and Neglect Policy. In-service conducted by RDO and RNC on 5/7/25 16. Staff and resident questionnaires 5/5/25. 17. Safe surveys on 5/2/25 18. Offered drug rehab services to resident 5/5/25 Implementation of Changes: 1. Audit of all residents who have a drug history or potential for drug use and have completed the drug policy acknowledgement form. This started on 5/7/25 and will end on 5/8/25. This will be ongoing to ensure all new admits and changes are made where necessary. This will be conducted by the DON or Designee. 2. Appropriate interventions are being put in place as needed. 3. All staff were re-educated on identifying intoxicated residents and the resident drug and alcohol abuse policy. This started on 5/7/25 and will end on 5/8/25. All staff in-services will be ongoing to ensure all PRN, new staff, and any staff not in-serviced for any reason receive then1 before the start of the shift. In-service will be conducted by the Administrator/DON or Designee. 4. Staff (nurses) in-service on facility drug policy, identifying intoxicated residents, Narcan administration, abuse, and neglect started on 5/7/25 and will end on 5/8/25. All staff in-services will be ongoing to ensure all PRN, new staff, and any staff not in-serviced for any reason receive them before the start of the shift. In-service will be conducted by the Administrator/DON or Designee. Monitoring: The Administrator/DON/Designee will be responsible for monitoring the implementation and effectiveness of in-service conducted on 5/7 /25 and ongoing. The Administrator/DON will review the effectiveness of this daily X 7 days and weekly X 4 weeks, then X 3 monthly, continued monitoring will be ongoing and report any adverse findings to the QAPI committee. All concerns noted will be addressed at the time of discove1y. Involvement of Medical Director The Medical Director met with the Interdisciplinary team on 5/6/25 and conducted an Ad HOC QAPI regarding resident drug use. The Medical Director was notified about the immediate Jeopardy on 5/7/25, the Plan of removal was reviewed and accepted by Medical Director. Involvement of QA: An Ad Hoc QAPI meeting was held with the Medical Director, facility administrator, director of nursing, to review the plan of removal on 5/7/25. Who is responsible for the implementation of the process? The Director of Nursing and Administrator will be responsible for the implementation of Process. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 5/7/25. On 5/08/25 the investigator began monitoring (12:30 PM-2:45 PM) to determine if the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Observation, interview, and record review on 5/08/25, 12:30 PM-1:15 PM, of Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10 revealed no concerns for abuse . Record review of residents' EHRs reflected no concerns for changes in physical, mental, or psychosocial status. Observations and interviews with residents and/or RPs revealed no concerns for abuse. The residents denied receiving any nonprescription drugs from staff or other residents. They also denied being physically, mentally, or emotionally abused. Interviews on 5/08/25, 1:20 PM-2:35 PM, conducted with the Administrator, DON, ADON, nurses, CMAs, and CNAs: RN B (1st shift), CNA F (1st shift), LVN L (3rd shift), MDS Nurse/LVN M (1st shift), LVN N (2nd shift), CMA O (2nd shift), CMA P (1st shift), CNA Q (2nd shift), RN R (PRN/all shifts), CNA S (2nd/3rd shift/weekends), RN T (2nd shift), CNA U (3rd shift), and LVN V (2nd shift) indicated they all participated in in-service trainings starting on 5/07/25-5/08/25. All staff were able to state per the facility's policy on drugs and alcohol that the facility was zero tolerance for drugs and alcohol on the premises unless ordered for the residents by the MD. The staff were able to state s/sx of intoxicated residents and who to report it to. The staff were also able to state how to identify and report any suspected or reported abuse. In addition, the nurses were able to state the protocol for identifying and treating residents suspected of an overdose and who to report it to. The Administrator and DON understood that it was their responsibility to implement the interventions and monitor for effectiveness. Record review of an in-service titled Resident Drug and Alcohol Abuse, dated 5/07/25, reflected all staff were re-educated on the facility's policy on drugs and alcohol. Record review of an in-service titled Intoxicated Residents, dated 5/07/25, reflected all staff were re-educated on recognizing s/sx of an intoxicated resident and who to notify. Record review of an in-service titled Abuse and Neglect, dated 5/07/25, reflected all staff were educated on the facility's policy on recognizing and reporting abuse and neglect. Record review of an in-service titled Naloxone Administration, dated 5/07/25, reflected all nurses were re-educated on the protocol for administering Naloxone to a resident suspected of an overdose. Record review of a document provided by the Administrator titled Drug & Alcohol Abuse Policy Acknowledgement & Consent dated 5/07/25, reflected the DON audited all residents who had a drug history, reviewed the drug and alcohol policy, and signed updated acknowledgement forms. Record review of an in-service titled Abuse and Neglect, dated 5/08/25, reflected the Administrator and DON were educated by the Regional Nurse Consultant and Regional Director of Operations regarding coordinating and implementing the facility's abuse and prevention policy and procedure. On 5/08/25 at 1:57 PM, the Administrator provided documents from an investigation binder that included the following: -Safe survey, dated 5/02/25 - Resident #1's Care Plan Conference notes, dated 5/05/25 - Resident #1's psychology/behavioral note, dated 5/05/25 -Resident #1's signed behavioral contract, dated 5/05/25 -Trauma screening for Resident #1, dated 5/06/25 - Police Report, dated 5/06/25 -Resident Drug and Alcohol Abuse Questionnaire, dated 5/06/25 -Corrective Action Memo for Activity Staff, dated 5/06/25 (which indicated the Activity Staff was suspended pending an investigation of abuse) -Self-report to state agency, dated 5/06/25 An Immediate Jeopardy (IJ) was identified on 5/07/25 at 1:56 PM and an IJ Template was provided to the Administrator at 3:00 PM. While the IJ was removed on 5/08/25, the facility remained out of compliance at a scope of isolated with the severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents for one resident (Resident #1) of ten residents reviewed for abuse. -The facility failed to implement the abuse and neglect policy and procedures to ensure that Resident #1 was free from physical abuse when he alleged he received methadone from a staff member, was found unresponsive, required Narcan, and tested positive for Methadone for which he did not have an order for. Resident #1 was transported to the local hospital on 4/30/25 and diagnosed with hypoxia (low oxygen) likely due to acute-on-chronic systolic heart failure. An Immediate Jeopardy (IJ) was identified on 5/07/25 at 1:56 PM and an IJ Template was provided to the Administrator at 3:00 PM. While the IJ was removed on 5/08/25, the facility remained out of compliance at a scope of isolated with the severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place all residents at an increased risk for abuse and neglect. Findings included: Review of the facility's policy titled Abuse Prevention and Prohibition Program, revised 08/2020, reflected in part the following: Purpose: To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. Policy: I. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property. A. Definitions for the meaning of key terms used in this policy. II. The Facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors. This policy statement also includes deprivation by any individual, including a caretaker, of goods, services or rights that are necessary for a resident to attain or maintain physical, mental, and psychosocial wellbeing. III. The Administrator is responsible for coordinating and implementing the Facility's abuse prevention policies, procedures, training programs, and systems. IV. This policy also identifies Special Considerations regarding the investigation of injuries of unknown origin, the reporting of suspected rape, and resident-to-resident abuse. Procedure: . IV Prevention A. Staff, residents and families will be able to report concerns, incidents and grievances without fear of retribution or retaliation. B. Supervisors shall immediately intervene, correct, and report identified situations where abuse, neglect or misappropriation of resident property is at risk for occurring. . VII Investigation A. The Facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, injuries of an unknown source, or criminal acts. . IX. Reporting/Response A. Facility Staff are Mandatory Reporters i. Facility owners, operators, employees, managers, agents, and contractors are obligated by the Elder Justice Act and any state specific regulations to report known or suspected instances of abuse of elder or dependent adults. . Review of the facility's policy titled Resident Drug and Alcohol Abuse, revised 08/2020, reflected in part the following: Purpose: To provide a safe and drug-free environment for residents while at the Facility. Policy Statement: I. The Facility will admit a resident who has a history of drug and alcohol abuse as long as their primary diagnosis is suitable for skilled care at this Facility. II. The Facility has a zero-tolerance policy for the use or possession of illegal drugs (including marijuana) or any type of drug apparatus in the Facility or on the grounds of the Facility. All illegal drugs and/or drug paraphernalia will be confiscated from the resident and /or their room. B. The only drugs permissible at the Facility and/or on Facility grounds are those for which there is an Attending Physician order. IV.Any resident found in violation of this policy will be discharged to a more appropriate setting for care (See Policy Transfer and Discharge). . Record review of Resident #1's face sheet, dated 5/08/25, reflected a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: acute systolic (congestive) heart failure, unspecified sequelae of cerebral infarction (stroke), major depressive disorder (mood disorder), and hx of cocaine and alcohol abuse. Record review of Resident #1's quarterly MDS assessment, dated 04/21/25, reflected his BIMS score was 12, which indicated moderate cognitive impairment. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #1 required moderate to maximal assistance with most ADLs and used a motorized wheelchair. The MDS Assessment under Section N-Medications, reflected Resident #1 was prescribed medication under the high-risk drug class that included and opioid. Record review of Resident #1's care plan, revised 5/05/25, reflected the resident required pain management r/t to generalized pain that included Gabapentin and Norco. Interventions included: administering analgesia (pain reliever) as ordered, anticipating the resident's need for pain relief immediately to any complaint of pain, monitoring/recording/reporting to nurse any s/sx of non-verbal pain, monitoring/recording/reporting to nurse loss of appetite, refusal to eat, and weight loss, monitoring/recording/reporting to nurse complaints of pain or requests for pain treatment, and observing and reporting changes in usual routine. Further review of this document reflected it was revised on 5/05/25 to reflect that Resident #1 had a history of drug abuse prior to admission to facility. Resident #1 had gone out to hospital and noted to have non prescribed narcotic medication in his system. Interventions included: Drug abuse policy was given to resident with education and signature, Narcan (medication to reverse opioid/narcotic overdose) provided PRN, psychiatric medication management NP to see resident, referral to psychiatric services, resident was offered rehabilitation services and declined, and resident was seen by psychologist. Record review of Resident #1's active consolidated physician orders, dated 5/08/25, reflected in part the following: -HYDROcodone-Acetaminophen oral tablet 5-325 MG (for pain relief) - give 1 tablet by mouth every 6 hours as needed for pain. Hold medication if drowsy and notify MD. -Gabapentin oral capsule 300 MG (for pain relief) - give 1 capsule by mouth three times a day for pain. Hold medication if drowsy and notify MD. Further review of this document revealed there was not an order for Methadone. Record review of Resident #1's hospital records, dated 4/30/25, reflected in part the following: HPI: 64 [sic] y.o. male with a past medical history of GERD, hyperlipidemia, hypertension, diabetes mellitus stroke, seizure disorder who was brought into ER from nursing home because of respiratory distress. During my encounter [Resident #1] was on BiPAP and poor historian so history is taken from ER notes. As per ER [Resident #1] is on opioid outpatient in likely took more than dysuria of narcotics and later on was found to be short of breath and drowsy for which EMS was called. On arrival to ER [Resident #1] was found to be drowsy and was given Narcan, [Resident #1] responded very well to Narcan however got very anxious for which morphine was administer after my suspicion of an opioid withdrawal. ABGs: PH 7.25 (normal range 7.35-7.45), pC02 58.7 (normal range 32.0-45.0 mmHg), P02 98 (normal range 83.0-108.0 mmHg). [Resident #1] was on non-rebreather mask initially and was later on placed on BiPAP. CTA chest negative for PE or pleural effusions. Troponin 122 (normal range 38.73-80.22 ng/L), BNP 125 (normal range less than 100 pg/mL). [Resident #1] was given Lasix 100 mg IV once and breathing treatment as well. Review of system is limited as [Resident #1] is on BiPAP and lethargic during my encounter. . Labs: Specimen: Clean Catch; Urine Methadone- Positive Opiate- Positive . Hospital Course/Long LOS Summary: [Resident #1] is a [AGE] year-old male with past medical history of systolic heart failure, diabetes, hypertension, sleep apnea, and chronic pain who presented to the emergency room for altered mental status and shortness of breath. [Resident #1] was admitted for acute hypoxic respiratory failure requiring supplemental O2 and BiPAP to maintain O2 saturation >92%. Likely related to acute on chronic systolic heart failure versus community acquired or aspiration pneumonia. [Resident #1] was started on IV Lasix (water pill) with good urine output. Discharge plan pending clinical improvement. . Record review of Resident #1's progress note, dated 4/30/25 at 9:30 AM by LVN A, reflected the following: [Resident #1] not alert and SOB noted. [Resident #1] responsive only to sternal rub. b/p 142/90 p137 r22 o2 sat 47% on RA. Applied o2 via mask rebreather at 15l. o2 sat 92%. EMS called and [Resident #1] transferred to [name] ED. Record review of a document titled Resident Out on Pass Log, dated 4/20/25-5/07/25, reflected Resident #1 had not signed out to leave the facility. Record review of Resident #1's EHR reflected the resident was seen by a psychologist to address his s/sx of depression on 5/05/25. The recommendations reflected the following: -Psychological consultation is recommended to assist staff in developing and implementing behavior plans to reduce [Resident 1's] affective and/or cognitive symptoms. -Individual therapy to reduce [Resident 1's] affective and/or cognitive symptoms. -Referral for medication evaluation. Record review of an in-service titled Abuse and Neglect, dated 5/01/25, reflected all staff were educated on the facility's policy on recognizing and reporting abuse and neglect. Record review of an in-service titled Resident Drug and Alcohol Abuse, dated 5/05/25, reflected all staff were educated on the facility's policy on drugs and alcohol. Record review of an in-service titled Intoxicated Residents, dated 5/05/25, reflected all staff were educated on recognizing s/sx of an intoxicated resident and who to notify. Record review of an in-service titled Naloxone Administration, dated 5/06/25, reflected all nurses were educated on the protocol for administering Naloxone to a resident suspected of an overdose. In an interview and observation on 5/06/25 at 11:42 AM, Resident #1 was sitting in his wheelchair in his room. He was dressed and well-groomed with no s/sx of distress. Observation of the room revealed it was clean with no evidence of drugs, alcohol, or paraphernalia. Resident #1 immediately asked if I was from social services and if he was in trouble. This state investigator stated No and asked Resident #1 about his recent hospital stay. Resident #1 stated he was transported to the hospital for what he thought was another stroke. Resident #1 stated he could not recall what happened but was told that he was found unresponsive in his room. Resident #1 looked concerned, then proceeded to state that he did not want to be in trouble or get anyone else in trouble; however, he became sick after taking Methadone that he received from a staff member. Resident #1 refused to identify the staff. He stated he must have taken too much, and it caused him to pass out. Resident #1 did not recall exactly when he took the drug or how much he consumed. Resident #1 stated he was sad about his mother, who was sick at a different nursing facility, and he needed something to take his mind off it. Resident #1 refused to provide any additional information. In an interview on 5/06/25 at 12:20 PM, LVN A stated she worked at the facility for about 6 months. She stated she worked with Resident #1 on 4/30/25 when he was transported to the ER. LVN A stated she entered Resident #1's room to check his blood sugar at approximately 7:30 AM and found the resident less responsive than usual and exhibited respiratory distress. LVN A stated she immediately called for help while checking Resident #1's vitals. She stated she was unable to get an O2 reading and put the resident on oxygen. LVN A stated EMTs had already been called and arrived at the facility to transfer Resident #1 to the local hospital. LVN A stated initially she was unsure what caused Resident #1's change in condition, but later found it appeared to be from a drug overdose based on clinical records. LVN A stated she was aware Resident #1 had a hx of drug use. She stated she had not ever seen the resident have possession of nonprescription drugs or use them at the facility. LVN A stated she had never seen any staff members or other residents with nonprescription drugs. She stated the staff were in-serviced on the facility's drug policy on 5/05/25. In an interview on 5/06/25 at 1:10 PM, RN B stated she worked at the facility since 2019. She stated she worked with Resident #1 during the incident on 4/30/25. RN B stated the nurses were checking blood sugars on the hall when LVN A called for her help in Resident #1's room. RN B stated LVN A informed that she was unable to obtain an O2 reading from Resident #1, and he was unresponsive. RN B stated when she entered the room, she found that Resident #1 was breathing but was not responding normally. She stated after calling his name loudly a few times, Resident #1 opened his eyes and said Yes then went back to sleep. RN B stated Resident #1 needed constant engagement to stay alert. RN B stated she remained in the room with Resident #1 until EMTs arrived. In an interview on 5/06/25 at 1:54 PM with the DON and Administrator, the DON stated on 04/30/25 she was alerted by LVN A that Resident #1 was in respiratory distress and needed to be sent out to the hospital. This state investigator informed them that Resident #1 admitted he received the Methadone from a staff member that he refused to identify. The DON stated Resident #1 returned to the facility during the weekend on 5/3/25 and the clinicals showed that Methadone was found in his system. The DON stated the MD and pain management team was notified. The DON stated a care plan meeting with Resident #1 was held on 5/05/25 and during an interview with the resident he denied using any drugs and did not report receiving any drug from staff. The DON stated Resident #1 only stated he was depressed about his mother. The DON stated a referral was sent for psychiatric services and Resident #1 was able to talk with a psychologist on 5/05/25. The Administrator stated staff were in-serviced on the facility's drug policy, s/sx of intoxicated residents, and abuse and neglect. He also stated a Resident Council meeting was scheduled to discuss the facility's drug policy and to see if there were any concerns. The Administrator and DON stated this was new information and they would need to consult with regional managers on how to move forward. In a further interview on 5/06/25 at 3:00 PM with the DON and Administrator, the Administrator stated the Regional Managers advised them to submit a self-report to the state agency and start a provider investigation regarding the alleged abuse. In an interview on 5/07/25 at 9:42 AM with the DON and Administrator, the Administrator stated the facility submitted a self-report to the stated agency and started the provider investigation. The Administrator stated Resident #1 was interviewed again and still denied any drug use and getting drugs from a staff member. The Administrator stated the police were called out and Resident #1 also denied everything to them. In a further interview on 5/07/25 at 11:50 AM with the DON and Administrator, The DON stated she received and reviewed Resident #1's hospital records on 5/02/25, prior to the resident discharging from the hospital, when it was found that Methadone was in the resident's system. The DON stated Resident #1 did not have an order to take Methadone at the facility and was not receiving any outpatient treatment where he would receive Methadone. The Administrator stated the incident had just happened and they were still gathering information to determine what happened, which is why a self-report was not submitted prior to the state investigator entering the facility. In an interview on 05/07/25 at 3:45 PM with the Regional Nurse Consultant and Regional Director of Operations, the Regional Nurse Consultant stated she was informed by the DON on 5/02/25 that Resident #1's hospital records indicated there was Methadone found in his system and she advised the DON to start an investigation. The Regional Director of Operations stated the facility began reviewing the resident sign-out logs, in-servicing staff, auditing medications in the facility to check for Methadone/narcotics and medication errors, and conducting safe surveys with staff and residents. The Regional Director of Operations stated the investigation continued over the weekend, with the DON doing pop-up visits to check the facility for drugs. Both Regional managers stated they were not sure why the DON and Administrator did not provide this information prior to the Immediate Jeopardy being called. This state investigator informed that the only evidence that was provided prior to the Immediate Jeopardy being called were the staff in-services, Resident #1's psychology assessment note, Resident #1's care plan conference notes, and a scheduled Resident Council Meeting to discuss the facility's drug policy. There was no evidence of medications audits, safe surveys, interviews, IDT notification, or a report to the state agency provided. The Administrator and DON were notified of an Immediate Jeopardy (IJ) on 5/07/25 at 2:57 PM, due to the above failures and the IJ Template was provided at 3:00 PM. The facility's Plan of Removal (POR) was accepted on 5/08/25 at 12:30 PM and included: Date: 5/7/25 PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it may concern, Summary of Details which lead to outcomes. F600 Free from Abuse On 5/6/25, during a complaint survey at [Nursing Facility]. The facility failed to ensure Resident #1 was free from abuse when he suffered respiratory distress after taking methadone that the resident reported was provided by a staff member. The notification of the alleged immediate jeopardy states as follows: Resident #1 is a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included: hx of stroke, major depressive disorder, and hx of alcohol and cocaine abuse. On 4/29/25 [sic], Resident# l was found to be in respiratory distress and less aroused than usual. He was sent out to the local hospital where he was diagnosed with hypoxia (low oxygen) likely due to acute-on-chronic systolic heart failure with labs that were positive for methadone. Identify residents who could be affected: All Residents have the potential to be affected by this deficiency Identify responsible staff/ what action taken: 1. Alleged employee suspended pending investigation. Last day employee worked was 4/27/25 2. Attending Physicians was notified of the incident involving the resident on 5/2/25 3. Trauma screen was completed on 5/6/25. 4. Police notified on 5/6/25. 5. Resident referred to Deer OAKS for psychological assessment on 5/5/25 6. Care plans updated on 5/5/25 7. Reviewed out on pass for 5/2/25 8. Reviewed advance entry for visitors on 5/2/25 9. Reviewed facility medications for use of methadone 5/2/25 10. Completed care plan conference with residents on 5/5/25 11. Resident seen by psychologist on 5/5/25 12. Drug abuse contract and policy discussed with residents and signed 5/5/25 13. Staff in-service on facility drug policy, identifying intoxicated residents, Narcan administration on 5/7/25, and will be completed on 5/8/25. All staff in-services will be ongoing to ensure all PRN, new staff, and any staff who are not in-serviced for any reason will receive it before the start of the shift. 14. Abuse and neglect in-service started on 5/7 /25 and will be completed on 5/8/25. All staff inservices will be ongoing to ensure all PRN, new staff, and any staff not in-serviced for any reason receive them before the start of the shift. In-service will be conducted by the Administrator/DON or Designee. 15. 1:1 in-service conducted for DON and Administrator on Abuse and Neglect Policy. In-service conducted by RDO and RNC on 5/7/25 16. Staff and resident questionnaires 5/5/25. 17. Safe surveys on 5/2/25 18. Offered drug rehab services to resident 5/5/25 Implementation of Changes: 1. Audit of all residents who have a drug history or potential for drug use and have completed the drug policy acknowledgement form. This started on 5/7/25 and will end on 5/8/25. This will be ongoing to ensure all new admits and changes are made where necessary. This will be conducted by the DON or Designee. 2. Appropriate interventions are being put in place as needed. 3. All staff were re-educated on identifying intoxicated residents and the resident drug and alcohol abuse policy. This started on 5/7/25 and will end on 5/8/25. All staff in-services will be ongoing to ensure all PRN, new staff, and any staff not in-serviced for any reason receive then1 before the start of the shift. In-service will be conducted by the Administrator/DON or Designee. 4. Staff (nurses) in-service on facility drug policy, identifying intoxicated residents, Narcan administration, abuse, and neglect started on 5/7/25 and will end on 5/8/25. All staff in-services will be ongoing to ensure all PRN, new staff, and any staff not in-serviced for any reason receive them before the start of the shift. In-service will be conducted by the Administrator/DON or Designee. Monitoring: The Administrator/DON/Designee will be responsible for monitoring the implementation and effectiveness of in-service conducted on 5/7 /25 and ongoing. The Administrator/DON will review the effectiveness of this daily X 7 days and weekly X 4 weeks, then X 3 monthly, continued monitoring will be ongoing and report any adverse findings to the QAPI committee. All concerns noted will be addressed at the time of discove1y. Involvement of Medical Director The Medical Director met with the Interdisciplinary team on 5/6/25 and conducted an Ad HOC QAPI regarding resident drug use. The Medical Director was notified about the immediate Jeopardy on 5/7/25, the Plan of removal was reviewed and accepted by Medical Director. Involvement of QA: An Ad Hoc QAPI meeting was held with the Medical Director, facility administrator, director of nursing, to review the plan of removal on 5/7/25. Who is responsible for the implementation of the process? The Director of Nursing and Administrator will be responsible for the implementation of Process. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 5/7/25. On 5/08/25 the investigator began monitoring (12:30 PM-2:45 PM) to determine if the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Observation, interview, and record review on 5/08/25, 12:30 PM-1:15 PM, of Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10 revealed no concerns for abuse. Record review of residents' EHRs reflected no concerns for changes in physical, mental, or psychosocial status. Observations and interviews with residents and/or RPs revealed no concerns for abuse. The residents denied receiving any nonprescription drugs from staff or other residents. They also denied being physically, mentally, or emotionally abused. Interviews on 5/08/25, 1:20 PM-2:35 PM, conducted with the Administrator, DON, ADON, nurses, CMAs, and CNAs: RN B (1st shift), CNA F (1st shift), LVN L (3rd shift), MDS Nurse/LVN M (1st shift), LVN N (2nd shift), CMA O (2nd shift), CMA P (1st shift), CNA Q (2nd shift), RN R (PRN/all shifts), CNA S (2nd/3rd shift/weekends), RN T (2nd shift), CNA U (3rd shift), and LVN V (2nd shift) indicated they all participated in in-service trainings starting on 5/07/25-5/08/25. All staff were able to state per the facility's policy on drugs and alcohol that the facility was zero tolerance for drugs and alcohol on the premises unless ordered for the residents by the MD. The staff were able to state s/sx of intoxicated residents and who to report it to. The staff were also able to state how to identify and report any suspected or reported abuse. In addition, the nurses were able to state the protocol for identifying and treating residents suspected of an overdose and who to report it to. The Administrator and DON also understood that it was their responsibility to implement the interventions and monitor for effectiveness. The Administrator and DON stated they received 1 on 1 education regarding the facility's abuse and neglect policy and were able to state they were responsible for implementing the policy to ensure all allegations of abuse, neglect, and exploitation were reported and investigated. Record review of the facility's policy titled Abuse Prevention and Prohibition Program, revised 08/2020, reflected in part the following: Purpose: To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. . Record review of an in-service titled Resident Drug and Alcohol Abuse, dated 5/07/25, reflected all staff were re-educated on the facility's policy on drugs and alcohol. Record review of an in-service titled Intoxicated Residents, dated 5/07/25, reflected all staff were re-educated on recognizing s/sx of an intoxicated resident and who to notify. Record review of an in-service titled Abuse and Neglect, dated 5/07/25, reflected all staff were educated on the facility's policy on recognizing and reporting abuse and neglect. Record review of an in-service titled Naloxone Administration, dated 5/07/25, reflected all nurses were re-educated on the protocol for administering Naloxone to a resident suspected of an overdose. Record review of a document provided by the Administrator titled Drug & Alcohol Abuse Policy Acknowledgement & Consent dated 5/07/25, reflected the DON audited all residents who had a drug history, reviewed the drug and alcohol policy, and signed updated acknowledgement forms. Record review of an in-service titled Abuse and Neglect, dated 5/08/25, reflected the Administrator and DON were educated by the Regional Nurse Consultant and Regional Director of Operations regarding coordinating and implementing the facility's abuse and prevention policy and procedure. On 5/08/25 at 1:57 PM, the Administrator provided documents from an investigation binder that included the following: -Safe survey, dated 5/02/25 - Resident #1's Care Plan Conference notes, dated 5/05/25 - Resident #1's psychology/behavioral note, dated 5/05/25 -Resident #1's signed behavioral contract, dated 5/05/25 -Trauma screening for Resident #1, dated 5/06/25 - Police Report, dated 5/06/25 -Resident Drug and Alcohol Abuse Questionnaire, dated 5/06/25 -Corrective Action Memo for Activity Staff, dated 5/06/25 (which indicated the Activity Staff was suspended pending an investigation of abuse) -Self-report to state agency, dated 5/06/25 An Immediate Jeopardy (IJ) was identified on 5/07/25 at 1:56 PM and an IJ Template was provided to the Administrator at 3:00 PM. While the IJ was removed on 5/08/25, the facility remained out of compliance at a scope of isolated with the severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for one resident (Residents #2) of six residents reviewed for respiratory care in that: -The facility failed to ensure that Residents #2, who required continuous oxygen therapy, continued to receive adequate oxygen when her portable oxygen tank ran out of oxygen while the resident was in the community at an appointment on 4/28/2025. Resident #2 was sent to the local hospital by the clinic after running out of oxygen and complaining of SOB and chest pain. The non-compliance was identified as past non-compliance (PNC). The Administrator and DON were notified of the PNC on 05/07/25 at 2:57 PM. The Immediate Jeopardy began on 04/28/25 and ended on 04/28/25. The facility had corrected the non-compliance before the state's investigation began. This failure could affect all residents who receive oxygen therapy by placing them at risk of receiving inadequate oxygen support, which could result in serious harm or death. Findings included: Record review of Resident #2's face sheet, dated 5/08/25, reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: Chronic Obstructive Pulmonary Disease (lung disease), emphysema (lung disease), chronic respiratory failure, and chronic bronchitis (inflammation of lungs). Record review of Resident 2's quarterly MDS assessment, dated 04/20/25, reflected her BIMS score was 10, which indicated moderate cognitive impairment. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #2 required setup to supervision assistance with most ADLs and used a manual wheelchair. The MDS Assessment under Section I-Active Diagnoses reflected Resident #2 had a primary medical condition of cardiorespiratory with other comorbidities that included chronic lung disease and respiratory failure. Further review of this document, under Section O-Special Treatments, Procedures, and Programs, reflected Resident #2 received oxygen therapy. Record review of Resident 2's care plan, revised 4/29/25, reflected the resident was on oxygen therapy r/t ineffective gas exchange and respiratory illness. Interventions included: changing respiratory equipment every 7 days, checking O2 sat every shift and PRN, providing extension tubing and portable oxygen apparatus, giving medications as ordered, requiring additional oxygen tank while away from the facility, monitoring for s/sx of respiratory distress and reporting to MD, O2 at 2 lpm, positioning to facilitate ventilation matching, re-directing if nasal canula was off, and suctioning as needed. Record review of Resident #2's consolidated physician orders, dated 05/06/25, reflected in part the following: -O2 at 2 liters per minute via nasal canula-start date: 2/25/25; discontinue date; 5/01/25 Record review of Resident #1's progress notes, dated 04/28/25 at 2:44 PM by LVN C, reflected the following: [Resident #2 went to appt [Surgical Clinic] sent to ER because she ran out of oxygen. Went to appt with a full tank of oxygen. [Resident #2] able to make needs known. Call light in reach. WCTM. Record review of Resident #2's hospital records, dated 04/28/25, reflected in part the following: [AGE] year-old woman history significant COPD on 2 L home oxygen who presents to ED with complaints of dyspnea (shortness of breath), pleuritic chest pain (sharp pain in chest when breathing) after running out of oxygen during an outpatient appointment. [Resident #2] reports she has been feeling unwell for about a day, she endorses increased cough. [Resident #2] is not sure of the home medications. In the ED chest x-ray showed left-sided opacity concerning for pneumonia. [Resident #2] was oxygen saturated 99% on 2 L In an interview and observation on 05/06/25 at 11:30 AM, Resident #2 was sitting on the side of her bed wearing a nasal cannula that was connected to an oxygen concentrator that was set on 2 lpm. Observation of the portable tank on the back of Resident #2's wheelchair revealed it was an e-tank that held 680 liters of oxygen and was full. Resident #2 stated she was not feeling well due having pneumonia. She stated the nurse was giving her abx. Resident #2 stated she went to the hospital about a week ago after she ran out of oxygen while at an appointment. She stated the staff woke her up at about 5:30 that morning to get ready for her appointment and she was so tired that she was fell asleep in her wheelchair while waiting for the Van Driver to come, so she did not see if the nurse checked her portable oxygen tank to make sure it was full like she normally did. Resident #2 stated because of this she felt like it was also her fault for running out of oxygen. Resident #2 stated she knew how to change the setting on her portable oxygen tank, but she did not change it that day. She stated it remained at whatever setting it was last set to, which was usually 2 lpm. Resident #2 stated she had already been feeling bad and while at her appointment her oxygen was running low, and she started feeling worst. Resident #2 stated her chest was hurting and she was short of breath so the 911 was called and after what seemed like an hour, she was transported to the hospital. In an interview on 05/06/25 at 1:54 PM with the DON and Administrator, the DON stated Resident #2's had a consultation for eye surgery at 8:45 AM and she left the facility at approximately 7:30 AM. The DON stated they were only expecting the appointment to last about 45 minutes, but it lasted over 2 hours. She stated they later found that was normal for those type of consultations due to all the testing required. The DON stated at approximately 10:30 AM, CNA D called and informed that Resident #2's oxygen was low, and the surgical center was giving the facility 15 minutes to bring more oxygen, or they were going to call 911. The DON stated the Van Driver was on her way; however, the nursing facility was about 20-25 minutes away and by the time she arrived Resident #2 had already been transported to the hospital. The DON stated Resident #2 was admitted to the hospital after being diagnosed with pneumonia. The DON stated a full oxygen tank at 2 lpm should have lasted 3-4 hours and LVN C stated she checked, and it was full before Resident #2 left. The DON stated the only explanation she could think of was that Resident #2 waited at the nurse's station for a while, using oxygen from her portable tank, before being transported to the appointment. The DON was asked if an oxygen tank with approximately 680 liters of oxygen, running at 2 lpm could last at least 5 hours and she stated it probably could if the settings were not adjusted. The Administrator stated in-servicing immediately began with all staff on 4/28/25 regarding residents on continuous oxygen therapy. He stated the staff were educated on checking the oxygen levels in portable tanks to ensure they were full before a resident left the facility and the updated protocol to send extra oxygen tanks with residents on appointments that would last longer than 2 hours. In an interview on 05/06/25 at 2:26 PM, LVN C stated she worked with Resident #2 on 04/28/25 when she went to the hospital after running low on oxygen while at an appointment. LVN C stated she assisted Resident #2 that morning before she was transported to her appointment, and she remembered checking the portable oxygen tank and it was completely full and set at 2 lpm. LVN C stated Resident #2 had a lot of respiratory issues, so she always made sure to check her oxygen tanks before she left the facility. LVN C stated Resident #2 was dressed and waiting for her appointment at about 7:15 AM and was using her portable oxygen tank because she required continuous oxygen therapy. In an interview on 05/07/25 at 11:00 AM, CNA D stated she worked on 4/28/25 and rode to the appointment with Resident #2. She stated the nurses checked the portable oxygen tanks before residents were transported to appointments, so she did not check it on that day. CNA D stated she did not make it to work until about 7:45 AM and Resident #2 and the Van Driver were already on the van waiting, she got on the van, and they headed to the appointment. CNA D stated when they arrived, they waited in the lobby for about 30 minutes before Resident #2 was called to the back. She stated while waiting, Resident #2 did not complain of shortness of breath or chest pains while being transported and was acting like her normal self. CNA D also stated she did not see Resident #2 change the setting on her portable oxygen tank. CNA D stated after about an hour, the staff from the surgical center came out and told her that Resident #2's oxygen tank was low, and they were giving them 15 minutes to get her another oxygen tank, or they would have to call 911. CNA D stated she called the facility to inform them and while she was still on the phone, the staff called 911 after they overheard her saying the driver was more than 15 minutes away. CNA D stated she saw Resident #2 being taken to the ambulance and she did not appear to be in distress. She stated Resident #2 was talking and trying to drink water but was asked to not drink anything. CNA D stated when she returned to the nursing facility, she was in-serviced on making sure residents had enough oxygen when going on appointments. CNA D stated she now knew that the aides were also responsible for checking the oxygen tanks and not just the nurses; however, only the nurses could hook the oxygen tanks up. Review of the facility's policy titled Oxygen Administration, revised 06/2020, revealed in part the following: Purpose: To prevent or reverse hypoxemia and provide oxygen to the tissues. . A facility's policy on respiratory care regarding portable oxygen tanks was requested from the Administrator on 5/8/25 at 11:46 AM, and he informed that the facility did not have that specific policy. The non-compliance was identified as past non-compliance (PNC). The Administrator and DON were notified of the PNC on 05/07/25 at 2:57 PM. The Immediate Jeopardy began on 04/28/25 and ended on 04/28/25. The facility had corrected the non-compliance before the state's investigation began. The facility took the following actions to correct the non-compliance prior to the survey: Record review of Residents #2, #6, #7, #8, #9, and #10 EHRs revealed their care plans included interventions to address respiratory needs. Observations on 05/06/25 from 11:30 AM-2:55 PM, revealed Residents #2, #6, #7, #8, #9, and #10 had no s/sx of respiratory distress and they all had oxygen concentrators and full portable oxygen tanks available. Interviews with residents and RPs on 5/06/25 from 11:30 AM-2:55 PM revealed no concerns for respiratory care of any residents running out of oxygen while in the community. Record review on 5/6/25 of in-service titled Portable Oxygen Tanks, dated 4/28/25, reflected all staff were educated by the DON on ensuring that residents on oxygen therapy always had adequate oxygen available and to notify the nurse or clinical staff if portable oxygen tanks were low. Record review on 5/6/25 of in-service titled Oxygen Supply for Appointments, dated 4/28/25, reflected all nurses were in-serviced by the DON regarding appointments for residents who required continuous oxygen therapy to ensure the residents had adequate oxygen while in the community. The nurses were educated on determining the approximate length of time of each appointment, documenting and communicating the information to all staff interacting with the residents and ensuring an extra portable oxygen tank was sent on appointments that would be longer than 2 hours. Record review on 5/6/25 of in-service titled Oxygen Supply for Appointments, dated 4/28/25, reflected all nurses were in-serviced by the DON regarding appointments orders for residents who required continuous oxygen therapy. The nurses were educated on putting orders for appointments by transportation in the EHR 3 days prior to the appointment date, and including information about the approximate length of time for the appointments to ensure the residents are transported with adequate oxygen. Record review on 5/6/25 of in-service titled Portable Oxygen Tanks, dated 4/28/25, reflected LVN C had 1 on 1 education by the DON on ensuring that residents on oxygen therapy always had adequate oxygen available and to switch out low portable oxygen tanks with full ones. Record review on 5/6/25 of in-service titled Portable Oxygen-Appointments, dated 4/28/25, reflected LVN C had 1 on 1 education by the DON on ensuring that residents on continuous oxygen therapy had a full portable oxygen tank before leaving the facility for an appointment and that an extra portable oxygen tank was sent with the residents for all appointments that would be longer than 2 hours. Record review on 5/6/25 of in-service titled Portable Oxygen Tanks, dated 4/28/25, reflected CNA D had 1 on 1 education by the DON on ensuring that residents on oxygen therapy always had adequate oxygen available and to notify the nurse if portable oxygen tanks were low. Record review on 5/6/25 of in-service titled Portable Oxygen-Appointments, dated 4/28/25, reflected CNA D had 1 on 1 education by the DON on ensuring that residents on continuous oxygen therapy had a full portable oxygen tank before leaving the facility for an appointment and that an extra portable oxygen tank was sent with the residents for all appointments that would be longer than 2 hours. Record review on 5/6/25 of in-service titled Portable Oxygen Tanks, dated 4/28/25, reflected the Van Driver had 1 on 1 education by the DON on ensuring that residents on oxygen therapy always had adequate oxygen available and to notify the nurse or clinical staff if portable oxygen tanks were low. Record review on 5/6/25 of in-service titled Portable Oxygen-Appointments, dated 4/28/25, reflected the Van Driver had 1 on 1 education by the DON on ensuring that residents on continuous oxygen therapy had full portable oxygen tanks before being transported to appointments with and extra portable oxygen tank if the appointments would be longer than 2 hours. Interviews from 5/6/25 (12:00 PM-3:30 PM)-5/8/25 (9:30 AM-10:00 AM), conducted with the Administrator, DON, nurses and CNAs: RN B (1st shift), LVN C (1st shift), CNA D (1st shift), CMA E (1st shift), CNA F (1st shift), RN G (2nd shift, weekends), LVN H (2nd/3rd shift weekends), RN I (3rd shift, PRN), LVN J (2nd shift), RN K (2nd shift) indicated they all participated in in-service trainings on 4/28/25. The nurses were able to state they were ultimately responsible for ensuring that residents who required oxygen therapy always had adequate oxygen available, and residents who required continuous oxygen therapy had full portable tanks when leaving the facility. The nurses were also able to state when confirming an appointment for residents on continuous oxygen therapy, they were responsible for determining the approximate length of time of the appointments, documenting it, and ensuring that the residents had 2 full portable oxygen tanks if the appointments were longer than 2 hours. The CNAs were able to state that while providing care to residents with portable oxygen tanks, they were also responsible for checking the tanks to ensure there was adequate oxygen and to immediately notify the nurse if there was not. The Administrator and DON stated the in-services would be ongoing to include new staff, PRN staff, and any other staff who did not receive the in-service prior to the start of their shifts. A document provided by the DON titled Midnight Census Report-Oxygen List, dated 4/28/25, reflected all residents on oxygen therapy were identified and any of those residents with schedule appointments had all information, including length of time, noted. A document provided by the DON titled AD Hoc Quality Assurance and Performance Improvement Plan, dated 4/28/25, reflected a QAPI meeting was held to discuss failure and interventions put in place to prevent failure from occurring again.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for adequate supervision. 1. On 09/28/23 the facility failed to ensure adequate supervision and services were provided to Resident #1, when she was allowed to sign herself out of the facility even though it was known she had impaired cognitive function, impaired thought process, and potential for delirium or acute episodes of confusion, due to dementia. 2. On 09/28/23 the facility failed to notify Resident #1's RP/POA she signed out of the facility, which caused the RP/POA not to know Resident #1's location and if she was safe for approximately 5 hours. Resident #1 was located at a nearby fast-food restaurant in a high-traffic area with a sunburn. An IJ was identified on 10/04/23 at 5:08 PM. The IJ template was provided to the facility's Administrator on 10/04/23 at 5:15 PM. While the IJ was removed on 10/05/23 at 2:00 PM, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm that was not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures put residents at risk of serious injury, hospitalization, or even death. Findings Include: A record review of Resident #1's Face Sheet, dated 10/03/23, reflected Resident #1 was a 61-year- old female, who originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #1's FM was listed as RP, POA- Financial, POA- Care. Resident #1 was listed as other. Resident #1's diagnoses included: dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), pain, difficulty in walking, need for assistance with personal care, lack of coordination, bipolar disorder (a brain disorder that causes changes in a person's mood, energy, and ability to function), and generalized anxiety disorder (mental health disorder that involves a persistent feeling of anxiety or dread that interferes with how you live your life). A record review of Resident #1's Quarterly MDS Assessment, dated 09/22/23, indicated Resident #1's BIMS score was 11, which indicated the resident's cognition was moderately impaired. The MDS indicated Resident #1 required limited one-person physical assistance for transfers, dressing, personal hygiene and toilet use. A record review of Resident #1's Care Plan, dated 07/04/23, reflected she required psychotropic medications due to diagnosis of bipolar, anti-anxiety medication due to diagnosis of anxiety disorder, and antidepressant medication due to diagnosis of depression. The interventions included to administer medications as ordered. The Care Plan reflected Resident #1 had impaired cognitive function or impaired thought process due to dementia and the goal was to maintain current level of cognitive function. The interventions included Administer meds as ordered. Communicate with the resident/family/caregivers) regarding resident's capabilities and needs. Keep the resident's, routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. The Care Plan reflected Resident #1 had potential for delirium or an acute episode of confusion due to dementia diagnosis and the goal included resident will free of s/sx of delirium (changes in behavior, mood, cognitive function, communication, level of consciousness, restlessness. The interventions included: Consult with family and interdisciplinary team, review chart to establish baseline level of functioning. Discuss with resident/family/caregivers concerns about delirium . Educate the resident/family/caregivers to observe for and report any s/sx of delirium . Monitor/record/report to MD new onset s/sx of delirium: changes in [behaviour ] altered mental status, wide variation in cognitive function through the day, communication decline, disorientation, lethargy, restlessness, and agitation. Altered sleep cycle, dehydration, infection, delusions, hallucinations . Review medical records for a DX or HX of the most common causes of Delirium: Congestive Heart Failure, Infections especially of the Urinary Tract, Upper Respiratory System, or Pneumonia, Diabetes, Dehydration or Electrolyte Imbalance, Chronic Obstructive Pulmonary Disease, Medication Toxicity or Interactions; or Benzodiazepine Withdrawal. The plan reflected Resident #1 had ADL Self Care Performance Deficit due to her diagnosis of bipolar disorder and the goal included she would be neat, clean, well-groomed and appropriately dressed daily. The interventions included staff providing supervision and assist with dressing, personal hygiene routine. The plan reflected Resident #1 had had potential for mood problem due to bipolar, dementia, GAD, and stated she had previously felt ideations of self-harm, she would bite her arm, and had been placed on 1 to 1 monitoring. A record review of Resident #1's Progress Notes, written by LVN A on 08/21/23 at 1:16 PM reflected, ADON reported to this nurse that pt [family member (FM)] had c/o patient was having a hard time forming sentences and putting thoughts in place, nurse assessed patient, alert and oriented X, pt states it is true she is having more of a hard time forming sentences and putting thoughts into words, but is not a new issue [issue] has been a on going problem and appears to be getting worse with time, reported back to ADON and MD. MD gave new order for labs CBC, CMP, Depakote level (test measures the level of acid in a person's blood), lipid panel and UA with C&S. A record review of Resident #1's Progress Notes, written by LVN B on 08/24/23 at 4:34 PM reflected, Telehealth visit conducted and MD provided new verbal orders for Namenda 10mg QD and CT scan to rule out possible stroke. Also to have speech evaluate for cognition. Information given to transportation to schedule. MAR updated and resident pleased with new orders. No other issues present at this time. A record review of Resident #1's Progress Notes, written by LVN A on 09/14/23 at 2:23 PM reflected, PCP here evaluating pt, pt c/o tremors and increase in memory loss, MD gave verbal order to start Primidone 50mg 1 tab QHS and increase Namenda to twice a day, notified [FM] no answer message left for call back. Pt aware of changes and agrees to changes. A record review of Resident #1's Progress Notes, written by LVN A on 09/14/23 at 3:12 PM reflected, [FM] RP in facility, notified of changes to medication, RP declined to start Primidone and/or increase Namenda, requesting to speak with PCP first, PCP notified, medications D/C as requested and Namenda decreased back to once a day as requested, PCP will contact RP. A record review of Resident #1's Progress Notes, written by the DON on 09/15/23 at 10:27 AM reflected, [Resident #1], residents [FM], informed this nurse that her [FM] told her that she threw her phone away because she didn't think she wanted to speak with her. Resident has been seen by psych and will be seen by a neurologist per [FM] request. A record review of Resident #1's Progress Notes, written by the ADON on 09/28/23 at 2:42 PM reflected, Resident sitting in lobby with some shorts, slides (sandals), and a gray tunic top on waiting for her ride per her. A record review of Resident #1's Progress Notes, written by the ADON on 09/28/23 at 3:07 PM reflected, Staff reported resident was currently next door at a fast-food restaurant, notified sister who was in the parking lot, she thanked staff and drove off. A record review of Resident #1's Progress Notes, written by the ADON on 09/28/23 at 3:08 PM reflected, Notified DON of residents were abouts. A record review of Resident #1's Progress Notes, written by the ADON on 09/28/23 at 3:11 PM reflected, Received a call from [police officer] of [police department] that resident had walked away from her [FM] and was requesting to be sent to [hospital]. Police notified ADON that resident was ignoring [FM] and acted as if she didn't know her. MD called and made aware. A record review of Resident #1's Progress Notes, written by LVN C on 09/28/23 at 9:59 PM reflected, Res (Resident) yet to be back to facility so writer reached out to the [FM] who then confirmed that she was admitted in [hospital] for further assessment. Text message sent to the DON. A record review of Resident #1's MAR, dated September 2023, reflected the following: Amlodipine Besylate Tablet 5 MG Give 1 tablet by mouth one time a day for HTN (Hypertension-when the pressure in your blood vessels is too high) Order Date 06/03/22. The MAR reflected the hour for the medication was 9:00 AM. In the box on 09/28/23, there was a 3 in the box, which indicated the medication was not given because the resident was away from the facility; Atenolol Tablet 25 MG Give 1 tablet by mouth one time a day for HTN Order Date 06/03/22. The MAR reflected the hour for the medication was 9:00 AM. In the box on 09/28/23, there was a 3 in the box, which indicated the medication was not given because the resident was away from the facility; Gemtesa Tablet 75 MG Give 1 tablet by mouth one time a day for Urinary Order date 06/03/22. The MAR reflected the hour for the medication was 9:00 AM. In the box on 09/28/23, there was a 3 in the box, which indicated the medication was not given because the resident was away from the facility; Namenda Oral Tablet 10 MG Give 1 tablet by mouth at bedtime related to Dementia Order Date 09/14/23. The MAR reflected the hour for the medication was 9:00 PM. In the box on 09/28/23, there was a 3 in the box, which indicated the medication was not given because the resident was away from the facility; Loratadine Tablet 10 MG Give 1 tablet by mouth one time a day for Allergies Order Date 06/03/22. The MAR reflected the hour for the medication was 9:00 AM. In the box on 09/28/23, there was a 3 in the box, which indicated the medication was not given because the resident was away from the facility; Benztropine Mesylate Tablet 1 MG Give 1 tablet by mouth two times a day related to Dementia. The MAR reflected the hours for the medication was 9:00 AM and 9:00 PM. In the box on 09/28/23 for 9:00 AM and 9:00 PM, there was a 3 in the box, which indicated the medication was not given because the resident was away from the facility; Buspirone HCI Oral Tablet 15 MG Give 1 tablet by mouth two times a day related to Bipolar Disorder The MAR reflected the hours for the medication was 9:00 AM and 9:00 PM. In the box on 09/28/23 for 9:00 AM and 9:00 PM, there was a 3 in the boxes, which indicated the medication was not given because the resident was away from the facility; Divalproex Dodium Tablet Delayed Release 500 MG Give 1 tablet by mouth two times a day related to Bipolar Disorder The MAR reflected the hours for the medication was 9:00 AM and 9:00 PM. In the box on 09/28/23 for 9:00 AM and 9:00 PM, there was a 3 in the boxes, which indicated the medication was not given because the resident was away from the facility; Metformin HCI Tablet 500 MG Give 1 tablet by mouth two times a day for Diabetes. The MAR reflected the hours for the medication was 9:00 AM and 9:00 PM. In the box on 09/28/23 for 9:00 AM and 9:00 PM, there was a 3 in the boxes, which indicated the medication was not given because the resident was away from the facility; and Robaxin Tablet 500 MG Give 1 tablet by mouth two times a day for muscle spasms Order date 07/02/23. The MAR reflected the hours for the medication was 9:00 AM and 9:00 PM. In the box on 09/28/23 for 9:00 AM and 9:00 PM, there was a 3 in the boxes, which indicated the medication was not given because the resident was away from the facility. A record review of the facility's Resident Out On Pass Log reflected on 09/28/23 at 7:06 AM, Resident #1 printed her name and in the section that was labeled Accompanied By (Name, Relationship) was written Self. A record review of Resident #1's Medical POA reflected on 01/27/20 Resident #1 signed and gave permission to her FM to act as her Agent to make any and all health care decisions for me. This Medical Power of Attorney takes effect 01/27/2020. Section B of the POA reflected there were no limitations on the decision-making authority of the agent. Section D of the POA reflected I understand that his power of attorney exists indefinitely from the date I execute this document unless I revoke the power of attorney. The POA reflected it was notarized The State of Texas on 01/27/20. A record review of Resident #1's hospital records, dated 09/28/23, reflected the ER patient course notes, dated 09/28/23 at 2:20, reflected Patient is very minimally communicative, she stating that she no longer wants to go back to the nursing home or live with her [FM] that he wants to go to the downtown shelter . we are getting a behavioral health consult and case management consult . 1715 (5:15 PM) . behavioral health wanted to put on detention warrant, but police department did not seemed worried about her, as she end up becoming voluntarily to Behavioral Health unit . Discharge to Behavioral. The ER's final impression/diagnosis was depressive disorder anxiety state. The ER doctor medically cleared Resident #1 and reported she needed a psychiatric evaluation. Resident #1 consented to observations for emergent care in the [psychiatric hospital] and the Psychiatric ER doctor accepted Resident #1 for an evaluation on 09/28/23 at 4:40 PM. HPI notes on 09/28/23 at 6:39 PM reflected . Legal Status: Voluntary due to concern about harm to self . patient is slow to answer triage questions. Patient states, I want to go to the Downtown Shelter . Interview details: . appears confused. oriented, but slow to respond and may be internally preoccupied . Admits that last night she slept in a nursing home but does not want to return to a nursing home, group home, or her [FM]'s home. Adamant that she can go to the shelter. Patient is sunburned. On 09/28/23 at 9:41 PM the Psychiatric doctor noted, Principal Diagnosis: Schizoaffective disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression). [Resident #1] is being discharged from Observation Status. [Resident #1] will be admitted for inpatient psychiatric care and treatment. Review of medical record indicates that [Resident #1] did not stabilize for discharge to home during this observation period . [Resident #1]'s continued mental illness requires higher level of care. Psychiatric initial evaluation dated 09/29/23 at 10:10 AM She has prolonged latency (the delay before a transfer of data begins following an instruction for its transfer) but is able to respond to short, simple questions if given enough time to answer. She states she ran away from her nursing home for lots of reason one being that she can not stomach the food there anymore. Patent states she does not want to go back to a NH (nursing home), her [FM]'s house, or a group home because she would just run away and says she doesn't want to be controlled and follow the rules of these homes . She was unable to answer most questions due to it being hard to get her thoughts together. She states she likely wont remember what we have talked about today . In a phone interview on 10/02/23 at 3:27 PM, Resident #1's FM stated when Resident #1 first admitted to the facility she was in MC. The FM stated about one year ago they went to the facility to visit Resident #1 and the facility had removed Resident #1 from Memory Care (MC) to Long Term Care (LTC). The FM stated she asked the DON why was Resident #1 moved and she was told Resident #1's BIMS had gone from 6 to 8, so, she no longer met the criteria for MC. The FM stated the facility never contacted her or discussed it with her in a care plan meeting, and she was Resident #1's POA. The FM stated she preferred Resident #1 to stay in MC because she knew she would eventually run away, just as she did on 09/28/23. The FM stated on 09/28/23 she went to the facility around 11AM to pick up Resident #1 to take her to a doctor's appointment. The FM stated they had already spoken to the DON the previous day and asked that Resident #1 be ready with her paperwork she needed for the doctor's appointment at 12 PM. The FM stated the DON said she would have Resident #1 and the paperwork ready. The FM stated when she arrived one of the nurse's (does not know her name) said to her oh wow you're back already. The FM stated she was confused and told her she was there to pick Resident #1 up for her doctor's appointment. She said the nurse told her that Resident #1 left earlier in the morning for her doctor's appointment. The FM stated she went to Resident #1's room and her roommate (Resident #2) said Resident #1 left early in the morning for a doctor's appointment. The FM said Resident #2 told her that Resident #1 was acting confused that morning because she jumped up really early about 6:45 AM and said she was going to her doctor's appointment and left out of the room. The FM stated Resident #2 told her she did not even change her night clothes or brush her teeth and just left out. The FM stated Resident #2 told her she knew something was not right because the previous night Resident #1 told her the appointment was at 12 PM but let out so early. The FM stated she told the ADON Resident #1 was missing. The FM stated she was crying and upset and the ADON was acting as if she didn't care. The FM stated the ADON told her Resident #1 probably signed out of the facility and left. The FM stated she told the ADON she cannot sign herself out because she has dementia. The FM stated they went to the front and receptionist said Resident #1 said she had a doctor's appointment and signed out. The ADON showed the FM the sign out log. The FM stated the signature did not look like her sisters . The FM stated she told them she was her POA, and she was not able to sign herself out because she has dementia and mental issues. The FM stated the facility did not even call her to let her know she signed herself out. The FM stated the ADON said she was able to sign herself out because of her BIMS score and it was her right. The FM said she told the ADON again, Resident #1 could not herself out with her mental issues. The FM stated she asked the ADON to call the police and the ADON told her she couldn't because she signed herself out and they had to wait a certain time to call the police, due to their policy. The FM stated she left the facility and a few minutes later the ADON called her and said an employee saw her earlier at a fast-food restaurant near the facility. The FM stated she went to the fast-food restaurant and Resident #1 was sitting outside at a table. The FM stated Resident #1 was in her gray nightgown and flip flops. She stated Resident #1's skin looked red and was acting frantic. The FM stated she told Resident #1 she had a doctor's appointment and attempted to get her in the car. She said Resident #1 was pushing away from her and wouldn't talk to her. The FM stated Resident #1 said was not going with her or to the facility. The FM stated a worker from the fast-food restaurant came outside and told her they were just about to call an ambulance because Resident #1 had been there for several hours, and they knew Resident #1 was not acting right. The FM stated Resident #1 started walking off down the busy access road, so she went to stop her and called 911. The FM stated the police came and Resident #1 was still refusing to go with her. She said she told police she cannot be out on her own because of her mental issues and she was her POA. The FM stated Resident #1 told the police she would not go with her, and she would go to the hospital. The FM stated the police asked Resident #1 about going back to the facility and she said no take her to a shelter. The FM stated the police called ambulance, who took her to the hospital. The FM stated the hospital would not discharge Resident #1 because of mental issues and admitted her into the psychiatric hospital. The FM stated in the last month she noticed Resident #1 had become more confused, her memory had gotten worse, and she had a difficult time forming sentences. The FM stated she talked to the facility about her decline and the doctor tried to give Resident #1 more medication. The FM stated she told the facility she did not want to give Resident #1 more medication and she wanted test done because she believed Resident #1could have had a stroke or something else was happening to make her memory get worse. The FM stated she was not able to remember a lot and her speech was getting worse. Stated she started looking around for her and could not find her. In an interview on 10/03/23 at 11:19 AM, Resident #2 stated Resident #1 walked out of the facility. Resident #2 stated a couple days ago Resident #1 got up early, said her FM was taking her to an appointment, walked out of the room, and she never saw her again. Resident #2 stated Resident #1's FM came to the room about 11:30/12:00 and asked where was Resident #1. Resident #2 stated she told the FM she thought Resident #1 was with her. Resident #2 stated she thought Resident #1 got confused because Resident #1 had previously told her the appointment was at 12PM but she left out of the room early at like 6:30/7:00 AM. Resident #2 stated Resident #1 did not get dressed and left out in her nightgown. She stated Resident #1 did not even wash her face or brush her teeth and didn't have on a bra or panties because she did not like to sleep in them. Resident #2 stated she just left out. She stated she spoke to Resident #1's FM later and they did not know where Resident #1 was for five hours. Resident #2 stated Resident #1 seems mentally ok sometimes but lately she seemed to be very confused about things all the time. A record review of Resident #2's Comprehensive MDS, dated [DATE], reflected her BIMS was 15, which indicated her cognition was intact. In an interview on 10/03/23 at 12:31 PM, the ADON stated on 09/28/23 she arrived at the facility about 6:45/7:00 AM and Resident #1 was sitting at the front with another resident. The ADON stated she said to Resident #1, you're up and dressed early and Resident #1 said her sister was coming to take her to a doctor's appointment. The ADON stated approximately 30 minutes later the receptionist contacted the nurse's station and said Resident #1 said her ride was there and she was signing herself out. The ADON said she told the receptionist she was aware that Resident #1 had an appointment. The ADON stated a couple hours later around 12 PM Resident #1's FM came to her asked where was Resident #1. She said she told the FM she thought she was with her because Resident #1 said she had an appointment. The ADON said Resident #1's FM was really upset and said, you just let her walk out. She stated she told the FM she signed herself out and didn't just walk out. The ADON said Resident #1's FM said Resident #1 had a mental disorder, so how did you all let her sign herself out. The ADON stated she went to the receptionist desk, checked the log and saw Resident #1 had signed out. She stated the receptionist said Resident #1 told her that her [FM] was there and signed out. The ADON stated she checked Resident #1's BIMS and she believed it was a 12, which meant she was able to sign herself out. The ADON stated Resident #1's FM got upset and was crying saying Resident #1 was out there alone with no money. The ADON stated Resident #1's FM wanted to call the police to do a missing person's report, but she told her their policy stated they had to wait 72 hours. The ADON stated Resident #1's FM left the facility. She stated a staff member (does not remember who) heard Resident #1's FM talking about the situation and told her they went to a nearby fast-food restaurant for lunch and saw Resident #1. The ADON stated she called Resident #1's FM to tell her were Resident #1 was. The ADON stated [NAME] after that she received a call from a police officer, who asked did Resident #1 live at the facility and if Resident #1's FM was in fact her relative because Resident #1's FM was trying to get Resident #1 in the car, but she refused and was upset. The ADON stated she verified to police that Resident #1's FM was in fact her FM. She said the police officer said Resident #1 refused to go with the FM and said to take her to [hospital], so he called EMS. The ADON stated the resident's BIMS determined if they were able to sign themselves out. She stated she was not exactly sure what the BIMS score had to be, but Resident #1 was cognitive and able to make decisions. The ADON stated Resident #1 normally signed herself out and walked out to her FM's car. She stated she assumed that was what Resident #1 was doing on 09/28/23 when she signed herself out. During a record review and interview on 10/03/23 at 12:59, the DON stated Resident #1 signed herself out and went to a nearby fast-food restaurant. The DON stated Resident #1's FM came to pick her up for an appointment and got upset that she wasn't at the facility. She stated residents had to have a BIMS of 13 to sign themselves out and Resident #1 had a BIMS of 13. The DON stated she had to check PCC because believed Resident #1 had a BIMS of 13. The Investigator informed the DON that Resident #1's current MDS reflected a BIMS of 11 and showed the DON Resident #1's BIMS assessments in PCC, which reflected a BIMS assessment dated [DATE] with score of 11 and BIMS assessment dated [DATE] with a score of 8. The DON stated she thought maybe the assessment was incorrect because she believed Resident #1 had a BIMS of 13. When the Investigator asked the DON if she felt it was safe for Resident #1 to sign herself out, even though her current Care Plan, reflected Resident #1 had impaired cognitive function and thought process and episodes of confusion due to her dementia diagnosis, the DON stated yes, because Resident #1 was cognitive enough to make sound decisions. The DON stated she did not know exactly what the policy was regarding residents being able to sign themselves, but they had been allowing residents with BIMS of 13 or higher to sign themselves out. When the Investigator asked the DON, was Resident #1 allowed to sign herself out even though she was not her own RP, she stated Resident #1 was her own RP. When the Investigator went to show the DON in PCC that Resident #1 was not her own RP, the information had been changed and reflected Resident #1 as her own RP and Resident #1's FM was listed as emergency contact and not RP and the POA information had been removed. The Investigator pointed out to the DON that she had reviewed Resident #1's record when she first entered the facility and took a snippet of the information, which, reflected Resident #1 was listed as other and not RP and her FM was listed as RP and care and financial POA. When the Investigator asked the DON why the information was changed, since she entered the facility, she stated she didn't know and would have to check into, but she had not changed the information. During a record review and interview on 10/03/23 at 1:12 PM, the Regional Director (RD), she stated she was reviewing Resident #1's clinical record in PCC and accidentally changed her information. She stated she went back in PCC and corrected the information. When the Investigator refreshed her tablet, the clinical record reflected Resident #1 as her own RP and her FM as RP and Care and Financial POA. The Investigator pointed out that Resident #1 was now listed as her own RP, which was not listed as such during the initial review, the RD stated oh but did not provide an additional response. In an interview on 10/04/23 at 10:20 AM, LVN A stated she did write the progress noted on 09/14/23 at 3:12 PM. LVN A stated the MD was in the facility and assessed Resident #1, due to complaints of tremors and increased memory loss. She stated after the assessment the MD gave an order for Primidone for the tremors and increased dosage in Namenda. LVN A stated when she called Resident #1's FM about the new orders she stated she did not want her to take more medications. She stated she notified the MD, who d/c the orders. LVN A stated she updated PCC (electronic medical information platform). LVN A stated when residents sign themselves out, the facility receptionist are supposed to review the list and if the resident was highlighted on the list, they were supposed to call the nurses station to verify they could leave. She stated the receptionist always called to verify regardless of if the resident was highlighted or not. LVN A stated if she was covering a hall and was not familiar with the resident, then go to the front to check with SW regarding BIMS and if they were ok to sign out. Stated she was not exactly sure of what the policy was, but she was informed the residents had to be cognitive with BIMS of 13 to sign out by themselves. LVN A stated she did not know Resident #1's BIMS but she was cognitive, and she would not have interjected with her leaving the facility. LVN A stated if the resident was not their own RP, then you must call their RP before allowing them to sign out. LVN A stated before the resident left, you were supposed to check to see if they would be gone during the time their medication was supposed to be administered and if so, they were supposed to offer the residents their medications. In an interview on 10/04/23 at 11:48 AM, CNA D stated she was assigned to Resident 1's hall on 09/28/23 from 6AM-2:00 PM. CNA D stated about 6:45 AM she went to provide care to Resident #2 and Resident #1 was already up and said her FM was picking her up for a doctor's appointment. She stated Resident #1 did say what time her appointment was. CNA D stated she told LVN E, who was the nurse for Resident #1's hall, that she was leaving for an appointment with her FM. She stated about 15-20 minutes later, she saw Resident #1 heading towards the front of the facility to leave. CNA D stated Resident #1 did occasional get confused but for the most part she was ok. CNA D stated Resident #1 did stutter and took a while to get her words out. In an interview on 10/04/23 at 11:57, LVN E stated she was the nurse assigned to Resident #1's hall on 09/28/23 from 6AM-2:00 PM. LVN E stated Resident #1 was up early and dressed. She stated Resident #1 told her she had a doctor's appointment at 12PM. LVN E stated a little while later the receptionist called to the nurse's station and said Resident #1 was leaving out for an appointment with her FM. She stated the receptionist was told they were aware. LVN E stated she knew her appointment was at 12PM but she figured her FM was there early. LVN E stated the residents were required to be cognitive and have a BIMS of 13 to leave by themselves. LVN E stated if the resident was not their own RP, then they you were supposed to call POA/RP. LVN E stated she did not know Resident #1's BIMS score but she knew she was cognitive. LVN E stated she did not know Resident #1 was not her own RP. She stated Resident #1 mostly went out of the facility with her FM, but there had also been times she signed herself out. LVN E stated Resident #1 always returned and was not known to be an elopement risk. LVN E stated the nurses were supposed to offer the resident's medications if they will be out when the medications were supposed to be administered. She stated Resident #1 was not offered her medications on 09/28/23 because she left before they could offer. In an interview on 10/04/25 at 12:45 PM, the DON stated the process they had been using for resident's signing out was the receptionist checked the list at the front before allowing the resident to sign out. The DON stated the list had highlighted names, which meant those residents were not allowed to sign out by themselves and the receptionist had to contact the nurse. She stated the IDT determined whose names were highlighted and they[TRUNCATED]