F0689

D

Failure to Monitor and Control Illicit Drug Use for a Resident on Chronic Opioid Therapy

Manteca, California Survey Completed on 01-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement and maintain effective preventive measures and monitoring for a resident with known drug-seeking behavior and repeated positive urine drug screens for illicit substances. The resident, admitted in 2013 with paraplegia, chronic pain syndrome, and major depressive disorder, had a history of polysubstance abuse and was on chronic methadone therapy for pain. Urine drug screens showed a positive result for cocaine and cannabis on 7/18/25 and additional positive results for cannabis on 8/21/25, 9/25/25, and 12/6/25. Despite these findings and multiple office visit notes from the MD documenting polysubstance abuse, opiate dependence, behavior issues, and instructions to monitor behavior, the facility did not implement ongoing, structured behavior monitoring or revise the care plan in response to the repeated positive tests.

The resident reported using marijuana for many years while residing at the facility and admitted to sniffing cocaine when stressed. He stated that he went alone to a nearby park, where a friend supplied him with cocaine and marijuana, and that he informed facility staff that a friend had given him cocaine. He also stated that he was never supervised by staff when leaving the premises and was allowed to go to the park by himself, and that after his positive drug test in July 2025 he stopped going to the park following a doctor’s order of no more day passes. The resident further reported that a visitor brought him marijuana brownies during visits in August, September, and December 2025, and that he brought a marijuana cartridge into the facility but was only told he could not smoke marijuana in the facility. He stated that no one at the facility had discussed substance use treatment services with him.

Staff interviews and record reviews showed that, although a care plan for history of substance use disorder and drug-seeking behaviors was initiated on 7/23/25, it was not revised after subsequent positive cannabis tests. The DON stated that behavior monitoring was documented in progress notes for only 72 hours after the 7/18/25 positive test and that no daily behavior tracking was implemented for drug-seeking behavior or drug use. LNs 1, 2, 3, and 4 confirmed there was no ongoing behavior monitoring log for drug use, no psychological evaluations documented for drug use, and no regular drug behavior monitoring despite continued positive urine drug screens and documented behavior issues such as agitation and yelling at staff. CNA 2 acknowledged that residents with a history of drug-seeking behavior should be monitored regularly and that unsupervised residents could go outside and consume illicit substances or be influenced by visitors. The facility’s visitation policy allowed for supervised visitation or denial of access for individuals with a history of bringing illegal substances, but there was no documentation that such measures were applied in this case, even though the IDT investigations repeatedly documented the resident’s continued cannabis use and refusal to stop.