Failure to Control Opioid-Related Hazards and Provide Adequate Supervision for Residents With SUD
Summary
The deficiency involves the facility’s failure to identify and control accident hazards and to provide adequate supervision and safety interventions for residents with known opioid use disorder, resulting in opioid overdoses for two residents. For one resident with psychoactive substance abuse and opioid dependence with withdrawal, the admission nursing assessment documented fentanyl use within the prior 30 days and intact cognition. The resident’s care plan noted risk for substance use related to a history of addiction and receipt of medication-assisted treatment (MAT), but did not include specific interventions for substance use risk or MAT management. Although physician orders included PRN Naloxone (Narcan) for suspected overdose and daily Methadone for opioid use disorder, the clinical record did not show that psychiatric/psychology services or contracted substance use disorder (SUD) program services were provided or refused. On one occasion, this resident became lethargic, drowsy, and difficult to arouse, with bilateral pinpoint pupils. A nurse administered two doses of Narcan one minute apart; the first was ineffective and the second produced a positive response, after which the resident admitted to using “illegal stuff.” Security and the APRN were involved, and the APRN documented that the resident admitted to using fentanyl brought into the facility at the time of admission. Security and social work staff conducted a room search and found five bags or dime bags with suspicious white residue tucked into the resident’s hat. Security staff reported that these bags were flushed down the toilet and that no further room searches had been conducted between admission and the overdose event, despite the known SUD history. The DNS acknowledged that the SUD/MAT care plan had been initiated but not completed, that there were no prior room searches, that the police were not notified because the bags were empty, and that the facility had no policy or procedure for suspected drug overdose. For a second resident with diagnoses including opioid dependence, cocaine dependence, and adjustment disorder, physician orders included PRN Narcan for suspected overdose, Gabapentin three times daily for pain, Sertraline daily for anxiety, and room searches every shift. The resident had intact cognition, was largely independent in mobility and toileting, and had a care plan identifying risk for substance use related to a history of addiction, with an intervention only to observe for signs and symptoms of withdrawal. A nursing note documented that the resident was observed in a wheelchair with slightly slurred speech and dilated pupils but remained alert, oriented, and able to follow commands; the resident refused to provide a toxicology sample and refused hospital transfer, and a room check revealed no contraband. The care plan was later updated to note the episode of dilated pupils and slumped posture, with interventions including 15-minute checks, monitoring labs, evaluating need for psychiatric services, and reinforcing the recovery plan, and documentation showed 15-minute checks were performed for 72 hours. Subsequently, the DNS documented responding to a STAT call and finding this resident on the bathroom floor with a formed bowel movement, unresponsive to verbal or tactile stimuli and without a pulse. CPR was initiated, 911 was called, and two doses of Narcan were administered without response before transfer to the emergency department, where the resident was pronounced deceased. The hospital record indicated the case was referred to the Medical Examiner due to suspected drug use and noted that facility staff reported the resident had a history of drug use and was observed associating with other residents known to use drugs. The DNS stated she questioned whether to report the unanticipated death to the State Agency and did not contact the Medical Examiner’s office for the cause of death. The Medical Examiner’s report later identified the cause of death as acute intoxication due to the combined effects of fentanyl, gabapentin, and sertraline. The DNS acknowledged that the resident’s care plan for risk of substance use contained only one initial intervention (observation for withdrawal), that additional monitoring beyond the 72-hour 15-minute checks was not implemented, that group therapy attendance was not tracked, and that the facility lacked a policy, procedure, or protocol for suspected drug overdose and Narcan administration. These failures, including incomplete risk-based care planning for residents with known SUD, lack of specific controls such as supervised visits, random room searches, visitor log management, random urine toxicology, and documented SUD support/refusal handling, absence of an overdose/Narcan protocol, failure to contact law enforcement when illegal drugs were suspected or observed, and failure to maintain chain of custody for contraband, led to one resident requiring two doses of Narcan for a suspected fentanyl overdose and another resident’s death from acute intoxication. Surveyors determined that these failures constituted noncompliance at the level of Immediate Jeopardy.
Removal Plan
- Ensure new admissions with a known recent history of substance use are evaluated for appropriate supervision based on a person-centered risk evaluation, with interventions initiated based on the level of risk.
- Educate nursing supervisors to ensure the Resident Care Plan (RCP) on admission for residents with substance use disorder (SUD) contains interventions to provide adequate support.
- Conduct audits of RCPs for new admissions with a history of SUD to ensure appropriate interventions and adequate supervision.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Unsafe Cord Placement and Failure to Follow Fall Interventions: A resident with cognitive impairment and wheelchair use had a TV power cord stretched tightly across the closet doorway, blocking access and creating an environmental hazard when staff had to lift the cord to open the closet. Another resident with severe cognitive impairment and a fall-risk care plan repeatedly ran barefoot in the hallway while staff observed but did not consistently provide planned interventions such as gripper socks, footwear, ambulation assistance, or redirection.
A resident with impaired cognition, cancer, non-Alzheimer's dementia, extensive ADL needs, and a fall history was identified as a high fall risk with care plan interventions including removing a movable bedside table. After a fall, the resident was found using the table as a walker, yet observations showed the table still placed beside the bed on multiple occasions, including when staff were present. Staff interviews confirmed they were unaware of the current fall prevention interventions and that the table remained at bedside for meals despite the care plan.
Failure to complete a restraint assessment before using a wheelchair alarm for a resident with muscle weakness, difficulty walking, repeated falls, and dementia. The care plan included the alarm as an intervention, but the record lacked an initial Restraint Evaluation, and the CNO confirmed the assessment had not been completed before the alarm was placed.
A resident with cognitive deficits, dementia, Alzheimer's disease, fracture, and repeated falls was dependent for toileting and care planned for an EZ stand with 2-person assist. During observed transfers, staff placed the harness and straps correctly, but the resident only rose to about 135 degrees and never came to a full stand, while staff remained by the bathroom door during privacy periods and continued the transfer despite the resident not standing fully. An RN stated the resident was expected to stand straight up with the EZ stand and that staff should sit the resident back down and try again if not.
A resident with Alzheimer's disease and dementia was found wandering in the parking lot after leaving the building unsupervised. A family member visiting another resident saw her looking into car windows and alerted staff, who were not aware she had exited until the report. Staff interviews showed the resident had been seen earlier eating in the dining room, but no one was actively looking for her or knew she had left the facility.
A resident with parkinsonism and Alzheimer's disease, severe cognitive impairment, and a fall history was pushed in her wheelchair without foot pedals and was not assisted when she called out for help. Nursing notes and staff interviews showed a CNA propelled the resident multiple times without foot pedals, including one instance where her socked foot hit the floor, and staff acknowledged that foot pedals should be used when pushing a resident.
Unsafe Cord Placement and Failure to Follow Fall Interventions
Penalty
Summary
The facility failed to ensure a television power cord was properly secured and maintained so it did not create an environmental accident hazard for R46. R46’s quarterly MDS identified moderate cognitive impairment, maximum assistance needed for dressing, grooming, and toileting hygiene, moderate assistance with transfers, and wheelchair use. During observation, R46 was in his room with the television mounted on the wall between the bathroom and closet, and the power cord ran across the closet doors and across the upper drawer of the dresser to a surge protector on top of the dresser. When R46 tried to open the closet doors, the cord was stretched tightly across the doorway and prevented the doors from opening fully unless the cord was lifted away. A later observation showed NA-D had to lift the cord above the closet door to open it and retrieve clothing. NA-D stated the cord had been positioned that way for about one year and could be dangerous if R46 pulled on it, and maintenance staff stated they were only notified that day that the television needed to be fixed. The facility also failed to ensure fall interventions were followed for R13, who had severe cognitive impairment with disorganized thinking and inattention, verbal behaviors toward others, and dependence on staff for footwear and partial to moderate assistance with dressing. R13’s care plan identified her as at risk for falls and included interventions such as ambulating with the resident, encouraging gripper socks, obtaining slip-on shoes, reducing noise, offering snacks, assisting her back to her room when running in the hallway, offering a wheelchair, and redirecting her to slow down. During observations, R13 repeatedly exited her room barefoot and ran through the hallway, including multiple times over an extended period, while staff observed but did not provide gripper socks or shoes, walk with her, redirect her to slow down, or offer other care-planned interventions. Staff interviews indicated they had difficulty redirecting her because she became agitated, and the DON stated the care plan should be followed to ensure safety.
Failure to Follow Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement care planned interventions to prevent further falls for one resident who was reviewed for falls. The resident had moderate impaired cognition, diagnoses including cancer and non-Alzheimer's dementia, required extensive assistance with ADLs including toileting, transfers, and locomotion, and had a history of falls. The resident's care plan identified the resident as a high fall risk related to de-conditioning, cognitive deficits, and prior falls, and included interventions such as anti-rollbacks on the wheelchair, appropriate footwear, keeping a wheelchair behind the resident when ambulating, and removing the mobile bedside table from beside the bed. After a fall in which the resident was found on the floor by the room doorway with the mobile bedside table in the hallway next to him, the resident stated he had been using the table as a walker. Despite the care plan and post-fall assessment identifying removal of the mobile bedside table as an intervention, observations showed the movable bedside table still placed alongside the bed on multiple occasions, including when staff were present in the room. Staff interviews confirmed they were unaware of the current fall prevention interventions, acknowledged the table was movable, and stated it remained at the bedside to facilitate meals. The DON confirmed the table had been at the bedside and was removed only after the surveyor discussed it with staff.
Failure to complete restraint assessment before wheelchair alarm use
Penalty
Summary
The facility failed to complete a restraint assessment before implementing a wheelchair alarm for Resident #18. Resident #18 was admitted with multiple diagnoses including muscle weakness, difficulty walking, repeated falls, and dementia. The care plan for impaired mobility and fall risk, dated 3/8/26, included a wheelchair alarm as an intervention. A Bed Safety and Transfer Device Evaluation dated 4/28/26 documented that the bed/chair alarm did not restrict mobility, but the record did not include an initial Restraint Evaluation dated on or around 3/8/26 to identify the comprehensive evaluation of the chair alarm. On 7/9/26, the CNO stated that a Restraint Evaluation had not been completed prior to the chair alarm being placed for Resident #18.
Inadequate Supervision During EZ Stand Transfers
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for one resident during transfers with an EZ stand lift. The resident had cognitive deficits and was dependent for toileting, with diagnoses including Alzheimer's disease, dementia, fracture, and repeated falls. The care plan identified a moderate fall risk related to weakness and directed toileting with an EZ stand and 2-person assist. During observation, nursing assistants placed the harness, safety belt, straps, and loops appropriately and assisted the resident with the lift, but the resident stood only to approximately 135 degrees and never came to a full stand. On two observed transfers, staff remained by the bathroom door while the resident was given privacy, then re-entered to continue the transfer and complete care. In both observations, the resident never achieved a full standing position despite encouragement and repeated attempts. One nursing assistant stated the transfer was safe because two staff were assisting, while the RN case manager stated she expected the resident to stand straight up when transferred with the EZ stand and that staff should sit the resident back down and try again if the resident did not. The RN case manager was unaware of any concerns about the resident transferring safely with the EZ stand. Facility policy was requested but not provided.
Resident Left Unsupervised and Was Found Wandering in Parking Lot
Penalty
Summary
The facility failed to recognize that a cognitively impaired resident had left the building unsupervised and was wandering in the parking lot. The resident had diagnoses including Alzheimer's disease, dementia, and anxiety disorder, and records showed she had moderately impaired cognition, walked and transferred independently, and had no documented wandering behaviors during the MDS lookback period. Although an elopement evaluation had previously concluded she was not at risk for elopement, the care plan identified confusion, impaired cognition, and lack of awareness of safety needs. On the day of the event, a family member visiting another resident saw the resident outside in the parking lot looking into car windows and walking from car to car with a jacket and pocketbook on her arm. The family member stated the resident appeared to be looking for someone and was in the middle area of the parking lot before she reported it to staff. Nurse #3 was notified and went to check on the resident, who was then brought back inside the facility. Staff interviews showed they were not actively looking for the resident and did not know she had exited the facility unsupervised until the family member reported seeing her outside. Staff accounts indicated the resident had been seen earlier in the dining room eating, but no one was aware she had left the building. Nurse #2 and NA #1 both stated they were not aware the resident was missing until the report from the family member. The administrator stated the resident exited through the front entrance doors, but it was not known whether she pushed the button behind the receptionist desk or was let out by a visitor. The previous NP stated the resident needed someone with her if she was outside the facility and could have wandered away if left alone.
Failure to Respond to Help Requests and Use Foot Pedals During Wheelchair Transport
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for R25 when staff did not respond to her requests for help and did not provide foot pedals while propelling her wheelchair. R25 had diagnoses of parkinsonism and Alzheimer's disease, and her records documented severely impaired cognition, including a BIMS score of four on a quarterly MDS. Her care plan stated she was independent with locomotion in her manual wheelchair, but other documentation reflected a history of falls and need for staff assistance with wheelchair mobility. The care plan also lacked documentation regarding foot pedals. Nursing notes and staff interviews showed multiple instances in which R25 was pushed in her wheelchair without foot pedals. On one occasion, a CNA propelled her out of the restroom and her socked foot hit the floor when the wheelchair was pushed. On another occasion, R25 was seated in her wheelchair, holding onto the back of a recliner and calling out for help, while the CNA walked by her. The CNA later propelled R25 down the hallway without foot pedals and at one point pushed the chair and let it go. Staff interviews confirmed that residents should have foot pedals when staff are pushing them, and the CNA stated she should not push R25 without foot pedals.
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