F0755

D

Failure to Ensure Availability of Methadone for Readmitted Resident

Yonkers, New York Survey Completed on 02-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that a prescribed methadone medication was available and administered to meet the needs of a resident upon readmission. The resident had diagnoses including opioid abuse with unspecified opioid-induced disorder, anxiety disorder, and obstructive uropathy, and the MDS documented that the resident was cognitively intact and received opioid medication daily. A physician’s order directed that methadone oral solution 40 mg be given once daily for opioid dependency, and the comprehensive care plan instructed staff to administer medications as ordered. The resident was hospitalized for hypoxia and pneumonia and later returned to the facility with medications documented as unchanged and with two antibiotics added.

On the day following readmission, the MAR showed the methadone order, but a progress note documented that the methadone dose was not given because the medication was not on hand. Nursing notes recorded that the resident was unable to receive methadone, became upset, and was yelling and using profanity due to not getting the medication. The RN Supervisor was informed that there was no methadone bottle available, and the physician was notified and indicated the resident would obtain methadone from the clinic on Monday. Interviews with the RN Supervisor, DON, Director of Admissions, and Medical Director revealed that the facility did not receive discharge paperwork or prior notification of the resident’s return from the hospital, that the methadone clinic was closed on weekends, and that there was an expectation for coordination with the hospital before discharge to ensure methadone availability. As a result, the resident did not receive the scheduled methadone dose after readmission.