**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide necessary services (drug counseling and surveillance [monitoring of behavior; activities]) and develop person centered care plans for the behavioral healthcare needs for substance abuse for one of three sampled residents (Resident 1), who had a history of drug abuse (the excessive or addictive use of drugs for nonmedical purposes) and prevent Resident 1 from experiencing a drug overdose (an excessive and dangerous dose of a drug) of opiate (a controlled drug used to treat pain or cause sleep) and fentanyl (a powerful, controlled drug that is used to treat severe pain) while residing in the facility by failing to: 1. Develop and implement behavior health care plans for drug abuse to meet the behavioral needs of Resident 1 ' s when Resident 1 was readmitted to the facility from the General Acute Care Hospital 2 (GACH) on [DATE] in accordance with the facility policies and procedures [P&P] titled Behavioral assessment, intervention and monitoring and Care plans, comprehensive person-centered. 2. Develop individualized interventions, which included drug abuse counseling and surveillance of a drug abuser, upon Resident 1 ' s readmission to the facility on [DATE], when Resident 1 was diagnosed with opiate and fentanyl overdose in GACH 3 on [DATE], in accordance with the facility P&P titled Behavioral assessment, intervention and monitoring and Care plans, comprehensive person-centered. 3. Assess and identify Resident 1 ' s behavioral needs for drug counseling and surveillance, upon readmission back to the facility from GACH 3 on [DATE], by identifying risk factors, causes and how Resident 1 was exposed to illicit (illegal) drug use, due to a recent opiate/fentanyl overdose incident in the facility, as indicated in the facility ' s policy and procedure [P&P] titled Management of Illicit Drug Use and Referrals, Social Services. 4. Attempt to perform voluntary inspections of Resident 1 ' s belongings, when facility staff had reasonable suspicion of possession of illicit drugs to prevent recurrence of illicit drug use and overdose. The facility did not conduct voluntary inspection of Resident 1 ' s belongings to ensure illicit drugs were no longer present in the resident ' s possession, upon readmission back to the facility, on [DATE], after being transferred to GACH 3 for opiate/fentanyl overdose, in accordance with the facility ' s P&P titled Behavioral assessment, intervention and monitoring and Management of Illicit Drug Use. On [DATE] at 6:56 PM, while onsite at the facility, the California Department of Public Health (CDPH) identified an Immediate Jeopardy situation (IJ, a situation in which the provider ' s noncompliance [not following rules] with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) regarding the failure to obtain necessary services, develop person centered care plans for the behavioral healthcare needs of a resident who had history of substance abuse and opiate/fentanyl overdose. The survey team notified the Director of Nursing (DON) and the Administrator (ADM) of the IJ situation on [DATE] at 6:56 PM, due to the facility ' s failure to obtain necessary services, develop person centered care plans for the behavioral healthcare needs of Resident 1. On [DATE] at 1:30 PM, the ADM provided an acceptable IJ Removal Plan (a detailed plan to address the IJ findings). On [DATE] at 2:27 PM, while onsite and after the surveyor verified/confirmed the facility ' s full implementation of the IJ Removal Plan, through observation, interview, and record reviews, and determined the IJ situation was no longer present, the IJ was removed onsite, in the presence of the ADM and the DON. The IJ Removal Plan dated [DATE], included the following: -On [DATE], the facility reviewed and developed a behavior care plan for drug abuse for Resident 1 ' s past history of drug abuse. The facility conducted an Interdisciplinary Team [IDT - a group of professionals from different disciplines who work together to provide personalized care)] meeting on [DATE], with Resident 1 regarding any drug use, which Resident 1 denied at the time. -The ADM conducted an investigation on [DATE], to determine the possibilities on how the incident on [DATE], could have happened. Based on ADM investigation (concluded on [DATE]) closer supervision could be needed by the gate. -On [DATE], the facility Security guards was immediately given in-service to be in close proximity (near) to the gate. The Security Guard was placed at the facility gate at 8 PM on [DATE]. Security Guards ' shifts are 7 AM to 3 PM and 3 PM to 11 PM, seven days a week. Security Guards will screen everyone they encounter, with an emphasis on looking for suspicious behavior and drug contraband [illicit goods] from all persons, including staff, residents and visitors. Security Guards will document all person interactions with time, date, and name. Security Guards will report abnormal findings to nursing supervisor. Staff will also have the responsibility for facility wide supervision and was in-serviced specifically for Fentanyl, regarding how to spot signs of active, potential usage and its physical form by the Director of Staff Development (DSD) on [DATE]. 48 staff out of 54 staff informed with an expected completion date [DATE]. ADM called the police to report the incident on [DATE], the call was placed at 1:55 PM, on [DATE]. In the ADM or DON ' s absence, the nursing supervisor can inform the police of any illicit activity. -On [DATE], the IDT reviewed all residents' charts to determine if there are other residents that have history of drug abuse, two residents found. The facility updated their behavior care plans to ensure their needs are met and completed. History of drug abuse created and placed at the Nursing Station with contents identifying all current residents that have a history of drug abuse, for staff reference. Staff informed regarding newly identified residents on [DATE]. -Developed an individualized intervention for Resident 1, which included scheduling of counseling from the facility Psychologist [a person who specializes in the study of mind and behavior] on [DATE], with a focus on opiate and fentanyl overdose and drug abuse. The Psychologist will visit Resident 1, two times a month. -Upon readmission, Resident 1 will be interviewed by Social Services, questions will include an emphasis on history of illicit drug abuse. -All nursing staff will review residents' records to establish if there is a history of drug abuse/use, care plans will be implemented for residents that are found to have a history of drug abuse. -Resident belongings will also be thoroughly checked (with the resident ' s permission) to ensure no contraband is present and brought into the facility. -Residents suspected of illicit drug usage (Fentanyl) will be drug tested in according to the facility ' s Illicit drug policy. Residents have the right to refuse drug testing as it is voluntary. -For ongoing suspicion of illicit drug use of residents, the IDT team will conduct and IDT meeting informing the resident of the facility policy, including that all drug testing is voluntary. -On [DATE], the facility staff conducted a search in Resident 1 ' s room with the resident ' s consent. This search was repeated on [DATE], no contraband found. The facility also conducted a whole facility search and no contraband was found on [DATE]. The facility will conduct weekly contraband searches every 4 weeks and them monthly for the next 6 months. -Resident 1 was prescribed Norco (a drug used to treat moderate to severe pain) every eight hours as needed for pain management. This is to prevent Resident 1 from seeking pain relief through illicit means. Findings: During a review of Resident 1 ' s GACH 2 records titled History and Physical [H&P] Report dated [DATE], indicated the resident came to the emergency room for worsening left shoulder pain. The H&P indicated under Assessment and Plan to rule out stroke [a medical emergency that occurs when blood flow to the brain is disrupted, damaging or killing brain tissue], adjust psychiatric [relating to mental illness] medications and for pain management. The GACH 2 record indicated Resident 1 was discharged with Acetaminophen [over the counter pain medication] 325 mg oral tablet: two tablets orally every 4 hours, as needed, for mild pain (1-3) pain scale. The GACH 2 record indicated the resident was discharged to the facility on [DATE]. The H&P under Social History indicated, Resident 1 has a remote history of smoking. Resident 1 has a history of drug abuse. During a review of Resident 1 ' s facility records titled admission Record indicated a facility readmission on [DATE], with diagnoses that included flaccid hemiplegia (a neurological condition characterized by weakness or paralysis and reduced muscle tone) affecting left non dominant side, chronic obstructive pulmonary disease (COPD -a group of lung diseases that block airflow and make it difficult to breathe). During a review of Resident 1 ' s facility records titled Order summary Report indicated the following active medication orders for Resident 1 dated [DATE]: Amlodipine Besylate (medication for blood pressure) 10 milligram [mg – unit of measurement] one time a day. Aspirin 81 mg (medication for CVA) 81 milligram one time a day. Ativan (medication for anxiety) 0.5 mg two times a day. Folic Acid (medication for anemia) 1 mg one time a day. Gabapentin (medication for numbness and pain from nerve damage) 300 mg three times a day. Ibuprofen (medication for pain) 600 mg as needed every 12 hours. Lactulose (medication to prevent complication of liver disease) 10 grams in 15 mg, one time a day. Lidocaine patch (medication for pain) 5% apply for 12 hours. Lisinopril (medication for blood pressure) 5 mg one time a day Milk of Magnesia (medication for constipation) 30 ml as needed one time a day Olanzapine (medication for mental illness) 5 mg 1 time a day Tylenol (medication for mild pain) 325 mg give 1 as needed every 6 hours Tylenol (medication for pain level 4-6) 325 mg give 2 as needed every 6 hours Vitamin B1(supplement) 100 mg one time a day Vitamin C (supplement) 500 mg one time a day Zolpidem Tartrate (medication for inability to sleep) 5 mg give one tablet During a review of Resident 1 ' s facility records titled History and Physical (H&P) dated [DATE], indicated the resident had fluctuating capacity to understand and make decisions. During a review of Resident 1 ' s facility records titled Social Service History & Initial Assessment dated [DATE], authored by the Social Services Director [SSD] indicated under Social Factors and History of drug/alcohol abuse, was left unmarked. During a review of Resident 1 ' s facility records titled Situation, Background Assessment, Recommendations [SBAR] dated [DATE] timed at 9:45 AM, indicated at 9:30 AM, Resident 1 was up in the wheelchair and conversing [talking] with the staff. The SBAR indicated Resident 1 started drooling (when saliva flows out of your mouth unintentionally) on the right side of his mouth. Resident 1 was non-verbal, non-responsive to pain and skin color was purple/clammy skin (skin that is wet from sweating). The SBAR further indicated Resident 1 ' s blood pressure was 111/74, pulse rate was 94, respirations was 12. Resident 1 ' s oxygen saturation (the amount of oxygen carried by red blood cells) was absent and a non-breather mask (a special medical device that helps provide you with oxygen in emergencies) oxygen inhalation at 10 Liters (metric unit of capacity) was placed on Resident 1. The SBAR indicated Resident 1 still remained unresponsive . The resident ' s pupil of eye constricted (to reduce the light entering the eye) and fixed (a pupil that does not respond to light). The resident ' s physician (Physician 1) was notified and made aware. The SBAR indicated 911 emergency services was notified and the resident was transferred to GACH 3. During a review of Resident 1 ' s GACH 3 records titled History and Physical dated [DATE], indicated [Resident 1] was found slumped [sitting with the body leaning forward, for example, because a person was asleep or unconscious] over in the wheelchair, then became unresponsive. No seizure [a sudden, uncontrolled movement] activity noted. Resident 1 was started on CPR (cardiopulmonary resuscitation, [an emergency treatment that's done when someone's breathing or heartbeat has stopped]) when paramedics arrived. Resident 1 was noted with agonal breathing (when someone who is not getting enough oxygen is gasping for air) and pinpoint pupils [a condition where the pupils of the eyes appear unusually small] with Glasgow coma scale (used to objectively describe the extent of impaired consciousness) of 3 (is the lowest possible score and is associated with an extremely high mortality rate). Resident 1 was given Narcan (is a medicine that treat someone from fentanyl or prescription opioid medicine overdose) with improvement. During a review of Resident 1 ' s GACH 3 Urine Drug Screen [UDS- used to detect illegal and some prescription drugs in the urine] dated [DATE] timed at 12:15 PM, the UDS indicated Resident 1 ' s urine indicated Presumptive Positive [shows a response, which is usually because a drug is present] for Fentanyl Urine and Opiates [a drug that contains opioids (a class of controlled drug used for moderate to severe pain)], Urine. During a review of Resident 1 ' s GACH 3 Physician Progress Notes dated [DATE], the Progress Notes indicated Resident 1 ' s Chest X-ray [a way for providers to get pictures of the inside of your body] and CT [Computed Tomography - an imaging test that helps healthcare providers detect diseases and injuries] of the head did not indicate any acute abnormal process. The GACH 3 Physician Progress Notes indicated under Problem List, indicated Resident 1 had syncope (a loss of consciousness for a short period of time), unresponsiveness, opiate overdose, possible respiratory arrest [a condition that exists at any point a patient stops breathing] due to accidental fentanyl overdose, and fentanyl/opioid positive on UDS. The Progress Notes further indicated to continue monitoring Resident 1 ' s vital signs [clinical measurements, specifically pulse rate, temperature, respiration [breathing] rate, and blood pressure] and administer Narcan as needed. During a review of Resident 1 ' s facility records titled admission Record indicated another readmission back to the facility on [DATE], with diagnoses that included syncope and collapse [fall down], personal history of other specified condition, flaccid hemiplegia affecting left non dominant side and COPD. During a review of Resident 1 ' s facility records titled Nursing admission Screening/History dated [DATE] indicated Resident 1 was readmitted back to the facility from GACH 3 with the following reasons . Possible respiratory arrest . Unresponsive and Syncope. During a review of Resident 1 ' s facility records titled IDT /Comprehensive Care Plan Summary dated [DATE], indicated the IDT met with Resident 1 and reviewed Resident 1 ' s plan of care. The IDT record indicated Resident 1 was re-admitted from GACH 3 on [DATE] , under the care of Physician 1 with left flaccid paralysis/hemiplegia [loss of strength in the arm, leg, and sometimes face on one side of the body], cerebrovascular accident [CVA -caused by blood clots and broke vessels in the brain), hepatic encephalopathy (brain disfunction caused by liver disfunction), anxiety (condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), hypertension (a condition in which the force of the blood against the artery walls is too high) .and bipolar disorder (a disorder associated with episodes of mood swings). The IDT record further indicated that the IDT had met with Resident 1 today [[DATE]] regarding GACH 3 reports of Fentanyl overdose. The IDT record indicated Resident 1 denied taking any medications other than what was prescribed for him. The IDT record indicated, Resident 1 denied taking opioids and/ or any other illegal substance. The IDT record indicated . Will continue to monitor Resident 1 ' s condition. Will provide frequent visual check for safety. Will continue current plan of care. During a review of Resident 1 ' s facility records titled Telephone Order (TO) dated [DATE], the TO indicated Physician 1 ' s telephone orders to continue previous medications and treatments as ordered. During an interview and observation on [DATE] at 1:43 PM, with Resident 1, Resident 1 was observed sitting in the wheelchair at the facility ' s Dining Room. Resident 1 stated, The day ([DATE]) I went to the hospital [GACH 3] I took a pill my friend gave me; it was supposed to make me feel better. I don ' t remember what happened that day, I woke up in the hospital (GACH 3). Resident 1 stated his friend dropped off the pill in front of the facility through the gate. Resident 1 stated the facility ' s security guard was present outside, when his friend gave him the pill. Resident 1 stated the security guard was not paying attention when he was handed the pill through the facility gate. Resident 1 stated he did not want to say who the friend was who gave him the pill. Resident 1 further stated, I learned my lesson and I would not do that again. During an interview on [DATE] at 3:45 PM with the ADM and concurrent record review of the facility ' s investigation regarding the incident that happened with Resident 1 on [DATE], the ADM provided typewritten staff interview statements that indicated the following information: -Facility record titled Facility Interview dated [DATE] and signed by the facility ADM, indicated a typewritten statement from Registered Nurse [RN] 1. The interview statement indicated, Registered Nurse (RN 1) stated that on she saw Resident 1 ' s change of condition. Immediately went to help and call 911. Did not notice anything unusual during the shift. -Facility record titled Facility Interview dated [DATE] and signed by the facility ADM, indicated a typewritten statement from Certified Nursing Assistant (CNA) 1. The interview statement indicated CNA 1 had [Resident 1] for an assignment. CNA 1 responded to the change of condition. Did not notice anything unusual during the shift. No visitors for Resident 1. No out on pass, aware of. -Facility record titled Facility Interview dated [DATE], and signed by the facility ADM, indicated [CNA 2] responded to the change of condition. Did not notice anything unusual during the shift. -Facility record titled Facility Interview dated [DATE], and signed by the facility ADM, indicated [CNA 3] night shift, did not notice anything unusual. No issues. -Facility record titled Facility Interview dated [DATE], and signed by the facility ADM, indicated [Resident 1] does not recall taking anything unusual. Felt fine until the incident, feels safe, no issues with facility. During an interview on [DATE] at 2:10 PM, CNA 1 stated she came in to work at 6:30 AM in the morning of [DATE] and remembered seeing Resident 1. CNA 1 stated before 8 AM, she helped Resident 1 get out of bed and up to the shower chair. CNA 1 stated that after the shower, CNA 1 took Resident 1 to the bathroom dressed him and helped him brush his teeth and get dressed. CNA 1 stated she recalled seeing Resident 1 wheeling himself out in his wheelchair into the hallway between 8:30 AM to 9:00 AM. CNA 1 stated a few minutes after that she heard RN 1 calling for help for Resident 1. CNA 1 stated she rushed over and saw Resident 1 looked pale and blue. CNA 1 stated, the paramedics arrived and took Resident 1 between 9:20 AM to 9:30 AM on [DATE]. During an interview on [DATE] at 2:15 PM, RN 1 stated she remembered in the morning of [DATE], Resident 1 came up to RN 1 to get his medications after breakfast around 8:50 AM to 9:00AM. RN 1 stated she gave Resident 1 an Ibuprofen (over the counter pain medication), for pain. RN 1 stated seeing Resident 1 wheeled himself away and was hanging out with the other residents in the hallway. RN 1 stated around 9:30 AM, she saw Resident 1 in the facility hallway in his wheelchair, drooling, with the head tilted to the side. RN 1 stated she called a Code Blue (a code that indicated that someone is experiencing a life-threatening medical emergency) and asked a CNA [unknown CNA] to assist her to put Resident 1 down to the floor. RN 1 stated Resident 1 ' s oxygen saturation level on [DATE] was around 91% to 92% [normal oxygen saturation levels are 95 % to 100%]. RN 1 stated she increased Resident 1 ' s oxygen level to 10 Liters (a unit of measurement) and instructed someone to call 911 emergency services. RN 1 stated Resident 1 would slightly open his eyes after he got oxygen but could not talk. During an interview with on [DATE] at 2:24 PM, with the DON, the DON stated Resident 1 was transferred to GACH 3 on [DATE], after being found unresponsive and drooling. The DON stated on [DATE], before Resident 1 arrived back at the facility, the DON spoke to a GACH 3 licensed nurse, who notified the facility that Resident 1 ' s urine drug test, tested positive for Fentanyl and other opiates. The DON stated the GACH 3 licensed nurse stated Resident 1 was admitted to GACH 3 for medication overdose. The DON stated there was no way he [Resident 1] can overdose . that did not happen. I think it was a stroke because of Resident 1 ' s history of CVA [cerebrovascular accident]. During the same interview on [DATE] at 2:24 PM and concurrent review of Resident 1 ' s Medication Administration Records (MAR) for [DATE] to [DATE], the DON stated that Resident 1 was not on Fentanyl or any types of opioid medications prior to the change in condition [syncope and unresponsiveness] on [DATE]. During another interview and concurrent record review on [DATE] at 2:45 PM, Resident 1 ' s active care plans was reviewed with the DON. During the interview, the DON stated there was no documented evidence that a care plan was developed for Resident 1 ' s history of drug abuse in the past as indicated in GACH 2 record dated [DATE] and GACH 3 records dated [DATE], or the recent fentanyl/opiate overdose on [DATE]. The DON stated, We [facility] did not do care plan because it [overdose] did not happen . that he [Resident 1] had an overdose (fentanyl or opioids). The DON further stated that the facility did not have any residents receiving fentanyl. During the same interview and concurrent record review on [DATE] at 2:45 PM, Resident 1 ' s IDT/Comprehensive care pan summary dated [DATE] was reviewed with the DON. When asked what the licensed nurses were monitoring for Resident 1, as indicated in the IDT care plan summary, the DON stated Resident 1 was being monitored for vitals sign abnormalities once a shift. During an interview on [DATE] at 3:24 PM, with the facility ' s security guard (SG 1), SG 1 stated that when someone comes to the facility gate, he would open the gate and inform the nurses. SG 1 stated he was never instructed to intervene or question if an unknown individual was seen outside the gate talking to a resident in the facility. During the same interview, on [DATE] at 3:24 PM, the SSD stated when a new resident is admitted or readmitted to the facility, the facility SSD and the licensed nurses would go over all of the resident ' s GACH records. The SSD stated that the SSD would complete a full social services assessment upon admission/readmission. The SSD stated the facility did not order or arrange any behavioral referrals for Resident 1 to see a psychologist or psychiatrist [a doctor specializing in the diagnosis and treatment of mental illness] for substance abuse counseling upon his readmission on [DATE], from GACH 3. During a concurrent interview and record review of Resident 1 ' s care plans developed from [DATE] to [DATE], with the facility ' s SSD on [DATE] at 2:22 PM, the SSD stated there was no care plan developed for Resident 1 ' s history of substance abuse from [DATE] and [DATE] facility readmissions. The SSD stated she did not know Resident 1 had a history of drug abuse as indicated in the GACH 2 Social History record, dated [DATE]. The SSD further stated Resident 1 did not have care plans developed for fentanyl overdose or drug abuse or any type of surveillance monitoring for substance abuse, because the facility did not believe Resident 1 ' s fentanyl and opiate overdose was real. The SSD stated the facility did not have any residents taking fentanyl medications. The SSD stated she did not search Resident 1 ' s entire room and belongings to search for illicit drugs, with Resident 1 ' s consent on [DATE] upon Resident 1 ' s readmission back to the facility from GACH 3 on [DATE]. During an interview on [DATE] at 4:29 PM with the DON, the DON stated there was no care plan developed to perform voluntary inspections of Resident 1 ' s room and belongings for possession of illicit drugs, upon Resident 1 ' s readmission from GACH 3 on [DATE]. The DON stated she searched Resident 1 ' s room on [DATE] with another facility staff but could not recall who the staff was and did not document the inspection. During a review of the facility ' s P&P titled, Management of Illicit Drug Use [not dated], the P&P indicated the purpose of the policy was To establish a consistent, complaint, and legal response to the identification, prevention, and management of illicit drug use among residents to ensure safety . The aim is to ensure the safety of all residents, staff, and the facility. The P&P further indicated 1. Prevention and Education- All new resident ' s history and physical will be reviewed upon admission for substance abuse history. This information will guide care planning and the prevention of potential issues. During a review of the facility ' s P&P titled, Referrals, Social Services revised on [DATE], the P&P indicated Social Services personnel shall coordinate most resident referrals with outside agencies . The P&P further indicated 3. Referrals for residents with psychological, history of alcohol or substance abuse related needs must be based on physician evaluation of resident need, after which Social Services will collaborate with the nursing department to arrange for recommended services. 4. Social services will collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician. 5. Social services will document the referral in the resident ' s medical record. 6. Social services and administration will maintain a listing of referral agencies that may provide assistance or therapy to residents with special problems and/or needs . During a review of the facility ' s P&P titled, Behavioral assessment, intervention and monitoring revised [DATE], the P&P indicated 1. The interdisciplinary team will thoroughly evaluate new or changing behavioral symptoms in order to identify underlying causes and address any modifiable factors that may have contributed to the resident ' s change in condition The care plan will incorporate findings from the comprehensive assessment and be consistent with current standards of practice. During a review of the facility ' s P&P titled Care plans, comprehensive person-centered, revised on [DATE], the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical and functional needs is developed and implemented for each resident.