Incident investigation·August 15, 2025

At approximately 8:45 a.m. on 08/15/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with staff and disclosed the reason for the visit. Today’s case management visit was conducted after reviewing two (02) incident reports submitted by the facility in which Resident #1 (R1) was admitted to Sherman Oaks Hospital around 10:00 a.m. on 08/02/25 with hip pain and later found unresponsive on the street near Providence-Tarzana Hospital around 2:00 p.m. on the same day. LPA conducted a record review of pertinent documents, including but not limited to R1’s discharge paperwork and face sheet around 9:40 a.m. on 08/14/25 and interviewed Staff #1 (S1) at approximately 9:50 a.m. on 08/14/25. Interview with S1 confirmed R1 was admitted to the hospital during the morning of 08/02/25 for hip pain. R1 was discharged that same day and returned to the facility. S1 later received a phone call from Providence-Tarzana Hospital noting R1 was found unresponsive near the hospital around 2:00 pm.. Record review indicated that R1 was admitted to the Emergency Room at Sherman Oaks Hospital at 11:16 a.m. on 08/02/25 for hip pain, nausea, vomiting, and opioid withdrawal. Discharge paperwork from Providence- Tarzana Hospital indicated that R1 was admitted for an accidental overdose and diagnosed with an altered mental status and opioid dependence on 08/02/25. Review of R1’s face sheet from 07/31/25 revealed they were already diagnosed with opioid dependence prior to these hospitalizations. Today, LPA obtained a resident list around 9:00 a.m. which indicated that R1 was in the hospital. LPA called the hospital around 11:45 a.m. this morning to speak with R1. A nurse in the Intensive Care Unit responded and explained that R1 was admitted yesterday, 08/14/25, for their second overdose in two (02) weeks. Interview with Staff #2 (S2) at approximately 2:00 p.m. today revealed that the home health nurse for R1's roommate reported that they discovered R1 unresponsive in their room around 8:30 a.m. on 08/14/25. The nurse also told S2 that R1 had drugs. Staff called 9-1-1, and S2 performed CPR until paramedics arrived. Review of R1’s plan of care at approximately 2:05 p.m. today revealed staff were to supervise R1 once per shift, or about every eight (08) hours. LPA reviewed a reappraisal from 08/03/25 noted the facility would "continue with wellness check" but did not reference increased supervision. LPA previously addressed the facility’s approach towards residents with substance abuse issues during a case management visit on 03/05/25. Interview with S1 at 12:15 p.m. on 03/05/25 revealed staff were aware of multiple residents drinking alcohol in the facility and staff have not received training on providing care and supervision to residents with substance abuse problems. Interview with the previous administrator at 1:30 p.m. on 03/05/25 revealed the facility could issue a training for all staff on dealing with substance abuse issues as well as updating the facility program plan to address care of residents with substance abuse issues. Based on interviews and record review, the facility did not create an adequate care plan update or reappraisal to address R1's opioid dependence and subsequent overdoses on 08/02/25 and 08/14/25. R1's documents did not address their needs, so staff were unable to prevent R1's second overdose on 08/14/25. Therefore a deficiency is issued today for an inadequate care plan update to address R1's needs and to ensure the facility could provide proper care and supervision for R1. A $500 immediate civil penalty is assessed today for a violation resulting in the overdose of R1. The licensee/administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f). No immediate health or safety concerns were observed during today's visit. Exit interview conducted. Appeal rights discussed. Copy of report provided.