Incident investigation·May 22, 2025

Licensing Program Analyst (LPA) Kelly Dulek conducted a case management visit with the purpose of continuing the investigation into a self-reported incident/death report. LPA arrived at the facility at 09:28AM and was greeted by front desk staff. LPA met with Executive Director (ED) Remon Pagels shortly after the visit began. Entrance interview conducted. An incident report and separate death report were received at the Woodland Hills Regional Office on 12/16/2024. Incident report indicated that on 12/15/2024, resident’s family member called the front desk asking for staff to check on Resident #1 (R1). Caregiver went to check on R1 and found R1 “passed away by taking [R1's] own life.” Caregiver called med techs, 9-1-1 was called and ED was contacted. LPA called ED and requested relevant facility documents for R1, including care plan and physician’s report. LPA requested the related police report from Ventura County Sheriff’s Office (VCSO.) LPA received the facility documents on 12/17/2024. The death investigation was referred to Community Care Licensing Division (CCLD)’s Investigation Branch (IB) and was assigned to Investigator Dennis Douglas. Investigator Douglas obtained relevant medical records for R1 and conducted both in person and telephonic interviews with staff, residents, and other relevant parties on the following dates: 01/03/2025, 02/07/2025, 02/18/2025, and 02/19/2025. LPA Dulek then reviewed all documents provided by the facility and IB Investigator. The following was then determined: Record review revealed that R1 had lived in the facility since 07/28/2018. According to facility staff, R1 served as a “facility ambassador” and was typically very social amongst the facility residents and potential new residents. R1 was described by ED as “independent;” incident report indicates R1 was not on care plan, medication management, or status check. Physician’s report signed on 06/14/2019 indicates R1 was able to Report Continued on LIC 809-C store and administer their own prescription and PRN medications and able to care for their own activities of daily living (ADLs.) Diagnoses listed as of 06/14/2019 include but are not limited to: anxiety disorder due to another medical condition and major depressive disorder, recurrent episode. Atria’s Resident Functional Needs Service Plan dated 10/21/2024 also lists these diagnoses and indicates R1 able to self-manage medications and does not require assistance with ADL care. However, on 12/02/2024, R1 was treated for a urinary tract infection (UTI) and was given antibiotics, a catheter, Buspar and Zoloft because R1 was anxious about urinating. R1 returned to the facility. After returning to the facility, staff noted R1 to be staying in their room more often and ordering tray service rather than eating meals in the common dining room. Documents reviewed revealed that Atria staff knew R1 was “having medical issues and depression because of these medical issues.” Staff knew that for about 2-3 weeks R1 did not leave their room for meals and for 2-3 days prior to R1’s death that R1 refused to eat some of their meals. Interview with R1’s family member revealed that R1 was reacting to the medication prescribed and R1 was experiencing increased anxiety. R1’s physician discontinued use of this particular medication on 12/09/2024. Physician explained to R1 and their family member that R1 would continue to experience the effects (bouts of depression) as the medication cycled out of R1’s system over several days. R1’s family member stated they did not directly inform the facility staff of the change in medication, the effect the medication had on R1 nor that R1 expressed suicidal ideations. On 12/15/2024, R1’s family member was unable to reach R1 by telephone and requested the facility staff conduct a status check. Staff found R1 in their room, apparently deceased and called 9-1-1. Responding police deemed R1’s death a suicide and R1’s death certificate indicated manner of death was suicide, cause of death listed as smothering asphyxia. Staff and ED interview revealed that R1 was “independent” and R1’s care plan dated 10/21/2024 does not indicate R1 required status checks, so facility staff stated they did not conduct regular status checks on R1. Executive Director provided LPA with documentation indicating a care task was added on 12/09/2024 directing care staff to “monitor for signs of anxiety” 7 days a week at 08:00AM, 01:00PM and 06:00PM through 12/23/2024. However, the facility did not provide documentation of status checks being completed and staff working on the date of R1’s death stated they checked on R1 due to the call from R1's family member and/or due to R1 not arriving in the dining room for breakfast. Staff did not mention status checks as a regularly scheduled task for R1. Additionally, no reassessment was completed following R1’s change in condition (UTI diagnosis and insertion of an indwelling catheter and increasing anxiety/depression.) And although R1 had previously been socially engaged at the facility, when staff noticed R1 was not leaving their room, no new care plan was initiated for R1. Report Continued on LIC 809-C Additionally, R1’s physician’s report signed on 06/14/2019 indicates R1 was able to store and administer their own medications, so leading up to R1’s death, facility staff was not assisting R1 with medications. However, no new physician’s report was completed due to R1’s change in condition. R1’s family member stated they did not directly inform the facility staff of R1’s change in medications. It should be noted that Atria policy on file with the Department states that all residents, including those who store and manage their own medications, are required to keep a current medication list on file with the facility. ED stated that this policy is no longer in effect, however Atria did not inform the Department of the change in policy. The medication list on file for R1 was dated 07/05/2018, therefore was not updated with the medications prescribed for the UTI on 12/02/2024. Even though the facility did not complete a reassessment nor obtain a new physician’s report or medication list following a change in condition, it is unclear whether these were contributory factors in R1’s suicide. The investigation did not provide sufficient evidence to prove a lack of care and/or supervision led to R1’s death. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency is cited (refer to LIC809-D). ED was informed that failure to correct the deficiency may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.