Health inspection·January 29, 2026

Title 22, Division 5, Chapter 3 §72513 (e). The administrator shall be responsible for informing the Department via telephone within 24 hours of any unusual occurrences as specified in Section 72541. Title 22, Division 5, Chapter 3 §72541. Occurrences such as ... unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. On 10/14/25 1:10 p.m., an unannounced visit was conducted at the facility to investigate an anonymous complaint regarding a resident, (Resident 1) who was found unconscious and was later diagnosed with an opioid overdose. The Department determined during the investigation of a complaint that the facility failed to report to the Department within 24 hours when Patient 1 was found unconscious in a room. Resident 1 was resuscitated by paramedics and later transported to an acute care hospital for post-resuscitation care and monitoring due to an opioid overdose. This failure prevented the regulatory agency from being able to timely monitor the facility's response and ensure appropriate follow-up action was taken to prevent recurrence. A review of the facility's records indicated on 9/29/25, Patient 1 was found unresponsive following an apparent overdose. The facility staff called the paramedics and the local law enforcement, and the patient was transported to an acute care hospital after Narcan was administered. Patient 1 was treated for a drug overdose and was hospitalized overnight at the hospital. A review of Patient 1's "Admission Record (AR)," indicated Patient 1 was admitted to the facility on 9/9/25 with diagnoses including Alcohol abuse, Psychoactive Substance abuse, Chronic Pain syndrome, Psychosis (mental health condition characterized by a loss of touch with reality), Depression (mood disorder that causes a persistent feeling of sadness and loss of interest), and Anxiety (mental health condition characterized by excessive worry, fear, and nervousness). A review of Patient 1's admission Minimum Data Set (MDS - a standardized assessment and screening tool) dated 9/16/25, Section C indicated a brief interview of mental status score of 11 (BIMS - a measurement of cognitive abilities that ranges from 0 to 15 with scores of 8 - 12 indicates moderate impairment). On 11/14/25 at 4:32 p.m., Patient 1 was observed awake in bed. Patient 1 confirmed he was sent to an acute care hospital for opioid overdose. A review of Patient 1's "Progress Notes (PN)," indicated Patient 1 left out on pass on 9/29/25 at 10:01 a.m. and returned to the facility at approximately at 6:30 p.m. the same day. During an interview with a Licensed Nurse (LN 1) on 10/16/25 at 3:28 p.m., LN 1 stated that Patient had gone Out on Pass during the day of the incident (09/29/2025) and came back around 6:30 p.m., and a Certified Nursing Assistant (CNA 1) confirmed Patient 1 had checked in and was notified when Patient 1 was back. CNA 1 claimed to have seen Patient 1 between 7:00 to 7:15 and he was OK. In about 15 minutes later the door was closed. And around that time was when LN 1 was notified by the CNA and when LN 1 got to the room Patient 1 was found face down in between the bed and the closet and was unconscious. LN 1 explained that Patient 1's oxygen levels were in the lower 80s. Paramedics were called and so were the local law enforcement, and the paramedics later resuscitated Patient 1. LN 1 stated that the police officer that came stated it looked like an overdose issue with Patient 1 and Narcan (a medication used to reverse or reduce the effects of opioids) was given. LN 1 further stated that the officer showed her the piece of foil which had residue of a white powder on it and a lighter with a pill crusher on the bedside table. LN 1 further stated that a family member of Patient 1 had expressed concerns about Patient 1 when out on pass because of the history of substance abuse and that Patient 1 might take something or buy something given the history of substance abuse. An interview with CNA 1 on 10/23/25 1:11 p.m., the CNA explained that on the day of incident, the CNA went to Patient 1's room to answer a call light but did not know who activated the call light because Patient 1 was found on the floor unconscious and a piece of foil with white powder on his bedside table. Immediately, a nurse was notified, and the supervisor called 911 paramedics and a police officer arrived and attended to the patient. The CNA stated Patient 1 was later taken to a hospital. A review of Patient 1's "Emergency Department Physician Notes (EDPN)," dated 9/29/25, the EDPN indicated Patient 1 was at the hospital for an overdose incident. Per Emergency Medical Services (EMS) Patient 1 had pinpoint pupils upon arrival. Narcan was given intramuscular (IM) and Patient 1 responded shortly thereafter, and Patient 1 later admitted to using opiates (substance used to treat pain or cause sleep). The EDPN indicated the police also found drug paraphernalia (equipment that is used to produce, conceal, and consume drugs) on Patient 1 at the facility. During an interview with the Director of Nursing (DON) on 10/16/25 at 2:12 p.m., the DON confirmed that the drug paraphernalia found in Patient 1's room was a piece of foil, white powdery substance, and a pill crusher. During an interview on 10/16/25 at 3:53 p.m., with the DON, the DON acknowledged Patient 1's opiate overdose incident was not reported to the Department by telephone or e-mail, and it should have been. The DON stated, "at the time, I didn't know, but it should have been reported." A review of the facility's policy and procedure (P&P) titled "Unusual Occurrences," dated 8/2025, the P&P indicated, "1. Unusual occurrences shall be reported by the facility within twenty-four (24) hours either by telephone (and confirmed in writing) or e-mail to the local health officer and the Department... Definitions: Unusual Occurrences such as... poisonings... or other... unusual occurrences which threaten the welfare, safety or health of patients..." The facility failed to report to the Department within 24 hours when Patient 1 was found unconscious in a room. Patient 1 was resuscitated by paramedics and later transported to an acute care hospital for post-resuscitation care and monitoring due to an opioid overdose.