On June 24, 2025, the Department received a Special Incident Report regarding the hospitalization of a Resident (R1), who was found to have suffered an apparent medication overdose on the morning of 6/19/25. After a subsequent Health and Safety visit revealed R1 had a known history of suicidal ideation, the Department initiated a full investigation to determine whether facility neglect contributed to the incident.

The Department’s investigation included a review of facility and hospital records, as well as interviews with staff and outside sources, including medical professionals and law enforcement.

R1’s facility records indicated that they were admitted to the facility in November of 2024 with previous diagnoses that included suicidal ideation, Major Depressive Disorder, and bipolar disorder. Records found in the facility from R1’s prior Skilled Nursing Facility (SNF) corroborated that R1 had a history of suicidal ideation and required extensive assistance with Activities of Daily Living (ADLs), Medication Management, Safety Monitoring, and oversight of overall health status. A review of R1’s Hospice Care Plan dated 6/2/2025 and applicable through 6/23/2025 listed several comorbidities which included depression, and suicidal ideations. According to their pre-placement Appraisal conducted on 11/25/24, R1 had depression, and required assistance with medications, and observation for pain or depression.

[Continued on LIC 809C]

• Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

• Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

A review of Hospital records dated June 19, 2025, confirmed that R1 was brought in by ambulance after being found by their Hospice Nurse (OS1) with an altered level of consciousness, and three empty bottles of Benadryl. Law Enforcement records were also reviewed which corroborated that R1 was found with empty bottles of Benadryl, had a history of Suicidal Ideation, and that R1 was taken to the hospital on a 5150 hold.

On 8/6/25, the Department interviewed the Administrator (ADM) as well as the facility staff that responded to the incident (S1 and S2). All three had worked in the facility for more than one year and were aware that R1 had a history of drug abuse and required medication management by facility staff. S1 observed R1 exhibiting signs of depression but was unaware of any suicidal ideation. S2 did not believe there was anything documented but clarified a hospice nurse had recently told them that R1 had thoughts of suicide. The Administrator (ADM) confirmed they were notified during R1’s admission that they had suicidal ideations, as well as a history of drug abuse and was drug seeking.

When asked about the day of the incident, S2 and S3 explained that they responded to R1’s room after being alerted by R1’s Hospice Nurse (OS1) that R1 was in bed, difficult to wake and could not verbally respond. OS1, S2, and S3 discussed that R1 was likely suffering an overdose, as three (3) empty bottles of allergy medication were discovered next to the bed. After observing that R1 was lying in bed lethargic and unable to verbally respond, S1 called the facility administrator and R1s responsible person (OS2). S2 left the room to find the facility administrator (ADM), who was in their office with OS1. After observing OS1 phoning CVS and their supervisor, S1 resumed their duties shortly after. The Department interviewed ADM who corroborated that they first learned of the incident after being approached by OS1 in their office. ADM clarified that they themselves phoned 9-1-1 after learning that 9-1-1 had yet to be called. When asked for clarification by the Department, both S1 and S2 confirmed that they did not phone 9-1-1, and they believed that approximately 30 minutes had elapsed before the facility administrator eventually called 9-1-1. S2 further believed R1 was having a medical emergency and believed that OS1 should have called 9-1-1 the moment R1 was discovered.

On 8/6/25, the Department interviewed Outside Source 1 (OS1), who confirmed that on the day of the incident, they arrived to R1’s room at approximately 11:35 am, and observed them leaning over, swaying next to their bed. R1 appeared disoriented, lethargic, and was unable to respond to questions. After checking R1’s vitals and placing them in their bed, OS1 observed three (3) empty bottles of allergy medication on R1’s bedside table.

[Continued on LIC 809C]

As R1 could not be kept awake, OS1 alerted facility staff after which S1 and S2 responded. The next day, the Department further questioned OS1 regarding the timeline of events. OS1 could not confirm the amount of time that had elapsed, but believed that law enforcement arrived at 12:15pm, approximately 45 minutes after R1 was discovered.

On 8/6/25, the Department interviewed R1 who confirmed that they had been taking the over the counter allergy medication for about six (6) months, and that they purchased the medication online, which was delivered along with snacks from CVS pharmacy. R1 believed the normal dosage was 2-3 pills, however they were taking six (6) pills before going to sleep. R1 could not confirm how many pills were taken before they were sent to the hospital, and believed they did not need to tell facility staff about the Benadryl as it was over-the-counter medication. During their interview with the department, ADM corroborated that prior to the incident regarding R1, there were no written policies in place regarding package deliveries, however staff have since been instructed to contact delivery personnel and observe packages for concerns. [See LIC 811 for list of confidential names]

Based on interviews conducted and records reviewed, the preponderance of the evidence shows that facility staff were aware that R1 had suicidal ideation, required monitoring, and obtained and consumed medications they were not capable of self-managing, resulting in an overdose requiring hospitalization. Further evidence shows that facility staff did not immediately phone 9-1-1 for R1’s medical emergency. Two (2) Deficiencies are being cited in accordance with the California Code of Regulations, Title 22, Division 6, and listed on the 809 D. As the violation resulted in the illness of a resident, an immediate $500 civil penalty is hereby assessed per Health and Safety Code 1569.49 (see LIC 421IM, attached). It shall also be noted that additional civil penalties are under review by the Department and may be assessed at a later date.

An exit interview was conducted with Administrator and a copy of this report, LIC 809D, LIC 421IM and Licensee/Appeals Rights (LIC 9058 01/16) will be provided at the conclusion of the visit. Signature below confirms receipt of the documents.