The incident at Northridge Health Center on April 28, 2025, exposed Resident #23 to drug smoke while he used a nasal cannula for oxygen — a combination that created immediate health risks staff failed to address.
LPN #202 discovered Resident #70 smoking from a pipe while sitting in his wheelchair just inside the bathroom doorway. The door was open. As soon as she entered the room, she could smell the illegal substance and saw Resident #70 smoking.
Resident #23 was lying in bed without his CPAP machine, wearing only his oxygen nasal cannula. The distance between his bed and the bathroom measured approximately seven feet, according to maintenance director measurements taken during the inspection.
Staff documented abnormal vital signs for Resident #23 but failed to assess him for drug exposure symptoms. No evaluation occurred until 4:01 P.M. the following day — nearly 20 hours later.
The Director of Nursing couldn't explain the delay. She told inspectors she "did not have an answer why" no assessment was documented on Resident #23 until the afternoon of April 29.
Multiple nurses required hospital evaluation for their own exposure to the illegal substance. The DON took over their shifts that night, working as charge nurse until 6:30 A.M. the following morning.
Neither Resident #70 nor Resident #23 went to the hospital.
The DON saw Resident #23 sleeping in bed and reported no concerns. She worked the entire night shift but never woke him for a physical assessment, despite the documented exposure and abnormal vital signs.
Clinical Nurse Practitioner #360 told inspectors that drug exposure could cause respiratory issues, including mental status changes. Staff should have monitored the resident for hours to days, depending on exposure levels.
She expected notification of abnormal vital signs but had no documentation of being contacted about Resident #23's condition. She couldn't confirm whether staff had notified her.
Physician #361 explained the medical risks during a telephone interview. If a resident smokes illegal drugs in the same room as another resident, staff should assess both patients' breathing, vital signs, cough, phlegm, and check for headaches.
The exposed resident could experience breathing problems and burning eyes, depending on exposure levels.
LPN #202 revealed additional details about Resident #23's condition during the incident. He often refused his CPAP machine and may have worn it later that night, but wasn't using it during the drug exposure.
The combination of oxygen therapy and drug smoke exposure created heightened medical risks that required immediate assessment and monitoring.
Staff documented the roommate's illegal drug use but failed to follow basic medical protocols for the exposed resident. The facility's response focused on the nurses' hospital evaluations while leaving Resident #23 unmonitored through the night.
The DON's decision to work as charge nurse demonstrated the facility knew about the exposure incident. Yet she made no attempt to wake Resident #23 for assessment during her extended shift.
Federal inspectors investigated the incident under three separate complaints filed against Northridge Health Center. The deficiency represents a failure to provide adequate medical assessment and monitoring following a documented exposure incident.
Resident #23 remained in his bed, breathing oxygen through a nasal cannula, while illegal drug smoke filled the seven-foot space between his bed and the bathroom where his roommate sat smoking from a pipe.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Northridge Health Center, The from 2025-09-11 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Northridge Health Center, The
- Browse all OH nursing home inspections