On 09/24/2025, at approximately 10:24 a.m., IB Investigator conducted an interview with R1. Additional interviews were conducted on 10/28/2025 at approximately 10:49 a.m. and 11:06 a.m. with two staff members, and at approximately 11:19 a.m. with the Administrator. On 01/14/2026, at approximately 9:05 a.m., IB Investigator interviewed R1’s family member. Further interviews were conducted on 01/16/2026 at approximately 9:15 a.m. and 10:07 a.m. with representatives from Foundation Aiding the Elder (FATE), and at approximately 10:59 a.m. with R1’s family member. On 02/12/2026, at approximately 5:25 p.m., IB Investigator interviewed the former facility Administrator. On 03/13/2026, interviews were conducted at approximately 10:30 a.m. and 11:11 a.m. with former facility administrators, and at approximately 11:27 a.m. with a Highland Hospice nurse. Attempted interviews were also made on 02/27/2026, at approximately 10:13 a.m., and on 03/13/2026, at approximately 10:10 a.m., with R1’s Primary Care Physician (PCP). Additional attempted interviews were conducted on 03/03/2026, at approximately 8:07 a.m., and on 03/13/2026, at approximately 10:06 a.m., with the hospital’s Licensed Clinical Social Worker (LCSW). On 03/13/2026, attempted interviews were also conducted at approximately 10:14 a.m. with an APS nurse; at approximately 10:17 a.m. with an APS Social Worker; at approximately 10:52 a.m. with a representative from Integrity Care Management; and at approximately 10:55 a.m. and 11:36 a.m. with a representative from Los Robles Home Health. IB Investigator also requested and reviewed copies of St. John’s Hospital medical records, Kaiser Medical Center medical records, and facility file documents related to the investigation.

Record review and interviews conducted revealed that R1 was admitted to the facility on 06/12/2021. A review of R1’s Physician’s Report, dated 07/30/2025, listed R1’s primary diagnoses as major neurocognitive disorder due to an unspecified disease, mild, without behavioral disturbance; atherosclerosis of the aorta; hyperthyroidism; inflammatory polyarthritis; migraine; osteoporosis; and dermatitis.

The report indicated that R1 was able to communicate and follow directions/instructions and did not exhibit behavioral expressions such as disorientation, lack of hazard awareness, lack of impulse control, unsafe wandering, elopement, expressions of frustration, or hallucinations.

Report Continued on LIC 9099C...

The investigation revealed that on 08/17/2025, R1 complained of left-sided abdominal pain and nausea and was administered PRN Zofran. R1 was asked whether they wanted to go to the emergency room (ER) for evaluation; however, R1 initially declined. Approximately one (1) hour later, although the pain had decreased, it was still present. R1 was again advised to go to the ER in case the condition was more serious and required medical attention, to which R1 agreed. R1 was subsequently transported by ambulance to the hospital. While at the hospital, R1 underwent testing and was kept overnight for observation.

Record review of hospital records revealed that R1 was admitted to the hospital on 08/17/2025 and discharged on 08/21/2025. Per report, R1 was admitted with left side plank pain which was described as aching and cramping and only on the left side. R1 was noted to be nauseous but no vomiting with one (1) episode of diarrhea in the morning. R1 denied any other symptoms while at the hospital and noted that pain was rather abrupt and consistent since it had started earlier that same day. Upon admission, it was noted that R1 did not meet the criteria for sepsis; however, R1 later developed a fever and became significantly hypotensive, while still not meeting sepsis criteria at that time. By 08/19/2025, while hospitalized, the physician’s assessment indicated that R1 was septic and severely dehydrated. R1 was treated with intravenous (IV) fluids, pain medication, and antiemetic medication. R1 was subsequently discharged on 08/21/2025 to a board and care facility while under hospice care.

Staff interviews revealed that R1 was transported to the hospital after stating they did not feel well and complained of “cramping.” Staff stated that whenever R1 complained of pain, the information was reported to R1’s family, and R1 was subsequently sent to the hospital for evaluation. Staff added that this procedure was followed whenever R1 became ill or complained of pain.

Staff further stated that R1 had eaten all meals during the days preceding the hospitalization and had not complained of any pain or discomfort prior to the day of hospitalization.

Report Continued on LIC 9099C...

Furthermore, PCC’s review of the information and documents obtained during the investigation reflected that although it took a couple of hours for R1 to be transported to the hospital following the initial complaint of pain, R1 had the right to accept or refuse medical care and services. Additionally, R1 did not have a fever or exhibit changes in vital signs prior to hospital admission; therefore, staff would not have recognized a change in R1’s condition. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore allegations “Due to neglect/lack of care: Staff did not seek timely medical care for resident leading to hospitalization for dehydration, sepsis, and urinary tract infection” and “Staff did not notice resident's change in condition” are deemed Unsubstantiated at this time.

It was also alleged that staff did not provide authorized representative a copy of resident's file. It was reported that R1’s family member requested copies of R1’s complete file on 08/22/2025 and had not yet received the requested documents. Record review and interviews conducted revealed that R1’s family member had been appointed as the successor trustee for R1’s trust, but not as Power of Attorney (POA). Furthermore, the LPA was not provided with any legally binding documentation designating R1’s family member as conservator or POA. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore allegation “staff did not provide authorized representative a copy of resident's file” is deemed Unsubstantiated at this time.

No citations issued at this time. Exit interview conducted. A copy of the report was provided.