complaint·March 3, 2026

Interview with Additional Witness 1 (AW1) corroborated statements made by ED and reported that R1 would have monthly medical visits at the facility. AW1 added that visits were increased during the month if concerns were addressed. AW1 reported receiving notice of R1’s transfer to the hospital on February 5, 2025. Interviews with 3 of 3 staff members indicated that R1 tended to keep to themselves and did not typically complain about pain or medical concerns. S2 added that R1 often refused medical assistance and did not observe any concerns during interaction with R1. Interview with R1 revealed that R1 could not recall his experience at the facility or the reason for his hospital stay. Through record review, it was revealed that on February 5, 2025, R1’s Primary Care Provider ordered lab work during the assessment and results required further evaluation. For the allegation that staff did not seek timely medical attention for R1, it was reported that facility staff delayed medical intervention. During an interview, ED stated that on February 5, 2025, R1’s PCP contacted the facility and instructed staff to arrange medical transport due to abnormal lab results. ED reported that R1 was transported the same day as directed in a timely manner. An interview with AW1 confirmed that they were informed R1 had been transported to the hospital on February 5, 2025, due to concerning laboratory findings. R1 was unable to recall their experience at the facility or the reason for hospitalization. A review of records obtained revealed that R1 was admitted to Hemet Global Medical on February 5, 2025. Intake notes indicated that R1 reported only back pain at the time and did not express additional discomfort. Additionally, Community Care Licensing Division received a Special Incident Report stating that on February 5, 2025, at approximately 2:30 PM, R1’s physician instructed staff to arrange medical transport. The report further stated that instructions were followed in a timely manner and responsible parties were notified. Based on interviews and record reviews, the allegation that staff neglect resulted in a resident to be hospitalized and staff did not seek timely medical attention for a resident is unsubstantiated. A finding that the complaint is unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted. A copy of this report was provided to ED, Teresa Mipilis.