complaint·December 9, 2025

...Continued from 9099 obstructive pulmonary disease (COPD) with acute exacerbation.R2 was discharged from SNF on 9/21/23. In R2’s discharge notes it states that “resident will be admitted to Cabrillo hospice services as resident requested”. R2 died three days later on 9/24/2023. R3 moved into the facility on 9/02/2023 after being discharged from Carmel Mountain Rehabilitation & healthcare. R3 was transferred to the facility by Cabrillo Hospice and their SNF discharge plan states that Cabrillo Hospice would be providing home health and DME for R3. R4 had compression fracture of t-11 and t-12. R4’s Transfer had been arranged by Cabrillo hospice, after they were discharged from Bella Vista Health Center on 8/28/2023. In R4’s Care notes from Bella Vista on 8/24/2023 state that R4 “may have hospice eval by Cabrillo Hospice and may discharge on 8/28”. R5 was on hospice and had been declining before their death on 9/22/23. On the allegation: Staff restrained residents R6 was admitted to the facility on 7/21/23 and was in hospice. R6 was admitted with DME and supplies including a hospital bed. At admission R6 was listed as a fall risk. In R6’s hospice notes there is no mention of encouraging R6 to get out of bed. The hospice care notes mention repositioning R6 on 8/21/23 and 9/4/23 and referred to teaching caregiver to turn R6 every two hours as tolerated by the patient. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.