complaint·September 23, 2025

In memory care staff were assisting residents with playing individual card games while other residents were listening to music. The Executive Director and the Activities Director reported that activities are always provided but many residents choose not to participate, which makes it very challenging for staff. 3 out of 4 residents interviewed reported that they have participated in activities at the facility. Based on the evidence gathered the allegation, is unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, staff did not safeguard resident’s personal items, revealed the following. It was reported that Resident 1 (R1) had their phone taken from them. The Administrator reported that R1’s responsible party refused to have R1’s items inventoried. The Administrator stated that they do not know what items R1 moved in with. Staff 1 (S1) reported that R1’s phone was found outside of their room, so they contacted R1’s responsible party and informed them. S1 reported that they didn’t think R1 could use the phone, so they contacted the responsible party. S1 reported that nothing was done to the phone, and it was given to R1’s responsible party in the condition it was found. R1’s responsible party stated that staff did give the phone back but there were new applications on the phone. R1’s responsible party would not answer any further questions during the investigation. 4 out of 4 staff interviewed reported that when residents’ belongings are found they are turned into lost and found until someone claims them. S1 reported that residents in memory care misplace or lose items, and they give it back to the resident or contact the responsible party. No other items were reported missing. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, Resident is not accorded privacy during visits, revealed the following. It was reported that during visits with R1 the family was not given privacy and visits were only allowed in the resident's room 2 times. At the time of the report, visits were allowed at facilities as long as Covid-19 precautions were implemented such as social distancing and wearing masks as outlined in PIN 21-17.1-ASC dated April 23, 2021 and PIN 21-17.2-ASC dated May 14, 2021. The Executive Director reported that all visitors are given privacy and had the choice of visiting in residents’ rooms, in the common areas or outside. 4 out of 4 staff interviewed reported that none of the visitors were denied access to residents' rooms or denied privacy on visits. R1’s responsible party did not answer any questions regarding visitation. 4 our of 4 residents interviewed reported they have always been given privacy during their visits. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, resident was malnourished while in care, revealed the following. It was reported that R1 lost 18 pounds during their stay at the facility and was not fed properly. 4 out of 4 staff interviewed reported that Resident 1 (R1) ate and had no issues with food. The Executive Director reported that R1’s responsible party requested meal logs showing R1 was eating and they were provided. A review of the records shows R1 ate breakfast lunch and dinner during their time at the facility from May 1, 2021 to May 18, 2021. On May 19, 2021 R1’s responsible party had R1 sent to Newport Bay Hospital. R1’s physician’s report showed R1 weighed 200 lbs. on April 5, 2021. Newport Bay Hospital closed on February 22, 2023 so no records are available to compare R1’s weight. R1’s where abouts are unknown. No evidence was gathered to support the allegation, therefore the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.