Complaint Investigation Report

The investigation revealed the following: Allegation #1- Staff did not prevent resident from engaging in inappropriate behaviors.

The details of the complaint alleged that the resident (R1) has a roommate that is sundowning and is up during the night, and R1 has caught the roommate messing with their oxygen tank. It was reported that the resident feels unsafe with their current roommate and would like to change rooms. On 7/1/25, from 10:00am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. 4 of 4 staff denied the allegation that the Staff did not prevent resident from engaging in inappropriate behaviors. All staff (S1-S4) interviewed stated that they had no knowledge that R1s roommate had allegedly interfered with their oxygen tank. They stated that no one told them about this issue and now that they know they will address the issue and take appropriate action.

The department interviewed residents (R1-R10) about the allegation and 9 of 10 residents that were interviewed denied any knowledge of ongoing issues with resident’s engaging in inappropriate behaviors. The majority of the resident’s stated that they either do not have a roommate or that they do not have any such issues with their current roommate and/or other resident’s.

The Department reviewed the Vista Del Mar Senior Living Work Order (Dated: 06/28/2025) and Facility Notes (Dated: 07/01/2025) and observed that a work order was created on 06/28/2025 to move the resident (R1) to another room in the facility. The department also observed that management was made aware of the issue between the two roommates and started the process of taking appropriate actions to resolve the concern. S1 stated that R1 was given an option to switch sides within the room to help resolve the disagreement but R1 declined the offer and chose to stay on their side of the room. Subsequently, the facility decided to move R1 and created a work order to do so on 06/28/2025. R1 is scheduled to be transferred to a new room within a week or so. Once the room has been prepped, the team will assist R1 with their move to their new location in the facility.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff did not prevent resident from engaging in inappropriate behaviors. 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 the allegation is Unsubstantiated .