Complaint Investigation Report

The complaint alleges that Staff implemented a restrictive facility environment for resident in care (R1) and R1’s personal rights were violated. The complainant states that the facility did not allow resident R1 access to the facility and could not leave the facility without family or chaperone. LPA Nakagawa reviewed documentation and found that the facility conducted a 2-week assessment to monitor for safety and level of care of R1; requesting the family provide 24-hour companion care to ensure resident R1’s safety during the assessment period. Administrator stated that during the course of the two week assessment R1 was allowed access throughout the facility, including access to all amenities, programs and interior garden areas. The accessibility of the interior footprint of the facility was never restricted. Access to the exterior of the facility was in accordance with the Physician’s Report of 04/03/2025, which stated that R1 could leave the facility accompanied by spouse, family member or designated staff/chaperone. Companion Care staff (CC1) stated that they were not to be interactive, only monitor and document and were not included in the designated staff (and only there for 2 weeks). On 05/12/2025, R1’s physician wrote a letter stating “R1 was seen on 05/12/2025. R1 may go outside unattended on site anywhere on campus at Atria. R1 may not leave the campus unattended”. Accessibility to the exterior of the facility including sidewalks outside the building was adopted into the Care Plan of R1. Accessibility at the facility was unrestricted; and the resident was not placed in Memory Care. The assessment process included the input from family, physicians, and the facility’s team and assessment tools to ensure that R1’s assessment was thorough and provided the information needed to make a comprehensive decision that would be the least restrictive environment and maintain a safe environment for R1’s placement. Ultimately, accessibility at the facility was unrestricted and R1 was admitted to Assisted Living with spouse. Based on the documentation from the assessment process the allegations that Staff implemented a restrictive facility environment for resident in care and committed a violation of Personal Rights are unsubstantiated. Although the allegations may have occurred, there is not a preponderance of evidence to verify that the allegations occurred therefore the allegations that Staff implemented a restrictive facility environment for resident in care and violated Personal Rights are UNSUBSTANTIATED.