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Inspectors rated the harm level as minimal, or potential for actual harm, affecting few residents.

That is what federal inspectors found when they responded to a complaint at the DeSoto memory care facility in late April 2026.

When inspectors raised the issue during the April 2026 complaint inspection, the administrator acknowledged the gap directly.

None of that made it onto the discharge form.

The resident, identified only as Resident 1 in the inspection report, was admitted to Regency Olympia on February 13, 2026, following a right hip fracture.

The resident, identified in federal inspection records only as Resident 94, was admitted on February 24, 2026 around noon.

She also acknowledged she had not been at the facility that morning.

The April 2026 complaint inspection found that Resident 7, who was on continuous oxygen, had entered the facility's designated smoking room.

He was not wearing a beard restraint.

That finding anchors a complaint inspection completed April 27, 2026, at the skilled nursing facility in Orange, California.

The resident at the heart of it is identified in inspection records only as Resident #89.

The drugs involved were not minor.