Complaint·January 6, 2026

During the course of this investigation, Christine Ferris (Department of Social Services Community Care Licensing Investigation Branch) conducted staff and resident interviews (R-1 through R-3) and obtained medical records. All interviewed residents are residing in the Transitional Memory Care (TCM) (where allegation allegedly occurred) and the census for the memory care unit is (36). LPA was unable to interview additional residents from this unit (LPA attempted to interview R-4 through R-6). Bot h, IB Investigator and LPA attempted to interview staff #6 (S-6) and were unsuccessful. Allegation: Staff did not seek timely medical care for resident resulting in injury. Per Christine Ferris (Department of Social Services Community Care Licensing Investigation Branch) investigation, the in-room camera video for 04/20/2025, R-1 was seen falling and could be heard complaining of pain in R-1’s right leg. Caregivers were observed picking R-1 up from the floor and placing R-1 in R-1’s wheelchair, then R-1’s bed. R-1 was visibly and verbally complaining of pain throughout the process and expressed R-1’s right leg and hip area hurt. Per S-4, S-4 did not call 911 immediately because S-4 did not know if R-1 “fell” or “slid” and S-4 wanted to obtain further information prior to calling 911. Per S-1, 911 should have been called immediately. R-1 was later transported to the hospital where R-1 was diagnosed with a fractured right hip. Staff interviews and medical records corroborate this allegation. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiency cited under LIC 9099D. Due to the seriousness of R-1’s injury, an immediate Civil Penalty of $1,000.00 is being issued during today’s visit. An exit interview was conducted. A copy of this report and appeals rights were provided to Dennis Robeniol . During the course of this investigation, Christine Ferris (Department of Social Services Community Care Licensing Investigation Branch) conducted staff and resident interviews (R-1 through R-3) and obtained medical records. All interviewed residents are residing in the Transitional Memory Care (TCM) (where allegation allegedly occurred) and the census for the memory care unit is (36). LPA was unable to interview additional residents from this unit (LPA attempted to interview R-4 through R-6). Both, IB Investigator and LPA attempted to interview staff #6 (S-6) and were unsuccessful. Allegation: Due to lack of supervision, resident was left on the floor for extended periods of time after falls. Per Christine Ferris (Department of Social Services Community Care Licensing Investigation Branch) investigation, it was alleged that on 10/04/2024, R-1 fell and was not discovered for (4) hours. Videos from R-1 in-room camera do not depict any dates or times as well as screenshots of the videos which do depict dates and times. Per the screenshots provided for 10/04/2024, R-1 is seen sitting on the couch in R-1’s room at 0153 hours and staff in R-1’s room at 0605 hours. Per the video, R-1 is seen lowering self to the floor from R-1s bed and attending to a blanket which R-1 placed on the floor. There is no video or screenshot of the time R-1 fell. The facility was unable to provide documentation regarding the time R-1 fell but documentation showed staff found R-1 in R-1’s bathroom at 0540 hours. Regarding R-1’s subsequent falls, documentation provided showed R-1 was discovered within a matter of seconds, minutes, and up to approximately one hour. Per staff interviewed, residents are checked on every (2) hours per shift. R-1 was unable to provide a meaningful statement. Staff interviews and video footage/screenshots do not corroborate this allegation. Allegation: Staff do not ensure resident's walker is within reach. Per staff interviews, R-1 had a walker and wheelchair but could walk independently. Staff interviews revealed that R-1’s would move R-1’s walker away from R-1’s bed. Interviewed staff indicated that R-1 did not always use R-1’s walker, remembered to use the walker or refused to use the walker. Interviewed staff indicated that they would remind R-1 to use R-1’s walker. Interviewed staff indicated that they did not have a log of when R-1 refused to use the walker. Staff interviews do not corroborate this allegation. Refer to LIC 9099C for the continuation of this report. Allegation: Staff did not respond to resident’s alarm mat timely. Per staff interviews, R-1 had a mat alarm next to R-1’s bed on the floor. Interviewed staff indicated that when R-1 stepped on the mat, an alarm would ring on a mat monitor (alert box) which was located in the dining room where there is always staff present. Per staff interviews, the alarm was loud and required staff to manually turn it off when it activated. Interviewed staff indicated that when R-1’s mat alarm would activate, staff would check on R-1 following the alarm notification. Interviewed staff indicated that they did not have a log of when R-1’s mat alarm would activate nor any kind of tracking on the mat monitor (alert box). Staff interviews do not corroborate this allegation. Allegation: Staff did not follow residents fall plan. Per staff interviews, R-1 did not have fall plan in place. Interviewed staff indicated that they conducted rounds “every 2 hours” and encouraged R-1 to use R-1’s walker which R-1 often refused to use or would forget to use it. Interviewed staff indicated that they did not have a log of the rounds that were conducted for R-1. R-1 file did not contain a fall plan in place. Interviews and lack of documentation pertaining to a fall plan do not corroborate this allegation. Allegation: Staff do not ensure residents oral hygiene needs are met. Per staff interviews, staff assisted R-1 with R-1’s oral hygiene. Interviewed staff indicated that at times, R-1 refused oral hygiene and would become physically aggressive with staff when attempting to assist R-1 with oral hygiene. Interviewed staff indicated that when R-1 cooperated with R-1’s oral hygiene (denture placement), staff would ensure that R-1’s dentures had polygrip. Interviewed staff indicated that they did not have a log of when R-1 refused to allow staff assist with oral hygiene. Staff interviews do not corroborate this allegation. Although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted. A copy of this report and appeals rights were provided to Dennis Robeniol.