complaint·March 24, 2026

During interviews with the residents, ten (10) out of eleven (11) did not corroborate the allegation. One of the residents interviewed stated that they have used their call pendant in the past, and that staff have always assisted them in a prompt manner whenever they have used it. Another resident interviewed stated that they have used the call button to request assistance from staff 2 - 3 times, and that each time staff responded within five (5) minutes and that staff have been helpful on each occasion. During interviews with the staff, none of them corroborated the allegation. During interview with S4, they explained that during the incident R1 had fallen off the side of their bed, and S4 stated that they proceeded with assisting R1 back into bed. S4 stated they initially asked R1 if they had hit their head or were injured and wanted to call 911, however R1 stated that they did not hit their head and did not wish to call 911. Another staff interviewed stated that the facility policy is to call 911 if a resident reports that they hit their head, however in this incident R1 did not hit their head and so paramedics were not called. In regards to the allegation that " Staff did not provide adequate supervision resulting in resident wandering into another resident's room," it is alleged that R11 had wandered into R1's bedroom during the night due to lack of supervision, and fell asleep on their couch, to which R1 requested assistance from staff members to assist R11 to their room. During interviews with the residents, ten (10) out of eleven (11) did not corroborate the allegation. During interview with R11, they stated that they do recall the incident. R11 stated that they recall that they were dizzy and half-asleep, missed the door to their bedroom and went into the wrong room on accident where they fell asleep on R1's couch. R2 - R10 did not report ever witnessing any residents wandering into the wrong bedroom in the past. During interviews with the staff, none of them corroborated the allegation. One of the staff interviewed stated that they were doing rounds to check on residents including R1 and R11, however during their previous check staff did not observe R11 in R1's room. Another staff member stated that after they became aware that R11 was asleep in R1's room, they assisted R11 back to their bedroom, and reiterated that staff do rounds during the night shift to supervise residents and ensure they do not wander into other resident bedrooms. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Sherry Fischer and a copy of this report was provided.