Complaint·April 29, 2026

LPA conducted interviews with residents R1, R2, R3, and R4. No interviews conducted with residents indicated any concerns regarding staffing. Interviews conducted with staff members (S3, S4, S5, S6, and S7) and witness (W1) did not indicate any concerns regarding staffing. LPA observed Raw Time Entry Report for staff schedule. LPA observed the facility to have approximately 13 staff members working in a day. LPA observed that staff were scheduled accordingly to ensure at least one (1) staff member was on shift and to account for breaks and shift changes. Allegation: Residents are not provided with adequate access to the facility's call system. Relevant party reported that residents, including R1, may not have access to their call buttons. Interviews conducted with R1, R2, R3, R4, S3, S4, S5, S6, S7, and W1 did not indicate any concerns regarding the care home's call system. LPA observed call buttons with residents during interviews. LPA tested R1's call button and observed staff respond to R1's call button within three (3) minutes. LPA observed call buttons located in the bathrooms of each resident's apartment. LPA observed call logs for resident R1, R2, R3, R4, R5, R6, R7, and R8 and observed the longest response time was less than ten (10) minutes. Allegation: Facility staff sleep while on shift. Relevant party reported that staff member (S1) has been sleeping at the facility during their shift. Interviews conducted with R1, R2, R3, R4, S3, S4, S5, S6, S7, and W1 did not indicate any concerns regarding staff sleeping while on shift. LPA observed a Corrective Counseling Documentation indicating that, on December 16, 2025, S1 was observed to be sleeping while on duty. S1 denied sleeping during shift per document. Staff member (S2) denied observing S1 sleeping while on duty per document. Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.