complaint·March 23, 2026

Six of six staff deny this allegation, the facility capacity is fifteen residents, and (15) residents currently reside in the facility. Five of five residents could not corroborate this allegation; residents’ do not know the business operations of the facility. Residents stated not knowing the number of residents in care and that the is staff adequately able to provide assistance to all the residents with their physical needs. Based on LPA observations; residents physical count and number of beds, record review and interviews. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Regarding the allegation: Facility is operating with insufficient staffing. It is alleged that the facility is improperly staffed, particularly during the evening and the nighttime. Six of six staff deny this allegation, according to the staff roster facility has sufficient staff to assist residents and to meet the residents needs and services. Four to five (4-5) staff are scheduled in the AM shift: 5AM- 1PM, four (4) staff are scheduled for PM shift 1pm to 9PM and one (1) staff during NOC shift (9pm- 5am). According to Administrator staff will work past regular scheduled shifts to assist with residents when required. Four of five residents stated the facility has adequate staff and residents are assisted with their daily needs and services. One of five residents stated facility could hire more staff, but is happy with the current staff persons. Based on LPA observations of residents’ rooms and residents’ bedding, and records review. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. A copy of this investigation complaint report was provided to Administrator Clememcia Bousheri.