Complaint·January 22, 2026

and staff from smoking inside the facility and 1 out of 9 residents stated they have smoked cigarettes in their room in the past, but management have spoken to them about following the house rules and they haven’t smoked in their room since. R2-R9 stated they have smelled cigarettes and marijuana lingering after residents have been smoking outside, but they have not personally seen any staff member or residents smoking inside the facility at any time. Residents also mentioned that there is a designated patio area for smoking in unit 3 and unit 4 which is used by the residents. Interviews were also conducted with staff members 1-9 (S1-S9) and 2 out of 9 staff members stated there was a resident smoking in their room (R9) in the past and house rules were discussed with them and since their discussion R9 has not been seen smoking in their room, nor have there been reports of R9 smoking inside the facility/room. The interviews with staff members 3-9 (S3-S9) stated they have heard rumors of smoking in residents room, but they have not personally seen them smoking inside the facility in the past or currently. Additionally, staff mentioned that residents have a designated smoking area outside of the facility in unit 3 and unit 4. #2 Allegation: Staff does not ensure food is of good quality and quantity The interviews conducted with Residents 1-9 (R1-R9) were asked about the food being of good quality and quantity and 9 out of 9 residents stated the food was okay and could use more seasoning on it but it’s eatable and if additional servings are requested it is provided or alternative options are available. The interviews conducted with staff members 1-9 (S1-S9) were asked does the staff ensure food is of good quality and 9 out of 9 staff members stated that the food in their opinion is of good quality and at times some residents complain about small portions, but a request for seconds can be made and provided if available. When asked, are there other options available, all 9 staff members said yes. #3 Allegation: Staff does not ensure emergency signal system is in good repair The interviews conducted with Residents 1-9 (R1-R9) were asked about the emergency signal system being in good repair and 9 out of 9 residents stated that the system works but it takes staff a long time to respond. When asked how long it takes for staff to respond, all 9 said it could be 15-30 minutes When asked does their call system works, all 9 said yes. During the tour of the facility LPA did not observe any staff or residents smoking inside of the facility and LPA did not smell any signs of Marijuana or cigarettes being smoked inside of the facility. LPA did observe residents going and coming outside from the designated smoking area in unit 3 and unit 4. LPA also toured the kitchen and LPA observed that there were menus available for review. There was a 7-day supply of non-perishables and a 5-day supply of perishable food. LPA also observed breakfast being served scrambled eggs with vegetables, toast, and raisin brain that was listed on the menu. LPA also tested the call system in rooms 204,209,212, and 216 and all buttons were in working order. Based on interviews, documents reviewed and observation during the investigation, the above allegation is found to be Unsubstantiated; meaning that 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. An exit interview was conducted where this report was discussed and provided to Joel Niblett- Administrator at conclusion of the visit with appeal rights.