complaint·September 15, 2025

Facility is understaffed resulting in residents waiting for a period of time to be assisted. - UNSUBSTANTIATED It was reported that one staff was attending to 120 residents by themselves, which resulted in residents waiting more than an hour to be assisted. LPA reviewed staff schedule for August 2025 and found staffing to be adequate. There was never only one staff on duty. Executive Director stated that the current census is 80 residents. The number of staff on duty for the AM shift is 1 med tech and two care givers in each house for a total of 9 staff. PM shift is the same with 1 less staff in house 1. NOC has a total of seven staff for all three houses. The average wait time for staff to answer a call light is 12 minutes. It was determined that the facility had adequate staffing for the month of August 2025, and residents are not waiting an unreasonable amount of time for staff to answer call lights. This allegation is unsubstantiated. This agency has investigated the above allegation. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted and a copy of the report was provided to administrator Jacob Stevens.