Complaint Investigation Report

LPA De Leon requested additional records from facility on 12/04/2025. LPA De Leon reviewed records on 12/08/2025, 12/11/2025 and 12/12/2025.

On the allegation: Facility has inadequate staffing. LPA’s conducted interviews with 8 out of 8 staff which revealed the facility has been on and off short staffed from summer of 2024 through summer of 2025. A staff stated residents’ needs are more than they used to be in assisted living. It takes longer to provide care to residents that need two-person assistance and transfers. A staff member stated the call buttons are answered as soon as they can be. If staff are with a resident, staff must finish with the resident before moving on to the next resident, some calls do have longer waiting times if staff are busy with a resident. Another staff member stated staffing is short on the weekends when too many staff are off, or the facility gets staff calling off and nobody to fill the vacant shift. A staff member said staff work alone for several hours on a weekday due to not having enough care staff scheduled to work. A staff member stated the facility hires then cuts back hours based on the needs of the current residents; staff feel the care plans are not updated to reflect the actual current needs of the residents. Administrator stated the facility uses a software system to determine the staffing ratios needed to meet residents’ needs. A staff stated if the care plans are not updated to reflect the current needs of the residents in care, then the staffing ratio requirements would not be sufficient at times. Medication Technicians stated they had to help caregivers, Caregivers stated they had to help in the dining room. A staff member stated they helped with housekeeping. Staff stated the dining room has been short staffed, and the facility was using caregivers to help take orders and get food if there were not enough kitchen staff to do so, the facility stopped using care staff for sanitary purposes. The waiting times for taking orders and getting food were longer at times when there were not enough staff. A staff member stated one of the housekeeping staff had to take off work for a while and some of the regular cleaning schedules were not kept up during a period of 1-2 weeks in resident apartments and in the common areas due to not having enough staff to help clean. A staff member said in 09/2025 the facility had hired more kitchen staff and the facility said it was fully staffed with servers, so the facility asked a server to cover the vacant housekeeper position. A staff member interview revealed activities program director quit, and a new one was not hired for several months leaving activities short staffed for a period of 1-3 months, some staff helped run a few activities during this period, but several activities were cancelled. The activities calendar was not followed during this time. 8 out of 8 staff said the facility has been short staffed for several months over the last year in a few departments.