Complaint Investigation Report

Regarding allegation “Facility does not have sufficient staffing to meet residents' needs” it was reported that due to inadequate staffing levels, residents’ needs are not consistently being met. The Marketing Director, Ashley Kumar, stated that in occasions staff call out; however, the facility utilizes a staffing agency to cover shifts when employees fail to report for duty. The representative further stated that on some occasions it is difficult to obtain coverage due to short notice from staff who do not come to work. In such instances, caregivers on duty are asked to remain beyond their scheduled shifts to provide partial coverage. Staff interviews revealed that required tasks are often not completed because although the facility schedules an adequate number of personnel, not all scheduled staff report for duty. Additionally, staff reported that caregivers provided through the staffing agency are frequently unfamiliar with the facility and residents’ needs, and in some cases are unable to perform assigned duties. AM shift staff stated that at the beginning of their shift, several residents are observed to be wet and soiled, and assistance with incontinence care has not been completed. Residents interviewed revealed ongoing concerns regarding staffing levels across all shifts. Several residents stated that it is difficult to receive timely assistance during the night shift and that staff do not check on them as frequently as needed. LPA Conway requested and reviewed facility timesheets for the month of September 2025, with specific analysis of staffing on September 18 and September 19, 2025. Review of the records revealed that during the night shift hours of approximately 2:30 AM to 6:30 AM, there were only two (2) facility staff and one (1) agency staff assigned to provide care for approximately seventy (70) residents. Additionally, review of the timesheets identified multiple scheduled caregivers who failed to report for duty during their assigned shifts. Based on the information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation of “Facility does not have sufficient staffing to meet residents' needs” has been SUBSTANTIATED at this time.