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F0725
D

Insufficient Staffing Resulting in Delayed Resident Care

Waterford, Michigan Survey Completed on 10-24-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple observations, interviews, and record reviews. One resident, who required assistance with most activities of daily living and had intact cognition, reported frequent staffing shortages and significant delays in having their call light answered, resulting in unmet needs. Another resident, who was dependent on staff for care due to hemiplegia, hemiparesis, and dementia, was reportedly left wet for several hours during a day shift when only one CNA was available to care for all residents on the first floor. Staffing records confirmed that only one CNA was present for approximately 4-5 hours, and additional help did not arrive until after lunch. Staff interviews corroborated that the staffing shortage led to delayed responses to call lights, residents not receiving bathing, and some residents remaining wet longer than appropriate. The staffing coordinator acknowledged a call-off that was not covered, and CNAs reported confusion about assignments and lack of timely communication regarding the need for assistance. Facility documentation indicated that staffing should be based on resident acuity, but on the day in question, the staffing was insufficient to meet resident care needs.

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