F0725

F

Insufficient Nursing Staff Leading to Delayed Care and Unanswered Call Lights

Farmington, Michigan Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs, particularly on weekend and night shifts, resulting in significant delays in incontinence care and response to call lights. Payroll Based Journal (PBJ) staffing data for a specified fiscal quarter showed the facility triggered for excessively low weekend staffing. Multiple residents reported inadequate staffing, including a ventilator-dependent resident who stated he activated his call light at 4:00 AM for an incontinence brief change and did not receive the needed care until 7:00 AM, despite staff entering his room twice without providing the requested care. His family member also believed there was not enough staff on weekends.

Additional residents on the first floor reported that during a specific midnight shift there was only one CNA on the floor from 2:00 AM to 7:00 AM, which interfered with timely assistance for a roommate who was scheduled to get out of bed by 6:00–6:30 AM and left two residents on the hallway screaming at one another without staff able to calm them. Another resident, who required two-person assistance, stated they did not believe there was enough staff to meet their needs and cited this as a reason for choosing hospice services to obtain more help with care. During a confidential resident council meeting with 12 residents, eight residents reported there was not enough staff, especially on weekends, describing situations where no staff appeared to be present, managers arriving late in the day, and call lights being ignored or passed by, resulting in waits of over an hour.

Staff interviews further supported the deficiency. One CNA reported that on a day when one CNA had called in, only two CNAs were working on the first floor for 33 residents. Another CNA, assigned 17 residents, acknowledged difficulty in providing timely assistance, including leaving a resident’s bedside table out of reach while preparing for a shower and then having to leave to help others. A CNA assigned to the ventilator unit reported working alone on multiple occasions, including a Sunday evening into the midnight shift, and stated that residents had to wait longer for assistance when call lights were activated while they were helping another resident. A nurse confirmed that on a specific Sunday midnight shift there was only one CNA on the first floor from 2:00 AM to 7:00 AM, with many unanswered call lights. The DON, responsible for staffing and scheduling, stated staffing was based on PPD and census and that managers filled in when staff called off, but initially reported being unaware of staffing problems on the cited night; subsequent review of schedules and time punches showed that two CNAs punched out at 2:30 AM, leaving only one CNA on the ventilator unit and one CNA on the first floor for the remainder of the shift, and the DON and on-call manager were not notified.