F0609

E

Failure to Report and Investigate Allegations of Neglect and Unmet Care Needs

Jackson, Michigan Survey Completed on 02-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement policies and procedures to ensure timely reporting of reasonable suspicions of a crime, including abuse and neglect, as required by section 1150B of the Act. The Nursing Home Administrator (NHA) reported that a cognitively intact resident with severe morbid obesity, cervical disc degeneration, muscle wasting, depression, and anxiety alleged she had received no care for 14 hours. The NHA stated this allegation was not reported because it was determined the event did not occur within the prior two hours. A concern form documented that the resident reported being left 14 hours without staff checking on her, not enough staff, and being told she had to go to bed, but there was no evidence that this allegation of neglect was reported to the State. The form was signed by the NHA, and staff witness statements lacked dates and times. Review of the resident’s electronic medical record for the date in question showed no evidence to support that the allegation of neglect did not occur.

During an interview, the same resident, who was calm and able to answer questions, reported that staff often tried to put her to bed earlier than she wanted due to staffing issues and that one night she was transferred to bed late at night and not gotten up until after mid-afternoon the next day because two staff were needed for a mechanical lift. She reported being unhappy about the long period she remained soiled and mentioned recent skin breakdown with no follow-up. Additional residents with intact decision-making abilities and significant physical care needs, including multiple sclerosis with functional quadriplegia, dementia with repeat falls, and Alzheimer’s disease with dependence for transfers and toileting, were also involved in care concerns related to staffing and potential neglect.

A CNA reported that on a weekend night there were no CNA staff on one floor for the entire night shift, and that two residents were left up in chairs all night, with one remaining in the chair into the following morning, and another resident found heavily soiled with urine and stool and requiring a shower after being left in a chair for the entire 12-hour shift. The CNA stated that potential allegations of abuse related to these care concerns were reported to nursing staff. An LPN confirmed that no CNA staff worked that night on the floor, that three residents were left up in chairs and remained in the same clothing when she returned for the day shift, and that management was informed because resident care needs were not met. The NHA reported having no knowledge of these three residents remaining up all night and stated there were no concern forms or additional allegations of abuse over that weekend, while the scheduler reported frequently being unable to fill CNA shifts, documenting care concerns and staffing issues on concern forms, and providing them to the NHA and DON. The report reflects that these multiple allegations and observations of potential neglect and unmet care needs were not consistently recognized, documented, or reported as required.