F0677

E

Failure to Provide Planned ADL Care and Showers Due to Staffing Shortages and Missed Assistance

Jackson, Michigan Survey Completed on 02-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide activities of daily living (ADL) care, including toileting, hygiene, transfers, and showers, as outlined in residents’ care plans and reflected in their MDS assessments. Multiple residents who were dependent on staff for ADLs reported not receiving timely or adequate care, and task documentation showed numerous missing entries for required care. One cognitively intact resident with severe morbid obesity, muscle wasting, and depression reported being put to bed early due to staffing issues and described an incident where she was transferred to bed late at night and not gotten out of bed until after mid-afternoon the next day, remaining in a soiled brief and reporting skin breakdown with no follow-up. A concern form documented her allegation of being left 14 hours without staff checking on her and being told she had to go to bed, but the facility’s internal form only reflected staff statements that she had been gotten up and changed, with no supporting evidence in the medical record and no documentation that the allegation of neglect was reported to the state.

Another resident with a history of stroke, right-sided weakness, and depression, who was dependent on staff for transfers, bed mobility, hygiene, dressing, showering, and toileting, had multiple undocumented ADL and hygiene tasks and missed showers on task reports over several weeks. During observation, this resident was found in bed with a family member expressing upset that the sheets were soiled and the resident was leaning in bed almost falling out. The family member stated that every visit resulted in complaints to staff about care concerns, including staffing, call light response times, and lack of dignity and respect, and that she was not aware of any formal concern form process. Another cognitively intact resident requiring moderate to maximum assistance for toileting and bathing reported not having received a shower for two weeks and only one shower in the prior two months, despite multiple complaints and completion of a concern form, with task reports showing multiple undocumented ADL and toileting tasks and several missed showers.

Additional residents with significant physical impairments and dementia, who required two-person assistance for transfers and toileting and staff assistance for showering and personal hygiene, were not provided ADL care as planned during a night shift when no CNA staff were present on one floor. A CNA reported that on that night, one resident was not laid down the entire night, another remained in a chair all night and into the next morning, and a third was found heavily soiled with urine and stool and required a shower after being left in a chair for the entire 12-hour shift. An LPN confirmed that no CNAs worked that night on the affected floor, that a CNA had stayed over late to get most residents to bed but left three residents up in chairs who remained in the same clothing until morning, and that management was informed because resident care needs were not met and there was a potential allegation of neglect. The scheduler reported chronic inability to fill CNA positions on multiple shifts, being instructed to add non-CNA staff to the schedule, and submitting concern forms about unmet care needs and staffing at least twice weekly.

Another resident with severe cognitive impairment, pneumonitis, severe protein-calorie malnutrition, non-pressure ulcers, dementia, and peripheral vascular disease required substantial assistance with showering and personal care and was dependent on staff for toileting and perineal hygiene. Family members reported that during a three-week stay, this resident received only one shower, wore a pull-up that he manipulated to urinate into a urinal, and was given a bedpan despite his inability to use it and his stated need for a commode. They described an incident where he was placed on a toilet with the call light behind him and out of reach, leaving him to yell repeatedly for help until someone responded. Task sheets showed that scheduled showers on multiple dates were not provided, with no reasons documented, one refusal documented without evidence of additional attempts, and no documentation that CNAs notified a nurse when showers were not completed. The DON stated that her expectation was that CNAs would re-approach residents and notify the nurse if showers could not be given, but the record contained no such documentation, further demonstrating the failure to provide and document ADL care as required.

Across these residents, interviews with CNAs and nursing staff indicated that staffing shortages forced staff to choose between passing meal trays and providing hands-on care, and that routine two-hour checks and changes could not be completed for all residents. The NHA reported no knowledge of the three residents left up all night and stated there were no concern forms for several of the affected residents in the prior 30 days, despite staff and scheduler reports that concerns and potential neglect had been reported. These observations, interviews, and record reviews collectively show that seven residents did not receive ADL care per their care plans and MDS-identified needs, including missed showers, prolonged periods without toileting or repositioning, remaining in soiled conditions, and lack of timely assistance with transfers and toileting, in the context of documented and reported staffing shortages and incomplete documentation of care.