F0725

E

Failure to Provide Adequate Nursing Staff Resulting in 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 provide adequate nursing staff to meet residents’ needs and to ensure that resident care was consistently delivered as required. One cognitively intact resident with severe morbid obesity, cervical disc degeneration, muscle wasting, depression, and anxiety reported being left in bed from approximately 11:00–11:30 p.m. until after 3:00 p.m. the next day because two staff were needed for a mechanical lift transfer and staff were not available. This resident also reported being left soiled for a long period and having recent skin breakdown, and stated that staff tried to put residents to bed early due to staffing issues, particularly on night shift. A concern form documented allegations that the resident was left 14 hours without staff checking on her, that there was not enough staff, and that she was told she had to go to bed, with no supporting documentation in the medical record to refute the allegation.

Another resident with a history of stroke affecting the right dominant side and depression, who was dependent on staff for transfers, bed mobility, hygiene, dressing, showering, and toileting, reported concerns about insufficient staffing, delayed call light response, and lack of dignity and respect. Review of this resident’s task reports over nearly a month showed multiple gaps in documentation of hygiene, ADLs, toileting, and several missed showers. During an observation, the resident’s family member found the resident’s sheets soiled and the resident leaning in bed almost falling out, and stated that every visit involved raising care concerns to staff without change, and that she was not aware of the concern form process. A third resident, cognitively intact and requiring moderate to maximum assistance for toileting and bathing, reported not having received a shower for two weeks and only one shower in the past two months, with multiple holes in task documentation for hygiene, ADLs, toileting, and showers, despite having previously reported complaints and concern forms without improvement.

Additional residents with multiple sclerosis and functional quadriplegia, dementia with repeat falls, and Alzheimer’s disease with chronic spinal pain, anxiety, and depression, all requiring significant staff assistance for transfers, toileting, and showers, were affected by staffing shortages on a specific weekend night shift. A CNA reported that on one night there were no CNA staff on the second floor night shift, only two nurses, and that one nurse who was called in as CNA coverage instead passed medications as a nurse. According to this CNA, three residents were left up in chairs all night, with two of them remaining in the same chairs and clothing when day shift arrived, and one resident was 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 CNA staff worked that night on the second floor, that a CNA had stayed over late to get most residents to bed but left three residents up in chairs, and that those three residents were still up and in the same clothing at 7:00 a.m. the next morning. The scheduler reported being unable to consistently fill CNA and nurse positions on the schedule, being instructed to add non‑nursing staff to the schedule, and completing concern forms about unmet care needs and staffing at least twice weekly, while the NHA reported having no concern forms for several of the affected residents and no knowledge of the three residents who remained up all shift.

The DON reported that 12 residents required assistance of two staff with care needs, underscoring the level of dependency among the resident population. Despite this, there were documented instances where no CNA coverage was present on a unit for an entire night shift, and where residents dependent on staff for basic ADLs, toileting, and transfers experienced prolonged periods without appropriate care, remained in chairs overnight, or were found soiled. Multiple staff interviews described chronic difficulty filling schedules, lack of support from management when staffing could not be secured, and repeated but unaddressed concern forms related to staffing and unmet resident care needs. These observations, interviews, and record reviews collectively demonstrate that the facility did not ensure sufficient nursing staff each day to meet the needs of residents and did not consistently provide the level of care required by residents’ conditions and care plans.