F0561

D

Failure to Honor Resident’s Morning Routine and Care Preferences

Traverse City, Michigan Survey Completed on 02-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to honor and support a resident’s stated preference for morning wake-up and assistance times, despite the resident being self-responsible for medical and financial decisions. The resident was admitted with aftercare needs following joint replacement surgery and required total assistance from two staff for dressing. During interviews, the resident reported routinely waking between 6:00 a.m. and 7:00 a.m., activating the call light to get dressed and ready for the day, and having clearly communicated this preferred schedule to staff. Over a weekend, staff did not assist the resident to get up and dressed until approximately 9:00–9:30 a.m., and staff told the resident they did not get people up that early or that the resident was not a priority.

The resident further reported missing a scheduled shower due to delays in assistance and experiencing an episode of bowel and bladder incontinence over the weekend because staff did not get him up in time, which he described as embarrassing. Bowel and bladder records confirmed an incontinent episode on 2/22/26. In a follow-up interview, the resident again stated he woke around 6:30 a.m. and staff refused to get him up, with assistance not provided until 7:45 a.m.; by the time he was ready, his breakfast had arrived but was then left to get cold while he was sent for a weight check. The resident expressed visible upset, frustration, and a lack of understanding as to why staff would not help or listen to his preferences. Review of the Kardex showed documentation of his dependence on staff for dressing but did not include his preferred time to get up in the morning, despite the DON’s statement that such preferences should be recorded there and staff education on resident rights and choices.