F0725

H

Systemic Understaffing Leading to Unmet ADL Needs, Delayed Call Responses, and Late Meals

Sault Ste. Marie, Michigan Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs for ADLs, timely incontinence care, repositioning, restorative services, and prompt response to call lights, as well as to provide timely, dignified, and palatable meal service. Staff, including an LPN and multiple CNAs, reported that there were never enough CNAs, that they worked short all the time, and that management did not replace staff who called in. Residents repeatedly reported fear, frustration, and distress related to long call light response times, lack of assistance, and inadequate staffing. Facility records, including Payroll Based Journal data, complaint logs, Quality Assistance Forms, and Resident Council minutes, documented ongoing concerns about low staffing, delayed call light response, and late meals, particularly on weekends and nights.

One resident was repeatedly observed lying in bed in urine and feces with feces on bedding, mattress, and hands, shivering and yelling for help over extended periods on multiple days, without timely staff response. Another resident, cognitively intact and recently admitted with a leg fracture, documented in a notebook and reported that call lights went unanswered for long periods, that no vital signs or assessments were done at admission, that meals were missed or significantly delayed, and that a call to the facility was answered by other residents rather than staff. This resident described waiting approximately 55 minutes for assistance to the bathroom after activating a call light and reported not receiving needed ice for a surgical wound.

Additional residents described being left wet and soiled in urine and feces for over two hours, not receiving showers for weeks despite documented shower schedules and preferences, and not being assisted out of bed as desired. One resident with spastic quadriplegic cerebral palsy, intact cognition, and total dependence for transfers reported not being gotten out of bed by the preferred wake time, experiencing significant pain when left in bed for extended periods, and having submitted multiple written grievances about staffing and delayed care. Another resident with quadriplegia and anoxic brain damage, totally dependent for mobility, reported not receiving restorative therapy or consistent splint use, while CNAs stated they did not perform restorative tasks due to lack of time and that only a restorative aide, unavailable on weekends and currently off work, handled such care. Observations and interviews also showed residents waiting in soiled briefs until after meals for morning care, meal trays piling up due to insufficient staff to pass them, and activities being rescheduled because dependent residents were not assisted out of bed in time to attend.

Facility documentation showed that the facility assessment set a maximum census of 78 residents, yet census data revealed 90 days in which the census exceeded this number, reaching up to 87 residents, with a high proportion of admissions and discharges occurring Friday through Sunday. Night shift schedules for multiple weekend days showed only 3.5 to 4 CNAs on duty for 73–82 residents. Complaints and Quality Assistance Forms from residents and families described residents sitting in stool and urine for hours, long call light waits (often 45 minutes to over an hour), residents not being toileted or put to bed when requested, residents not being gotten out of bed for days, and staff telling residents that there were not enough staff to honor their preferences for getting in and out of bed. Responses on these forms frequently cited staff education or asserted that staffing was adequate, and several forms lacked documented resolution, while concerns about staffing, call light response, and late meals recurred month after month in Resident Council minutes.