F0550

E

Failure to Ensure Dignified, Respectful Care and Timely Toileting Assistance

West Bloomfield, Michigan Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure residents were treated with dignity and respect, particularly regarding toileting, incontinence care, and staff interactions. One resident with diagnoses including difficulty in walking, polyneuropathy, and primary insomnia, and a BIMs score of 15 indicating no cognitive impairment, reported that night shift staff were not responsive to toileting needs. This resident stated they were only changed once during the night around 11:00 PM–12:00 AM and not again until approximately 6:30 AM, and that when they used the call light at night, a CNA would enter, ask what was needed, turn off the call light, and leave without providing toileting assistance until morning, resulting in the resident using the restroom in their brief. Another resident, also cognitively intact with a BIMs score of 15 and admitted with diagnoses including urinary tract infection and muscle disorder, reported that when they used the call light, it took staff so long to respond that they forgot what they had requested, and that it was difficult to get their brief changed on the night shift.

A family member of one resident reported to the state agency that CNAs did not help the resident when the call light was used at night and that nurses did not administer nighttime medications until after 11:00 PM. The same family member stated they believed grievance forms were only available for missing items and not for nursing concerns, and also reported that the social worker did not follow up on requests. Resident council minutes over several months documented repeated concerns about staff attitudes and professionalism, including cleaning staff being rude, nurses and aides not being professional, ongoing issues with name tags, a Foley catheter not being emptied, and a CNA demanding a resident wear a brief and lecturing the resident about incontinence. In a confidential resident council interview with eight residents, multiple residents reported that some aides and nurses did not treat them with dignity, stating that staff did not “have a heart for the people” and did not actually care. The DON later reported being unaware of these dignity concerns. These findings occurred despite a facility policy on promoting and maintaining resident dignity that requires respectful communication and acting upon resident preferences.