F0725

E

Insufficient Nursing Staff Leading to Missed and Delayed ADL Care

Southfield, Michigan Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

Surveyors identified a failure to provide sufficient nursing staff to meet residents' needs, particularly on the second floor, resulting in delayed or missed ADL care such as incontinence care, dressing, showers, and getting residents out of bed. The facility’s own facility assessment, last updated 1/15/26, outlined expected daily staffing levels for licensed nurses and CNAs on each unit, but review of assignment sheets, census, and time punch reports for specific dates showed multiple call‑offs and staffing that did not meet those levels. The DON acknowledged that Unit 1 should have three CNAs on day shift and that the staffing documentation confirmed this was not consistently achieved. The facility’s staffing policy stated that licensed nurses and nursing assistants would be available 24/7 and that staffing numbers would be based on resident needs and the facility assessment, but the actual staffing patterns did not align with these standards.

Multiple residents reported that inadequate staffing led to missed or delayed care. One resident stated they had been left an entire shift without incontinence care, especially on night shift, and that they did not receive their scheduled bed baths. Another resident reported missing therapy sessions because there were not enough staff to get them ready, and therapy documentation showed at least one missed session due to the resident having a bowel movement and later dinner, and another session where the resident remained supine in bed in a gown, requesting in‑room therapy because they were not yet dressed. A resident reported that their roommate’s family repeatedly requested that the roommate be gotten out of bed, but staff left her in bed every day; the same resident described frequent situations with only one nurse and two aides for the hallway, long waits for assistance over 30 minutes, missed showers, and a recent weekend when residents were not gotten out of bed and meals were served in rooms.

Additional interviews corroborated ongoing staffing shortages and their impact on care. On a morning when three CNAs were scheduled for Unit 1, one CNA was not present, and the nurse could not explain who was covering that CNA’s assignments; residents listed as “early get up” were still in bed, undressed, and in hospital gowns. Another resident reported that sometimes there was only one CNA for all of Unit 1 and part of Unit 2, resulting in long waits and a missed scheduled shower or bed bath the prior week. During a resident council meeting, several residents reported untimely call light response, being forced to accept showers at times chosen by CNAs rather than their preferred times, being left in bed until early afternoon or for entire weekends, and a night shift that “disappears” with call lights going unanswered for hours. A CNA reported multiple call‑offs on a recent Sunday, no management assistance that day, and an inability to complete all assigned tasks when working short. The DON and Administrator both acknowledged challenges with staffing and excessive call‑offs, and HR reported ongoing hiring efforts and instability in the scheduler position.