F0725

F

Failure to Maintain Sufficient Nursing Staff Leading to Missed Care and Hygiene

Charlevoix, Michigan Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The facility failed to provide sufficient nursing staff to meet residents’ care needs and ensure their safety, as evidenced by multiple staff and resident interviews, record reviews, and observations. A complaint to the State Agency reported that only two nurses were in the building when there should have been at least three, and that the DON, Infection Control Nurse, and Administrator were absent, leaving staff feeling they were “drowning” with no help. A CNA reported the facility was constantly understaffed, often with just two CNAs for a census of 50 or more residents, many of whom were incontinent, resulting in residents sitting in excrement longer than appropriate. Another CNA described “strangely low” staffing, with night-shift CNAs finding residents already asleep with dirty dinner trays still in front of them because day-shift CNAs lacked time to clear them, and noted that there were usually only two CNAs at night and sometimes only one, with travel CNAs occasionally walking out upon realizing they were the only CNA on duty. Review of daily staffing sheets from November through March showed 46 occasions with only two CNAs on duty and seven occasions with only one CNA, while the census ranged from 42–58 residents, 26% of whom required two-person transfers.

Residents reported delays and missed care directly related to low staffing. One resident stated there were often only one or two CNAs working the entire building, leading to extended call light response times, prolonged periods in soiled briefs, and going over a week without bathing. Another resident, incontinent of urine, reported several nights with only one CNA on duty and estimated waiting an hour or more for assistance after activating her call light. A CNA confirmed that showers were frequently missed due to low staffing and explained that on a day when three CNAs were scheduled, one called in sick, leaving only two CNAs and making it “nearly impossible” to help residents shower. Review of the shower binder showed that several residents had not received showers for 11–15 days, and one resident had only one shower recorded for the entire month. One resident was observed with a long beard and overgrown hair and reported not having had a shower in about two weeks and not receiving regular shaving assistance, which staff attributed to lack of time. The facility assessment lacked specific staffing needs by shift and for census levels between 51–62, and the NHA acknowledged that ideal staffing would be three nurses and three CNAs at a minimum but stated that what the facility wanted and what it could obtain were different, and that there was no specific contingency policy for staff call-ins.