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F0725
F

Inadequate Weekend CNA Staffing Below Facility Assessment Requirements

Hubbell, Michigan Survey Completed on 03-03-2026

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate nursing staff on weekends to meet resident needs and to comply with its own Facility Assessment (FA) and CMS requirements, potentially affecting all 44 residents. CMS Payroll Based Journal (PBJ) staffing data for fiscal year quarter 4 of 2025 showed the facility triggered for excessively low weekend staffing. During an interview and record review, the Chief Operating Officer (COO) confirmed that weekend schedules and payroll records revealed low Certified Nurse Aide (CNA) staffing on specific weekend dates and shifts, including day and afternoon shifts staffed with only 3 to 3.5 CNAs. These staffing levels were below the FA, last updated 2/1/25, which specified a minimum of 4–5 CNAs on day shift and a minimum of 4 CNAs on afternoon shift. The deficiency occurred in the context of a CMS final rule, effective 8/8/24, requiring that facility assessments directly inform and determine staffing requirements. The report does not identify specific residents by condition or medical history but states that the inadequate staffing had the potential to affect all 44 residents residing in the facility, in terms of their physical, mental, and psychosocial well-being.

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