F0725

E

Inadequate Nursing Staff, RN Coverage, and Call Light Response

Lapeer, Michigan Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate nursing staff, including RNs, LPNs, and CNAs, to meet residents’ needs and to ensure required RN coverage, resulting in resident reports of long call light response times, delays in ADL assistance, and cold meals. During a confidential group interview with seven cognitively intact residents, all participants reported concerns with call light response, including waiting up to an hour for staff to respond, nurses not answering call lights, call lights being turned off without care being provided, and staff stating they would return but not doing so. The group stated these problems occurred at all times of day and were worse during shift changes. They also reported that staff frequently left the building to smoke, including CNAs who verbalized needing a cigarette after difficult care encounters, and that these concerns had been raised multiple times in Resident Council without resolution.

Residents provided specific examples of unmet care needs related to inadequate staffing. One resident reported there were not enough staff to help during mealtimes, describing meal carts sitting in the hall for up to 40 minutes before trays were passed. Another resident described a roommate who needed help sitting up and with tray setup; the tray reportedly sat for about 45 minutes and was close to an hour before staff came in, by which time the food was believed to be cold. Another resident reported that their roommate required feeding assistance but staff were sometimes not available to provide this. Individual interviews corroborated these group concerns: one resident with heart failure, respiratory disorder, anemia, deep vein thrombosis, and hypertension, who was cognitively intact and dependent for transfers, toileting, dressing, and required maximum assistance with bathing, stated there were not enough people to answer call lights and expressed frustration with long waits for care. Another cognitively intact resident needing assistance with all care reported waiting 45 minutes in the bathroom for staff to answer a call light and believed food was cold when delivered due to insufficient staffing. A third cognitively intact resident needing assistance with all care reported multiple instances of long waits for call light response, sometimes up to an hour. A newly admitted resident who needed assistance with care stated that call lights were not always answered timely on both day and night shifts.

Record review and staff interviews showed systemic issues with staffing levels, RN coverage, and required staffing documentation. The posted Daily Staffing Report near the front office was dated five days prior to the surveyor’s observation and was not updated daily as required. The DON reported that the corporate office was responsible for submitting PBJ staffing data to CMS and acknowledged that the facility’s PBJ report for the 4th fiscal quarter (July–September 2025) had not been submitted. The DON also stated that several nurses had left recently and in fall 2025, that many staff were working beyond 12-hour shifts and extra days, and that she herself frequently worked on the floor as a nurse, sometimes for 12-hour shifts and then again later the same day. The Administrator confirmed awareness that the PBJ report for the 4th quarter had not been submitted, acknowledged that the Daily Staffing Report was supposed to be updated daily but was not current, and agreed that some nurses had left and the DON was working many days on the floor.

Further review of clinical staffing documents revealed missing Daily Staffing Reports and schedules for multiple days across several months, including days immediately prior to survey entry. Many Daily Staffing Reports did not identify whether nurses were RNs or LPNs and simply listed "Nurse" with counts for day and night shifts. On specific dates, documentation showed low numbers of clinical staff and lack of RN coverage, such as one nurse on night shift for over 60 residents, two aides on night shift for 68 residents, and days where only LPNs were listed with no RN identified. On one date, the schedule showed one night-shift nurse leaving at 2:00 a.m., leaving a single nurse alone for four hours. Multiple dates in late 2025 and early 2026 lacked any documented RN coverage on the Daily Staffing Reports. These documented staffing patterns, combined with resident reports of long call light response times, delayed ADL and toileting assistance, and delayed meal delivery, demonstrate the facility’s failure to ensure adequate nursing staff and required RN coverage to meet residents’ needs.