F0725

E

Failure to Maintain Sufficient Nursing Staff Leading to Delayed Care and Medications

West Bloomfield, Michigan Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient nursing staff on all shifts to meet resident needs, resulting in prolonged call light response times and delays in medication administration and treatments. During a confidential resident council interview with eight residents, all participants reported concerns about staffing and response times. Residents stated that at times there was no nurse on their wing until midnight, that the day nurse had to stay late, and that morning medications and pain patches due between 9:00 AM and 10:00 AM were not administered on time. Multiple residents reported waiting from 20 minutes up to two hours for call lights to be answered, and described going to the nurses’ station to find staff talking and laughing while they were still waiting for assistance.

Individual resident and family interviews further detailed the impact of inadequate staffing. One resident reported that call light responses averaged 1 to 1.5 hours and that there were also insufficient housekeeping and laundry staff, resulting in rooms being cleaned only every other or third day and laundry not being returned as expected. The same resident reported that on some occasions there was no nurse to relieve the day nurse, causing evening medications to be given very late or not until the next morning. Another resident reported that on a recent Sunday there was no nurse available until 11:00 AM, causing them to miss their morning medications, and stated that staffing had worsened since the beginning of the year, with only one nursing aide assigned to an entire hall. A third resident reported long call light response times, especially on the afternoon shift, and a family member reported that their loved one had stopped using the call light because there were not enough staff to answer it and had fallen over a weekend while attempting to go to the bathroom.

Staff interviews and facility documentation confirmed ongoing staffing shortages and practices that did not ensure adequate nurse coverage. An LPN reported that staffing had declined from three nurses on the first floor to two nurses and four to five CNAs, which they felt was not enough to meet resident needs, leading to treatments being done late or not at all after the treatment nurse position was eliminated and floor nurses assumed all treatments. Another LPN stated that staffing had been poor, that usually four nurses were scheduled for the building, and that on some occasions only three nurses were scheduled, which they felt could not safely cover both floors. The staffing coordinator acknowledged that the building was short staffed, that about five nurses had recently resigned, and that the facility did not permit the use of agency or PRN nurses to fill gaps. The coordinator stated that staffing was based on PPD levels set by corporate, without directly incorporating resident acuity, and that nursing managers were expected to adjust for acuity. The facility’s own nursing staffing policy required 24-hour nursing services, a licensed nurse on each shift, and staffing based on resident number, acuity, and diagnoses, but the reported practices and outcomes showed these standards were not consistently met.