Citations in Michigan
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Michigan.
Statistics for Michigan (Last 12 Months)
Financial Impact (Last 12 Months)
Some of the Latest Corrective Actions taken by Facilities in Michigan
- Revised Safe Water Temperatures policy to align with regulatory standards (J - F0689 - MI)
- Educated all staff on Safe Water Temperatures policy, removing untrained personnel from the schedule (J - F0689 - MI)
- Implemented ongoing audits of resident-area water temperatures (daily for seven days, then twice weekly) with QAPI Committee oversight (J - F0689 - MI)
- Verified proper transmission of exit-door alarm notifications to staff pagers and facility monitors (J - F0689 - MI)
- Provided refresher training to clinical staff on locating care-plan details in EMR devices and keeping devices on their person (G - F0689 - MI)
- Established weekly audits of five care plans, five transfers, and staff device usage to ensure transfer practices match care-plan directives (G - F0689 - MI)
Unsafe Hot Water Temperatures, Inadequate Fall Response, and Unsupervised Tobacco Use
Penalty
Summary
The facility failed to ensure that hot water temperatures in resident care areas were maintained within the safe and comfortable range of 100-120 degrees Fahrenheit. Multiple observations revealed that water temperatures in several resident rooms, including those occupied by individuals with severe and moderate cognitive impairment, were significantly above the recommended maximum, with some readings as high as 152.6 degrees Fahrenheit. The facility's maintenance logs did not reflect these excessive temperatures, and there were missing documentation sheets for the required monitoring period. Staff interviews indicated inconsistent practices in temperature monitoring and a lack of immediate recognition or reporting of hazardous water temperatures. Additionally, the facility did not adequately investigate or implement interventions following multiple falls experienced by a resident with severe cognitive impairment and a history of wandering and difficulty walking. Despite several documented falls, including one resulting in a head laceration and hospitalization, the care plan was not updated with new interventions, and incident reports or investigations were not consistently completed. Observations further showed that safety measures, such as ensuring the resident's walker and call light were within reach, were not reliably maintained. The facility also failed to prevent potential accidents by allowing a visually impaired resident unsupervised access to chewing tobacco and a spit cup in his room. Staff were aware of the resident's use of chewing tobacco, but there was no specific policy addressing its use, and the tobacco was left accessible at the bedside. Interviews with staff and family confirmed that the resident had been using chewing tobacco in his room for an extended period, and the facility's smoking policy did not address smokeless tobacco products or their safe storage and supervision.
Removal Plan
- Community residents are assessed by the Director of Nursing and designees to ensure no negative effects related to water temperatures. Resident showers are taken offline to ensure safety of water temperatures, including bed baths.
- The water temperature is adjusted to ensure temperatures within regulatory standard. The Maintenance Director and designee conduct a community audit of resident area water sources to ensure appropriate temperatures per regulatory guidance.
- The Administrator reviews the policy and procedure related to Safe Water Temperatures with changes completed as necessary. Community staff are educated on the policy for Safe Water Temperatures, with all staff completed or removed from the schedule.
- The Maintenance Director or designee conducts an audit of resident room water temperatures daily, on both shifts for seven days, then twice weekly thereafter to ensure water temps meet regulatory standards. Results of the audits are brought to the Quality Assurance Performance Improvement Committee for review. Any changes to the auditing process are determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance.
Failure to Prevent and Respond to Resident Elopement
Penalty
Summary
A deficiency occurred when a resident with a known history of dementia, behavioral disturbances, and frequent exit-seeking behaviors successfully eloped from the facility. The resident had a documented risk of elopement, as evidenced by a recent assessment and multiple progress notes indicating repeated attempts to leave the facility, including a prior successful exit. The care plan included the use of a Wanderguard device, but the resident refused to wear it on her wrist, so it was attached to her walker, which she rarely used. On the day of the incident, the resident exited through a delayed egress door that alarmed, but staff did not immediately respond to the alarm or recognize the resident's absence until several minutes later. Staff interviews and record reviews revealed that the alarm on the exit door was heard by a CNA, who checked the area briefly but did not conduct a thorough search before resetting the alarm, assuming the resident was elsewhere in the building. Other staff members began searching rooms only after realizing the resident was missing, and the charge nurse was unfamiliar with the elopement protocol, leading to delays in initiating a missing person alert. The resident was ultimately found outside the facility by emergency personnel after being unsupervised for approximately 19 minutes near a busy street and ambulance garage. Further review showed that staff had not received adequate education or debriefing following the elopement, and there was a lack of consistent implementation of interventions for the resident's exit-seeking behaviors. The resident's room was located near an exit that was not easily visible from the nurses' station, and staff responses to alarms were inconsistent, with some assuming others would respond. The facility's policy required specific precautions for residents at risk of elopement, but these were not effectively implemented in this case.
Removal Plan
- All staff will be educated that they acknowledge and understand that in the event they hear an exit door alarming, they observe the alarm on the facility monitors or a page is obtained stating that an exit door has been opened or is alarming they will respond to investigate.
- If staff are caring for a resident when this alert is obtained, they will ensure their resident is safe and then respond.
- Staff that have not signed stating understanding will not be permitted to work until education has been obtained.
- Any staff who are found not to be compliant will be reeducated.
- Door alarms were set off and notifications were verified to be sent to staff pagers and facility monitors.
- Resident #1 will be moved to the locked unit in LTC once appropriate notifications have been made due to her noncompliance to wear a wanderguard and her risk of elopement.
- Until this move occurs Resident #1 will be placed on 1:1 monitoring when out of her room.
- All residents who score a 1.0 or higher on the elopement assessment have been reassessed to ensure proper interventions are in place.
- Any resident in the facility that is deemed to be an elopement risk a wanderguard will be placed and care planned for that resident.
- Any resident that is refusing to wear a wanderguard will be moved to the locked unit in long term care for increased supervision and safety.
- If a bed is not available in the locked unit, the resident will be placed on 1:1 supervision until an appropriate room is available.
Failure to Follow Transfer Protocols Results in Resident Injuries
Penalty
Summary
The facility failed to ensure that appropriate transfer techniques were implemented for two residents, resulting in injuries. One resident, a female admitted for physical and occupational therapy following a previous femur fracture, was assessed as requiring limited assistance for transfers, with therapy recommendations including the use of a front-wheeled walker, wheelchair, gait belt, and verbal cues. During an assisted transfer from the bathroom to the bed, the CNA did not use a gait belt as required by the resident's care plan. While the CNA was pulling down the bedding, the resident let go of her walker to point at the bed control and fell backward, sustaining a hand laceration and a new acute fracture to her distal femur. The CNA admitted to not checking the care plan and not realizing a gait belt was required for the transfer. Another resident, a female with gastroparesis and dependent for care, was to be transferred with a hoyer lift to the toilet and a slide board only for bed-to-wheelchair transfers. Over a weekend, staff used a slide board transfer to the toilet instead of the required hoyer lift, and when the process took too long, staff reportedly picked the resident up and placed her on the toilet, resulting in bruising on her inner upper arms. Multiple interviews confirmed that the resident's care plan specified a hoyer lift for toilet transfers, and staff were either unaware of or did not follow these instructions. The resident and several staff members reported the improper transfer and resulting bruising. In both cases, the deficiencies were due to staff not following the residents' care plans and not using the required assistive devices or transfer techniques. Staff either did not check the care plans or made assumptions about the residents' transfer status, leading to improper handling and injury. The incidents were witnessed, reported, and confirmed through interviews, observations, and record reviews.
Plan Of Correction
1. One of the residents had discharged at the time of the survey. The care plans of the other affected resident were reviewed and updated by the Interdisciplinary Team (IDT). Updated level of assistance and transfer status were shared with clinical teams by leadership to ensure understanding and compliance. 2. All residents have the potential to be affected. 3. Clinical Oversight Committee will audit care plans to ensure clear direction and appropriate levels of assistance. Refreshed education was provided to clinical staff on where to locate care plan information on EMR devices, and they were reminded to always carry these devices to be ready to verify care plans and assistance levels. Policies were reviewed, and no necessary updates were identified. 4. Routine audits of five care plans are conducted weekly at Clinical Oversight meetings for clarity of assistance levels. Additionally, five weekly audits are performed on transfers to ensure the transfer aligns with care plans. There are also five weekly audits of staff demonstrating where to locate care plan information on devices, and audits to ensure devices are on staff members at all times to guarantee they are always ready to access the care plan. 5. The Executive Director is responsible for compliance.
Deficient Fire Safety Training and Evacuation Plan Implementation
Penalty
Summary
The facility failed to ensure that there was a written plan for the protection and evacuation of all residents in the event of an emergency, and did not provide periodic staff training consistent with their expected roles as outlined in the Fire Safety Plan. During an observation and interview, two out of three dietary staff members were unable to correctly describe the procedures for activating the installed range hood suppression system, and one dietary staff member could not identify which extinguisher should be used on a grease fire. These deficiencies were confirmed by both the Maintenance Director and the Dietary Manager during the observation. The lack of proper staff instruction and knowledge could affect all 128 residents in the event of a fire involving the deep fat fryer or kitchen range equipment.
Plan Of Correction
Element I: The dietary staff was given education regarding the procedure for activating the suppression system and which fire extinguisher to use for a grease fire. Element II: All residents and staff have the potential to be affected by the deficient practice. Element III: The fire prevention plan policy was reviewed by the IDT and deemed appropriate. All dietary staff will be educated on the fire prevention plan with emphasis on the suppression system and the appropriate fire extinguisher to use for a grease fire. The dietary supervisor/designee will ensure new hires are educated on the first day of training in the kitchen. In addition, the fire prevention plan has been added to the staff meeting agenda. Element IV: The dietary supervisor/designee will conduct random audits to ensure the staff can appropriately verbalize the use for fire extinguishers and suppression system. These audits will be weekly for 4 weeks then monthly for 2 months until compliance has been maintained. The results will be brought to the QAPI meetings. Element V: The dietary supervisor/administrator are responsible for continued compliance.
Missing Circuit Breaker Locking Device for Fire Alarm Booster Module
Penalty
Summary
The facility failed to ensure that the fire alarm system was tested and maintained in accordance with an approved program that complies with NFPA 70 and NFPA 72. During an observation in the Mechanical Room (Memory Care), it was found that the required circuit breaker locking device was not provided in the circuit breaker panel for the installed fire alarm booster module. This omission was confirmed through an interview with the facility Maintenance Director at the time of observation. The lack of the locking device could potentially allow for unauthorized tampering with the fire alarm system, and this deficiency could affect all 64 residents in the facility.
Plan Of Correction
ELEMENT 1 The circuit breaker locking device has been placed on in the circuit breaker panel in the Mechanical room on Orchard View. ELEMENT 2 The Maintenance Director and/or designee did an audit on all circuit breaker panels in the facility to ensure there is a locking device present. Any areas of noncompliance were addressed immediately. ELEMENT 3 The Maintenance Director has been reeducated to ensure that the required circuit breaker locking device in the circuit breaker panel mechanical room for our installed fire alarm booster module on Orchard View is present. ELEMENT 4 The Maintenance Director/designee will conduct weekly audits for 2 months to ensure that the required circuit breaker locking device in the circuit breaker panel mechanical room for our installed fire alarm booster module on Orchard View is present. ELEMENT 5 Date of compliance 06/27/2025. The Maintenance Director and/or designee will be responsible for sustained compliance.
Latest Citations in Michigan
A resident with psychiatric and cognitive disorders became agitated and aggressive, leading to administration of Haloperidol and transfer to a hospital on a psychiatric petition. Required transfer documentation, including details of the resident's health status, transfer arrangement, and destination, was not completed or included in the medical record, as confirmed by the DON and facility leadership.
A resident with multiple psychiatric diagnoses exhibited severe behavioral disturbances, leading to a psychiatric petition and hospital transfer. The incident, including staff interventions and the use of emergency medication, was not documented in the EHR as required, despite facility policy mandating such documentation.
A resident with severe cognitive impairment and a history of agitation was found sleeping with her head on a nurses' station desktop, unsupervised and not positioned with dignity. The RN responsible acknowledged this was not appropriate, and the DON confirmed it did not meet facility standards for resident dignity, despite care plan interventions for supervision and visibility.
The facility did not provide adequate staff training on fire safety procedures, as two dietary staff members could not correctly explain how to activate the range hood suppression system, and one could not identify the correct extinguisher for a grease fire. These deficiencies were confirmed by the Maintenance Director and Dietary Manager, potentially affecting all residents during a kitchen fire emergency.
A resident with a PEG tube and a history of dysphagia was observed self-administering oral medications without staff supervision, contrary to physician orders specifying administration via PEG tube. The LPN confirmed that the resident had not been assessed for self-administration, and the facility's policy requiring direct observation during medication pass was not followed.
A resident with a PEG tube and a history of dysphagia and aspiration was observed self-administering whole pills orally without staff supervision, despite physician orders specifying medication administration via PEG tube. Staff interviews confirmed the resident was at high risk for aspiration, and there was no assessment or care plan allowing self-administration of medications by mouth.
A resident with a PEG tube and history of dysphagia was observed self-administering oral medications without staff supervision, despite the MAR indicating medications were given via PEG tube. An LPN confirmed the medications were given orally and not as documented, and there was no assessment, care plan, or order for self-administration in the resident's record.
A resident was found sleeping in a wheelchair with her head on the nurse's station desk while a Nurse Practitioner was present but not attending to her, and no other staff were in the area. This situation failed to uphold the resident's dignity as required by federal regulations.
An LPN was observed retrieving an unlabeled and undated inhaler from the medication cart for a resident with Alzheimer's and impaired cognition who required assistance with medication administration. The DON was unsure if inhalers needed to be dated, despite facility policy requiring medications to be dated and discarded per manufacturer guidelines. This failure to properly label and date the inhaler resulted in a deficiency.
The facility did not maintain adequate nursing staff coverage, particularly on weekends and certain shifts, resulting in unmet resident care needs such as long wait times for assistance, missed showers, and resident frustration. Staffing records and interviews confirmed frequent call-ins, difficulty filling open positions, and reliance on bonuses to encourage staff to work extra shifts, but these measures were insufficient to ensure consistent coverage.
Failure to Document Resident Transfer Following Psychiatric Emergency
Penalty
Summary
A deficiency occurred when the facility failed to ensure proper transfer documentation for a resident with multiple psychiatric and cognitive diagnoses, including anxiety disorder, mood disorder, unspecified psychosis, and dementia with behavioral disturbance. The resident, who had moderate cognitive impairment and used a wheelchair, became increasingly agitated and aggressive, culminating in a physical altercation with staff and an attempt to leave the unit by force. The situation escalated to the point where the resident was administered Haloperidol and transferred to a local hospital on a psychiatric petition. Despite the severity of the incident and the transfer to the hospital, the facility did not complete or include the required transfer documentation in the resident's medical record. The only documentation available was an incident report, which was marked as privileged and confidential and not part of the medical record, and a progress note regarding the administration of Haloperidol. There were no progress notes or late entries detailing the resident's transfer disposition or destination, and the DON confirmed that a hospital transfer notice had not been completed. The facility's own "Transfer and Discharge Guideline" requires documentation of the resident's health status, the basis for transfer, and the services to be provided by the receiving provider. However, these requirements were not met in this case, as the necessary information regarding the resident's health status, safety, transfer arrangement, and destination was missing from the medical record. The deficiency was confirmed during interviews and record review, with facility leadership unable to provide additional documentation.
Failure to Document Psychiatric Incident and Hospital Transfer in EHR
Penalty
Summary
The facility failed to include critical documentation in the electronic health record (EHR) for a resident who experienced a significant behavioral incident that resulted in a psychiatric petition and transfer to a hospital. The resident, who had diagnoses including anxiety disorder, mood disorder, unspecified psychosis, and dementia with behavioral disturbance, became increasingly agitated and aggressive, culminating in physical altercations with staff and other residents. Despite staff interventions, including administration of PRN medications and attempts at redirection, the resident's behavior escalated to the point of property damage and threats of violence. An incident report was created by the DON detailing the resident's actions, staff responses, and the subsequent decision to transfer the resident to a hospital under a psychiatric petition. This report included information about the administration of Haloperidol and the use of emergency services. However, this incident report was marked as "Privileged and Confidential - Not part of the Medical Record," and the corresponding clinical documentation was not entered into the resident's EHR. Upon review, the DON acknowledged that the incident and the rationale for the psychiatric petition should have been documented in the resident's clinical record, as it reflected significant changes in the resident's condition and the facility's inability to provide appropriate care at that time. The facility's own policy required documentation of all services, changes in condition, and incidents in the medical record, but this was not followed in this case. No additional documentation was provided by facility leadership when requested.
Resident Dignity Not Maintained During Supervision Lapse
Penalty
Summary
A resident with severe cognitive impairment, altered mental status, and a history of restlessness and agitation was observed sleeping at the nurses' station with her head resting directly on the desktop. The registered nurse responsible for her care acknowledged that this positioning was not optimal and did not maintain the resident's dignity, stating that the resident should have been returned to her room to sleep in her bed. The nurse was not in a position to directly supervise the resident at the time she was observed, and another nurse practitioner present stated she was not responsible for the resident but had been helping to keep her calm. The resident's care plan included interventions such as encouraging her to be in common areas when awake, increasing the frequency of checks, and ensuring she was up in a wheelchair in visible fields when rambling. Despite these interventions, the resident was left unsupervised and allowed to sleep in a public area in a manner that did not promote dignity or respect, as required by facility policy. The Director of Nursing confirmed that this did not meet the facility's standards for maintaining resident dignity and that alternative arrangements were available for such situations.
Deficient Fire Safety Training and Evacuation Plan Implementation
Penalty
Summary
The facility failed to ensure that there was a written plan for the protection and evacuation of all residents in the event of an emergency, and did not provide periodic staff training consistent with their expected roles as outlined in the Fire Safety Plan. During an observation and interview, two out of three dietary staff members were unable to correctly describe the procedures for activating the installed range hood suppression system, and one dietary staff member could not identify which extinguisher should be used on a grease fire. These deficiencies were confirmed by both the Maintenance Director and the Dietary Manager during the observation. The lack of proper staff instruction and knowledge could affect all 128 residents in the event of a fire involving the deep fat fryer or kitchen range equipment.
Plan Of Correction
Element I: The dietary staff was given education regarding the procedure for activating the suppression system and which fire extinguisher to use for a grease fire. Element II: All residents and staff have the potential to be affected by the deficient practice. Element III: The fire prevention plan policy was reviewed by the IDT and deemed appropriate. All dietary staff will be educated on the fire prevention plan with emphasis on the suppression system and the appropriate fire extinguisher to use for a grease fire. The dietary supervisor/designee will ensure new hires are educated on the first day of training in the kitchen. In addition, the fire prevention plan has been added to the staff meeting agenda. Element IV: The dietary supervisor/designee will conduct random audits to ensure the staff can appropriately verbalize the use for fire extinguishers and suppression system. These audits will be weekly for 4 weeks then monthly for 2 months until compliance has been maintained. The results will be brought to the QAPI meetings. Element V: The dietary supervisor/administrator are responsible for continued compliance.
Failure to Supervise Medication Administration and Follow Physician Orders
Penalty
Summary
A resident with a history of cerebral ischemia, dysphagia following cerebral infarction, and gastrostomy status was observed self-administering oral medications without staff supervision. The resident, who has a PEG tube, was seen walking out of his room holding a medication cup with approximately four pills, dropping one on the floor, picking it up, and returning it to the cup before ingesting the remaining pills. The resident was not supervised during this process, despite facility policy requiring direct observation during medication administration. The resident's electronic health record did not contain an assessment for self-administration of medications, a care plan for self-administration, or a physician's order permitting self-administration. Further review of the physician's orders indicated that all prescribed medications were to be administered via the PEG tube, not orally. The LPN involved acknowledged that supervision should have occurred and that the resident had not been formally assessed for self-administration. The DON confirmed that the resident was not assessed for self-medication and should have been supervised. Facility policy also specifies that medications must remain under the direct observation of the person administering them during medication pass, which was not followed in this instance.
Failure to Administer Medications via PEG Tube and Lack of Supervision
Penalty
Summary
A deficiency occurred when a resident with a PEG tube and a history of dysphagia, cerebral ischemia, and recurrent aspiration was observed self-administering whole pills orally without staff supervision. The resident was seen walking out of his room holding a medication cup with several whole pills, dropping one on the floor, picking it up, and then returning to his room to swallow the pills. The resident's medical record indicated that all prescribed medications were ordered to be administered via PEG tube, and there was no assessment, care plan, or physician order permitting self-administration of medications by mouth. Interviews with staff, including an LPN and the SLP, confirmed that the resident was at high risk for aspiration and that medications should have been given via PEG tube as ordered. The SLP noted that the resident coughed when attempting to swallow pills and was at risk for silent aspiration. The facility's policy required verification of physician orders and monitoring for aspiration during tube feeding, but these procedures were not followed in this instance, resulting in the resident receiving medications by an incorrect route and without adequate supervision.
Failure to Accurately Document and Supervise Medication Administration
Penalty
Summary
A resident with a history of cerebral ischemia, dysphagia following cerebral infarction, and gastrostomy status was observed independently taking oral medications from a medication cup without staff supervision. The resident, who had a PEG tube in place, dropped a pill on the floor, picked it up, and returned it to the cup before ingesting the remaining pills. The resident stated he was taking his pills, and there was no staff present to supervise the administration. Interview with an LPN revealed that the resident was given several medications in pill form to take orally, and the LPN acknowledged not supervising the resident during administration. Review of the resident's electronic health record showed no assessment, care plan, or order for self-administration of medications. Additionally, the Medication Administration Record (MAR) inaccurately documented that the medications were administered via PEG tube, contrary to the actual oral administration observed. The Director of Nursing confirmed the inaccuracy in the MAR and stated that documentation should reflect the actual treatment provided.
Resident Dignity Not Maintained at Nurse's Station
Penalty
Summary
A deficiency was identified when a resident was observed sleeping at the Beck nurse's station, seated in a wheelchair with her head resting directly on the desk. At the time of observation, a Nurse Practitioner was present in the nurse's station but was seated in a different area, facing away from the resident and actively typing on a computer. No other staff members were present in the area during this time. The incident was noted during a review focused on respect, dignity, and the right of residents to retain and use personal possessions, as outlined in §483.10(e). The facility failed to maintain the dignity of the resident by allowing her to sleep in a public and potentially undignified manner at the nurse's station without staff engagement or intervention.
Failure to Label and Date Inhaler in Medication Cart
Penalty
Summary
A deficiency was identified when an LPN was observed retrieving an inhaler from the medication cart for a resident, which was found to be unlabeled and undated. Upon inquiry, the LPN confirmed that there was no date opened on the inhaler. Review of the resident's physician order indicated the use of Ventolin HFA Inhalation Aerosol Solution, to be administered four times daily for shortness of breath. The resident's medical record showed a diagnosis of Alzheimer's disease, impaired cognition, and a need for assistance with activities of daily living, including medication administration. Further review of the facility's policy on medication management stated that medications are to be dated and discarded according to manufacturer guidelines. When questioned, the DON expressed uncertainty about the requirement to date inhalers and indicated a need to review the policy. The failure to label and date the inhaler as required by both facility policy and federal regulations led to the cited deficiency.
Plan Of Correction
Corrective action taken for resident 56. The unlabeled inhaler was removed from the cart and replaced with a new inhaler from pharmacy which was labeled and dated appropriately. All residents have the potential to be affected by the deficient practice. All med carts were audited by unit managers and no unlabeled/dated medications were found. The Medication Management Policy was reviewed by the IDT and deemed to be appropriate. All licensed nurses will be educated on the Medication Management Policy with an emphasis on labeling and dating medications according to manufacturer guidelines. Resident name labels have been made available at each nursing station. The DON/designee will conduct random audits of the medication carts to ensure that all medication are appropriately labeled and dated. These audits will be weekly x4 weeks and then monthly x2 until compliance has been maintained. The results will be brought to QAPI for further recommendations. The DON/NHA are responsible for continued compliance.
Deficiency Due to Insufficient Nursing Staff Coverage
Penalty
Summary
The facility failed to ensure adequate nursing staff to meet the needs of residents, as evidenced by multiple resident interviews and review of staffing records. Residents reported long wait times for assistance, particularly on weekends and during certain shifts, with one resident stating she waited 30-45 minutes for help and experienced incontinence as a result. Several residents expressed frustration about insufficient staff coverage, especially on weekends and second shift, and noted that call lights were not answered promptly. Review of the facility's PBJ (Payroll-Based Journal) staffing data for the first quarter of 2025 revealed low weekend staffing. The facility's policy states that sufficient numbers of licensed nurses and CNAs are to be available 24/7, but interviews with staff and review of schedules indicated frequent call-ins and difficulty filling open positions, particularly on weekends. The facility attempted to address call-ins by offering bonuses and asking staff to stay over, but gaps in coverage persisted. The Human Resources staff confirmed that agency staff were not used and that new hires often did not remain after orientation, further contributing to staffing shortages. Staffing levels discussed included a requirement for 4 CNAs and 2 nurses on day and afternoon shifts, and 1-2 CNAs and 2 nurses on night shift, depending on census. Despite these requirements, both residents and staff reported that actual staffing often fell short, especially on weekends. The facility's inability to consistently provide sufficient nursing staff resulted in unmet resident care needs, including missed showers and delayed responses to call lights, leading to resident dissatisfaction and compromised care.