F0725

F

Failure to Maintain Adequate Nursing Staff to Meet Resident Care Needs

Salem, Illinois Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient nursing staff on a daily basis to meet residents’ needs in a timely manner and to ensure adequate licensed nurse coverage on each shift. Multiple residents with significant ADL, toileting, and repositioning needs reported prolonged waits for assistance despite care plans specifying frequent turning, toileting assistance, and incontinence care. The facility’s own staffing policy states that adequate staffing will be maintained on each shift to meet resident needs and regulatory requirements, yet interviews and record review showed that staffing levels were often inadequate for the 47 residents in-house.

One resident with polyosteoarthritis, morbid obesity, COPD, a sacral pressure ulcer, and dependence for toileting and turning/repositioning reported that she is supposed to be repositioned at least every two hours but sometimes goes longer than that. She stated that when she activates her call light or yells out, it can take staff a very long time to respond, and that there are times when it takes a long time for a nurse to come to her room or bring pain medication. Another resident with moderately impaired cognition, muscle weakness, and a history of repeated falls, who requires substantial/maximal assistance with toileting and transfers, reported that he feels the facility is very short-staffed. He described waiting up to 20 minutes or longer for call lights to be answered and recounted a recent fall that occurred after he put on his call light, became impatient while waiting for staff, and attempted to move on his own.

Additional residents described similar delays and unmet care needs. One cognitively intact resident who is dependent for toileting and needs assistance with transfers stated that it takes staff "forever" to help him get dressed in the morning and that he has experienced incontinence episodes while waiting for staff to answer his call light. Another resident requiring substantial/maximal assistance with toileting and transfers reported waiting over 30 minutes at times for call lights to be answered and having incontinence episodes while waiting, then needing assistance with cleanup. A ventilator- and tracheostomy-dependent resident with muscular dystrophy, contractures, and dependence for toileting and turning/repositioning stated that there are times when only one CNA is assigned to her hallway, which includes multiple residents with vents and trachs, and that she has waited over an hour for assistance with repositioning and for call lights to be answered.

Staff interviews corroborated that staffing was frequently insufficient to meet resident needs. Multiple CNAs reported working entire halls alone for extended periods, including a CNA who worked a 12-hour shift alone on one hall and was unable to complete all resident care, such as turning/repositioning, incontinence care, and showers. CNAs stated that when short-staffed, call light response times could be 15 minutes or longer, and residents who required turning every two hours were not consistently turned on schedule, with intervals stretching to 2.5–3 hours while staff tried to balance feeding and other care tasks. CNAs also reported that call-ins were sometimes not covered, that they had to borrow staff from other halls to complete transfers and repositioning, and that some resident care likely went unfinished on short-staffed days.

The Director of Nursing acknowledged that the facility did not have enough nurses or CNAs and stated that they were losing staff "left and right." She reported that staffing patterns left, after 3 a.m., only one nurse, one respiratory therapist, and two CNAs to cover a specialized trach/vent unit and other high-acuity halls, and that she did not feel this was a safe number of staff to provide proper care. She stated that nurses and CNAs were in a hurry to get as much done as possible and might be missing things or delaying assessments and care. A physician also indicated that there had been discussions about resident care in relation to current staffing and that decisions about staffing were up to the facility company. These statements, combined with resident reports and care plan requirements, demonstrate that the facility failed to maintain adequate staffing on each shift to meet residents’ assessed needs in a timely manner.