F0725

E

Insufficient CNA Staffing on 100 Hall Delays Call Light Response and Resident Care

Salem, Illinois Survey Completed on 03-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient nursing staff on the 100 hall to meet residents’ needs in a timely manner and to ensure adequate assistance with care. A family member reported that during evening hours and on weekends it is very hard to get assistance from staff when call lights are activated, and that she has to walk the halls to find staff to assist a resident. During a resident council meeting, two cognitively intact residents stated that in the evening it is difficult to get someone to answer call lights, and one of these residents lives on the 100 hall. The daily census report shows there were 10 residents residing on the 100 hall.

A CNA reported that residents need to be turned and repositioned every two hours or as needed, but stated she performs bed checks “as often as I can by myself,” explaining that the next CNA does not arrive until 10:00 a.m. and that residents requiring two-person assistance may not be attended to until that time if she cannot find help. On the morning in question, the CNA stated she had been working alone on the 100 hall since 6:00 a.m. due to a call-in and was only able to begin bed checks at 8:54 a.m., completing care only for residents requiring one-person assistance while no other CNA was present or scheduled on the hall. A respiratory therapist stated that CNAs are responsible for repositioning during two-hourly rounds, that respiratory therapy will help with bed checks if needed, and that there are two CNAs assigned to the 100 hall only “if they are lucky,” despite residents there being mainly dependent on staff. The regional director of clinical services stated that staffing is based on public health guidelines and resident needs when assigning staff.