F0725

F

Insufficient Nursing Staff Leading to Delayed Meals and Call Light Responses

Canton, Ohio Survey Completed on 03-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs in a timely manner, particularly during meals and in response to call lights. During confidential interviews with 25 residents, nine residents and one family member reported that staffing levels were inadequate to provide timely assistance. Reported concerns included delayed responses to call lights, staff turning off call lights and not returning, lack of assistance with ambulation, and untimely toileting and incontinence care, as well as worries about safety in an emergency. The facility’s staffing policy required adequate staffing on each shift to ensure residents’ needs and services were met, but observations and interviews showed this was not consistently achieved.

Multiple observations during breakfast service showed residents waiting extended periods between tray delivery and staff assistance, with food left uncovered and no offers to reheat meals. One resident was seated in the dining room shortly before 9:00 A.M., but her tray was not uncovered until after 9:30 A.M., and staff did not begin assisting her until nearly 10:00 A.M., after which she consumed only a small portion of her meal and was not offered to have it warmed. Another resident had a meal placed in front of her without a cover and did not receive feeding assistance for over 20 minutes; she ate toast with encouragement but stopped after the first bite of eggs, and staff did not offer to warm the food. A third resident’s tray was placed in front of him uncovered, and he did not receive assistance for about 18 minutes; after one bite he refused further food, and no alternative or reheating was offered. CNAs reported that residents who required assistance with eating had to wait until CNAs finished serving other residents on the units, resulting in breakfast often not starting until around 9:30–10:00 A.M. for those needing help, with typically only two staff assisting about 13 residents in the dining room.

Additional observations showed delayed responses to call lights and untimely toileting and incontinence care. One resident activated his call light at 11:00 A.M. because he was wet and needed changing; the light remained on until 11:41 A.M., when a CNA returned from break and provided incontinence care, finding the resident’s brief full of urine. The CNA and the DON both acknowledged that a 41‑minute wait was too long. In another instance, a resident’s call light remained on for approximately 25 minutes while she waited for assistance to get out of the bathroom; she eventually ambulated to the nurses’ station to report the delay. A CNA explained that during meals, all but one CNA were required to assist in the dining room, leaving a single CNA to monitor the hall, respond to call lights, and feed a resident, which prevented timely responses to all call lights. Family and therapy staff also reported that residents were receiving breakfast significantly later than they had previously, and that one resident who required one‑on‑one supervision for safe eating could not be accommodated in her room due to insufficient staffing.