§483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.
§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.
§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.
§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.
§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.
§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
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Observations:
Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's dignity was maintained for two of five residents reviewed (Resident 2 and 4).
Findings include:
The facility's policy regarding call lights, dated October 28, 2025, indicated that staff members who are alerted of an activated call light are responsible for responding promptly to promote a secure atmosphere for residents.
A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 2, dated January 9, 2025, revealed that the resident was alert and oriented, able to make his needs known, required assistance from staff for daily care needs including toileting, hygiene, and transfers and had medical diagnosis that included multiple sclerosis (disease affects the nerves in the brain and spinal cord).
Interview with Resident 2 on February 28, 2023, at 1:56 p.m. revealed that he had to wait for an extended period of time for staff to respond to his call bell.
A call bell log for January 2026, for Resident 2 revealed that it took staff 19 minutes to respond to his call bell on January 1, 2026. It took staff 21 minutes to respond to his call bell on January 3; 27 minutes to respond on January 11; 19 minutes on January 26; 1 hour on January 27; 41 minutes on January 28; and 18 minutes on January 31, 2026. A call log for February 2026 revealed it took staff 16 minutes to respond to his call bell on February 1 at 8:51 a.m. and 46 minutes on February 1, 2026, at 2:48 p.m.
An annual MDS assessment for Resident 4, dated January 6, 2026, revealed that the resident was cognitively intact, required assistance from staff for daily care needs including toileting, hygiene, and transfers and had medical diagnosis that included hemiplegia (severe or complete loss of strength on one side of the body) and hemiparesis (weakness on one side of the body )following a stroke and diabetes.
Review of a grievance form for Resident 4 dated December 15, 2025, revealed that the resident stated that he was put into bed on Sunday at about 10:00 p.m. and no one checked on him until around 4:00 a.m. He tried calling the nurses station with his cellphone, but it just rang and rang. Then staff did come in and help him, and they told him they were short staffed.
Review of a call bell log for Resident 4 dated December 14, 2025, through December 16, 2025, revealed that his call bell was activated on December 14, 2025, at 9:19:49 p.m. and the response time for that call out was one hour and 47 seconds.
Interview with Resident 4 on February 3, 2026, at 3.24 p.m. revealed that on the evening of December 14, 2025, it took staff a long time to get him into bed after he made the request. He would sometimes call the front desk to get a faster response than waiting for staff to respond to his call bell, however, that night no one answered the telephone at the front desk.
Interview with the Assistant Director of Nursing on February 3, 2026, at 3:22 p.m. revealed that the call bell wait times listed above were excessive and not acceptable, and that she expects the call bells to be answered within five minutes as anyone can answer a call bell.
28 Pa. Code 201.29(j) Resident rights.
| | Plan of Correction - To be completed: 02/24/2026
The submission of this plan of correction does not constitute admission or agreement on the part of the provider with the deficiencies or conclusions contained in the Statement of Deficiencies. This plan of correction is prepared and executed solely to respond to the allegations of non-compliance cited during the survey ended on February 4, 2026.
1. Actions taken for the situation identified:
The facility cannot retroactively address the incident. No Residents, including Residents 2 and 4, were adversely affected.
2. How the facility will act to protect residents in similar situations:
Staff, including agency, will be re-educated on responsibility to respond to call bells/lights timely.
3. System changes and measures to be taken:
The Director of Nursing/Designee will educate staff on Regulation F550, Resident Rights, and timely call bell response. Nurses will be responsible for monitoring call bell/light response times to ensure residents needs are addressed timely.
4. Monitoring mechanisms to assure compliance:
The Director of Nursing/Designee will perform five (5) random call-bell response time audits per week to ensure staff is responding to call bells timely, then monthly for 2 months. Identified issues will be addressed upon discovery. To monitor compliance, audit results will be reviewed through monthly Quality Assurance Performance Improvement Committee meetings, and further action plans and audits will continue until substantial compliance is achieved. Ongoing self-monitoring will help to ensure facility continues to meet quality standards.
5. Date Corrective Action will be completed:
Substantial compliance is expected by 2/24/26
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