§483.35 Nursing Services.
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.71.
§483.35(a) Sufficient Staff.
§483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:
(i) Except when waived under paragraph (f) of this section, licensed nurses; and
(ii) Other nursing personnel, including but not limited to nurse aides.
§483.35(a)(2) Except when waived under paragraph (f) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.
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Observations:
Based on review of facility policy and resident council minutes, observations, and staff and resident interviews, it was determined that the facility failed to provide sufficient nursing staff and services to promote the physical and mental well-being and meet the needs for four of 19 residents interviewed (Residents R3, R24, R25, and R43).
Findings include:
Review of facility policy entitled "Cell Phone/Camera Usage," with a policy review date of 5/01/25, revealed that "Personal cell phones should not be used during work time."
Review of grievances in January of 2025 revealed that there were concerns with staff members on their cell phones and education was provided by the Director of Nursing (DON).
Review of resident council minutes over three months from February, March, and April of 2025, revealed the following: April 2025 resident council minutes revealed there were complaints of staff observed constantly on their phones; Most of the occurrences were on day and afternoon shift; Call bell wait times were 30 minutes or longer.
Interviews during the resident council meeting on 5/28/25, between 11:00 a.m. and 11:45 a.m. revealed four of four alert and oriented residents in attendance had concerns related to staff not responding to their call bells timely. All residents in attendance revealed that staff are constantly on their telephones texting or having private conversations with other people. All residents in the resident coucil meeting stated that it delays their care response times and it makes residents upset.
Resident R24 indicated that it could take 30-45 minutes for his/her call bell to be answered and staff are typically seen in the hallways, at the nurse's station, or in resident's rooms talking or on their phones having private conversations. Resident R3 indicated that he/she will wait for 30 minutes to 60 minutes to receive assistance to use the restroom after placing his/her call bell on and requires full assistance by staff. Residents R3, R24, R25, and R43 indicated they wait 30 minutes or longer when their call bell is placed on to be responded to by staff. All residents agreed that they observe staff on their phones and standing talking to one another during their shifts.
During observations of two of two resident care areas during the week of the survey, from 5/27/25, to 5/30/25, there were observations of staff sitting at the nurses stations and in the hallway on their personal cell phones.
During an interview with the DON and Assistant Director of Nursing on 5/30/25, at approximately 1:15 p.m. it was confirmed that residents do complain to administration about employees on their cell phones.
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.12(d)(4)(5) Nursing services
| | Plan of Correction - To be completed: 07/19/2025
F0725
1. The facility maintains that all residents' needs were met including residents R3, R24, R25 and R43. The affected residents are routinely visited by their Guardian Angels and any concern is immediately addressed.
2. R3 and R25 have discharged and therefore, we are unable to correct the perceived inattention. The facility's management staff act as the "Guardian Angel" to assigned residents. Part of their visit is to inquire if needs are being met. The assigned Guardian Angel for R24 and R43 will perform call bells audits at least weekly for four weeks. Additionally, call bell audits will be added to the Guardian Angel Rounding Form to capture any potential issues with the timely answering of call bells and cell phone usage by staff.
3. The Director of Nursing/Assistant Director of Nursing (DON/ADON), Nursing Home Administrator (NHA) or designee will re-educate all full time and part time staff on the facility's Cell Phone/Camera Usage as well as Telephone Calls and Messages per Employee Handbook by July 5,2025. Staff members subsequently observed using their cell phone in the resident care area to include the nursing station will be subject to the facility's disciplinary process.
4. The DON/ADON or RN (Registered Nurse) Supervisor will conduct rounding at least 2 times per shift to ensure staff are not on cell phones in the resident care area to include nurses' station, common areas and residents' rooms. This rounding shall be done at least 5 days per week for four weeks, then 3 days per week for four weeks, then weekly for four weeks.
5. The NHA will interview all cognitively capable residents on possible impact of cell phone usage by staff by July 11, 2025.
6. The Resident Council must formally invite the management staff to attend their meetings. The NHA, DON/ADON, and the Social Services Director (SSD) will ask for a formal invite for July Resident Council Meeting to listen to and address concerns.
7. The Human Resource Director (HRD) will educate all newly hired staff on the facility's Cell Phone/Camera Usage policy including the potential for disciplinary consequences.
8. Outcomes will be reported to the Quality Assurance and Performance Improvement Committee for review and recommendations.
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