§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 resident and staff interviews, Resident Council minutes review, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of eight of eleven residents (Residents R1, R2, R3, R4, R5, R6, R7, and R8).
Findings include:
During an interview on 11/5/25, at 5:00 p.m. when asked if he felt the facility maintained enough staff to care for resident needs, Resident R1 stated, " No. " Resident R1 stated that call light response " usually takes a long time. " Resident R1 further stated that he receives late medications and is not assisted in and out of bed timely.
During an interview on 11/5/25, at 5:03 p.m. when asked if she felt the facility maintained enough staff to care for resident needs, Resident R2 stated, " There could be more. "
During an interview on 11/5/25, at 5:09 p.m. when asked if he felt the facility maintained enough staff to care for resident needs, Resident R3 stated, " At times not. "
During an observation on 11/5/25, at 6:18 p.m., Resident R4 and Resident R5's room smelled overpoweringly of urine.
Review of Resident R4's toileting record indicated Resident R4 was incontinent of urine, and incontinence care was documented on 11/5/25, at 2:25 p.m. and not documented as completed again until 11/6/25, at 12:32 a.m.
During an interview on 11/5/25, at 2:56 p.m., Resident R6, when asked if she felt the facility maintained sufficient staff to care for resident needs, stated, "At times I be sitting in piss for two to three hours. People don't want to help. I had to call my family at 2:00 a.m. to have them call (the nurses). When I call the nurse's station, they hang up on me. " Resident R6 stated that he waited from 3:00 a.m. until 11:00 a.m. before receiving assistance. Resident R6 stated he has been told, "You aren't the only one here" and stated, "You are lucky to see them one time a shift." Observation at this time revealed large amounts of a brown substance under Resident R6's fingernails and for Resident R6 to be malodorous.
During an interview on 11/5/25, at 6:35 p.m., Resident R7, when asked if she felt the facility maintained sufficient staff to care for resident needs, stated, "No, all I hear is complaints that they only have three aides, and I have to wait. One time the night shift aide found out she had the whole floor and told me I will have to wait." Resident R7 stated she has waited up to three hours for assistance after activating her call light. Resident R7 stated that she was told on Monday (11/3/25) that she could not have a shower due to insufficient staffing, and that she would get it on Tuesday, "But I didn't end up getting a shower at all." "I'm completely dependent on aides. I've laid as much as 12 hours in my own body fluids. Sunday is the worst."
Review of Resident R7's shower record revealed that on her scheduled shower day of Monday, 11/3/25, or Tuesday 11/4/25, she did not receive a shower. No shower refusals were documented.
Review of Resident Council meeting minutes for 8/22/25, included concerns about staff not assisting to change soiled sheets.
Review of Resident Council meeting minutes for 9/24/25, included concerns about from two residents about not getting showers when scheduled.
Review of a grievance filed on behalf of Resident R8, dated 8/20/25, revealed concerns that Resident R8 was still in bed at 11:30 a.m. and had not been provided bathing assistance.
During an interview on 11/5/25, at approximately 7:15 p.m. the Nursing Home Administrator and confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of eight of eleven residents.
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(e)(6) Management.
28 Pa. Code: 201.20(a) Staff development.
28 Pa. Code: 211.12(a)(c)(d)(1)(2)(3)(4) Nursing services.
| | Plan of Correction - To be completed: 12/16/2025
Residents R1, R2, R3, R4, R5, R6, R7, and R8 continue to reside in the facility and are being provided nursing and related services to maintain the highest practicable physical, mental and psychosocial well-being.
The facility has addressed the concerns for Residents R1–R8 who verbalized care concerns.
The eight residents were assessed head-to-toe for changes in skin integrity, hydration, psychosocial distress, and unmet needs.
Missed showers were completed, and bathing schedules were reviewed with each resident.
Call bell functionality involved in the noted rooms were checked and confirmed operational.
The DON/designee completed interviews of a random sample of 15 residents regarding call light response times, assistance with toileting, and bathing access; Any concerns identified were corrected at the time of discovery.
The DON/designee re-educated CNAs and nurses on timely toileting, incontinence care, documentation expectation, and call light response times. The scheduler has been re-educated by the NHA/designee on scheduling sufficient nursing staff to provide related services to attain or maintain the highest practicable physical, mental and psychosocial well-being.
DON/designee will conduct call light rounds 3x a week × 4 weeks, then weekly × 4 weeks, then monthly × 3 months.
Unit managers will review shower logs 3 times weekly × 4 weeks, then weekly × 8 weeks, then monthly × 3 months. Missed showers with no refusal documented will be offered a shower
NHA or designee will conduct weekly audits x 4, then monthly x 2 of nursing staffing to ensure sufficient nursing staff were provided to attain or maintain the highest practicable physical, mental and psychosocial well-being of the residents.
Results will be reported to the monthly QA committee for further review.
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