§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, resident observations, and resident and staff interviews, 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 10 of 15 residents (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10) and for four of five staff members (Employee E1, E2, E3, and E4).
Findings Include:
Review of the facility policy, "Answering the Call Light" dated 8/27/25, indicated, "The purpose of this procedure is to ensure timely responses to the resident's requests and needs."
Review of the facility policy, "Activities of Daily Living, (ADL), Supporting" dated 6/1/25, indicated, "Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene."
During an observation on 2/17/26, at approximately 10:56 a.m. Resident R1 was noted to have a large amount of brown substance underneath his very long, curled over fingernails.
Review of Resident R1's point of care documentation from 1/18/26, through 2/17/26, revealed Resident R1's scheduled shower days were Wednesdays and Saturdays, on evening shift.
1/21/26: Documented as "Shower"
1/24/26: Documented as "Not Applicable"
1/28/26: Documented as "Not Applicable"
1/31/26: Documented as "Not Applicable"
2/04/26: Documented as "Not Applicable"
2/07/26: Documented as "Not Applicable"
2/11/26: Documented as "Refused"
2/14/26: Documented as "Bed bath"
Review of facility census information confirmed Resident R1 was not out of the facility on any dates from 1/18/26, through 2/17/26.
During an observation on 2/17/26, at approximately 10:57 a.m. Resident R2 was noted to have a large amount of dandruff and dry skin crusted on his hair.
Review of Resident R2's point of care documentation from 1/18/26, through 2/17/26, revealed Resident R2 did not have documented scheduled shower days.
1/20/26: Documented as "Bed/Towel Bath"
2/07/26: Documented as "Bed/Towel Bath"
2/10/26: Documented as "Not Applicable"
2/11/26: Documented as "Not Applicable"
2/14/26: Documented as "Bed/Towel Bath"
Review of facility census information confirmed Resident R2 was not out of the facility on any dates from 1/18/26, through 2/17/26.
During an interview on 2/17/26, at approximately 11:00 a.m. Resident R3 stated that call light response times can be excessive, and it depends on what staff is working.
During an interview on 2/17/26, at approximately 11:00 a.m. Resident R4 stated that "they are so short-staffed."
During an interview on 2/17/26, at approximately 11:10 a.m. Resident R5 stated that "they are very understaffed. It stresses the aides out and it's not food for the patients."
During an interview and observation on 2/17/26, at approximately 11:15 a.m. Resident R6 stated that call light response times can be excessive. Resident R6 was noted to have a large amount of brown substance underneath his fingernails.
During an interview on 2/17/26, at approximately 11:18 a.m. Resident R7 stated that "could always use more help."
During an interview on 2/17/26, at approximately 11:18 a.m. Resident R7 stated that "could always use more help."
During an interview on 2/17/26, at approximately 12:41 p.m. Resident R8, when asked if the facility maintained enough staff to care for residents, stated "Sometimes." When asked about call light response times, Resident R8 stated "Depends."
During an interview on 2/17/26, at approximately 12:45 p.m. Resident R9, when asked if the facility maintained enough staff to care for residents, stated "No" and further stated that there is a delay in getting people dressed and out of bed in the morning. When asked about call light response times, Resident R8 stated "Call lights are long, because there isn't enough staff."
During an observation on 2/17/26, at approximately 12:50 p.m. Resident R10 was noted to have a large amount of brown substance underneath his fingernails. When asked if he wanted his facial hair shaved, Resident R10 nodded his head affirmatively.
Review of Resident R10's point of care documentation from 1/18/26, through 2/17/26, revealed Resident R10's scheduled shower days were Wednesdays and Saturdays, on evening shift.
1/21/26: Documented as "Not Applicable"
1/24/26: Documented as "Bed/Towel Bath"
1/28/26: Documented as "Not Available" (resident was hospitalized)
1/31/26: Documented as "Not Available" (resident was hospitalized)
2/04/26: Documented as "Not Applicable"
2/07/26: No documentation
2/11/26: Documented as "Bed/Towel Bath"
2/14/26: No documentation
Review of facility census information confirmed Resident R10 was in the facility from 1/18/26, through 1/27/26, and from 2/3/26, through 2/17/26.
During staff interviews completed during the survey, the following was stated in response to questions about facility staffing:
Employee E1, "Do you want me to tell the truth, do you want me to lose my job? They are killing us. They are killing us."
Employee E2, "Crappy. Changes day-to-day. You never know what's going to go on."
Employee E3, "It's horrible."
Employee E4, "They just had a call off. We work short on daylight and then have to pick up on evenings and our days off."
During an electronic interview on 2/17/26, at approximately 1:30 p.m. the Nursing Home Administrator and the Director of Nursing 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 for ten of fifteen 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: 03/30/2026
The facility cannot correct the past insufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 10 of 15 residents.
R1,R2,R3,R4,R5,R6,R7,R8,R9, and R10 needs were addressed and met.
An initial Audit was completed on current Residents to ascertain if any other Residents were in need of hair, nail care, and showers.
All current resident shower schedules and shower days have been reviewed.
Nursing staff were educated to inform the charge nurse when and if ADL's and Showers were not completed.
All staff were educated on the Call Bell Response Policy.
IDT Team will review showers during clinical meetings to ensure showers are completed as scheduled.
DON/Designee will conduct Call Bell Audits on Random shifts, on each all, 3 times a week, for two weeks, then, weekly x 2 weeks, then, monthly x 2 months.
DON/Designee will conduct Random Audits on showers and nail care on Both Units 3x a week for two weeks, then, weekly x 2 weeks, then, monthly x 2 months.
Findings will be submitted to Monthly QA.
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