Observations:
Based on review of facility policy, observations, and resident and staff interviews it was determined that the facility failed to provide activity of daily living assistance for six of 29 residents (Resident R1, R2, R3, R4, R5, and R6).
Findings include:
Review of the facility policy "Accessibility and Timely Response" dated 1/1/26, indicated All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified.
During an observation of the Ebensburg Nursing Unit on 6/19/26, at approximately 11:15 a.m. multiple call lights were observed to be alarming, with both red and white lights illuminated above resident doors.
At this time, Activities Employee E1 was observed in the hallway where four call lights were illuminated. When asked about the call lights not being responded to, Activities Employee E1 stated, "I'm Activities." When asked if she was still able to respond to call light to ensure resident's safety in case they had fallen or respond to non-nursing request, Activities Employee E1 stated, "Well, I guess I could."
During an observation on 6/19/26, at approximately 11:20 a.m. the surveyor approached the nursing station and asked the staff member standing at the desk what the call lights that were illuminated red meant. The staff member stated, "I think that means they are in the bathroom, I'm not an aide." When asked what her position was, the staff member stated, "I'm a Unit Clerk." At this time, Unit Clerk Employee E2 then exited the nurses' station and the unit without responding to any of the alarming call lights.
During an observation of the call light monitor at the nurse's station on 6/19/26, at approximately 11:23 a.m. revealed call lights were illuminated on the monitor for Resident R1, Resident R2, Resident R3 and R4's room, and Resident R5.
During an observation on 6/19/26, at approximately 11:25 a.m. the call lights still illuminated on the Ebensburg Nursing Unit, Social Services Employee E3 was observed walking past Resident R1 and R2's rooms without stopping to ensure resident safety or attempting to respond to a possible non-nursing request.
During an interview on 6/19/26, at approximately 11:35 a.m. Resident R6 stated that call light responses can take up to a half hour.
During an interview on 6/19/26, at approximately 12:00 p.m. the Nursing Home Administrator confirmed the facility failed to provide activity of daily living assistance for failed to provide activity of daily living assistance for six of 29 residents.
28 PA. Code:201.18(b)(2) Management.
28 PA. Code:201.29(a) Resident's Rights
| | Plan of Correction - To be completed: 08/03/2026
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction This plan of correction is submitted as the facility's credible allegation of compliance.
The facility has determined that all residents have the potential to be affected.
The Nursing Home Administrator or designee will provide education to all staff regarding the need for timely provision of assistance for residents through response to call-bells.
The Nursing Home Administrator or designee, will conduct observations of 10 call-bell responses to include all shifts each week for 4 weeks or until sufficient compliance has been achieved to ensure staff are responding timely to call-bells and to ensure that all available staff are responding appropriately to call-bells. Satisfaction interviews will be conducted with 5 residents each week for 4 weeks to determine satisfaction with the timeliness and response to their call-bell use.
Audit results will be reviewed with the Quality Assurance and Quality Improvement Committee for analysis and further recommendation.
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