§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 (e) 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 (e) 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, resident interviews and confidential staff interviews, 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 (Resident R1, R2, R3, R4, R5, R6, R7, and R8).
Findings Include:
Review of the facility policy "Staffing" dated 9/11/25, indicated "Our facility provides adequate staffing to meet needed care and services for our resident population."
Review of the facility policy "Answering the Call Light" dated 9/11/25, indicated the facility will "ensure timely responses to the resident's requests and needs."
During an interview on 4/6/26, at 12:40 p.m. when asked if she thought the facility maintained sufficient staffing to care for residents, Resident R1 stated, "No. My thing is, when I need to go to the bathroom, I have to wait and wait." Resident R1 confirmed that she has urinated while waiting for a bed pan to be provided. When asked about receiving showers, Resident R1 stated, "I haven't had a shower in I don't know how long. I feel crummy."
Review of Resident R1's bathing record for 3/12/26, through 4/5/26, confirmed Resident R1 has only received bed baths.
During an interview and observation on 4/6/26, at 12:50 p.m. Resident R2's room smelled strongly of urine. When asked about call light response, Resident R2 stated, "Depends. Quicker in the day than in the night." Resident R2 confirmed he has urinated while waiting for assistance to be provided.
During an interview and observation on 4/6/26, at 12:50 p.m. when asked about call light response, Resident R3 stated, "Depends on what is going on."
During an interview on 4/6/26, at 12:58 p.m. Resident R4 stated that she waited nine hours to get back into bed on the previous Friday (4/3/26). Observation at this time revealed Resident R4's fingernails to have a brown substance under the nails.
During an interview and observation on 4/6/26, at 1:25 p.m. when asked if she thought the facility maintained sufficient staffing to care for residents, Resident R5 stated, "Not enough, especially in the evening."
During an interview and observation on 4/6/26, at 1:29 p.m. when asked if she thought the facility maintained sufficient staffing to care for residents, Resident R6 stated, "I think they are understaffed."
During an interview and observation on 4/6/26, at 1:30 p.m. when asked if she thought the facility maintained sufficient staffing to care for residents, Resident R7 stated, "I don't think so." When asked if call light response time were long, Resident R7 stated, "Sometimes, yes."
During an interview on 4/6/26, at 1:40 p.m. when asked if she thought the facility maintained sufficient staffing to care for residents, Resident R8 stated, "No. They are way understaffed." When asked if call light response times were long, Resident R8 stated, "Oh my God, yes. Hours and sometimes never. I don't know why they give them to us if they don't answer."
During an interview on 4/6/26, at approximately 2:30 p.m. the Nursing Home Administrator 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: 05/25/2026
To ensure ongoing compliance with sufficient nursing staff, the facility has strengthened its census-based staffing oversight process. Nursing coverage is evaluated routinely by reviewing prior shift staffing levels and projecting required coverage for upcoming shifts based on anticipated resident census. R1 (BIMS 10) received a shower on 4/15 but frequently refuses, staff to continue to encourage. R2 (BIMS 15) room was cleaned. R3 (BIMS 14) has no skin breakdown due to concerns with call lights. R4 has since returned home, but her fingernails were cleaned prior to going home. R5 (BIMS 12) and R6 (unidentified) justifiably feels like Peter's township is understaffed, the facility has had issues with agency nurse/CNA call off's and is implementing plans to correct. R7 (BIMS 8) and R8 (BIMS 11) have no skin breakdown.
If advance review indicates potential risk of falling below the required ratios of 1:10 (daylight), 1:11 (evening), or 1:15 (night), timely scheduling adjustments will be initiated. These adjustments may include reallocation of internal staff, approval of additional hours, or engagement of contracted supplemental staffing partners. A whole house audit was completed by wound nurse and outside wound provider (Logo's) on 4/17 to identify and new wounds in the facility; any new wounds identified will be treated appropriately. A whole house audit of showers will be completed, and any concerns will be addressed. A whole house audit will be conducted to ensure all fingernails are trimmed and free of debris, if any concerns are identified they will immediately be addressed.
The facility continues active recruitment efforts to enhance nurse aide staffing stability, including online job advertising, local community outreach, and employee referral initiatives. Agency partnerships have also been expanded to improve access to qualified personnel when necessary. The Director of nursing will educate the nursing staff on call light response times, showers and ADL's to ensure all residents receive the highest practicable physical, mental, and psychosocial well-being at the facility.
To verify sustained compliance, nurse aide ratio audits will be conducted five days per week for a three-week period by the Nursing Home Administrator or designee. Audit findings will be reviewed through the facility's monthly QAPI process to evaluate effectiveness and guide any additional operational improvements. To ensure residents receive the highest practicable physical, mental, and psychosocial well-being at the Peter's township post-acute will audit call light response times on 3-11 and 11-7 shift on 3 random resident rooms 5 times a week x 4 weeks. An audit will also be completed on 5 residents per day to ensure showers are being completed and nail care is provided; this will be done 5 times a week x 4 weeks. call lights on all shifts 5 times a week x 4 weeks. The results of these audits will be brought to QAPI to be reviewed for continuation or discontinuation.
The facility continues active recruitment efforts to enhance nurse aide staffing stability, including online job advertising, local community outreach, and employee referral initiatives. Agency partnerships have also been expanded to improve access to qualified personnel when necessary. The Director of nursing will educate the nursing staff on call light response times and ADL's to ensure all residents receive the highest practicable physical, mental, and psychosocial well-being at the facility.
To verify sustained compliance, nurse aide ratio audits will be conducted five days per week for a three-week period by the Nursing Home Administrator or designee. Audit findings will be reviewed through the facility's monthly QAPI process to evaluate effectiveness and guide any additional operational improvements. To ensure residents receive the highest practicable physical, mental, and psychosocial well-being at the Peter's township post-acute will audit call light response times on 3 call lights on all shifts 5 times a week x 4 weeks. The results of these audits will be brought to QAPI to be reviewed for continuation or discontinuation.
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