Pennsylvania Department of Health
TITUSVILLE NURSING AND REHAB
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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TITUSVILLE NURSING AND REHAB - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an Abbreviated Complaint Survey completed on December 1, 2025, at Titusville Nursing and Rehab it was determined that there were no federal deficiencies identified under the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities as it relates to the Health portion of the survey process; however, the facility was not in compliance with 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

§ 211.12(e) LICENSURE Nursing services.:

(e) The facility shall designate a charge nurse who is responsible for overseeing total nursing activities within the facility on each tour of duty each day of the week.

Observations:

Based on review of the facility provided nursing staffing documents and staff interview, it was determined that the facility failed to ensure a charge nurse who is responsible for overseeing total nursing activities within the facility was on each tour of duty each day of the week for one of 21 days reviewed (11/14/25).

Findings include:

Review of facility provided staffing information for 11/14/25, revealed the overnight shift lacked a charge nurse to oversee total nursing activities within the facility for the entire shift.

During an interview on 12/1/25, at approximately 1:12 p.m. the Nursing Home Administrator confirmed that the facility failed to meet the required charge nurse staffing on each tour of duty each day of the week on the date and shift listed above.

Plan of Correction - To be completed: 01/02/2026

Facility will continue to take measures to adequately provide staff to ensure the needs of residents are met.

The Director of Nursing or designee will provide re-education on minimum staffing ratios including the requirements of a charge nurse to RN Supervisors, Human Resources and Scheduling Coordinator who are responsible for maintaining adequate staffing and staffing ratios.

The Director of Nursing or designee will audit the daily schedules to ensure that a charge nurse has been scheduled and will audit that protocols were followed if a call off occurred.

Audits will be completed weekly x 4 weeks to ensure charge nurse requirements were met. Results of these audits will be reviewed at Quality Assurance and Process Improvement Meetings until substantial compliance is achieved.

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on review of the facility nursing staffing documents and staff interview, it was determined that the facility failed to ensure a minimum of one Nurse Aide (NA) per 10 residents for the day shift for one of 21 days reviewed (11/2/25) and failed to ensure a minimum of one NA per 15 residents for the overnight shift for one of 21 days reviewed (11/4/25).

Findings include:

Review of facility nursing staffing documents for the time period from 11/1/25 through 11/21/25, revealed the following NA staffing shortage for the day shift where the NA ratios were not met:

11/2/25 census of 60 residents 5.33 NAs worked and 6.00 were required

Review of facility nursing staffing documents for the time period from 11/1/25 through 11/21/25, revealed the following NA staffing shortage for the overnight shift where the NA ratios were not met:

11/4/25 census of 61 residents 3.10 NAs worked and 4.07 were required

During an interview on 12/1/25, at 11:17 a.m. the Nursing Home Administrator confirmed that the facility failed to meet the minimum NA ratio requirements on the dates and shifts listed above.

Plan of Correction - To be completed: 01/02/2026

No residents were identified by the facility as experiencing harm due to the lack of nurse aide staffing ratios on 11/2/25, day shift and 11/4/25, night shift.

The facility clinical leadership Facility will continue to take measures to adequately provide staff to ensure the needs of residents are met.

The Director of Nursing or designee will provide re-education on minimum staffing ratios including to RN Supervisors, Human Resources and Scheduling Coordinator who are responsible for maintaining adequate staffing and staffing ratios.

The Director of Nursing or designee will audit the daily schedules to ensure the minimum number of staff to resident ratios have been scheduled and will audit that protocols were followed if a call off occurred.

Audits will be completed weekly x 4 weeks, and results of these audits will be reviewed at Quality Assurance and Process Improvement Meetings until substantial compliance is achieved.

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