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F0725
F

Insufficient Nursing Staff Resulting in Delayed Care and Unmet Resident Needs

Butler, Pennsylvania Survey Completed on 07-25-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple resident and staff interviews, as well as direct observations. Residents reported delays in receiving meals, with food often arriving cold due to late distribution. Several residents stated that they did not receive regular showers, particularly on weekends, and had to wash themselves or argue with staff to receive basic hygiene care. Residents also reported long wait times, up to 15-20 minutes, for staff to respond to call bells. Seven residents in a group interview expressed concerns about chronic understaffing. Staff interviews corroborated these concerns, with nurse aides reporting that they were sometimes responsible for as many as 60 residents with only three aides available. Staff stated that this level of staffing made it impossible to answer call lights promptly or provide showers as scheduled. The nursing home administrator confirmed that the facility did not have enough nursing staff to provide necessary care and services to maintain the highest practicable well-being of the majority of residents reviewed. These findings were cited as violations of state regulations regarding staffing and resident care.

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