F0725

E

Insufficient Nursing Staff Leading to Missed ADLs and Cancelled Activities

Saxonburg, Pennsylvania Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The facility failed to provide sufficient nursing staff to meet residents’ needs for activities of daily living (ADLs) and activities participation, resulting in unmet care needs for five of six interviewed residents. Facility policies dated 1/15/26 required staff to provide necessary services for bathing, dressing, grooming, oral care, transfers, ambulation, toileting, eating, and communication, and to assist residents to and from activities with accommodations in schedules and timing. Multiple residents reported that there were not enough aides, especially on the 2 p.m. to 10 p.m. shift, leading to missed showers on scheduled shower days, prolonged call light response times of up to an hour, and residents sometimes not being gotten out of bed at all because there was not enough staff to return them to bed.

Residents also reported that activities, including Bingo and card games, were repeatedly cancelled or not attended because of insufficient staff to assist with transport and supervision. Several residents stated that Bingo, normally held three times a week, had not occurred for about a week, and that they were sometimes unable to go to the dining room to eat because there were not enough staff to supervise and help those who needed assistance. Staff reportedly informed residents that activities and dining room attendance were being limited or cancelled due to staffing shortages, particularly on specific shifts. The Nursing Home Administrator confirmed that the facility did not have sufficient nursing staff to provide nursing and related services necessary to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the affected residents.