Pennsylvania Department of Health
BRADFORD HILLS NURSING & REHABILITATION CENTER
Patient Care Inspection Results

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BRADFORD HILLS NURSING & REHABILITATION CENTER
Inspection Results For:

There are  96 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
BRADFORD HILLS NURSING & REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey in response to a Complaint, completed on March 29, 2024, at Bradford Hills Nursing and Rehabilitation Center 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; however, the facility was not in compliance with 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey process.


 Plan of Correction:


211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:

Based on a review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure a minimum of one nurse aide per 12 residents during the dayshift for one out of 21 days, and one nurse aide per 12 residents during the evening shifts for 10 out of 21 days reviewed.

Findings include:

Review of nursing staff care hours provided by the facility revealed the following nurse aides (NA) scheduled for the following resident census:

Dayshift:

March 2, 2024, 9.60 nurse aides for a census of 124; requires 10.33 nurse aides.

Evening:

February 28, 2024, 10.30 nurse aides for a census of 126; requires 10.50 nurse aides.
February 29, 2024, 9.90 nurse aides for a census of 126; requires 10.50 nurse aides.
March 1, 2024, 9.10 nurse aides for a census of 124; requires 10.33 nurse aides.
March 2, 2024, 9.80 nurse aides for a census of 124; requires 10.33 nurse aides.
March 4, 2024, 9.80 nurse aides for a census of 125; requires 10.42 nurse aides.
March 8, 2024, 8.20 nurse aides for a census of 125; requires 10.42 nurse aides.
March 9, 2024, 8.80 nurse aides for a census of 125; requires 10.42 nurse aides.
March 22, 2024, 7.60 nurse aides for a census of 124; requires 10.33 nurse aides.
March 23, 2024, 9.40 nurse aides for a census of 124; requires 10.33 nurse aides.
March 25, 2024, 8.70 nurse aides for a census of 124, requires 10.33 nurse aides.

The findings were reviewed with the Nursing Home Administrator and Director of Nursing on March 29, 2024, at 2:15 PM.


 Plan of Correction - To be completed: 05/01/2024

Tag 5510

1. Facility residents have the potential to be affected.

2. Nursing care hours will be reviewed daily for the current day and the remainder of the week for compliance with the current regulation of 1 nurse aide per 12 residents on day/evening shift and 1 nurse aide per 20 residents on the night shift.

3. Facility will continue to advertise and actively review/schedule interviews/hire new applicants upon applying for a nurse aide position to meet regulation.

4. Facility will utilize per diem staff and/or approved agency staff to fill in open shifts along with asking fulltime nurse aides and/or LPN's to fill in the opened nurse aide positions.

211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:

Based on review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure a minimum of one licensed practical nurse per 25 residents during the day shift for three of 21 days reviewed; one licensed practical nurse per 30 residents during the evening shift for three of 21 days reviewed; and one licensed practical nurse per 40 residents during the night shift for one of 21 days reviewed.

Findings include:

Review of nursing staff care hours provided by the facility revealed the following licensed practical nurse (LPN) scheduled for the following resident census:

Day shift:

February 27, 2024, 4.90 LPNs for a census of 125; requires 5.00 LPNs.
February 29, 2024, 4.00 LPNs for a census of 126; requires 5.04 LPNs.
March 2, 2024, 4.00 LPNs for a census of 124; requires 4.96 LPNs.

Evening shift:

March 2, 2024, 4.00 LPNs for a census of 124; requires 4.13 LPNs.
March 3, 2024, 3.50 LPNs for a census of 125; requires 4.17 LPNs.
March 23, 2024, 4.00 LPNs for a census of 124; requires 4.13 LPNs.

Night shift:

March 6, 2024, 3.00 LPNs for a census of 125; requires 3.13 LPNs.

The findings were reviewed with the Nursing Home Administrator and Director of Nursing on March 29, 2024, at 2:15 PM.


 Plan of Correction - To be completed: 05/01/2024

Tag 5530

1. Facility residents have the potential to be affected.

2. Nursing care hours will be reviewed daily for the current day and the remainder of the week for compliance with the current regulation of 1 LPN per 25 residents on day shift, 1 LPN per 30 residents on evening shift and 1 LPN per 40 residents on the night shift.

3. Facility will continue to advertise and actively review/schedule interviews/hire new applicants upon applying for a LPN position to meet regulation.

4. Facility will utilize per diem staff and/or approved agency staff to fill in open shifts along with asking current RN's to fill in the opened LPN positions.

211.12(i)(1) LICENSURE Nursing services.:State only Deficiency.
(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.

Observations:

Based on the nursing staffing schedules and staff interview, it was determined that the facility failed to ensure the total of nursing care hours provided in each 24-hour period was a minimum of 2.87 hours per patient day (PPD), effective July 1, 2023, on two of the 21 days reviewed.

Findings include:

Review of nursing staff care hours provided by the facility revealed that the facility failed to meet the minimum hours per patient day on the following dates:

March 2, 2024, with 2.79 hours per resident per day.
March 9, 2024, with 2.78 hours per resident per day.

The facility failed to meet the required nursing staffing PPD.

The findings were reviewed with the Nursing Home Administrator and Director of Nursing on March 29, 2024, at 2:15 PM.


 Plan of Correction - To be completed: 05/01/2024

Tag 5630
1. No ill effect to residents noted as a result of the finding.
2. DON or designee will audit the PPD staffing daily to ensure the minimum staffing requirement is achieved. If not achieved immediate action will be taken to secure additional staff to meet the minimum requirements. Immediate action to achieve minimum staffing levels includes bringing in unscheduled staff; utilizing agency staffing; and utilizing nursing administration staff for direct resident care.
3. DON or designee will educate the staffing scheduler, RN Supervisors on the requirement to meet the state requirements.
4. Findings from the daily audit for ppd will be reported to QAPI x 3 months by the DON or scheduler.


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