Pennsylvania Department of Health
BROAD ACRES HEALTH AND REHABILITATION CENTER
Patient Care Inspection Results

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BROAD ACRES HEALTH AND REHABILITATION CENTER
Inspection Results For:

There are  82 surveys for this facility. Please select a date to view the survey results.

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BROAD ACRES HEALTH AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, State Licensure Survey, Civil Rights Compliance Survey, and an Abbreviated Survey to review two Complaints completed on September 13, 2024, it was determined that Broad Acres Health and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


483.25(m) REQUIREMENT Trauma Informed Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.25(m) Trauma-informed care
The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide culturally, competent, trauma-informed care, and to eliminate or mitigate re-traumatization for one of six residents reviewed for mood/behavior (Residents 7).

Findings include:

Clinical record review revealed the facility admitted Resident 7 on April 19, 2024, and added a diagnosis of Post Traumatic Stress Disorder (PTSD, a mental and behavioral disorder that develops related to a terrifying event) on May 1, 2024.

Review of Resident 7's social history and evaluation completed on April 23, 2024, revealed a trauma screening questionnaire (a group of questions related to symptoms that may occur due to a traumatic event) that indicated Resident 7 had difficulty concentrating at least twice in the past week. The questionnaire did not include questions related to her diagnosis of PTSD or triggers that may mitigate re-traumatization.

Review of Resident 7's current care plan revealed a history of depression, PTSD, and anxiety. The care plan indicated that the PTSD was related to her husband's death and that she had panic attacks at times. The care plan did not identify what triggers her panic attacks related to her husband's death that occurred approximately 20 years ago or how she deals with them.

Further review of Resident 7's clinical record contained no evidence the facility collaborated with the resident, and as appropriate, the resident's family, friends, and any other healthcare professionals (such as psychologists, and mental health professionals) to identify triggers to develop and implement individualized interventions to prevent re-traumatization.

Resident 7's care plan was revised on September 13, 2024, and a progress note was entered into her clinical record on September 12, 2024, at 7:57 PM indicating a conversation was held with her to determine her potential triggers. This was after the surveyor made the facility aware that her clinical record failed to identify her potential triggers on September 12, 2024, at 2:00 PM.

These findings were confirmed with the Director of Nursing on September 13, 2024, at 2:00 PM.

28 Pa Code 211.12 (d)(3)(5) Nursing services


 Plan of Correction - To be completed: 11/01/2024

A progress note was entered into Resident 7's clinical record after having a conversation with her to determine her triggers. The Care Plan was updated to reflect her triggers.

An audit will be conducted on all residents with a diagnosis of PTSD to ensure there are triggers identified in the clinical record as well as the care plan.

Policies and Procedures were updated to include triggers related to PTSD and to develop appropriate interventions to avoid those triggers. Education was provided to the Social Services Director and Social Services Assistant on the updated policies and procedures related to appropriate trauma informed care interventions.

An audit will be conducted for 4 weeks to ensure all residents with a diagnosis of PTSD have triggers identified that may mitigate re-traumatization in the clinical record and care plan

483.35(g)(1)-(4) REQUIREMENT Posted Nurse Staffing Information:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.35(g) Nurse Staffing Information.
§483.35(g)(1) Data requirements. The facility must post the following information on a daily basis:
(i) Facility name.
(ii) The current date.
(iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:
(A) Registered nurses.
(B) Licensed practical nurses or licensed vocational nurses (as defined under State law).
(C) Certified nurse aides.
(iv) Resident census.

§483.35(g)(2) Posting requirements.
(i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift.
(ii) Data must be posted as follows:
(A) Clear and readable format.
(B) In a prominent place readily accessible to residents and visitors.

§483.35(g)(3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard.

§483.35(g)(4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater.
Observations:

Based on observation, review of posted daily nurse staffing data, and staff interview, it was determined that the facility failed to ensure daily nurse staff data was posted for both nursing units (A and B wing).


Findings include:

Observation on September 11, 2024, at 1:46 PM revealed the facility's posted nursing time did not include the total number and the actual hours worked of licensed and unlicensed nursing staff directly responsible for resident care for first and second shifts.

Subsequent observations on September 12, 2024, at 2:48 PM, and September 13, 2024, at 11:12 AM again revealed the facility's posted nursing time did not include the total number and the actual hours worked of licensed and unlicensed nursing staff directly responsible for resident care for first and second shifts. The posting did not include the facility's name.

Interview with the Director of Nursing on September 13, 2024, at 11:42 confirmed these findings.

28 Pa. Code 201.14(a) Responsibility of licensee


 Plan of Correction - To be completed: 11/01/2024

There were no adverse effects to the residents due to the posted nursing time not including the total number and actual hours worked of licensed and unlicensed nursing staff directly responsible for resident care


An audit was conducted of the last 30 days of posted nursing times to ensure posted nursing time sheets are filled out in their entirety

Education was provided to the Nursing Administration department and RN Supervisors to ensure all posted nursing time sheets are filled out in their entirety.

An audit will be conducted weekly for 4 weeks of all posted nursing time sheets to ensure the sheets are filled out in their entirety. All audits will be brought to QAPI to ensure compliance

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

§483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

§483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

§483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

§483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(k).
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to notify a resident and/or their responsible party in writing of a transfer to the hospital with the required information for five of nine residents reviewed (Residents 11, 16, 24, 30, and 50).

Findings include:

Clinical record review for Resident 16 revealed that they were transferred to the hospital on August 31, 2024, after a change in their condition. There was no documentation that the facility provided written notification to the resident's responsible party regarding the transfer that included the required contents: reason for the transfer, effective date of the transfer, location to which the resident was transferred, a statement of the resident's right to appeal, including the name, contact, email, and address, how to obtain and appeal form, assistance completing and submitting the appeal form and hearing request, contact, email, and address information for the Office of the State Long-Term Care Ombudsman, and information for the agency responsible for the protection and advocacy of individuals with developmental disabilities.

Clinical record review for Resident 30 revealed that they were transferred to the hospital on January 27, 2024, after there was a change in their condition. There was no documentation that the facility provided written notification to their responsible party as required regarding the transfer that included the required contents listed above.

Clinical record review for Resident 50 revealed that they were transferred to the hospital on December 29, 2023, after there was a change in their condition. There was no documentation that the facility provided written notification to their responsible party, or the State Ombudsman as required regarding the transfer that included the required contents listed above.

The surveyor reviewed the above information for Residents 16, 30, and 50 during an interview with the Nursing Home Administrator and Director of Nursing on September 12, 2024, at 2:20 PM.

Clinical record review for Resident 11 revealed that she was transferred to the hospital on January 30, 2024, after there was a change in her condition. There was no documentation that the facility provided written notification to her responsible party as required regarding the transfer that included all the required contents as listed above.

Clinical record review for Resident 24 revealed that they were transferred to the hospital on June 13, 2024, after there was a change in his condition. There was no documentation that the facility provided written notification to his responsible party, or the State Ombudsman as required regarding the transfer that included the required contents listed above.

Interview with Employee 1 (business office manager) on September 13, 2024, at 9:16 AM confirmed these findings.

28 Pa. Code 201.14 (a) Responsibility of license

28 Pa. Code 201.29(a) Resident rights


 Plan of Correction - To be completed: 11/01/2024

There were no adverse effects to residents 16, 30, 11, 24 and 50 because the form did not include all of the required contents. June 2024's and December's 2023 transfer logs were updated with resident 24 and resident 50's information and resent to the Ombudsman.

An audit of the last 12 months of transfer logs was completed to verify all transfer logs sent to the Ombudsman were completed timely and with all of the residents who are required to be on the form. The transfer letter was reviewed and updated to ensure all of the required information is on the letter.

The Business Office Manager and Accounts Payable Coordinator were in-serviced on the required contents of the transfer letter and to ensure transfer logs are sent to the Ombudsman in the proper timeframe.

An audit will be completed weekly for 4 weeks to verify all residents who are to be on the transfer log sent to the Ombudsman are on the form. Form will be reviewed weekly to ensure all required contents of the form are on the form. Audits will be reviewed at QAPI.

§ 211.12(f.1)(3) LICENSURE Nursing services. :State only Deficiency.
(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 a review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure a minimum of one nurse aide (NA) per 10 residents during the day shift for 11 of 21 days reviewed, one NA per 11 residents during the evening shift for 16 of 21 days reviewed, and one NA per 15 residents during the night shift for 20 of 21 days reviewed.

Findings include:

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

Day shift (requires one NA per 10 residents):

August 11, 2024, 7.50 NAs for a census of 83, requires 8.30 NAs
August 12, 2024, 7.64 NAs for a census of 83, requires 8.30 NAs
August 15, 2024, 7.35 NAs for a census of 85, requires 8.50 NAs
August 17, 2024, 6.21 NAs for a census of 85, requires 8.50 NAs
August 18, 2024, 4.80 NAs for a census of 84, requires 8.40 NAs
August 19, 2024, 8.16 NAs for a census of 86, requires 8.60 NAs
August 20, 2024, 7.85 NAs for a census of 86, requires 8.60 NAs
August 21, 2024, 8.70 NAs for a census of 88, requires 8.80 NAs
August 23, 2024, 8.69 NAs for a census of 88, requires 8.80 NAs
September 9, 2024, 8.33 NAs for a census of 84, requires 8.40 NAs
September 10, 2024, 6.98 NAs for a census of 84, requires 8.40 NAs

Evening shift (requires one NA per 11 residents):

August 11, 2024, 7.23 NAs for a census of 83, requires 7.55 NAs
August 12, 2024, 6.55 NAs for a census of 83, requires 7.55 NAs
August 13, 2024, 6.30 NAs for a census of 82, requires 7.45 NAs
August 14, 2024, 6.05 NAs for a census of 85, requires 7.73 NAs
August 16, 2024, 6.79 NAs for a census of 85, requires 7.73 NAs
August 17, 2024, 6.63 NAs for a census of 84, requires 7.64 NAs
August 18, 2024, 5.94 NAs for a census of 85, requires 7.73 NAs
August 19, 2024, 7.05 NAs for a census of 86, requires 7.82 NAs
August 20, 2024, 7.82 NAs for a census of 87, requires 7.91 NAs
August 21, 2024, 7.75 NAs for a census of 88, requires 8.00 NAs
August 22, 2024, 5.90 NAs for a census of 87, requires 7.91 NAs
August 24, 2024, 7.21 NAs for a census of 87, requires 7.91 NAs
September 7, 2024, 7.58 NAs for a census of 84, requires 7.64 NAs
September 8, 2024, 7.26 NAs for a census of 84, requires 7.64 NAs
September 9, 2024, 7.05 NAs for a census of 84, requires 7.64 NAs
September 10, 2024, 6.95 NAs for a census of 84, requires 7.64 NAs

Night shift (requires one NA per 15 residents):

August 11, 2024, 4.48 NAs for a census of 83, requires 5.53 NAs
August 12, 2024, 5.01 NAs for a census of 82, requires 5.47 NAs
August 13, 2024, 4.43 NAs for a census of 83, requires 5.53 NAs
August 14, 2024, 4.39 NAs for a census of 85, requires 5.67 NAs
August 15, 2024, 4.24 NAs for a census of 84, requires 5.60 NAs
August 16, 2024, 4.46 NAs for a census of 84, requires 5.60 NAs
August 17, 2024, 4.25 NAs for a census of 84, requires 5.60 NAs
August 18, 2024, 4.35 NAs for a census of 86, requires 5.73 NAs
August 19, 2024, 4.64 NAs for a census of 86, requires 5.73 NAs
August 20, 2024, 4.58 NAs for a census of 88, requires 5.87 NAs
August 21, 2024, 4.86 NAs for a census of 88, requires 5.87 NAs
August 22, 2024, 4.94 NAs for a census of 88, requires 5.87 NAs
August 23, 2024, 4.75 NAs for a census of 87, requires 5.80 NAs
August 24, 2024, 3.88 NAs for a census of 87, requires 5.80 NAs
September 6, 2024, 4.68 NAs for a census of 85, requires 5.67 NAs
September 7, 2024, 5.24 NAs for a census of 84, requires 5.60 NAs
September 9, 2024, 4.94 NAs for a census of 84, requires 5.60 NAs
September 10, 2024, 4.43 NAs for a census of 82, requires 5.47 NAs
September 11, 2024, 5.08 NAs for a census of 83, requires 5.53 NAs
September 12, 2024, 4.21 NAs for a census of 83, requires 5.53 NAs

During a meeting with the Nursing Home Administrator and Director of Nursing on September 11, 2024, at 2:00 PM they confirmed that the facility did not meet regulatory NA-to-resident ratios as evidenced above.


 Plan of Correction - To be completed: 11/01/2024

A review of the staffing schedules for will be conducted to ensure compliance with the ratio of 1 nurse aide per 10 residents on 1st shift, 1 nurse aide per 11 residents on 2nd shift and 1 nurse aide per 15 residents on night shift.

An inservice will be conducted with the Scheduler to ensure compliance with the ratio of 1 nurse aide per 10 residents on first shift, 1 nurse aide per 11 residents on 2nd shift and 1 nurse aide per 15 residents on night shift

An audit will be conducted weekly of the next 4 weeks of nursing schedules to ensure compliance with the ratio of 1 nurse aide per 10 residents on first shift, 1 nurse aide per 11 residents on 2nd shift and 1 nurse aide per 15 residents on night shift.
§ 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 a review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift on two of the 21 days reviewed, one LPN per 30 residents during the evening shifts on four of the 21 days reviewed, and one LPN per 40 residents during the overnight shift on 7 of the 21 days reviewed.

Findings include:

Review of nursing staff care hours provided by the facility revealed the following staff scheduled for the following resident census:

Day shift (requires one LPN per 25 residents):

August 11, 2024, 2.56 LPNs for a census of 83, requires 3.32 LPNs
August 20, 2024, 3.23 LPNs for a census of 86, requires 3.44 LPNs

Evening shift (requires one LPN per 30 residents):

August 15, 2024, 2.49 LPNs for a census of 85, requires 2.83 LPNs
August 21, 2024, 2.89 LPNs for a census of 88, requires 2.93 LPNs
September 7, 2024, 2.73 LPNs for a census of 84, requires 2.80 LPNs
September 10, 2024, 2.60 LPNs for a census of 84, requires 2.80 LPNs

Overnight shift (requires one LPN per 40 residents):

August 11, 2024, 1.25 LPNs for a census of 83, requires 2.08 LPNs
August 15, 2024, 1.05 LPNs for a census of 84, requires 2.10 LPNs
August 20, 2024, 2.18 LPNs for a census of 88, requires 2.20 LPNs
August 21, 2024, 1.75 LPNs for a census of 88, requires 2.20 LPNs
August 23, 2024, 2.05 LPNs for a census of 87, requires 2.18 LPNs
September 9, 2024, 1.99 LPNs for a census of 84, requires 2.10 LPNs
September 11, 2024, 1.55 LPNs for a census of 83, requires 2.08 LPNs

During a meeting with the Nursing Home Administrator and Director of Nursing on September 11, 2024, at 2:00 PM they confirmed that the facility did not meet regulatory LPN-to-resident ratios as evidenced above.


 Plan of Correction - To be completed: 11/01/2024

A review of the staffing schedules will be conducted to ensure compliance with the ratio of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening and 1 LPN per 40 residents overnight.

An in service will be conducted with the Scheduler to ensure compliance with the ratio of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening and 1 LPN per 40 residents overnight.

An audit will be conducted weekly of the next 4 weeks of nursing schedules to ensure compliance with the ratio of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening and 1 LPN per 40 residents overnight.
§ 211.12(i)(2) LICENSURE Nursing services.:State only Deficiency.
(2) Effective July 1, 2024, 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 3.2 hours of direct resident care for each resident.

Observations:

Based on review of nursing staffing hours 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 3.2 hours per patient day (PPD), effective July 1, 2024, for 15 of 21 days reviewed.

Findings include:

Review of nursing staff care hours for August 11 through 24, 2024, and September 6 through 12, 2024, revealed that the facility failed to meet the minimum hours per patient day for the following days:

August 11, 2024, 2.83 hours PPD
August 12, 2024, 3.11 hours PPD
August 14, 2024, 3.04 hours PPD
August 15, 2024, 2.84 hours PPD
August 16, 2024, 3.07 hours PPD
August 17, 2024, 2.85 hours PPD
August 18, 2024, 2.57 hours PPD
August 19, 2024, 3.06 hours PPD
August 20, 2024, 2.93 hours PPD
August 21, 2024, 3.02 hours PPD
August 22, 2024, 2.96 hours PPD
August 23, 2024, 3.18 hours PPD
August 24, 2024, 3.14 hours PPD
September 9, 2024, 3.07 hours PPD
September 10, 2024, 2.92 hours PPD

During a meeting with the Nursing Home Administrator and Director of Nursing on September 11, 2024, at 2:00 PM they confirmed that the facility did not meet regulatory daily hours PPD as evidenced above.


 Plan of Correction - To be completed: 11/01/2024

There were no immediate adverse affects
A review of the staffing schedules for 4 weeks will be conducted to ensure compliance with a minimum of 3.20 hours per patient day of direct nursing care

An in service will be conducted with the Scheduler to ensure compliance with a minimum of 3.20 hours per patient day of direct nursing care

An audit will be conducted weekly for the next 4 weeks of nursing schedules to ensure compliance with a minimum of 3.20 hours per patient day of direct nursing care

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