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  78 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.
BROAD ACRES HEALTH AND 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 14, 2024 it was determined that Broad Acres Health and Rehabilitation 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 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 two out of 21 days, nurse aide per 12 residents during the evening shifts for five of 21 days reviewed; and failed to ensure a minimum of one nurse aide per 20 residents during the overnight shifts for one 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:
February 3, 2024, 6.89 nurse aides for a census of 89; requires 7.42 nurse aides.
March 3, 2024, 6.18 nurse aides for a census of 81; requires 6.75 nurse aide.

Evening shift:
February 3, 2024, 6.74 nurse aides for a census of 89; requires 7.42 nurse aides.
March 2, 2024, 6.16 nurse aides for a census of 82; requires 6.83 nurse aides.
March 3, 2024, 6.18 nurse aides for a census of 81; requires 6.75 nurse aides.
March 8, 2024, 6.72 nurse aides for a census of 82; requires 6.83 nurse aides.
March 10, 2024, 5.21 nurse aides for a census of 80; requires 6.67 nurse aides.

Overnight shift:
February 29, 2024, 4.13 nurse aides for a census of 83; requires 4.15 nurse aides.

The Director of Nursing was notified via phone of the above findings on 3/14/24 at 12:38 PM.



 Plan of Correction - To be completed: 04/26/2024

A review of the staffing schedules for will be conducted to ensure compliance with the ratio of 1 nurse aide per 12 residents on 1st shift, 1 nurse aide per 12 residents on 2nd shift and 1 nurse aide per 20 residents on night shift

An inservice will be conducted with the Scheduler to ensure compliance with the ratio of 1 nurse aide per 12 residents on first shift, 1 nurse aide per 12 residents on 2nd shift and 1 nurse aide per 20 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 12 residents on first shift, 1 nurse aide per 12 residents on 2nd shift and 1 nurse aide per 20 residents on night shift. Facility will be in compliance with Department's revised guidance for staffing ratios that will allow use of mathematical calculations when implemented.
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 two of 21 days reviewed; and one licensed practical nurse per 30 residents during the evening shift for one of 21 days reviewed; and one licensed practical nurse per 40 residents during the night shift for nine 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:
January 29, 2024, 3.01 LPNs for a census of 88; requires 3.52 LPNs.
January 30, 2024, 3.10 LPNs for a census of 88; requires 3.52 LPNs

Evening shift:
February 3, 2024, 2.79 LPNs for a census of 89; requires 2.97 LPNs.

Night shift:
January 28, 2024, 1.89 LPNs for a census of 88; requires 2.20 LPNs.
January 29, 2024, 1.78 LPNs for a census of 88; requires 2.20 LPNs.
January 30, 2024, 2.10 LPNs for a census of 88; requires 2.20 LPNs.
January 31, 2024, 1.64 LPNs for a census of 88; requires 2.20 LPNs.
February 1, 2024, 1.70 LPNs for a census of 90; requires 2.25 LPNs.
February 3, 2024, 2.09 LPNs for a census of 89; requires 2.23 LPNs.
March 3, 2024, 1.76 LPNs for a census of 81; requires 2.03 LPNs.
March 10, 2024, 1.75 LPNs for a census of 78; requires 1.95 LPNs.
March 12, 2024, 1.68 LPNs for a census of 79; requires 1.98 LPNs.

The Director of Nursing was notified via phone of the above findings on 3/14/24 at 12:38 PM.



 Plan of Correction - To be completed: 04/26/2024

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. Facility will be in compliance with Department's revised guidance for staffing ratios that will allow use of mathematical calculations when implemented.
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 one 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:

February 3, 2024, with 2.81 hours per resident per day.

The facility failed to meet the required nursing staffing PPD.

The Director of Nursing was notified via phone of the above findings on 3/14/24 at 12:38 PM.


 Plan of Correction - To be completed: 04/26/2024

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 2.87 hours per patient day of direct nursing care

An in service will be conducted with the Scheduler to ensure compliance with a minimum of 2.87 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 2.87 hours per patient day of direct nursing care


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