Pennsylvania Department of Health
BONHAM NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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BONHAM NURSING AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an abbreviated complaint survey completed on April 19, 2024, at Bonham Nursing Center there were no federal deficiencies cited under the requirements of 42 CFR Part 483, Subpart B Requirements for Long Term Care Facilities as they relate to the health portion of the survey process, but the facility was not in compliance with the following requirements of the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

§ 211.12(f.1)(2) LICENSURE Nursing services. :

(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 nurse staffing and staff interview, it was determined that the facility failed to ensure the minimum Nurse Aides (NA) staff to resident ratio was provided on the night shift for two shifts out of 21 reviewed.

Findings include:

A review of the facility's weekly staffing records April 12, 2024, through April 18, 2024, revealed that on the following dates the facility failed to provide minimum nurse aides (NA) staff of 1:20 on night shift based on the facility's census.

Review of facility census data indicated that on April 14, 2024, the facility census was 46, which required 2.30 nurse aides (NA) during night shift. Review of the nursing time schedules revealed only 1.59 NA worked the night shift on April 14, 2024.

Review of facility census data indicated that on April 18, 2024, the facility census was 46, which required 2.30 nurse aides (NA) during night shift. Review of the nursing time schedules revealed only 2.16 NA worked the night shift on April 18, 2024.

During an interview on April 19, 2024, at approximately 1:00 PM, the Nursing Home Administrator confirmed that the facility failed to provide a minimum nurse aide staffing ratios on the above shifts.

Plan of Correction - To be completed: 05/21/2024

1. The facility cannot retroactively correct the nurse aide ratios.
2. The facility is focusing on retention of existing nurse aides and recruitment of new nurse aides.
3. The Scheduler and Nursing Supervisors will be re-educated by NHA/Designee regarding the new ratio requirements for nurse aides. Nurse aide ratios will be reviewed for accuracy and needs.
4. Ratios will be quality monitored weekly for 4 weeks and monthly for 2 months. Findings will be submitted to the QAPI committee for further recommendations.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(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 nurse staffing and staff interview, it was determined that the facility failed to ensure the minimum licensed practical nurse (LPN) staff to resident ratio was provided on the night shifts for two shifts out of 21 reviewed.

Findings include:

A review of the facility's weekly staffing records April 12, 2024, through April 18, 2024, revealed that on the following dates the facility failed to provide minimum licensed practical nurse (LPN) staff of 1:40 on the night shift based on the facility's census.

If the facility census is 59 or under on the night shift and the facility has chosen to substitute an LPN for a Registered Nurse (RN), with an RN on call, this will require an additional LPN to satisfy the requirement.

A review of facility census data indicated that on April 15, 2024, and April 17, 2024, the facility census was 46 on night shift.

The facility substituted an LPN for an RN on the night shift on April 15, 2024, and April 17, 2024, but failed to ensure additional LPN to meet the LPN ratio on the overnight shift.

During an interview on April 19, 2024, at approximately 1:00 PM, the Nursing Home Administrator confirmed that the facility failed to provide a minimum licensed practical nurse staffing ratios on the above shifts.

Plan of Correction - To be completed: 05/21/2024

1. The facility cannot retroactively correct the LPN ratios.
2. The facility is focusing on retention of existing LPNs and recruitment of new LPNs.
3. The Scheduler and Nursing Supervisors will be re-educated by the NHA/Designee regarding the new ratio requirements for LPNs. LPN ratios will be reviewed for accuracy and needs.
4. Ratios will be quality monitored weekly for 4 weeks and monthly for 2 months. Findings will be submitted to the QAPI committee for further recommendations.

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