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

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BONHAM NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  57 surveys for this facility. Please select a date to view the survey results.

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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 a revisit completed on October 29, 2024, it was determined that Bonham Nursing and Rehabilitation Center corrected the federal deficiencies cited during the survey of August 1, 2024, under the requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care however they continued to be out of compliance with the following requirements of 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


§ 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 nurse staffing and staff interview, it was determined the facility failed to ensure the minimum nurse aide staff to resident ratio was provided on each shift for 1 shift out of 21 reviewed.

Findings include:

Review of the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, Nursing Services, dated July 1, 2023, indicated the following subsections.
(f.1) In addition to the director of nursing services, a facility shall provide all of the following:
(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.

A review of the facility's weekly staffing records revealed that on the following date the facility failed to provide minimum nurse aide staff 1:15 on the night shift based on the facility's census per the regulation that was effective July 1, 2024.

October 27, 2024 - 2.57 nurse aides on the evening shift, versus the required 2.87 for a census of 43.

On the above date mentioned no additional excess higher-level staff were available to compensate this deficiency.

An interview with the Nursing Home Administrator on October 29, 2024, at approximately 2:00 PM, confirmed the facility had not met the required nurse aide to resident ratio on the above date.


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

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. :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 nurse staffing, resident census, and staff interview, it was determined that the facility failed to provide a minimum of one LPN (licensed practical nurse) per 40 residents on the night shift on 3 shifts out of 21 reviewed.

Findings include:

The minimum required ratio on the night shift is one LPN for every 40 residents. A review of the facility's daily staffing records revealed that the facility did not meet the required minimum LPN-to-resident ratios on the following dates:

October 22, 2024 - 0.00 LPNs on the night shift, versus the required 1.05 for a census of 42.
October 26, 2024 - 0.13 LPNs on the night shift, versus the required 1.08 for a census of 43.
October 28, 2024 - 1.06 LPNs on the night shift, versus the required 1.08 for a census of 43.

On the above dates mentioned no additional excess higher-level staff were available to compensate this deficiency.

An interview with the Nursing Home Administrator on October 29, 2024, at approximately 2:00 PM, confirmed the facility had not met the required LPN-to-resident ratios on the above dates.



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

1. The facility cannot retroactively correct the LPN ratios.
2. The facility is focusing on retention of existing LPNs and recruitment of new LPNs through efforts of the Staffing Committee.
3. The Scheduler and Nursing Supervisors will be re-educated by the NHA/Designee regarding the new ratio requirements for LPNs. Daily staffing meetings will review calculations of the LPN ratios for accuracy.
4. Daily 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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