Pennsylvania Department of Health
Patient Care Inspection Results

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Inspection Results For:

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BRIDGEVILLE REHABILITATION & CARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a revisit survey completed on February 23, 2024, it was determined that Bridgeville Rehabilitation and Care Center failed to correct the deficiency identified during the survey of January 10, 2024, as related to the requirements of the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

 Plan of Correction:

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.


Based on review of nursing time schedules and staff interview it was determined that the facility administrative staff failed to provide the minimum number of general nursing hours to each resident in a 24 hour period on eight of eight days (2/15/24 through 2/22/24).

Findings include:

Nursing time schedules for the time period of 2/15/24 through 2/22/24, revealed that the facility failed to maintain 2.87 hours of general nursing care to each resident in a 24 hour period on the following dates:

2/15/24-2.50 PPD.
2/16/24-2.30 PPD.
2/17/24-2.32 PPD.
2/18/24-2.63 PPD.
2/19/24-2.86 PPD.
2/20/24-2.75 PPD.
2/21/24-2.62 PPD.
2/22/24-2.79 PPD.

During an interview on 2/23/24 at 2:35 p.m. the Nursing Home Administrator confirmed the the facility failed to provide the minimum number of general nursing hours to each resident in a 24 hour period on eight of eight days.

 Plan of Correction - To be completed: 04/10/2024

There were no adverse effects to the residents of our facility as a result of decreased HPPD on 2/15/24 through 2/22/24.

The Administrator, Director of Nursing, ADON, HR and Payroll-Scheduler will be educated on the state requirement for HPPD by the RN Nurse Educator/designee.

Staffing meetings will be held 5 days a week to review HPPD from the previous day and the projected HPPD, as well as the upcoming week to ensure appropriate staffing levels. If projected staffing levels are below the minimum of 2.87, then the facility will reach out to current staff and staffing agencies to enlist to meet the minimum requirement. Facility will continue to recruit staff through all platforms.

Our Corporate team has opened additional agency positions and have created an internal agency (POD staff) to provide additional staffing support.

When conducting the daily review of HPPD, we will not take admissions when we don't meet minimum state HPPD staffing requirements.

Audits of HPPD will be completed 5 days a week x4 by the NHA/designee to ensure HPPD meets the state minimums. Results of the audits will be submitted to the QAPI committee monthly for review and recommendations.

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