Pennsylvania Department of Health
REHABILITATION CENTER AT BRETHREN VILLAGE, LLC
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 19 surveys for this facility. Please select a date to view the survey results.

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REHABILITATION CENTER AT BRETHREN VILLAGE, LLC - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare Recertification, State Licensure and Civil Rights Compliance survey completed on June 28, 2024, it was determined that Rehabilitation Center at Brethren Village was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Nursing Care Facilities 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)(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 review of three weeks of facility staffing data, it was determined that the facility failed to ensure a minimum of one licensed practical nurse (LPN) per 30 residents on evening shift (Weeks of December 31, 2023 and June 21, 2024).

Findings include:

Review of the weeks of December 31, 2023 and June 21, 2024, revealed the following dates on evening shift did not meet the requirement of LPN per 30 residents:

December 31, 2023, June 23, June 24, and June 25, 2024 .

Interview with the Director of Nursing on June 27, 2024, at 2:15 p.m. confirmed that the staffing ratios for LPNs were not met on the above dates.

Plan of Correction - To be completed: 07/10/2024

1. Education provided to scheduling team regarding staffing ratios

2. DON/NHA to review schedule regularly

3. Reviewed scheduling ratios with nursing supervisors

4. Any issues with scheduling to meet ratios to be reported to QAPI

5. We have numerous contracts with staffing agencies and will utilize these agencies to fill staffing gaps as needed

6. We are able to, and have, offered incentives to our Team members to pick up shifts or extend their shifts as needed to meet the staffing ratios.

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