Pennsylvania Department of Health
BRADFORD MANOR
Patient Care Inspection Results

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BRADFORD MANOR
Inspection Results For:

There are  83 surveys for this facility. Please select a date to view the survey results.

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BRADFORD MANOR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a Follow-up Survey completed on April 18, 2025, it was determined that Bradford Manor failed to correct all the deficiencies cited during the revisit survey of January 26, 2025, and continued to be out of 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)(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 review of facility nursing staffing information and staff interview, it was determined that the facility failed to ensure the Nurse Aide (NA) ratios were met of one NA per 10 residents for the day shift for 12 of 14 days reviewed (4/01/25, 4/02/25, 4/03/25, 4/04/25, 4/05/25, 4/06/25, 4/07/25, 4/09/25, 4/10/25, 4/11/25, 4/12/25 and 4/13/25); failed to ensure one NA per 11 residents for the evening shift for seven of 14 days (4/02/25, 4/05/25, 4/06/25, 4/07/25, 4/08/25, 4/12/25, and 4/13/25); and failed to ensure one NA per 15 residents during the overnight shift for nine of 14 days (4/01/25, 4/03/25, 4/04/25, 4/06/25, 4/08/25, 4/11/25, 4/12/25, 4/13/25, and 4/14/25).

Findings include:

Review of facility nursing staffing information for the time period from 4/01/25, through 4/14/25, revealed the following NA staffing shortages for the day shift where the NA ratios were not met:

4/01/25census of 77 residents6.32 NAs worked and 7.70 were required.
4/02/25census of 74 residents7.07 NAs worked and 7.40 were required.
4/03/25census of 74 residents7.05 NAs worked and 7.40 were required.
4/04/25census of 76 residents6.96 NAs worked and 7.60 were required.
4/05/25census of 76 residents7.32 NAs worked and 7.60 were required.
4/06/25census of 79 residents5.47 NAs worked and 7.90 were required.
4/07/25census of 79 residents6.95 NAs worked and 7.90 were required.
4/09/25census of 79 residents7.07 NAs worked and 7.90 were required.
4/10/25census of 81 residents7.05 NAs worked and 8.10 were required.
4/11/25census of 81 residents6.68 NAs worked and 8.10 were required.
4/12/25census of 82 residents6.13 NAs worked and 8.20 were required.
4/13/25census of 82 residents7.08 NAs worked and 8.20 were required.

Review of facility nursing staffing information for the time period from 4/01/25, through 4/14/25, revealed the following NA staffing shortages for the evening shift where the NA ratios were not met:

4/02/25census of 74 residents6.20 NAs worked and 6.73 were required.
4/05/25census of 76 residents5.40 NAs worked and 6.91 were required.
4/06/25census of 79 residents5.03 NAs worked and 7.18 were required.
4/07/25census of 79 residents5.57 NAs worked and 7.18 were required.
4/08/25census of 78 residents6.71 NAs worked and 7.09 were required.
4/12/25census of 82 residents4.83 NAs worked and 7.45 were required.
4/13/25census of 82 residents5.95 NAs worked and 7.45 were required.


Review of facility nursing staffing information for the time period from 4/01/25, through 4/14/25, revealed the following NA staffing shortages for the overnight shift where the NA ratios were not met:

4/01/25census of 77 residents4.56 NAs worked and 5.13 were required.
4/03/25census of 74 residents4.13 NAs worked and 4.93 were required.
4/04/25census of 77 residents4.97 NAs worked and 5.13 were required.
4/06/25census of 79 residents4.12 NAs worked and 5.27 were required.
4/08/25census of 79 residents4.27 NAs worked and 5.27 were required.
4/11/25census of 82 residents4.77 NAs worked and 5.47 were required.
4/12/25census of 82 residents4.43 NAs worked and 5.47 were required.
4/13/25census of 82 residents5.07 NAs worked and 5.47 were required.
4/14/25census of 81 residents4.48 NAs worked and 5.40 were required.

During an email correspondence interview on 4/18/25, at 11:23 a.m. the Nursing Home Administrator confirmed that the facility did not meet the minimum NA ratio for the above days and shifts.



 Plan of Correction - To be completed: 06/15/2025

This plan of correction has been prepared and executed because the law requires it. This plan does not constitute an admission that any of the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract obligation or position. Bradford Manor reserves the right to raise all possible contestations and defenses in any civil, criminal, claim, action or proceeding. Please accept this plan of correction as Bradford Manor's credible allegation of compliance.
All residents received appropriate care and services to meet their needs on the identified days and there was no direct correlation to an individual resident. Residents of Bradford Manor will be protected from future nurse aide staff ratios below the 1:10 nurse aide for days, 1:11 nurse aide for evenings and 1:15 for nights by a proactive preview of daily staff assignments and schedules to ensure adequate staff coverage by DON/Designee. The scheduler or designee will review projected staffing levels and audit to ensure staffing levels were met with the Director of Nursing or designee, 3 times a week x2 weeks, two times a week x2 and then monthly X2 months to ensure that any foreseeable staffing levels below nurse aide ratios are adequately covered. Bradford Manor will continue to aggressively advertise externally for the recruitment of nursing assistant applicants to enhance current staffing levels. Bradford Manor is an approved site of the Pennsylvania Nurse Aide Training and Competency Evaluation Program and has ongoing nurse aide training classes throughout the year. Bradford Manor is currently offering a referral bonus to staff for recruiting new employees. Call-in incentives are also being utilized to entice employees to pick up unscheduled shifts. Bradford Manor will continue to hold open interviews weekly. Staffing will be considered when reviewing referrals. Results of the audits will be reviewed at Quality Assurance Performance Improvement meetings. Education will be provided by the Nursing Home Administrator to the Director of Nursing, Scheduler and Human Resource Coordinator on the NA ratios to resident required per shift on 5/1/25.

§ 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 facility nursing staffing information and staff interview, it was determined that the facility failed to ensure the Licensed Practical Nurse (LPN) ratios were met of one LPN per 25 residents on the day shift for 12 of 14 days (4/03/25, 4/04/25, 4/05/25, 4/06/25, 4/07/25, 4/08/25, 4/09/25, 4/10/25, 4/11/25, 4/12/25, 4/13/25, and 4/14/25); failed to ensure one LPN per 30 residents on the evening shift for 10 of 14 days 4/01/25, 4/02/25, 4/04/25, 4/07/25, 4/09/25, 4/10/25, 4/11/25, 4/12/25, 4/13/25, and 4/14/25); and failed to ensure one LPN per 40 residents on the overnight shift for seven of 14 days (4/04/25, 4/06/25, 4/07/25, 4/11/25, 4/12/25, 4/13/25,and 4/14/25).

Findings include:

Review of facility nursing staffing information for the time period from 4/01/25, through 4/14/25, revealed the following LPN staffing shortages for the day shift where the LPN ratios were not met:

4/03/25census of 74 residents1.98 LPNs worked and 2.96 were required.
4/04/25census of 76 residents2.96 LPNs worked and 3.04 were required.
4/05/25census of 76 residents2.00 LPNs worked and 3.04 were required.
4/06/25census of 79 residents2.00 LPNs worked and 3.16 were required.
4/07/25census of 79 residents2.98 LPNs worked and 3.16 were required.
4/08/25census of 78 residents2.89 LPNs worked and 3.12 were required.
4/09/25census of 79 residents2.99 LPNs worked and 3.16 were required.
4/10/25census of 81 residents3.00 LPNs worked and 3.24 were required.
4/11/25census of 81 residents1.99 LPNs worked and 3.24 were required.
4/12/25census of 82 residents2.06 LPNs worked and 3.28 were required.
4/13/25census of 82 residents1.98 LPNs worked and 3.28 were required.
4/14/25census of 80 residents2.63 LPNs worked and 3.20 were required.

Review of facility nursing staffing information for the time period from 4/01/25, through 4/14/25, revealed the following LPN staffing shortages for the evening shift where the LPN ratios were not met:

4/01/25census of 77 residents2.00 LPNs worked and 2.57 were required.
4/02/25census of 74 residents2.00 LPNs worked and 2.47 were required.
4/04/25census of 76 residents2.50 LPNs worked and 2.53 were required.
4/07/25census of 79 residents2.00 LPNs worked and 2.63 were required.
4/09/25census of 79 residents2.00 LPNs worked and 2.63 were required.
4/10/25census of 81 residents2.00 LPNs worked and 2.70 were required.
4/11/25census of 81 residents2.00 LPNs worked and 2.70 were required.
4/12/25census of 82 residents2.00 LPNs worked and 2.73 were required.
4/13/25census of 82 residents2.00 LPNs worked and 2.73 were required.
4/14/25census of 81 residents2.00 LPNs worked and 2.70 were required.

Review of facility nursing staffing information for the time period from 4/01/25, through 4/14/25, revealed the following LPN staffing shortages for the overnight shift where the LPN ratios were not met:

4/04/25census of 77 residents1.28 LPNs worked and 1.93 were required.
4/06/25census of 77 residents1.54 LPNs worked and 1.93 were required.
4/07/25census of 79 residents1.54 LPNs worked and 1.98 were required.
4/11/25census of 82 residents1.50 LPNs worked and 2.05 were required.
4/12/25census of 82 residents1.00 LPNs worked and 2.05 were required.
4/13/25census of 82 residents1.00 LPNs worked and 2.05 were required.
4/14/25census of 81 residents1.25 LPNs worked and 2.03 were required.


During an email correspondence interview on 4/18/25, at 11:23 a.m. the Nursing Home Administrator confirmed that the facility did not meet the minimum LPN ratio for the above days and shifts.



 Plan of Correction - To be completed: 06/15/2025

All residents received appropriate care and services to meet their needs on the identified days and there was no direct correlation to an individual resident. Residents of Bradford Manor will be protected from future Licensed Practical Nurse (LPN) staff ratios below the 1:25 days, 1:30 evenings and 1:40 nights by a proactive preview of daily staff assignments and schedules to ensure adequate staff coverage by Director of Nursing (DON) or Designee. The scheduler or designee will review projected staffing levels and audit to ensure levels were met with the DON or designee, 3 times a week x2 weeks, two times a week x2 and then monthly X2 months to ensure that any foreseeable staffing levels below nurse aide ratios are adequately covered. Bradford Manor now has a recruiter to assist with filling open positions. Bradford Manor will continue to aggressively advertise externally for recruitment of LPN applicants to enhance current staffing levels. Bradford Manor will continue to have open interviews weekly. A sign on bonus is currently being offered to new LPNs. Bradford Manor is currently offering a referral bonus to staff for recruiting new employees. Call-in incentives are also being utilized to entice employees to pick up unscheduled shifts. Staffing levels will be considered when reviewing referrals for acceptance. Results of the audits will be reviewed at Quality Assurance Performance Improvement Meetings. Nursing Home Administrator provided education to the Director of Nursing, Scheduler and Human Resource Coordinator on the requirements of LPNS to Residents ratios required per shift on 5/1/2025.
§ 211.12(i)(2) LICENSURE Nursing services.:State only Deficiency.
(2) Effective July 1, 2024, 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 3.2 hours of direct resident care for each resident.

Observations:


Based on review of facility nursing staffing information and staff interview, it was determined that the facility failed to provide the minimum number of general nursing care hours of 3.2 hours of direct resident care hours per resident in a 24-hour period for seven of 14 days reviewed (4/01/25 through 4/14/25)

Findings include:

Review of nursing staffing information for the time period from 4/01/25, through 4/14/25, revealed that the hours of direct resident care was below 3.2 minimum per patient per day (PPD) on the following dates:

4/01/25 3.17
4/02/25 3.07
4/03/25 2.86
4/04/25 2.89
4/05/25 2.89
4/06/25 2.48
4/07/25 2.76
4/08/25 2.86
4/09/25 3.11
4/10/25 3.08
4/11/25 2.77
4/12/25 2.20
4/13/25 2.45
4/14/25 2.82

During an email correspondence interview on 4/18/25, at 11:23 a.m. the Nursing Home Administrator confirmed the facility did not meet the 3.2 minimum hours of direct resident care on the above dates.



 Plan of Correction - To be completed: 06/15/2025

All residents received appropriate care and services to meet their needs on the identified days and there was no direct correlation to an individual resident. Residents of Bradford Manor will be protected from future daily patient per day (PPD) ratios below 3.2 by a proactive preview of daily staff assignments and schedules to ensure adequate staff coverage by Director of Nursing (DON) or Designee. The scheduler or designee will review projected staffing levels with the DON or designee, 3 times a week x2 weeks, two times a week x2 and then monthly X2 months to ensure that any foreseeable PPD levels below 3.2 are adequately covered and audit to ensure levels were met. Bradford Manor will continue to aggressively advertise externally for the recruitment of nursing assistant applicants to enhance current staffing levels. Bradford Manor will continue to have open interviews weekly. Bradford Manor is an approved site of the Pennsylvania Nurse Aide Training and Competency Evaluation Program and has ongoing nurse aide training classes throughout the year. Bradford Manor is currently offering a referral bonus to staff for recruiting new employees. Call-in incentives are also being utilized to entice employees to pick up unscheduled shifts. Bradford Manor now has a recruiter on staff to assist with filling open positions. Staffing levels will be considered when reviewing referrals. Results of the audits will be reviewed at Quality Assurance Performance Improvement Meetings. Nursing Home Administrator provided education to the Director of Nursing, Scheduler and Human Resource Coordinator on the requirement of 3.2 hours of direct resident care hours per resident in a 24-hour period on 5/1/2025.

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