(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.
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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.
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