Observations:
Based on review of facility nursing staffing documents and staff interview, it was determined that the facility failed to meet the Nurse Aide (NA) ratios of one NA per 10 residents on day shift for two of seven days reviewed (6/19/26 and 6/20/26); failed to meet the NA ratio of one NA per 11 residents on the evening shift for three of seven days reviewed (6/20/26, 6/21/26, and 6/22/26); and failed to meet the NA ratio of one NA per 15 residents on the overnight shift for six of seven days reviewed (6/18/26, 6/19/26, 6/20/26, 6/21/26, 6/22/26, and 6/23/26).
Findings include:
Review of facility nursing staffing documents for the time period from 6/17/26, through 6/23/26, revealed the following NA staffing shortages for the day shift where the NA ratios were not met:
6/19/26 census of 78 residents 7.23 NAs worked and 7.80 were required
6/20/26 census of 78 residents 6.35 NAs worked and 7.80 were required
Review of facility nursing staffing documents for the time period from 6/17/26, through 6/23/26, revealed the following NA staffing shortages for the evening shift where the NA ratios were not met:
6/20/26 census of 78 residents 6.97 NAs worked and 7.09 were required
6/21/26 census of 77 residents 6.90 NAs worked and 7.00 were required
6/22/26 census of 78 residents 6.52 NAs worked and 7.09 were required
Review of facility nursing staffing documents for the time period from 6/17/26, through 6/23/26, revealed the following NA staffing shortages for the overnight shift where the NA ratios were not met:
6/18/26 census of 78 residents 4.23 NAs worked and 5.20 were required
6/19/26 census of 78 residents 3.13 NAs worked and 5.20 were required
6/20/26 census of 78 residents 3.19 NAs worked and 5.20 were required
6/21/26 census of 77 residents 3.23 NAs worked and 5.13 were required
6/22/26 census of 78 residents 3.16 NAs worked and 5.20 were required
6/23/26 census of 78 residents 4.26 NAs worked and 5.20 were required
During a telephone interview on 6/29/26, at 11:15 a.m. the Director of Nursing confirmed that the facility did not meet the minimum NA ratios for the above days and shifts.
| | Plan of Correction - To be completed: 09/11/2026
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 Nursing and Rehab 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 Nursing and Rehab will continue to aggressively advertise externally for the recruitment of nursing assistant applicants to enhance current staffing levels. A recruiter is on staff to assist with filling open positions. Bradford Manor Nursing and Rehab 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 Nursing and Rehab has partnered with the school district to be able to hire Co-op students that are already certified nursing assistants. Call-in incentive pay is always paid to employees to pick up unscheduled shifts. We are currently working on increasing the pick-up bonus. We have contracted with a staffing agency to help with open shifts. Bradford Manor Nursing and Rehab will continue to hold open interviews weekly. We have partnered with our local PA Career Link so they will advertise jobs on their website too. Staffing will be considered when reviewing referrals. Education will be provided by the Nursing Home Administrator to the Director of Nursing and Human Resource Coordinator on the NA to resident ratios required per shift by 7/31/26. Results of the audits will be reviewed at Quality Assurance Performance Improvement meetings.
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