Pennsylvania Department of Health
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
Inspection Results For:

There are  129 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated complaint survey completed on February 9, 2024, at Broad Mountain Health and Rehabiliation it was determined that there were no federal deficiencies identified under the requirements of 42 CFR Part 483 Subpart B as they relate to the health portion of the survey process but the facility was not in 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)(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.

Based on a review of nurse staffing and staff interview, it was determined that the facility failed to ensure the minimum licensed practical nurse (LPN) staff to resident ratio was provided on the night shift for one shift out of 42 reviewed.

Findings include:

A review of the facility's weekly staffing records January 12, 2024, through January 18, 2024, and February 2, 2024, through February 8, 2024, revealed that on the following date the facility failed to provide minimum LPN staff of 1:40 on the night shift based on the facility's census.

Review of facility census data indicated that on February 7, 2024, the facility census was 89, which required 17.80 LPN hours during night shift.

Review of the nursing time schedules revealed 2.13 LPNs provided care on the night shift on February 7, 2024, for a total of only 16.00 LPN hours. No additional excess higher-level staff were used to compensate this deficiency.

An interview with the Director of Nursing (DON) on February 9, 2024, at 12:45 PM, confirmed the facility had not met the required minimum licensed practical nurse (LPN) to resident ratios on the night shift on the above date.

 Plan of Correction - To be completed: 04/05/2024

1. Cannot retroactively correct staffing.
2. Facility will schedule above required minimums for staffing all shifts; retain a relationship with three agencies for support in case our own staff are unavailable for any reason; and enforce policy and procedure when absences are incurred as necessary and appropriate to provide safe and effective care for residents in our community.

3. New requirement for staff to immediately notify Director of Nursing or designee if any absences result in ratios or minimum staffing requirements not being met so we could utilize resources including bonuses, agency support, or qualified leadership team members serving residents in replacement.

4. Staffing will be audited daily X 5 for 8 weeks.

5. Audit findings will be shared with Quality Assurance Committee Routinely.

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