Pennsylvania Department of Health
BETHLEHEM NORTH SKILLED NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

BETHLEHEM NORTH SKILLED NURSING AND REHABILITATION CENTER
Inspection Results For:

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BETHLEHEM NORTH SKILLED NURSING AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on an Abbreviated survey in response to a complaint completed on August 21, 2024, at Bethlehem North Skilled Nursing and Rehabilitation Center, it was determined that there were no federal deficiencies identified under the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care; however, the facility was not in compliance with the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

§ 211.12(f.1)(2) LICENSURE Nursing services. :

(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:

Based on review of nursing time schedules it was determined that the facility failed to meet the minimum Nursing Aide (NA) ratio of one NA for per 10 residents on the day shift (7 AM- 3 PM) on two of seven days reviewed.

Findings include:

Review of nursing time schedules for August 11, through August 17, 2024, revealed that the facility failed to ensure that the minimum ratio of one NA for 10 residents on the day shift was met on August 11, and August 17, 2024.

Plan of Correction - To be completed: 09/15/2024

1. Nursing administration and scheduler will be re-educated on July 1,2024 nurse aide staffing requirements.

2. Nurse aide staffing ratios will be reviewed for the last 7 days to evaluate if nurse aide ratios are met.

3. Weekly audit of nurse aid ratios will be conducted for 30 days by NHA/designee to ensure nurse aid ratios are met.

4. Tracking and trends to be submitted to the QAPI committee.

§ 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 nursing time schedules, it was determined that the facility failed to meet the minimum Licensed Practical Nurse (LPN) to resident ratio of 1 LPN per 40 residents on the night shift (11PM-7AM) on six of seven days reviewed.

Findings include:

Review of nursing time schedules from August 11, through August 18, 2024, revealed that the facility failed to meet the minimum ratio of one LPN per 40 residents on the night shift on August 12, 13, 14, 15, 16, 17, 2024.

Plan of Correction - To be completed: 09/15/2024

1. Nursing administration and scheduler will be re-educated on July 1,2023 LPN nurse staffing requirements.

2. LPN staffing ratios will be reviewed for the last 7 days to evaluate if LPN ratios are met.

3. Weekly audits of LPN ratios will be conducted for 30 days by NHA/designee to ensure LPN ratios are met.

4. Tracking and trends to be submitted to the QAPI committee.

§ 211.12(i)(2) LICENSURE Nursing services.:

(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 a review of nursing time schedules, it was determined that the facility failed to provide a minimum of 3.2 hours of direct care for each resident for four of seven days reviewed.

Findings include:

Review of nursing schedules for seven days from August 11 through August 17, 2024, revealed the following total nursing care hours below minimum requirements:

August 11, 2.77
August 12, 2.78,
August 16, 2.74
August 17, 2.75.

Plan of Correction - To be completed: 09/15/2024

1. Nursing administration and scheduler will be re-educated on new July 1, 2024 HPPD staffing requirements.

2. HPPD will be reviewed for the last 7 days to evaluate if the state minimum PPD of 3.20 is met.

3. Weekly audit of HPPD will be conducted for 30 days by NHA/designee to ensure minimal HPPD is met.

4. Tracking and trends to be submitted to the QAPI committee for review and recommendation.

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