Pennsylvania Department of Health
BROAD ACRES HEALTH AND REHABILITATION CENTER
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

BROAD ACRES HEALTH AND REHABILITATION CENTER
Inspection Results For:

There are 77 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.


BROAD ACRES HEALTH 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 two Complaints completed on December 16, 2023, at Broad Acres Health 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 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey process.

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.

Plan of Correction - To be completed: 01/31/2024

There were no immediate adverse affects

A review of the staffing schedules for will be conducted to ensure compliance with the ratio of 1 nurse aide per 12 residents on 1st shift, 1 nurse aide per 12 residents on 2nd shift and 1 nurse aide per 20 residents on night shift

An inservice will be conducted with the Scheduler to ensure compliance with the ratio of 1 nurse aide per 12 residents on first shift, 1 nurse aide per 12 residents on 2nd shift and 1 nurse aide per 20 residents on night shift

An audit will be conducted weekly of the next 4 weeks of nursing schedules to ensure compliance with the ratio of 1 nurse aide per 12 residents on first shift, 1 nurse aide per 12 residents on 2nd shift and 1 nurse aide per 20 residents on night shift. Facility will be in compliance with Department's revised guidance for staffing ratios that will allow use of mathematical calculations when implemented.

§ 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 a review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift for three of the 21 days reviewed, one LPN per 30 residents during the evening shift for three of the 21 days reviewed, and one LPN per 40 residents during the night shift for seven of the 21 days reviewed.

Findings include:

A review of nursing care hours provided by the facility dated from November 25, 2023, through December 15, 2023, revealed the following on the day shift:

December 2, 2023, census of 82 with three LPNs, required four LPNs
December 8, 2023, census of 78 with three LPNs, required four LPNs
December 14, 2023, census of 82 with three LPNs, required four LPNs

A review of nursing care hours provided by the facility dated from November 25, 2023, through December 15, 2023, revealed the following on the evening shift:

November 28, 2023, census of 81 with two LPNs, required three LPNs
December 1, 2023, census of 83 with two LPNs, required three LPNs
December 7, 2023, census of 78 with twos LPN, required three LPNs

A review of nursing care hours provided by the facility dated from November 25, 2023, through December 15, 2023, revealed the following on the night shift:

November 27, 2023, census of 80 with one LPN, required two LPNs
November 28, 2023, census of 81 with two LPNs, required three LPNs
November 29, 2023, census of 82 with two LPNs, required three LPNs
November 30, 2023, census of 82 with two LPNs, required three LPNs
December 1, 2023, census of 82 with two LPNs, required three LPNs
December 2, 2023, census of 82 with two LPNs, required three LPNs
December 15, 2023, census of 86 with two LPNs, required three LPNs

Confirmed the above findings with the Administrator on December 18, 2023, at 9:25 AM.

Plan of Correction - To be completed: 01/31/2024

There were no immediate adverse affects

A review of the staffing schedules will be conducted to ensure compliance with the ratio of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening and 1 LPN per 40 residents overnight.

An in service will be conducted with the Scheduler to ensure compliance with the ratio of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening and 1 LPN per 40 residents overnight.

An audit will be conducted weekly of the next 4 weeks of nursing schedules to ensure compliance with the ratio of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening and 1 LPN per 40 residents overnight. Facility will be in compliance with Department's revised guidance for staffing ratios that will allow use of mathematical calculations when implemented.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement