(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 documents and staff interview, it was determined that the facility failed to meet the Nurse Aide (NA) ratios for one NA per 10 residents on day shift for four of 21 days reviewed (10/5/25, 10/11/25, 10/16/25, 10/18/25); failed to meet the NA ratio for one NA per 11 residents on the evening shift for nine of 21 days reviewed (10/6/25, 10/9/25, 10/13/25, 10/14/25, 10/16/25, 10/17/25, 10/21/25, 10/22/25, 10/23/25); and failed to meet the NA ratio for one NA per 15 residents on the overnight shift for seven of 21 days reviewed (10/8/25, 10/9/25, 10/10/25, 10/14/25, 10/16/25, 10/21/25, 10/23/25).
Findings include:
Review of facility nursing staffing documents for the time period from 10/5/25, through 10/25/25, revealed the following NA staffing shortages for the day shift where the NA ratios were not met:
10/05/25 census of 72 residents 6.40 NAs worked and 7.20 were required
10/11/25 census of 72 residents 7.05 NAs worked and 7.20 were required
10/16/25 census of 72 residents 6.41 NAs worked and 7.20 were required
10/18/25 census of 69 residents 5.19 NAs worked and 6.90 were required
Review of facility nursing staffing documents for the time period from 10/5/25, through 10/25/25, revealed the following NA staffing shortages for the evening shift where the NA ratios were not met:
10/06/25 census of 70 residents 5.52 NAs worked and 6.36 were required
10/09/25 census of 71 residents 6.40 NAs worked and 6.45 were required
10/13/25 census of 69 residents 5.87 NAs worked and 6.27 were required
10/14/25 census of 69 resident 3.34 NAs worked and 6.27 were required
10/16/25 census of 72 residents 6.02 NAs worked and 6.55 were required
10/17/25 census of 72 residents 5.50 NAs worked and 6.55 were required
10/21/25 census of 71 residents 6.23 NAs worked and 6.45 were required
10/22/25 census of 70 residents 5.31 NAs worked and 6.36 were required
10/23/25 census of 72 residents 3.65 NAs worked and 6.55 were required
Review of facility nursing staffing documents for the time period from 10/5/25, through 10/25/25, revealed the following NA staffing shortages for the overnight shift where the NA ratios were not met:
10/08/25 census of 71 residents 4.08 NAs worked and 4.73 were required
10/09/25 census of 71 residents 4.03 NAs worked and 4.73 were required
10/10/25 census of 73 residents 3.00 NAs worked and 4.87 were required
10/14/25 census of 69 residents 4.28 NAs worked and 4.60 were required
10/16/25 census of 72 residents 3.67 NAs worked and 4.80 were required
10/21/25 census of 71 residents 2.81 NAs worked and 4.73 were required
10/23/25 census of 72 residents 4.49 NAs worked and 4.80 were required
During a telephone interview on 11/13/25, at 3:35 p.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: 01/30/2026
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 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. A recruiter is on staff to assist with filling positions. 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 incentive pay is always paid to employees to pick up unscheduled shifts. Bradford Manor will continue to hold open interviews weekly. Shift differential was increased from $0.50/hr to $2.00/hr. 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 11/26/25. Results of the audits will be reviewed at Quality Assurance Performance Improvement meetings.
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