Pennsylvania Department of Health
 BROAD MOUNTAIN HEALTH & REHABILITATION CENTER
Patient Care Inspection Results

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BROAD MOUNTAIN HEALTH & REHABILITATION CENTER
Inspection Results For:

There are  140 surveys for this facility. Please select a date to view the survey results.

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BROAD MOUNTAIN HEALTH & REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated compliant survey and a revisit survey completed on November 18, 2025, it was determined that Broad Mountain Nursing and Rehabilitation corrected the federal deficiencies cited during the surveys of September 10, 2025 and October 17, 2025, however continued to be out of compliance under the 42 CFR Part 483 Subpart B Requirements for Long Term Care and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.
Observations:

Based on observation and resident and staff interviews, it was determined the facility failed to provide housekeeping and maintenance services to maintain a safe, clean and homelike environment in resident areas on two of two resident floors (first floor shower room and second floor dining room and residential units).

Findings included:

An observation on November 19, 2025, at 8:55 AM in the first-floor shower room revealed a large hole in the wall along the baseboard trim near the toilet and a missing ceiling tile in front of the privacy curtain.

An observation on November 19, 2025, at 12:00 PM on the second floor East Wing revealed a 4-inch brown stain, resembling a water stain, with noted black stains within the brown on a ceiling tile near the nurses station.

An observation on November 19, 2025, at 12:35 PM of the second floor East Wing dining room revealed three ceiling tiles that contained large brown stains, resembling water stains.

An observation on November 19, 2025, at 12:40 PM of Resident 5's room revealed a used rubber glove, a used plastic cup, a towel, and multiple crumbs and debris under the resident's bed.

An observation on November 19, 2025, at 12:45 PM of Resident 8's room revealed a Kennedy cup (lightweight, spill-proof drinking cup designed to be easy to hold and grip) with the lid removed on the floor containing brown liquid. The brown liquid was splattered on the floor between Resident 8 and Resident 6's bed and was also noted to be splattered on Resident 6's fitted bed sheet. Under Resident 8's nightstand were multiple used tissues, napkins, and a used face mask.

Interview with Resident 7, Resident 6 and 8's roommate, during the time of the observation, reported that housekeeping does not come into their room to clean every day. The residents stated, "somedays the floor is so bad, it's embarrassing."
Continued observation of Resident 7's room revealed a tabletop oscillating fan positioned on top of a transfer board (a flat, smooth board used in therapy and rehabilitation to help a person move safely from one surface to another when they cannot stand or bear full weight) which was on top of the push handles of her roommate's wheelchair. The fan was plugged into the wall outlet. When questioned about the unsafe location and position of the fan, Resident 7 stated that the fan had previously been on an over-the-bed table, but staff removed the table to give it to another resident and propped the fan on the back of the wheelchair handles.

Further observation revealed two positioning wedges (wedges utilized to support a resident to maintain a side lying position to offload pressure on their backside) in direct contact with floor in the corner of her room by the window.

Interview with the Nursing Home Administrator and Director of Nursing on November 19, 2025, at 3:50 PM confirmed the facility's environment should be kept in good repair and maintained in a clean and homelike manner.

28 Pa Code 201.18(e)(2.1) Management






 Plan of Correction - To be completed: 12/02/2025

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. This statement applies to all observations listed below.

Step 1
The first floor shower room hole in the wall along the baseboard trim near the toilet was repaired and the missing ceiling tile in front of the privacy curtain was replaced. The east wing ceiling tile near the nurses station was replaced. The east wing dining room tiles were replaced. R# 5's room was cleaned and items from under the bed were removed (used glove, plastic cup, towel, crumbs, and debris). R# 8's Kennedy cup and lid was removed and the brown liquid on the floor was cleaned. Linens for R# 6 and R# 8 were replaced. Area was cleaned under R# 8's nightstand. R# 7's room was cleaned and items appropriately placed with over bed table provided. Wedges were removed from the floor.

Step 2
To identify other residents that have the potential to be affected, the NHA, housekeeping supervisor, maintenance / designee will complete a facility wide audit to determine concerns needing to be addressed related to good repair and clean environment.

Step 3
To prevent this from re-occurring, the NHA/designee will educate facility staff on maintaining the facility in good repair and clean environment.

Step 4
To monitor and maintain compliance, the NHA/designee will conduct environmental rounds to ensure compliance 5 times per week. The audits will be completed weekly times 4 weeks and then monthly times 2. The results of the audits will be forwarded to QAPI committee for further review and recommendations.
483.35(a)(1)(2) REQUIREMENT Sufficient Nursing Staff:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.35 Nursing Services.
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.71.

§483.35(a) Sufficient Staff.

§483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:
(i) Except when waived under paragraph (f) of this section, licensed nurses; and
(ii) Other nursing personnel, including but not limited to nurse aides.

§483.35(a)(2) Except when waived under paragraph (f) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.
Observations:

Based on a review of nursing staffing hours and staff to resident ratios, resident census, clinical records, select facility policy, and resident and staff interviews, it was determined that the facility failed to provide sufficient nursing staff to ensure that each resident received timely, person-centered care, services, and supervision necessary to maintain the physical, mental, and psychosocial well-being of the resident population for five of 18 sampled residents (Residents 1, 2, 3, 7, and 9).

Findings include:

A review of the clinical record revealed Resident 1 was admitted to the facility on March 18, 2016, with diagnoses including cerebral vascular accident (stroke) with left-sided weakness and dementia (A condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems). A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment used to plan resident care) dated September 14, 2025, revealed the resident required staff assistance for activities of daily living and had a BIMS score of 14 (Brief Interview for Mental Status, a tool used to measure cognitive function; a score of 1315 indicates cognition is intact). A review of a facility investigation dated October 26, 2025, at 3:30 PM revealed Employee 1, nurse aide, answered Resident 1's call bell and found the resident on the floor lying on her stomach, partially under the bed with blankets underneath her. The resident stated she had attempted to transfer from her bed into her chair and slipped, causing her to fall. Resident 1 resided on the east wing of the second floor.

A review of the clinical record revealed Resident 2 was admitted on December 26, 2018, with diagnoses including dementia. A quarterly MDS dated September 4, 2025, revealed the resident required staff assistance for activities of daily living and had a BIMS score of 3 (a score of 07 indicates severe cognitive impairment). A review of a facility investigation report dated October 26, 2025, at 4:00 PM revealed Resident 2 was seated in a chair in the east wing resident dining room next to the wheelchair weight scale, which was stored and utilized in that area. Employee 2, nurse aide, was assisting the resident to the bathroom. Resident 2 stood up from the chair as Employee 2 turned to retrieve her walker. Resident 2 tripped over the wheelchair weight scale and fell, striking her head on the glass door. Documentation revealed she sustained a 2 centimeter by 0.4 cm (centimeter) laceration (wound caused by tearing of the skim) on the top left side of her head and a 1.8 cm by 0.2 cm laceration to her left cheek. She was sent to the hospital and received three staples and steri strips (soft adhesive wound closure strips).

A review of the clinical record revealed Resident 3 was admitted on June 3, 2025, with diagnoses including dementia. A quarterly MDS dated September 4, 2025, revealed the resident required staff assistance for activities of daily living and had a BIMS score of 3, indicating severe cognitive impairment. A review of facility investigative documentation dated October 26, 2025, at 4:30 PM revealed Resident 3 was wandering between the east and west nursing units and was on a 15-minute observation schedule related to a previous elopement from the facility on October 11, 2025. Employee 3, nurse aide, observed Resident 3 enter the shower room located between the east and west wing units. The resident sat down on the bathtub and fell backward into the tub. A licensed nurse assessed the resident, and no injury was documented.

A review of a written witness statement dated October 26, 2025, at 4:30 PM from Employee 3, nurse aide, revealed documentation indicating that the employee reported seeing Resident 3 walking in the hallway from the west unit toward the east unit and that the employee followed the resident with the intention of bringing her back to the west unit, where the resident resided. The statement documented that Resident 3 turned into the west shower room, located between the east and west nursing units, and that when the employee turned the corner into the shower room, the resident was sitting on the edge of the bathtub. The written statement further documented that, "as I approached her, she fell backwards into the tub, striking her head then her back on the inside of the tub." The statement noted that the resident had last been observed by the employee 15 minutes prior as part of the resident's every-15-minute monitoring.

A review of the facility document titled "Resident Observation/Monitoring Tool" (every 15-minute watch record) dated October 26, 2025, revealed documentation that Resident 3 was recorded as ambulating and wandering in the hallway continuously from 2:15 PM through 3:30 PM, at which time the record documented that Employee 3 rendered care. The documentation further revealed that Resident 3 was recorded as continuing to wander in the hallway from 3:30 PM through 5:45 PM.

A review of the facility census for October 26, 2025, for the 3:00 PM to 11:00 PM shift revealed a total census of 105 residents, with 39 residents on the second-floor west unit and 44 residents on the east unit. A review of nursing documentation revealed that during this shift there were two residents on the west unit who were placed on every-15-minute observation and one resident on the east unit who required one-to-one supervision (continuous direct visual observation by a designated staff member).

A review of nursing staffing records dated October 26, 2025, revealed that one RN Supervisor was scheduled for the entire building. Documentation for the east wing showed two licensed practical nurses (LPNs) scheduled for four-hour shifts and one LPN scheduled for an eight-hour shift, along with three nurse aides scheduled for eight-hour shifts and two nurse aides scheduled for four-hour shifts for a census of 44 residents. Documentation indicated that the resident requiring one-to-one supervision required a staff member to remain with the resident continuously, rendering that employee unavailable to provide care to additional residents.

A review of staffing documentation for the west unit revealed one LPN and three nurse aides scheduled for a census of 39 residents. Documentation further indicated that two residents on the west unit were on every-15-minute observation, including Resident 3, who was recorded throughout the day wandering on her unit and in other areas of the second floor. The documentation indicated that these monitoring responsibilities required dedicated staff time.
A review of facility investigative documentation revealed that three resident falls occurred within one hour, between 3:30 PM and 4:30 PM, on October 26, 2025, during the 3:00 PM to 11:00 PM shift. At that time, residents on the second floor were documented as requiring safety checks, toileting, and other activities of daily living, including preparation for the evening meal. Based on review of the staffing records and monitoring assignments, the documented staffing levels did not demonstrate that sufficient personnel were available to complete these duties during this shift.

During an interview on November 18, 2025, at 2:00 PM, the findings regarding staffing levels at the time of the three falls were reviewed with the Director of Nursing. No additional information was provided to indicate that staffing available during the shift exceeded the staffing levels documented in the staffing records.

A review of Resident 7's clinical record revealed admission on September 19, 2025, with diagnoses including congestive heart failure (a condition in which the heart cannot pump adequately), Type 2 diabetes (a condition affecting the body's ability to regulate blood sugar), and morbid obesity. An annual MDS dated September 16, 2025, revealed total staff dependence for toileting, bed mobility, and transfers and a BIMS score of 15, indicating intact cognition. During an interview on November 18, 2025, at 12:45 PM, Resident 7 stated she often waited over one hour for call bell response and that she experienced incontinence and soiled bedding while waiting. She stated this occurred most often on second shift and also on third shift.

A review of Resident 9's clinical record revealed the resident was admitted to the facility on December 10, 2021, with diagnoses which included heart failure and muscle weakness.

A quarterly Minimum Data Set (MDS) assessment dated September 30, 2025, revealed that Resident 9 was totally dependent on staff for toileting, bathing/showers, bed mobility and transfers. The resident was cognitively intact with a BIMS score of 14.

During an interview on November 18, 2025, at 3:14 PM, Resident 9 reported that his favorite activity in the facility was playing Bingo. The resident stated, "I just love to play Bingo, and they don't have enough people to get me up and out of bed. So, I don't get to go. I know they're short (staffed) and I don't want to bother them."

A review of the facility's shower schedule dated November 17, 2025, revealed that Resident 9 was scheduled to receive a shower during the 3:00 PM to 11:00 PM shift. Resident 9 reported during the interview on November 18, 2025, that he did not receive a shower or a bed bath the night before.

A review of the shower schedule for November 17, 2025, revealed seven residents were scheduled to receive a shower during the 3:00 PM to 11:00 PM shift. A review of the shower logs revealed documentation that only one of the seven scheduled residents received a shower. The logs further revealed that four residents received bed baths instead of a shower, and two shower logs, including Resident 9's, were not completed. There was no documented evidence that any residents scheduled for showers on November 17, 2025, during the 3:00 PM to 11:00 PM shift declined a shower or preferred a bed bath.

During a telephone interview on November 18, 2025, at 6:00 PM, Employee 5, reported that insufficient nurse aide staffing on the east wing resulted in delays in answering call bells, missed showers, and missed turning and repositioning schedules. Employee 5 reported that many residents on the east wing required the assistance of two staff members for toileting, bed mobility, and transfers and that two residents required one-to-one direct supervision (defined as continuous direct visual observation). Employee 5 reported that additional staff were not consistently scheduled to provide one-to-one supervision and that existing staff were expected to provide the one-to-one monitoring while also caring for the additional 42 residents on the wing.

Interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on November 18, 2025, at 10:00 AM confirmed that there were two residents on the East Wing who require 1:1 supervision 24 hours/day.

Review of the facility's policy titled "Resident Observation Policy" last reviewed by the facility on July 2, 2025, stated that if a resident is on 1:1 monitoring, the additional staff member assigned will remain with the resident in view at all times. Should the assigned staff member need to leave the area they are responsible for to ensure the resident is directly observed during their absence by another staff member. Staff members will complete the observation/monitoring tool.

Review of the nursing schedule for November 17, 2025, for the 11:00 PM-7:00 AM shift revealed only two nurse aides and one LPN (Licensed Practical Nurse) were assigned to the East Wing, which had a census of 44 residents. While an RN Supervisor was on duty, she was not assigned exclusively to the East Wing. The NHA and DON stated that the RN Supervisor's workstation had been moved to the East Wing on November 17, 2025, to assist staff "as needed".

Review of the Resident Observation/Monitoring Tool for the two residents on 1:1 dated November 18, 2025, revealed that Employee 6 (RN Supervisor) initialed entries for both residents at 2:45 AM, 3:00 AM, 5:00 AM and 5:15 AM despite the residents not being roommates or in adjacent rooms.

During an interview on November 18, 2025, at 3:50 PM the NHA and DON confirmed that both residents could not have been continuously observed at the same time by Employee 6.

A review of nursing time schedules, resident census data, and staff interview information revealed that the facility did not meet minimum nurse aide staffing ratios on five of fourteen reviewed dates (October 24, October 25, October 26, October 28, and November 17, 2025). A review of census records and staffing schedules revealed the number of nurse aides scheduled on those dates was below the minimum required ratios for the applicable shifts, and there was no documentation that additional higher-level staff were available to compensate. During an interview with the Nursing Home Administrator (NHA) on November 18, 2025, at 3:45 PM, the findings regarding nurse aide staffing ratios were reviewed, and no additional information was provided to demonstrate that required staffing levels were met.

A review of nursing schedules, resident census data, and staff interview information revealed that the facility did not meet the minimum licensed practical nurse (LPN) staffing ratios on five of fourteen reviewed dates (October 25, November 12, November 15, November 16, and November 17, 2025). A review of staffing schedules revealed that the number of LPNs scheduled on those dates was below the minimum required ratios for the applicable shifts, and there was no documentation that additional higher-level staff were available to compensate. During an interview with the NHA on November 18, 2025, at 3:45 PM, the findings regarding LPN staffing ratios were reviewed, and no additional information was provided to demonstrate that required staffing levels were met.

A review of nursing staffing documentation, resident census data, and staff interview information revealed that the facility did not consistently provide the minimum 3.2 hours of general nursing care per resident per day as required under Pennsylvania state licensure regulations. A review of the facility's weekly staffing records revealed general nursing care hours below the required 3.2 hours on October 25, October 26, October 28, and October 30, 2025. During an interview with the NHA on November 18, 2025, at 3:45 PM, the findings regarding general nursing hours were reviewed, and no additional information was provided to demonstrate that the required hours were met.

A review of clinical records, staffing schedules, census data, and interview information revealed the facility did not ensure sufficient nursing staff, based on actual resident census and acuity (the level of care and supervision required), to provide necessary services and supervision, and staffing documentation showed state minimum staffing ratios and required nursing hours per resident per day were not met on multiple reviewed dates.

28 Pa. Code 211.12 (c)(d)(1)(3)(4)(5) Nursing services

28 Pa. Code 201.18(b)(1)(e)(1)(2)(3)(6) Management.


 Plan of Correction - To be completed: 12/02/2025

Step 1
The facility cannot retroactively correct the cited sufficient nursing staffing.

Step 2
To identify other residents that have the potential to be affected, the NHA/designee will audit 1 weeks' worth of schedules to determine if sufficient nursing staff was provided and to identify any trends/patterns related to not meeting sufficient nursing staff with plans to address as needed post the audits completed.

Step 3
To prevent this from re-occurring, the RVPO/designee will educate the NHA and DON on sufficient staffing to ensure residents receive timely, person-centered care, services and supervision.

Step 4
To monitor and maintain compliance, the NHA/designee will audit the nursing schedules related to sufficient staffing requirements to meet timely, person-centered care, services, and supervision. The audits will be completed 5 times per week times 4 weeks and then monthly times 2. The results of the audits will be forwarded to QAPI committee for further review and recommendations.
51.3 (g)(1-14) LICENSURE NOTIFICATION:State only Deficiency.
51.3 Notification

(g) For purposes of subsections (e)
and (f), events which seriously
compromise quality assurance and
patient safety include, but not
limited to the following:
(1) Deaths due to injuries, suicide
or unusual circumstances.
(2) Deaths due to malnutrition,
dehydration or sepsis.
(3) Deaths or serious injuries due
to a medication error.
(4) Elopements.
(5) Transfers to a hospital as a
result of injuries or accidents.
(6) Complaints of patient abuse,
whether or not confirmed by the
facility.
(7) Rape.
(8) Surgery performed on the wrong
patient or on the wrong body part.
(9) Hemolytic transfusion reaction.
(10) Infant abduction or infant
discharged to the wrong family.
(11) Significant disruption of
services due to disaster such as fire,
storm, flood or other occurrence.
(12) Notification of termination of
any services vital to continued safe
operation of the facility or the
health and safety of its patients and
personnel, including, but not limited
to, the anticipated or actual
termination of electric, gas, steam
heat, water, sewer and local exchange
of telephone service.
(13) Unlicensed practice of a
regulated profession.
(14) Receipt of a strike notice.

Observations:

Based on a review of facility documentation and staff interviews, it was determined that the facility failed to notify the State Licensing Agency, the Pennsylvania Department of Health, of an event with the potential to compromise resident safety for all residents in the facility (census of 106 residents).

Findings include:

During a telephone interview with the Nursing Home Administrator (NHA) on November 20, 2025, it was revealed there was an incident in the facility laundry area on November 9, 2025, at 9:45 PM. The NHA reported that nursing staff noted an odor coming from the laundry area and identified the odor as originating from one of the three industrial dryers that had been in use. Staff stopped the dryer, removed the contents, and notified maintenance personnel. Maintenance staff arrived at the facility and removed the dryer from service. The Administrator reported that on November 10, 2025, the dryer company was contacted, and an appointment was scheduled for inspection. The Administrator stated that she did not report the incident to the State Licensing Agency because there was no actual fire within the building.

A review of a facility report submitted to the State Licensing Agency dated November 20, 2025, revealed that on November 9, 2025, at 9:45 PM, nursing staff detected an odor upon exiting the west elevator located outside the laundry area on the first floor. When the nursing supervisor investigated, the laundry aide reported that the odor was coming from one of the dryers. There was smoke present inside the dryer and subsequently in the laundry room once the dryer door was opened. The laundry aide removed the towels from the dryer, placed them into a bucket of water, and removed them from the building. The maintenance director was contacted and instructed staff to turn off the circuit breaker for the dryers in the laundry room. Documentation revealed that the dryer maintenance company was contacted on November 10, 2025, inspected the equipment on November 11, 2025, and the dryer was repaired and returned to service on November 12, 2025.

This failure to notify the State Licensing Agency of an event with the potential to compromise resident safety did not comply with mandated reporting requirements and had the potential to affect the oversight of health and safety conditions for all residents in the facility.




 Plan of Correction - To be completed: 12/02/2025

Step 1
The dryer event was submitted to the PA Department of Health on 11/20/2025.

Step 2
To identify other residents that had the potential to be affected, the facility had the dryer company inspect all of the dryers and repairs were made to the dryer that was taken out of service. All dryers functioning.

Step 3
To prevent this from re-occurring, the RVPO will educate the NHA and DON on notification of events that require reporting to the PA Department of Health with the potential to compromise resident safety.

Step 4
To monitor and maintain compliance, the NHA/DON will audit events 5 times per weeks during morning meeting to ensure events with the potential to compromise resident safety are reported to the PA Department of Health. The audits will be completed weekly times 4 weeks and then monthly times 2. The results of the audits will be forwarded to QAPI committee for further review and recommendations.
§ 211.12(f.1)(3) LICENSURE Nursing services. :State only Deficiency.
(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.

Observations:

Based on a review of nurse staffing and staff interview, it was determined the facility failed to ensure the minimum nurse aide staff to resident ratio was provided on each shift for 7 shifts out of 42 shifts reviewed.

Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum nurse aide staff of 1:10 on the day shift, 1:11 on the evening shift, and 1:15 on the night shift based on the facility's census per the regulation effective July 1, 2024.

October 24, 2025 10.27 nurse aides on the day shift, versus the required 10.50 for a census of 105.

October 25, 2025 9.57 nurse aides on the day shift, versus the required 10.50 for a census of 105.

October 25, 2025 9.17 nurse aides on the evening shift, versus the required 9.55 for a census of 105.

October 26, 2025 10.07 nurse aides on the day shift, versus the required 10.50 for a census of 105.

October 26, 2025 9.23 nurse aides on the evening shift, versus the required 9.55 for a census of 105.

October 28, 2025 10.20 nurse aides on the day shift, versus the required 10.40 for a census of 104.

November 17, 2025 6.00 nurse aides on the night shift, versus the required 7.07 for a census of 106.


On the above dates mentioned no additional excess higher-level staff were available to compensate for this deficiency.

An interview with the Nursing Home Administrator on November 18, 2025, at 3:45 PM confirmed the facility had not met the required nurse aide to resident ratios on the above dates.






 Plan of Correction - To be completed: 12/02/2025

Step 1
The facility cannot retroactively correct the cited nurse aide staff to resident ratio

Step 2
To identify other residents that have the potential to be affected, the NHA/designee will audit 1 weeks' worth of schedules to review CNA staffing
ratios to identify any trends/patterns related to not meeting ratios with plans to address as needed.

Step 3
To prevent this from re-occurring, the RVPO/designee will educate NHA/DON re: ensuring the CNA ratios are met.

Step 4
To monitor and maintain compliance, the NHA/designee will audit the nursing schedules related to CNA staffing ratios to ensure compliance. The audits will be completed 5 times per week times 4 weeks and then monthly times 2. The results of the audits will be forwarded to QAPI committee for further review and recommendations.
§ 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.
Observations:

Based on a review of nurse staffing, resident census, and staff interview, it was determined the facility failed to provide a minimum of one LPN (licensed practical nurse) per 25 residents on the day shift, one LPN per 30 residents on the evening shift, and one LPN per 40 residents on the night shift on 7 shifts out of 42 shifts reviewed.

Findings include:

The minimum required ratio on the day shift is one LPN for every 25 residents, the minimum required ratio on the evening shift is one LPN for every 30 residents, and the minimum required ratio on the night shift is one LPN for every 40 residents. A review of the facility's daily staffing records revealed that the facility did not meet the required minimum LPN-to-resident ratios on the following dates:

October 25, 2025 3.94 LPNs on the day shift, versus the required 4.20 for a census of 105.

October 25, 2025 3.09 LPNs on the evening shift, versus the required 3.50 for a census of 105.

October 25, 2025 2.03 LPNs on the night shift, versus the required 2.63 for a census of 105.

November 12, 2025 3.94 LPNs on the day shift, versus the required 4.04 for a census of 101.

November 15, 2025 3.72 LPNs on the day shift, versus the required 4.12 for a census of 103.

November 16, 2025 3.97 LPNs on the day shift, versus the required 4.16 for a census of 104.

November 17, 2025 4.09 LPNs on the day shift, versus the required 4.20 for a census of 105.


An interview with the Nursing Home Administrator on November 18, 2025, at 3:45 PM confirmed the facility had not met the required LPN-to-resident ratios on the above shifts.






 Plan of Correction - To be completed: 12/02/2025

Step 1
The facility cannot retroactively correct the cited LPN staff to resident ratio

Step 2
To identify other residents that have the potential to be affected, the NHA/designee will audit 1 weeks' worth of schedules to review LPN staffing
ratios to identify any trends/patterns related to not meeting ratios with plans to address as needed.

Step 3
To prevent this from re-occurring, the RVPO/designee will educate NHA/DON re: ensuring the LPN ratios are met.

Step 4
To monitor and maintain compliance, the NHA/designee will audit the nursing schedules related to LPN staffing ratios to ensure compliance. The audits will be completed 5 times per week times 4 weeks and then monthly times 2. The results of the audits will be forwarded to QAPI committee for further review and recommendations.
§ 211.12(i)(2) LICENSURE Nursing services.:State only Deficiency.
(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 nurse staffing, resident census and staff interview, it was determined the facility failed to consistently provide minimum general nursing care hours of 3.2 hours to each resident daily.

Findings include:

A review of the facility's staffing levels revealed that on the following dates the facility failed to provide minimum nurse staffing of 3.2 hours of general nursing care to each resident per the regulation effective July 1, 2024:

October 25, 2025 2.81 direct care nursing hours per resident.
October 26, 2025 3.04 direct care nursing hours per resident.
October 28, 2025 3.15 direct care nursing hours per resident.
October 30, 2025 3.19 direct care nursing hours per resident.

The facility's general nursing hours were below the minimum required levels on the dates noted above.

An interview with the Nursing Home Administrator on November 18, 2025, at 3:45 PM confirmed the facility failed to consistently provide minimum general nursing care hours to each resident daily.






 Plan of Correction - To be completed: 12/02/2025

Step 1
The facility can't retroactively correct the cited minimum general nursing care hours to resident ratio.

Step 2
To identify other residents that have the potential to be affected, the NHA/designee will audit 1 weeks' worth of schedules to review nursing care hours to resident ratios to identify any trends/patterns related to not meeting ratios with plans to address as needed.

Step 3
To prevent this from re-occurring, the RVPO/designee will educate NHA/DON re: ensuring the minimum general nursing care hours are met.

Step 4
To monitor and maintain compliance, the NHA/designee will audit the nursing schedules related to meeting minimum general nursing care hours to resident ratios to ensure compliance. The audits will be completed 5 times per week times 4 weeks and then monthly times 2. The results of the audits will be forwarded to QAPI committee for further review and recommendations.

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