Pennsylvania Department of Health
FAIRLANE GARDENS NURSING AND REHAB AT READING
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

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
FAIRLANE GARDENS NURSING AND REHAB AT READING
Inspection Results For:

There are  131 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.
FAIRLANE GARDENS NURSING AND REHAB AT READING - 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 February 1, 2024, it was determined that Fairlane Gardens Nursing and Rehabilitation at Reading 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)(2) LICENSURE Nursing services. :State only Deficiency.
(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 a review of nursing time schedules and staff interview, it was determined that the facility failed to meet the minimum nurse aide (NA) to resident ratios for five of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from January 10, 2024, to January 31, 2024, revealed the following:

The facility failed to meet the minimum NA to resident ratio of one NA for 12 residents on evening shift (3:00 p.m. to 11:00 p.m.) on January 12, 18, 22, 25, 2024.

The facility failed to meet the minimum NA to resident ratio of one NA for 20 residents on night shift (11:00 p.m. to 7:00 a.m.) on January 18, 2024.

In an interview on February 1, 2024, at 1:50 p.m., the Nursing Home Administrator confirmed that the facility did not meet the minimum required nursing staff to resident ratio on the days identified.



 Plan of Correction - To be completed: 02/26/2024

1. Facility cannot retroactively correct the CNA staffing Ratio requirements
2. NHA, DON, and staffing scheduler will have daily meetings to ensure CNA staffing ratios are being met. Facility will continue to hire and utilize agency staff for open shifts.
3. NHA, or designee, will educate staffing scheduler and DON on maintaining the CNA staff ratios based off of current census.
4. NHA, or designee, will perform audits with DON and staffing scheduler to ensure CNA staffing rations are being met based off of current census. Results of audits will be presented at monthly Quality Assurance and Improvement Plan meetings for 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 nursing time schedules and staff interview, it was determined that the facility failed to meet the minimum licensed practical nurse (LPN) to resident ratio for three of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from January 10, 2024, to January 31, 2024, revealed the following:

The facility failed to meet the minimum LPN to resident ratio of one LPN for 30 residents on evening shift (3:00 p.m. to 11 p.m.) on January 17, 2024.

The facility failed to meet the minimum LPN to resident ratio of one LPN for 40 residents on night shift (11 p.m. to 7 a.m.) on January 12, 2024, and January 22, 2024.

In an interview on February 1, 2024, at 1:50 p.m., the Nursing Home Administrator confirmed that the facility did not meet the minimum required nursing staff to resident ratio on the days identified.



 Plan of Correction - To be completed: 02/26/2024

1. Facility cannot retroactively correct the LPN staffing Ratio requirements
2. NHA, DON, and staffing scheduler will have daily meetings to ensure LPN staffing ratios are being met. Facility will continue to hire and utilize agency staff for open shifts.
3. NHA, or designee, will educate staffing scheduler and DON on maintaining the LPN staff ratios based off of current census.
4. NHA, or designee, will perform audits with DON and staffing scheduler to ensure LPN staffing rations are being met based off of current census. Results of audits will be presented at monthly Quality Assurance and Improvement Plan meetings for review and recommendations.


211.12(i)(1) LICENSURE Nursing services.:State only Deficiency.
(1) Effective July 1, 2023, 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 2.87 hours of direct resident care for each resident.

Observations:

Based on a review of nursing time schedules and staff interview, it was determined that the facility failed to provide a minimum of 2.87 hours of direct care for eight of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from January 10, 2024, to January 31, 2024, revealed the following total nursing care hours below minimum requirements:

Friday, January 12, 2024, 2.74 care hours per resident
Saturday, January 13, 2024, 2.75 care hours per resident
Monday, January 15, 2024, 2.80 care hours per resident
Tuesday, January 16, 2024, 2.79 care hours per resident
Wednesday, January 17, 2024, 2.77 care hours per resident
Sunday, January 21, 2024, 2.86 care hours per resident
Monday, January 22, 2024, 2.79 care hours per resident
Tuesday, January 23, 2024, 2.80 care hours per resident

In an interview on February 1, 2024, at 1:50 p.m., the Nursing Home Administrator confirmed that the facility did not meet the minimum required nursing care hours.



 Plan of Correction - To be completed: 02/26/2024

1. Facility cannot retroactively correct the PPD hours below minimum requirements
2. NHA, DON, and staffing scheduler will have daily meetings to ensure PPD hours are above minimum required 2.87. Facility will continue to hire and utilize agency staff for open shifts.
3. NHA, or designee, will educate staffing scheduler and DON on maintaining at least the minimum required PPD of 2.87.
4. NHA, or designee, will perform audits with DON and staffing scheduler to ensure PPD hours are at, or above state minimum required hours. Results of audits will be presented at monthly Quality Assurance and Improvement Plan meetings for review and recommendations.


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

Visit the PA Power Port