Pennsylvania Department of Health
WEST READING 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

WEST READING SKILLED NURSING AND REHABILITATION CENTER
Inspection Results For:

There are 139 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.


WEST READING 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 on June 5, 2024, it was determined that West Reading Skilled Nursing and Rehabilitation was not in compliance with the following requirements of 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 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 15 of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from May 14, 2024, to June 3, 2024, revealed the following:

The facility failed to meet the minimum NA to resident ratio of one NA for 12 residents on day shift (7:00 a.m. to 3:00 p.m.) on May 18, 19, 25, 26, 27, 28, and June 1, 2, 2024.

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 May 16, 17, 21, 24, 25, 27, and June 1, 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 May 17, 19, 22, 23, 24, 29, and June 1, 2, 2024.

During an interview on June 4, 2024, at 3:15 p.m., the Nursing Home Administrator confirmed that the facility did not meet the minimum required nursing staff to resident ratios on the days identified.

Plan of Correction - To be completed: 06/19/2024

This plan of correction is the center's credible allegation of compliance. 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 conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provision of Federal and State Law.
1. Facility cannot retroactively correct the failure to meet the ratio requirements of the Certified Nursing Aides as identified in the outlined PA-2567, with the survey end date of June 4, 2024.
2. Education given to the Nurse Scheduler and Director of Nursing on the Certified Nursing Aides ratio requirements.
3. Facility is actively recruiting Certified Nurses Aides through outside marketing sources; utilizing outside Nurse Agency to supplement Certified Nursing Aides; and daily staffing meetings being conducted in attempts to maintain State Mandated ratios for Certified Nursing Aides.
4. The Administrator will audit the staffing schedules to ensure the appropriate number of Certified Nursing Aides are scheduled to achieve compliance. Audits will occur five times per week for four weeks; four times per week for four weeks and three times per week for four weeks. The results of the audits will be submitted to the QA 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 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 ratios for seven of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from May 14, 2024, to June 3, 2024, revealed the following:

The facility failed to meet the minimum LPN to resident ratio of one LPN for 25 residents on day shift (7:00 a.m. to 3:00 p.m.) on May 25, and June 1, 2024.

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 11:00 p.m.) on May 18 and 25, 2024.

The facility failed to meet the minimum LPN to resident ratio of one LPN for 40 residents on night shift (11:00 p.m. to 7:00 a.m.) on May 18, 19, 23, 25, 28, and June 1, 3, 2024.

During an interview on June 4, 2024, at 3:15 p.m., the Nursing Home Administrator confirmed that the facility did not meet the minimum required nursing staff to resident ratios on the days identified.

Plan of Correction - To be completed: 06/19/2024

1. Facility cannot retroactively correct the failure to meet the ratio requirements of the Licensed Practical Nurses as identified in the outlined PA-2567, with the survey end date of June 4, 2024.
2. Education given to the Nurse Scheduler and Director of Nursing on the Licensed Practical Nurses ratio requirements.
3. Facility is actively recruiting Licensed Practical Nurses through outside marketing sources; utilizing outside Nurse Agency to supplement Licensed Practical Nurses; and daily staffing meetings being conducted in attempts to maintain State Mandated ratios for Licensed Practical Nurses.
4. The Administrator will audit the staffing schedules to ensure the appropriate number of Licensed Practical Nurses are scheduled to achieve compliance. Audits will occur five times per week for four weeks; four times per week for four weeks and three times per week for four weeks. The results of the audits will be submitted to the QA Committee.

§ 211.12(i)(1) LICENSURE Nursing services.:

(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.

Plan of Correction - To be completed: 06/19/2024

1. Facility cannot retroactively correct the failure to meet the overall PPD requirements of the nursing staff as identified in the outlined PA-2567, with the survey end date of June 4, 2024.
2. Education given to the Nurse Scheduler and Director of Nursing on the overall PPD requirements for nursing staff.
3. Facility is actively recruiting Certified Nurses Aides and Licensed Practical Nurses through outside marketing sources; utilizing outside Nurse Agency to supplement Certified Nursing Aides and Licensed Practical Nurses; and daily staffing meetings being conducted in attempts to maintain State Mandated PPD requirements.
4. The Administrator will audit the staffing schedules to ensure the facility is staffed appropriately to reach the mandated State PPD. Audits will occur five times per week for four weeks; four times per week for four weeks and three times per week for four weeks. The results of the audits will be submitted to the QA Committee.

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