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:

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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 completed on May 2, 2026, it was determined that West Reading Skilled Nursing and Rehabilitation Center was not in compliance with the following requirements of 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:

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.

§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;

Observations:
Based on clinical record review and resident interview, it was determined that the facility failed to provide care and services to maintain activities of daily living (showering) for three of 11 sampled residents. (Residents 2, 8, 11)

Findings include:

Clinical record review revealed that Resident 2 had diagnoses that included diabetes mellitus and heart failure. Review of the Minimum Data Set (MDS) assessment dated February 7, 2026, revealed that the resident had no cognitive impairment, and required assistance from staff for showers and personal hygiene. Review of facility documentation revealed that the resident was to receive a shower on Tuesdays and Fridays. In an interview on May 2, 2026, at 10:03 a.m., Resident 2 denied refusing any showers and stated that he was told that there aren't enough aides to provide showers. A review of the clinical record for the past 30 days revealed no documented evidence that Resident 2 received, was offered, or refused a shower on April 3 and 7, 2026.

Clinical record review revealed that Resident 8 had both legs amputated below the knees, and diagnoses that included diabetes mellitus and muscle wasting. A review of the MDS assessment dated April 3, 2026, revealed that the resident had no cognitive impairment and required substantial assistance from staff for showers and personal hygiene. Review of facility documentation revealed that the resident was to receive a shower on Mondays and Thursdays. In an interview on May 2, 2026, at 09:00 a.m., Resident 8 denied refusing any showers and stated that he was told that there aren't enough aides to provide showers. A review of the clinical record for the past 30 days revealed no documented evidence that Resident 8 received, was offered, or refused a shower on April 14, 2026.

Clinical record review revealed that Resident 11 had diagnoses that included a history of strokes and muscle wasting. A review of the MDS assessment dated April 6, 2026, revealed that the resident had a minor cognitive impairment, and required substantial assistance from staff for showers and personal hygiene. Review of facility documentation revealed that the resident was to receive a shower on Tuesdays and Fridays. In an interview on May 2, 2026, at 09:40 a.m., Resident 11 denied refusing any showers and stated that he was told that there aren't enough aides to provide showers. A review of the clinical record for the past 30 days revealed no documented evidence that Resident 11 received, was offered, or refused a shower on April 7, 2026.

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

Plan of Correction - To be completed: 06/05/2026

1.
Resident 2, Resident 8, Resident 11 have been interviewed by Unit Managers to determine their preferred days and shifts for showers and have been provided complete showers at those times.

2.
Current residents in the facility have been scheduled for showers using the Task GG-Shower/Bath entry including shift and days along with a PRN availability

3.
Nursing Staff will be educated on Shower/bathing documentation, notifying the Nurse/Manager of refusals by residents so they can reapproach the residents to confirm the refusal and possibly offer another time/shift.

4.
DON/designee will audit Shower schedules 10 residents/week x 4 weeks for compliance with scheduled patterns. Care plans will be updated accordingly for refusals of showers and bathing. Trends will be reviewed in QAPI monthly for follow up and recommendations as needed.

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(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 nursing time schedules, 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 April 11, 2026, through May 1, 2026, revealed the following:

The facility failed to meet the minimum NA to resident ratio of one NA for ten residents on day shift (7:00 a.m. to 3:00 p.m.) on April 19, 21, and 27, 2026 and May 1, 2026.

The facility failed to meet the minimum NA to resident ratio of one NA for 15 residents on night shift (11:00 p.m. to 7:00 a.m.) on April 11, 12, 13, 14, 18, 19, 20, 21, 22, 24, 25, 28, and 30, 2026, and May 1, 2026.

Plan of Correction - To be completed: 06/05/2026

1,2) Nurse aide staffing ratios will be reviewed for the last 7 days to evaluate if nurse aide ratios are met.

3) Nursing scheduler will be re-educated on staffing and PPD requirements.

4) Weekly audit of nurse aid ratios will be conducted for 60 days by NHA/designee to ensure nurse aid ratios are met. Tracking and trends to be submitted to the QAPI 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, it was determined that the facility failed to meet the minimum licensed practical nurse (LPN) to resident ratios for eight of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from April 11, 2026, through May 1, 2026, 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 April 11, 12, 18, 19, 25, and 26, 2026.

The facility failed to meet the minimum LPN to resident ratio of one LPN for 40 residents on night shift April 13, 18, and 30, 2026.

Plan of Correction - To be completed: 06/05/2026

1,2) LPN staffing ratios will be reviewed for the last 7 days to evaluate if LPN ratios are met.

3) Nursing scheduler will be re-educated on staffing and PPD requirements.

4) Weekly audit of LPN ratios will be conducted for 60 days by NHA/designee to ensure LPN ratios are met. Tracking and trends to be submitted to the QAPI committee.

§ 211.12(i)(2) LICENSURE Nursing services.:

(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 nursing time schedules, it was determined that the facility failed to provide a minimum of 3.2 hours of direct care for each resident for 16 of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from April 11, 2026, through May 1, 2026, revealed the following total nursing care hours below minimum requirements:

Saturday, April 11, 2026: 3.06
Sunday, April 12, 2026: 3.15
Monday, April 13, 2026: 2.99
Tuesday, April 14, 2026: 2.97
Saturday, April 18, 2026: 3.08
Sunday, April 19, 2026: 2.75
Monday, April 20, 2026: 3.08
Tuesday, April 21, 2026: 3.03
Wednesday, April 22, 2026: 3.10
Friday, April 24, 2026: 3.04
Saturday, April 25, 2026: 3.18
Sunday, April 26, 2026: 3.10
Monday, April 27, 2026: 2.96
Tuesday, April 28, 2026: 3.01
Thursday, April 30, 2026: 3.08
Friday, May 1, 2026: 2.77

Plan of Correction - To be completed: 06/05/2026

1,2) HPPD will be reviewed for the last 7 days to evaluate if the state minimum PPD of 2 is met.

3) Nursing scheduler will be re-educated on staffing and PPD requirements.

4) Weekly audit of HPPD will be conducted for 60 days by NHA/designee to ensure minimal HPPD is met. Tracking and trends to be submitted to the QAPI committee.

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