Pennsylvania Department of Health
WEST READING SKILLED NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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WEST READING SKILLED NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  133 surveys for this facility. Please select a date to view the survey results.

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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 a Medicare/Medicaid Recertification survey, State Licensure survey, and Civil Rights Compliance survey completed January 25, 2024, 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 as the relate to the Health portion of the survey.





 Plan of Correction:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  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.
§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:

Based on policy review, observation, and staff interview, it was determined that the facility failed to store food in a sanitary manner in the dietary department.

Findings include:

Review of the facility's policy entitled, "Refrigerated/ Frozen Storage," last reviewed November 3, 2023, revealed that all foods were to be labelled with a date received and prepared food items were to be dated.

Observation during the kitchen tour on January 23, 2024, at 10:00 a.m., revealed that in the kitchen freezer, there were three bags of spinach removed from the original box and not dated. In the snack refrigerator, there was a tray of 14 dishes containing applesauce or fruit cocktail that were not dated. There was a dish of pureed fruit cocktail with a date of January 6, 2024. In the milk refrigerator, there were two containers of cottage cheese with a "use-by" date of January 19, 2024, and two containers of icing that were not dated. In the cook's refrigerator, there were two mislabeled chef salads.

The coffee machine table had a bottom shelf that had multiple areas of peeling paint. The shelf had three pitchers that were stored upside down, with the top rim directly touching the peeling paint areas. The pitchers were used for residents per the Dietary Manager (DM).

In an interview conducted on January 23, 2024, at 10:30 a.m., the DM confirmed all the previously mentioned food items should have been dated and were not and that the expired items should have been removed.

28 Pa. Code 201.14(a) Responsibility of licensee.








 Plan of Correction - To be completed: 03/06/2024

1. The facility cannot retroactively correct the missing dates on the food items in the various refrigerators. The facility cannot retroactively correct the shelf with peeling paint.
2. The items identified that were not dated were dated correctly. The table with the peeling paint was discarded. A new stainless steel table was purchased and replaced the old table.
3. Education was done with all dietary staff on dating/labeling of all food. A one-time audit was conducted on the remaining tables in the kitchen to ensure no further tables needed to be replaced.
4. Administrator/designee will audit food being stored in refrigerators to ensure dating is being completed three times per week for four weeks. Tables will be checked to ensure no peeling paint once monthly for three months with all results to be reported to the QA Committee.


483.20(g) REQUIREMENT Accuracy of Assessments: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.
§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment was completed to accurately reflect the resident's current status for two of 27 sampled residents. (Residents 10, 32)

Findings include:

Clinical record review revealed that Resident 10 had diagnoses that included vascular dementia and major depressive disorder recurrent with psychotic symptoms. On November 29, 2023, the resident received a last dose of an anti-psychotic medication (Risperidone). The MDS assessment dated December 22, 2023, indicated that the resident was still on an anti-psychotic medication. The MDS inaccurately reflected that the resident was still on an anti-psychotic medication during the assessment look back period of seven days.

Clinical record review revealed that Resident 32 had diagnoses that included diabetes mellitus and muscle wasting. On November 25, 2023, the physician directed nursing to administer enteral nutrition via a tube. The MDS assessment dated December 1, 2023, indicated that the resident did not have any enteral nutrition and was not receiving any tube feeding formula through the tube during the seven day review period. The MDS inaccurately reflected that Resident 32 did not have a feeding tube and was not receiving any enteral nutrition through it during the seven day review period.

In an interview on January 25, 2024, at 8:59 a.m., the Director of Nursing confirmed that both MDS assessments had not accurately reflected Resident 10 and 32's status during the seven day review period and had to be modified by the facility.










 Plan of Correction - To be completed: 03/06/2024

1. Residents numbered 10 and 32's MDS were corrected to reflect the errors noted during the survey.
2. A one time audit was performed on residents that have a tube-feed and is currently prescribed antipsychotic medications to ensure accurate documentation on the MDS.
3. Education was given to the Licensed Nurses in the RNAC department on proper coding of residents who are currently on antipsychotic medications and residents with a tube feed.
4. Administrator/designee will complete a review of completed MDS's with residents who are prescribed antipsychotic medications and who have a tube feed weekly for three months. Results of the audits will be reviewed at the QA meeting monthly for three months.

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility: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.
§483.25(c) Mobility.
§483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

§483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

§483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.
Observations:

Based on clinical record review, observation and staff interview, it was determined that the facility failed to provide services and treatment to prevent a further decrease in range of motion and contractures for one of four sampled residents with limited range of motion. (Resident 62)

Findings include:

Clinical record review revealed that Resident 62 had diagnoses that included a stroke with left sided paralysis, dementia, abnormal posture and contracture of the muscle. The Minimum Data Set assessment dated August 20, 2023, indicated that the resident had some memory impairment, required extensive assistance from staff for dressing and had limitations in range of motion in both lower extremities.

Review of an occupational therapy discharge summary dated November 8, 2023, revealed that there was a recommendation for staff to apply a left lower extremity bean bag splint at all times. Review of the care plan identified the resident had a self care deficit related to activities of daily living due to physical limitations due to a stroke. There was an intervention for staff to apply a left lower extremity bean bag splint at all times.

On January 23, 2024, at 10:00 a.m., 11:58 a.m., and 1:00 p.m., the resident was dressed and in his chair without the bean bag splint in place on his lower left extremity. On January 24, 2024, at 10:14 a.m. and 12:00 p.m., the resident was again dressed and in his chair without the bean bag splint in place on his lower left extremity.

In an interview on January 25, 2024, at 9:28 a.m., the Director of Rehabilitation Therapy stated that the bean bag splint was to be applied by staff at all times on his lower left leg in order to help prevent contractures and further decrease in range of motion.

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





 Plan of Correction - To be completed: 03/06/2024

1. Facility cannot retroactively correct that the beanbag splint was not donned on Resident 62.
2. A screen was sent to Occupational Therapy to reassess if the beanbag splint is still indicated for Resident 62. A one-time audit on residents with splints done to ensure the indication of each resident splint. Resident kardex updated on residents who are ordered splints.
3. Education given to nursing staff for following the kardex and application of resident splints.
4. DON/designee will perform five audits weekly for six weeks to ensure compliance with splints. Results will be reviewed at the QA meeting.

483.25 REQUIREMENT Quality of Care: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.
§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure physician's orders were implemented for one of 27 sampled residents. (Resident 15)

Findings include:

Clinical record review revealed that Resident 15 had diagnoses that included chronic kidney disease, hyperkalemia(high blood potassium), and anemia of chronic kidney disease. The resident had an arteriovenous (AV) fistula (an artificial tube used to connect an artery to a vein for hemodialysis) placed on the left arm in December 2021. On December 22, 2021, a physician directed staff to not obtain Resident 15's blood pressure or blood draws from the left arm related to the left arm AV fistula site. Review of Resident 15's blood pressure summary revealed that from December 22, 2023, through January 22, 2024, nursing had taken the resident's blood pressure in the left arm 25 of 96 times.

In an interview conducted on January 25, 2024, at 10:00 a.m., the Director of Nursing confirmed that the staff should have taken Resident 15's blood pressure using the right arm.

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









 Plan of Correction - To be completed: 03/06/2024

1. Facility cannot retroactively correct the blood pressures that were taken on Resident 15.
2. A one-time audit done to review orders on all dialysis residents for which extremity a blood pressure is permitted to be done.
3. Education given to nursing staff on the proper extremity that a blood pressure can be taken on all dialysis residents. All residents who are on dialysis, will have the individualized kardex updated to reflect which arm is to be used when taking the blood pressure.
4. DON/designee will complete five audits per week on dialysis residents who have orders for blood pressures to ensure proper placement of the blood pressure cuff for four weeks. Results will be reviewed at the QA meeting.

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

§483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

§483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

§483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

§483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).
Observations:

Based on clinical record review, it was determined that the facility failed to notify the residents and the residents' representatives regardless of transfers from the facility and reasons for the moves in writing for six of nine sampled residents who were transferred to the hospital. (Residents 19, 28, 32, 79, 81, 123)

Findings include:

Clinical record review revealed that Resident 19 was transferred and admitted to the hospital on December 14, 2023, after a change in condition. There was no documented evidence that the resident, the resident's responsible party, or the legal representative was provided written information regarding the resident's transfer to the hospital.

Clinical record review revealed that Resident 28 was transferred and admitted to the hospital on September 12, 2023, after a change in condition. There was no documented evidence that the resident, the resident's responsible party, or the legal representative was provided written information regarding the resident's transfer to the hospital.

Clinical record review revealed that Resident 32 was transferred and admitted to the hospital on November 9, 2023, and January 1, 2024, after a change in condition. There was no documented evidence that the resident, the resident's responsible party, or the legal representative was provided written information regarding the resident's transfer to the hospital.

Clinical record review revealed that Resident 79 was transferred and admitted to the hospital on October 4, 2023, and December 20, 2023, after a change in condition. There was no documented evidence that the resident, the resident's responsible party, or the legal representative was provided written information regarding the resident' transfer to the hospital.

Clinical record review revealed that Resident 81 was transferred and admitted to the hospital on October 3, 2023, after a change in condition. There was no documented evidence that the resident, the resident's responsible party, or the legal representative was provided written information regarding the resident's transfer to the hospital.

Clinical record review revealed that Resident 123 was transferred and admitted to the hospital on October 27, 2023, after a change in condition. There was no documented evidence that the resident, the resident's responsible party, or the legal representative was provided written information regarding the resident's transfer to the hospital.

In an interview on January 24, 2024, at 12:54 p.m., the Administrator confirmed that written transfer information, including the reasons for the move, was not provided to the residents and the residents' representatives.











 Plan of Correction - To be completed: 03/06/2024

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 omission of the missing Notice of Transfer forms for the Six residents identified.
2. Education was provided for the nursing staff on the use of the Notice of Transfer form for any resident being transferred to an acute care setting.
3. Moving forward, any Notice of Transfer forms that are completed by the nursing staff, the original will be sent with the resident and a copy will be sent to administration for review and forwarded to the RP by mail.
4. Residents that are transferred to an acute care setting will be reviewed in morning clinical meeting to ensure the Notice of Transfer form was sent with the resident. Weekly summaries will be done and reviewed with the Director of Nursing and RN Unit Manager for three months. Results of the weekly audit will be reported to the QA meeting for three months for review.

§ 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, it was determined that the facility failed to meet the minimum nurse aide (NA) to resident ratios for 41 shifts in the last 21 days.

Findings include:

Review of nursing schedules for 21 days from (list the specific weeks of staffing reviewed), 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.) January 2, 3, 4, 13, 14, 15, 16, 19 and 23, 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 January 2, 3, 4, 5, 6, 7, 12, 13, 14, 16, 17, 20, 21, 22, 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 2, 3, 5, 6, 7, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 24, 2024.

In an interview on January 25, 2024, at 1:00 p.m., the Administrator confirmed that the facility failed to meet the the minimum NA to resident ratios on the dates and shifts listed above.






 Plan of Correction - To be completed: 03/06/2024

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 January 25, 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. :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, it was determined that the facility failed to meet the minimum licensed practical nurse (LPN) to resident ratios for 28 shifts of 21 days reviewd.

Findings include:

Review of nursing schedules for 21 days from January 1, 2024 through January 24, 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 January 20, 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 January 2, 3, 6, 7, 11, 16, 18, 19, 20, 23, 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.) January 2, 4, 5, 6, 7, 11, 12, 13, 14, 15, 16, 18, 19, 20, 21, 22, and 24, 2024.

In an interview on January 25, 2024, at 1:00 p.m., the Administrator stated that the facility failed to meet the LPN to resident ratios on the days listed above.



 Plan of Correction - To be completed: 03/06/2024

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 January 25, 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.: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, it was determined that the facility failed to provide a minimum of 2.87 hours of direct care for each resident for 16 of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from January 1 through January 22, 2024, revealed the following total nursing care hours below minimum requirements:

January 1, 2024= 2.68
January 2, 2024= 2.27
January 3, 2024= 2.65
January 4. 2-24= 2.84
January 6, 2024= 2.41
January 7, 2024= 2.67
January 13, 2024= 2.44
January 14, 2024= 2.63
January 15, 2024= 2.82
January 16, 2024= 2.54
January 17, 2024= 2.80
January 18, 2024= 2.72
January 19, 2024= 2.55
January 20, 2024= 2.23
January 21, 2024= 2.60
January 22, 2024= 2.76

In an interview on January 25, 2024, at 1:00 p.m., the Administrator confirmed that the facility failed to meet the minimum of 2.87 hours of direct care for each resident for the days listed above.




 Plan of Correction - To be completed: 03/06/2024

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 January 25, 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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