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P5520

Non-compliance with Nurse Aide to Resident Ratios

Reading, Pennsylvania Survey Completed on 02-02-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to meet the required nurse aide (NA) to resident ratios on two separate occasions within a 21-day review period. Specifically, on January 19, 2025, during the day shift from 7:00 a.m. to 3:00 p.m., the facility did not maintain the mandated ratio of one NA per ten residents. Additionally, on January 17, 2025, during the night shift from 11:00 p.m. to 7:00 a.m., the facility did not meet the required ratio of one NA per fifteen residents. These deficiencies were identified through a review of the nursing schedules for the specified period.

Plan Of Correction

1. Staffing Manager or designee will schedule the daily nursing staff to meet the minimum ratios of 1 CNA per 10 residents during 7AM-3PM shift, 1 CNA per 11 residents 3PM-11PM shift, and 1 CNA per 15 residents during 11PM-7AM shifts. 2. NHA, DON, Staffing Coordinator re-inserviced on new staffing ratio / PPD requirements. 3. Nursing staff ratio audits will be conducted by DON or designee daily as well as running the actual hours worked report from timeclock software, to ensure all hours are verified. 4. Reports will be reviewed at monthly QAPI meetings.

See complete original report
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