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P5530

Failure to Meet Minimum LPN Staffing Ratios

West Reading, Pennsylvania Survey Completed on 07-26-2025

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 comply with state regulations requiring minimum licensed practical nurse (LPN) to resident ratios during specified shifts. A review of nursing schedules for a 21-day period revealed that on eight separate days, the facility did not meet the mandated LPN staffing levels. Specifically, the day shift on one day did not have the required one LPN per 25 residents, the evening shift on two days did not meet the one LPN per 30 residents ratio, and the night shift on six days failed to provide one LPN per 40 residents. These findings were based solely on the review of the facility's nursing time schedules for the period in question. No additional information regarding the residents' medical history, conditions, or specific outcomes related to the staffing deficiencies was provided in the report.

Plan Of Correction

1&2. Nurse Scheduler re-educated on the LPN ratio requirements of 1 LPN to 25 residents on day shift, 1 LPN to 30 residents on evening shift, and 1 LPN to 40 residents on night shift. 3. The facility is actively recruiting LPNs; utilizing Nurse Agency to supplement LPNs; and Mon-Fri staffing meetings conducted in attempts to maintain State Mandated ratios for LPNs. 4. The DON and/or designee will randomly audit the staffing schedules to ensure the appropriate number of LPNs are scheduled to achieve compliance. The results of the audits will be submitted to the QA Committee to determine if additional action is necessary.

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