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P5640

Failure to Meet Minimum Nursing Care Hours Requirement

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 meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per 24-hour period. A review of nursing schedules for a 21-day period revealed that on five specific days, the total nursing care hours fell below the mandated minimum. The recorded care hours per resident on these days ranged from 2.91 to 3.11, which did not satisfy the required threshold. This deficiency was identified through the examination of documented nursing time schedules and was not linked to any specific residents' medical histories or conditions.

Plan Of Correction

1 & 2. Nurse Scheduler re-educated on the PPD requirements of 3.2 hours of direct care for each resident. 3. The facility is actively recruiting Nursing staff; utilizing Nurse Agency to supplement Nursing Staff; and Mon-Fri staffing meetings conducted in attempts to maintain State Mandated PPD of 3.2 hours of direct care for each resident. 4. The DON and/or designee will randomly audit the staffing schedules to ensure the appropriate number of Nursing Staff 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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