F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
clinical record review and resident interview, it was determined that the facility failed to provide services to
enhance each resident's quality of life by offering showers as scheduled to three of seven sampled
residents. (Residents 2, 5, 6)
Findings include:
Clinical record review revealed that Resident 2 had diagnoses that included congestive heart failure and
diabetes mellitus. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was
oriented and required staff assistance for bathing. The resident was to receive a shower twice per week.
During an interview on September 15, 2023, at 11:30 a.m., the resident reported that she preferred to take
a shower twice a week and was not offered the opportunity to do so. Resident 2 stated that she would not
refuse the opportunity to shower and had requested that staff wake her up to shower if she were sleeping.
Review of documentation in the clinical record revealed that the resident was not offered a shower nine of
nine scheduled times in the past 30 days.
Clinical record review revealed that Resident 5 had diagnoses that included anemia and depression. The
MDS assessment dated [DATE], indicated the resident was oriented and required staff assistance for
bathing. During an interview on September 15, 2023, at 12:20 p.m., Resident 5 stated that she preferred to
take a shower twice a week and was not offered the opportunity to do so. Resident 5 stated that she would
not refuse the opportunity to shower. Review of documentation in the clinical record revealed that the
resident was not offered a shower seven of nine scheduled times in the past 30 days.
Clinical record review revealed that Resident 6 had diagnoses that included anxiety and hypertension. The
MDS assessment dated [DATE], indicated that the resident was oriented and required staff assistance for
bathing. The resident was to receive a shower twice per week. During an interview on September 15, 2023,
at 12:30 p.m., Resident 6 stated that at times he had wash himself in the sink because staff did not offer
him the opportunity to shower. Review of documentation in the clinical record revealed that the resident was
not offered a shower three of eight scheduled times in the past 30 days.
28 Pa. Code 211.12(d)(5) Nursing services.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 6
Event ID:
395351
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395351
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/15/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
West Reading Skilled Nursing and Rehabilitation Ce
425 Buttonwood Street
West Reading, PA 19611
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0585
Level of Harm - Minimal harm
or potential for actual harm
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must
establish a grievance policy and make prompt efforts to resolve grievances.
Based on facility policy review, review of facility documentation, and interview, it was determined that the
facility failed to promptly act upon a resident grievance for one of four sampled residents. (Resident 2)
Residents Affected - Few
Finding include:
Review of the facility policy entitled, Grievance/Concern, last reviewed July 19, 2023, revealed that the
facility was to assure prompt receipt and resolution of a resident's grievance.
Review of facility documentation revealed that on July 21, 2023, Resident 2 submitted a concern form
regarding her blanket that was not returned from the laundry. Further review of the concern form revealed
no documented follow up action. In an interview on September 15, 2023, at 12:30 p.m., Resident 2 stated
that the facility has still not addressed her missing blanket.
In an interview on September 15, 2023, at 1:15 p.m., the Director of Nursing confirmed that there was no
documentation to support that the facility promptly acted upon Resident 2's grievance.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395351
If continuation sheet
Page 2 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395351
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/15/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
West Reading Skilled Nursing and Rehabilitation Ce
425 Buttonwood Street
West Reading, PA 19611
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0801
Level of Harm - Minimal harm
or potential for actual harm
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the
food and nutrition service, including a qualified dietician.
Based on staff interview, it was determined that the facility failed to employ a full-time qualified dietary
services manager in the absence of a full-time qualified dietitian.
Residents Affected - Many
Findings include:
During an interview on September 15, 2023, at 1:05 p.m., the Director of Nursing (DON), stated that the
facility did not currently employ a certified dietary manager. The DON also stated that there was not a full
time registered dietitian at the facility. There was no evidence that the facility employed a certified dietary
manager in the absence of a full time qualified dietitian.
28 Pa Code 201.18(e)(1)(6) Management.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395351
If continuation sheet
Page 3 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395351
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/15/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
West Reading Skilled Nursing and Rehabilitation Ce
425 Buttonwood Street
West Reading, PA 19611
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0804
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Level of Harm - Minimal harm
or potential for actual harm
Based on facility policy review, observation, resident interview, and results of a test tray audit, it was
determined that the facility failed to provide food that was palatable and at appetizing temperatures on two
of three nursing units. (Station two and Station four)
Residents Affected - Some
Findings include:
Review of the facility policy entitled, Meal Service, effective May 1, 2023, revealed that meals are to be
served accurately, timely, and at the appropriate temperatures.
On September 15, 2023, from 11:00 a.m. through 11:30 a.m., Residents 2, 4, 5, and 6 stated that their
meals are consistently cold.
Results of a test tray audit conducted on September 15, 2023, at 12:15 p.m., revealed meatloaf with gravy
at a temperature of 119 degrees Fahrenheit (F), scalloped potatoes at a temperature of 139 degrees F, and
green beans at a temperature of 109 degrees F. The meatloaf and green beans were cool to taste.
On September 15, 2023, from 12:45 p.m. through 1:00 p.m., Residents 2 and 5 were in their rooms with
their lunch trays in front of them and Resident 7 was in the dining room with her lunch tray in front of her. In
an interview at that time Resident 2 stated that her meal was cold and Resident 5 stated that her lunch was
cold. Resident 7 stated that her meal was cold and that the meals were always cold.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395351
If continuation sheet
Page 4 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395351
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/15/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
West Reading Skilled Nursing and Rehabilitation Ce
425 Buttonwood Street
West Reading, PA 19611
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0806
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure each resident receives and the facility provides food that accommodates resident allergies,
intolerances, and preferences, as well as appealing options.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
clinical record review, review of facility documentation, observation, and interview, it was determined that
the facility failed to ensure that a resident's preference at meal times had been accommodated for two of
seven sampled residents. (Residents 2, 7)
Findings include:
Review of the facility's weekly menu revealed that the lunch meal for September 15, 2023, was meatloaf
with gravy, green beans, lyonnaise potatoes, and a seasonal fruit cup.
Clinical record review revealed that Resident 2 was admitted to the facility with diagnoses that included
diabetes mellitus. A Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was
alert and able to make her needs known. Resident 2's ongoing care plan revealed she had an altered
nutrition status and interventions were to honor her food preferences and provide salt free seasoning
packets with her meals. During an interview on September 15, 2023, at 11:10 a.m. Resident 2 stated that
she does not receive condiments, meal items, or water as requested. On September 15, 2023, at 12:50
p.m., her lunch tray was observed on her bedside table without salt free seasoning packets or two cups of
water. The resident received macaroni and cheese and potatoes. Resident 2 stated that she did not want
the macaroni and cheese and preferred meatloaf. The resident's tray card indicated that the resident was
on a regular diet and was to receive salt free seasoning packets and two cups of water.
Clinical record review revealed that Resident 7 was admitted to the facility with diagnoses that included
obesity and chronic obstructive pulmonary disease. A MDS assessment dated [DATE], indicated that the
resident was alert and able to make her needs known. Resident 7's ongoing care plan revealed she had the
potential to be at nutritional risk and an intervention was to honor her food preferences. On September 15,
2023, at 12:55 p.m., Resident 7's lunch tray was observed and she received macaroni and cheese and
green beans. In an interview at that time the resident stated that she did not want the macaroni and cheese
or green beans and preferred meatloaf. Resident 7's stated that the facility consistently sends her items she
does not like.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395351
If continuation sheet
Page 5 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395351
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/15/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
West Reading Skilled Nursing and Rehabilitation Ce
425 Buttonwood Street
West Reading, PA 19611
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0809
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and
requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to
eat at non-traditional times or outside of scheduled meal times.
Based on a review of the facility's meal schedule, observation, and resident and staff interview, it was
determined that the facility failed to ensure that meals were served at regularly scheduled times in
accordance with the resident needs on one of three nursing units. (Station 2)
Findings include:
Review of the facility's meal schedule revealed that the scheduled times for lunch on the Station two
nursing unit was 11:10 a.m. and 11:25 a.m.
On September 15, 2023, from 11:00 a.m., through 11:30 p.m., and at 12:55 p.m. Residents 2, 4, 5, 6, and 7
stated that their meals always arrrived late. On September 15, 2023, the unit manager of station 2 (RN1)
stated that lunch was scheduled for 11:10 a.m. and 11:25 a.m. Observation on Station 2 nursing unit, on
September 15, 2023, revealed Residents 2, 4, 5, 6, and 7 received their lunch trays at 12:45 p.m. through
1:00 p.m., over an hour past the scheduled meal times.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395351
If continuation sheet
Page 6 of 6