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Inspection visit

Health inspection

WEST READING SKILLED NURSING AND REHABILITATION CECMS #3953516 citations on this visit
6 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

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

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Citations

6 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0550GeneralS&S Dpotential for harm

    F550 - Resident Rights

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  • 0585GeneralS&S Dpotential for harm

    F585 - Grievances

    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.

  • 0801GeneralS&S Fpotential for harm

    F801 - Staffing

    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.

  • 0804GeneralS&S Epotential for harm

    F804 - Food and drink

    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  • 0806GeneralS&S Dpotential for harm

    F806 - Food and drink

    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

  • 0809GeneralS&S Epotential for harm

    F809 - Frequency of Meals

    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.

FAQ · About this visit

Common questions about this visit

What happened during the September 15, 2023 survey of WEST READING SKILLED NURSING AND REHABILITATION CE?

This was a inspection survey of WEST READING SKILLED NURSING AND REHABILITATION CE on September 15, 2023. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at WEST READING SKILLED NURSING AND REHABILITATION CE on September 15, 2023?

Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.