Inspection visit
Health inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0623
Level of Harm - Potential for
minimal harm
Residents Affected - Many
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
clinical record review, it was determined that the facility failed to notify the residents and the residents'
representatives regardless of transfers from the facility and reasons for the moves in writing for six of nine
sampled residents who were transferred to the hospital. (Residents 19, 28, 32, 79, 81, 123)
Findings include:
Clinical record review revealed that Resident 19 was transferred and admitted to the hospital on [DATE],
after a change in condition. There was no documented evidence that the resident, the resident's
responsible party, or the legal representative was provided written information regarding the resident's
transfer to the hospital.
Clinical record review revealed that Resident 28 was transferred and admitted to the hospital on [DATE],
after a change in condition. There was no documented evidence that the resident, the resident's
responsible party, or the legal representative was provided written information regarding the resident's
transfer to the hospital.
Clinical record review revealed that Resident 32 was transferred and admitted to the hospital on [DATE],
and January 1, 2024, after a change in condition. There was no documented evidence that the resident, the
resident's responsible party, or the legal representative was provided written information regarding the
resident's transfer to the hospital.
Clinical record review revealed that Resident 79 was transferred and admitted to the hospital on [DATE],
and December 20, 2023, after a change in condition. There was no documented evidence that the resident,
the resident's responsible party, or the legal representative was provided written information regarding the
resident' transfer to the hospital.
Clinical record review revealed that Resident 81 was transferred and admitted to the hospital on [DATE],
after a change in condition. There was no documented evidence that the resident, the resident's
responsible party, or the legal representative was provided written information regarding the resident's
transfer to the hospital.
Clinical record review revealed that Resident 123 was transferred and admitted to the hospital on [DATE],
after a change in condition. There was no documented evidence that the resident, the resident's
responsible party, or the legal representative was provided written information regarding the resident's
transfer to the hospital.
(continued on next page)
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
01/25/2024
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 0623
Level of Harm - Potential for
minimal harm
In an interview on January 24, 2024, at 12:54 p.m., the Administrator confirmed that written transfer
information, including the reasons for the move, was not provided to the residents and the residents'
representatives.
Residents Affected - Many
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
01/25/2024
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 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
clinical record review and staff interview, it was determined that the facility failed to ensure that the
Minimum Data Set (MDS) assessment was completed to accurately reflect the resident's current status for
two of 27 sampled residents. (Residents 10, 32)
Residents Affected - Few
Findings include:
Clinical record review revealed that Resident 10 had diagnoses that included vascular dementia and major
depressive disorder recurrent with psychotic symptoms. On November 29, 2023, the resident received a
last dose of an anti-psychotic medication (Risperidone). The MDS assessment dated [DATE], indicated that
the resident was still on an anti-psychotic medication. The MDS inaccurately reflected that the resident was
still on an anti-psychotic medication during the assessment look back period of seven days.
Clinical record review revealed that Resident 32 had diagnoses that included diabetes mellitus and muscle
wasting. On November 25, 2023, the physician directed nursing to administer enteral nutrition via a tube.
The MDS assessment dated [DATE], indicated that the resident did not have any enteral nutrition and was
not receiving any tube feeding formula through the tube during the seven day review period. The MDS
inaccurately reflected that Resident 32 did not have a feeding tube and was not receiving any enteral
nutrition through it during the seven day review period.
In an interview on January 25, 2024, at 8:59 a.m., the Director of Nursing confirmed that both MDS
assessments had not accurately reflected Resident 10 and 32's status during the seven day review period
and had to be modified by the facility.
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
01/25/2024
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 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
Based on clinical record review and staff interview, it was determined that the facility failed to ensure
physician's orders were implemented for one of 27 sampled residents. (Resident 15)
Residents Affected - Few
Findings include:
Clinical record review revealed that Resident 15 had diagnoses that included chronic kidney disease,
hyperkalemia(high blood potassium), and anemia of chronic kidney disease. The resident had an
arteriovenous (AV) fistula (an artificial tube used to connect an artery to a vein for hemodialysis) placed on
the left arm in December 2021. On December 22, 2021, a physician's order directed staff to not obtain
Resident 15's blood pressure or blood draws from the left arm related to the left arm AV fistula site. Review
of Resident 15's blood pressure summary revealed that from December 22, 2023, through January 22,
2024, nursing had taken the resident's blood pressure in the left arm 25 of 96 times.
In an interview conducted on January 25, 2024, at 10:00 a.m., the Director of Nursing confirmed that the
staff should have taken Resident 15's blood pressure using the right arm.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
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
01/25/2024
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 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM
and/or mobility, unless a decline is for a medical reason.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
clinical record review, observation and staff interview, it was determined that the facility failed to provide
services and treatment to prevent a further decrease in range of motion and contractures for one of four
sampled residents with limited range of motion. (Resident 62)
Findings include:
Clinical record review revealed that Resident 62 had diagnoses that included a stroke with left sided
paralysis, dementia, abnormal posture and contracture of the muscle. The Minimum Data Set assessment
dated [DATE], indicated that the resident had some memory impairment, required extensive assistance
from staff for dressing and had limitations in range of motion in both lower extremities.
Review of an occupational therapy Discharge summary dated [DATE], revealed that there was a
recommendation for staff to apply a left lower extremity bean bag splint at all times. Review of the care plan
identified the resident had a self care deficit related to activities of daily living due to physical limitations due
to a stroke. There was an intervention for staff to apply a left lower extremity bean bag splint at all times.
On January 23, 2024, at 10:00 a.m., 11:58 a.m., and 1:00 p.m., the resident was dressed and in his chair
without the bean bag splint in place on his lower left extremity. On January 24, 2024, at 10:14 a.m. and
12:00 p.m., the resident was again dressed and in his chair without the bean bag splint in place on his
lower left extremity.
In an interview on January 25, 2024, at 9:28 a.m., the Director of Rehabilitation Therapy stated that the
bean bag splint was to be applied by staff at all times on his lower left leg in order to help prevent
contractures and further decrease in range of motion.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
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
01/25/2024
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on policy review, observation, and staff interview, it was determined that the facility failed to store
food in a sanitary manner in the dietary department.
Residents Affected - Many
Findings include:
Review of the facility's policy entitled, Refrigerated/ Frozen Storage, last reviewed November 3, 2023,
revealed that all foods were to be labelled with a date received and prepared food items were to be dated.
Observation during the kitchen tour on January 23, 2024, at 10:00 a.m., revealed that in the kitchen freezer,
there were three bags of spinach removed from the original box and not dated. In the snack refrigerator,
there was a tray of 14 dishes containing applesauce or fruit cocktail that were not dated. There was a dish
of pureed fruit cocktail with a date of January 6, 2024. In the milk refrigerator, there were two containers of
cottage cheese with a use-by date of January 19, 2024, and two containers of icing that were not dated. In
the cook's refrigerator, there were two mislabeled chef salads.
The coffee machine table had a bottom shelf that had multiple areas of peeling paint. The shelf had three
pitchers that were stored upside down, with the top rim directly touching the peeling paint areas. The
pitchers were used for residents per the Dietary Manager (DM).
In an interview conducted on January 23, 2024, at 10:30 a.m., the DM confirmed all the previously
mentioned food items should have been dated and were not and that the expired items should have been
removed.
28 Pa. Code 201.14(a) Responsibility of licensee.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395351
If continuation sheet
Page 6 of 6
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Back to topCitations
5 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.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the January 25, 2024 survey of WEST READING SKILLED NURSING AND REHABILITATION CE?
This was a inspection survey of WEST READING SKILLED NURSING AND REHABILITATION CE on January 25, 2024. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at WEST READING SKILLED NURSING AND REHABILITATION CE on January 25, 2024?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before tran..."
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.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.