Pennsylvania Department of Health
WEST READING SKILLED NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

WEST READING SKILLED NURSING AND REHABILITATION CENTER
Inspection Results For:

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WEST READING SKILLED NURSING AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey and an Abbreviated survey in response to one complaint, completed January 29, 2026, it was determined that West Reading Skilled Nursing and Rehabilitation Center, was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey.\~

Plan of Correction:

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Observations:
Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide assistance with dining in a manner that promoted and maintained dignity for one of 31 sampled residents. (Resident 3)

Findings include:

Clinical record review revealed that Resident 3 had diagnoses that included muscle wasting, dysphagia (difficulty in swallowing), protein-calorie malnutrition, and history of a traumatic brain injury. Review of the Minimum Data Set (MDS) assessment, dated December 19, 2025, revealed that the resident had significant cognitive impairment and required staff assistance with eating. Review of Resident 3's care plan revealed that staff was to assist the resident with meals as needed, encourage the resident to take small bites, provide verbal cues to take frequent drinks, and check for food in the mouth after swallowing. On January 28, 2026, from 12:25 p.m. through 12:40 p.m., licensed practical nurse (LPN) 1 was observed standing while assisting Resident 3 with lunch.

In an interview on January 29, 2026, at 11:00 a.m., the Director of Nursing stated that staff should not stand when feeding residents.

CFR 483.10 (a)(1) Resident Rights
Previously Cited 2/18/25

28 Pa. Code 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 02/27/2026

Nurse (LPN 1) has been educated to be seated nearby the resident that is being fed in order to maintain dignity. Resident 3 continues to require assistance with feeding/drinking from staff.
Residents who require assistance with feeding will receive the assistance from staff who will be seated close by maintaining their dignity.
Nursing staff and Therapy staff that assist with meals will be educated to help maintain the resident's dignity by remaining seated while feeding. Education will include residents' rights to be dignified.
Unit Manager's/designee will audit staff at mealtimes twice a day, 3x/week for 6 weeks to ensure that staff are seated while feeding residents. Trends will be reviewed in QAPI monthly for follow up and recommendations as needed.

483.20(g)(h)(i)(j) REQUIREMENT Accuracy of Assessments:

§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

§483.20(h) Coordination. A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals.

§483.20(i) Certification.
§483.20(i)(1) A registered nurse must sign and certify that the assessment is completed.
§483.20(i)(2) Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment.

§483.20(j) Penalty for Falsification.
§483.20(j)(1) Under Medicare and Medicaid, an individual who willfully and knowingly-
(i) Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or
(ii) Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty or not more than $5,000 for each assessment.
§483.20(j)(2) Clinical disagreement does not constitute a material and false statement.

Observations:
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 current status of three of 31 sampled residents. (Residents 1, 10, 13)

Findings include:

Clinical record review revealed that Resident 1 received oxygen therapy starting on September 25, 2025. The MDS assessment dated December 12, 2025, incorrectly indicated in Section O (Special treatments, Procedures, Programs) that the resident was not receiving oxygen therapy during the previous seven days.

In an interview on January 29, 2026, at 10:50 a.m., the Director of Nursing confirmed that Resident 1's MDS assessment was inaccurate.

Clinical record review revealed that Resident 10 had diagnoses that included hepatic (liver) failure and asthma. Review of Resident 10's MDS dated December 5, 2025, indicated that Resident 10 received an anticoagulant medication. Review of Resident 10's clinical record revealed no physician's orders for an anticoagulant medication.

Clinical record review revealed that Resident 13 had diagnoses that included cerebrovascular disease (affects blood vessels in the brain) and bipolar disorder. Review of Resident 13's MDS dated November 4, 2025, indicated that Resident 13 received an anticoagulant medication. Review of Resident 13's clinical record revealed no physician's orders for an anticoagulant medication.

Plan of Correction - To be completed: 02/27/2026

1. RNAC/MDS have corrected MDS submitted for Residents 1, 10, and 13.
2. Current Residents who receive Oxygen, anticoagulant and antiplatelet therapies will have it correctly captured on their next MDS. Submitted January MDS' will be audited for accuracy with any modifications submitted appropriately.

3.RNAC/MDS coordinators will be educated on accuracy of assessments.

4. 5 Random audits will be conducted weekly for 8 weeks by DON/designee to ensure MDS assessments ready for submission are accurate with Oxygen use, anticoagulant, and antiplatelet use. Trends will be reviewed in QAPI monthly for follow up and recommendations as needed.

483.25 REQUIREMENT Quality of Care:

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:
Based on clinical record review and staff interview, it was determined that the facility failed to implement physicians' orders for two of 31 sampled residents. (Residents 1 and 30)

Findings include:

Clinical record review revealed that Resident 1 had diagnoses that included hypertension (high blood pressure) and renal dialysis. A physician's order dated December 12, 2025, directed staff to administer a blood pressure medication (midodrine) three times a day on Tuesday, Thursday, Saturday, and Sunday and two times a day on Monday, Wednesday, and Friday. The physician ordered that staff were not to administer the medication if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its highest) was greater than 130 millimeters of mercury (mm/Hg). Review of Resident 1's Medication Administration Records (MARs) for December 2025 and January 2026, revealed that staff administered midodrine three times in December and four times in January when Resident 1's SBP was greater than 130mm/Hg.

Clinical record review revealed that Resident 30 had diagnoses that included hypotension (low blood pressure), chronic respiratory failure, and peripheral vascular disease. A physician's order dated May 15, 2025, directed staff to administer a blood pressure medication (midodrine) three times a day. The physician ordered that staff were not to administer the medication if the resident's SBP was greater than 120 mm/Hg. Review of Resident 30's MARs for October, November, and December 2025, and January 2026, revealed that staff administered midodrine 28 times in October, 39 times in November, 26 times in December, and two times in January when Resident 30's SBP was greater than 120mm/Hg.

In an interview on January 29, 2026, at 10:44 a.m., the Director of Nursing confirmed that the medications were administered outside of parameters ordered by the physicians for Residents 1 and 30.

CFR 483.25 Quality of Care

Previously cited 12/10/24

28 Pa. Code 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 02/27/2026

1. Resident 1 has received her midodrine medication according to physician orders. Resident 30 has received his midodrine medication according to physician orders.
2. Current Residents with BP parameters for midodrine use will be reviewed by DON/Designee and updated as needed and are receiving Midodrine according to physician ordered parameters.
3. Current Nurse Staff will be educated on following physician ordered parameters for administration of medications, documentation on EMAR or in progress notes when medication is held or administered according to physician ordered parameters.
4. Random weekly audits of 10 residents will be conducted by DON/designee regarding ordered parameters for BP/HR to ensure compliance with physician orders. Audits will continue for 6 weeks. Trends will be reviewed in QAPI monthly for follow up and recommendations as needed.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.71 and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Observations:
Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to follow policies and procedures to prevent the spread of infection for one of 31 sampled residents. (Resident 113)

Findings include:

Review of the facility policy entitled, "Enhanced Barrier Precautions," (EBP) last reviewed November 14, 2025, revealed that enhanced barrier precautions were to be used with any resident with an indwelling medical device when contact is expected. Precautions included the use of protective gowns during the high risk activities and staff were to be trained on what was considered high risk activity.

Clinical record review revealed that Resident 113 had diagnoses that included a stroke and dysphagia (difficulty in swallowing), and had a gastrostomy tube (a tube to deliver nutrition, fluids, or medication directly into the stomach) in place. Review of the Minimum Data Set assessment, dated November 3, 2025, revealed that the resident had significant cognitive impairment and had a feeding tube. Review of Resident 113's care plan revealed that the staff were to follow EBP when providing personal care and when handling the feeding tube. On January 27, 2026, at 10:30 a.m., a sign was observed on the wall outside Resident 113's room indicating that staff were to follow Enhanced Barrier Precautions when providing high contact direct-care, including providing hygiene and feeding tube device care. At that time, Licensed Practical Nurse 1 (LPN 1) was observed sitting on Resident 113's bed, not wearing a protective gown while providing care to the resident's feeding tube. On the same day from 10:31 a.m. to 10:41 a.m. LPN 1 and Nurse Aide 2 (NA 2) provided hygiene care to Resident 113 while not wearing gowns. In an interview on January 27, 2026, at 10:45 a.m., NA 2 confirmed that she and LPN 1 were providing hygiene care to Resident 113.

In an interview on January 29, 2026, at 11:03 a.m., the Director of Nursing stated that staff should have worn gowns when providing care to Resident 113.

28 Pa. Code 211.10(d) Resident care policies.

28 Pa. Code 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 02/27/2026

1. Resident 113 remains on Enhanced Barrier Precautions with appropriate PPE available to staff for use just outside of resident's room and appropriate signage on the wall for staff to read and follow. LPN1 & NA2 have been educated to follow the directions on the EBP signs for those residents.
2. Residents who meet the requirements for Enhanced Barrier Precautions have appropriate signage outside of their room and adequate available PPE.
3. Current staff are educated on following the Enhanced Barrier Protection signage outside of those residents' rooms affected, donning and doffing procedures, and appropriate disposal of used PPE.
4. Random audits of 10 residents requiring EBP will be conducted by the DON/IP/designee weekly x6 weeks to ensure compliance from staff with following the Enhanced Barrier Precautions requirements. Trends will be reviewed in QAPI monthly for follow up and recommendations as needed.

483.90(g)(1)(2) REQUIREMENT Resident Call System:

§483.90(g) Resident Call System
The facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from-

§483.90(g)(1) Each resident's bedside; and
§483.90(g)(2) Toilet and bathing facilities.

Observations:
Based on a review of facility policy, observation, and staff interview, it was determined that the facility failed to maintain a fully functioning resident call bell system for one of 31 sampled residents. (Resident 30)

Findings include:

Review of the facility policy "NSG Call Lights," dated November 15, 2025, revealed the statement, "Patients will have a call light or alternative communication device at each patient's bedside, toilet, and bathing room to allow patients to call for assistance when unattended."

Observation on January 27, 2026, at 11:27 a.m., revealed the call light failed to light and the signal failed to sound at the nurse's station when the button on the cord at Resident 30's bed was pressed. During an interview at 11:45 a.m., Nurse Aide 1 (NA 1) confirmed the cord was damaged and required replacement.
During an interview on January 28, 2026, at 1:30 p.m., the Administrator confirmed that the facility failed to maintain a fully functioning resident call bell system in one room.

28 PA Code 201.14(a) Responsibility of licensee.

28 Pa Code 205.28 (c)(1) Nurses' station.

Plan of Correction - To be completed: 02/27/2026

1. Resident 30 had his call bell replaced on 1/27/25.
2. A Comprehensive house audit of call bells is being completed to ensure residents have a fully functioning call bell system for their use.
3. Facility staff will be educated on the Nursing Call Light policy
4. Random audits of 5 rooms per week x6 weeks will be conducted by DON/NHA/designee to ensure call bells are fully functioning. Trends will be reviewed in QAPI monthly for follow up and recommendations as needed.

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:
Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum nurse aide (NA) to resident ratios for 14 of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from October 11 through 27, 2025, December 23 through 29, 2025, and January 22 through 28, 2026 revealed the following:

The facility failed to meet the minimum NA to resident ratio of one NA for ten residents on day shift (7:00 a.m. to 3:00 p.m.) on October 11, 12, 16, and 17, 2025, and December 28 and 29, 2025, and January 23, 24, 25, 26, and 27, 2026.

The facility failed to meet the minimum NA to resident ratio of one NA for 15 residents on night shift (11:00 p.m. to 7:00 a.m.) on October 11, 14, and 17, 2025, and December 25, 27, 28, and 29, 2025, and January 24, 25, 26, and 27, 2026.

During an interview on January 29, 2026, at 12:40 p.m., the Administrator confirmed that the facility did not meet the required NA to resident ratios on the days identified.

Plan of Correction - To be completed: 02/27/2026

1,2) Nurse aide staffing ratios will be reviewed for the last 7 days to evaluate if nurse aide ratios are met.
3) Nursing scheduler will be re-educated on staffing and PPD requirements.
4) Weekly audit of nurse aid ratios will be conducted for 60 days by NHA/designee to ensure nurse aid ratios are met. Tracking and trends to be submitted to the QAPI committee.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:
Based on a review of nursing time schedules and staff interview, it was determined that the facility failed to meet the minimum licensed practical nurse (LPN) to resident ratios for 20 of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from October 11 through 27, 2025, December 23 through 29, 2025, and January 22 through 28, 2026 revealed the following:

The facility failed to meet the minimum LPN to resident ratio of one LPN for 25 residents on day shift (7:00 a.m. to 3:00 p.m.) on January 24, 2026.

The facility failed to meet the minimum LPN to resident ratio of one LPN for 40 residents on night shift (11:00 p.m. to 7:00 a.m.) on October 11, 13, 14, 15, 16, and 17, 2025, and December 23, 24, 25, 26, 27, 28, and 29, 2025, and January 22, 23, 24, 25, 26, 27, and 28, 2026.

During an interview on January 29, 2026, at 12:40 p.m., the Administrator confirmed that the facility did not meet the required LPN to resident ratio on the days identified.

Plan of Correction - To be completed: 02/27/2026

1,2) LPN staffing ratios will be reviewed for the last 7 days to evaluate if LPN ratios are met.
3) Nursing scheduler will be re-educated on staffing and PPD requirements.
4) Weekly audit of LPN ratios will be conducted for 60 days by NHA/designee to ensure LPN ratios are met. Tracking and trends to be submitted to the QAPI committee.

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Plan of Correction - To be completed: 02/27/2026

1,2) HPPD will be reviewed for the last 7 days to evaluate if the state minimum PPD of 2 is met.
3) Nursing scheduler will be re-educated on staffing and PPD requirements.
4) Weekly audit of HPPD will be conducted for 60 days by NHA/designee to ensure minimal HPPD is met. Tracking and trends to be submitted to the QAPI committee.

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