Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wyomissing Health And Rehabilitation Center during CMS and state inspections, most recent first.
Two residents did not receive care according to physician orders and documented plans. One resident with Parkinson’s disease, aphasia, prior CVA, and a feeding tube had missing MAR documentation for multiple scheduled medications and no TAR evidence of ordered tube feeding or required water flushes during a day shift. Another resident with dementia and depression had no TAR documentation of ordered daily wound care to two fingers, and observations showed the fingers covered with band aids instead of the prescribed saline cleansing, oil emulsion gauze, and gauze dressing; the DON confirmed the orders were not implemented as written.
Surveyors found that the facility failed to follow physician-ordered pressure ulcer treatments and wound care protocols for two residents with significant skin breakdown. One resident with multiple pressure sores and deep tissue injuries had detailed orders for cleansing, packing, and dressing multiple wound sites each evening, but the TAR showed no evidence these treatments were completed on several dates. Another resident with multiple sclerosis and a sacral ulcer had orders for continuous negative pressure wound therapy at 125 mmHg with dressing changes and shift checks, as well as repositioning in bed, yet documentation did not show the therapy was functioning on multiple shifts. Observations confirmed the NPWT pump was turned off and disconnected while the resident lay flat in bed without repositioning, and the DON acknowledged the lack of documentation that ordered treatments and repositioning had been provided.
Surveyors found that the facility did not ensure ordered medications were available and administered for two residents. One resident with cancer-related pain had an order for PRN oxycodone, but when the resident complained of pain, the nurse documented that the oxycodone was unavailable and could not be given. Another resident with diabetes and polyneuropathy had new orders for insulin glargine, metoprolol, metformin, and gabapentin, but nursing notes indicated these medications were not available from the pharmacy and were not administered. The DON confirmed that the medications were not given because they were unavailable and that staff should have used the emergency supply.
The facility failed to follow its abuse reporting policy and state requirements by not timely reporting two separate resident-to-resident altercations involving physical aggression and injury. In one case, a resident with multiple medical conditions and no memory impairment was heard yelling that another resident had struck him and was seen being shoved onto his bed, but the allegation was not reported to authorities within the required timeframe. In another case, a resident with dementia and agitation was shoved onto his bed by his roommate, sustaining lip and eye injuries, and this allegation also was not reported within the required reporting window. The Administrator confirmed that these incidents of alleged abuse were not reported to state and local agencies as required.
Two residents with complex medical conditions were admitted or readmitted, and their initial assessments, including skin assessments, were completed solely by an LPN without RN review or co-signature. The DON confirmed that these assessments lacked RN oversight, which does not meet professional standards of quality.
Two newly hired nurse aides began working before their state registry status was verified, contrary to facility policy requiring pre-employment screening. The DON confirmed that documentation of registry verification was not completed prior to their start dates.
Physician orders for a blood test and daily weights were not carried out for three residents with serious medical conditions. The DON confirmed that a blood test was not performed as ordered for a resident with vascular disease, and daily weights were not documented for two residents with chronic illnesses, indicating a failure to follow medical orders.
A resident was admitted without a documented inventory of personal belongings, as required by facility policy. Review of the clinical record and confirmation from the DON showed that the inventory was not completed or maintained in the record.
The facility did not provide written transfer notifications or Ombudsman information to residents and their representatives when several residents were transferred to the hospital after a change in condition. The DON confirmed that neither the residents, their responsible parties, nor the Ombudsman received the required written notices.
Surveyors found that the nurse staffing information posted in the lobby was outdated, displaying data from the previous day. The DON confirmed that the posted information was not accurate or current.
A facility failed to follow physician's orders for a resident with hypertension, heart disease, and dementia. Staff did not check the resident's blood pressure before administering amlodipine 13 times and did not check blood pressure or heart rate before administering metoprolol 12 times over two months. The DON confirmed the lack of documentation for these vital signs prior to medication administration.
A resident with cognitive impairment and malnutrition was not provided with necessary foot care, despite a physician's order for podiatry consultation. The resident was observed with long and jagged toenails, and the facility's records indicated a need for podiatry services since July, yet no evidence of care was found. The DON confirmed the oversight.
Failure to Follow Physician Orders for Medications, Tube Feeding, and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement physician orders for two residents. For one resident with Parkinson’s disease, aphasia, a history of stroke, and an abdominal feeding tube for nutrition and medications, clinical record review showed multiple ordered medications were not documented as given on a specific date. The MAR for that date lacked documentation of administration of amlodipine besylate ordered daily for hypertension at 2:00 p.m., carbidopa-levodopa ordered three times daily for Parkinson’s disease at 12:00 p.m., and baclofen ordered three times daily for muscle spasms at 12:00 p.m. In addition, physician orders directing continuous tube feeding with Jevity 1.5 at 65 mL/hr from 1:00 p.m. to 7:00 a.m., and specific water flushes (60 mL before and after each medication and feeding, 5 mL between medications, and every shift) were not documented as completed on the day shift for that date. The TAR showed no evidence that the tube feeding formula was administered as ordered or that the required tube flushes were performed on that shift. For another resident with dementia and depression, a physician’s order directed daily day-shift wound care to the right hand’s second and third fingers, including cleansing with saline, application of oil emulsion gauze, and wrapping with a gauze dressing. Review of the TAR for a specific date showed no documented evidence that this wound treatment was provided. Observations on a later date revealed that the resident’s affected fingers were covered with band aids instead of the ordered gauze dressing. In an interview, the DON confirmed there was no evidence that staff implemented the physician’s orders as written and that the resident’s hand wounds were covered with band aids rather than the prescribed gauze dressing.
Failure to Provide Ordered Pressure Ulcer Treatments and Maintain Negative Pressure Wound Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide physician-ordered pressure ulcer treatments and services to promote healing and prevent new pressure sores for two residents with significant skin breakdown. For one resident with a seizure disorder and metabolic encephalopathy, admission assessments and an MDS indicated a sacral pressure sore and multiple deep tissue injuries present on admission. The care plan identified actual skin breakdown with an intervention for staff to provide treatments as ordered. Physician orders directed specific wound care to multiple sites (sacrum, right and left hips, left and right lower back, lower spine, and right plantar foot), including cleansing with normal saline, application of Santyl, Medihoney, skin prep, betadine-moistened gauze, packing with saline-moistened gauze, and covering with bordered foam or gauze dressings on the evening shift. Review of the Treatment Administration Records for this resident showed no evidence that any of the ordered wound treatments were completed on multiple specific dates in December, January, and March. These missed treatments involved all ordered wound sites, indicating that the facility did not follow the physician’s wound care regimen as required by its own wound management policy, which states that the physician or wound consultant determines appropriate treatment and staff are to follow the physician’s orders and product instructions. There was no documentation to show that the ordered cleansing, packing, and dressing applications were carried out on the identified dates. For another resident with multiple sclerosis and a sacral pressure ulcer, a wound care note and MDS documented a sacral pressure sore, cognitive intactness, and total dependence on staff for care. The care plan included interventions for staff to provide treatments as ordered and to reposition the resident in bed. Physician orders required application of black foam and a negative pressure wound therapy (NPWT) dressing connected to a vacuum pump set at 125 mmHg continuously, with dressing changes three times weekly and checks of placement and function every shift. The TAR contained no documented evidence that the NPWT treatment was functioning during several shifts. Observations showed the resident lying flat on her back with the bed flat, the wound pump turned off and disconnected, and the resident reporting that the pump had not worked since the previous afternoon and that staff did not reposition her. Further observation confirmed she remained flat in bed without repositioning, and the DON acknowledged there was no documentation that the treatments for one resident or repositioning and NPWT for the other had been completed as ordered.
Failure to Obtain and Administer Ordered Medications From Pharmacy
Penalty
Summary
Surveyors identified that the facility failed to ensure physician-ordered medications were available and administered as prescribed for two residents. One resident was admitted with neoplasm-related pain and pancreatic cancer and had a care plan intervention for staff to administer medications as ordered. On February 7, 2026, a physician ordered oxycodone every three hours as needed for severe pain. On February 9, 2026, nursing documentation showed the resident complained of pain, but the nurse was unable to administer the ordered oxycodone because it was not available. Another resident was admitted with diagnoses including polyneuropathy and diabetes. On February 5, 2026, a physician ordered insulin glargine at bedtime, metoprolol tartrate twice daily, metformin twice daily, and gabapentin twice daily. Nursing documentation on that same date indicated these medications were unavailable from the pharmacy and therefore were not administered. In an interview, the DON confirmed that the medications for both residents had not been administered as ordered because they were not available from the pharmacy and acknowledged that staff should have utilized the emergency supply.
Failure to Timely Report Allegations of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to timely report allegations of abuse to the required state and local agencies for two residents. Facility policy titled "Abuse Policy - Prevention and Management," last reviewed in August 2025, required that incidents, investigations, and the facility's response to suspected abuse or neglect be reported immediately upon receiving information, and that incidents without serious bodily injury be reported no later than 24 hours after identifying a suspicion of abuse. For one resident with diagnoses including intellectual disability, liver transplant failure, heart failure, and type II diabetes, and with no memory impairment per the MDS, facility documentation showed that on December 29, 2025, the resident was heard yelling that another resident had struck him and was observed being shoved onto his bed before the residents were separated. There was no evidence that this alleged abuse was reported to the required state and local agencies until January 19, 2026, which was 21 days after the incident. For another resident with diagnoses including dementia with agitation and type II diabetes, and significant memory impairment per the MDS, facility documentation dated January 14, 2026, showed that the resident was involved in an altercation in which his roommate shoved him onto his bed, resulting in injuries to his lip and eye. There was no evidence that this alleged abuse incident was reported to the required state and local agencies until January 19, 2026, five days after the incident. In an interview on January 19, 2026, the Administrator confirmed that the facility did not report these incidents of alleged abuse to the required state and local agencies in a timely manner, contrary to facility policy and state regulatory requirements.
Failure to Ensure RN Oversight in Admission Assessments
Penalty
Summary
The facility failed to ensure that nursing services met professional standards of quality by not having a Registered Nurse (RN) conduct or review admission and readmission assessments for two residents. According to Pennsylvania Code Title 49, RNs are responsible for assessing, planning, implementing, and evaluating nursing care, while Licensed Practical Nurses (LPNs) may participate in these activities using focused assessments. In both cases, the initial admission/readmission assessments, including initial skin assessments, were completed solely by an LPN without evidence of RN oversight or co-signature. Resident 1 was readmitted with multiple diagnoses, including diabetes mellitus, chronic obstructive pulmonary disease, generalized anxiety disorder, suicidal ideation, and a history of venous thrombosis and embolism. Resident 2 was admitted with diagnoses such as cirrhosis of the liver, hepatic encephalopathy, acute posthemorrhagic anemia, acute respiratory failure with hypoxia, and acute kidney failure. The Director of Nursing confirmed that the assessments for both residents were conducted by an LPN without RN involvement, which does not meet the required professional standards.
Failure to Verify Nurse Aide Registry Status Prior to Employment
Penalty
Summary
The facility failed to verify the professional license or registration status of two newly hired nurse aides prior to the start of their employment, as required by its own Abuse Policy-Prevention and Management. According to the policy, screening for all potential hires must include an inquiry to the state nurse aide registry, with results recorded before employment begins. However, documentation showed that both employees began working as nurse aides before the registry inquiries were completed, with verification for both occurring several months after their start dates. The Director of Nursing confirmed that there was no documented evidence of registry verification prior to employment for these individuals, which was not in accordance with facility policy.
Failure to Implement Physician Orders for Lab Work and Daily Weights
Penalty
Summary
The facility failed to implement physician's orders for three residents, as evidenced by clinical record reviews and staff interviews. For one resident with peripheral vascular disease, a physician ordered a Complete Blood Count to be obtained on a specific date, but there was no documented evidence that the blood test was performed. The Director of Nursing confirmed that the blood work was not completed and that nursing staff did not communicate the order to the laboratory. Additionally, two other residents with chronic conditions, including chronic kidney disease, failure to thrive, congestive heart failure, liver cell cancer, and edema, had physician orders to be weighed daily. Review of their records showed multiple dates where there was no documentation that daily weights were obtained as ordered. The Director of Nursing confirmed the lack of documentation for these daily weights, indicating that the physician's orders were not followed for these residents.
Failure to Document Inventory of Personal Belongings on Admission
Penalty
Summary
The facility failed to document an inventory of personal belongings upon admission for one of the 19 sampled residents. According to the facility's policy, the nursing department is required to complete and maintain a documented inventory of all residents' personal belongings in the clinical record at the time of admission. Review of the clinical record for the identified resident showed no evidence that such an inventory was completed or included. This was confirmed by the Director of Nursing during an interview, who acknowledged the absence of the required documentation in the resident's clinical record.
Failure to Provide Required Written Transfer Notifications and Ombudsman Information
Penalty
Summary
The facility failed to provide written notification to residents and their representatives regarding transfers to the hospital, including the reasons for the transfers and information about the Ombudsman, as required. Clinical record reviews for five residents who were transferred to the hospital after a change in condition revealed no documented evidence that written transfer notices were given to the residents or their responsible parties. Additionally, there was no documentation that copies of these notices were sent to a representative of the Office of the State Long-Term Care Ombudsman. During an interview, the Director of Nursing confirmed that the required notifications and written copies of transfer notices were not sent to the residents, their representatives, or the Ombudsman for these transfers. The deficiency was identified for all five residents reviewed who experienced a transfer out of the facility due to a change in condition.
Failure to Post Current Nurse Staffing Information
Penalty
Summary
During a facility tour, surveyors observed that the nurse staffing information posted in the lobby was not current, as it displayed data from the previous day. This observation was confirmed in an interview with the Director of Nursing, who acknowledged that the posted staffing data was incorrect and not up to date. No information about specific residents or their medical conditions was included in the report.
Failure to Implement Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to implement physician's orders for a resident diagnosed with hypertension, heart disease, and dementia. The orders required staff to administer amlodipine and metoprolol daily, with specific instructions to hold the medications if the resident's systolic blood pressure was below 100 mmHg or if the heart rate was below 60 beats per minute for metoprolol. A review of the medication administration records for August and September 2024 showed that staff did not obtain the resident's blood pressure before administering amlodipine 12 times in August and once in September. Additionally, there was no evidence that staff checked the resident's blood pressure or heart rate before administering metoprolol 11 times in August and once in September. The Director of Nursing confirmed the lack of documentation for these vital signs prior to medication administration, as required by the physician's order.
Failure to Provide Necessary Foot Care
Penalty
Summary
The facility failed to provide necessary nail care to promote foot health for a resident, identified as Resident 12, who was part of a sample of 20 residents. The clinical record review showed that Resident 12 had diagnoses including protein calorie malnutrition and cognitive communication deficit, with cognitive impairment noted in a Minimum Data Set assessment. A physician's order from September 13, 2024, instructed staff to consult podiatry services as needed. However, on October 23, 2024, the resident was observed with long and jagged toenails, indicating a lack of foot care. A facility resident list from July 15, 2024, had already identified the resident as needing podiatry services, yet there was no evidence of the resident being seen by a podiatrist or receiving foot care. The Director of Nursing confirmed in an interview that the resident had not been seen by a podiatrist despite being identified as needing such services since July 2024.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Reading
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Spruce Manor Nursing & Rehabilitation Center | 0.7 mi | ★★★★★ | 5 | 0 |
| West Reading Skilled Nursing And Rehabilitation Ce | 1 mi | ★★★★★ | 6 | 0 |
| Highlands At Wyomissing | 1.5 mi | ★★★★★ | 0 | 0 |
| Mifflin Center | 1.8 mi | ★★★★★ | 7 | 0 |
| Transitional Sub-acute Unit | 3.1 mi | ★★★★★ | 1 | 0 |
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