Wyomissing Health and Rehab: RN Assessment Failures - PA
State inspectors documented the lapse during a January 2, 2026, complaint inspection. The Director of Nursing confirmed it herself that afternoon.
The first resident had been readmitted to the facility with a list of diagnoses that demanded close clinical attention: diabetes, chronic obstructive pulmonary disease, a history of venous thrombosis and embolism, generalized anxiety disorder, and suicidal ideation. On December 5, 2025, a single LPN, identified in inspection records as Employee E1, completed the admission and readmission assessment, which included an initial skin assessment. No registered nurse reviewed it. No registered nurse co-signed it. There was no evidence in the clinical record that a registered nurse had been involved at all.
The second resident was admitted the same day, December 5, 2025, by the same LPN. That resident's diagnoses included unspecified cirrhosis of the liver, hepatic encephalopathy, acute posthemorrhagic anemia, acute respiratory failure with hypoxia, and acute kidney failure. The same gap existed in the record: Employee E1 completed the assessment alone, and no RN reviewed or co-signed it.
Hepatic encephalopathy is a condition in which a failing liver allows toxins to accumulate in the bloodstream and reach the brain, causing confusion, disorientation, and in severe cases, coma. A resident arriving with that diagnosis alongside acute kidney failure and acute respiratory failure is, by any clinical measure, unstable. The same is true of a resident carrying a documented history of suicidal ideation. These are not routine admissions.
Pennsylvania's nursing practice standards draw a clear line between what a registered nurse does and what a licensed practical nurse does. Under Title 49 of the state's Professional and Vocational Standards, an RN is responsible for assessing human responses and planning, implementing, and evaluating nursing care. An LPN participates in that process using focused assessments, but the full assessment responsibility belongs to the registered nurse. The distinction is not administrative. It reflects the difference in training, licensure, and legal accountability.
When inspectors interviewed the Director of Nursing on January 2 at 3:54 p.m., she did not dispute the finding. She confirmed that the initial admission and readmission assessments for both residents had been conducted by an LPN without RN oversight or assistance.
The inspection was triggered by a complaint, not a routine survey cycle. Inspectors pulled five resident records and found the problem in two of them, both tied to the same employee, both on the same date.
What the records do not show is whether anyone flagged the gap before inspectors arrived. The clinical records contained no evidence of a corrective note, an addendum, or a late co-signature from an RN. The assessments stood as completed, by an LPN, without review.
The facility is cited under two Pennsylvania codes: one governing management and one governing nursing services. The harm level was classified as minimal harm or potential for actual harm, the lower end of the federal deficiency scale. That classification reflects what inspectors could document, not necessarily what the residents experienced during the days between their admission assessments and the January inspection.
Both residents came through the door with conditions that can deteriorate quickly and without obvious warning. One had a brain affected by liver failure. The other had told someone, at some point, that she wanted to die. The nurse who assessed them worked alone, without the oversight the state requires, and the people responsible for ensuring that oversight didn't catch it, or didn't correct it, until a complaint brought inspectors through the door four weeks later.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Wyomissing Health and Rehabilitation Center from 2026-01-02 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 3, 2026 · Our methodology
WYOMISSING HEALTH AND REHABILITATION CENTER in READING, PA was cited for violations during a health inspection on January 2, 2026.
State inspectors documented the lapse during a January 2, 2026, complaint inspection.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.