Cycle 1
Health 2025-05-21 · Fire 2025-05-21
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Wyomissing, PA
Highlands At Wyomissing
5-star overall rating with 5-star inspections with 3 recent health deficiencies
2000 Cambridge Avenue, Wyomissing, PA
(610) 775-2300
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
80
Certified beds
Average residents
32
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1989-07-11
CMS approved date
Coverage
Medicare
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.02
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
1.76
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
4.31
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
7.10
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
2.79
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
6.61
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.74
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.18
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.03
CMS adjusted RN staffing hours
Adjusted total hours
7.17
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
53%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,637
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.67
Composite VBP score used to determine payment impact.
Payment multiplier
0.9822
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.66% · Performance 21.98% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.24
Baseline 4.07% · Performance 6.57% · Measure score 4.24 · Achievement 4.24 · Improvement 0
Total nurse turnover
0
Baseline 64.08% · Performance 84.52% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
3.63
Baseline 3.77 hours · Performance 4.11 hours · Measure score 3.63 · Achievement 3.63 · Improvement 1.18
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.69% |
10.72%
3 pts worse
|
Worse than the National Rate · Eligible stays 393 · Observed rate 13.74% · Lower 95% interval 11.12% |
| Discharge to community | 66% |
50.57%
15.4 pts better
|
Better than the National Rate · Eligible stays 377 · Observed rate 61.01% · Lower 95% interval 60.27% |
| Medicare spending per beneficiary | 0.63 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 97.5% |
95.27%
2.2 pts better
|
Numerator 195 · Denominator 200 |
| Falls with major injury | 1% |
0.77%
0.2 pts worse
|
Numerator 2 · Denominator 200 |
| Discharge self-care score | 36.77% |
53.69%
16.9 pts worse
|
Numerator 57 · Denominator 155 |
| Discharge mobility score | 23.23% |
50.94%
27.7 pts worse
|
Numerator 36 · Denominator 155 |
| Pressure ulcers or injuries, new or worsened | 0.5% |
2.29%
1.8 pts better
|
Numerator 1 · Denominator 200 · Adjusted rate 0.62% |
| Healthcare-associated infections requiring hospitalization | 6.57% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 227 · Observed rate 5.29% · Lower 95% interval 4.75% |
| Staff COVID-19 vaccination coverage | 98.78% |
8.2%
90.6 pts better
|
Numerator 162 · Denominator 164 |
| Staff flu vaccination coverage | 100% |
42%
58 pts better
|
Numerator 408 · Denominator 408 |
| Discharge function score | 41.29% |
56.45%
15.2 pts worse
|
Numerator 64 · Denominator 155 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 35 · Denominator 35 |
| Transfer of health information to patient | 98.61% |
96.28%
2.3 pts better
|
Numerator 142 · Denominator 144 |
| Resident COVID-19 vaccinations up to date | 5.68% |
25.2%
19.5 pts worse
|
Numerator 5 · Denominator 88 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.7
0.3 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.4 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.2 |
1.2
1 pts better
|
1.8
1.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.2 · Observed 0.2 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.9% |
86.9%
10 pts better
|
93.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 100.0% · Q3 93.9% · Q4 96.3% · 4Q avg 96.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.9% |
93.5%
1.6 pts worse
|
95.5%
3.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 10.9% |
3.2%
7.7 pts worse
|
3.3%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 12.1% · Q3 12.1% · Q4 7.4% · 4Q avg 10.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.5%
6.5 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 5.9% |
6.5%
0.6 pts better
|
5.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 11.1% · Q3 8.0% · Q4 4.5% · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.2% |
19.9%
0.3 pts worse
|
19.6%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 22.2% · Q3 20.0% · Q4 22.7% · 4Q avg 20.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.9% |
18.7%
8.8 pts better
|
16.7%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 10.0% · Q3 10.0% · 4Q avg 9.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.3% |
18.3%
9 pts worse
|
14.9%
12.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · 4Q avg 27.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.1% |
0.9%
3.2 pts worse
|
1.0%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 6.2% · Q3 2.3% · Q4 2.5% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 37.9% |
26.4%
11.5 pts worse
|
19.8%
18.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 53.3% · Q2 41.1% · Q3 32.4% · Q4 22.5% · 4Q avg 37.9% |
| Percentage of long-stay residents with pressure ulcers | 2.1% |
5.3%
3.2 pts better
|
5.1%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.7% · Q3 0.0% · Q4 3.3% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 81.5% |
68.9%
12.6 pts better
|
81.7%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 77.1% · Q2 79.5% · Q3 81.8% · Q4 88.3% · 4Q avg 81.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.7% |
9.8%
3.1 pts better
|
12.0%
5.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.7% · Observed 5.7% · Expected 9.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.5%
0.1 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 1.8% · Q3 2.0% · Q4 1.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 71.8% |
68.7%
3.1 pts better
|
79.7%
7.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 71.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.3% |
23.1%
9.2 pts worse
|
23.9%
8.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.3% · Observed 25.1% · Expected 18.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-18 · Fire 2024-07-18
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-06-29 · Fire 2023-06-29
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
8 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-07-18
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-07-31
E · Potential for more than minimal harm
2024-07-18
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-07-31
E · Potential for more than minimal harm
2024-07-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-07-31
E · Potential for more than minimal harm
2024-07-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-07-31
E · Potential for more than minimal harm
2024-07-18
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2024-07-31
F · Potential for more than minimal harm
2023-06-29
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-07-31
F · Potential for more than minimal harm
2023-06-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-31
F · Potential for more than minimal harm
2023-06-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-31
C · Minimal harm
2023-06-29
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-07-31
C · Minimal harm
2023-06-29
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-07-31
C · Minimal harm
2023-06-29
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-07-31
C · Minimal harm
2023-06-29
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-07-31
C · Minimal harm
2023-06-29
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-07-31
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-21
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-21
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-06-04
B · Minimal harm
2025-05-21
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-05-21
D · Potential for more than minimal harm
2024-07-18
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-09-16
D · Potential for more than minimal harm
2024-07-18
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-09-16
D · Potential for more than minimal harm
2023-06-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-07-14
Penalties and ownership
What sits behind the stars
Ownership
Deacosta, Kevin
Corporate Officer · Individual
Deacosta, Kevin
W-2 Managing Employee · Individual
Pessognelli, Marianne
Corporate Officer · Individual
Pessognelli, Marianne
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Wyomissing Health And Rehabilitation Center
Reading, PA
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Mifflin Center
Shillington, PA
4-star overall rating with 4-star inspections with 6 recent health deficiencies
#3
Spruce Manor Nursing & Rehabilitation Center
West Reading, PA
5-star overall rating with 5-star inspections with 1 recent health deficiencies
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