Pennsylvania Department of Health
PHOEBE BERKS HEALTH CARE CENTER, INC.
Patient Care Inspection Results

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PHOEBE BERKS HEALTH CARE CENTER, INC.
Inspection Results For:

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PHOEBE BERKS HEALTH CARE CENTER, INC. - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and a Civil Rights Compliance survey, and an Abbreviated survey in response to a complaint, completed on May 1, 2025, it was determined that Phoebe Berks Health Care 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.



 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 affects more than a limited 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. This deficiency was not found to be throughout this facility.
§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, group interview, staff interview, and review of electronic call bell logs, it was determined that the facility failed to answer call bells in a timely manner to provide care and services respectful of each resident's dignity and preferences to promote the quality of life for seven of 18 sampled residents. (Residents 42, 45, 54, 56, 73, 77, 82)

Findings include:

Clinical record review revealed that Resident 45 had diagnoses that included radiculopathy (compressed nerve in the spine that cause pain), muscle weakness, and difficulty walking. The Minimum Data Set (MDS) assessment dated March 6, 2025, indicated that the resident was able to communicate his needs to staff and required assistance from staff for activities of daily living such as toileting and dressing.

Clinical record review revealed that Resident 54 had diagnoses that included congestive heart failure, diabetes, muscle weakness, and late onset Alzheimer's disease. The MDS assessment dated March 27, 2025, indicated that the resident was able to communicate her needs to staff and required extensive assistance from staff for transfers and activities of daily living such as toileting and dressing.

Clinical record review revealed that Resident 56 had diagnoses that included post polio syndrome (condition that causes gradual muscle weakness) and difficulty walking. The MDS assessment dated February 2, 2025, indicated that the resident was able to communicate her needs to staff and required assistance from staff for transfers and activities of daily living such as toileting, dressing, and personal hygiene.

Clinical record review revealed that Resident 73 had diagnoses that included Parkinson's disease and neuromuscular dysfunction of bladder (urinary bladder problems due to a disease). The MDS assessment dated February 7, 2025, indicated that the resident was able to communicate her needs to staff and required extensive assistance from staff for transfers and activities of daily living such as toileting.

During a group interview on April 30, 2025, at 10:00 a.m., Residents 45, 54, 56, and 73 reported that it took long periods of time (30 minutes or more) for staff to answer their call bells and get assistance.

Clinical record review revealed that Resident 42 had diagnoses that included congestive heart failure, muscle weakness, and difficulty walking. The MDS assessment dated February 1, 2025, indicated that the resident was able to communicate his needs to staff and required assistance from staff for transfers and activities of daily living such as toileting. In an interview on April 30, 2025, at 10:38 a.m., Resident 42 stated that staff took a long time to answer call bells which has affected his ability to receive care and services in a timely manner.

Clinical record review revealed that Resident 77 had diagnoses that included a history of traumatic injuries, peripheral vascular disease, muscle weakness, and difficulty walking. The MDS assessment dated March 6, 2025, indicated that the resident was able to communicate her needs to staff and required extensive assistance from staff for transfers and activities of daily living such as toileting. In an interview on April 30, 2025, at 11:00 a.m., Resident 77 stated that staff took a long time to answer call bells which has affected her ability to receive care and services in a timely manner.

Clinical record review revealed that Resident 82 had diagnoses that included partial paralysis to the right side following a stroke, chronic kidney disease, muscle weakness, and difficulty walking. The MDS assessment dated April 5, 2025, indicated that the resident was able to communicate her needs to staff and required extensive assistance from staff for transfers and activities of daily living such as toileting. In an interview on April 30, 2025, at 11:55 a.m., Resident 82 stated that staff took a long time to answer call bells which has affected her ability to receive care and services in a timely manner.

In an interview on April 30, 2025, at 1:00 p.m., the Administrator revealed that staff were expected to respond to a call light within 15 minutes or less.

Review of the facility form entitled, "Device Activity Report," for Residents 42, 45, 54, 56, 73, 77, and 82, revealed that from April 1 through April 30, 2025, there were 158 occurrences when the call bell response time exceeded 15 minutes which included: April 2, 2025, at 7:39 p.m., Resident 42 waited 68 minutes; April 7, 2025, at 12:37 a.m., Resident 45 waited 58 minutes; April 9, 2025, at 7:36 a.m., Resident 54 waited 91 minutes; April 20, 2025, at 8:16 a.m., Resident 56 waited 20 minutes; April 22, 2025, at 3:46 a.m., Resident 73 waited 65 minutes; April 14, 2025, at 1:53 a.m., Resident 77 waited 168 minutes; and April 9, 2025, at 8:02 a.m., Resident 82 waited 41 minutes.

During an interview on May 1, 2025, at 10:45 a.m., the Administrator confirmed the aforementioned residents waited more than the expected response time of 15 minutes.

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





 Plan of Correction - To be completed: 06/30/2025

1. The facility maintenance department will conduct a review of 100% of all assigned call bell pagers in the center to ensure all are programmed and fully operational by 5/31/2025.
2. The Director of Nursing/designee will educate all healthcare center staff on the pager protocol and call bell policy by 6/15/2025.
3. The nursing supervisor/designee will conduct random audits of pagers to ensure all assigned staff have operational pagers and that they are in use. The frequency of audits will be conducted at 3 per shift for four weeks, then 2 per shift for 4 weeks, and 10 per week for 1 month. The results of the audit will be reviewed by the Nursing Home Administrator with the QAPI committee for further recommendation or action.
4. Call bell response times will be audited. Audits of random call bells will be conducted at 3 per shift for four weeks, then 2 per shift for 4 weeks, and 10 per week for 1 month. The results of the audit will be reviewed by the Nursing Home Administrator with the QAPI committee for further recommendation or action.
5. Call bell audits will be reviewed by visiting Administrator/designee with resident council for three months and the residents' feedback will be reviewed by the NHA/designee with the QAPI committee for further recommendation or action.

483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan: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.
§483.21 Comprehensive Person-Centered Care Planning
§483.21(a) Baseline Care Plans
§483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

§483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

§483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.
Observations:

Based on clinical record review, policy review, and staff interview, it was determined that the facility failed to ensure that the baseline care plan summary was provided to the resident or representative for two of 18 sampled residents.
(Residents 17, 64)

Findings include:

Review of the facility policy entitled, "Baseline Care Plan," dated January 20, 2025, revealed that a baseline plan of care was to be developed within 48 hours of admission. The baseline care plan was to include healthcare information necessary to properly care for a resident and must include initial goals based on admission orders, physician orders, dietary orders, therapy orders, social services, and pre-admission screening resident review, if applicable. The baseline care plan will include trauma-informed care goals and interventions under the psychosocial well-being care plan if identified immediately upon admission, and the resident and/or representative were to be provided a written summary of the baseline care plan.

Clinical record review revealed that Resident 17 was admitted to the facility on April 10, 2025. The baseline care plan was developed on April 10, 2025. There was a lack of evidence to support that the facility provided the resident and/or representative with a summary of the baseline care plan that included all the required components.

Clinical record review revealed that Resident 64 was admitted to the facility on January 22, 2025. The baseline care plan was developed on January 22, 2025. There was a lack of evidence to support that the facility provided the resident and/or representative with a summary of the baseline care plan that included all the required components.

During an interview on April 30, 2025, at 2:30 p.m., the Administrator confirmed that there was no evidence the baseline care plan summary was provided to the residents and/or their representatives.

28 Pa. Code 201.18 (b)(1) Management.









 Plan of Correction - To be completed: 06/30/2025

1. A comprehensive care plan review was completed with resident/responsible party 64 on 5/14/25.
2. Social Services will conduct a care plan review in a manner that can be fully understood with resident 17 by 5/31/2025
3. The Director of Nursing/designee will educate all licensed nurses by 6/15/2025 on the requirement for all residents/responsible parties to receive a summary of their baseline care plan.
4. The Director of Nursing/designee will conduct an audit of 100% of residents admitted for 4 weeks, then 50% of residents for four weeks, and 25% of residents for 4 weeks to ensure they or their responsible parties have received a summary of their baseline care plan. The results of the audit will be reviewed by Director of Nursing/designee with the QAPI committee for further recommendation or action.

§ 211.12(f.1)(3) LICENSURE Nursing services. :State only Deficiency.
(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 8 of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from April 9 through 29, 2025, 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 April 10, 15 and 20, 2025.

The facility failed to meet the minimum NA to resident ratio of one NA for 11 residents on evening shift (3:00 p.m. to 11:00 p.m.) on April 11 and 23, 2025.

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 April 10, 13, 20, 22 and 29, 2025.



 Plan of Correction - To be completed: 06/30/2025

1. The daily nursing facility schedule will be reviewed by the Administrator and/or Director of Nursing to ensure that required staffing ratios are scheduled and met.
2. The scheduler and nursing supervisors will be educated by 5/31/25 on the nurse/aide ratios as of 7/1/2024.
3. An audit of schedules/timecards- All 3 shifts, 2 days a week for 2 months will be conducted. Results of the audit will be reported by the NHA/DON to the QAPI committee for review and further recommendation.


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