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

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
PHOEBE BERKS HEALTH CARE CENTER, INC.
Inspection Results For:

There are  52 surveys for this facility. Please select a date to view the survey results.

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PHOEBE BERKS HEALTH CARE CENTER, INC. - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000


Based on an Emergency Preparedness Survey completed on May 13, 2025, at Phoebe Berks Health Care Center, Inc., it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.



 Plan of Correction:


Initial comments:Name: HEALTH CENTER - Component: 01 - Tag: 0000


Facility ID #167802
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 13, 2025, it was determined that Phoebe Berks Health Care Center, Inc. was not in compliance with the following requirements of the Life Safety Code for an existing nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a two-story, Type II (111), protected noncombustible structure, with a penthouse and basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Cooking Facilities: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.
Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2




Observations:
Name: HEALTH CENTER - Component: 01 - Tag: 0324

Based on observation and interview, it was determined the facility failed to maintain secondary use signage for K-type portable fire extinguishers used in kitchens, affecting one of nine smoke compartments within the component.

Findings include:

1. Observation on May 13, 2025, at 12:30 PM, revealed the K-type portable fire extinguisher, located within the ground floor Kitchen, lacked accompanying secondary use signage.

Interview with the Maintenance Director on May 13, 2025, at 12:30 PM, confirmed the lack of secondary use signage at the K-type portable fire extinguisher.



 Plan of Correction - To be completed: 05/20/2025

Signage has been added to the column(all 4 sides)above the type K extinguisher that reads(use Ansul system before using the fire extinguisher). Signs will be checked during monthly building rounds and reported back to the EVS director for the next 3 months. Results will be reported by the EVS Director/Designee to the QAA Committee x 3 months for review and further recommendations.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Name: HEALTH CENTER - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler protecting system in a continuously reliable operating condition, affecting one of nine smoke compartments within the component.

Findings include:

1. Observation on May 13, 2025, at 11:20 AM, revealed the sprinkler head protecting the 2nd floor Laundry Room lacked an escutcheon.

Interview with the Maintenance Director on May 13, 2025, at 11:20 AM, confirmed the sprinkler head lacked an escutcheon.



 Plan of Correction - To be completed: 07/01/2025

The sprinkler head escutcheon has been replaced. The laundry closet will be inspected monthly during building rounds for the next 3 months for missing escutcheons and replaced if needed. The laundry closet will be checked quarterly for the presence of sprinkler head escutcheon and reported back to the EVS director. Results will be reported by the EVS Director/Designee to the QAA Committee x 3 months for review and further recommendations.

NFPA 101 STANDARD Portable Fire Extinguishers: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.
Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10
Observations:
Name: HEALTH CENTER - Component: 01 - Tag: 0355

Based on document review and interview, it was determined the facility failed to provide documentation verifying portable fire extinguishers had been subjected to monthly inspections, within the previous twelve months, affecting one of nine smoke compartments within the component.

Findings include:

1. Review of documentation on May 13, 2025, at 12:40 PM, revealed the facility lacked documentation verifying the portable fire extinguisher, located within the ground floor I.T. Room, had been inspected since the annual inspection in September, 2024.

Interview with the Maintenance Director on May 13, 2025, at 12:40 PM, confirmed the lack of documentation verifying the portable fire extinguisher had been inspected on a monthly basis, since September 2024.



 Plan of Correction - To be completed: 07/01/2025

This fire extinguisher has been Inspected. This location has been updated on the fire extinguisher inventory list for monthly checks. Audits of the fire extinguisher owner's quick checks will be completed quarterly. Results will be reported by the EVS Director/Designee to the QAA Committee x 3 months for review and further recommendations.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.
Observations:
Name: HEALTH CENTER - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of smoke barrier walls, affecting two of nine smoke compartments within the component.

Findings include:

1. Observation on May 13, 2025, at 12:44 PM, revealed an unprotected penetration of the ground floor smoke barrier wall, above the double doors, around an orange flexible conduit.

Interview with the Director of Maintenance on May 13, 2025, at 12:44 PM, confirmed the unprotected smoke barrier wall penetration.



 Plan of Correction - To be completed: 07/01/2025

The unsealed penetration will be repaired using an approved through-penetration fire stop system. The facility will maintain the rating of smoke barrier walls and evaluate incorporating an above ceiling permit system. Random audits of all firewalls will be conducted and documented areas missing fire proofing will be reported to the EVS director and addressed promptly using the TPFS. These audits will be conducted quarterly. Results will be reported by the EVS Director/Designee to the QAA Committee for review and further recommendations.

NFPA 101 STANDARD Utilities - Gas and Electric: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.
Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2




Observations:
Name: HEALTH CENTER - Component: 01 - Tag: 0511

Based on observation and interview, it was determined the facility failed to maintain components of electrical wiring, affecting one of nine smoke compartments within the component.

Findings include:

1. Observation on May 13, 2025, at 10:49 AM, revealed exposed electrical wiring, located above the 2nd floor ceiling light, closest to the Service Elevator.

Interview with the Maintenance Director on May 13, 2025, at 10:49 AM, confirmed the exposed electrical wiring.



 Plan of Correction - To be completed: 05/16/2025

The ceiling light exposed wires have been placed in a UL listed junction box. Random audits of the ceiling lights in the hallways will be conducted monthly for the next 3 months for exposed wires and reported to the EVS director. Results will be reported by the EVS Director/Designee to the QAA Committee x 3 months for review and further recommendations.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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.
Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5
Observations:
Name: HEALTH CENTER - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to monitor the use of surge suppressors and receptacle multipliers, affecting three of nine smoke compartments within the component.

Findings include:

1. Observation on May 13, 2025, at 11:30 AM, revealed a surge suppressor, suspended by its electrical cable, in use, within the 2nd floor East Serving Kitchen.

Interview with the Maintenance Director on May 13, 2025, at 11:30 AM, confirmed the surge suppressor was suspended from electrical wiring.

2. Observation on May 13, 2025, at 11:39 AM, revealed a receptacle multiplier, in use, in the 1st floor Bistro Kitchen.

Interview with the Maintenance Director on May 13, 2025, at 11:39 AM, confirmed the use of a receptacle multiplier.

3. Observation on May 13, 2025, at 12:06 PM, revealed a surge suppressor, supplying electrical power to a coffee machine, within the 1st floor Community Life Room.

Interview with the Maintenance Director on May 13, 2025, at 12:06 PM, confirmed the high draw appliance was plugged into a surge suppressor.




 Plan of Correction - To be completed: 05/15/2025

The power strip was removed and an outlet was installed to plug directly into an outlet. A review was completed of other kitchens to ensure any refrigerators/freezers are plugged directly into a wall outlet. All kitchens will be checked monthly for the next 3 months by EVS Director / Designee to ensure any refrigerators are plugged directly into a wall outlet and not in a power strip/extension cord. Results will be reported by the EVS Director/Designee to the QAA Committee x 3 months for review and further recommendations.




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