Berks County Home- Berks Heim
Inspection history, citations, penalties and survey trends for this long-term care facility in Leesport, Pennsylvania.
- Location
- 1011 Berks Road, Leesport, Pennsylvania 19533
- CMS Provider Number
- 395094
- Inspections on file
- 20
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Berks County Home- Berks Heim during CMS and state inspections, most recent first.
A resident with dementia, behavioral disturbance, and anxiety was receiving PRN Lorazepam gel for anxiety per a physician order. The care plan directed staff to administer the anti-anxiety medication as ordered, and MARs showed repeated PRN administrations over multiple months. However, there was no physician documentation in the clinical record providing a rationale to extend the PRN Lorazepam order beyond 14 days, and no stop date was included in the orders. The DON confirmed the absence of a stop date or rationale for the continued PRN psychotropic use, resulting in a cited deficiency.
The facility did not meet the required nurse aide (NA) to resident ratios on three occasions over a 14-day period. Specifically, the facility failed to maintain the minimum ratio of one NA per ten residents during the day shift on two occasions and did not meet the required ratio of one NA per eleven residents during the evening shift on another occasion. These deficiencies were confirmed by the Administrator.
The facility did not meet the required minimum of 3.2 hours of direct nursing care per resident on two days within a 14-day review period. Specifically, the care hours fell short on December 25, 2024, and January 1, 2025, with 3.14 and 3.10 hours per resident, respectively. The Administrator confirmed the shortfall.
The facility failed to store food in a sanitary manner in the dietary department, as required by its policy. Observations revealed that several containers of prepared food items in warming cabinets and air curtain refrigerators were not labeled, dated, or covered. The Dietary Manager confirmed that all prepared foods should be covered, labeled, and dated to prevent foodborne illness.
The facility failed to accurately complete MDS assessments for two residents. One resident's MDS inaccurately indicated daily use of a trunk restraint without a physician's order or actual use. Another resident's MDS did not reflect the required hemodialysis sessions, despite having end-stage renal disease and a physician's order for dialysis.
A facility failed to implement safety interventions for a resident at risk for falls, who had a history of falling and used a walker. Despite care plan interventions for appropriate footwear, the resident fell multiple times, including a fall where she hit her head while wearing regular socks instead of non-skid ones.
The facility failed to document the rationale for the continued use of PRN anti-anxiety medications for two residents, leading to a deficiency. One resident with dementia and anxiety had a PRN Ativan gel order administered multiple times without justification for extending the order beyond 14 days. Another resident with Alzheimer's and anxiety had a similar issue with PRN Ativan, and pharmacy recommendations to include a duration for the order were ignored. The DON confirmed the absence of a stop date or rationale for continuing the PRN Ativan.
Lack of Physician Rationale for Extended PRN Lorazepam Use
Penalty
Summary
The facility failed to document the rationale for the continued use of a PRN anti-anxiety psychotropic medication for one resident. Clinical record review showed that Resident 83 had dementia with behavioral disturbance and anxiety, and the MDS assessment indicated the resident had been administered an anti-anxiety medication. The care plan identified use of an anti-anxiety medication related to an anxiety disorder, with an intervention for staff to administer medications as ordered. On June 24, 2025, a physician ordered Lorazepam gel to be given every eight hours as needed for anxiety. Medication Administration Records showed that this PRN Lorazepam gel was administered five times in July 2025, five times in August 2025, and nine times in September 2025. There was no documentation in the clinical record from the physician providing a rationale to extend the PRN Lorazepam gel order beyond 14 days from the original order date. In an interview on October 10, 2025, the Director of Nursing confirmed that there was no stop date or rationale in the orders to extend the PRN Lorazepam medication, resulting in a deficiency under 28 Pa. Code 211.12(d)(1)(5) for nursing services.
Failure to Meet Nurse Aide to Resident Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident ratios on three occasions over a 14-day period. Specifically, the facility did not maintain the minimum ratio of one NA per ten residents during the day shift on December 25, 2024, and January 1, 2025. Additionally, the facility did not meet the required ratio of one NA per eleven residents during the evening shift on December 31, 2024. These deficiencies were identified through a review of nursing schedules and were confirmed by the Administrator during an interview on January 13, 2025.
Plan Of Correction
Administrator, Assistant Administrator, and Nursing Administration including Nursing Supervisors will review staffing ratios and PPD requirements. The DON or designee will re-educate the Nursing Supervisors and nursing schedulers on the ratio and PPD requirements. A daily audit of nursing hours/ratios will be completed by the DON or designee for 7 days, then weekly for three weeks, and then every other week for 4 weeks. Results of the audits will be reported to the QAPI committee.
Deficiency in Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day. This deficiency was identified during a review of nursing schedules over a 14-day period from December 22, 2024, to January 4, 2025. Specifically, on December 25, 2024, the facility provided only 3.14 hours of care per resident, and on January 1, 2025, only 3.10 hours per resident. The Administrator confirmed during an interview that the facility did not meet the required nursing care hours on these days.
Plan Of Correction
Administrator, Assistant Administrator and Nursing Administration including Nursing Supervisors will review staffing ratios and PPD requirements. The DON or designee will re-educate the Nursing Supervisors and nursing schedulers on the ratio and PPD requirements. A daily audit of nursing hours/ratios will be completed by the DON or designee for 7 days, then weekly for three weeks and then every other week for 4 weeks. Results of the audits will be reported to the QAPI committee.
Failure to Store Food Properly in Dietary Department
Penalty
Summary
The facility failed to adhere to its policy on storing food in a sanitary manner, as observed during a survey of the dietary department. The policy required that all food items be labeled with the product name, use-by date, and the date the product was prepared or opened. Additionally, containers were to be covered, labeled, and dated. However, during the initial tour, it was found that several containers of prepared food items in Warming Cabinet #1 were neither labeled nor dated, and the Dietary Manager was unable to identify the contents or the time they were placed in the cabinet. Similarly, Warming Cabinet #2 contained a container of pureed chicken and several mugs of fortified food that were not labeled or dated, along with a container of ground chicken that was also not dated. Further observations revealed that the air curtain refrigerators in the dietary department contained multiple trays of food items that were not covered, labeled, or dated. Air curtain refrigerator #1 had trays of regular and pureed peppered cabbage, as well as tossed salad, none of which were labeled or dated. Air curtain refrigerator #2 contained trays of desserts that were not labeled, dated, or covered. Additionally, another large refrigerator in the department had trays of desserts that were similarly not covered, labeled, or dated. The Dietary Manager confirmed that all prepared foods were supposed to be covered, labeled, and dated according to facility policy and standards of practice to prevent foodborne illness.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for two residents. For Resident 60, the MDS assessment inaccurately indicated the use of a trunk restraint while in a chair or out of bed daily during the seven-day review period, despite the clinical record showing no physician's order or actual use of such a restraint. For Resident 65, who had end-stage renal disease and required hemodialysis, the MDS assessment did not reflect the physician's order for dialysis on Mondays, Wednesdays, and Fridays, as documented in the resident's care plan.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that assessed safety interventions were in place to prevent falls for a resident at risk for falls. The resident had diagnoses including anxiety, a history of falling, abnormal gait and mobility, lack of coordination, and unsteadiness on her feet. The Minimum Data Set assessments indicated memory impairment, use of a walker, and multiple falls during assessment periods. The care plan included interventions for the resident to wear appropriate footwear when ambulating and non-skid socks at night. However, nursing documentation revealed that the resident fell six times on the evening shift from July through September 2024. On September 5, 2024, the resident fell backwards and hit her head while wearing regular socks, indicating the facility failed to ensure the resident had non-skid footwear as required.
Failure to Document Rationale for PRN Anti-Anxiety Medication Use
Penalty
Summary
The facility failed to document the rationale for the continued use of PRN anti-anxiety medications for two residents, leading to a deficiency. Resident 40, diagnosed with dementia with behavioral disturbance and anxiety, had a physician's order for PRN Ativan gel for anxiety since February 19, 2023. The medication was administered multiple times from June to September 2024, but there was no documentation justifying the extension of the PRN order beyond 14 days from the original order date. Similarly, Resident 51, with Alzheimer's disease and anxiety disorders, had a PRN Ativan order from March 22, 2024, which was administered several times from June to September 2024 without documented rationale for extending the order beyond 14 days. Additionally, pharmacy recommendations for Resident 51 on May 27, 2024, and June 17, 2024, suggested including a duration for the PRN Ativan order, but these recommendations were not acknowledged or acted upon by the physician. The Director of Nursing confirmed the absence of a stop date or rationale for continuing the PRN Ativan for both residents. This lack of documentation and failure to act on pharmacy recommendations contributed to the deficiency identified in the facility's nursing services.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
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