Phoebe Berks

In the surveyor’s words

From the most serious findings on record at Phoebe Berks, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF550May 1, 2025

  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 [DATE], 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. […]

• No harm, potential for more than minimal, patternF550May 27, 2022

  Based on clinical record review and observation, it was determined that the facility failed to provide assistance with dining in a manner that promoted and maintained dignity in two of three dining rooms. ([NAME] Corner South Hallway, Heritage Court) In addition the facility failed to provide up to date activity schedules to one of 18 sampled residents. (Resident 81) Findings include: Clinical record review revealed that Resident 45 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current care plan revealed that the resident had cognitive impairment and staff was to provide assistance with all activities of daily living. On May 21, 2022, the physician ordered for staff to feed Resident 45 all meals. On May 24, 2022, from 12:25 p.m. […]

• No harm, potential for more than minimal, patternF689May 27, 2022

  Based on clinical record review and observation, it was determined that the facility failed to provide adequate supervision and interventions to prevent accidents for two of eight sampled residents at risk for falls. (Residents 60, 82) Findings include: Clinical record review revealed that Resident 60 had diagnoses that included dementia with behavioral disturbance, muscle weakness, difficulty in walking, and a history of falling. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was cognitively impaired, required extensive staff assistance with dressing, required limited staff assistance with walking, and had fallen since the previous assessment completed on February 3, 2022. […]

• No harm, potential for more than minimal, isolatedF641Mar 18, 2026

  Based on clinical record review and staff interview, it was determined that the facility failed to complete an accurate Minimum Data Set (MDS) assessment for one of seven sampled residents. (Resident 3)Findings include:Clinical record review revealed that Resident 3 had diagnoses that included osteoarthritis and osteoporosis. Review of Resident 3's MDS dated [DATE], section J, indicated that the resident had not been assessed for pain. In an interview on March 18, 2026, at 11:27 a.m., the Director of Nursing confirmed Resident 3's MDS was inaccurate and that the resident should have been assessed for pain.

• No harm, potential for more than minimal, isolatedF655May 1, 2025

  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. […]