Health inspection·October 20, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and resident interview, it was determined that the facility failed to ensure that meals were served in a manner that maintained each resident's dignity on one of six nursing units. ([NAME] Commons) Findings include: Observations of the lunch meal on [NAME] Commons nursing unit on Ocotber 18, 2023, between 12:18 p.m. and 1:05 p.m., revealed Residents 120 and 247 seated at a table, taking utensils and food off each other's meal trays. Resident 120 then proceeded to eat her meal using a folded piece of paper as a utensil. During the same observation period, Resident 299 was seated at the table next to Residents 120 and 247. Resident 299 was observed making comments like I'm hungry, where is the food, it's ridiculous to wait, and why are they eating? Resident 299 was not served her lunch tray until 1:05 p.m. Observation of the lunch meal on [NAME] Commons nursing unit on October 19, 2023, between 12:41 p.m. and 1:04 p.m., revealed residents 142, 282, and 296 seated at a table. The residents had been served and were eating their lunch meals. Residents 185 and 246 were seated in chairs, next to the table while residents 142, 282, and 296 ate their meals. Resident 246 was not served a lunch tray until 1:03 p.m. During the same observation period, Residents 100, 239, 134, and 82 were seated together at a table. Residents 100, 134, and 239 were served a lunch tray and were eating their meals. Resident 82 was not served a lunch tray until 1:04 p.m. 28 Pa. Code 201.29(a) Resident rights. Page 1 of 4 395094 395094 10/20/2023 Berks County Home- Berks Heim 1011 Berks Road Leesport, PA 19533

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, observation, and resident interview, it was determined that the facility failed to accomodate resident needs by providing access to the call bell system and personal items for one of 37 sampled residents. (Resident 195) Residents Affected - Few Findings include: Clinical record review revealed that Resident 195 had diagnoses that included Parkinson's disease. According to the Minimum Data Set assessment, dated October 5, 2023, the resident had no cognitive impairment, could communicate care needs, had impaired vision, and was dependent on staff for care. Review of the care plan revealed that the resident was at risk for falls and that staff was to keep her call bell and other objects within reach. On October 17, 2023, at 11:09 a.m., the resident was observed in her chair near the foot of the bed. The call bell was at the head of the bed. The resident stated at that time that she could not reach it. On October 18, 2023, at 9:45 a.m., the resident was observed in her chair near the foot of the bed. The television remote control was on the floor. The resident's cell phone was on the overbed table and out of reach. Her call light was under a pillow that was propping her arm and the resident stated she could not reach these items. On October 19, 2023, at 11:02 a.m., the resident was observed seated in her chair near the foot of the bed. The call bell was on the overbed table at the foot of the bed. The resident stated that she could not reach it. 28 Pa. Code 211.12(d)(5) Nursing services. 395094 Page 2 of 4 395094 10/20/2023 Berks County Home- Berks Heim 1011 Berks Road Leesport, PA 19533

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff interview, it was determined that the facility failed to ensure physician's orders were implemented for one of 37 sampled residents. (Resident 137) Residents Affected - Few Findings include: Clinical record review revealed that Resident 137 had diagnoses that included hypertension (high blood pressure). On September 6, 2023, the physician ordered staff to administer a blood pressure medication (metoprolol tartrate) twice a day. Staff were not to administer the medication if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its highest) was less than 105 millimeters of mercury (mmHg). Review of Resident 137's medication administration records revealed that staff administered the medication when the resident's SBP was less than 105 mm/Hg one time in September and four times in October of 2023. In an interview on October 20, 2023, at 12:35 p.m., the Assistant Director of Nursing (ADON1) confirmed that the medications were administered outside of established parameters for Resident 137. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395094 Page 3 of 4 395094 10/20/2023 Berks County Home- Berks Heim 1011 Berks Road Leesport, PA 19533

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that safety interventions for falls were in place for two of 37 sampled residents. (Residents 162, 297) Findings include: Clinical record review revealed that Resident 162 had diagnoses that included dementia, anxiety, unsteadiness on feet, and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had cognitive impairment and required extensive assistance from staff with transferring, personal hygiene, and dressing. Review of the care plan revealed that staff was to use bilateral (both sides) elevating leg rests for transport in the wheelchair. On October 18, 2023, at 12:20 p.m., and October 19, 2023, at 10:47 a.m. and 1:15 p.m., Resident 162 was observed in her wheelchair being transported by staff without bilateral elevating leg rests in the hallway. In an interview on October 20, 2023 at 9:24 a.m., the Director of Nursing confirmed that staff should have used bilateral elevating leg rests when transporting Resident 162 in her wheelchair. Clinical record review revealed that Resident 297 had diagnoses that included dementia, anxiety, osteoarthritis, and unsteadiness on feet. Review of the MDS assessment dated [DATE], revealed that the resident had cognitive impairment. Review of the care plan revealed that staff were to ensure that the resident had his walker with him at all times while ambulating. Review of a facility incident report dated October 17, 2023, revealed that Resident 297 was standing in the hallway holding the rail on the wall and needed to be lowered to the floor by staff. The intervention was for staff to encourage the use of a walker while the resident was ambulating and to offer rest periods. On multiple occasions on October 18, 2023, between 12:14 p.m. and 12:56 p.m., Resident 297 was observed ambulating in the common area without his walker. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395094 Page 4 of 4