F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
clinical record review and staff interview, it was determined that the facility failed to develop a
comprehensive care plan to meet each resident's needs identified in the comprehensive assessment for
one of 16 sampled residents. (Resident 15)
Findings include:
Clinical record review revealed that Resident 15 was admitted to the facility on [DATE], and had diagnoses
that included depression. The Minimum Data Set Care Area Assessment summary dated March 23, 2025,
noted that the resident's psychotropic drug use was to be addressed in the care plan. Review of the
medication administration record in March and April 2025, revealed the resident was receiving an
antidepressant. There was no documented evidence that interventions to address Resident 15's
psychotropic drug use were included in the current care plan.
In an interview on April 9, 2025, at 2:40 p.m., the Director of Nursing confirmed there was no documented
evidence that the care area was addressed in the Resident 15's current care plan.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
395648
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395648
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Peter Becker Community
800 Maple Avenue
Harleysville, PA 19438
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on policy review, observation, and staff interview, it was determined that the facility failed to properly
store food and maintain sanitary conditions in two of two kitchenettes (Great Oak and Elm) and in the main
kitchen of the dietary department.
Findings include:
Review of the facility's policy entitled, Date Marking for Food Safety, dated March 20, 2025, revealed that
staff were to label food items with the date the item was opened and the items were to be discarded by the
use-by date.
Observations during the tour of the two kitchenettes and the main kitchen on April 8, 2025, at 10:30 a.m.,
revealed the following:
In the Great Oak kitchenette reach-in cooler, there was an opened container of cottage cheese with a
use-by date of March 21, 2025, and had an opening date of April 8, 2025, written on the lid. In the deli
cooler, there was a pan of egg salad with a use-by date of April 4, and a bagel with a use-by date of
December 24, 2024. There was a pan of lettuce and a cut wrapped sweet potato that were both not dated.
In the Elm kitchenette reach-in cooler, there was a dished pan of pears labeled use-by April 4, and a dished
pan of pureed fruit cup labeled use-by April 3. In the deli cooler, there was a container of chicken salad with
a use-by date of April 6, a container of tuna salad labeled use-by April 6, a package of six hot dogs labeled
use-by April 6, a container of lemon slices labeled use-by March 15, a package of cream cheese labeled
use-by March 28, and a package of sliced provolone cheese labeled use-by March 14, and all items were
opened. There was a container of 10 eggs, a cut wrapped onion, and an opened package of sliced cheese
that were not dated.
In the Main Kitchen reach in cooler, there was a package of cheese slices that was open to air and an
opened package of whipped topping that was not dated. In the walk-in cooler, there was a container of
cottage cheese with a use-by date of March 21, 2025. There was a container of 17 eggs and a large
container of 30 peeled potatoes in water that were not dated. In dry storage, there was an opened package
of walnuts that was not dated.
In an interview on April 8, 2025, at 11:30 a.m., the Assistant Director of Dining confirmed these items
should have been dated, expired items should have been removed, and the food items were for use in the
skilled areas.
28 Pa. Code 201.14(a) Responsibility of licensee.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395648
If continuation sheet
Page 2 of 2
