Health inspection·May 1, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 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. Clinical record review revealed that Resident 54 had diagnoses that included congestive heart failure, diabetes, muscle weakness, and late onset Alzheimer's disease. The MDS assessment dated [DATE], indicated that the resident was able to communicate her needs to staff and required extensive assistance from staff for transfers and activities of daily living such as toileting and dressing. Clinical record review revealed that Resident 56 had diagnoses that included post polio syndrome (condition that causes gradual muscle weakness) and difficulty walking. The MDS assessment dated [DATE], indicated that the resident was able to communicate her needs to staff and required assistance from staff for transfers and activities of daily living such as toileting, dressing, and personal hygiene. Clinical record review revealed that Resident 73 had diagnoses that included Parkinson's disease and neuromuscular dysfunction of bladder (urinary bladder problems due to a disease). The MDS assessment dated [DATE], indicated that the resident was able to communicate her needs to staff and required extensive assistance from staff for transfers and activities of daily living such as toileting. During a group interview on April 30, 2025, at 10:00 a.m., Residents 45, 54, 56, and 73 reported that it took long periods of time (30 minutes or more) for staff to answer their call bells and get assistance. Clinical record review revealed that Resident 42 had diagnoses that included congestive heart failure, muscle weakness, and difficulty walking. The MDS assessment dated [DATE], indicated that the resident was able to communicate his needs to staff and required assistance from staff for transfers Page 1 of 3 395880 395880 05/01/2025 Phoebe Berks 1 Heidelberg Drive Wernersville, PA 19565

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and activities of daily living such as toileting. In an interview on April 30, 2025, at 10:38 a.m., Resident 42 stated that staff took a long time to answer call bells which has affected his ability to receive care and services in a timely manner. Clinical record review revealed that Resident 77 had diagnoses that included a history of traumatic injuries, peripheral vascular disease, muscle weakness, and difficulty walking. The MDS assessment dated [DATE], indicated that the resident was able to communicate her needs to staff and required extensive assistance from staff for transfers and activities of daily living such as toileting. In an interview on April 30, 2025, at 11:00 a.m., Resident 77 stated that staff took a long time to answer call bells which has affected her ability to receive care and services in a timely manner. Clinical record review revealed that Resident 82 had diagnoses that included partial paralysis to the right side following a stroke, chronic kidney disease, muscle weakness, and difficulty walking. The MDS assessment dated [DATE], indicated that the resident was able to communicate her needs to staff and required extensive assistance from staff for transfers and activities of daily living such as toileting. In an interview on April 30, 2025, at 11:55 a.m., Resident 82 stated that staff took a long time to answer call bells which has affected her ability to receive care and services in a timely manner. In an interview on April 30, 2025, at 1:00 p.m., the Administrator revealed that staff were expected to respond to a call light within 15 minutes or less. Review of the facility form entitled, Device Activity Report, for Residents 42, 45, 54, 56, 73, 77, and 82, revealed that from April 1 through April 30, 2025, there were 158 occurrences when the call bell response time exceeded 15 minutes which included: April 2, 2025, at 7:39 p.m., Resident 42 waited 68 minutes; April 7, 2025, at 12:37 a.m., Resident 45 waited 58 minutes; April 9, 2025, at 7:36 a.m., Resident 54 waited 91 minutes; April 20, 2025, at 8:16 a.m., Resident 56 waited 20 minutes; April 22, 2025, at 3:46 a.m., Resident 73 waited 65 minutes; April 14, 2025, at 1:53 a.m., Resident 77 waited 168 minutes; and April 9, 2025, at 8:02 a.m., Resident 82 waited 41 minutes. During an interview on May 1, 2025, at 10:45 a.m., the Administrator confirmed the aforementioned residents waited more than the expected response time of 15 minutes. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395880 Page 2 of 3 395880 05/01/2025 Phoebe Berks 1 Heidelberg Drive Wernersville, PA 19565

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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. The baseline care plan will include trauma-informed care goals and interventions under the psychosocial well-being care plan if identified immediately upon admission, and the resident and/or representative were to be provided a written summary of the baseline care plan. Clinical record review revealed that Resident 17 was admitted to the facility on [DATE]. The baseline care plan was developed on April 10, 2025. There was a lack of evidence to support that the facility provided the resident and/or representative with a summary of the baseline care plan that included all the required components. Clinical record review revealed that Resident 64 was admitted to the facility on [DATE]. The baseline care plan was developed on January 22, 2025. There was a lack of evidence to support that the facility provided the resident and/or representative with a summary of the baseline care plan that included all the required components. During an interview on April 30, 2025, at 2:30 p.m., the Administrator confirmed that there was no evidence the baseline care plan summary was provided to the residents and/or their representatives. 28 Pa. Code 201.18 (b)(1) Management. 395880 Page 3 of 3