Health inspection·November 20, 2025

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **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 document the rationale for the continued use of as needed (PRN) anti-anxiety medications for two of 24 sampled residents. (Residents 2 and 3)Findings include:Clinical record review revealed that Resident 2 had diagnoses that included dysphagia (difficulty swallowing), malnutrition, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had no cognitive impairment and had been administered an anti-anxiety medication. On September 16, 2025, a physician ordered for staff to administer an anti-anxiety medication (lorazepam) every 12 hours as needed for anxiety. Review of the Medication Administration Record (MAR) revealed that the anti-anxiety medication had been administered three times in November 2025. Clinical record review revealed that Resident 3 had diagnoses that included dysphagia, heart failure, and anxiety. Review of the MDS assessment dated [DATE], revealed that the resident had no cognitive impairment and had been administered an anti-anxiety medication. On October 5, 2025, a physician ordered for staff to administer an anti-anxiety medication (clonazepam) every eight hours as needed for anxiety. Review of the MARs revealed that the anti-anxiety medication had been administered two times in October 2025 and 13 times in November 2025.There was no documented evidence that the physician re-evaluated the medications and/or documented a rationale for the extended duration and use beyond 14 days. In an interview on November 20, 2025 at 10:33 a.m., the Director of Nursing confirmed that there was no stop date or rationale in the orders to extend the PRN medications. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Page 1 of 3 395938 395938 11/20/2025 Complete Care at Berkshire LLC 5501 Perkiomen Avenue Reading, PA 19606

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **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 ensure that the Minimum Data Set (MDS) assessment was completed to accurately reflect the current status of one of 25 sampled residents. (Resident 86)Findings include:Clinical record review revealed that Resident 86 was placed on hospice on March 28, 2025. The MDS assessment dated [DATE], incorrectly indicated in Section O (Special treatments, Procedures, and Programs) that the resident was not on hospice during the previous seven days.In an interview on November 20, 2025, at 9:20 a.m., the Director of Nursing confirmed that Resident 86's MDS assessment was inaccurate. Residents Affected - Few 395938 Page 2 of 3 395938 11/20/2025 Complete Care at Berkshire LLC 5501 Perkiomen Avenue Reading, PA 19606

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 facility policy review, observation, and staff interview, it was determined that the facility failed to store and serve food in a sanitary manner in the dietary department and on one of two nursing units. (1st floor) Findings include:Review of the facility policy entitled, Labeling and Dating Inservice, dated August 25, 2025, revealed that staff were to discard items that were past their use-by date.Observations during the kitchen tour on November 18, 2025, at 10:00 a.m., revealed the following:In the freezer, there were bags of French toast, muffins, and fish patties that were opened and not dated. There was a bag of dinner rolls and a box of blueberries that were not sealed and were opened to air. On the floor inside the freezer, there were two areas of a frozen, brown liquid substance that had shoe marks in both. In the walk-in cooler, there was an opened package of breakfast ham that was labeled use-by November 15, 2025. In the preparation area, the utensil drawer had three utensils that had a dried, sticky substance in the serving piece of each. Inside the microwave cavity and the door rim, there were multiple areas with peeling paint which exposed a reddish-brown area underneath them and a hole on the inside of the microwave. On the floor under the juice station, there was an area of dried, sticky liquid and four plastic lids. In the cooks' area, the flour bin had dried food debris along the top of it. Under the rack storing containers, there was a cherry tomato and paper debris. In the cooks' utensil drawer, there was a metal and plastic spatula that each had chips along the entire blade of each. Observation of the 1st floor nourishment room on November 18, 2025, at 11:42 a.m., revealed the top of the refrigerator door had an area of brown dried liquid on it. Inside the refrigerator, there was an area of a dried, sticky substance that had dripped from inside to the floor outside. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management. 395938 Page 3 of 3