Berkshire Commons, Genesis Healthcare.

“The resident-home contract was not signed by the resident as required.”

“The facility failed to safeguard a resident's money and property when the resident was admitted to the hospital. A staff member gained unauthorized access to the resident's credit card and made fraudulent purchases at an online store. The staff member was charged with credit card theft.”

“A prescription for narcotic medication belonging to a discharged resident was delivered to the home but was not documented in the medication tracking system or placed in secured storage. The medication was left on top of the medication cart and subsequently went missing. The facility had no effective procedure in place to ensure safe storage and accountability of controlled medications.”

“Staff member B's annual medication practicum training record was not properly documented. The practicum date did not match the completed date in the training records.”

“A resident's initial support plan was finalized without involving the resident or the resident's designated person in its development.”

“A resident-home contract was not signed by the resident, and the home did not document attempts to obtain the resident's signature.”

“A resident admitted to the Secure Dementia Care Unit lacked documentation that the resident does not object to admission, though documentation of the designated person's non-objection was present.”

“A resident record did not include documentation of health care services provided by visiting nurse or home health agencies.”

“A staff member accepted and cashed a check presented as a Christmas gift from a resident, violating the requirement that resident funds and property shall only be used for the resident's benefit. The staff member was terminated from the facility.”

“The facility failed to immediately report multiple medication errors to prescribers. Several residents did not receive prescribed medications on specific dates and times, but prescribers were not notified of these errors.”

“The facility failed to timely report multiple medication administration incidents to the Department. Prescribed medications were not administered to several residents on various dates, and incidents were reported 1-4 hours after occurrence rather than within the required timeframe.”

“Two residents' annual medical evaluations were incomplete; the medical professional section was not filled out on the evaluation forms.”

“The facility failed to maintain adequate supplies of glucometer test strips, resulting in a resident missing blood sugar checks at scheduled times. Additionally, a prescription was not promptly sent to the pharmacy.”

“The facility failed to follow prescribers' orders for multiple residents. Prescribed medications were not administered on multiple occasions because medications were not available in the home, and prescribed blood glucose checks were not completed due to lack of glucometer strips.”

“Resident did not receive prescribed medication (1 tablet orally twice a day for clot prevention) on multiple dates. While progress notes indicate the home contacted the doctor on specified dates, there is no documentation of the prescriber's response to the medication errors.”

“The home failed to report a medication incident (resident did not receive scheduled medication at 9:00 a.m.) to the Department within 24 hours, instead reporting it at 4:23 p.m. Additionally, a complaint of abandonment investigated by Office on Aging was not reported to the Department.”

“Resident with cardiac history and recent stents was admitted to the home and subsequently hospitalized with 100% occlusion of a prior stent. The resident had been prescribed medication for blood clot prevention but was not administered the last 5 prescribed doses prior to hospitalization due to medication unavailability with no documented response from the prescriber.”

“Resident did not receive prescribed medication (1 tablet orally twice a day for clot prevention) on specified dates, including the a.m. dose on another specified date.”

“Resident did not receive prescribed cardiac medication (1 tablet orally twice a day for clot prevention) on multiple dates. The resident's Legal Guardian was not notified of the missed medication doses until after the resident's hospitalization.”

“Resident #2's glucometer was not calibrated to the correct date or time. This was a repeated violation from 7/23/25.”

“The home exceeded the maximum safe evacuation time of 15 minutes specified by a fire safety expert during a fire drill on 12/12/2024, with an evacuation time of 18 minutes 38 seconds.”

“Resident #3 is prescribed Tamsulosin HCL 0.4 mg at bedtime, but the medication administration record does not document that the medication was administered on 8/1/25.”

“A used Novolog 100 units/ml flexpen in the medication cart did not have the date of opening documented. According to manufacturer's instructions, the pen should be used within 28 days of opening if kept at room temperature.”

“Privacy coding was not omitted from License Inspection Summaries from prior inspections (8/8/24 and 11/7/24) that were placed at the facility's front desk, violating resident record confidentiality requirements.”

“On 7/26/25 and 7/27/25, from 7 A.M. to 11 P.M., 37 residents were present in the home with no staff persons trained in first aid and certified in obstructed airway techniques and CPR present.”

“Direct care Staff person A did not receive required annual training topics including medication self-administration, meeting resident needs, dementia care, infection control, personal care service needs, safe management techniques, and care for residents with mental illness or intellectual disability during training year 1/1/24 to 12/31/24.”

“Staff person A did not receive required annual training in emergency preparedness procedures, recognition and response to crises, resident rights, The Older Adult Protective Services Act, falls and accident prevention, and new population groups during training year 1/1/24 to 12/31/24.”

“Resident #5's enabler bar was found not properly secured to the bed, creating a potential hazard to resident safety.”

“Support plans for two residents in the secure dementia care unit were not updated to address wandering and exit-seeking behaviors, and one support plan was not updated following an incident where one resident punched another resident who had wandered into their room.”

“A resident hit another resident after removing a cushion from the sofa that the second resident did not approve of. No injuries were reported to either resident.”

“The home failed to timely secure medical care for a resident experiencing urinary difficulties. Testing was ordered by the nurse practitioner, but the resident was not seen by a physician to assess symptoms until being sent to the hospital. The home did not promptly arrange physician evaluation despite documented health status decline.”

“One resident struck another resident in the face, resulting in a scratch to the resident's nose. These two residents had a previous history of altercations. This was noted as a repeat violation from 5/15/2024.”

“Resident #1 engaged in aggressive behaviors resulting in physical harm to another resident, including 3 bruises and 2 skin tears on Resident #2's arm, and slapping incidents in the Secure Dementia Care Unit. This was attributed to a recent decrease in medications ordered by the consulting physician.”

“Resident was taken out of the home by a family member on 3/3/24 and was not administered scheduled morning medications/supplements. An incident report was not submitted to the Department regarding this medication error.”

“Resident was found smoking and subsequently denied the ability to smoke. The home's smoking assessment determined the resident could not smoke safely but failed to offer supervised smoking as an alternative, instead prohibiting smoking entirely.”

“Resident was found smoking inside the home outside of the facility's designated smoking area.”

“Resident was taken out of the home by a family member on 3/3/24 and prescribed medications and supplements scheduled for 9am administration were not given as per physician's orders.”

“Two residents were found engaged in a sexual act by staff, and this incident was not reported to the Area Agency on Aging as required by the Older Adult Protective Services Act and 6 Pa. Code § 15.21–15.27.”

“When an allegation of abuse involving staff was received on 11/1/2023, the home failed to immediately develop and implement a plan of supervision or suspend the staff members involved in the alleged incident.”

“An allegation of abuse was received on 11/1/2023 but was not reported to the Department until 11/15/2023, failing to meet the required 24-hour reporting deadline.”