Phoebe Berks Village.

“Staff person E recorded a video of a resident nude from the waist up and showed it to other staff members. Staff person D did not report the incident, and the facility did not report the allegation of abuse to the local Area Agency on Aging until another staff person notified administration.”

“Staff person E recorded a video of a resident without consent and showed it to other staff. The facility did not report this incident to the Department within 24 hours until another staff person notified administration.”

“Staff person E recorded a video of a resident nude from the waist up in a sexual manner in a common area, showed it to other staff members, and offered to show it to additional staff. The conduct violated the resident's dignity and respect.”

“A laptop on the medication cart in the hallway was unlocked, unattended, and accessible to residents' records, compromising the confidentiality of resident information.”

“Over a two-month period, staff observed one resident engaging in sexual activities with another resident who lacked capacity to consent due to cognitive impairment. The resident with a bedroom key took the other resident to private areas and engaged in sexual contact, including an incident where feces were involved. Both residents were unable to consent to sexual activity due to their cognitive status.”

“The resident's assessment did not address significant behavioral changes and concerning interactions with another resident that occurred over a two-month period. The home failed to complete an assessment when the resident's condition significantly changed and did not develop a plan to keep both residents safe.”

“The resident's support plan addendum did not identify the individual responsible for addressing the resident's concerning behaviors, with the frequency and responsible party section left blank.”

“The support plans for residents were not revised to reflect significant changes in their conditions and behaviors, specifically the concerning interactions between the two residents that required modification of their care and supervision plans.”

“A laptop on a medication cart was left unlocked, unattended, and accessible to residents, allowing access to residents' medication administration records.”

“Bedside mobility devices in resident rooms were not firmly attached to beds and moved freely, posing a hazard to residents.”

“A resident's medical evaluation did not include documentation of whether the personal care home can safely meet the resident's needs.”

“A resident's record did not include a current list of all medications, specifically missing certain over-the-counter medications the resident had in their room.”

“A resident's medication administration record did not include prescribed daily blood glucose checks before meals.”

“A medication administration record was missing the initials of the staff person who administered a prescribed topical medication at 8:00 a.m., and this was a repeat violation.”

“A resident prescribed daily blood glucose checks before meals did not receive any of these prescribed checks during the inspection period, and this was a repeat violation.”

“A resident's assessment was missing documentation of certain diagnoses, and this was a repeat violation.”

“A video camera monitoring and recording the entrance lacks proper posting that addresses the recording purposes, violating resident privacy rights.”

“A copy of Chapter 2600 regulations was not posted in a conspicuous and public place in the home. This is a repeat violation.”

“Medication carts in three separate locations were observed with unlocked narcotic record books, empty medication packet wrappers, and unlocked laptops containing resident medication records left unattended and accessible to residents.”

“An enabler bar in Room 189a was not covered, was separated 3½ inches from the bed, and had an opening measuring approximately 12 x 6 inches, creating a hazard.”

“Two medication carts in the secured dementia care unit had hand sanitizer bottles, sanitized cloth containers, and hand lotion with poison control warnings left unlocked, unattended, and accessible to residents in a unit where not all residents have been assessed as capable of safely using poisons.”

“Approximately 1 inch of lint was accumulated in the lint trap of a dryer in the secured dementia care unit, creating a fire hazard.”

“A chair blocked the egress from the Secured Dementia Care Unit (Poppy Lane) to the outside of the home, obstructing an emergency exit route.”

“The home's emergency procedures were not posted in a conspicuous and public place in the home as required.”

“Combustible materials including lint, plastic cups, dryer sheets, napkins, and plastic gloves were located behind laundry room dryers. Additionally, 8 mattresses, a wooden cabinet, and a step ladder were located next to the hot water heater in the mechanical room. This is a repeat violation.”

“A resident reported allegations of potential abuse during an evaluation at Tower Health Hospital on April 18, 2025 at 11:00 a.m. The home submitted an incident report at 4:30 p.m., which was greater than 24 hours after the incident occurred, violating the requirement to report within 24 hours. (Note: The Plan of Correction indicates this part of the violation was withdrawn by BHSL.)”

“A resident prescribed to have lidocaine patches applied to both knees daily at 8:00 a.m. did not receive the prescribed medication on March 28, 2025 because only one patch was available in the home instead of the two required by the prescriber's order.”

“A resident was prescribed lidocaine patches to be applied to each knee daily at 8:00 a.m. and removed at 8:00 p.m. On March 28, 2025, only 1 patch was available to apply instead of 2, and the resident's physician was not notified of this medication error.”

“A resident's current assessment was completed, but the resident's previous annual assessment was not completed on schedule, violating the requirement for annual assessments.”

“The home failed to report a resident's refusal of prescribed medications to the prescriber within 24 hours as required.”

“The home failed to report resident's verbal accusations of abuse against staff (claims of being tied up, whipped, hit, having phone/remote stolen, and being locked in room) to the Area Agency on Aging as required by the Older Adult Protective Services Act.”

“The home failed to report resident's abuse allegations and medication errors (Probiotic Cap not administered 3/6/25-3/13/25 and another medication not administered 3/2/25-3/7/25 due to unavailability) to the Department's regional office within 24 hours as required.”

“A resident requiring twice-daily blood glucose readings with insulin administered on a sliding scale had an inaccurate blood glucose reading recorded on the Medication Administration Record (MAR), resulting in incorrect medication storage, access, and distribution procedures.”

“A resident's blood glucose reading was inaccurately recorded on the MAR, resulting in the resident receiving an incorrect insulin dose that did not follow the prescriber's sliding scale order.”

“Trash receptacles in the 2nd floor kitchenette and memory care kitchenette were not covered, failing to prevent insect and rodent penetration.”

“The first aid kit in the home's memory care unit was missing a thermometer, which is a required item.”

“A resident pushed another resident, causing the resident to fall backward and hit their head, resulting in a contusion and back pain lasting several weeks. This constitutes physical abuse/neglect.”

“A resident-to-resident physical altercation incident was not reported to the Department within 24 hours. The incident occurred on 9/13/2024 after supervisory staff left for the weekend, and timely reporting was not made.”

“Staff persons working in the Village Gardens secure dementia unit indicated they did not know the location of the first aid kit, with activities aide and two dietary aides unfamiliar with its location.”

“Frozen French toast slices in the memory care unit freezer were stored in a metal tin loosely covered with plastic wrap that did not cover the entire tin, failing to meet sealed container requirements.”

“Blood glucose readings were not documented accurately. Two readings were documented as different values than what was actually shown in the glucometer, indicating improper medication monitoring and documentation procedures.”

“A resident was not administered a prescribed medication at the scheduled 8:00am time, but the medication administration record was falsely documented to indicate the medication was given. The missed dose was discovered during a routine narcotic count.”

“A resident with an order for one-half tablet twice daily at 8am and 7pm was not administered the medication at the scheduled 8am time, failing to follow the prescriber's orders.”

“A resident admitted to personal care was regularly placed in the secure dementia unit during daytime hours and escorted back to personal care at night without formal admission to the secure unit. Since the resident was not formally admitted to the secure dementia unit, this regular placement constitutes prohibited restraint.”

“The facility did not post the License Inspection Summary dated 11/28/23 in a conspicuous and public place as required.”

“During lunch in the memory care unit, staff person A warned a resident they would have to eat in another room if they didn't quiet down. The resident was not treated with dignity and respect.”

“The facility did not have documentation that staff persons B, C, and D received fire safety training by a fire safety expert for the annual training year 2023. Staff person B also did not have training in emergency preparedness in 2023.”

“The first aid kit stored in the medication room did not contain tweezers or a CPR breathing shield as required.”

“The refrigerator in the memory care kitchenette contained 2 trays of pie slices that were not covered or labeled with the date they were stored.”

“French toast sticks were found in the freezer of the memory care kitchenette in a torn plastic bag that was not sealed properly. A metal container of butter was stored on the counter of the 2nd floor kitchenette and was not covered.”

“A slipper sock was found behind the dryer in the memory care laundry room, posing a fire hazard. This was a repeated violation from 9/27/23.”

“Fire extinguishers in the memory care kitchenette and 2nd floor pantry had inspection tags indicating the inspection had expired in August of 2024.”

“On 11/29/23 a fire drill evacuation took 9 minutes and 49 seconds, exceeding the maximum safe evacuation time of 8 minutes specified in the facility's fire safety inspection letter dated 5/2/23. This was a repeated violation from 9/27/23.”

“A resident's bedside mobility device was uncovered and had a 6-inch by 9-inch opening in the rail, which did not meet FDA guidelines and required a cover.”

“A fire drill on an unspecified date recorded an evacuation time of 9 minutes 49 seconds, which exceeded the facility's established safe evacuation time of 8 minutes as specified in the fire safety letter.”

“During fire drills, not all residents evacuated to designated meeting places: one drill had 80 of 81 residents evacuate, and another had 81 of 82 residents evacuate.”

“Off-going nursing staff signed narcotic count sheets before the counts were completed and verified with oncoming nursing staff in both the personal care and secured dementia care communities, violating controlled substance procedures.”

“A resident fall requiring hospitalization was not reported to the Department of Human Services within the required 24-hour timeframe.”

“Resident #3 was physically aggressive towards resident #4 on three occasions, striking, slapping, punching, and threatening another resident with a fork, failing to treat residents with dignity and respect.”

“Medical evaluation for Resident #1 does not include date of birth. Medical evaluation for Resident #3 does not include height, weight, pulse rate, blood pressure, or temperature.”

“Resident #1's support plans do not document addendums of all falls or safety interventions including neurological checks and frequency. Resident #2's support plan was not updated after placement on neurological checks following a fall. Resident #3's support plan was not updated after three incidents of aggression towards another resident.”

“Resident #2's and Resident #3's Resident Assessment Support Plans were not signed by the residents, and there was no documentation that the residents refused to sign or were unable to sign.”

“The refrigerator in the Personal Care Home breakroom to the left of room 80 had a thermometer reading 48 degrees, exceeding the required maximum of 40°F for refrigerated food storage.”

“A computer on the medication cart in the Secure Dementia Care Unit hallway was left unlocked and unattended with resident confidential information visible on the screen. Staff utilizing the computer were out of line of sight of the cart.”

“Emergency telephone numbers were not posted on or by the phone at the entrance to the Personal Care Side of the building.”

“In Room 401, one resident sleeping in a recliner did not have a light source that could be turned on from the recliner. This was a repeat violation from 6/28/2022.”

“The 2nd floor freezer in the kitchenette contained unlabeled, unidentifiable food stored in it.”