Inspection Reports for
Berks Leisure Living
1399 FAIRVIEW DRIVE,, LEESPORT, PA, 19533
Back to Facility Profile34 Reports
Inspection Report — Jul 31, 2026
Complaint Investigation
Date: Jul 31, 2026
Visit Reason
The inspection was conducted as a complaint investigation at Berks Leisure Living on 07/31/2026.
Findings
No regulatory citations or deficiencies were identified during this unannounced partial inspection.
Report Facts
Residents Served: 36
Residents Receiving Supplemental Security Income: 6
Residents Age 60 or Older: 33
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Intellectual Disability: 4
Residents with Physical Disability: 3
Inspection Report — Mar 10, 2026
Renewal
Date: Mar 10, 2026
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements and verify the submitted plan of correction.
Findings
The facility had multiple deficiencies including issues with criminal background checks, staff qualifications, sanitary conditions, emergency telephone postings, food storage and labeling, fire extinguisher inspections, annual medical evaluations, medication self-administration assessments, medication availability, and adherence to prescriber's orders. All deficiencies had accepted plans of correction with ongoing compliance measures.
Citations (13)
Criminal background checks were not requested timely for two staff members prior to employment.
Direct care staff verification of high school diploma, GED, or active registry was missing for one staff member.
Four ice cube trays had a tan substance frozen in the ice and two boxes of frozen chicken had a brown sauce-like substance on them in freezers.
Emergency telephone numbers for nearest hospital and fire department were not posted by resident telephones in the front hallway and dining room.
Opened bag of breadcrumbs and container of Raisin Bran cereal in the kitchen were not labeled or dated.
Refrigerator #1 had no thermometer and several freezers had temperatures above required levels.
Soggy green pepper with mold and a dented can of fruit cocktail were found in the dry goods area.
Fire extinguisher in the boiler room had not been inspected by a fire safety expert since November 2024.
Resident 1’s annual medical evaluation was incomplete and lacked required medical professional certification.
Resident 2 self-administers medication but lacked required assessment by a qualified medical professional.
Resident 3’s prescribed medications were not available in the home at the time of inspection.
Resident 4’s MAR documented medication administration that did not occur because medication was unavailable.
Resident 5’s prescribed medication was not administered due to unavailability in the home.
Report Facts
Residents Served: 33
Hospice Current Residents: 2
Residents Receiving Supplemental Security Income: 4
Residents Age 60 or Older: 30
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 4
Residents with Mobility Need: 1
Staff Total Daily: 34
Staff Waking: 26
Inspection Report — Nov 24, 2025
Complaint Investigation
Date: Nov 24, 2025
Visit Reason
The inspection was conducted as a complaint investigation with a partial, unannounced visit to the facility on 11/24/2025.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents served: 40
Current Hospice Residents: 2
Residents receiving Supplemental Security Income: 5
Residents aged 60 or older: 37
Residents diagnosed with Intellectual Disability: 4
Residents diagnosed with Mental Illness: 1
Residents with Mobility Need: 2
Residents with Physical Disability: 0
Inspection Report — Sep 10, 2025
Complaint Investigation
Date: Sep 10, 2025
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial visits on 09/10/2025 and 09/16/2025, followed by an off-site review on 09/26/2025 to assess compliance with licensing requirements.
Complaint Details
The visit was complaint-related, triggered by allegations of staff sleeping on duty and failure to report suspected abuse. The complaint was substantiated as violations were found and corrective actions implemented.
Findings
The facility was found to have multiple violations related to failure to immediately report suspected resident abuse, inadequate supervision of staff, delayed incident reporting, insufficient assistance with activities of daily living, failure to treat residents with dignity and respect, and lack of positive interventions to address resident behavioral issues. Corrective actions including staff termination, education, and updated support plans were implemented.
Citations (6)
15a Resident Abuse Report: Staff person A was found sleeping while the only staff present, delaying reporting of suspected abuse until staff person C viewed the allegation weeks later.
15c Supervision: Staff person A continued working without suspension or supervision plan after the abuse allegation until investigation led to termination.
16c Written Incident Report: The incident was not reported to the Department within 24 hours as required, causing delayed notification.
23a Activities of Daily Living Assistance: Resident did not receive required assistance with making and keeping appointments due to staff person A sleeping.
42c Treatment of Residents: Residents were involved in a physical altercation causing injury, indicating failure to treat residents with dignity and respect.
201 Positive Interventions: The facility failed to implement positive interventions to address bullying and threatening behavior among residents.
Report Facts
Residents Served: 5
Total Daily Staff: 7
Waking Staff: 5
Inspection Report — Mar 26, 2025
Follow-Up
Date: Mar 26, 2025
Visit Reason
The inspection was conducted as a follow-up review of the facility's plan of correction related to an incident.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing deficiencies in assistance with activities of daily living and sanitary conditions. Continued compliance and ongoing monitoring were emphasized.
Citations (2)
Failure to provide assistance with bathing and hygiene as indicated in the resident’s assessment and support plan, resulting in a resident found with feces on body, walls, and towels on wheelchair.
Failure to maintain sanitary conditions, with a resident found with feces on body, walls, and towels on wheelchair.
Report Facts
Residents Served: 40
Total Daily Staff: 42
Waking Staff: 32
Current Residents in Hospice: 1
Residents Receiving Supplemental Security Income: 9
Residents 60 Years or Older: 39
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 2
Inspection Report — Nov 5, 2024
Follow-Up
Date: Nov 5, 2024
Visit Reason
The inspection was a partial, unannounced incident investigation conducted on 11/05/2024 to review the submitted plan of correction related to a resident abuse allegation.
Complaint Details
The visit was complaint-related due to an incident where staff person A was overheard yelling loudly and threatening a resident, causing the resident to cry. The complaint was substantiated as violations of abuse reporting and supervision requirements were confirmed.
Findings
The facility was found to have violated regulations regarding immediate reporting and supervision of staff involved in resident abuse. Staff person A was overheard verbally abusing a resident and threatening them, but the incident was not reported immediately and the staff person was not suspended promptly. The facility has since implemented training and suspended/terminated the involved staff.
Citations (3)
Failure to immediately report suspected abuse of a resident and comply with staff restrictions.
Failure to immediately develop and implement a plan of supervision or suspend staff involved in alleged abuse.
Resident was verbally abused and intimidated by staff, causing emotional distress.
Report Facts
Residents Served: 39
Current Residents in Hospice: 2
Residents Receiving Supplemental Security Income: 12
Residents Age 60 or Older: 38
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 1
Residents with Physical Disability: 0
Total Daily Staff: 40
Waking Staff: 30
Inspection Report — Oct 2, 2024
Complaint Investigation
Date: Oct 2, 2024
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial inspection on 10/02/2024.
Complaint Details
The inspection was triggered by a complaint, as stated under Inspection Information on page 2.
Findings
The inspection identified multiple deficiencies related to food storage, labeling, thawing procedures, and medication administration errors including incomplete medication labeling and failure to follow prescriber's orders. The submitted plan of correction was fully implemented and accepted.
Citations (6)
Leftover food in the kitchen was stored without labels indicating contents and dates.
Food was not stored in closed or sealed containers, including frozen chicken nuggets and hard boiled eggs.
Food was thawed improperly at room temperature instead of approved methods like refrigeration or microwave.
Medication containers lacked complete pharmacy labels including prescribed dosage and administration instructions.
Medication administration records were not initialed by staff at the time medications were given on multiple dates.
Prescriber's orders for insulin administration were not properly followed, resulting in medication errors on the resident's MAR.
Report Facts
Residents Served: 39
Current Hospice Residents: 4
Residents Receiving Supplemental Security Income: 12
Residents Age 60 or Older: 38
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 1
Residents with Physical Disability: 0
Total Daily Staff: 40
Waking Staff: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Supervisor | Named in oversight of food labeling and storage deficiencies. | |
| General Manager | Named in oversight of food labeling and storage deficiencies. | |
| LPN | Responsible for medication oversight and audits related to medication labeling and administration. | |
| Administrator | Responsible for medication oversight and audits related to medication labeling and administration. |
Inspection Report — Jul 24, 2024
Date: Jul 24, 2024
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 42
Current Hospice Residents: 2
Residents Receiving Supplemental Security Income: 12
Residents Age 60 or Older: 41
Residents Diagnosed with Intellectual Disability: 2
Residents Diagnosed with Mental Illness: 0
Residents with Mobility Need: 0
Residents with Physical Disability: 0
Inspection Report — Apr 10, 2024
Follow-Up
Date: Apr 10, 2024
Visit Reason
The inspection visit was conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to renewal and complaint reasons.
Findings
The facility was found to have implemented the plan of correction fully, addressing multiple deficiencies including resident personal equipment safety, storage of poisonous materials, trash receptacle coverage, outdated food, medication storage and record keeping, and support plan documentation. Continued compliance and preventive actions were established.
Citations (9)
The enabler bar in Resident #5's and Resident #6's room was not attached to the bed frame, posing a possible limb or head entrapment hazard.
A container of clear yellow liquid cleaner was found in the laundry room without an original manufacturer's label.
Three trash cans located in the kitchen were found uncovered, allowing potential penetration of insects and rodents.
Two dumpsters outside the home had lids open at the time of inspection, not preventing penetration of insects and rodents.
A bag of Roseli Mozzarella cheese in the pantry refrigerator was found to contain mold.
Resident #4 stored self-administered medications in an unlocked bedside drawer and did not lock the door when leaving the room.
Glucometers for Residents #1, #2, and #3 were not properly calibrated to the current date and time.
Resident #7's medication administration record did not list a diagnosis or purpose for a prescribed medication.
Resident Assessment Support Plans for Residents #5 and #6 did not document bedside mobility devices, their use, risks, or hygiene needs for Resident #5.
Report Facts
Residents Served: 45
Staffing Hours: 45
Waking Staff: 34
Residents Receiving Supplemental Security Income: 12
Residents Age 60 or Older: 44
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Intellectual Disability: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nancy Miller | Medical Manager | Named in findings related to correction of glucometer calibration and medication record omissions. |
| Carol Lowery | Lead Cook | Named in findings related to outdated food and trash receptacle violations. |
Inspection Report — Mar 7, 2023
Complaint Investigation
Date: Mar 7, 2023
Visit Reason
The inspection was conducted as a result of an incident, as indicated by the reason 'Incident' for the unannounced partial inspection on 03/07/2023.
Complaint Details
The inspection was complaint-related due to an incident, but no deficiencies or citations were found, indicating no substantiated violations.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Residents Served: 44
Total Daily Staff: 44
Waking Staff: 33
Residents Receiving Supplemental Security Income: 7
Residents Age 60 or Older: 43
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Intellectual Disability: 5
Residents with Mobility Need: 0
Residents with Physical Disability: 0
Inspection Report — Feb 28, 2023
Renewal
Date: Feb 28, 2023
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
The inspection found multiple regulatory violations including failure to post required regulations and emergency procedures, expired boiler certificate, unsigned resident contracts, incomplete fire safety orientation for staff, improper labeling of poisonous materials, fire hazard in smoking area furniture, dietary and medication errors, and documentation issues. All violations had plans of correction accepted and were implemented by April 11, 2023.
Citations (15)
Pennsylvania Code Chapter 2600 regulations were not posted in a public conspicuous area of the home.
Certificate of Boiler Pressure Vessel Operation expired on 2/3/23.
Resident contracts were not signed by the residents.
Ancillary staff member did not complete first day fire safety orientation.
Poisonous materials not stored in original labeled containers.
Emergency procedures not posted in a conspicuous and public place.
Resident medical evaluation not completed within annual guidelines.
Smoking area furniture did not meet California fire resistance standards.
Resident served red meat contrary to dietary restrictions.
Medication label for warfarin sodium was incorrect.
Medication Administration Record (MAR) for warfarin sodium was incorrect.
Prescriber not notified of resident medication refusals.
Residents not educated on right to refuse or question medication.
Resident additional assessments not completed annually within timeframe.
Resident Documentation of Medical Evaluation altered with correction fluid.
Report Facts
Residents Served: 44
Staffing Hours: 43
Staffing Hours: 87
Staffing Hours: 65
Residents Age 60 or Older: 43
Residents with Mental Illness: 4
Residents with Intellectual Disability: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Yankowy | Lead Inspector | Lead inspector for the renewal inspection conducted on 02/28/2023. |
Inspection Report — Feb 15, 2023
Date: Feb 15, 2023
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 44
Waking Staff: 33
Residents Receiving Supplemental Security Income: 11
Residents 60 Years of Age or Older: 43
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 0
Residents with Physical Disability: 0
Inspection Report — Apr 21, 2022
Renewal
Date: Apr 21, 2022
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report — Jan 25, 2022
Renewal
Date: Jan 25, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the facility license for Berks Leisure Living.
Findings
The inspection identified multiple deficiencies related to financial management, resident safety, medication administration, staff training, and facility maintenance. Plans of correction were submitted and verified as implemented by follow-up reviews.
Citations (17)
No signed receipt to verify resident received cash disbursement.
Resident funds were commingled in one joint bank account.
Resident was not informed about opening an interest-bearing account for funds held over $200.
Residents/POA were not provided quarterly accounts of financial transactions.
Missing signed rent rebate form in resident's record.
Refund check to resident was not mailed within 30 days of discharge.
Direct care staff member lacked verification of completion of required training and competency test.
Resident's bedrail was not covered, posing an entanglement hazard.
Snow was not fully removed from steps exiting the building.
No thermometer located in the two freezers in the kitchen.
Notification letter to fire department contained outdated census and resident location information.
Resident's medication self-administration assessment was not completed annually as required.
Glucometer date and time were not correctly calibrated.
Medication Administration Record did not list prescribed PRN medication and lacked documentation of effectiveness.
No documentation that resident received prescribed insulin as ordered.
Support plan was not revised within 30 days upon completion of annual assessment.
Resident did not have required annual additional assessment completed.
Report Facts
Residents served: 38
Resident funds balance: 19550.78
Staffing hours: 38
Waking staff hours: 29
Residents receiving SSI: 9
Residents aged 60 or older: 37
Residents diagnosed with mental illness: 3
Residents diagnosed with intellectual disability: 2
Residents with physical disability: 1
Inspection Report — Jul 20, 2021
Follow-Up
Date: Jul 20, 2021
Visit Reason
The inspection visit on 07/20/2021 was conducted as a complaint investigation and a follow-up to verify the implementation of a previously submitted plan of correction.
Complaint Details
The visit was complaint-related involving an allegation of abuse by Direct care staff member A against Resident #1. The complaint was substantiated by findings that the home did not implement a plan of supervision and did not report the allegation to the Department as required.
Findings
The facility was found to have violated regulations related to abuse allegations involving a staff member and a resident, specifically failing to implement a plan of supervision and failing to report the allegation to the Department within 24 hours. The submitted plan of correction was reviewed and determined to be fully implemented.
Citations (2)
Failure to implement a plan of supervision for a staff member involved in an abuse allegation.
Failure to report an allegation of abuse to the Department within 24 hours.
Report Facts
Residents Served: 41
Total Daily Staff: 43
Waking Staff: 32
Residents 60 Years or Older: 40
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 2
Residents Receiving Supplemental Security Income: 4
Notice — Mar 19, 2021
Date: Mar 19, 2021
Visit Reason
This document serves as a license renewal notification and certificate of compliance for Berks Leisure Living, a Personal Care Home, confirming the facility's authorized operation and informing about the requirement for an annual onsite inspection within the next twelve months.
Findings
The Department has issued a regular license in response to the renewal application and advises that an annual inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter. |
Inspection Report — Jan 13, 2021
Renewal
Date: Jan 13, 2021
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements for Berks Leisure Living.
Findings
The inspection identified several deficiencies including water contamination, inadequate bedside lighting, medication storage issues, improper documentation of blood glucose readings, and missing annual assessments for some residents. Plans of correction were submitted and mostly accepted, with ongoing compliance required.
Citations (5)
Brown water spurt from faucet in room C-5 bathroom sink indicating contaminant level violation.
Bedside lamp not within reach for resident in a room, posing fall risk.
Prescription inhaler for Resident #2 lacked original box and usage date.
Blood glucose readings for Resident #1 were inaccurately documented.
Residents #3 and #4 did not have annual assessments completed in 2020.
Report Facts
Residents Served: 45
Supplemental Security Income Recipients: 9
Residents Age 60 or Older: 44
Residents Diagnosed with Mental Illness: 6
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 1
Residents with Physical Disability: 0
Total Daily Staff: 46
Waking Staff: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anne Graziano | Signed the letter regarding plan of correction implementation. |
Inspection Report — Aug 31, 2020
Routine
Date: Aug 31, 2020
Visit Reason
The inspection was conducted as a routine licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Notice — Nov 27, 2019
Date: Nov 27, 2019
Visit Reason
This document serves as a renewal notification and license issuance for Berks Leisure Living to operate as a Personal Care Home. It informs the owner of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It is an administrative notice confirming license renewal and outlining future inspection requirements.
Inspection Report — Nov 21, 2019
Renewal
Date: Nov 21, 2019
Visit Reason
The inspection was conducted as a renewal and complaint-related visit to assess compliance with licensing requirements and investigate complaints.
Complaint Details
The inspection included a complaint investigation component, but the substantiation status is not explicitly stated.
Findings
The facility was found to have violations related to posting of required influenza posters, combustible storage hazards, and smoking area guidelines. Plans of correction were submitted and fully implemented as of February 2020.
Citations (3)
Regulation 2600.18: The facility did not have the required influenza poster provided by the Pennsylvania Department of Health posted in the facility.
Regulation 2600.125.a: A sock was found lying behind a dryer in the laundry room, creating a combustible and fire hazard.
Regulation 2600.144.c: Evidence of smoking was observed in an undesignated smoking area at the bottom of exterior stairs behind the activity room.
Report Facts
Residents Served: 47
Resident Support Staff: 0
Total Daily Staff: 48
Waking Staff: 36
Residents Receiving Supplemental Security Income: 11
Residents Age 60 or Older: 46
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 1
Residents with Physical Disability: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Denise M. Kasaba | Administrator | Named in relation to plan of correction signatures and administration |
Inspection Report — Feb 15, 2019
Date: Feb 15, 2019
Visit Reason
The inspection was a partial, unannounced visit triggered by an incident at the personal care home.
Findings
The inspection found a violation of 55 Pa.Code §2600.42(b) involving a resident grabbing another resident's breasts without consent. A plan of correction was submitted to prevent recurrence.
Citations (1)
55 Pa.Code §2600.42(b) - A resident grabbed another resident's breasts without consent during a social room interaction, constituting abuse.
Report Facts
Number of Residents Served: 48
Number of Residents 60 Years or Older: 47
Number of Residents with Mental Illness: 4
Number of Residents with Intellectual Disability: 2
Number of Residents Receiving Supplemental Security Income: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Denise Kasaba | Administrator | Named as facility administrator in the report header. |
| Kristin DeVries | Department representative on-site during inspection. | |
| Vanessa Mendez | Department representative on-site during inspection. | |
| Ray Calvin Miller Jr. | Owner/Administrator | Signed the plan of correction as legal entity representative. |
Inspection Report — Jan 17, 2019
Complaint Investigation
Date: Jan 17, 2019
Visit Reason
The inspection was conducted as a complaint and incident investigation at Berks Leisure Living personal care home on January 17, 2019 and February 5, 2019.
Complaint Details
The inspection was triggered by complaints and incidents related to suspected abuse and failure to report incidents timely. The violations were substantiated as the facility failed to submit timely reports and implement required interventions.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including failure to timely report suspected abuse and failure to implement positive interventions to modify or eliminate resident behaviors. The facility submitted plans of correction with partial implementation status as of June 2019.
Citations (3)
55 Pa.Code §2600.15(a): The home failed to immediately report suspected abuse of a resident, as a report was not submitted to the Department until 1/7/19 despite the incident occurring on 12/15/18.
55 Pa.Code §2600.16(c): The home failed to report an incident or condition to the Department's complaint hotline within 24 hours as required, delaying the report submission until 1/7/19.
55 Pa.Code §2600.201: The home did not implement positive interventions to modify or eliminate sexual compromising behaviors by staff toward residents since October 2018.
Report Facts
Number of Residents Served: 49
Staffing Hours - Total Daily Staff: 49
Staffing Hours - Waking Staff: 37
Residents Age 60 or Older: 48
Residents with Mental Illness: 4
Residents with Intellectual Disability: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Denise Kasaba | Administrator | Named as Administrator and Legal Entity Representative involved in plan of correction. |
| Jason Harvey | Inspector | Department representative conducting the inspection on 01/17/2019 and 02/05/2019. |
Notice — Nov 27, 2018
Date: Nov 27, 2018
Visit Reason
Notification of renewal application approval and issuance of a regular license for Berks Leisure Living Personal Care Home. The letter also informs about the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It is a license renewal notice and certificate of compliance.
Inspection Report — Nov 8, 2018
Annual Inspection
Date: Nov 8, 2018
Visit Reason
The inspection was an annual licensing inspection combined with complaint investigation and renewal review for Berks Leisure Living.
Complaint Details
The inspection included complaint investigation related to failure to report incidents and medication errors. Specific substantiation status is not stated.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including failure to report incidents, undated carbon monoxide detector batteries, incomplete staff training, outdated fire department notification, incomplete medical evaluations, improper medication administration documentation, and failure to calibrate medical equipment.
Citations (12)
Regulation 2600.16(c) was violated because the home did not submit required incident reports to the Department within 24 hours as mandated.
Regulation 2600.18 was violated because the batteries in the carbon monoxide detectors were not dated as required by The Care Facilities Carbon Monoxide Standards Act.
Regulation 2600.85(e) was violated because a direct care staff person had only 9.5 of the required 12 hours of annual training for 2017.
Regulation 2600.65(g) was violated because staff person A did not complete required annual training on Emergency Preparedness for 2017.
Regulation 2600.124 was violated because the home's letter to the fire department was not updated to reflect residents no longer living in the home.
Regulation 2600.141(a)(2) was violated because residents' DMEs did not indicate body positioning or immunization history as required.
Regulation 2600.144(c)(1) was violated because cigarette butts and matches were found outside the designated smoking area, violating fire safety rules.
Regulation 2600.185(a) was violated because a resident's glucometer was not calibrated to the correct month, day, and time.
Regulation 2600.187(a) was violated because medication administration records did not properly document insulin administration times and doses.
Regulation 2600.187(b) was violated because a resident's medication (Ketoconazole cream) was not administered as ordered and not properly documented.
Regulation 2600.188(b) was violated because a medication error was not immediately reported to the resident, designated person, and prescriber.
Regulation 2600.227(a) was violated because a resident's support plan did not document all required information and did not indicate safe use or avoidance of poisonous materials.
Report Facts
Number of Residents Served: 47
Staff Training Hours: 9.5
Insulin Reading: 214
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ray Calvin Miller Jr. | Administrator | Named as legal entity representative and administrator signing plans of correction. |
| Amy Deluca | On-site inspector listed on page 2 and author of violation report. |
Inspection Report — Jun 11, 2018
Complaint Investigation
Date: Jun 11, 2018
Visit Reason
The inspection was conducted due to an incident involving suspected verbal abuse between staff and a resident.
Complaint Details
The complaint involved a verbal abuse incident between staff person 'A' and resident #1 on 2/18/2018. The abuse was not immediately reported to the Department's Licensing Office or the Aging and Berks County Aging Office Protective Services. The incident report was received by fax on 3/1/2018. The home submitted plans of correction addressing reporting and supervision.
Findings
The facility was found to have failed to immediately report suspected abuse, submit a plan of supervision for the involved staff, and timely report the incident to the regional office as required by regulations.
Citations (3)
Regulation 56 Pa.Code §2600 2600.15(a) - The home failed to immediately report suspected abuse of a resident as required by law.
Regulation 56 Pa.Code §2600 2600.15(c) - The home failed to immediately submit a plan of supervision or notice of suspension for the staff involved in the verbal abuse incident.
Regulation 56 Pa.Code §2600 2600.16(c) - The home failed to submit a timely report within 24 hours of a suspected verbal abuse incident involving a resident.
Report Facts
Number of Residents Served: 47
Total Daily Staff: 47
Waking Staff: 35
Residents 60 Years or Older: 46
Residents with Mental Illness: 3
Residents with Intellectual Disability: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Denise Kasaba | Administrator | Named in facility header information |
| Nancy Miller | Medical Manager | Signed plan of correction documents related to abuse reporting and supervision |
Inspection Report — Apr 27, 2018
Complaint Investigation
Date: Apr 27, 2018
Visit Reason
The inspection was conducted as a complaint investigation at Berks Leisure Living.
Complaint Details
The inspection was complaint-driven. The violation involved medication administration errors for resident #1. The plan of correction included suspension of the staff involved and monthly reviews with medical staff.
Findings
Violations of 55 Pa. Code Chapter 2600 related to medication administration were found. The home failed to follow the directions of the prescriber for resident #1's medications on 4/15/18.
Citations (1)
Regulation 55 Pa.Code §2800 2600.187(d): The home did not follow the directions of the prescriber. On 4/15/18, staff person A did not administer resident #1's 4pm medications including Mag Oxide 400mg, Metformin 1000mg, Alprazolam 1mg, and Warfarin 10mg until the 8pm med pass.
Report Facts
Number of Residents Served: 46
Total Daily Staff: 46
Waking Staff: 35
Residents Age 60 or Older: 44
Residents with Mental Illness: 3
Residents with Intellectual Disability: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Denise Kasaba | Administrator | Named as Administrator on page 2 and signed the plan of correction on page 3. |
| Kimberli Foulkes | Department representative on-site during inspection on 4/27/2018. |
Inspection Report — Nov 30, 2017
Renewal
Date: Nov 30, 2017
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing inspection and renewal process for Berks Leisure Living Inc. The visits occurred on multiple dates including September 7, 2017, November 30, 2017, February 15, 2018, and March 15, 2018.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 related to medication administration, staff training, fire safety orientation, hot water temperature, food storage, and documentation were identified. Plans of correction were submitted and partially implemented with ongoing monitoring by the Administrator and Medical Manager.
Citations (16)
Regulation 55 Pa.Code §2600.182(c): Medication administration errors were found where the medication administration record (MAR) and pharmacy label did not match for resident #1, and staff failed to notice the discrepancy.
Regulation 55 Pa.Code §2600.183(b): Prescription medications and syringes were unlocked and accessible in resident #2's room, violating medication security requirements.
Regulation 55 Pa.Code §2600.187(a): Medication records for resident #1 and #3 lacked matching MAR and pharmacy labels, and staff failed to properly initial medication administration.
Regulation 55 Pa.Code §2600.18: The certificate of boiler or pressure vessel operation had expired and required renewal to maintain compliance.
Regulation 55 Pa.Code §2600.57(b): The home failed to provide the required minimum 48 hours of direct care staffing, only providing 42.75 hours.
Regulation 55 Pa.Code §2600.57(d): The home failed to provide the required minimum 36 hours of direct care staffing during waking hours, only providing 35.25 hours.
Regulation 55 Pa.Code §2600.65(a): Direct care staff did not complete required fire safety orientation on their first day of work.
Regulation 55 Pa.Code §2600.65(d): Direct care staff hired after April 24, 2006 did not complete required supervised training and competency testing before providing unsupervised care.
Regulation 55 Pa.Code §2600.89(b): Hot water temperature in resident bathrooms exceeded the maximum allowed 120°F, measuring 136.6°F in one room.
Regulation 55 Pa.Code §2600.103(i): Outdated or unlabeled food items were found in the home's kitchen and pantry, including opened bags without labels or dates.
Regulation 55 Pa.Code §2600.105(g)(2): Lint buildup was found in dryer ducts, posing a fire hazard.
Regulation 55 Pa.Code §2600.144(c)(1): Smoking receptacles were not properly maintained and located, and the designated smoking area was not clearly identified.
Regulation 55 Pa.Code §2600.185(a): The home failed to implement proper procedures for safe storage, access, and documentation of medications and medical equipment for residents #2 and #3.
Regulation 55 Pa.Code §2600.187(c): The home failed to document refusals of prescribed medication for resident #1 and notify the prescriber within required timeframes.
Regulation 55 Pa.Code §2600.187(d): The home failed to follow physician orders for medication administration changes for resident #3.
Regulation 55 Pa.Code §2600.107(c): The home failed to maintain at least a 3-day supply of nonperishable food and drinking water, with only 141 gallons of emergency water on hand.
Report Facts
Number of Residents Served: 48
Total Daily Staff: 48
Waking Staff: 36
Hot Water Temperature: 136.6
Hot Water Temperature: 128.1
Hot Water Temperature: 122.9
Emergency Water Supply: 141
Required Direct Care Staffing Hours: 48
Actual Direct Care Staffing Hours: 42.75
Required Direct Care Staffing Hours During Waking Hours: 36
Actual Direct Care Staffing Hours During Waking Hours: 35.25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Maynor | Administrator | Named in multiple medication administration and plan of correction sections |
| Ray Calvin Miller Jr. | Administrator | Signed multiple plans of correction and inspection reports |
| Gerald Dumas | Department representative present on 09/07/2017 inspection | |
| Kimberli Foulkes | Department representative present on 09/07/2017 and 11/30/2017 inspections | |
| Ryan Novak | Department representative present on 11/30/2017 and 02/15/2018 inspections | |
| Cindy Yellenic | Department representative present on 02/15/2018 inspection | |
| Jacqueline L. Rowe | Director | Signed cover letter dated March 23, 2018 |
Inspection Report — May 4, 2017
Date: May 4, 2017
Visit Reason
The inspection was an unannounced licensing inspection conducted by the Pennsylvania Department of Human Services on May 4, 2017, to assess compliance with 55 Pa.Code Chapter 2600 relating to Personal Care Homes.
Findings
The facility was found to be in violation of 55 Pa.Code §2600.18 due to operating a salon/beauty shop without a license. The facility has initiated corrective actions including contracting a licensed plumber and obtaining permits to meet licensing requirements.
Citations (1)
55 Pa.Code §2600.18 - The facility operated a salon/beauty shop without a valid license, which is required to comply with all applicable Federal, State, and local laws.
Report Facts
Number of Residents Served: 47
Total Daily Staff: 47
Waking Staff: 35
Number of Residents Age 60 or Older: 46
Number of Residents Receiving Supplemental Security Income: 5
Number of Residents with Mental Illness: 3
Number of Residents with Intellectual Disability: 1
Number of Current Hospice Residents: 0
Number of Hospice Residents in Past Year: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Maynor | Administrator | Named as Administrator and Legal Entity Representative responsible for plan of correction |
Inspection Report — Mar 23, 2017
Renewal
Date: Mar 23, 2017
Visit Reason
The inspection was conducted as a full, unannounced visit for renewal, complaint, and incident reasons on March 23 and 24, 2017, with follow-up on June 28, 2017.
Complaint Details
The inspection included complaint and incident investigations related to medication errors, incident reporting failures, and resident treatment concerns. Some violations were repeat from previous inspections dated 2016-03-17 and 2016-10-26.
Findings
Multiple violations were found related to incident reporting, resident dignity, criminal background checks, pest control, food safety, medical evaluations, medication administration, and documentation. Plans of correction were partially implemented with ongoing monitoring required.
Citations (18)
55 Pa.Code §2600.16(c): The home failed to report incidents to the Department within 24 hours as required, including a resident fall and disrespectful staff behavior.
55 Pa.Code §2600.42(c): A staff person was disrespectful to a resident by raising their voice and using colored pencils inappropriately.
55 Pa.Code §2600.51: A staff member did not have a completed criminal background check at the time of hire.
55 Pa.Code §2600.85(e): Trash bags and dumpster lids were left uncovered, allowing potential insect and rodent penetration.
55 Pa.Code §2600.103(i): Food items in the refrigerator and pantry were not labeled or dated as required.
55 Pa.Code §2600.141(a)(2): The annual medical evaluation for a resident was incomplete and missing key information.
55 Pa.Code §2600.141(b)(1): The annual medical evaluation was faxed with pen and ink changes and incomplete documentation.
55 Pa.Code §2600.144(b): The home's smoking policy did not specify the designated smoking area.
55 Pa.Code §2600.181(e): A resident was self-administering medication without proper recognition or knowledge of medication use.
55 Pa.Code §2600.182(c): Medication administration errors occurred including wrong medications given and failure to follow the 7 steps of medication administration.
55 Pa.Code §2600.183(b): The home's first aid kit contained unauthorized medications and was not properly monitored.
55 Pa.Code §2600.184(c): Sample prescription medications were not labeled with required information including date and prescriber.
55 Pa.Code §2600.187(a): Medication records lacked required documentation including injection site and staff initials.
55 Pa.Code §2600.187(c): Refusals to take prescribed medication were not properly documented or reported to the prescriber.
55 Pa.Code §2600.187(d): The home failed to follow prescriber directions for medication administration.
55 Pa.Code §2600.190(a): Staff did not complete required medication administration training and documentation was incomplete.
55 Pa.Code §2600.185(a): The home did not implement procedures for safe medication storage and use when residents were out of the facility.
55 Pa.Code §2600.227(d): Resident support plans were not signed by residents and did not document receipt of outside services.
Report Facts
Staff Count: 43
Fine Amount: 230
Fine Amount: 138
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Maynor | Administrator | Named as legal entity representative and responsible for ongoing compliance and plans of correction. |
Notice — Jan 24, 2017
Date: Jan 24, 2017
Visit Reason
The document serves as a renewal notification and license issuance for Berks Leisure Living to operate as a Personal Care Home.
Findings
The Department of Human Services approved the renewal application and issued a regular license. The Department will conduct an annual onsite inspection within the next twelve months to ensure compliance.
Report Facts
Inspection Report — Dec 29, 2016
Complaint Investigation
Date: Dec 29, 2016
Visit Reason
The inspection was conducted as a complaint investigation at Berks Leisure Living.
Complaint Details
The inspection was triggered by a complaint. The violation involved unsecured medication left accessible to residents.
Findings
A violation was found regarding unsecured prescription and OTC medications, specifically an Advair inhaler left accessible on the nursing station ledge. The staff person responsible was no longer employed, and the facility implemented a plan of correction to prevent recurrence.
Citations (1)
REGULATION 55 Pa.Code §2600: Prescription medications, OTC medications, CAM and syringes must be kept locked and inaccessible to residents. An Advair inhaler was left unlocked and accessible on the nursing station ledge.
Report Facts
Number of Residents Served: 45
Number of Residents who Receive Supplemental Security Income: 5
Number of Residents who Are 60 Years of Age or Older: 44
Number of Residents who Have Mental Illness: 2
Number of Residents who Have an Intellectual Disability: 3
Number of Current Hospice Residents: 1
Number of Hospice Residents in Past Year: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Maynor | Administrator | Signed the plan of correction and is responsible for ongoing compliance |
| Jason Harvey | Department representative on-site during inspection |
Inspection Report — Oct 26, 2016
Complaint Investigation
Date: Oct 26, 2016
Visit Reason
The inspection was a complaint investigation conducted as a partial, unannounced visit on October 26, 2016, and November 8, 2016, to evaluate compliance with 55 Pa.Code Chapter 2600 for Personal Care Homes.
Complaint Details
The inspection was triggered by a complaint. The report documents multiple violations substantiated through resident and staff interviews and observations.
Findings
Multiple violations were found related to medication administration errors, confidentiality breaches, staff behavior, and medication storage security. The facility was required to implement corrective actions to ensure resident safety, confidentiality, and dignity.
Citations (8)
Regulation 55 Pa.Code §2600 requires reporting incidents to the Department within 24 hours. The facility failed to report a medication error and incidents of missing resident money to the Department.
Regulation 55 Pa.Code §2600 requires resident records to be confidential. The staff book containing confidential resident information was found unlocked and accessible on the medication cart.
Regulation 55 Pa.Code §2600 mandates residents be treated with dignity and respect. Staff interviews revealed that the Administrator could be rude and disrespectful to residents.
Regulation 55 Pa.Code §2600 requires prescription medications to be administered by trained staff. On 9/17/16, no trained staff were available to administer medications during a specified time period.
Regulation 55 Pa.Code §2600 requires medications and syringes to be kept locked. The medication cart outside the Administrator's office was found unlocked and accessible.
Regulation 55 Pa.Code §2600 requires medications stored in refrigerators to be kept locked. Resident #4's insulin supplies were stored unlocked in the refrigerator, and a lockbox was broken and not reported.
Regulation 55 Pa.Code §2600 requires following prescriber directions. Resident #1 did not receive prescribed Tylenol on 9/18/16 at 12am due to a late Med Tech arrival and medication error.
Regulation 55 Pa.Code §2600 requires medication errors to be immediately reported to the resident, designated person, and prescriber. The medication error involving Resident #1 was not reported to the prescriber.
Report Facts
Number of Residents Served: 46
Staffing Hours - Resident Support: 0
Staffing Hours - Total Daily Staff: 47
Staffing Hours - Waking Staff: 35
Number of Residents 60 Years or Older: 45
Number of Residents with Mental Illness: 3
Number of Residents with Intellectual Disability: 3
Number of Residents with Mobility Need: 1
Number of Current Hospice Residents: 1
Number of Hospice Residents in Past Year: 1
Number of Residents Receiving Supplemental Security Income: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Maynor | Administrator | Named as the facility Administrator responsible for corrective actions and cited in findings regarding staff behavior and compliance. |
| Ryan Novak | Department representative conducting the inspection on 10/26/2016. | |
| Julienne Rushin | Department representative conducting the inspection on 11/08/2016. |
Inspection Report — Mar 17, 2016
Renewal
Date: Mar 17, 2016
Visit Reason
The inspection was conducted as a renewal licensing inspection of Berks Leisure Living facility on March 17, 2016.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including medication errors, unsigned resident contracts, unsafe storage of poisonous materials, sanitary condition issues, improper food storage temperatures, fire safety hazards, incomplete medical evaluations, smoking violations, and medication administration record inaccuracies. Plans of correction were submitted for each violation.
Citations (17)
55 Pa.Code 2600.16(c) - The home failed to report a medication error to the Department within 24 hours as required.
55 Pa.Code 2600.25(h) - The resident home contract for resident #1 was not signed by the resident as required.
55 Pa.Code 2600.82(c) - Poisonous materials were not kept locked and inaccessible; bleach was used by a resident capable of handling poisonous materials.
55 Pa.Code 2600.85(a) - Staff used contaminated glucometers and were not properly trained on blood glucose readings.
55 Pa.Code 2600.103(f) - Freezer temperatures were improperly maintained above 0°F, risking food spoilage.
55 Pa.Code 2600.105(g)(1) - Lint trap of laundry dryer was coated with heavy lint accumulation, posing fire hazard.
55 Pa.Code 2600.125(a) - Combustible and flammable materials were improperly stored near heat sources in laundry area.
55 Pa.Code 2600.132(d) - Fire safety drill conducted on 1/17/16 lasted 15 seconds, less than required time for evacuation.
55 Pa.Code 2600.132(e) - Nighttime fire drill was held after the required six-month interval, constituting a violation.
55 Pa.Code 2600.141(b)(1) - Resident #2 did not have a current medical evaluation as required; evaluation was overdue.
55 Pa.Code 2600.144(c)(1) - Smoking violations occurred with extinguished cigarettes and plastic cigar filters found outside designated smoking areas.
55 Pa.Code 2600.183(d) - Expired inhalers and medication samples were kept in the home; inhalers were not dated for usage monitoring.
55 Pa.Code 2600.186(c) - Resident #5's medication administration record indicated Spiriva inhaler was discontinued but no physician's order was on file.
55 Pa.Code 2600.187(a) - Medication administration records for resident #3 were inaccurate and incomplete, including incorrect sliding scale insulin dosages.
55 Pa.Code 2600.187(d) - Resident #4's insulin administration documentation was inaccurate and incomplete, with a typo in the description.
55 Pa.Code 2600.88(b) - Medication error was not immediately reported to the resident, designated person, and prescriber as required.
55 Pa.Code 2600.225(c) - Resident #2 did not have timely additional assessments completed; delay in receiving DME caused oversight.
Report Facts
Number of Residents Served: 45
Total Daily Staff: 46
Walking Staff: 35
Number of Current Hospice Residents: 1
Number of Residents 60 Years or Older: 43
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Maynor | Administrator | Named in multiple findings and signed plans of correction. |
Notice — Feb 1, 2016
Date: Feb 1, 2016
Visit Reason
This document serves as a renewal notification and license issuance for Berks Leisure Living Personal Care Home following receipt of a renewal application dated January 21, 2016.
Findings
The Department advises that an onsite inspection will be conducted within the next twelve months to ensure compliance with Title 55, PA Code, Chapter 2600. No inspection findings are reported in this document.
Report Facts
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