Inspection Reports for Berks Leisure Living
1399 FAIRVIEW DRIVE,, LEESPORT, PA, 19533
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
11.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
151% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
82% occupied
Based on a March 2025 inspection.
Census over time
Inspection Report
Follow-Up
Census: 40
Capacity: 49
Deficiencies: 2
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.
Deficiencies (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
License Capacity: 49
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
Follow-Up
Census: 39
Capacity: 49
Deficiencies: 3
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.
Deficiencies (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
License Capacity: 49
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
Complaint Investigation
Census: 39
Capacity: 49
Deficiencies: 6
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.
Deficiencies (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
License Capacity: 49
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
Census: 42
Capacity: 49
Deficiencies: 0
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
License Capacity: 49
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
Follow-Up
Census: 45
Capacity: 49
Deficiencies: 9
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.
Deficiencies (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
License Capacity: 49
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
Complaint Investigation
Census: 44
Capacity: 49
Deficiencies: 0
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
License Capacity: 49
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
Renewal
Census: 44
Capacity: 49
Deficiencies: 15
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.
Deficiencies (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
License Capacity: 49
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
Census: 44
Capacity: 49
Deficiencies: 0
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
Renewal
Deficiencies: 0
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
Renewal
Census: 38
Capacity: 49
Deficiencies: 17
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.
Deficiencies (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
License capacity: 49
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
Follow-Up
Census: 41
Capacity: 49
Deficiencies: 2
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.
Deficiencies (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
License Capacity: 49
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
Capacity: 49
Deficiencies: 0
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
Maximum capacity: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter. |
Inspection Report
Renewal
Census: 45
Capacity: 49
Deficiencies: 5
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.
Deficiencies (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
License Capacity: 49
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. |
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