Village At Penn State, The

Based on observation and staff interview, it was determined that the facility failed to store food and maintain food service equipment in accordance with professional standards for food service safety in the facility's main kitchen.Findings include: An observation in the facility's Atrium kitchen and supply room, and the main kitchen on May 12, 2026, at 9:20 AM revealed the following: The Atrium gas burners were observed with black, charred particulate matter that was cooked on to the metal grates. The metal control knobs on the Atrium stove were observed to have a large amount of dust, debris, and grease built up between the knobs. The Atrium oven was observed with black and charred debris throughout the base of the oven and on the oven door. The supply room ice machine was observed to have plastic lids, a small square bucket, a cup, and boxes of gloves behind ice machine on the floor. The supply room refrigerator contained a container of milk was bulging and leaking. And was noted to be frozen. The main kitchen walk-in freezer had an uncovered sheet cake sitting on a shelf. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and staff interview it was determined that the facility failed to ensure that active physician orders incorporated resident wishes related to end-of-life care for one of four residents reviewed for advanced directives concerns (Resident 3). Findings include: Clinical record review revealed the facility admitted Resident 3 on March 30, 2026. Review of Resident 3's active physician order dated March 20, 2026, revealed staff are to implement full treatment in the event of a medical emergency (Full Code, chest compressions and breathing assistance). A POLST (Physician Orders for Life Sustaining Treatment, portable medical order form that records treatment wishes so that emergency personnel know what treatments the resident wants in the event of a medical emergency) form signed by Resident 3 on March 23, 2026, revealed Resident 3 wanted staff to implement DNR (Do Not Resuscitate, do not provide chest compressions or assist with breathing) directives in the event of a medical emergency. The above findings for Resident 3 were reviewed during a meeting with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to implement a comprehensive person-centered care plan regarding a cardiac pacemaker for two of 11 residents reviewed (Residents 28 and 33).Findings Include: Clinical record review for Resident 28 revealed a diagnosis list that included the presence of a cardiac pacemaker (an electronic device to help regulate the beating of the heart), sick sinus syndrome (a malfunctioning of the heart that impacts the heart's natural pacemaker node), and atrial fibrillation (an irregular heart rhythm). Medical provider documentation for Resident 28 dated April 8, 2026, at 10:29 AM also revealed a diagnosis list that included the presence of a cardiac pacemaker. A quarterly Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) for Resident 28 dated March 18, 2026, revealed an active diagnosis of the presence of a cardiac pacemaker. Review of Resident 28's care plan revealed no current comprehensive, person-centered care plan that addressed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on a review of employee personnel and education records and staff interview, it was determined that the facility failed to ensure that each nurse aide received 12 hours of in-service training annually for one of three nurse aides reviewed (Employee 1). Findings include: Review of Employee 1's (nurse aide) personnel record revealed that the facility hired her on April 17, 2023. Review of training records provided by the facility for Employee 1 dated April 2025, to April 2026, revealed that Employee 1 completed six hours and 25 minutes of in-service education. Interview with the Nursing Home Administrator on May 14, 2026, at 12:04 PM confirmed the above findings for Employee 1. 28 Pa. Code 201.19(7) Personnel policies and procedures 28 Pa. Code 201.20(a)(6)(d) Staff development

Based on observation and staff interview, it was determined the facility failed to store food and maintain food service equipment in a safe and sanitary manner in the facility's main kitchen, Atrium kitchen, and pantry.Findings include:Observation of the Atrium kitchen on June 3, 2025, at 9:30 AM revealed the following:Multiple sheet pans were observed stored and in use in the cooking area contained significant black buildup on the pans.A large plastic wrap holder on the production table was observed with dried liquid splatter, food crumbs, and dust on the exterior and interior of the holder.The flooring under the dish machine, cooler, and food cooking equipment contained dirt/debris buildup on the flooring and wall edges.A three-tier black cart located across from the dish machine with clean glasses and trays stored on it had dried spills, dried food, and debris on the shelves of the cart.An observation of the main kitchen on June 3, 2025, at 9:50 AM, which is utilized to store food and prepare some food items for the Atrium kitchen revealed the following:A significant buildup of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that pain management was provided that was consistent with professional standards of practice for two of two residents reviewed (Residents 4 and 18).Findings include:Clinical record review for Resident 4 revealed current physician orders for Oxycodone HCI 5 milligrams (mg)Clinical record review for Resident 4 revealed current physician orders for Acetaminophen (a medication used to control mild pain) extra strength 500 mg by mouth every four hours as needed for pain, (no pain level identified), Oxycodone HCI (a narcotic pain medication used to control moderate to severe pain) oral tablets 5 mg every six hours as needed for moderate to severe pain, and Oxycodone HCI oral tablets 5 mg give 2.5 mg every four hours as needed for pain (no pain level identified).Review of Resident 4's most recent quarterly MDS (Minimum Data Set, an assessment completed by the facility, at intervals to determine the care needs of the resident) dated May 20, 2025, revealed that she had occasional pain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to ensure that the facility determined a resident's ability to self-administer medications for one of one resident reviewed (Resident 14). Findings include: Observation of Resident 14 on June 4, 2025, at 12:35 PM revealed she was sitting in her chair beside her bed with her bedside table in front of her. On the bedside table she had Flonase nasal spray (a steroid medication used to treat various signs and symptoms that could be caused by allergies) and Afrin nasal spray (a medication used to treat nasal congestion and stuffiness). She indicated that she brought them to the facility from the hospital. She said that both medications have been on her windowsill or overbed table since she came to the facility on May 21, 2025. She also indicated that she does self-administer the medications. Clinical record review for Resident 14 revealed no physician's order that the resident may self-administer the medication, or that the facility determined the resident was able…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, clinical record review, and staff interview, it was determined that the facility failed to implement interventions related to fall injury prevention for one of four residents reviewed (Resident 31) and failed to provide adequate supervision resulting in a fall for one of four residents reviewed (Resident 23).Findings include:Clinical record review for Resident 31 revealed a diagnosis list that included a history of falling.Resident 31's quarterly Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated April 9, 2025, revealed that staff assessed the resident as having a BIMS (Brief Interview for Mental Status) of 5, which indicated severe cognitive impairment.Review of Resident 31's care plan revealed that the resident is at risk for falls due to unsteady gait and poor balance. An intervention dated December 17, 2024, instructed staff to have dycem (a material used to prevent slipping or sliding) on the seat of the resident's wheelchair and the top of the pressure alarm to prevent sliding.Clinical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interview, it was determined that the facility failed to store food items and maintain a safe and sanitary environment in the main kitchen and smaller kitchen area located on the skilled nursing unit. Findings included: Initial tour of the facility's main kitchen on July 16, 2024, between 11:10 AM and 11:40 AM with Employee 1, Director of Dining, revealed the following: Observation of the walk-in freezer off the hallway revealed: A package of veggie burgers was undated, and the package was open exposing them to the ambient air. Several packages of what Employee 1 identified as ground pork sausage were undated. An undated bag of breadsticks was open to the ambient air. Observation of the walk-in cooler off the hallway revealed: A package of onions had an expired use-by date of 7/9. Four bags of celery had no dates on them. A container labeled plain halibut had an expired use-by date of 7/14. There were eight foil wrapped items in a tray that Employee 1 identified as potatoes with no labels or dates on them. There were multiple packaged avocado halves in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review, review of facility documents, and staff interview, it was determined that the facility failed to prevent abuse for one of one resident reviewed (Resident 8). Findings include: Clinical record review for Resident 8 revealed that on May 9, 2024, at 10:30 PM a nurse aide noted her to be sitting on the floor on the left side of her bed. The resident indicated that she slid out of bed. Concurrently, Employee 2, Registered Nurse, was made aware that Resident 8 fell out of bed, and the need to assess her for injuries. Review of the facility investigation into the fall revealed that Resident 8 did not have any injuries from the fall but there were concerns documented by Employee 3, nurse aide and Employee 4, Licensed Practical Nurse, that indicated they reported to the Director of Nursing (DON) that when Employee 2 came to assess Resident 8, she was verbally inappropriate to her. The investigation also confirmed that Resident 8 was interviewed and that the nurse was rude and unprofessional. Review of a witness statement from Employee 4, dated May 9, 2024,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and staff interview, it was determined that the facility failed to monitor for the effectiveness or adverse consequences of psychotropic medication use for one of five residents reviewed (Resident 8). Findings include: Clinical record review for Resident 8 revealed a current physician's order for Zoloft (a medication used to treat depression) 25 milligrams (mg) one time a day. Review of Resident 8's current care plan revealed a care plan focus area for depression related to dementia. The goal was for Resident 8 to remain free of signs and symptoms of depression, anxiety, or sad mood. The interventions indicated to monitor for side effects and effectiveness of the medication. Further clinical record review revealed no documented evidence that Resident 8 was being monitored for side effects or effectiveness of the medication. Interview with the Director of Nursing and Nursing Home Administrator on July 18, 2024, at 12:15 PM confirmed the above noted findings that there was no documented evidence that they were monitoring Resident 8 for side effects or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.