Pennsylvania Department of Health
 MANOR AT PENN VILLAGE, THE
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
MANOR AT PENN VILLAGE, THE
Inspection Results For:

There are  151 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
MANOR AT PENN VILLAGE, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on two Complaint Investigations, completed on August 12, 2024, at The Manor At Penn Village, it was determined that there were no federal deficiencies, related to the Health portion of the survey process, identified under the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care as they relate to the Health portion of the survey process; however, the facility was not in compliance with 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


§ 211.12(f.1)(3) LICENSURE Nursing services. :State only Deficiency.
(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:
Based on a review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure a minimum of one nurse aide (NA) per 10 residents during the day shift for nine of 21 days reviewed, one NA per 11 residents during the evening shift for 10 of the 21 days reviewed, and one NA per 15 residents during the night shift for 20 of 21 days reviewed.

Findings include:

Review of nursing staff care hours provided by the facility revealed the following nurse aides scheduled for the resident census:

Day shift (requires one NA per 10 residents):
July 21, 2024, 11.73 NAs for a census of 123, requires 12.3 NAs
July 25, 2024, 12.27 NAs for a census of 126, requires 12.6 NAs
July 26, 2024, 12.27 NAs for a census of 125, requires 12.5 NAs
July 27, 2024, 11.73 NAs for a census of 124, requires 12.4 NAs
July 28, 2024, 11.73 NAs for a census of 124, requires 12.4 NAs
July 30, 2024, 11.73 NAs for a census of 123, requires 12.3 NAs
August 6, 2024, 11.73 NAs for a census of 124, requires 12.4 NAs
August 7, 2024, 11.73 NAs for a census of 121, requires 12.1 NAs
August 9, 2024, 11.2 NAs for a census of 122, requires 12.2 NAs

Evening shift (requires one NA per 11 residents):

July 18, 2024, 10.67 NAs for a census of 125, requires 11.36 NAs
July 19, 2024, 10.67 NAs for a census of 125, requires 11.36 NAs
July 21, 2024, 10.13 NAs for a census of 123, requires 11.18 NAs
July 22, 2024, 10.67 NAs for a census of 120, requires 10.91 NAs
July 23, 2024, 10.67 NAs for a census of 120, requires 10.91 NAs
July 25, 2024, 11.20 NAs for a census of 125, requires 11.36 NAs
July 26, 2024, 11.20 NAs for a census of 125, requires 11.36 NAs
July 27, 2024, 10.67 NAs for a census of 124, requires 11.27 NAs
July 28, 2024, 10.67 NAs for a census of 124, requires 11.27 NAs
August 8, 2024, 11.20 NAs for a census of 124, requires 11.27 NAs

Night shift (requires one NA per 15 residents):

July 18, 2024, 7.47 NAs for a census of 125, requires 8.33 NAs
July 19, 2024, 7.47 NAs for a census of 125, requires 8.33 NAs
July 20, 2024, 7.47 NAs for a census of 125, requires 8.33 NAs
July 21, 2024, 6.40 NAs for a census of 123, requires 8.20 NAs
July 22, 2024, 7.47 NAs for a census of 120, requires 8.0 NAs
July 23, 2024, 7.47 NAs for a census of 120, requires 8.0 NAs
July 24, 2024, 7.47 NAs for a census of 121, requires 8.07 NAs
July 25, 2024, 7.47 NAs for a census of 125, requires 8.33 NAs
July 26, 2024, 7.47 NAs for a census of 125, requires 8.33 NAs
July 27, 2024, 4.0 NAs for a census of 124, requires 8.27 NAs
July 28, 2024, 4.0 NAs for a census of 124, requires 8.27 NAs
July 29, 2024, 5.33 NAs for a census of 124, requires 8.27 NAs
July 30, 2024, 7.47 NAs for a census of 123, requires 8.20 NAs
August 5, 2024, 5.87 NAs for a census of 121, requires 8.07 NAs
August 6, 2024, 7.47 NAs for a census of 124, requires 8.27 NAs
August 7, 2024, 7.47 NAs for a census of 121, requires 8.07 NAs
August 8, 2024, 7.47 NAs for a census of 124, requires 8.27 NAs
August 9, 2024, 7.47 NAs for a census of 122, requires 8.13 NAs
August 10, 2024, 7.47 NAs for a census of 121, requires 8.07 NAs
August 11, 2024, 6.93 NAs for a census of 121, requires 8.07 NAs

Interview with the Nursing Home Administrator and the Director of Nursing on August 12, 2024, at 1:55 PM, confirmed that the facility did not meet regulatory NA-to-resident ratios as evidenced above.



 Plan of Correction - To be completed: 09/17/2024

The facility cannot retroactively correct past Nursing aide ratios.
The facility will continue to take measures to adequately provide nurse-aid staff to ensure the needs of the residents are met. Measures will be put in place to adequately provide staff with the required nurse aide to resident ratios. These measures include, continuing our retention committee, increased advertising efforts, utilization of agency staff, and sign on bonuses.
The Director of Nursing/designee will educate minimum staffing ratios to RN Supervisors, HR, and the nursing scheduler who are responsible to maintain adequate staffing ratios. The Director of Nursing/designee will audit the daily schedules 5x week x 6 weeks to ensure that the minimum number of nurse aide staff to resident ratios have been scheduled. The results of the audits will be reviewed at the facilities QAPI meeting for recommendations.
§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:
Based on a review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift on one of the 21 days reviewed, one LPN per 30 residents during the evening shifts on one of the 21 days reviewed, and one LPN per 40 residents during the overnight shift on 19 of the 21 days reviewed.

Findings include:

Review of nursing staff care hours provided by the facility revealed the following staff scheduled for the following resident census:

Day shift (requires one LPN per 25 residents):

July 20, 2024, 4.75 LPNs for a census of 125, requires 5.0 LPNs

Evening shift (requires one LPN per 30 residents):

August 7, 2024, 3.0 LPNs for a census of 121, requires 4.03 LPNs

Overnight shift (requires one LPN per 40 residents):

July 17, 2024, 2.5 LPNs for a census of 125, requires 3.13 LPNs
July 18, 2024, 3.0 LPNs for a census of 125, requires 3.13 LPNs
July 19, 2024, 3.0 LPNs for a census of 125, requires 3.13 LPNs
July 20, 2024, 3.0 LPNs for a census of 125, requires 3.13 LPNs
July 21, 2024, 3.0 LPNs for a census of 123, requires 3.08 LPNs
July 24, 2024, 2.5 LPNs for a census of 121, requires 3.03 LPNs
July 25, 2024, 3.0 LPNs for a census of 125, requires 3.13 LPNs
July 26, 2024, 3.0 LPNs for a census of 125, requires 3.13 LPNs
July 27, 2024, 2.5 LPNs for a census of 124, requires 3.10 LPNs
July 28, 2024, 2.5 LPNs for a census of 124, requires 3.10 LPNs
July 29, 2024, 3.0 LPNs for a census of 124, requires 3.10 LPNs
July 30, 2024, 3.0 LPNs for a census of 123, requires 3.08 LPNs
August 5, 2024, 3.0 LPNs for a census of 121, requires 3.03 LPNs
August 6, 2024, 2.5 LPNs for a census of 124, requires 3.10 LPNs
August 7, 2024, 3.0 LPNs for a census of 121, requires 3.03 LPNs
August 8, 2024, 3.0 LPNs for a census of 124, requires 3.10 LPNs
August 9, 2024, 3.0 LPNs for a census of 122, requires 3.05 LPNs
August 10, 2024, 2.0 LPNs for a census of 121, requires 3.03 LPNs
August 11, 2024, 3.0 LPNs for a census of 121, requires 3.03 LPNs

Interview with the Nursing Home Administrator and the Director of Nursing on August 12, 2024, at 1:55 PM, confirmed that the facility did not meet regulatory LPN-to-resident ratios as evidenced above.




 Plan of Correction - To be completed: 09/17/2024

The facility cannot retroactively correct past LPN ratios. The facility will continue to take measures to adequately provide LPN staff to ensure the needs of the residents are met. Measures will be put in place to adequately provide staff with the required LPN to resident ratios. These measures include, continuing our retention committee, increased advertising efforts, utilization of agency staff, and sign on bonuses. The Director of Nursing/designee will educate minimum staffing ratios to RN Supervisors, HR, and the nursing scheduler who are responsible to maintain adequate staffing ratios.
The Director of Nursing/designee will audit the daily schedules 5x week x 6 weeks to ensure that the minimum number of LPN staff to resident ratios have been scheduled. The results of the audits will be reviewed at the facilities QAPI meeting for recommendations.
§ 211.12(i)(2) LICENSURE Nursing services.:State only Deficiency.
(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:
Based on review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure the total of nursing care hours provided in each 24-hour period was a minimum of 3.2 hours per patient day (PPD), effective July 1, 2024, for 19 of the 21 days reviewed.

Findings include:

Review of nursing staff care hours for July 17 through 30, 2024, and August 5 through 11, 2024, revealed that the facility failed to meet the minimum hours per patient day for the following days:

July 17, 2024, 3.18 hours PPD
July 18, 2024, 2.94 hours PPD
July 19, 2024, 2.94 hours PPD
July 20, 2024, 2.98 hours PPD
July 21, 2024, 2.86 hours PPD
July 22, 2024, 3.18 hours PPD
July 23, 2024, 3.17 hours PPD
July 24, 2024, 3.19 hours PPD
July 25, 2024, 3.02 hours PPD
July 26, 2024, 3.04 hours PPD
July 27, 2024, 2.63 hours PPD
July 28, 2024, 2.63 hours PPD
July 29, 2024, 3.06 hours PPD
July 30, 2024, 3.09 hours PPD
August 5, 2024, 3.05 hours PPD
August 6, 2024, 3.0 hours PPD
August 7, 2024, 2.99 hours PPD
August 8, 2024, 3.08 hours PPD
August 9, 2024, 3.15 hours PPD

Interview with the Nursing Home Administrator and the Director of Nursing on August 12, 2024, at 1:55 PM, confirmed that the facility did not meet regulatory daily hours PPD as evidenced above.





 Plan of Correction - To be completed: 09/17/2024

The facility cannot retroactively correct past PPD staffing levels. The facility will continue to take measures to adequately provide nursing staff to ensure the needs of the residents are met. Measures will be put in place to adequately provide staff. These measures include, continuing our retention committee, increased advertising efforts, utilization of agency staff, and sign on bonuses. The Director of Nursing/designee will educate ppd staffing levels to RN Supervisors, HR, and the nursing scheduler who are responsible to maintain adequate staffing ratios. The Director of Nursing/designee will audit the daily schedules 5x week x 6 weeks to ensure that the minimum PPD staffing levels have been scheduled. The results of the audits will be reviewed at the facilities QAPI meeting for recommendations.

Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance


Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement
Visit the PA Power Port