Pennsylvania Department of Health
VILLAGE AT PENN STATE, 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


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 38 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.


VILLAGE AT PENN STATE, THE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare Recertification Survey, State Licensure Survey, and Civil Rights Compliance Survey completed on July 19, 2024, it was determined that The Village At Penn State was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey process.

Plan of Correction:

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Observations:

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 a box with an expiration date of July 3, 2024.
Two operating fans on the condenser unit located in the interior of the cooler revealed a significant accumulation of dust.

Observation of the area that surrounded the main dumpsters to the main kitchen included two medical gloves (one black and one purple) on the ground, three discarded Styrofoam cups/bowls, a significant accumulation of dead leaves, and multiple paper/plastic items discarded behind the recycling dumpster.

Observation of the walk-in cooler in the main kitchen revealed a partially filled gallon milk container with a sell by date of July 2, 2024, and a container of lemon juice with an expiration date of May 20, 2024.

The main kitchen had a significant accumulation of dust on a ceiling vent and adjacent ceiling tile above a food prep area. The protective coverings on two of the ceiling lights were partially ajar.

There was a damaged corner of the wall at the floor between the kitchen and the dishwashing area. A concurrent interview with Employee 1 revealed that maintenance is aware of the issue. Employee 1 further noted that water from the dishwashing area leaks through the damaged wall area and "puddles" on the floor in the main kitchen area.

Observation of the smaller kitchen located on the skilled nursing unit between 11:40 AM and 11:50 AM revealed the following:

A floor drain near the food prep area contained various debris.

Observation of Employee 5, dish washer, revealed the employee was observed in the kitchen area. Employee 5 had a full beard but did not have a beard guard covering the facial hair. A concurrent interview with Employee 1 revealed that the facility does not require Employee 5 to wear a hair restraining device over his beard.

An operating air conditioning unit had an extensive build-up of a black colored substance on the vents of the unit.

The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on July 18, 2024, at 12:08 PM.

28 Pa. Code 201.14(a) Responsibility of licensee

Plan of Correction - To be completed: 08/26/2024

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies. To remain in compliance with federal and state regulations, the facility has taken or will take actions set forth in the following plan of correction.

1. Following the initial tour issues identified were corrected on the same day; food items observed in the main kitchen that were unlabeled, undated, open to air or expired were discarded, the main dumpster/ recycling storage area and the ceiling vent above the food prep area were cleaned, ceiling tiles were replaced and the light covers were adjusted to the proper fit. The floor, drain, and air conditioning unit in the smaller kitchen were cleaned. Per food service industry standards, bearded employees will be required to wear beard covers in kitchen areas.
2. The damaged wall in the main kitchen will be repaired by the date of compliance.
3. The Director of Dining Services/ designee will educate dining staff in both kitchen areas of food storage, preparation, distribution and serving in accordance with professional standards for food service safety. The Director of Dining Services/ designee will review, and revise as needed the kitchen cleaning/ sanitization checklist.
4. The Director of Dining/ designee will audit both kitchen areas to validate compliance weekly for one quarter then monthly for 2 quarters. Audit findings will be reviewed by the facility quality assurance and performance improvement committee for recommendation as needed.
5. Date of compliance August 26, 2024

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Observations:

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, revealed that she notified Employee 2, that Resident 8 slid out of bed and was on the floor and she needed her to come and assess her. Employee 2 was trying to roll Resident 8 on to her side to assess her for injuries and rolled her into the door jamb bumping her right leg very hard . Resident 8 yelled and said it hurt. Employee 2 then yelled at Resident 8 and said, "if you are not going to roll, I will mark you as a refusal. I am not hurting my back." Employee 2 rolled Resident 8 again and rolled her against the door jamb very roughly and she yelled again and looked at Employee 3 and said, "I hate her."

Review of a statement from Employee 3 dated May 9, 2024, revealed that when Employee 2 came into the room to examine Resident 8, she seemed very annoyed and spoke in a very rude manner. She indicated that Employee 2 never told Resident 8 that she was going to roll her over, she just tried to flip her over causing her right shin bone to crack off the bathroom door jam. She stated that Employee 2 then proceeded to tell Resident 8 that if she was not going to roll, she would mark her as a refusal. Employee 2 then proceeded to try to roll her again causing her right leg to crack off the door jamb again.

Review of Employee 2's statement dated May 10, 2024, related to this event revealed that she tried to turn Resident 8 to check her back side and right hip, which she said hurt but she kept resisting being turned. Every time she would try to turn Resident 8, she would push back. She indicated that she had an actively dying resident receiving frequent sedation and no licensed practical nurse on duty, so she was passing medications too. She also indicated in her statement that she had been very busy preparing for a long-distance move and was entering the final three days of her nearly 2-month notice. She then stated that she believed this incident was related to stress and frustration due to all these events together and that she was sorry and never meant any harm or disrespect.

Review of the Director of Nursing's (DON) summary of the event revealed that on May 10, 2024, at 8:30 AM she interviewed Resident 8 who indicated that she slipped out of bed and called for help. Resident 8 indicated that they came and got her up and that another nurse came and was very angry with her for falling out of bed and yelled at her. She said the nurse told her that she broke the rules that were laid out for her and that she was not to go to the bathroom by herself. Resident 8 then indicated that the nurse "threw" her against the wall." When Resident 8 was assessed, there were no apparent injuries.

Interview with the DON and Nursing Home Administrator on July 18, 2024, at 12:05 PM revealed that they unsubstantiated the allegation of abuse because Employee 8 did not intend to cause harm. They also indicated that they were going to educate her on recognizing stress and actions to take, but Employee 2 did not return to the facility after the investigation, and that they did not educate other staff responsible for the care of residents related to stress prevention and abuse.

The facility failed to substantiate verbal and physical abuse related to Resident 8 and failed to educate all staff related to stress management and abuse prevention as it related to this event, to prevent reoccurrence.

28 Pa. Code 201.18(e)(1) Management

28 Pa. Code 201.29(a) Resident rights

Plan of Correction - To be completed: 08/26/2024

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies. To remain in compliance with federal and state regulations, the facility has taken or will take actions set forth in the following plan of correction.

1. Resident 8 does not display any negative effects from the event.
2. Employee 2 no longer works at the facility.
3. The nursing home administrator will educate staff on abuse prevention, reporting, investigation and documentation requirements. A checklist will be developed as a reference tool for use during an investigation to ensure all requirements are met. The education will additionally include managing stress, recognizing burn out, self- care and employee assistance programs available for staff.
4. Social service will interview 3 random residents weekly x4 then monthly x5 about their care and caregivers. Indicators of potential abuse will be reported immediately to the administrator for further investigation. Social service will report audit findings to the quality assurance and performance improvement committee for further recommendations as needed.
5. Date of compliance August 26, 2024

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use:

§483.45(e) Psychotropic Drugs.
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

§483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

§483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Observations:

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 effectiveness related to her antidepressant medication Zoloft.

The facility failed to ensure proper monitoring of psychotropic medication use for Resident 8.

483.45(d)(e)(1)-(2) Drug Regimen is Free From Unnecessary Drugs
Previously cited deficiency 10/5/2023

28 Pa. Code 211.9(a)(1)(k) Pharmacy services

28 Pa. Code 211.10(a) Resident care policies

28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Plan of Correction - To be completed: 08/26/2024

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies. To remain in compliance with federal and state regulations, the facility has taken or will take actions set forth in the following plan of correction.

1) Monitoring for side effects and/ or effectiveness of Zoloft 25 mg. daily to treat depression for resident 8 will be added to the medication administration record.

2) Current residents receiving psychotropic medications will be reviewed to validate monitoring of side effects and effectiveness of the medication. Missing documentation of monitoring for side effects and effectiveness will be added to medication administration records for identified residents.

3) The Director of Nursing will educate licensed nursing staff regarding monitoring for effectiveness, side effects and documentation requirements of psychotropic drug use.

4) Audits of 4 random residents with psychotropic drug orders will be conducted weekly x 4 then monthly X 2 months to validate licensed nurse documentation of monitoring for effectiveness and side effects. The Director of Nursing will report audit results to the quality assurance and performance improvement committee for further recommendation as needed.
5) Date of compliance August 26, 2024

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