Pennsylvania Department of Health
 VILLAGE AT PENN STATE, THE
Building 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
VILLAGE AT PENN STATE, THE
Inspection Results For:

There are  40 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:Name: - Component: -- - Tag: 0000


Based on an Emergency Preparedness Survey completed on May 19, 2026, at The Village at Penn State, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.




 Plan of Correction:


Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000


Facility ID# 15550201
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 19, 2026, it was determined that The Village at Penn State was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a two story, Type II (111), protected, noncombustible building, with a partial basement, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Stairways and Smokeproof Enclosures: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.
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2




Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to ensure that stairways used as exits were not used for any purpose that has the potential to interfere with egress, affecting one of three floors.

Findings include:

1. Observation on May 19, 2026, at 10:04 am, revealed contractor paint supplies were being stored in the 2nd Floor Stair Tower near Resident Room H210.

Exit interview with the Facility Administrator and Facilities Manager, on May 19, 2026, at 10:30 am, confirmed the supplies being stored in the stair tower.





 Plan of Correction - To be completed: 07/06/2026

1. Paint supplies were removed from 2nd floor stair tower.
2. Paint contractor was verbally educated that supplies cannot be stored in stairwells.
3. "No Storage" signage will be placed in alcoves of stairwells.
4. EVS Director/ designee will round weekly x one month then monthly for 5 months to ensure there is no storage in stairwells. Audit results will be reported to the Quality Assurance Performance Improvement committee for review and recommendation.
5. Date of compliance June 30, 2026
NFPA 101 STANDARD Hazardous Areas - Enclosure: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.
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain one hazardous area enclosure, affecting one of five smoke compartments.

Findings include:

1. Observation on May 19, 2026, at 10:14 am, 2nd floor, revealed an unsealed penetration of the wall around smoke detector conduit inside the Electrical Room near the lounge.

Exit interview with the Facility Administrator and Facilities Manager, on May 19, 2026, at 10:30 am, confirmed the unsealed penetration of the wall.




 Plan of Correction - To be completed: 06/30/2026

1. The penetration of the wall around the smoke detector inside the electrical room on 2nd floor was sealed on 5/20/26.
2. Preventative maintenance schedule is in place to monitor and repair penetrations.
3. Date of compliance June 30, 2026
NFPA 101 STANDARD Alcohol Based Hand Rub Dispenser (ABHR):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.
Alcohol Based Hand Rub Dispenser (ABHR)
ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met:
* Corridor is at least 6 feet wide
* Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols
* Dispensers shall have a minimum of 4-foot horizontal spacing
* Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room
* Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30
* Dispensers are not installed within 1 inch of an ignition source
* Dispensers over carpeted floors are in sprinklered smoke compartments
* ABHR does not exceed 95 percent alcohol
* Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11)
* ABHR is protected against inappropriate access
18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0325

Based on observation and interview, it was determined the facility failed to protect Alcohol Based Hand Rub Dispenser through-out the facility.

Findings include:

1. Observation on May 19, 2026, between 9:45 am, to 10:15 am, revealed several ABHR dispensers were installed over electrical switches in Resident Rooms on 1st and 2nd floor.

Exit interview with the Facility Administrator and Facilities Manager, on May 19, 2026, at 10:30 am, confirmed the ABHR dispensers installed over electrical switches.




 Plan of Correction - To be completed: 06/30/2026

1. Alcohol based hand rub (ABHR) sanitizer dispensers in resident rooms will be relocated away from electrical sources.
2. Maintenance staff will check all ABHR dispensers in the facility to ensure the location is away from electric source.
3. Date of compliance June 30, 2026
NFPA 101 STANDARD Electrical Systems - Other: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.
Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 6 (NFPA 99)
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0911

Based on observation and interview, it was determined the facility failed to maintain the electrical system, affecting one of three floors.

Findings include:

1. Observation on May 19, 2026, at 10:09 am, 2nd floor revealed an old unused nurse call system lacked a cover over the electrical wiring within the Beauty Shop.

Exit interview with the Facility Administrator and Facilities Manager, on May 19, 2026, at 10:30 am, confirmed the electrical systems deficiency.




 Plan of Correction - To be completed: 06/30/2026

1. A full cover plate will be installed over the old nurse call system wiring in the beauty shop by date of compliance.
2. Maintenance staff will complete a facility walk through to inspect areas where call bells were replaced to ensure cover plates are present. Cover plates will be installed for exposed old system wiring discovered during audit.
Date of compliance June 30, 2026

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