Based on review of job descriptions, facility policy review, clinical record review, and staff interviews, it was determined that the facility administration failed to effectively manage the code status for residents to ensure accuracy in accordance with the resident wishes, which placed the residents at harm and in an Immediate Jeopardy situation. Findings Include: Review of the job description for the Nursing Home Administrator (NHA), with a revision date of (MONTH) (YEAR), revealed in the Position Summary: Responsible for daily operations of the Skilled Nursing Facility and Assisted Living Facility in accordance with current applicable Federal, State, and local standards, guidelines, and regulations as directed by the policies and procedures. …
F835 citations in Pennsylvania
Administration · Administration Deficiencies
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Pennsylvania cites F835 more often than its own record predicts
2.57 times the share F835 takes of citations nationally.
Of every deficiency written in Pennsylvania in 2025, this is the portion that was F835.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Pennsylvania surveyors wrote
F835 findings written in Pennsylvania, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on review of job descriptions, facility policies and clinical records, observations and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to ensure that staff are provided guidance on the implementation of one on one to maintain resident safety for one of three resident reviewed (Resident 1) who broke a window in her room and fell to the ground from the second floor resulting in harm, internal bleeding in the skull and hospitalization . …
Based on review of job descriptions, clinical records, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed effectively manage the facility to protect residents from elopement. This failure resulted in a resident, who was a known elopement risk, exiting the resident's assigned nursing unit unsupervised (Resident R1). This failure created an Immediate Jeopardy situation for one of fourteen residents who were documented as elopement risks (Resident R1). …
The short window
Recent years
| Year | Share of Pennsylvania citations | vs expected |
|---|---|---|
| 2023 | 0.57% | 1.98× |
| 2024 | 0.76% | 2.31× |
| 2025 | 0.76% | 2.57× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Pennsylvania surveyors cite →
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