Based on the review of facility documentation, review of personal records and interviews with staff, it was determined that the facility failed to ensure that a professional staff possessed required nursing license in accordance with applicable state law. Review of one of six personnel files revealed that Employee E21, who was an unlicensed staff, and provided care as a Registered Nurse, to 63 residents. Employee E21 did not have a verifiable educational background and registration, as a Registered Nurse. This failure resulted in an Immediate Jeopardy situation to 63 residents who received care and services from Employee E21. (Employee E21). Findings Include: Review of the Professional Nursing Law The Act of [DATE] P.L 317, No 69, revealed that Section 3. …
F839 citations in Pennsylvania
Administration Deficiencies
Employ staff that are licensed, certified, or registered in accordance with state laws.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Pennsylvania cites F839 more often than its own record predicts
1.61 times the share F839 takes of citations nationally.
Of every deficiency written in Pennsylvania in 2025, this is the portion that was F839.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Pennsylvania surveyors wrote
F839 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 facility documentation and staff interviews, it was determined that the facility did not ensure one member of the nursing staff was appropriately licensed while providing care to residents on six of six days reviewed (6/22/26, 6/23/26, 6/24/26, 6/25/26, 6/26/26 and 6/29/26). Findings include: Review of facility documentation revealed that Licensed Practical Nurse (LPN), Employee E1, had worked on the following dates and hours as an LPN: 6/22/26- 8 hour shift 6/23/26 - 8 hour shift 6/24/26 -12 hour shift 6/25/26- 16 hour shift 6/26/26 -16 hour shift 6/29/26- 12 hour shift Further review revealed that the nursing license for LPN Employee E1 had been suspended on 6/17/26. During an interview on 8/21/26, at 1:00 p.m. …
The short window
Recent years
| Year | Share of Pennsylvania citations | vs expected |
|---|---|---|
| 2024 | 0.01% | 0.23× |
| 2025 | 0.09% | 1.61× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Pennsylvania surveyors cite →
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