Based on review of facility policy, a resident council group interview, observations and staff interview it was determined that the facility failed to maintain proper ventilation for two out of two Resident Central Shower Rooms (First and Second Floors). Findings include: The facility Resident rights policy, last reviewed on 7/13/23, indicated that the residents have the right to a comfortable environment. The resident council group interview on 9/26/23, at 11:00 a.m. indicated two of the eleven residents present stated that they can't breathe easily in the shower rooms on the first and second floor due to the lack of ventilation and air circulation. Observations on 9/26/23, at 1:00 p.m. …
F923 citations in Pennsylvania
Environmental Deficiencies
Have enough outside ventilation via a window or mechanical ventilation, or both.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2023
Pennsylvania cites F923 more often than its own record predicts
1.03 times the share F923 takes of citations nationally.
Of every deficiency written in Pennsylvania in 2023, this is the portion that was F923.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Pennsylvania surveyors wrote
F923 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 observation and staff interview, it was determined that the facility failed to ensure that there was adequate outside ventilation on one of three nursing units. (South wing) Findings include: During all days of the survey, heavy persistent urine odors were noted on the South wing nursing unit hallways. In an interview on (MONTH) 24, 2019, at 10:16 a.m., the Director of Maintenance stated that the ventilation system on the South wing was a closed system, with no outside ventilation in the main corridors where the odors were noted. 28 Pa. Code 207.2(a) Administrator's responsibility. Previously cited 2/9/18, 4/6/18
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