Pennknoll Village

In the surveyor’s words

From the most serious findings on record at Pennknoll Village, in the surveyor’s own words.

• Immediate jeopardy, patternF880Apr 30, 2022

  Based on review of established infection control guidelines, the facility's policies and documents, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable infections, by failing to follow infection control guidelines from the Centers for Disease Control (CDC) and the Pennsylvania Department of Health (PA DOH) to reduce the spread of infections and prevent cross-contamination during the COVID-19 pandemic for 12 of 58 residents reviewed (Residents 9, 14, 23, 34, 49, 68, 70, 71, 99, 100, 103, 106). […]

• Actual harm, isolatedF600May 29, 2025

  Based on clinical record reviews, staff interviews, and investigation reports, it was determined that the facility failed to ensure that residents were free from neglect which resulted in harm as evidenced by a fall with fracture for one of five residents reviewed (Resident 3). Findings include: The facility's policy regarding abuse, neglect, exploitation, and misappropriation, dated January 16, 2025, revealed that each resident was afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. Nurse aide documentation revealed that Resident 3 was an extensive assist of two for bed mobility and toileting at the time of the fall. […]

• Actual harm, isolatedF689May 29, 2025

  Based on clinical record reviews, staff interviews, and investigation reports, it was determined that the facility failed to ensure that a safe environment was provided for one of five residents reviewed (Resident 3) resulting in a fall with fracture. Findings include: The facility's policy regarding fall prevention, dated January 16, 2025, revealed that the facility was to provide an environment that is free from accident hazards over which the facility has control, and provide supervision to prevent avoidable accidents. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated May 16, 2025, indicated that the resident was cognitively intact, could understand and was understood. […]

• Actual harm, isolatedF600Aug 2, 2023

  Based on review of policies, investigative reports, and residents' clinical records, as well as staff and resident interviews, it was determined that the facility failed to ensure that residents were free from neglect caused by a failure to follow a resident's physician orders to prevent worsening of a non-pressure skin condition for one of six residents reviewed (Resident 2). Findings include: The facility's policy regarding abuse, neglect, exploitation, and misappropriation, dated February 9, 2023, revealed that each resident was afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. […]

• Actual harm, isolatedF600Mar 30, 2023

  Based on review of facility policy, clinical records, and investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that two of 39 residents reviewed (Residents 22, 67) were free from sexual abuse perpetrated by another resident (Resident 296). Findings include: The facility's policy regarding abuse, neglect, exploitation, and misappropriation, dated February 9, 2023, revealed that each resident was afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. Sexual abuse was non-consensual sexual contact of any type with a resident. […]