Village at Penn State, The

In the surveyor’s words

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

• Actual harm, isolatedF689May 14, 2026

  Based on clinical record review, review of facility policies and procedures, and staff interview, it was determined that the facility failed to implement interventions for fall prevention which resulted in actual harm of pelvic fracture for one of three residents reviewed for falls (Resident 4). Findings include: Review of facility policy titled Falls Risk Assessment System Guidelines, last reviewed without changes January 31, 2026, revealed all residents will be assessed for initial risk for falls using The Fall Risk Assessment. Residents that score a 15 or greater will be considered at risk for falls. A plan of care will be initiated to address the fall risk factors. This assessment will begin on admission and be completed within 24 hours. […]

• No harm, potential for more than minimal, widespreadF812Jun 6, 2025

  Based on observation and staff interview, it was determined the facility failed to store food and maintain food service equipment in a safe and sanitary manner in the facility's main kitchen, Atrium kitchen, and pantry.Findings include:Observation of the Atrium kitchen on June 3, 2025, at 9:30 AM revealed the following:Multiple sheet pans were observed stored and in use in the cooking area contained significant black buildup on the pans.A large plastic wrap holder on the production table was observed with dried liquid splatter, food crumbs, and dust on the exterior and interior of the holder.The flooring under the dish machine, cooler, and food cooking equipment contained dirt/debris buildup on the flooring and wall edges.A three-tier black cart located across from the dish machine with… […]

• No harm, potential for more than minimal, widespreadF812Jun 6, 2025

  Based on observation and staff interview, it was determined the facility failed to store food and maintain food service equipment in a safe and sanitary manner in the facility's main kitchen, Atrium kitchen, and pantry. Findings include: Observation of the Atrium kitchen on June 3, 2025, at 9:30 AM revealed the following: Multiple sheet pans were observed stored and in use in the cooking area contained significant black buildup on the pans. A large plastic wrap holder on the production table was observed with dried liquid splatter, food crumbs, and dust on the exterior and interior of the holder. The flooring under the dish machine, cooler, and food cooking equipment contained dirt/debris buildup on the flooring and wall edges. […]

• No harm, potential for more than minimal, patternF812May 14, 2026

  Based on observation and staff interview, it was determined that the facility failed to store food and maintain food service equipment in accordance with professional standards for food service safety in the facility's main kitchen.Findings include: An observation in the facility's Atrium kitchen and supply room, and the main kitchen on May 12, 2026, at 9:20 AM revealed the following: The Atrium gas burners were observed with black, charred particulate matter that was cooked on to the metal grates. The metal control knobs on the Atrium stove were observed to have a large amount of dust, debris, and grease built up between the knobs. The Atrium oven was observed with black and charred debris throughout the base of the oven and on the oven door. […]

• No harm, potential for more than minimal, patternF697Jun 6, 2025

  Based on clinical record review and staff interview, it was determined that the facility failed to ensure that pain management was provided that was consistent with professional standards of practice for two of two residents reviewed (Residents 4 and 18).Findings include:Clinical record review for Resident 4 revealed current physician orders for Oxycodone HCI 5 milligrams (mg)Clinical record review for Resident 4 revealed current physician orders for Acetaminophen (a medication used to control mild pain) extra strength 500 mg by mouth every four hours as needed for pain, (no pain level identified), Oxycodone HCI (a narcotic pain medication used to control moderate to severe pain) oral tablets 5 mg every six hours as needed for moderate to severe pain, and Oxycodone HCI oral tablets 5 mg… […]