A list of the most recent deficiencies for The Manor at Penn Village. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-02-01 | 2024-03-18 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-02-01 | 2024-03-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-02-01 | 2024-03-18 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-02-01 | 2024-03-18 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-02-01 | 2024-03-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-02-01 | 2024-03-18 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-01-26 | 2024-02-28 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-01-26 | 2024-02-28 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-01-26 | 2024-02-28 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-01-26 | 2024-02-28 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-01-26 | 2024-02-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-26 | 2024-02-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-26 | 2024-02-28 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-01-26 | 2024-02-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-26 | 2024-02-28 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-01-26 | 2024-02-28 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-01-26 | 2024-02-28 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-01-26 | 2024-02-28 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-01-26 | 2024-02-28 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-01-26 | 2024-02-28 | N |
| Provide or obtain dental services for each resident. | Health | 2024-01-26 | 2024-02-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-26 | 2024-02-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-26 | 2024-02-28 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-01-26 | 2024-02-28 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-01-26 | 2024-02-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-02 | 2024-01-19 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-01-02 | 2024-01-19 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-01-02 | 2024-01-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-19 | 2023-08-04 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-02-03 | 2023-03-28 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-02-03 | 2023-03-28 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-02-03 | 2023-03-28 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-02-03 | 2023-03-28 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-02-03 | 2023-03-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-03 | 2023-03-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-03 | 2023-03-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-03 | 2023-03-28 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-02-03 | 2023-03-28 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-02-03 | 2023-03-28 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-02-03 | 2023-03-28 | N |
| Provide or obtain dental services for each resident. | Health | 2023-02-03 | 2023-03-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-03 | 2023-03-28 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-02-03 | 2023-03-28 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-02-03 | 2023-03-28 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-02-21 | 2023-03-28 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-02-21 | 2023-03-28 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-02-21 | 2023-03-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-02-21 | 2023-03-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-02-21 | 2023-03-28 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-02-21 | 2023-03-28 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-02-25 | 2022-04-15 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-02-25 | 2022-04-15 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-02-25 | 2022-04-15 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-02-25 | 2022-04-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-25 | 2022-04-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-25 | 2022-04-15 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-02-25 | 2022-04-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-02-25 | 2022-04-15 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-02-25 | 2022-04-15 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-02-25 | 2022-04-15 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-02-25 | 2022-04-15 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-02-25 | 2022-04-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-25 | 2022-04-15 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-02-25 | 2022-04-15 | N |
| Use approved construction type or materials. | Fire Safety | 2022-02-07 | 2022-04-04 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-02-07 | 2022-04-04 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-02-07 | 2022-04-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-02-07 | 2022-04-04 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-02-07 | 2022-04-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-07 | 2022-04-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-02-07 | 2022-04-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-02-07 | 2022-04-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-02-07 | 2022-04-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-29 | 2021-11-03 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-09-29 | 2021-11-03 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-12-07 | Not Fixed | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-31 | Not Fixed | Y |
