Pennknoll Village: Care Plan Oversight Failures - PA
Federal inspectors who surveyed the facility on January 15, 2025 found that Pennknoll Village's Quality Assurance and Performance Improvement committee, the internal body charged with identifying and fixing care failures, had proven ineffective at correcting deficient practices related to how the facility revises and updates resident care plans.
That finding alone would be notable. What made it worse was the timeline.
The same deficiency, problems with quality of care and following physician's orders, had already been cited during a survey that ended February 23, 2024. Nearly a year earlier. When inspectors documented that earlier violation, the facility responded with a formal plan of correction. The plan was specific. Staff would conduct audits. The results of those audits would be reported to the QAPI committee for review. The committee would oversee the fixes.
None of it worked.
The January 2025 inspection found the same category of deficiency still present, which is how inspectors determined the QAPI committee had failed at its core function. The committee had received audit results, or was supposed to have. It had the information it needed, or was supposed to have gathered it. And still, the deficient practice continued.
Care plans are not administrative paperwork. They are the document that tells every nurse, aide, and therapist on every shift what a specific resident needs, what risks they carry, what the physician has ordered for them. When care plans are not updated to reflect changes in a resident's condition or new physician orders, the people delivering care are working from outdated information. The gap between what a care plan says and what a resident actually needs is where harm occurs.
Pennknoll Village is a nursing facility in Everett, a small borough in Bedford County in south-central Pennsylvania. The January 2025 inspection was a standard health survey.
The specific citation was F657, which covers the development and revision of comprehensive care plans. The deficiency as written focused not just on the care plan failures themselves but on the facility's inability to fix them after being told to. That is a different kind of failure. A first-time citation means something went wrong. A repeated citation, with an intervening plan of correction that demonstrably did not work, means the system designed to prevent things from going wrong also went wrong.
QAPI programs exist precisely to break that cycle. Facilities are required to maintain them, to staff them, to take findings seriously. At Pennknoll Village, the committee reviewed whatever audit results it received and the deficient practice continued anyway. Whether the audits were incomplete, whether the committee's response to the findings was inadequate, or whether corrective actions were never fully implemented, the inspection report does not specify. What it specifies is the outcome: the problem persisted.
For residents, this is not an abstract institutional failure. A care plan that hasn't been updated after a physician changes an order means a resident may not receive the care the physician ordered. An aide who checks an outdated care plan before a shift may not know a resident's condition has changed. A family member who asks what the plan is for their loved one may be told something that is no longer accurate.
The facility had a full year. It had a documented corrective plan. It had a committee whose purpose was to make sure that plan worked.
The January 2025 inspection found it hadn't.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pennknoll Village from 2025-01-15 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 9, 2026 · Our methodology
PENNKNOLL VILLAGE in EVERETT, PA was cited for violations during a health inspection on January 15, 2025.
That finding alone would be notable.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.