Premier at Perry Village: Discharge Planning Failures - PA
The discharge summary prepared by the facility made no mention of the catheter at all. There were no instructions on catheter management. No referrals to outside providers who could monitor it. The woman was also receiving supplemental oxygen during her stay, and that, too, went unmentioned in the paperwork that followed her out the door.
She left without knowing what to watch for, without a follow-up plan, and without any record that home health services had been arranged, though the inspection record indicates referrals existed somewhere in her file.
Federal inspectors cited the facility following a complaint inspection completed September 4, 2025. The deficiency, tagged F0627, was rated as minimal harm or potential for actual harm, affecting few residents. The regulatory finding covers discharge planning, the process facilities are supposed to use to ensure residents can safely manage their care once they leave.
A Foley catheter is a tube inserted through the urethra into the bladder to drain urine. Patients who go home with one in place need to understand how to keep it clean, how to recognize signs of infection, and who to call if something goes wrong. Urinary tract infections tied to indwelling catheters are among the most common and preventable complications in post-acute care. Without instruction, a patient has no framework for any of that.
The Director of Nursing, interviewed by inspectors at 1:48 p.m. on September 4, acknowledged the facility had already identified the problem on its own. After Resident 1 was discharged, she said, staff conducted an internal audit and found issues with the discharge summary. The DON told inspectors that education was subsequently provided to two employees, identified in the report as Employee 1 and Employee 2, both registered nurses. The training focused on completing discharge summaries fully and retaining copies of any patient education provided, including education specific to Foley catheter management.
The facility, in other words, caught its own error, trained the staff responsible, and was ready to describe all of this to inspectors by the time they arrived. What it could not produce was evidence that the resident herself ever received the information she needed before she left.
That gap is the core of what inspectors documented. Not a failure that went unexamined, but a failure that was examined only after the fact, after the woman was already home, already managing a catheter with no guidance, already without a referral to anyone who might have checked on her.
The inspection report does not describe what happened to Resident 1 after discharge. It does not say whether she developed an infection, whether she struggled with the catheter, or whether anyone from the facility followed up with her directly. The record ends at the facility's door.
Premier at Perry Village is located in New Bloomfield, Perry County, a small community in central Pennsylvania. The inspection was a complaint survey, meaning someone, whether a resident, family member, or other party, contacted regulators before inspectors arrived. The report does not identify who filed the complaint or what specifically prompted it.
The deficiency cited carries references to three sections of Pennsylvania's nursing home regulations, covering licensee responsibility, management obligations, and nursing services. The federal tag, F0627, addresses the requirement that facilities create and implement discharge plans that prepare residents and their caregivers for post-discharge care.
The registered nurses who prepared Resident 1's discharge summary received training afterward. Whether the woman who left with the catheter ever received a call, a visit, or a belated set of instructions is not something the inspection report addresses.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Premier At Perry Village For Nursing and Rehab, Ll from 2025-09-04 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: September 25, 2026 · Our methodology
PREMIER AT PERRY VILLAGE FOR NURSING AND REHAB, LL in NEW BLOOMFIELD, PA was cited for violations during a health inspection on September 4, 2025.
The discharge summary prepared by the facility made no mention of the catheter at all.
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.