Pennknoll Village

F-F585, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to resolving grievances.

The facility's plan of correction for a deficiency regarding a failure to revise or update care plans, cited during

the survey ending February 23, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under

F-F657, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to revising/updating care plans.

The facility's plan of correction for a deficiency regarding quality of care, following physician's orders, cited

during the survey ending February 23, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under

F-F684, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to quality of care, following physician's orders.

The facility's plan of correction for a deficiency regarding a failure to conduct nurse aide performance reviews, cited during the survey ending February 23, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under

F-F730, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to conducting nurse aide performance reviews.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 12 395422 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395422 B. Wing 01/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pennknoll Village 208 Pennknoll Road Everett, PA 15537

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 The facility's plan of correction for a deficiency regarding a failure to honoring food and drink preferences, cited during the survey ending February 23, 2024, revealed that the facility developed a plan of correction Level of Harm - Minimal harm or that included completing audits and reporting the results of the audits to the QAPI committee for review. The potential for actual harm results of the current survey, cited under

F-F804.

28 Pa. Code 201.14(a) Responsibility of Licensee.

28 Pa. Code 201.18(e)(1) Management.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 12 395422

F-F807, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to honoring residents food and drink preferences. Residents Affected - Some Refer to