Inspection·May 16, 2024

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on review of the facility's job descriptions, and interviews with staff, it was determined that the facility failed to ensure the consistent services of a full-time Director of Nursing (35 or more hours a week) in the facility. Findings include: The facility's job description for the Director of Nursing (DON), undated, revealed that as a Health Care Director of Services, the DON is entrusted with the responsibility of caring for the facility's residents, families, co-workers, visitors, and all others. The primary purpose of the job position is to plan, organize, develop, and direct the overall operation of the nursing service department in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility. Information reported to the State Department of Health indicated that Registered Nurse 1 started as the DON for the facility on May 1, 2024. Interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for completion of MDS assessments) on May 13, 2024, at 3:34 p.m. revealed that Registered Nurse 1 started in the beginning of May as the facility's interim DON, and that she was the facility's regional nurse consultant. She indicated that Registered Nurse 1 has not been present in the facility for the past two weeks. She indicated that the facility is currently searching to hire an administrator, DON, and an Assistant Director of Nursing (ADON), because they do not currently have an ADON for the facility. Interview with the interim Nursing Home Administrator on May 13, 2024, at 4:30 p.m. confirmed that Registered Nurse 1 has not been in the facility as the DON for the past two weeks. Interview with the interim Nursing Home Administrator on May 16, 2024, at 2:40 p.m. confirmed that there was no documented evidence that Registered Nurse 1 worked 35 or more hours a week in the facility as DON. 28 Pa Code 201.3 Definitions. 28 Pa Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(6) Management. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395422 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2024 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)