Health inspection·May 29, 2025

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few Based on clinical record reviews, staff interviews, and investigation reports, it was determined that the facility failed to ensure that residents were free from neglect which resulted in harm as evidenced by a fall with fracture for one of five residents reviewed (Resident 3). Findings include: The facility's policy regarding abuse, neglect, exploitation, and misappropriation, dated January 16, 2025, revealed that each resident was afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. Nurse aide documentation revealed that Resident 3 was an extensive assist of two for bed mobility and toileting at the time of the fall. The care plan for Resident 3, dated June 2, 2023, for a self-care performance deficit related to limited mobility included interventions for two assist with bed mobility. An occupational therapy note for Resident 3, dated for the certification period of May 2 to May 31, 2025, indicated that Resident 3 was dependent and in need of two assist for toileting hygiene. A nursing note for Resident 3, dated May 6, 2025, at 6:49 a.m., revealed that Registered Nurse 1 was called to the room where the resident was found on the floor between the beds. She was face down moaning in pain and was rolled onto her back with the support of three staff. A registered nurse assessment at that time revealed that there was bleeding and bruising to the nose and right side of the face, as well as skin tears to the right elbow and right shin. The resident was sent to the emergency room for evaluation. An emergency room X-ray report for Resident 3, dated May 6, 2025, at 10:59 a.m., revealed a nondisplaced fracture of the third digit of the right hand. An incident report for Resident 3, dated May 6, 2025, at 5:52 a.m. revealed that Nurse Aide 2 was in the resident's room providing incontinent care when the resident shifted her weight causing her to slip through the aide's arms and roll onto the floor between the beds. Nurse Aide 2 performed care by herself and did use a two person assist. A witness statement, dated May 6, 2025 at 5:52 a.m., revealed that the Nurse Aide 2 was removing Resident 3 from the bedpan when the resident shifted her weight and slid through her hands and off the bed. She indicated that the RN and other aide were in another room attending to a resident at that time. She went on to say that she was trying to get Resident 3 settled in time for the other aide to leave at 6:30 a.m., because at that time she would be by herself. In addition, she indicated that (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 4 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 05/29/2025 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)