Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Premier At Perry Village For Nursing And Rehab, Ll during CMS and state inspections, most recent first.
A facility failed to ensure MDS assessments accurately reflected resident status for four residents. One resident’s alarm use was coded inconsistently with the care plan, another resident receiving hospice had prognosis coded as not terminal, a third resident’s chair alarm was marked not in use despite the care plan, and a fourth resident receiving hospice also had prognosis coded as not terminal. The NHA stated the MDS entries were coded in error.
The facility failed to complete annual performance reviews for two nurse aides reviewed. One aide had a prior evaluation more than 12 months before the most recent review, and the other aide had no previous performance evaluations completed.
A resident with CHF and GERD was discharged home without confirmation of home health services, despite multiple unsuccessful referrals. The discharge summary lacked documentation of the resident's Foley catheter, oxygen needs, and education on catheter care, and did not include a post-discharge plan of care or instructions for follow-up.
The facility failed to maintain hazardous area doors within allowed gap margins and in good repair. Observations revealed that doors in the laundry and storage rooms had gaps greater than one-eighth of an inch and were damaged, with some repaired using unauthorized substances. These issues were confirmed by the Director of Maintenance.
The facility failed to ensure corridor doors positively latch and remain unobstructed. The Main Dining Room doors did not latch properly, and a decoration on the door knob of a resident's room impeded the door from closing. These issues were confirmed by the Director of Maintenance.
The facility failed to maintain battery back-up lighting for the generator transfer switch in one of four smoke zones. During an observation, the battery back-up light did not illuminate when tested, and this was confirmed by the Director of Maintenance. This deficiency indicates a failure to meet NFPA standards for essential electrical systems.
A resident with a history of metabolic encephalopathy and other conditions was found with a bag of Tylenol pills, which he ingested, claiming they were candy. The facility failed to notify the resident's physician until eight hours later, despite the potential risk of Tylenol toxicity. The delay in notification was due to the night shift nurses not contacting the physician immediately, although the resident showed no signs of toxicity. When informed, the physician ordered the resident to be sent to the ED for evaluation.
The facility failed to ensure accurate MDS documentation for two residents. One resident, with hypertension and anxiety, was administered oxygen therapy, but the MDS did not reflect this. Another resident, with major depressive disorder and dementia, had a bed alarm order, but the MDS inaccurately marked it as 'No'. These discrepancies were confirmed through clinical record reviews and interviews with the NHA.
The facility failed to develop comprehensive care plans for three residents, omitting critical focus areas such as smoking supervision and dementia care. A resident with major depressive disorder and hypertension did not have a smoking care plan, while another with dementia lacked a dementia care plan. Additionally, a resident with urinary retention and cancer did not have their smoking status reflected in their care plan. These deficiencies were confirmed by the NHA.
The facility failed to update care plans for three residents, resulting in discrepancies with current physician orders. One resident's care plan included Ativan for seizures, which was discontinued months earlier. Another resident's care plan did not reflect updated dietary orders, and a third resident's care plan inaccurately indicated a therapeutic diet. The Nursing Home Administrator confirmed these discrepancies.
A facility failed to provide appropriate respiratory care for a resident with obstructive sleep apnea and asthma by not obtaining a physician order for a BiPAP machine. Despite the resident's documented use of CPAP and BiPAP, there was no physician order in the clinical record since admission. The Nursing Home Administrator confirmed the oversight, highlighting a lapse in adhering to professional standards.
A resident with specific dietary equipment needs was not provided with a Kennedy cup during meals, despite physician orders and care plan requirements. Observations over three consecutive days confirmed the absence of the Kennedy cup, although a lipped plate was provided. The Nursing Home Administrator acknowledged the oversight.
A cook in the facility was observed handling food items such as hamburger buns, lettuce, and tomato with the same gloved hands that had touched non-food items like tray tickets and packaging. This unsanitary practice was confirmed by the NHA, who stated that dietary staff should avoid direct contact with food after touching non-food items.
The facility failed to provide evidence of a QA Committee meeting during the first quarter of 2024. The NHA stated that the meeting was held by the prior administration, but no documentation, such as a sign-in sheet, was provided to confirm this. Despite follow-up, the NHA could not produce evidence of the meeting.
A resident with Alzheimer's disease and muscle weakness suffered a scalp laceration and leg injury after falling from a litter chair during transport in a facility van. The transportation driver failed to ensure the resident was properly secured, as the safety belt was not fastened. The driver had not received competency training for the litter chair, and there was no written procedure for its use. The incident resulted in actual harm to the resident.
Inaccurate MDS Coding for Alarms and Hospice Status
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected resident status for four of 21 residents reviewed. For Resident 5, the clinical record showed diagnoses of hypertension and dysphagia, and the care plan included elopement-related interventions such as door alarms and a wander guard, while a chair alarm had been discontinued. However, the Significant Change MDS completed on July 18, 2025 and the Quarterly MDS completed on October 17, 2025 were coded inconsistently with the record, with chair alarm marked as used daily on one assessment and other alarms marked as not being used, and later other alarms marked as not being used despite the door alarm being in place. The NHA stated these MDS assessments were coded incorrectly and that Section P0200 F. Other should have reflected daily use of the door alarm. For Resident 14, the record showed malignant neoplasm of the pelvis and palliative care, with a physician order to admit the resident to hospice services and a care plan stating the resident was receiving hospice care related to end stage illness. The Significant Change MDS coded J1400 Prognosis as No, indicating the resident was not terminally ill and not receiving hospice services, although the NHA stated this was in error and that the resident had been receiving hospice services. For Resident 56, the care plan included a chair alarm for falls risk, but the annual MDS coded the chair alarm as not being used; the NHA stated this was incorrect and that the chair alarm should have been coded as being used daily. For Resident 99, the record showed chronic kidney disease and palliative care, with a physician order for hospice services and a care plan stating the resident was receiving hospice care, yet both the Significant Change MDS and Quarterly MDS coded J1400 Prognosis as No; the NHA stated these assessments were marked in error and should have reflected hospice services.
Missing Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to complete a performance review for nurse aide staff at least once every 12 months for two of five employees reviewed. Employee 1 was hired on July 13, 2021, and the most recent performance evaluation in the record was dated December 8, 2025; during interview, the Nursing Home Administrator stated that Employee 1's prior performance evaluation was completed on October 17, 2024. Employee 2 was hired on October 15, 2024, and the most recent performance evaluation in the record was dated December 9, 2025; the Nursing Home Administrator stated that Employee 2 was hired in October 2024 and did not have any previous performance evaluations completed.
Failure to Ensure Safe and Documented Discharge Preparation
Penalty
Summary
The facility failed to ensure that a resident was adequately prepared for a safe and orderly discharge, and did not provide a complete discharge summary with a post-discharge plan of care. The resident, who had diagnoses including congestive heart failure and gastroesophageal reflux disease, was discharged home with physician orders for home health services, including physical therapy, occupational therapy, and skilled nursing. Multiple referrals to home health agencies were made, but all were unable to accept the resident prior to discharge. Despite this, the resident was discharged home without confirmation that home health services were in place, and there was no evidence that the physician was notified of the lack of services or that additional referrals were made at the time of discharge. The resident had an indwelling Foley catheter and was receiving oxygen at the facility, but the discharge summary did not mention the catheter, oxygen needs, or provide documentation of education on catheter management. There was also no instruction for follow-up with outside providers for catheter management or mention of the home health referrals in the discharge summary. The facility's policy required that residents and/or responsible parties receive teaching and discharge instructions, but there was no evidence that these requirements were met for this resident.
Deficiencies in Hazardous Area Door Maintenance
Penalty
Summary
The facility was found to have deficiencies in maintaining hazardous area doors within the allowed gap margins and in good repair. During an observation on December 16, 2024, it was noted that doors in three of four smoke zones had gaps greater than one-eighth of an inch. Specifically, the laundry's soiled-side and clean-side doors, as well as storage room doors across from the Nurses' Station and by Resident Room 418, all exhibited gaps exceeding the permissible size. This was confirmed through an interview with the Director of Maintenance. Additionally, the hazardous area doors were found to be damaged and repaired using unauthorized or unidentified substances. The laundry's soiled-side door was damaged on the surface and edge and filled with an unauthorized filler, while the clean-side door was also damaged on the surface and edge. These findings were again confirmed by the Director of Maintenance during the interview.
Plan Of Correction
1. The facility will request a TLW to correct K321, so that the facility can have adequate time to order and replace laundry soiled side door, laundry clean side door. The facility will also request TLW to have adequate time to repair gaps in the laundry soiled side door, laundry clean side door, Central Supply door, and Storage Room door by room 418. TKW request until 6/19/2025. 2. The Maintenance Supervisor will receive re-education by the Administrator on the allowed gap margins for interior doors. 3. The facility will complete an initial audit of all facility doors then audit 5 facility doors per week for 4 weeks to ensure that the door gap margins do not exceed the allowed gap margins, then quarterly for one year. 4. Audits will be reviewed at the next QAPI meeting.
Corridor Door Latching and Obstruction Deficiencies
Penalty
Summary
The facility failed to maintain corridor doors to positively latch and remain unobstructed from closing in two of four smoke compartments. During an observation on December 16, 2024, at 1:20 PM, it was noted that the Main Dining Room double doors, located directly in from the Main Entrance, did not positively latch when closed. This deficiency was confirmed through an interview with the Director of Maintenance at the same time. Additionally, at 1:40 PM on the same day, the corridor door to Resident Room 403 was found to be impeded from closing due to a decoration hanging on the door knob. This obstruction was also confirmed by the Director of Maintenance during an interview conducted at the time of the observation.
Plan Of Correction
1. The main dining room double door was repaired. The decoration was removed from the doorknob of room 403. 2. The Maintenance Supervisor will receive re-education by the administrator on indoor door closure and impeding door closures. 3. The facility will complete an initial audit of all facility doors then 5 random facility doors monthly for 1 year to ensure adequate door closure and no impeded door closures. 4. Audits will be reviewed at the next QAPI meeting. 5. The facility will be in substantial compliance by 2/14/2025.
Failure to Maintain Battery Back-Up Lighting for Generator Transfer Switch
Penalty
Summary
The facility failed to maintain battery back-up lighting for the generator transfer switch in one of four smoke zones. During an observation on December 16, 2024, at 12:50 PM, it was noted that the battery back-up light did not illuminate when tested. This deficiency was confirmed through an interview with the Director of Maintenance at the same time, who acknowledged the failure of the battery back-up light. The report indicates that the facility did not meet the requirements for maintaining essential electrical systems as outlined by NFPA standards. The deficiency was specifically related to the battery back-up lighting, which is crucial for ensuring the functionality of the generator transfer switch during power outages. The lack of proper maintenance and testing of this component led to the failure observed during the survey.
Plan Of Correction
1. Battery backup lighting was repaired. 2. The Maintenance Supervisor will receive re-education from the Administrator on maintaining the battery back up lighting for the generator transfer switch. 3. The facility will conduct an audit monthly of the battery back up lighting. 4. Audits will be reviewed in the next QAPI meeting. 5. The facility will be in substantial compliance by 2/14/2025.
Delayed Physician Notification of Potential Medication Ingestion
Penalty
Summary
The facility failed to promptly notify a resident's physician of an incident involving the potential ingestion of medication, which could have resulted in a negative outcome. The facility's policy requires immediate notification of the resident, their attending physician, and a representative in the event of changes in the resident's condition or status. However, in the case of a resident with a history of metabolic encephalopathy, anxiety disorder, depression, and low back pain, the physician was not notified until approximately eight hours after the incident occurred. The incident involved the resident being found with a bag of pills, which he claimed were candy, and taking an unknown amount of them. The pills were later identified as 500 mg Tylenol. Despite the potential risk of Tylenol toxicity, the resident's physician was not informed until the following morning, after the night shift had monitored the resident for symptoms of toxicity. The delay in notification was due to the night shift nurses not contacting the physician immediately after the incident. The deficiency was further highlighted by the fact that when the physician was finally informed, he ordered the resident to be sent to the emergency department for evaluation. The facility's Nursing Home Administrator and Director of Nursing acknowledged the delay but justified it by stating that the resident showed no signs of toxicity and that the facility's policy allowed for a 24-hour notification window. However, the staff involved in the morning shift felt that the physician should have been notified immediately after the incident occurred.
Plan Of Correction
1. The physician was notified of the incident for resident 44. 2. An initial audit of residents who have had incidents with potential for negative outcomes was completed to ensure the physician was notified. 3. Nursing staff were educated on the need to notify physicians timely of incidents with potential for negative outcomes. 4. Five audits of incidents for MD notification will be audited weekly for 4 weeks, then monthly for 2 months to ensure compliance by DON or designee. Results of these audits will be presented to the QAA committee for review. 5. The facility will be in substantial compliance by 1/7/25.
Inaccurate Resident Assessments in MDS Documentation
Penalty
Summary
The facility failed to ensure accurate resident assessments for two residents, leading to discrepancies in their Minimum Data Set (MDS) documentation. For one resident, who had diagnoses of hypertension and anxiety, there was a physician's order for oxygen therapy to maintain saturation above 91% as needed for shortness of breath. Despite being administered oxygen on multiple occasions, the MDS did not reflect the use of oxygen therapy, marking it as 'No'. This discrepancy was identified during a review of the clinical records and confirmed through an interview with the Nursing Home Administrator. Another resident, diagnosed with major depressive disorder and dementia, had a physician's order for a bed alarm. However, the MDS inaccurately marked the use of a bed alarm as 'No'. This error was also identified during a clinical record review and confirmed in an interview with the Nursing Home Administrator. Both instances highlight the facility's failure to ensure that the MDS accurately reflected the residents' current status and care needs, as required by regulations.
Plan Of Correction
1. Residents 8 and 60 had modifications of their MDS completed. 2. An initial audit of MDS completed in the past 30 days was completed to ensure accuracy of Section 00110 C1 and P0200 A. 3. Education was completed with MDS staff on ensuring accuracy of these sections of the MDS. 4. 5 audits of Section 00110 C1 and 5 audits of Section P0200 A will be completed weekly x 4, then monthly x 2 by DON or designee. Results of these audits will be shared with the QAA committee for review. 5. The facility will be in substantial compliance by 1/7/25.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for three residents, addressing their medical, physical, mental, and psychosocial needs. Resident 10, diagnosed with major depressive disorder and hypertension, was identified as a smoker who required supervision. However, her care plan did not include a smoking care plan until it was added on December 4, 2024, after the deficiency was noted. Similarly, Resident 60, who was admitted with major depressive disorder and dementia, did not have a dementia care plan in place upon admission, which was only added on December 4, 2024. Resident 75, diagnosed with urinary retention and cancer, was also identified as a smoker. Despite having multiple smoking evaluations indicating their smoking status, their care plan did not reflect their desire to smoke until it was updated on December 4, 2024. These omissions in the care plans were confirmed by the Nursing Home Administrator, who acknowledged that the care plans should have included these focus areas prior to the survey findings.
Plan Of Correction
1. Residents 10, 60, and 75 had their care plans corrected to reflect smoking and dementia diagnosis. 2. An initial audit of residents who smoke and residents with dementia diagnosis was completed to ensure that their care plans reflect these items. 3. Education was completed with nursing staff, therapy staff, and IDT on ensuring that care plans are developed for residents who smoke and residents that have dementia diagnosis. 4. 5 audits of residents who smoke and 5 residents with dementia diagnosis will be conducted weekly x 4, then monthly x 2 by DON or designee. Results of these audits will be presented to the QAA committee for review. 5. The facility will be in substantial compliance by 1/7/25.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised for three residents, leading to discrepancies between the care plans and the current physician orders. For Resident 1, the care plan included an intervention of intramuscular Ativan for seizure activity, initiated in July 2024. However, the physician orders did not include Ativan, as it had been discontinued in May 2024. This discrepancy was confirmed during an interview with the Nursing Home Administrator (NHA), who acknowledged that the care plan should have been updated at the time of discontinuation. Resident 11's care plan was not updated to reflect the current physician orders for a consistent, controlled carbohydrate, liberal renal diet with dysphagia advanced texture and thin consistency. The care plan had not been revised since June 2023, despite changes in dietary orders. Similarly, Resident 60's care plan inaccurately indicated a therapeutic altered diet related to diabetes, while the current physician orders specified a regular diet with regular texture and thin consistency. The NHA confirmed that Resident 60's care plan was incorrect and should have been updated to reflect the current diet.
Plan Of Correction
1. Residents 1, 11, and 60 had their care plans revised. 2. An initial audit of residents who had antianxiety medications discontinued in the past 30 days was completed to ensure accuracy, as well as an initial audit of residents who have had diet changes in the past 30 days has been conducted to ensure accuracy. 3. Education was completed with nursing staff and the IDT on ensuring that care plans are updated timely with any revision. 4. Five audits of residents with discontinued antianxiety medications and five audits of residents with diet changes will be conducted weekly for 4 weeks, then monthly for 2 months by the DON or designee. Results of these audits will be presented to the QAA committee. 5. The facility will be in substantial compliance by 1/7/25.
Failure to Obtain Physician Order for Respiratory Device
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident diagnosed with obstructive sleep apnea and asthma. Observations revealed the presence of a CPAP or BiPAP machine at the resident's bedside, but there was no physician order for either device in the resident's clinical record since their admission. Despite documentation in nursing progress notes indicating the resident's use of CPAP and BiPAP on multiple occasions, the necessary physician order was absent. The resident's care plan included the use of CPAP at bedtime per order, but the facility's records did not reflect an actual physician order for the device. An email from the Nursing Home Administrator confirmed that the resident used a BiPAP, not a CPAP, and acknowledged the lack of a physician order prior to the surveyor's inquiry. This oversight indicates a failure to adhere to the facility's policy and professional standards of practice regarding respiratory care.
Plan Of Correction
1. Resident 44 had orders revised to reflect BiPAP use. 2. An initial audit of residents who use BiPAPs was conducted to ensure accuracy with physician orders. 3. Education was completed with licensed nursing staff on ensuring that orders for BiPAPs are completed. 4. 2 new admissions will be audited for BiPAP orders weekly x 4, then monthly x 2 by DON or designee. Results of this audit will be presented to the QAA committee for review. 5. The facility will be in substantial compliance by 1/7/25.
Failure to Provide Adaptive Feeding Devices
Penalty
Summary
The facility failed to provide adaptive feeding devices for a resident, identified as Resident 53, who required them. According to the facility's policy on 'Assistance with Meals,' adaptive devices such as silverware with enlarged handles, plate guards, and specialized cups should be provided to residents in need. Resident 53's clinical record indicated a need for a lip plate and a Kennedy cup with meals, as per active physician orders dated September 10, 2024. The resident's care plan, revised on November 3, 2023, also specified the use of these devices. Observations conducted on December 2, 3, and 4, 2024, revealed that while Resident 53 was provided with a lipped plate during lunch, the Kennedy cup was consistently missing. This oversight was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the resident should have been served with a Kennedy cup. The deficiency was noted under the regulatory code 28 Pa code 211.6(a) - Dietary Services.
Plan Of Correction
1. Resident 53 had no adverse effect from not receiving kennedy cup with noon meal. 2. An initial audit of resident who use kennedy cups was completed to ensure that it was received as ordered. 3. Education was completed with dietary and nursing staff on ensuring that kennedy cups are provided as ordered. 4. 5 audits of residents who require kennedy cups will be conducted weekly x 4, then monthly x 2 by NHA or designee. Results of this audit will be presented to the QAA committee for review. 5. The facility will be in substantial compliance by 1/7/25.
Sanitation Breach in Food Service
Penalty
Summary
The facility failed to maintain sanitary conditions during food service, as observed during a tray line inspection in the kitchen. Employee 1, a cook, was seen wearing gloves on both hands while handling various items. The employee picked up a resident tray ticket from a cart and placed it on a resident tray, then opened a package of hamburger buns by tearing a hole in the bag. Using the same gloved hands, the employee removed a hamburger bun from the package and subsequently reached into a bin to remove lettuce and tomato, placing them on a resident plate. This process was repeated for three additional resident trays, with the employee continuing to touch tray tickets, hamburger buns, lettuce, and tomato without changing gloves. During an interview, the Nursing Home Administrator confirmed that dietary staff should not have direct contact with resident food items after touching non-food items such as tray tickets and food packaging.
Plan Of Correction
1. Employee 1 was provided education on not touching nonfood items with the same gloves as touching food items. 2. Observational audits of meal service (tray line) for 3 meals per day x 3 days to ensure appropriate sanitary service. 3. Education was provided to the dietary staff on proper procedure on performing tray line. 4. 2 weekly observations of tray line will be conducted weekly x 4, then monthly x 2 by NHA or designee. Results of this audit will be presented to the QAA committee for review. 5. The facility will be in substantial compliance by 1/7/25.
Lack of Documentation for QA Meeting in First Quarter
Penalty
Summary
The facility failed to provide evidence that a Quality Assurance (QA) Committee meeting was held during the first quarter of 2024. This deficiency was identified through a review of facility documentation and staff interviews. The Nursing Home Administrator (NHA) stated that the meeting was conducted by the prior administration, but she did not receive the sign-in sheet or any documentation confirming the meeting took place. Despite follow-up inquiries, the NHA was unable to provide any evidence of the meeting, confirming the lack of documentation for the first quarter of 2024.
Plan Of Correction
1. The facility was unable to find quarter 1 signature sheet for QAA meeting. 2. The facility has conducted monthly QAA meetings since April of 2024. Signature sheets were available for review. An audit of these signature sheets was completed to ensure that meetings were conducted monthly. 3. Education was provided to the QAA committee on the importance of conducting QAA meetings as scheduled. 4. QAA meeting will be audited monthly x 2 by NHA or designee. The results of these audits will be presented to the QAA committee for review. 5. The facility will be in substantial compliance by 1/7/25.
Resident Injury Due to Inadequate Supervision During Transport
Penalty
Summary
The facility failed to provide adequate supervision and assistive devices to prevent accidents, resulting in harm to a resident. The incident involved a resident with Alzheimer's disease, unspecified lack of coordination, and generalized muscle weakness, who sustained a scalp laceration and a leg injury during transport. The resident fell from a litter chair while being transported in the facility van, leading to a 12 cm laceration on the head and a fracture of the distal femur, among other injuries. The deficiency was attributed to the transportation driver's failure to ensure the resident was properly secured in the litter chair. The driver, Employee 1, did not verify that the safety belt was fastened around the resident, assuming it was secured because it was not visible under the blankets. The incident occurred when the driver made a turn in the parking lot, causing the resident to roll off the litter chair. The facility's investigation revealed that Employee 1 had not received competency training for the use of the litter chair prior to the incident. Further investigation showed that there was no written procedure for staff to follow regarding the use of the litter chair, and other drivers also lacked competency training. The Nursing Home Administrator confirmed that the resident was not properly secured, and the transport driver failed to ensure the resident's safety, resulting in actual harm. The facility identified these issues during the survey and acknowledged the lack of proper training and procedures as contributing factors to the incident.
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Illustrative
What surveyors actually found near you
We read the 242 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near New Bloomfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stonebridge Health & Rehabilitation Center | 6.1 mi | ★★★★★ | 0 | 0 |
| Transitions Healthcare Allens Cove | 8.9 mi | ★★★★★ | 8 | 0 |
| Claremont Nursing & Rehabilitation Center | 14.5 mi | ★★★★★ | 15 | 0 |
| Letort Spring Nursing And Rehab Llc | 14.6 mi | ★★★★★ | 23 | 0 |
| Northern Dauphin Nursing And Rehabilitation Center | 15.1 mi | ★★★★★ | 2 | 0 |
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