Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Village At Penn State, The during CMS and state inspections, most recent first.
A resident with dementia, repeated falls, and a high fall-risk score was found on the floor after calling out from her room. Her call bell was not alerting, her cane was out of reach, and the chart showed no fall-prevention interventions were included in the care plan before the fall. She complained of hip and head pain, was sent out for evaluation, and imaging showed two displaced pelvic rami fractures.
Food Storage and Kitchen Sanitation Deficiencies: The facility failed to store food and maintain food service equipment in accordance with professional standards. Observations found the Atrium stove and oven with heavy charred debris, dust, grease, and particulate matter; items stored on the floor behind the ice machine in the supply room; a bulging, leaking, frozen container of milk in the supply room refrigerator; and an uncovered sheet cake in the main kitchen walk-in freezer.
A resident’s active physician order directed full code measures, including chest compressions and breathing assistance, while the resident’s signed POLST indicated DNR wishes. The discrepancy was identified during survey review and later confirmed by the DON, who noted a new order for DNR with limited interventions.
The facility failed to develop comprehensive, person-centered care plans for two residents with pacemakers. One resident’s record showed a pacemaker, sick sinus syndrome, and atrial fibrillation, but the care plan did not address the pacemaker, related assessments, clinical care, or precautions. The other resident had a pacemaker with recent replacement, yet the care plan also lacked pacemaker-related assessments, care, and precautions.
The facility failed to ensure that one nurse aide completed the required 12 hours of annual in-service training. Records showed the aide was hired in 2023 and completed only 6 hours and 25 minutes of in-service education during the reviewed annual period, and the NHA confirmed the findings.
Incomplete Transfer and Bed-Hold Notices: The facility failed to provide two residents' responsible parties with written transfer notices containing all required information after hospital transfers. One resident's bed-hold and transfer paperwork lacked written notice of the transfer/discharge, the reasons for the move, and appeal rights information, while another resident's transfer notice and email to family also omitted appeal rights details and instructions for obtaining and submitting an appeal form. Social Services confirmed the missing documentation.
Surveyors identified multiple sanitation and food storage deficiencies, including soiled kitchen equipment, dirty floors, and undated food items in freezers. Observations included buildup on sheet pans, unclean carts and tables, pooled liquid in the pantry, and improper storage of food and non-food items together. These issues were confirmed with facility leadership.
Two residents received PRN pain medications without clear parameters or guidance for staff on which medication to administer based on pain levels. The facility lacked policies defining pain severity and did not provide specific instructions in physician orders, leading to inconsistent pain management practices.
A resident was found self-administering Flonase and Afrin nasal sprays without a physician's order or documented assessment by the facility to determine her ability to safely self-administer these medications. The medications were kept at her bedside, and the lack of required authorization and evaluation was confirmed by the NHA and DON.
Two residents with a history of falls and cognitive or physical impairments were not provided with required fall prevention interventions or adequate supervision. One resident fell from a wheelchair due to missing dycem, as specified in the care plan, and another fell while ambulating with a nurse aide who was not providing close supervision, despite therapy documentation indicating the need for stand-by or contact guard assistance.
The facility failed to maintain proper food storage and sanitation in the main and smaller kitchens. Observations included undated and expired food items, dust accumulation, and debris around dumpsters. A dishwasher was seen without a beard guard, and an air conditioning unit had a black substance build-up. These issues were discussed with the Nursing Home Administrator and DON.
A resident experienced verbal and physical mistreatment by an RN during an assessment after a fall. Witnesses reported the RN was rough and rude, rolling the resident into a door jamb and threatening to mark her as a refusal. The RN cited stress and personal issues as contributing factors. The facility did not substantiate abuse allegations due to lack of intent and failed to educate staff on stress management and abuse prevention.
A facility failed to monitor the effectiveness or adverse consequences of psychotropic medication for a resident with a physician's order for Zoloft, used to treat depression. The resident's care plan required monitoring for side effects and effectiveness, but there was no documented evidence of such monitoring. This deficiency was confirmed by the DON and Nursing Home Administrator.
Failure to Implement Fall Prevention Interventions Resulted in Pelvic Fracture
Penalty
Summary
The facility failed to implement interventions for fall prevention for a resident admitted with dementia and repeated falls, resulting in an actual pelvic fracture. The resident’s admission diagnoses included dementia and repeated falls, and the fall risk assessment identified multiple risk factors, including prior falls, disorientation, ambulation, incontinence, poor vision, balance problems, decreased muscular coordination, and use of a cane. The resident’s fall risk score was 21, which indicated high risk for falls and required prevention protocol to be initiated immediately and documented on the care plan. Facility policy required residents at risk for falls to have interventions incorporated into the plan of care, such as bed exit alarms, call light within reach, toileting assistance, environmental hazard reduction, low bed position, and other measures. However, review of the resident’s initial and comprehensive care plan found no evidence that fall interventions were implemented until after the fall event. The record also showed inconsistencies in the resident’s fall history between the fall risk assessment and the admission MDS, and physical therapy documentation reflected difficulty walking and muscle weakness, with the resident requiring partial to moderate assistance for ambulation. On the day of the incident, nursing staff heard the resident calling out and found her on the floor in her room. She was wearing nonslip footwear, her call bell was not alerting, and her cane was several feet away. She had last been toileted earlier that morning. After being assisted up, she complained of pain in her right hip and the back of her head, was placed in a wheelchair, and sent for further evaluation. Imaging later showed two displaced fractures of the pelvic rami, and she remained hospitalized for treatment of the pelvic fractures. The DON confirmed the finding during interview.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store food and maintain food service equipment in accordance with professional standards for food service safety in the main kitchen. An observation in the Atrium kitchen and supply room, and the main kitchen revealed the Atrium gas burners with black, charred particulate matter cooked onto the metal grates, the metal control knobs on the Atrium stove with a large amount of dust, debris, and grease built up between the knobs, and the Atrium oven with black and charred debris throughout the base and on the oven door. In the supply room, the ice machine had plastic lids, a small square bucket, a cup, and boxes of gloves stored behind it on the floor. The supply room refrigerator contained a container of milk that was bulging, leaking, and noted to be frozen. The main kitchen walk-in freezer had an uncovered sheet cake sitting on a shelf.
Failure to Align Code Status Orders With Resident Wishes
Penalty
Summary
The facility failed to ensure that active physician orders reflected Resident 3’s wishes for end-of-life care. Resident 3 was admitted on March 30, 2026, and the active physician order dated March 20, 2026 directed staff to provide full treatment in the event of a medical emergency, including chest compressions and breathing assistance. However, a POLST form signed by Resident 3 on March 23, 2026 indicated a DNR preference, meaning no chest compressions or breathing assistance in a medical emergency. The discrepancy between the active order and the resident’s documented wishes was reviewed with the Nursing Home Administrator and DON, and the DON later confirmed that a new physician order dated May 13, 2026 noted DNR with limited interventions.
Incomplete Care Plans for Residents with Pacemakers
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for two residents with cardiac pacemakers. Resident 28 had diagnoses that included a cardiac pacemaker, sick sinus syndrome, and atrial fibrillation, and the medical provider documentation and quarterly MDS also identified the pacemaker as an active diagnosis. Review of the care plan showed no current comprehensive plan addressing the pacemaker, related assessments, clinical care, or associated precautions. Resident 33 also had diagnoses that included a cardiac pacemaker, sick sinus syndrome, and atrial fibrillation, and provider documentation noted a pacemaker with recent replacement. X-ray documentation identified a left-sided pacemaker. Review of the care plan showed no current comprehensive, person-centered plan addressing the pacemaker, related assessments, clinical care, or associated precautions.
Nurse Aide In-Service Training Deficiency
Penalty
Summary
The facility failed to ensure that each nurse aide received 12 hours of annual in-service training for one of three nurse aides reviewed, Employee 1. Review of Employee 1’s personnel record showed that she was hired on April 17, 2023. Review of the training records provided by the facility for Employee 1 for the period from April 2025 to April 2026 showed that she completed only six hours and 25 minutes of in-service education. The Nursing Home Administrator confirmed these findings during interview on May 14, 2026, at 12:04 PM.
Incomplete Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to provide a written transfer notice with all required contents to the responsible parties for two residents who were hospitalized. For one resident, the clinical record showed admission to the hospital, and the facility form related to bed hold information and transfer notification did not include written notification of the transfer or discharge and the reasons for the move, nor did it include a statement of appeal rights with the name, mailing and email address, and telephone number of the entity receiving appeal requests, or information on how to obtain an appeal form and assistance with completing and submitting the appeal hearing request. An interview with Social Services confirmed there was no evidence that written notification had been given to the resident representative. For another resident, the resident was transferred to the hospital, and the transfer notice provided to the resident and emailed to the family did not contain all required components. Specifically, it lacked a statement of the resident's appeal rights, including the name, mailing and email address, and telephone number of the entity receiving such requests, as well as information on how to obtain an appeal form and assistance in completing and submitting the appeal hearing request. Social Services confirmed these findings during interview, and the transfer and bed-hold notifications for both residents were reviewed with the Nursing Home Administrator and DON.
Sanitation and Food Storage Deficiencies in Kitchen and Pantry Areas
Penalty
Summary
Surveyors observed multiple sanitation and storage deficiencies in the facility's main kitchen, Atrium kitchen, and pantry. In the Atrium kitchen, several sheet pans in use had significant black buildup, and a plastic wrap holder on the production table was found with dried liquid splatter, food crumbs, and dust both inside and outside. The flooring under the dish machine, cooler, and cooking equipment had visible dirt and debris, and a three-tier cart used to store clean glasses and trays was soiled with dried spills and food debris. In the main kitchen, the walk-in freezer floor had a significant buildup of dirt and debris, and a speed-rack in the walk-in cooler was soiled with dried food, spills, dust, and debris. The wall behind the handwashing sink was covered in brown splatter, and cooking equipment such as the tilt kettle, braising kettle, flat top, grill, and stove had thick dust and blackened debris buildup. The director of dining services indicated that some equipment was out of service and awaiting replacement. In the pantry storage area, surveyors found a large amount of pooled liquid in front of the ice machine, sticky and debris-laden flooring, and dirt under equipment and along wall edges. A metal table holding a juice dispenser had dried orange spills and a sticky, dusty lower shelf, with a cardboard box and an opened can of paint stored on it. Two upright freezers contained multiple food items, including cupcakes, potato tots, onion rings, cream chipped beef, beef stew, and meat lasagna, none of which were labeled with dates to indicate when they were placed in storage or when they should be used by. These findings were reviewed with facility leadership.
Lack of Pain Management Parameters for PRN Medications
Penalty
Summary
The facility failed to provide pain management services consistent with professional standards of practice for two residents. For one resident, physician orders included as-needed (PRN) medications for pain, such as Acetaminophen and Oxycodone, but the orders did not specify pain level parameters for when each medication should be administered. The resident's medication administration records showed that Oxycodone was given for varying pain levels, including moderate and severe pain, but Acetaminophen was not administered at all during the month. The facility did not have a policy defining mild, moderate, or severe pain, and there was no guidance for nurses on which medication to use based on the resident's reported pain level. For another resident, orders for PRN Acetaminophen and Tramadol were present, but again, there were no pain scale parameters to guide staff on which medication to administer for specific pain levels. The medication administration records indicated that both medications were given for a range of pain scores, including high pain levels, but without documented criteria for their use. Interviews with the DON and Nursing Home Administrator confirmed the absence of pain management parameters and policies, resulting in inconsistent and potentially inappropriate pain management for both residents.
Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
A deficiency was identified when a resident was observed self-administering Flonase and Afrin nasal sprays, which she had brought from the hospital and kept on her bedside table or windowsill since admission. The resident confirmed that she self-administered these medications. Review of the clinical record revealed there was no physician's order permitting self-administration, nor any documentation that the facility had assessed or determined the resident's ability to safely self-administer her medications. This information was confirmed with the Nursing Home Administrator and Director of Nursing.
Failure to Implement Fall Prevention Interventions and Provide Adequate Supervision
Penalty
Summary
The facility failed to implement care-planned interventions and provide adequate supervision to prevent accidents for two residents with a history of falls. One resident, who had severe cognitive impairment and was assessed as a fall risk due to unsteady gait and poor balance, had a care plan intervention requiring dycem on the wheelchair seat and pressure alarm to prevent sliding. However, on the night of the incident, the dycem was not in place, and the resident fell from the wheelchair, sustaining a skin tear. Staff documentation confirmed the absence of the dycem at the time of the fall, and facility leadership could not provide further documentation regarding the missing intervention. Another resident, also identified as a high fall risk with a recent history of multiple falls, intermittent confusion, and decreased balance, experienced a fall while ambulating in the hallway with a nurse aide. The resident lost consciousness briefly after hitting her head during the fall and was transported to the hospital. Clinical records and therapy notes indicated that the resident required supervision or contact guard assistance for ambulation and needed frequent verbal cues for safety. Despite these documented needs, the resident's care plan did not specify the required level of ambulation assistance, and the nurse aide was walking ahead of the resident rather than providing close supervision at the time of the fall. The facility's failure to follow care-planned interventions for fall prevention and to provide adequate supervision for residents at high risk for falls resulted in preventable accidents. Documentation and interviews confirmed that the necessary interventions and supervision were not consistently implemented for these residents, directly contributing to their falls and injuries.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to maintain proper food storage and a sanitary environment in both the main kitchen and a smaller kitchen area on the skilled nursing unit. During an initial tour, it was observed that the walk-in freezer contained undated and open packages of veggie burgers and ground pork sausage, as well as an undated bag of breadsticks. The walk-in cooler had expired onions, undated celery, expired halibut, unlabeled potatoes, and expired avocado halves. Additionally, the cooler's condenser unit had a significant accumulation of dust. The area around the main kitchen dumpsters was littered with medical gloves, Styrofoam cups, dead leaves, and other debris. Inside the main kitchen, a partially filled milk container and a lemon juice container were found with expired dates, and there was a significant accumulation of dust on a ceiling vent and adjacent ceiling tile. The protective coverings on two ceiling lights were partially ajar, and there was a damaged wall corner between the kitchen and dishwashing area, which allowed water to leak and puddle on the floor. In the smaller kitchen on the skilled nursing unit, a floor drain near the food prep area contained various debris. Employee 5, a dishwasher, was observed in the kitchen area with a full beard but without a beard guard, which the facility does not require. An air conditioning unit in the same area had an extensive build-up of a black colored substance on its vents. These observations were reviewed with the Nursing Home Administrator and Director of Nursing, indicating a failure to adhere to professional standards for food storage and sanitation.
Failure to Prevent Abuse and Educate Staff on Stress Management
Penalty
Summary
The facility failed to prevent abuse for a resident, identified as Resident 8, who was involved in an incident on May 9, 2024. A nurse aide found the resident on the floor, having slid out of bed, and called for a registered nurse, Employee 2, to assess her for injuries. During the assessment, Employee 2 was reported to have been verbally inappropriate and physically rough with Resident 8. Witnesses, including a nurse aide and a licensed practical nurse, reported that Employee 2 rolled Resident 8 into a door jamb, causing her pain, and spoke to her in a rude manner, threatening to mark her as a refusal if she did not comply. Employee 2 admitted to being stressed and frustrated due to personal circumstances and work demands, which she believed contributed to her behavior. The facility's investigation into the incident revealed that Resident 8 did not sustain any injuries from the fall or the subsequent handling by Employee 2. However, the Director of Nursing's summary indicated that Resident 8 felt mistreated and reported being yelled at and thrown against the wall by Employee 2. Despite these findings, the facility did not substantiate the abuse allegations, citing a lack of intent to harm by Employee 2. Furthermore, the facility failed to educate staff on stress management and abuse prevention following the incident, as Employee 2 did not return to the facility, and no further staff education was conducted to prevent recurrence.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to monitor the effectiveness or adverse consequences of psychotropic medication use for one of the residents reviewed. Resident 8 had a physician's order for Zoloft, a medication used to treat depression, at a dosage of 25 milligrams once daily. The resident's care plan included a focus area for depression related to dementia, with a goal for the resident to remain free of signs and symptoms of depression, anxiety, or sad mood. The care plan interventions required monitoring for side effects and effectiveness of the medication. However, there was no documented evidence that Resident 8 was being monitored for side effects or effectiveness of the Zoloft medication. This was confirmed during an interview with the Director of Nursing and the Nursing Home Administrator. The facility's failure to ensure proper monitoring of the psychotropic medication use for Resident 8 was noted as a deficiency.
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What surveyors actually found near you
We read the 131 citations issued within 25 miles in the last 12 months — 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.
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Nursing homes near State College
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Juniper Village At Brookline-rehabilitation And Sk | 3.1 mi | ★★★★★ | 2 | 0 |
| Foxdale Village | 3.2 mi | ★★★★★ | 0 | 0 |
| Embassy Of Hearthside | 3.3 mi | ★★★★★ | 43 | 0 |
| Centre Care Rehabilitation And Wellness Services | 4.3 mi | ★★★★★ | 5 | 0 |
| Valley View Haven, Inc | 16.8 mi | ★★★★★ | 5 | 0 |
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