Pennypack Rehab and Care Center

Inspectors wroteBased on family interview, review of facility policy and review of clinical record, it was determined that facility did not ensure to timely notify resident representative after change in condition for one of 12 residents reviewed (Resident R5)

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure complete and accurate documentation related to a hospital discharged for 1 of 8 resident reviewed. (Resident 53) Findings Include: Review of Resident R53' s nursing notes dated March 13, 2026, at 12:51 p.m. revealed that the resident was transported for an Oncology appointment. Resident R53 was transferred to the local hospital from the Oncology appointment on March 13, 2026, at 6:33 p.m. due to a change in condition. Further review of nursing notes revealed no additional documentation or follow-up communication with the hospital, related to the resident admitting diagnosis, stay and discharge status. Interview with the Director of Nursing, Employee E2 on May 21, 2026, at 2:00p.m. confirmed that there was no follow up documentation related to Resident R53 transfer to the hospital. 28 Pa. [...]

Inspectors wroteBased on interviews with staff and residents, reviews of clinical records, review of personal funds accounting records and facility's policies and procedures, it was determined that for one of eight residents reviewed, the facility failed to maintain separate accounting and records for each resident's personal funds entrusted to the facility on the resident's behalf. (Resident Cl1)

Inspectors wroteBased on staff interviews, review of clinical records and review of facility documents, it was determined that the facility failed to ensure residents were assessed and monitored after fall incidents for one out of two residents reviewed (Resident R1).

Inspectors wroteBased on the review of clinical records, and interviews with staff, it was determined that the facility failed to inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate for one of 5 residents reviewed. (Resident R1). Findings Include:Review of clinical record revealed that Resident R1 was admitted to the facility on [DATE]. Review of admission agreement for Resident R1 signed by resident and facility staff, at the time of resident's admission, revealed that the charges for the services including charges for residents stay at the facility when not covered under Medicare/Medicaid or insurance was not informed to the resident. [...]

Inspectors wroteBased on observations, review of facility policy and staff interviews, it was determined that the facility failed to ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety.

Inspectors wroteBased on staff interviews and review of facility documentation, it was determined that the facility failed to conduct a complete and thorough investigation related to an allegation of potential abuse/neglect for 1 out of 13 residents reviewed (Resident R101)

Inspectors wroteBased on clinical record reviews, review of facility policies and interviews with staff, it was determined that the facility failed to complete a discharge MDS assessment for one of 19 residents reviewed (Resident R9).

Inspectors wroteBased on review of facility policy and review of clinical records, it was determined that the facility failed to develop and implement a baseline care plan for one of six new admissions reviewed (Resident R19). Findings Include: Review of facility policy on Care Plans-Baseline revealed that under section Policy Statement A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. Under section Policy Interpretation and Implementation #1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: a. [...]

Inspectors wroteBased on observations, review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to follow physician orders during medication administration for one of five residents observed during medication administration (Resident R34).

Inspectors wroteBased on observations, review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure appropriate enteral feeding practices related to labeling and implementing dietician recommendations for one of two residents reviewed related to enteral feeds (Resident R33).

Inspectors wroteBased on a review of clinical records and facility policies and procedures, observations, and interviews with staff, it was determined that the facility failed to provide respiratory care and supplemental oxygen according to physician's order for one of seventeen residents reviewed. (Resident R40).

Inspectors wroteBased on clinical record reviews and interviews with staff, it was determined that the facility failed to ensure physician visits were completed as required for one of 19 residents reviewed (Resident R4).

Inspectors wroteBased on observations, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that personal foods were stored and labeled in accordance with food safety standards for one of one medication rooms reviewed (A/B Wing medication room).

Inspectors wroteBased on review of clinical record, review of facility policy, and interview with facility staff, it was determined that the facility failed to ensure that residents were free of significant medication errors for one of five newly admitted resident reviewed (Resident R1). Findings Include: Review of facility policy titled Medication and Treatment Orders and dated July 2016, revealed the following; 15. Upon admission, the admitting nurse will review the transfer record of the newly admitted patient. The admitting nurse will then notify the attending physician or on-call physician to review admission medications on the transfer record. After medications are reviewed with the physician, the admitting nurse or designee will input the approved medications from the transfer record into the PCC Emar system. [...]

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to notify the representative of the Office of the State Long Term Care Ombudsman for two of 16 resident records reviewed (Residents R2, R36).

Inspectors wroteBased on observation, review of facility policy and procedures and interview with staff, it was determined that the facility failed to maintain an effective infection control program related to the transportation, sorting, washing, and drying of soiled resident clothing and the storage of clean linens and residents' clothing in the laundry room.

Inspectors wroteBased on review of clinical records, facility documentation, and interviews with staff, it was determined that the facility failed to issue the resident/resident representative a Notice of Medicare Non-Coverage (NOMNC) prior to termination of Medicare A services, as required, for one of three residents' records reviewed (Resident R25).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the PASRR (Preadmission Screening and Resident Review) was not appropriately completed for one of 24 residents reviewed (Resident R16).

Inspectors wroteBased on observations, clinical record review, review of facility documents and staff interviews, it was determined that the facility failed to revise the care plan for fall prevention, for one of 24 residents reviewed (Resident R25).

Inspectors wroteBased on observation, review of resident's records, facility's policies and interviews with staff, it was determined that the facility failed to ensure adequate pain management was provided for one resident documented with severe pain of 16 resident records reviewed (Resident R38).

Inspectors wroteBased on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater for three of four residents observed during medication administration (Resident R31, R48, and R49).

Inspectors wroteBased on review of facility policy, review of clinical records, interviews with staff and residents, it was determined that the facility failed to implement the facility abuse policy for one of four residents reviewed . (Resident R1) Findings Include: Review of facility policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating last revised September 2022 states, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Further review of the facility policy revealed, 1. [...]

Inspectors wroteBased on observation, review of facility policy, review of facility documentation, review of clinical records, interviews with staff, and interviews with the resident it was determined the facility failed to conduct an investigation timely to rule out neglect and/or abuse for one of four sampled residents (Resident R1). Findings Include: Review of facility policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating last revised September 2022 states, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Further review of the facility policy revealed, 1. [...]