William Penn Care Center

Inspectors wroteBased on review of facility policy, facility documents, clinical record review, and staff interviews, it was determined that the facility failed to reassess an elopement risk and implement interventions to prevent elopement after displaying exit-seeking behaviors, and the facility failed to ensure proper supervision for a resident (Resident R1) resulting in an elopement for one of five residents reviewed (Resident R1).

Inspectors wroteBased on review of facility policy, clinical records, staff interview, and observations, it was determined that the facility failed to ensure a resident with a tracheostomy (trach- a surgical created opening in the neck that provides a direct secure airway) was monitored and documented as appropriate respiratory care for one of three residents (R3) and failed to provide appropriate respiratory care for four of six residents (Residents R11, R32, R67 and R69).

Inspectors wroteBased on a review of facility policy, resident clinical records, and staff interview, it was determined the facility failed to ensure the coordination of hospice services with facility services to meet the needs of each resident for end of life care for three of five residents (Resident R9, R24 and R78).

Inspectors wroteBased on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to prevent cross contamination during a dressing change for one of three residents (Resident R24), failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for three of 10 months (February 2026, March 2026, and April 2026) and failed to maintain a comprehensive program for water management to monitor the potential development and spread of Legionnaires (an infection of the lungs caused by bacteria, commonly spread by water) for 10 of 10 months. (July 2025 - April 2026).

Inspectors wroteBased on review of the facility policy and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for 3 of 10 months (February 2026, March 2026 and April 2026).

Inspectors wroteBased on clinical record review, facility policy, resident interview and staff interview, it was determined that the facility failed to treat each resident with respect by failing to address a resident by their preferred name for one of eight residents (Resident R61). Review of facility policy Resident Rights dated 1/6/26, indicated that residents will be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individually. Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnoses, or care needs. Review of clinical record revealed that Resident R61 was admitted to the facility on [DATE]. Review of Resident R61's care plan dated 11/21/25, revealed the name the resident prefers to be addressed as. [...]

Inspectors wroteBased on review of facility policy, observation, and staff interview it was determined that the facility failed to maintain the confidentiality of resident's medical information on one of four medication carts (East Medication Cart).

Inspectors wroteBased on review of facility policy, clinical record review, closed resident records and staff interview, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for two of four resident hospital transfers (Resident R24 and Closed Resident Record CR87).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to properly monitor weight and nutrition status by failing to obtain a monthly weight for one of eight residents (Resident R8), and failed to individualize care plans to address the resident specific nutritional concerns for two of two residents (Resident R8, and R90).

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly secure a treatment cart while not in use for one of three treatment carts (East Hall Treatment Cart), failed to properly store medications in one of two medication storage rooms (East Medication Room) and in two of four medication carts (A Hall Medication Cart and C Hall Medication Cart).

Inspectors wroteBased on a review of facility policy, facility provided documentation, and staff interviews, it was determined the facility failed to designate a consistent qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections for one of 10 months (April 2026).

Inspectors wroteBased on review of facility policy, clinical record reviews and staff interviews, it was determined that the facility failed to initiate a thorough investigation for incident or accidents for one of five residents (Residents R1). The facility Incident and Accident policy dated 1/28/25, indicated for staff to report, investigate, and review and accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. Review of the clinical record indicated Resident R1was admitted to facility 10/18/24. Review of Resident R1s Minimum Data Set (MDS, periodic assessment of resident care needs) dated 1/18/26 included diagnoses of cardiomegaly (enlarged heart), hyperlipidemia and anxiety. Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R1' score to be 13, cognitively intact. [...]

Inspectors wroteBased on review of facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to provide adequate supervision resulting in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of five residents (Resident R1). Review of facility policy Elopements and Wandering Residents dated 1/28/25, indicated the facility ensures that residents which exhibit wandering behaviors and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. [...]

Inspectors wroteBased on review of facility policy, clinical records and staff interview, it was determined that the facility failed to provide documentation of medication regimen reviews (MRR) completed at least monthly for three of three sampled resident records (Resident R20, R59, R67).

Inspectors wroteBased on a review of policy, observation and staff interview, it was determined that the facility failed to properly maintain kitchen equipment in a sanitary condition creating the potential for cross contamination in the main kitchen of the facility.

Inspectors wroteBased on review of facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to provide adequate supervision resulting in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of four residents (Resident R44).

Inspectors wroteBased on a review of the facility policy, clinical record review and staff interview, it was determined that the facility failed to accurately assess the nutritional status, and failed to update an individualized care plan to address the resident's specific nutritional concerns for one of four residents (Resident R65) records reviewed.

Inspectors wroteBased on facility policy and staff interview it was determined that the facility failed to provide medical record access for one of four residents (Resident R1).

Inspectors wroteBased on review of clinical record review, and staff interview, it was determined that the facility failed to implement an effective discharge planning process that focuses on the resident's discharge goals and effectively transition them to post-discharge care for one of three residents (Resident R2).

Inspectors wroteBased on review of clinical record review and staff interviews it was determined that the facility failed to follow physician orders for one of two residents (Resident R1).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for three out of nine residents (Residents R1, R2 and R3).

Inspectors wroteBased on review of the facility assessment and staff interview, it was determined that the facility failed to provide a qualified full time social worker for a facility with more than 120 beds.

Inspectors wroteBased on review of facility financial documents, interviews with vendor and staff, it was determined that the facility failed to pay bills in a timely manner.

Inspectors wroteBased on review of facility policies, resident clinical records, documentation provided by the facility, facility investigation, personnel records, family and staff interviews, it was determined that the facility failed to ensure that a resident was free from neglect, which resulted in actual harm as evidenced by right tibia (the anterior of two bones below the knee) fractures for one out of three residents (Resident R27).

Inspectors wroteBased on a review of facility policies, observations and staff interviews it was determined that the facility failed to properly store food products, and verify the washing temperature of the dish machine in the Main Kitchen (Main Kitchen), which created the potential for food borne illness. Findings Include: Review of the facility policy Cleaning Dishes/Dish Machine, last reviewed 1/320/24, indicated that the dish machine will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitizing. Prior to use, verify proper temperatures and machine function. Staff should check the dish machine gauges throughout the cycle to assure proper temperatures for sanitization. Thermal strips may be used as verification that the temperature is adequately hot. [...]

Inspectors wroteBased on a review of the facility policy, clinical record review and staff interview, it was determined that the facility failed to assess the nutritional status of three of six residents ( Resident R3, R35, and R67) records reviewed.

Inspectors wroteBased on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to follow enhanced barrier precautions for two of twenty residents (Residents R33 and R74), failed to have proper signage for Transmission Based Precautions, and staff knowledge for one of one positive Covid resident (Resident R180).

Inspectors wroteBased on review of facility records and staff interviews, it was determined that the facility failed to have a designated Infection Preventionist (IP) qualified with specialized training in infection prevention and control for six of twelve months (February 2024 - July 2024).

Inspectors wroteBased on review of facility in-service documentation, personnel records, and staff interviews it was determined that the facility failed to implement and maintain an effective training program for five of ten employee files reviewed (Nurse Aides (NA) Employee E9, NA Employee E16, NA Employee E25, NA Employee E27, and Licensed Practical Nurse (LPN) Employee E26).

Inspectors wroteBased on review of clinical records and facility provided documents, and staff interviews, it was determined that the facility failed to ensure that residents were free from misappropriation (the act of stealing something that you have been trusted to care of and using it for yourself) of $5,251.83 for one of three residents reviewed (Resident R5).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and misappropriation of property of residents for one of three residents reviewed (Closed Record Resident CR1).

Inspectors wroteBased on review of facility policy, clinical records, facility provided documents, resident, and staff interviews, it was determined that the facility failed to report an alleged allegation of misappropriation of property for one of three residents (Resident CR1).

Inspectors wroteBased on review of facility policy, clinical records, facility provided documents, and staff interview, it was determined that the facility failed to investigate a potential allegation of abuse/neglect for misappropriation of property for one of three residents (Closed Record Resident CR1).

Inspectors wroteBased on review of facility policy, resident records, admission documentation and staff interview, it was determined that the facility failed to maintain admission documentation for two of three residents (Resident R2, R60).

Inspectors wroteBased on facility policy, clinical record review and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two out of two residents sampled with facility-initiated transfers (Residents R67, and R72).

Inspectors wroteBased on review of facility policy, clinical records, observations, resident and staff interview it was determined that the facility failed to provide care as per physician's order and failed to provide weekly assessments for one out of four sampled residents with a surgical area (Resident R74).

Inspectors wroteBased on review of facility policies, observations, clinical record review, and staff interview, it was determined that the facility failed to provide appropriate care of respiratory equipment for two of four residents (Residents R70 and R71).

Inspectors wroteBased on review of facility policy, resident record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for two of two residents (Resident R1, and R67).

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store medications properly and securely in two of three medications carts (East Hall Medication Carts A and B).

Inspectors wroteBased on facility documents, resident clinical records, and staff interview, it was determined that the facility failed to ensure a representative signed a binding arbitration agreement on behalf of a resident lacking capacity to understand the agreement terms for two of three residents (Resident R2, R60).

Inspectors wroteBased on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for identified resident problems for one for eight residents (Resident R1).

Inspectors wroteBased on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for identified resident problems for one for eight residents (Resident R1).

Inspectors wroteBased on review of the facility assessment and staff interview, it was determined that the facility failed to provide a qualified full time social worker for a facility with more than 120 beds.