Pennsylvania Department of Health
 PENNYPACK REHAB AND CARE CENTER
Patient Care Inspection Results

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PENNYPACK REHAB AND CARE CENTER
Inspection Results For:

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PENNYPACK REHAB AND CARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Revisit survey completed on May 22, 2026, it was determined that Pennypack Rehab and Care Center, continued to be not in compliance with the State deficiencies cited during the Revisit survey dated February 17, 2026, under the 28 PA Code, Commonwealth of Pennsylvania Term Care Licensure Regulation related to health portion of the survey process.




 Plan of Correction:


§ 211.12(f.1)(3) LICENSURE Nursing services. :State only Deficiency.
(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:


Based on review of nursing staff schedules and interviews with staff, it was determined that the facility failed to maintain required staffing ratios, including one nurse aide per 10 residents during the day shift on seven out of seven days reviewed (May 15, 16, 17, 18, 19, 20, and 21, 2026).

Findings include:

Review of facility census data revealed that on May 15, 2026, the facility census was 46, which required 31.36 hours of nurse aides during the evening shift and 23 hours on the Night Shift. Review of the nursing time schedules revealed 22.70 hours of nurse aide care were provided on the evening shift and 15.63 hours of nurse aide care were provided on the night shift.

Review of facility census data revealed that on May 16, 2026, the facility census was 46, which required 34.50 hours of nurse aides during the day shift and 31.36 hours of nurse aides during the evening shift. Review of the nursing time schedules revealed 29.41 of hours of nurse aide care were provided on the day shift and 20.47 hours of nurse aide care were provided on the evening shift.

Review of facility census data revealed that on May 17, 2026, the facility census was 45, which required 30.68 hours of nurse aides during the evening shift. Review of the nursing time schedules revealed 23.92 of hours of nurse aide care were provided on the evening shift.

Review of facility census data revealed that on May 18, 2026, the facility census was 46, which required 34.50 hours of nurse aides during the day shift, 31.36 hours of nurse aides during the evening shift, 23.00 hours on the Night Shift. Review of the nursing time schedules revealed 30.34 of hours of nurse aide care were provided on the day shift, 24.36 hours of nurse aide care was provided on the evening shift, and 14.75 hours of nurse aide care were provided on the night shift.

Review of facility census data revealed that on May 19, 2026, the facility census was 45, which required 33.75 hours of nurse aides during the day shift, 30.68 hours of nurse aides during the evening shift, and 22.50 hours on the Night Shift. Review of the nursing time schedules revealed 31.46 of hours of nurse aide care were provided on the day shift, 22.62 hours of nurse aide care was provided on the evening shift, and 16.67 hours of nurse aide care was provided on the night shift.

Review of facility census data revealed that on May 20, 2026, the facility census was 45, which required 33.75 hours of nurse aides during the day shift and 30.68 hours of nurse aides during the evening shift. Review of the nursing time schedules revealed 28.82 of hours of nurse aide care were provided on the day shift and 27.38 hours of nurse aide care were provided on the evening shift.

Review of facility census data revealed that on May 21, 2026, the facility census was 46, which required 34.50 hours of nurse aides during the day shift. Review of the nursing time schedules revealed 32.00 of hours of nurse aide care were provided on the day shift.




 Plan of Correction - To be completed: 06/30/2026

1.The facility reviewed the CNA ratios for the dates

2.Other days were reviewed to see if ratios were met

3.Scheduling coordinator will be educated on CNA ratios

4.DON/designee will conduct daily audits to verify CNA ratios for all shifts weekly x 4 weeks. Results will be presented to QAPI
§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:

Based on review of nursing staff schedules and interviews with staff, it was determined that the facility failed to maintain required staffing ratios, including one LPN (Licensed Practical Nurse) per 25 residents during the day shift, one LPN per 30 residents during the evening shift and one LPN per 40 residents during the overnight shift on two of seven days reviewed (May 16 and 18, 2026).

Findings include:

Review of facility census data revealed that on May 16, 2026, the facility census was 45, which required 14.40 hours of LPNs during the day shift. Review of the nursing time schedules revealed 15.38 hours of LPN care was provided during the shift.

Review of facility census data revealed that on May 18, 2026, the facility census was 46, which required 14.72 hours of LPNs during the day shift and 12.27 hours of LPNs during the evening shift. Review of the nursing time schedules revealed 7.82 hours of LPN care was provided during the day shift and 7.33 hours of LPN care was provided during the evening shift.




 Plan of Correction - To be completed: 06/30/2026

1.The facility reviewed the LPN ratios for those dates.

2.Other days were reviewed to see if ratios were met

3.Scheduling coordinator will be educated on LPN ratios

4.DON/designee will conduct daily audits to verify LPN ratios for all shifts weekly x 4 weeks. Results will be presented to QAPI
§ 211.12(f.1)(5) LICENSURE Nursing services. :State only Deficiency.
(5) Effective July 1, 2023, a minimum of 1 RN per 250 residents during all shifts.
Observations:

Based on review of nursing staff schedules and interviews with staff, it was determined that the facility failed to maintain required staffing ratios, including one RN (Registered Nurse) per 250 residents during all shifts on three of seven shifts reviewed (May 15, 16, and 17, 2026).

Findings include:

Review of facility census data revealed that on May 15, 2026, the facility census was 45, which required 8.00 hours of RNs during the day shift. Review of the nursing time schedules revealed 5.68 hours of RN care were provided during the shift.

Review of facility census data revealed that on May 16, 2026, the facility census was 46, which required 8.00 hours of RNs during the evening shift. Review of the nursing time schedules revealed 7.88 hours of RN care were provided during the shift.

Review of facility census data revealed that on May 17, 2026, the facility census was 45, which required 8.00 hours of RNs during the day and evening shift. Review of the nursing time schedules revealed 7.85 hours of RN care were provided during the day shift and 7.88 hours of RN care was provided during the evening shift.



 Plan of Correction - To be completed: 06/30/2026

1.The facility reviewed the RN ratios for the dates mentioned

2.Other days were reviewed to see if ratios were met

3.Scheduling coordinator will be educated on RN ratios for each shift

4.DON/designee will conduct daily audits to verify nursing ratios for all shifts weekly x 4 weeks. Results will be presented to QAPI

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