Pennsylvania Department of Health
 PENNYPACK REHAB AND CARE CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
PENNYPACK REHAB AND CARE CENTER
Inspection Results For:

There are  45 surveys for this facility. Please select a date to view the survey results.

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PENNYPACK REHAB AND CARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000
Based on an Emergency Preparedness Survey completed on May 28, 2026, it was determined Pennypack Nursing and Rehabilitation Center had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.
 Plan of Correction:


403.748(a), 416.54(a), 418.113(a), 441.184(a), 482.15(a), 483.475(a), 483.73(a), 484.102(a), 485.542(a), 485.625(a), 485.68(a), 485.727(a), 485.920(a), 486.360(a), 491.12(a), 494.62(a) STANDARD Develop EP Plan, Review and Update Annually:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
§403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a).

The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements:

(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following:

* [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach.

* [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually.

* [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years.

.
Observations:
Name: - Component: -- - Tag: 0004 Based on document review and interview, it was determined that the facility failed to develop and maintain an Emergency Preparedness Plan that must be reviewed and updated at least annually, for one of one plan. Findings include: Document review on May 28, 2026, at 10:00 a.m., revealed the facility failed to conduct an annual review of the Emergency Preparedness Plan. Exit interview with the Administrator and Maintenance Director on May 28, 2026, at 12:30 p.m., confirmed the missing documentation.
 Plan of Correction - To be completed: 06/30/2026

Facility has updated the Emergency Preparedness Plan and will conduct an annual review thereafter.

Maintenance director reeducated on maintaining an Emergency Preparedness Plan that will be reviewed and updated annually.

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000
Facility ID# 941002Component 01Main BuildingBased on a Medicare/Medicaid Recertification Survey completed on May 28, 2026, it was determined that Pennypack Nursing and Rehabilitation Center - Main Building was not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy.  Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).This is a one-story, Type III (200), unprotected ordinary building, with a partial basement, that is fully sprinklered.
 Plan of Correction:


NFPA 101 STANDARD Number of Exits - Story and Compartment:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
Number of Exits - Story and Compartment
Not less than two exits, remote from each other, and accessible from every part of every story are provided for each story. Each smoke compartment shall likewise be provided with two distinct egress paths to exits that do not require the entry into the same adjacent smoke compartment.
18.2.4.1-18.2.4.4, 19.2.4.1-19.2.4.4
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0241 Based on observation, document review, and interview, it was determined the facility failed to maintain required exiting on each floor level, affecting one of two levels. Findings include: 1. Observation and document review on May 28, 2026, at 9:00 a.m., revealed there were less than two acceptable exits remote from each other, in the basement. One exit led onto the first-floor corridor. Exit interview with the Administrator and Maintenance Director on May 28, 2026, at 12:30 p.m., confirmed the lack of two acceptable exits from the basement.
 Plan of Correction - To be completed: 06/30/2026

Facility requests that an FSES evaluation be conducted by the Pennsylvania Department of Health to update current FSES relevant to the basement, lacking at least two acceptable remote exits from the basement.
NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345 Based on observation and interview, it was determined the facility failed to maintain the fire alarm system, affecting one of four smoke compartments in the facility. Findings include: 1. Observation on May 28, 2026, at 11:40 a.m., revealed, on the first floor, the smoke detector inside Resident room B-14 Bathroom, was not secured to the ceiling. Exit interview with the Administrator and the Maintenance Director on May 28, 2026, at 12:30 p.m., confirmed the smoke detector was not secured to the ceiling.
 Plan of Correction - To be completed: 06/30/2026

Smoke detector has been secured to the ceiling

Audits of other rooms conducted to ensure all smoke detectors are secured to ceiling

Maintenance director re-educated on requirement that smoke detectors must be attached to ceiling

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0374 Based on observation and interview, it was determined the facility failed to ensure doors in smoke barrier walls were maintained to resist the passage of smoke, affecting two of four smoke compartments within this component. Findings include: 1. Observation on May 28, 2026, at 11:25 a.m., revealed smoke doors, A-Hall, failed to close smoke tight when tested. Exit Interview with the Administrator and Maintenance Director on May 28, 2026, at 12:30 p.m., confirmed the doors failed to close smoke tight.
 Plan of Correction - To be completed: 06/30/2026

Door has been adjusted to close smoke tight

All other smoke doors tested to ensure they close smoke tight

Maintenance Director re-educated on ensuring smoke door close smoke tight

NFPA 101 STANDARD Fire Drills:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712 Based on document review and interview, it was determined the facility failed to ensure fire drills were conducted quarterly, at various times, on nine of twelve required drills. Findings include: 1. Document review on May 28, 2026, at 9:35 a.m., revealed the facility could not provide documentation that fire drills had been conducted for the Second and Third shifts in Quarter Two, and that times of shifts varied throughout the nine months. Exit Interview with the Administrator and Maintenance Director on May 28, 2026, at 12:30 p.m., confirmed the fire drills were not consistent.
 Plan of Correction - To be completed: 06/30/2026

Fire drills to be completed monthly, and quarterly on each shift

Maintenance Director re-educated on the requirement of completing fire drills monthly and quarterly per shift and unexpected times

NFPA 101 STANDARD Soiled Linen and Trash Containers:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Soiled Linen and Trash Containers
Soiled linen or trash collection receptacles shall not exceed 32 gallons in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gallons/square feet. A total container capacity of 32 gallons shall not be exceeded within any 64 square feet area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gallons shall be located in a room protected as a hazardous area when not attended.
Containers used solely for recycling are permitted to be excluded from the above requirements where each container is less than or equal to 96 gallons unless attended, and containers for combustibles are labeled and listed as meeting FM Approval Standard 6921 or equivalent.
18.7.5.7, 19.7.5.7
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0754 Based on observation and interview, it was determined the facility failed to properly store soiledlinen receptacles greater than 32-gallons in capacity in a protected hazardous storage area, in oneof four smoke compartments within the component. Findings include: 1. Observation on May 28, 2026, at 10:45 a.m., revealed four filled soiled linen containers with a combined capacity exceeding 32 gallons being stored in the A-Wing shower room. Exit Interview with the Administrator and Maintenance Director on May 28, 2026, at 12:30 p.m., confirmed the soiled linen containers were stored outside of a protected hazardous storage area.
 Plan of Correction - To be completed: 06/30/2026

Soiled linens have been removed from the shower room and placed in a protected area

Maintenance Director educated on storage of soiled linen inside of protected area
NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918 Based on document review and interview, it was determined the facility failed to maintain required testing of emergency generator components, affecting one generator. Findings Include: 1. Document review on May 28, 2026, at 9:15 a.m., revealed the facility lacked documentation showing the following required emergency generator maintenance items had been conducted: a) monthly testing of battery electrolyte specific gravity or conductance testing. Exit Interview with the Administrator and Maintenance Director on May 28, at 12:30 p.m., confirmed the missing documentation.
 Plan of Correction - To be completed: 06/30/2026

Emergency gravity testing completed and will be tested monthly

Maintenance Director educated on generator maintenance testing

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923 Based on observation and interview, it was determined the facility failed to maintain storage of oxygen cylinders and ensure oxygen cylinders were separated from combustible materials within one of four smoke compartments within component. Findings include: 1. Observation on May 28, 2026, between 10:30 a.m., and 12:30 p.m., revealed: a) Empty cylinders were in the full cylinder location within the exterior bulk oxygen storage shed. b) A-Wing - Oxygen was stored within a soiled utility room surrounded by hazards and combustibles Exit Interview with the Administrator and Maintenance Director on May 28, 2026, at 12:30 p.m., confirmed the oxygen cylinder storage location deficiencies
 Plan of Correction - To be completed: 06/30/2026

Empty cylinders have been removed from the full oxygen shed

Oxygen was removed from the soiled utility room

Maintenance Director re-educated on safe oxygen storage

Initial comments:Name: VESTIBULE - Component: 02 - Tag: 0000
Facility ID# 941002Component 02Vestibule AdditionBased on a Medicare/Medicaid Recertification Survey completed on May 28, 2026, at Pennypack Nursing and Rehabilitation Center -Vestibule Addition, it was determined there were no deficiencies identified under the requirements of the Life Safety Code for an existing Nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).This is a one-story, Type II (000), unprotected non-combustible building, that is fully sprinklered.
 Plan of Correction:



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