Pennypack Rehab: Two Falls Left Unassessed, Undocumented - PA
The resident's physician did not find out any of this had happened until three days later.
The nurse, identified in inspection records only as Employee E5, was coming on shift the night of October 29, 2025, still putting his belongings away, when he saw the resident sliding off the chair. He and a nursing aide picked the resident up off the floor. Then, less than half an hour later, the resident fell again.
When investigators from the Pennsylvania Department of Health asked Employee E5 what he did after the falls, his answer was direct. He did not do anything.
No clinical note was entered in the resident's chart for either fall. No assessment was documented, no check of the resident's cognition, no blood pressure reading, no pulse, no look at the skin for bruising or breaks. Nothing in the chart showed that any nurse evaluated whether the resident had been hurt. The falls, as far as the official medical record was concerned, did not happen.
The Director of Nursing confirmed this during an interview on November 13, 2025. She acknowledged that nursing staff had not notified the resident's physician after either fall. The attending physician, interviewed the following day, said he did not learn that his patient had fallen on October 29 until November 1, three days after the fact.
Three days is a long time when an elderly person has hit the floor twice in the same half hour. Falls in nursing home residents carry real risks: undetected fractures, internal bleeding, head injuries that do not show symptoms immediately. The window in which early assessment matters most is the hours right after a fall, not the days.
The inspection, triggered by a complaint, was conducted on November 14, 2025. Investigators reviewed the resident's clinical record and found no trace of either fall documented by staff. The record of the DON's own internal interview with Employee E5, conducted on November 5, became part of how inspectors reconstructed what had actually occurred. The nurse had told his own employer what he saw and what he failed to do. That account sat in the facility's files for more than a week before state inspectors arrived.
The violation was cited under Pennsylvania nursing services regulations and carries a harm level of minimal harm or potential for actual harm, affecting few residents. That designation reflects the regulatory framework's language, not necessarily what the resident experienced on the floor of Pennypack Rehab on a Wednesday night in late October.
What the record shows is a resident who fell, got up, fell again, and was never formally assessed. A nurse who was present for both falls and, by his own account, did nothing. A physician kept in the dark for 72 hours. And a chart with no entry at all, as though the evening passed without incident.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pennypack Rehab and Care Center from 2025-11-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 22, 2026 · Our methodology
PENNYPACK REHAB AND CARE CENTER in PHILADELPHIA, PA was cited for violations during a health inspection on November 14, 2025.
The resident's physician did not find out any of this had happened until three days later.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.