Pennypack Rehab: Family Not Told of Mother's Fall - PA
That is how the family of a woman with vascular dementia, a history of repeated falls, and a heart rhythm disorder learned she had fallen at Pennypack Rehab and Care Center on Lawndale Avenue, not from a nurse, not from an aide, not from anyone on staff. The woman in the next bed told them.
Inspectors from the Centers for Medicare and Medicaid Services visited the facility on May 22, 2026, and documented what they found in the days before. On Monday, May 18, at approximately 2:30 in the afternoon, the resident identified in inspection records as Resident R5 fell. By Tuesday morning at 10:15, her son, listed as her representative, had still received no call.
When inspectors interviewed him that Tuesday, he told them he was still waiting to hear from nursing staff about what had happened the day before. His mother had been complaining of knee pain. He knew something had happened only because her roommate, Resident R23, had told him.
R5's clinical record listed her medical history in full: vascular dementia, a progressive degenerative disease of the brain. Glaucoma. Acute and chronic respiratory failure. Gait and mobility abnormalities. Sick sinus syndrome, a malfunction of the heart's natural pacemaker that causes irregular heart rhythms. A documented history of repeated falls. This was not a resident whose family could reasonably be considered low-priority for notification.
The inspection record shows no evidence in R5's progress notes that anyone at the facility had attempted to contact her representative after the fall. It also shows something that made the lapse harder to explain away: R5 had a second emergency contact on file. Her spouse. Neither her son nor her spouse had been notified.
The facility's own written policy on acute condition changes, revised in March 2018, did not include any protocol for notifying a resident's representative when a resident's condition changed. No designated staff member responsible for making the call. No required timeframe for when notification had to happen. No documentation requirements to confirm it had been done.
The policy, in other words, had no mechanism to ensure what happened to R5's family would not happen. It described clinical responses to acute changes without addressing the most basic obligation to the people waiting at home.
Inspectors cited the deficiency under Pennsylvania nursing services regulations and rated the level of harm as minimal harm or potential for actual harm. One resident was identified as affected.
That rating reflects the regulatory category, not the experience of a son who spent the night after his mother's fall without knowing she was in pain, who learned what happened not from the people responsible for her care but from an elderly woman in the other bed.
Pennypack Rehab and Care Center operates at 8015 Lawndale Avenue in the Northeast Philadelphia neighborhood of Pennypack. The inspection was completed May 22, 2026.
What the record does not show is when, or whether, the facility called R5's son before inspectors arrived and asked him directly. It does not show whether anyone on the nursing staff was disciplined, retrained, or even made aware that the family had spent more than twenty hours without word. It does not show what R5's son said when he finally did get an explanation, or what he told his mother, or whether her knee pain turned out to be something worse.
He had been waiting for nursing staff to tell him what happened to his mother. The roommate got there first.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pennypack Rehab and Care Center from 2026-05-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: October 31, 2026 · Our methodology
PENNYPACK REHAB AND CARE CENTER in PHILADELPHIA, PA was cited for violations during a health inspection on May 22, 2026.
The woman in the next bed told them.
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.