Pennypack Rehab And Care Center

Review of interview dated November 5, 2025 conducted by the DON with Employee E5 (licensed nurse on the 10:45 p.m. through the 7:00 p.m. nursing shift) revealed that Employee E5 reported that he came in the building on October 29, 2025 and was in the process of putting his belongings away when he witnessed the resident sliding off the chair.

Employee E5 reported that both he and a nurse aide picked the resident off the floor.

Employee E5 also stated that the resident had a 2nd fall 20-25 minutes after the first fall.

Continued interview revealed that when asked what he did after the falls, the licensed nurse reported that he did not do anything.

Review of the resident's clinical record provided no evidence of a clinical note regarding any of the 2 reported falls, and no evidence that the resident was assessed by nursing staff (e.g. changes in resident's cognition; vital signs such as pulses, blood pressure and respiratory rate; assessing the resident's range of motion, skin integrity, pain, etc.) regarding any of the 2 reported falls.

Review of the resident's clinical record did not show evidence that the physician was notified for any of the above referenced 2 falls that were reported by nursing staff to have occurred by licensed nursing staff.

During an interview with the Director of Nursing on November 13, 2025, at 12:11 p.m. it was discussed and confirmed that nursing staff did not notify the physician of Resident R1 by facility staff after the 2 falls that nursing staff reported that he had.

During an interview with the resident's attending physician on November 14, 2025, at 11:03 a.m. the physician confirmed that he was not notified by nursing staff that Resident R1 had a fall (s) on October 29, 2025 until November 1, 2025.28 Pa.

Code 211.10(d) Resident care policies28 Pa.

Code 211.12(d)(1)(5) Nursing services

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