William Penn Nursing and Rehab

In the surveyor’s words

From the most serious findings on record at William Penn Nursing and Rehab, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jun 30, 2023

  Based on observation and staff interview, it was determined that the facility failed prepare, store, and serve food, and maintain equipment in accordance with professional standards for food service safety in the facility's main kitchen and on one of two nursing units (nursing unit one). Findings include: An observation of the facility's main kitchen on June 27, 2023, at 9:50 AM revealed the following: Employee 1, cook, was observed from the entrance to the kitchen working in a preparation area with facial hair covering sides of his face, lip, and chin, uncovered. Upon walking to the preparation area, the employee had donned a beard covering. Upon concurrent interview, Employee 1 stated he had forgot about the beard guard this morning, and that he had been working since 5:30 AM. […]

• No harm, potential for more than minimal, widespreadF812Jul 14, 2022

  Based on observation, staff interview, and review of facility documents, it was determined that the facility failed to store food in a sanitary environment and assure monitoring was in place to prevent the potential for food borne illness in the main kitchen. Findings include: A tour of the facility's main kitchen on July 11, 2022, at 10:10 AM revealed the following: Two large bins observed on the lower shelf of a preparation table, one bin was labeled flour and one sugar, and appeared to have product used out of both bins. Both bins were labeled with a sticker indicating an open date of June 2, with no year specified, and a use by date of July 2, 2022. […]

• No harm, potential for more than minimal, widespreadF812Jul 9, 2021

  Based on observation and staff interview, it was determined that the facility failed to store food in a manner to prevent the potential for food borne illness and maintain equipment in a clean and safe operating condition in the facility's main kitchen. Findings include: Initial tour of the facility's main kitchen with Employee 6, dietary manager, on [DATE], at 11:00 AM revealed the following: A three-compartment sink was observed with water in the first compartment with food service equipment sitting in the water, the second compartment was empty, and the third compartment was full of water. Spatulas, pitchers, and other equipment sat wet, on the drying area at the end of the third compartment of the sink. […]

• No harm, potential for more than minimal, patternF759Apr 17, 2026

  Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to ensure a medication error rate of less than five percent (Residents 63 and 79).Findings include:The facility's medication error rate was 12 percent based on 25 medication opportunities with three medication errors.Observation on April 17, 2026, of Resident 79's medication administration at 8:28 AM revealed that Employee 3, licensed practical nurse, administered one 20 mg (milligram) tablet of Lasix (a diuretic medication used to treat fluid retention). Clinical record review for Resident 79 revealed a physician order dated April 6, 2026, stating, Furosemide 20 MG Tablet TAKE THREE TABLETS (60MG) BY MOUTH ONCE DAILY RELATED TO EDEMA, UNSPECIFIED. […]

• No harm, potential for more than minimal, patternF812Apr 17, 2026

  Based on observation and staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner and maintain equipment in a sanitary condition, in the facility's main kitchen. Findings include: Initial tour of the facility's main kitchen with Employee 1, dietitian, on April 14, 2026, at 10:12 AM revealed the following: The wall mounted soap dispenser located adjacent to the handwashing sink was coming off the wall. The walk-in freezer contained a box of bagged broccoli cuts and lima beans that were open to the ambient air. The spice rack contained the following outdated containers of spices: ground all spice with a use by date of July 19, 2024; rosemary with a written use by date of September 19, 2024; thyme with a use by date of March 6, 2025. […]