Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pennswood Village during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of resistiveness to care was physically abused by a nurse aide, who punched the resident and twisted their wrist and hand during morning care. This resulted in a bruise and hematoma, with the abuse substantiated by both facility investigation and police. The incident was reported by another staff member and confirmed through documentation and interviews.
The facility did not maintain the fire resistance rating of smoke barrier partitions, as unsealed penetrations were observed in smoke barrier walls on the ground floor. These penetrations were found above smoke doors by room W7 and W1 around data wires, and by the DON's Office around two 3-inch pipes. This was confirmed in an exit interview with the Facility Administrator and Maintenance Supervisor.
The facility failed to maintain electrical wiring protection, affecting one of two floors. Observations revealed missing cover plates on junction boxes and an HVAC device, exposing inner wiring. These deficiencies were confirmed during an exit interview with the Facility Administrator and Maintenance Supervisor.
A resident on blood thinner medication fell and hit their head, but the facility failed to notify the physician in a timely manner, resulting in a delay of emergency medical care. Despite abnormal blood pressure readings and complaints of head pain, the physician was not informed until 10 hours later, leading to the resident's hospitalization and subsequent death due to a subdural hematoma.
A resident on Xarelto fell and hit their head, but the facility staff failed to notify the physician in a timely manner, leading to a delay in medical intervention. The resident exhibited elevated blood pressure and pain, yet was not reassessed promptly. Eventually, the resident was transferred to the hospital, where a subdural hematoma was diagnosed, and the resident passed away. The NHA and DON acknowledged the deficiencies, contributing to an Immediate Jeopardy situation.
Failure to Prevent Physical Abuse Resulting in Resident Harm
Penalty
Summary
A facility failed to protect a resident's right to be free from physical abuse, resulting in actual harm. The resident, who had severe cognitive impairment due to Alzheimer's disease and other conditions, was known to be resistive to care and sometimes combative. During morning care, the resident began kicking and punching staff. One nurse aide (E2) observed another nurse aide (E1) respond by punching the resident in the abdomen and aggressively twisting the resident's wrist and hand. This resulted in a bruise and hematoma to the resident's right hand and wrist, which was later documented by nursing and physician assessments. The facility's own investigation, as well as interviews and documentation, confirmed that the abuse occurred. The incident was reported by a staff member, and the abuse was substantiated by both the facility and the police. The resident did not recall the incident due to cognitive impairment, but physical findings were consistent with the reported abuse. The facility's failure to prevent this physical abuse constituted a violation of the resident's rights and resulted in actual physical harm.
Unsealed Penetrations in Smoke Barrier Walls
Penalty
Summary
The facility failed to maintain the fire resistance rating of smoke barrier partitions, which is a requirement for ensuring safety in the event of a fire. During observations conducted on December 9, 2024, it was noted that there were unsealed penetrations in the smoke barrier walls at several locations on the ground floor. Specifically, these penetrations were found above smoke doors by room W7 around data wires, above smoke doors by room W1 on the storage side around data wires, and above smoke doors by the Director of Nursing's Office around two 3-inch pipes. These observations were confirmed during an exit interview with the Facility Administrator and Maintenance Supervisor.
Plan Of Correction
The facility does and shall continue to ensure common fire walls are maintained free of unsealed penetrations. Pennswood Village Facilities will seal holes and penetrations using through penetration fire stop system C-AJ-8255 products in the following area. Repair shall be made 12/30/2024. The Maintenance Manager/Designee will continue to conduct inspections on a quarterly basis to identify any penetrations of common fire walls and seal them with the required sealant. Results of ongoing inspections will be reported to the Quality Assurance and Performance Improvement (QAPI) Team by the Maintenance Manager/Designee. Pennswood Village Maintenance Manager/Designee will oversee compliance.
Exposed Electrical Wiring in Facility
Penalty
Summary
The facility failed to maintain the protection of electrical wiring, which affected one of two floors. During an observation on December 9, 2024, at 10:10 a.m., it was noted that in the Housekeeping/Electrical Room on the ground floor, two junction boxes above the ceiling tiles were missing their cover plates, leaving the inner wiring exposed. Additionally, at 10:20 a.m. on the same day, it was observed that in the corridor by the elevator on the ground floor, an HVAC device was missing a cover plate, also exposing the inner wiring. These deficiencies were confirmed during an exit interview with the Facility Administrator and Maintenance Supervisor on December 9, 2024, at 12:15 p.m.
Plan Of Correction
The facility does and shall continue to ensure the protection of electrical wiring within the facility. Pennswood Village Facilities will place cover plates on the junction boxes in the Housekeeping/Electrical Room, and ensure that the HVAC device by the elevator has the missing cover is properly fastened to the unit. Repair shall be made by 12/30/2024. The Maintenance Manager/Designee will continue to conduct weekly rounds to identify and repair electrical wiring issues. The Maintenance Manager/Designee will see that all electrical work being done in the facility is done to completion. Pennswood Village Maintenance Manager/Designee will oversee compliance.
Failure to Timely Notify Physician After Resident Fall
Penalty
Summary
The facility failed to provide care and services that met professional standards of quality for a resident who was on blood thinner medication and sustained a fall in the bathroom. The resident, who was on Xarelto, a medication that increases the risk of bleeding, fell and hit their head, but the facility did not notify the physician in a timely manner. Despite the resident's increased blood pressure and complaints of head pain, the physician was not informed until approximately 10 hours after the fall, leading to a delay in emergency medical care. The facility's policy required timely notification of the physician for significant changes in a resident's condition, including accidents with potential for physician intervention. However, the staff failed to follow this policy. The resident's neurological assessments showed abnormal blood pressure levels, but there was no documented evidence that the physician was notified of these changes or the resident's anticoagulant medication use until much later. The resident eventually developed symptoms such as headache, nausea, and vomiting, prompting a transfer to the hospital where a subdural hematoma was diagnosed. Interviews with staff revealed a lack of awareness and communication regarding the resident's condition and medication. The nurse practitioner and registered nurses involved did not ensure timely reassessment or notification of the physician, contributing to the delay in care. The facility's failure to adhere to its own policies and procedures resulted in the resident not receiving necessary medical attention in a timely manner, ultimately leading to the resident's death in the hospital.
Plan Of Correction
Facility will immediately and accurately communicate with the physician/provider any pertinent change in condition of a resident. Notification of Changes in Resident's Status Policy has been reviewed and revised to include that the phone should be utilized or in person for all communication regarding significant change in status with physician/provider. Documentation to include physician/provider response. Education has been provided to all RNs and LPNs regarding the revised facility policy of Notifying Changes in Resident's Status. This education included assessing residents after change in condition, appropriate and complete notification of the physician/provider and method of notification. 85% of all RNs and LPNs have completed education by the end of the day 12/4/24. 100% of RNs and LPNs completed education by the end of the day 12/6/24. Every fall incident will be audited by interdisciplinary team to assure that appropriate and complete physician/provider notification has occurred. The audit will be reported on at Quality Assurance and Performance Improvement (QAPI) meeting by DON/Designee for a minimum of four quarters.
Removal Plan
- Facility will immediately and accurately communicate with the physician/provider any pertinent change in condition of a resident.
- Notification of Changes in Resident's Status Policy has been reviewed and revised to include that the phone should be utilized or in person for all communication regarding significant change in status with physician/provider. Documentation to include physician/provider response.
- Education has been implemented of all RNs (Register Nurse) and LPNs (Licensed Practical Nurse) regarding the revised facility policy of Notifying Changes in Resident's Status. This education includes assessing residents after change in condition, appropriate and complete notification of the physician/provider and method of notification. 85% of all RNs and LPNs will have completed education. 100% of RNs and LPNs will have completed education. If staff are not available, they will be educated prior to the start of their next shift in facility.
- Every fall incident will be audited by interdisciplinary team to assure that appropriate and complete physician/provider notification has occurred. The audit will be reported on at Quality Assurance and Performance Improvement (QAPI) for four quarters.
Failure to Timely Notify Physician After Resident Fall
Penalty
Summary
The Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility, resulting in a deficiency related to the care of Resident R17. The resident, who was on the anticoagulant medication Xarelto, fell in the bathroom and hit their head. Despite the elevated risk of bleeding due to the medication, the staff did not notify the physician in a timely manner. The incident report documented the fall at 2:05 a.m., but the physician was not notified until 3:40 p.m., and there was no evidence of a physician response. Following the fall, Resident R17 exhibited elevated blood pressure and complained of pain, yet the staff did not reassess the resident's condition in a timely manner. The resident's neurological assessments showed consistently high blood pressure, but there was no documentation of physician notification regarding these findings. The resident was eventually transferred to the hospital after developing symptoms such as headache, nausea, and vomiting, where a CT scan revealed a subdural hematoma. The resident passed away at the hospital due to the injury. Interviews with facility staff, including the night shift supervisor and the physician, revealed a lack of appropriate communication and follow-up procedures. The staff failed to notify the physician of the resident's anticoagulant use and high blood pressure, which could have influenced the medical response. The NHA and DON confirmed the deficiencies in staff actions and documentation, acknowledging the failure to meet federal and state guidelines, which contributed to an Immediate Jeopardy situation.
Plan Of Correction
The Nursing Home Administrator and Director of Nursing will fulfill essential duties and responsibilities of their position to ensure that the Federal and State guidelines and regulation are followed. Nursing Home Administrator and Director of Nursing reviewed and revised the Notification of Changes in Resident's Status Policy. The revision includes that the phone should be utilized or in person for all communication regarding significant change in status with physician/provider. Documentation to include physician/provider response. Education has been provided to all RNs and LPNs regarding the revised facility policy of Notifying Changes in Resident's Status. Nursing Home Administrator and Director of Nursing will continue to attend continuing education (CEU) approved by their state boards on a biennial basis. NHA will continue to complete 48 hours of continuing education every two years that are approved by the Board of Examiners of Nursing Home Administrators or National Association of Long-Term Care Administrator Boards (NAB). DON will continue to complete 30 hours of continuing education every two years that are approved by the State Board of Nursing. NHA/Designee and DON/Designee will conduct a root cause analysis on all reportable incidents submitted to Department of Health. Reportable incidents and their root cause analysis will be reported on at Quality Assurance and Performance Improvement (QAPI) meeting for a minimum of four quarters by NHA/Designee.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Newtown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Chandler Hall Health Services | 0.9 mi | — | 0 | 0 |
| Pickering Manor Home | 1.1 mi | — | 15 | 0 |
| Holland Center For Rehabilitation And Nursing | 2 mi | — | 2 | 0 |
| Crestview Center | 2.4 mi | — | 4 | 0 |
| Richboro Rehabilitation & Nursing Center | 2.7 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.