Phoenix Center For Rehabilitation And Nursing,the
Inspection history, citations, penalties and survey trends for this long-term care facility in Phoenixville, Pennsylvania.
- Location
- 833 South Main Street, Phoenixville, Pennsylvania 19460
- CMS Provider Number
- 395284
- Inspections on file
- 26
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Phoenix Center For Rehabilitation And Nursing,the during CMS and state inspections, most recent first.
Surveyors found that multiple residents’ rooms and the 3rd floor lounge were not maintained in a clean, sanitary condition. Numerous room curtains were visibly soiled or stained, one room had peeling and missing wallpaper behind the beds, and a shower used by a resident contained a brown substance on the floor. That resident reported that staff rinse a roommate’s bedpan in the shower and leave brown residue without cleaning or disinfecting, preventing the resident from using the shower. The lounge carpet also had dark stains and paper debris. These conditions were confirmed by the DON, and the NHA stated that one resident’s constant presence in the room made wall repair difficult.
A resident with CHF and leg wounds was found with soiled and stained bed linens that had not been changed for several days after readmission. The linens had visible stains from coffee, blood, and food or juice spills, and staff were unaware of when they were last changed, resulting in a failure to provide a clean and homelike environment.
The facility did not provide written notice of its bed-hold policy to several residents or their representatives when they were transferred to the hospital, as confirmed by clinical record review and staff interviews. This deficiency involved residents with acute medical conditions and was identified through review of facility policies, records, and interviews with the DON.
A resident was given Tramadol on three occasions despite a pain score of zero, contrary to physician orders that specified use only for moderate to severe pain. Required non-pharmacological interventions were not attempted or documented before administering the medication, and the DON could not explain the rationale for this action.
Surveyors found that staff failed to follow physician orders for oxygen tubing changes, feeding assistance, and fluid restrictions for several residents, and did not timely address a skin condition for a resident with Alzheimer's disease. These deficiencies were confirmed through record review, observations, and staff interviews.
A resident's ability to smoke safely was not re-evaluated as required by facility policy, with the last assessment documented several months prior and no subsequent reassessments performed. The DON confirmed the lapse in ongoing evaluation, resulting in a failure to maintain a hazard-free environment.
The facility did not maintain safe hot water temperatures in resident rooms and shower rooms, with water readings exceeding regulatory limits. Staff failed to consistently monitor or document water temperatures, and there was no clear procedure for ensuring water safety before resident care, especially for nonverbal or cognitively impaired individuals. The issue persisted due to a broken boiler and lack of timely communication and oversight.
The Nursing Home Administrator did not ensure effective management of the facility's hot water system, leading to water temperatures above 110°F throughout the building. Despite being informed of the issue, no new interventions were implemented, and there was no documentation of temperature monitoring, placing residents at risk for serious injury from burns and resulting in Immediate Jeopardy.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents with unstageable sacrum pressure ulcers, one of whom also had a PEG tube. Observations revealed a lack of EBP signage or communication in their rooms, contrary to the facility's policy designed to minimize the spread of MDROs. The deficiency was confirmed by the DON and Nursing Home Administrator.
A resident was found fully clothed and covered with a blanket in their room, which had a non-functioning heating unit that emitted smoke and a burning plastic smell when used. The room temperature was measured at 68°F, and the resident reported feeling cold. The Nursing Home Administrator confirmed the heating unit was not working and that the temperature was uncomfortable for the resident.
A resident experienced a fall resulting in a head injury and was transported to the emergency department. The facility failed to immediately notify the resident's representative, as required by policy. The notification was delayed until several hours after the incident, which was confirmed by the DON during an interview.
The facility did not meet the required nurse aide staffing ratios during the day shift for four days in a reviewed week. The regulation mandates a minimum of one nurse aide per 10 residents, which was not achieved on several days. This was confirmed through a review of schedules and an interview with the Nursing Home Administrator.
The facility did not meet the required LPN staffing ratios on several occasions during a specific week. The day shift lacked the mandated one LPN per 25 residents on four days, the evening shift was short on one day, and the night shift did not meet the requirement on another day. This was confirmed by staffing data and an interview with the Nursing Home Administrator.
The facility did not meet the required minimum of 3.2 hours of direct nursing care per resident per day for a week, with PPD hours ranging from 3.04 to 3.16. This was confirmed by the Nursing Home Administrator.
A resident with intact cognitive status was verbally abused by a staff member in the kitchen. The staff member threatened physical harm and used derogatory language, which was confirmed by multiple witnesses. Despite the abuse, the resident reported feeling safe and did not experience harm. The facility's investigation substantiated the incident, although all dietary staff had completed mandatory abuse training.
The facility failed to implement Enhanced Barrier Precautions for residents with medical devices, such as feeding tubes and catheters, as required by their policy. Observations showed no PPE or EBP signage in the rooms of affected residents, and the Nursing Home Administrator confirmed the absence of these precautions throughout the building.
The facility failed to monitor the nutritional status of three residents, resulting in significant weight changes that were not promptly addressed. One resident gained 15.8 pounds, another lost 32 pounds, and a third lost 7.3 pounds. Re-weights were requested but not conducted in a timely manner, and interventions were delayed, as confirmed by staff interviews.
A facility failed to offer Advance Directives to a resident upon admission, as confirmed by the absence of documentation in the clinical record and an interview with the Nursing Home Administrator. This issue was previously cited, indicating a recurring compliance problem.
A resident experienced a significant change in condition, with bright red bloody urine and blood clots observed from his Foley catheter. Despite facility policy requiring prompt notification, the physician was not informed of this change. Later, the resident was found lethargic with large clots and was sent to the ER. The Nursing Home Administrator confirmed the physician was not notified initially.
A resident experienced an unwitnessed fall while receiving care, leading to abnormal vital signs and eventual cardiac arrest. Despite the facility's policy requiring thorough investigation of such incidents, no comprehensive investigation was conducted to determine the cause of the fall and subsequent events. The resident was transferred to the hospital, where they were pronounced dead.
A resident experienced inadequate monitoring and care after returning from the hospital, with no vital signs or full assessment documented during a significant health change. The resident was later found at the hospital with severe symptoms. Additionally, the facility failed to schedule recommended urology follow-ups after hospital discharges.
A facility failed to assess the necessity of a Foley catheter for a resident upon admission and did not conduct a voiding trial until requested by the resident's spouse and an RN from an outside agency. The voiding trial was successful, indicating the catheter may not have been necessary.
A resident's tube feeding was not administered as per physician orders, with the enteral feed pump found turned off and lacking documentation for the interruption. The prescribed continuous feeding of Jevity 1.5 at 55 ml/hour was not maintained, resulting in a failure to provide the ordered nutrition.
The facility failed to provide timely respiratory treatment for a resident with Sepsis, COPD, and respiratory failure. Despite having a BIPAP order from the hospital, the order was not implemented until two days after admission due to a lack of communication and review of hospital documents by the DON.
Unclean Resident Rooms and Lounge Environment on 3rd Floor Unit
Penalty
Summary
Surveyors identified that multiple resident rooms and common areas on the 3rd floor care unit were not maintained in a clean and sanitary condition. During observations conducted between 10:00 a.m. and 12:00 p.m. on April 22, 2026, window curtains in the rooms of fifteen residents were noted to be soiled or stained with brown discoloration. In one resident room, wallpaper was observed peeling off the wall behind one bed, and wallpaper was missing on portions of the wall behind both beds. In another resident’s shower, a brown substance was observed on the shower floor. That resident reported that staff flush the roommate’s bedpan in the toilet and sometimes rinse the bedpan in the shower, leaving brown substances in the shower without cleaning or disinfecting it, and stated that he/she had been unable to use the shower because it had not been sanitized. Additional observations on the same unit showed that the 3rd floor lounge area carpet had dark stains and paper debris present. These environmental concerns, including the soiled curtains, deteriorating wallpaper, unclean shower, and stained, debris-littered lounge carpet, were observed in the presence of the DON on the afternoon of April 22, 2026. In a subsequent interview, the NHA acknowledged that the resident in one of the affected rooms rarely leaves the room, which the NHA stated made it difficult for maintenance to repair the wall. The DON confirmed the observations and noted that residents sometimes eat lunch in the lounge area.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
A deficiency was identified when a resident, recently readmitted with a diagnosis of congestive heart failure and skin openings on both legs, was found to have soiled and stained bed linens several days after returning to the facility. During an observation, the resident's mattress was only partially covered with a sheet, and both the mattress and additional sheets displayed large dried brown, red, and yellow stains. The resident reported that the stains were from coffee, blood from leg wounds, and food or juice spills, and stated that the bed sheets had not been changed since readmission several days prior. An interview with the nursing assistant assigned to the resident revealed that, as an agency staff member, they were unaware of when the bed linens were last changed and confirmed that the sheets had not been changed that morning. The Director of Nursing was informed of these findings. The facility failed to provide a clean, comfortable, and homelike environment for the resident, as required by regulation.
Failure to Provide Bed-Hold Policy Notification Upon Hospital Transfer
Penalty
Summary
The facility failed to provide written notice of its bed-hold policy to residents or their representatives at the time of transfer to the hospital for five out of ten residents reviewed. Clinical record reviews for multiple residents with significant medical conditions, such as acute respiratory failure, acute kidney injury, and gram-negative sepsis, showed that these individuals were transferred and admitted to the hospital. However, there was no documentation in their records indicating that the required bed-hold policy notification was given at the time of transfer. Interviews with the Director of Nursing confirmed that neither the residents nor their representatives received the bed-hold policy information upon discharge to the hospital. This deficiency was identified through facility policy review, clinical record review, and staff interviews, and was cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee.
Failure to Follow Physician Orders and Non-Pharmacological Interventions for Pain Management
Penalty
Summary
A deficiency occurred when a resident was administered Tramadol HCl 50 mg on three occasions despite having a pain scale score of zero, which did not meet the physician's order specifying use only for moderate to severe pain. The clinical record also indicated that required non-pharmacological interventions, such as repositioning, distraction, massage, or other comfort measures, were not attempted or documented prior to administering the medication. The facility's policy required medications to be given according to physician orders and to utilize non-pharmacological interventions when appropriate, but these steps were not followed. During an interview, the DON was unable to provide a reason for the administration of Tramadol when the resident reported no pain.
Failure to Follow Physician Orders and Timely Address Resident Care Needs
Penalty
Summary
The facility failed to follow physician orders and provide timely care for several residents. For one resident with acute respiratory failure, oxygen tubing was not changed weekly as ordered, with documentation showing the tubing was last changed six days prior to the observed date, despite orders for weekly changes. Another resident with multiple sclerosis and dysphagia had physician orders for staff assistance with feeding, but was observed feeding themselves with their fingers on multiple occasions without staff assistance, contrary to the orders. A third resident with chronic kidney disease had a physician-ordered fluid restriction, but records showed that both nursing and dietary staff failed to monitor and document fluid intake properly, resulting in the resident receiving more fluids than prescribed on multiple days. Additionally, a resident with Alzheimer's disease developed a body rash that was reported in June, but there was no evidence in the clinical record that the skin issue was addressed or assessed for a month, until a physician order for Nystatin cream was given in late July. Staff interviews confirmed these failures to follow physician orders and to address the resident's skin condition in a timely manner.
Failure to Reassess Smoking Safety for Resident
Penalty
Summary
The facility failed to provide a hazard-free environment for one resident by not following its own smoking policy. According to the facility's policy, a resident's ability to smoke safely must be re-evaluated quarterly, upon a significant change in physical or cognitive status, and as determined by staff. Review of the clinical record for one resident showed that the most recent smoking assessment was completed on June 9, 2024, and no further assessments were documented. During an interview, the DON confirmed that no additional smoking assessments had been performed since that date. This lapse resulted in the facility not ensuring ongoing evaluation of the resident's ability to smoke safely, as required by policy.
Failure to Maintain Safe Hot Water Temperatures Creates Immediate Jeopardy
Penalty
Summary
The facility failed to maintain safe hot water temperatures in resident rooms and shower rooms across all three nursing units. Observations revealed water temperatures ranging from 124 to 129 degrees Fahrenheit, exceeding the Commonwealth of Pennsylvania's regulatory maximum of 110 degrees Fahrenheit. Maintenance staff confirmed that the water temperatures were too high and that the boiler responsible for residential hot water was broken, resulting in the use of a service area boiler that could not be adjusted below 135 degrees Fahrenheit. The issue was first noticed by the maintenance employee shortly after starting employment, and documentation showed that the necessary repair part had been pending for several weeks. Facility documentation could not provide evidence that water temperatures were being regularly monitored, recorded, or logged in resident care areas. There were no thermometers or temperature logs available in the shower rooms, and staff interviews revealed inconsistent practices for checking water temperature before resident use. Some nursing assistants reported relying on residents' feedback regarding comfort, which was not feasible for nonverbal or cognitively impaired residents. When asked, staff were unable to demonstrate the use of a thermometer or locate one for testing water temperature. The Nursing Home Administrator was unaware of the water temperature issue until returning from an absence, and no policy could be provided regarding staff procedures for ensuring safe water temperatures prior to showers. The lack of monitoring, documentation, and clear procedures for verifying water temperature before resident care led to the identification of Immediate Jeopardy to resident safety due to the risk of burns from excessively hot water.
Failure to Manage Hot Water Temperatures Creates Immediate Jeopardy
Penalty
Summary
The Nursing Home Administrator failed to effectively manage the facility's hot water system, resulting in water temperatures above 110 degrees Fahrenheit on all floors. Observations and interviews confirmed that the water was leaving the boiler at 135 degrees and could not be lowered due to a needed repair. The boiler designated for service areas was being used for residential areas, and there was no documented evidence that water temperatures were being monitored during this period. The Administrator was made aware of the issue upon returning from a leave of absence, but no new interventions were implemented to address the excessively hot water until the necessary boiler part could be installed. This lack of action and monitoring placed residents at risk for serious injury from burns and resulted in an Immediate Jeopardy situation.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure Enhanced Barrier Precautions (EBP) were in place for two residents who required them. According to the facility's policy, EBP is an infection control intervention designed to reduce the transmission of Multidrug Resistant Organisms (MDROs) by employing targeted gown and glove use during high-contact resident care activities. The policy mandates that EBP should be implemented for residents with wounds or indwelling medical devices, regardless of MDRO colonization status, and for those with an infection or colonization with an MDRO when contact precautions do not otherwise apply. Clinical record reviews revealed that both residents had unstageable sacrum pressure ulcers, with one resident also having a percutaneous endoscopic gastrostomy (PEG) tube. Observations of their rooms showed a lack of EBP signage or communication, indicating that the necessary precautions were not being followed. The Director of Nursing and the Nursing Home Administrator confirmed that the EBP process was not adhered to for these residents, highlighting a deficiency in the facility's infection prevention and control program.
Plan Of Correction
POC- complaint survey 3/20/25 1. No residents were affected by the practice. 2. DON/designee will audit facility to determine which residents could be potentially affected. 3. DON/ADON will educate staff on EBP and EBP Policy will be posted at nursing station. 4. ADON/designee will round daily for four weeks then weekly thereafter to ensure enhance barrier precaution signs are hung and visible where necessary. Any findings will be presented in QAPI. 5. Corrective action will be completed by 4/4/2025.
Failure to Maintain Adequate Room Temperature for Resident Comfort
Penalty
Summary
The facility failed to provide a comfortable environment for a resident by not maintaining an adequate room temperature. Observations showed the resident was fully clothed and covered with a blanket while lying in bed, and the resident reported that the room's heating unit was not functioning. When the heating unit was turned on, it emitted smoke and a burning plastic smell, and the resident stated feeling cold. The room temperature was measured at 68 degrees Fahrenheit by the Nursing Home Administrator, who confirmed the heating unit was not working and acknowledged that the temperature was uncomfortable for the resident. These findings were based on direct observation, resident interview, and staff confirmation.
Failure to Notify Resident's Representative of Injury
Penalty
Summary
The facility failed to immediately notify the resident's representative of an accident involving a resident, which resulted in an injury. The incident involved a resident who was found on the floor with a pool of blood at the head and hands, indicating a fall. The resident sustained a contusion and a laceration on the forehead, which continued to bleed. Vital signs were taken, and emergency services were called, resulting in the resident being transported to the emergency department. Despite the severity of the incident, the resident's representative was not informed immediately, as the notification was delayed until later in the morning. The facility's policy, revised in December 2016, mandates prompt notification of the resident's representative in the event of an accident or incident resulting in injury. However, in this case, the notification was not made until several hours after the incident, contrary to the policy requirements. The Director of Nursing confirmed during an interview that the resident's representative was not notified immediately of the fall and subsequent hospitalization, highlighting a deficiency in adhering to the notification requirements outlined in 42 CFR Part 483 and the 28 PA Code regulations.
Plan Of Correction
1. D.O.N. / A.D.O.N. will provide education to nurses re policy of notification of change of condition and also use of INTERACT Tools for Change of Condition by 9-13-24. 2. D.O.N. / A.D.O.N. will provide education to nurses to enter all vital signs in Vital Signs tab instead of just nursing notes so that alerts for changes in condition are active by 9/13/14. 3. Clinical team will audit all changes in condition during clinical meeting by 9/1/24. 4. D.O.N. will develop a change in condition checklist that includes notifying responsible parties for each change of condition. Checklist to be completed at time of change. 5. D.O.N. will audit weekly for 4 weeks, then biweekly for one month, then monthly, with results reported to QAPI and to Regional Leadership Team.
Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide staffing ratios during the day shift for four out of seven days in the week of December 8, 2024. Specifically, on December 10, 12, 13, and 14, 2024, the facility did not provide the minimum of one nurse aide per 10 residents as mandated by the regulation effective July 1, 2024. This deficiency was identified through a review of nursing time schedules and confirmed during an interview with the Nursing Home Administrator on December 17, 2024, at 1:45 p.m.
Plan Of Correction
1. Scheduler will continue to schedule sufficient staffing for shift. 2. If a call off occurs, Scheduler or Shift Supervisor will check to see who can stay late or come in early and also post shift(s) with agency. 3. If aide position cannot be filled in time, Scheduler or Shift Supervisor will check to see if any nurses can stay late or come in early and will adjust staffing sheet to indicate any hours a nurse may have filled in as an aide. 4. Facility will continue to work on staff recruitment and retention as identified in our Facility Assessment. 5. Facility is participating in a job fair on 10/30/2024 to recruit more staff. 6. Facility will schedule additional staffing through staffing resources available to the facility.
LPN Staffing Ratio Deficiency
Penalty
Summary
The facility failed to meet the required staffing ratios for Licensed Practical Nurses (LPNs) on multiple occasions during the week of December 8, 2024. Specifically, the facility did not have the mandated one LPN per 25 residents during the day shift on December 8, 10, 11, and 13, 2024. Additionally, the evening shift on December 13, 2024, did not meet the requirement of one LPN per 30 residents. Furthermore, the night shift on December 14, 2024, failed to have one LPN per 40 residents. This deficiency was confirmed through a review of facility staffing data and an interview with the Nursing Home Administrator on December 17, 2024, at 1:45 p.m., who acknowledged that the staffing ratios were not met on the specified dates.
Plan Of Correction
1. Scheduler will continue to schedule sufficient staffing for shift. 2. If a call off occurs, Scheduler or Shift Supervisor will check to see who can stay late or come in early and also post shift(s) with agency. 3. If aide position cannot be filled in time, Scheduler or Shift Supervisor will check to see if any nurses can stay late or come in early and will adjust staffing sheet to indicate any hours a nurse may have filled in as an aide. 4. Facility will continue to work on staff recruitment and retention as identified in our Facility Assessment. 5. Facility is participating in a job fair on 10/30/2024 to recruit more staff. 6. Facility will schedule additional staffing through staffing resources available to the facility.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day for the week beginning December 8, 2024. A review of the nursing staffing documents revealed that the facility provided less than the required hours on each day of the week, with per patient day (PPD) hours ranging from 3.04 to 3.16. This deficiency was confirmed during an interview with the Nursing Home Administrator on December 17, 2024, who acknowledged the shortfall in meeting the required direct care hours on the specified dates.
Plan Of Correction
1. Scheduler will continue to schedule sufficient staffing for shift. 2. If a call off occurs, Scheduler or Shift Supervisor will check to see who can stay late or come in early and also post shift(s) with agency. 3. If aide position cannot be filled in time, Scheduler or Shift Supervisor will check to see if any nurses can stay late or come in early and will adjust staffing sheet to indicate any hours a nurse may have filled in as an aide. 4. Facility will continue to work on staff recruitment and retention as identified in our Facility Assessment. 5. Facility is participating in a job fair on 10/30/2024 to recruit more staff. 6. Facility will schedule additional staffing through staffing resources available to the facility.
Verbal Abuse Incident Involving a Resident and Staff Member
Penalty
Summary
The facility failed to protect a resident from verbal abuse, as evidenced by an incident involving Resident 1 and Employee 3 (E3). The incident occurred when Resident 1, who had an intact cognitive status as per the Minimum Data Set assessment, attempted to enter the kitchen to offer help, believing the kitchen was short-staffed. During this interaction, E3 verbally abused Resident 1 by threatening physical harm and using derogatory language. Multiple investigation statements corroborated that E3 threatened to slap Resident 1 and used offensive terms, further stating that Resident 1 would not receive a meal. The facility's investigation confirmed the verbal abuse, and a mandated report (PB-22) substantiated the incident. Despite the abuse, Resident 1 reported feeling safe in the facility and did not experience harm from the incident. The facility's policy on abuse and neglect, last revised in November 2019, defines abuse as actions causing physical harm, pain, or mental anguish, which includes verbal abuse. The investigation revealed that all dietary department staff had completed mandatory abuse training prior to employment, yet the incident still occurred.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish Enhanced Barrier Precautions (EBP) for four residents who required them due to the presence of medical devices. The facility's policy mandates the use of EBP for residents with infections or colonization with Multidrug Resistant Organisms (MDROs), wounds, or indwelling medical devices. However, observations revealed that there was no evidence of Personal Protective Equipment (PPE) or EBP signage in the rooms of the affected residents. Resident 16 had a PEG feeding tube, Resident 54 and Resident 58 both had Foley catheters, and Resident 173 had both a Foley catheter and a PICC line for antibiotic usage. Despite these conditions, none of the rooms had the required PPE or EBP signage. The Nursing Home Administrator confirmed that Enhanced Barrier Precautions were not in place throughout the building, indicating a systemic failure to adhere to the facility's infection prevention and control policy.
Failure to Monitor Nutritional Status
Penalty
Summary
The facility failed to adequately monitor the nutritional status of three residents, leading to significant weight changes that were not promptly addressed. Resident 4 experienced a weight gain of 15.8 pounds, or 9.3%, between July 18 and August 1, 2024. Despite a registered dietitian's request for a re-weight on August 2, 2024, the re-weight was not conducted until August 20, 2024, as confirmed by Employee E3. Resident 15 showed a weight loss of 32 pounds, or 13.22%, from July 31 to August 8, 2024. A re-weight was requested on August 8, 2024, but was not completed, and the next recorded weight on August 20, 2024, indicated the initial weight was inaccurate. Employee E3 confirmed that the weight loss was not addressed until August 20, 2024, and noted that the resident's medical conditions and medications could have contributed to the weight changes. Resident 66 experienced a weight loss of 7.3 pounds, or 11%, between April 10 and May 17, 2024. A re-weight was requested on May 17, 2024, but was not completed, and the next weight recorded on June 4, 2024, confirmed the accuracy of the May 17 weight. The weight loss was not addressed until June 6, 2024, when a new intervention was ordered. The Nursing Home Administrator confirmed that the weight loss identified on May 17, 2024, was not addressed until June 6, 2024. These deficiencies indicate a failure to adhere to the facility's policy on timely weight monitoring and intervention.
Failure to Offer Advance Directives Upon Admission
Penalty
Summary
The facility failed to ensure that the formulation of Advance Directives was offered to a resident upon admission. Specifically, for Resident 223, there was no evidence in the clinical record that Advance Directives were formulated or offered to the resident's representative at the time of admission. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the absence of any documentation or existence of Advance Directives for Resident 223. This issue was previously cited on two occasions, indicating a recurring problem with compliance in this area.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition for one of the residents, identified as Resident 173. According to the facility's policy titled 'Change in a Residents Condition or Status,' revised in December 2016, the facility is required to promptly notify the resident, their attending physician, and representative of any significant changes in the resident's medical, mental, or emotional condition. On December 9, 2023, at 6:50 a.m., a nursing entry in Resident 173's progress notes indicated that the resident was found in bed with bright red bloody urine draining from his Foley catheter and bright red blood clots coming from his penis. However, there was no documented evidence that the resident's physician was notified of this significant change in condition. Later that day, at 3:40 p.m., another nursing entry noted that Resident 173 was lethargic and had large clots coming from his penis, with the Foley bag filled with bright red blood. A new order was received to send the resident to the emergency room for evaluation. An interview with the Nursing Home Administrator on August 22, 2024, confirmed that the resident's physician was not notified of the change in condition when the bleeding was first observed in the morning. This failure to notify the physician promptly is a violation of the facility's policy and the relevant Pennsylvania Code sections regarding clinical records and nursing services.
Failure to Investigate Resident Fall Leading to Cardiac Arrest
Penalty
Summary
The facility failed to thoroughly investigate a fall involving a resident, which resulted in a possible injury and subsequent cardiac arrest. The resident, who was admitted for respite care, experienced an unwitnessed fall while a nurse aide was providing care. The aide attempted to prevent the fall but was unsuccessful. After the fall, the resident was assessed and found to have no apparent injuries, although vital signs were abnormal. The resident was transferred to the emergency room after the physician on call was contacted. During the transfer process, the resident stopped breathing, and CPR was initiated by EMTs. The resident was later pronounced dead at the hospital. The facility's documentation and clinical records did not provide evidence of a thorough investigation into the cause of the fall, the potential injury, and the resulting cardiac arrest. The Nursing Home Administrator confirmed that a comprehensive investigation was not conducted. The facility's policy requires that all alleged violations, including injuries of unknown source, be thoroughly investigated and reported, but this was not adhered to in this case.
Failure to Monitor Resident Health and Follow Hospital Discharge Instructions
Penalty
Summary
The facility failed to provide adequate care and monitoring for a resident following their transfer from an acute care hospital. The resident, who had a history of urinary issues, was found with a non-patent catheter and blood in the urine. Despite these significant changes in condition, there was no documented evidence of vital signs being taken or a full assessment being completed before the resident was sent to the emergency room. Upon arrival at the hospital, the resident was found to have a high fever, low blood pressure, low oxygen saturation, and signs of dehydration, indicating a severe deterioration in health status that was not adequately monitored by the facility. Additionally, the facility failed to follow up on hospital discharge instructions for the resident, which included recommendations for a urology consultation. Despite being discharged from the hospital on two separate occasions with instructions to follow up with urology, the facility did not schedule these appointments. This lack of follow-up care further demonstrates the facility's failure to adhere to recommended care protocols and adequately manage the resident's health needs.
Failure to Assess Foley Catheter Necessity
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with a Foley catheter. Resident 54 was observed with a Foley catheter, and upon review of the clinical record, it was found that there was no assessment conducted to determine the necessity of the catheter upon admission. Additionally, the facility did not attempt a voiding trial to assess the resident's ability to urinate independently after admission. It was only after a request from the resident's spouse and an RN from an outside agency that a voiding trial was conducted, which was successful. The Nursing Home Administrator confirmed that the facility did not assess the need for the catheter or attempt a voiding trial until it was specifically requested.
Failure to Administer Tube Feeding as Ordered
Penalty
Summary
The facility failed to ensure that tube feedings were delivered according to physician orders for a resident. Resident 16 had a physician's order for continuous enteral feeding with Jevity 1.5 at a rate of 55 ml/hour. However, observations revealed that the enteral feed pump was turned off at one point, and there was no documentation explaining why the pump was not functioning or how much feeding was missed. On one occasion, a new bottle of Jevity 1.5 was placed, but the pump was not running as ordered, leading to a discrepancy in the amount of nutrition provided to the resident. The clinical record lacked evidence to justify the interruption in the feeding schedule, indicating a failure to adhere to the prescribed nutritional plan.
Failure to Provide Timely Respiratory Care
Penalty
Summary
The facility failed to provide timely respiratory treatment and services for Resident CL1, who was admitted with diagnoses of Sepsis, COPD, and acute and chronic respiratory failure. Despite having a BIPAP order from the hospital dated February 10, 2024, and additional documentation uploaded to the resident's EMR on February 15, 2024, the BIPAP order was not implemented until February 17, 2024, two days after the resident's admission. This delay occurred because the admitting nurse relied on the transfer form from the hospital, which did not indicate the use of BIPAP, and the DON did not review the hospital documents that specified the need for overnight BIPAP use. Interviews with the admission staff and the DON revealed that the hospital documentation was uploaded to the resident's EMR for clinical staff to review, but the DON did not review these documents. The BIPAP order was only made after the resident's daughter informed the facility of the necessity. The clinical records review also failed to show that the physician was notified about the BIPAP order from the hospital. This lack of communication and timely action led to the deficiency in providing necessary respiratory care for Resident CL1.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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