Phoenix Center for Nursing: Soiled Sheets Since Admission - PA
This is what inspectors found on the morning of September 2, 2025, in the room of a resident at Phoenix Center for Rehabilitation and Nursing, a person who had been readmitted from the hospital just four days earlier with congestive heart failure and open skin wounds on both legs.
The resident was sitting in a chair beside the bed when inspectors arrived at 11:52 a.m. He explained the stains himself. The brown ones were from coffee. The red ones were blood from his legs. The stains on the other sheets were from juice and food spills that had happened multiple times since he returned from the hospital on August 29. He couldn't remember exactly when each spill or bleed had occurred. What he could say was that his sheets had not been changed since he arrived last Friday.
That was four days.
The nursing assistant assigned to the room, an agency staff member identified in the report as Employee E1, was interviewed three minutes after inspectors spoke with the resident. She said she didn't know when the sheets had last been changed. Then she offered a second explanation: the sheets hadn't been changed that morning because she hadn't gotten a chance to do it yet.
It was nearly noon.
The Director of Nursing was informed of the findings at 12:05 p.m. The inspection report does not describe any response.
The violation was cited under Pennsylvania's resident room standards and classified as causing minimal harm or potential for actual harm, affecting few residents. One resident was reviewed for this specific deficiency. That resident was the one sitting beside the blood-stained bed.
The clinical picture here matters. Congestive heart failure causes fluid to accumulate in the legs, feet, lungs, and other organs. This resident had been admitted with that diagnosis and with skin openings on both legs, the kind of wounds that bleed onto sheets and that require monitoring. The inspection report does not describe what wound care the resident was or wasn't receiving. It describes what inspectors could see: dried blood on fabric that hadn't been laundered in four days.
Nursing homes are required under Pennsylvania code to provide residents with a homelike environment. That phrase can sound abstract. What it looked like in practice, according to this inspection, was a resident alert enough to explain his own stains to an investigator, oriented enough to remember the date he came back from the hospital, sitting in a chair next to a mattress he had been sleeping on for four nights while it collected evidence of everything that had happened to him.
The agency aide's explanation, that she hadn't gotten around to it yet, does not appear to have been challenged in the report. Whether she had been assigned the task, whether the facility had any system for tracking linen changes, whether anyone had checked the room in four days, none of that is addressed in the inspection findings. The report documents what was there. It does not explain how it got that way.
Phoenix Center for Rehabilitation and Nursing submitted this inspection was conducted as a complaint survey. The report does not identify who filed the complaint or what it originally alleged.
The resident remained in the facility as of the inspection date. The report ends there.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Phoenix Center For Rehabilitation and Nursing,the from 2025-09-02 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
PHOENIX CENTER FOR REHABILITATION AND NURSING,THE in PHOENIXVILLE, PA was cited for violations during a health inspection on September 2, 2025.
The resident was sitting in a chair beside the bed when inspectors arrived at 11:52 a.m.
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.