Phoenix Center For Rehabilitation And Nursing,the
PHOENIX CENTER FOR REHABILITATION AND NURSING,THE in PHOENIXVILLE, PA — inspection on September 2, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, a review of clinical records, and interviews with residents and staff, it was determined that the facility failed to provide a homelike environment for one of the three residents reviewed (Resident 1).Findings include:A review of Resident 1's admission assessment dated [DATE], revealed the resident was readmitted to the facility from the hospital for diagnosis of Congestive Heart Failure (CHF-A weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs).
The same assessment revealed that the resident was alert and oriented, and had skin openings on both legs.During an observation on September 2, 2025, at 11:52 a.m. Resident 1 was observed sitting on a chair beside the bed.
The mattress was only half covered with a white flat sheet.
The sheet covering the bottom part of the mattress had large dried brown stains and multiple dried red stains in different sizes.
Additional observation revealed two loose white sheets on top of the bed, also with multiple dried dark yellow to light brown stains in different sizes.An interview with Resident 1 was conducted on September 2, 2025, at 11:55 a.m. Resident 1 reported that the brown stains on the bottom of the bed were from coffee spills, the red stains were blood from his/her legs, and the stains on the other sheets were from juice and food spills that occurred several times since he came back last August 29, 2025.
The resident was unable to recall when the spills and blood stains occurred but reported that his bed sheets had not been changed since he/she arrived at the facility last Friday, August 29, 2025.An interview conducted with Nursing Assistant, Employee E1, on September 2, 2025, at 11:59 a.m., revealed that she/he was an agency staff member and did not know when the last time Resident 1's bed sheets were last changed.
Employee E1 reported that Resident 1's bed sheets had not been changed since this morning because she /he did not get a chance to do it yet.
The above was conveyed with theDirector of Nursing on September 2, 2025, at 12:05 p.m.
The facility failed to ensure Resident 1 was provided with a homelike environment.28 Pa.
Code 204.5(f) resident rooms
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
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