Phoenix Center For Rehabilitation And Nursing,the
Inspection Findings
F-Tag F0584
F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
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 REDACTED], 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.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
PHOENIX CENTER FOR REHABILITATION AND NURSING,THE in PHOENIXVILLE, PA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in PHOENIXVILLE, PA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from PHOENIX CENTER FOR REHABILITATION AND NURSING,THE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.