Pennsylvania Department of Health
BROOKMONT HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

BROOKMONT HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

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BROOKMONT HEALTHCARE AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a revisit and abbreviated complaint survey completed on February 4, 2026, it was determined that Brookmont Healthcare and Rehabilitation Center corrected the federal deficiencies cited during the survey of December 19, 2025, under the requirements of 42 CFR Part 483 Subpart B Requirements for Long-Term Care however remained out of compliance with the following requirements of 28 PA Code Commonwealth of Pennsylvania Long-Term Care Licensure Regulations.

Plan of Correction:

§ 211.10(d) LICENSURE Resident care policies.:

(d) The policies shall be designed and implemented to ensure that the resident receives proper care to prevent pressure sores and deformities; that the resident is kept comfortable, clean and well-groomed; that the resident is protected from accident, injury and infection; and that the resident is encouraged, assisted and trained in self-care and group activities.

Observations:

Based on review of facility policy, observation, and staff interviews, it was determined the facility failed to implement its medication administration and safety practices to ensure residents were protected from an avoidable accident hazard when a medicated cream was left unlabeled and unsecured in a resident room in one out of five nursing units sampled (North Unit).

Findings include:

A review of a facility policy titled "Medication Policy," last reviewed August 6, 2025, revealed medications are to be administered by licensed nurses or by other legally authorized staff to do so, as ordered by the physician and in accordance with professional standards of practice in a manner that prevents contamination or infection.

Observation on February 4, 2026, at 11:43 AM in resident room 52 revealed a white cream substance in a clear plastic medication cup with a spoon present on the window-side television dresser. The cup was not labeled with the resident's name, the name of the medication, or instructions for use.

During an interview on February 4, 2026, at 11:45 AM, Employee 1, Nurse Aide (NA), stated she was unable to identify the white substance but believed it to be zinc paste (zinc oxide paste, a medicated topical skin protectant used to treat and prevent skin irritation). The NA confirmed the container was not labeled and stated that nurses sometimes leave creams at the bedside to be utilized for resident care.

During an interview on February 4, 2026, at 11:49 AM, Employee 2, Licensed Practical Nurse (LPN), stated that unlabeled creams should not be left on residents' dressers. The LPN stated creams are to be applied as ordered by the physician and any remaining medication should be properly secured or discarded.

Medicated creams are intended for external (skin) use only and are not intended to be ingested (swallowed). Leaving an unlabeled medicated substance in an accessible location within a resident room created a foreseeable risk that the cream could be ingested, misused, or accessed by another resident, particularly residents who may have cognitive impairment (difficulty with memory, judgment, or understanding). The presence of a spoon further increased the potential for ingestion.

During an interview on February 4, 2026, at 12:30 PM, the above findings were reviewed with the nursing home administrator (NHA) and director of nursing (DON). The facility failed to implement resident care policies designed to protect residents from accident and injury when a medicated cream was left unlabeled and unsecured in a resident room, creating a potential ingestion and safety hazard.

Plan of Correction - To be completed: 03/16/2026

Please note that the filing of this plan of correction does not constitute any admission to the alleged violations set for in the statement of deficiencies. This plan of correction is being filed as evidence of the facility continues compliance with all applicable laws.
- The facility cannot retroactively correct this deficiency
- Audit residents to ensure that there are no creams left at bedside
- Educate licensed staff on medication administration and safety practices
-weekly audits x4
- Monthly audits X2
- Results will be brough to QAPI

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