Pennsylvania Department of Health
DRESHER HILL HEALTH & REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

DRESHER HILL HEALTH & REHABILITATION CENTER
Inspection Results For:

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DRESHER HILL HEALTH & REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and a Civil Rights Compliance survey completed on January 30, 2026, it was determined that Dresher Hill Health and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.
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Plan of Correction:

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Observations:

Based on observation and staff interview, it was determined that the facility failed to properly store food and maintain sanitary conditions in the dietary department and on two of four nursing units. (First floor, Second floor)

Findings include:

Observations during the tour of the dietary department on January 27, 2026, at 10:10 a.m., and January 29, 2026, at 9:35 a.m., revealed the following:

In the dry storage area, there was a bottle of Realemon Juice with a best buy date of October 21, 2025. On the lower shelf of the cook's prep table, a container had lemon extract with a best by date of October 10, 2024, and a box of food dye with an expiration date of November 3, 2023. The container also had dirty measuring spoons. In the walk-in freezer there was a box of Harborbanks seafood shrimp that was open with no open date or expiration date and one box of gluten free breaded mini shrimp bags that was open with no open date or expiration date.

The back splash of the griddle and stove had thick dry discolored splatter. The oven doors and knobs had dry thick discolored splatter. The shelf over the cooking surface was dusty. The flat griddle, that was confirmed not used for breakfast, had food debris and crumbs on the griddle and the front scrap disposal area. The stove top had charred debris crumbs and a white powdery dusty debris. The meat slicer table had crumbs and was sticky. There was debris and crumbs on the meat slicer. The top of the steamer was dusty. The steam table and prep table bottom shelf had crumbs, debris and a paper clip. The cook's prep table was dusty andhad a dried slice of bread on the lower shelf. A wall shelf that contained the cooking spices had thick dust and debris. The lower shelf of the food prep table next to the dish area was dusty with dirt and debris.

Observation of the first floor pantry January 27, 2026, at 1:53 p.m., revealed ice built up in the refrigerator freezer and the refrigerator floor had dried discolored staining and debris. In the microwave there was thick food splatter that contained crumbs and debris. During an interview on January 27, 2026, at 1:57 p.m., the Director of Nursing confirmed that the microwave is used to reheat resident food.

Observation of the second floor pantry January 27, 2026, at 12:18 p.m., revealed ice built up in the refrigerator freezer and the refrigerator floor had dried liquid staining and debris. In the microwave there was food splatter that contained crumbs and debris. In an interview on January 27, 2026, at 12:23 p.m., a nurse aide (NA 3) confirmed that the microwave is used to reheat resident food. The ice scoop was observed on the dusty lower shelf of the rolling table for the ice cooler instead of being placed in the attached ice scoop pocket. In the cabinet below the sink there was a stained bath blanket.

28 Pa. Code 201.14(a) Responsibility of licensee.

Plan of Correction - To be completed: 02/18/2026

Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

1. Bottle of real lemon juice and lemon extract were discarded. A box of food dye was discarded. Measuring spoons were cleaned. Harbor banks seafood shrimp and a box of gluten free breaded shrimp were discarded. The griddle, the back splash of the griddle and stove, the stove top, oven doors, and knobs have been cleaned. The shelf over the cooking area has been cleaned. The meat slicer, steamer, steam table, prep table bottom shelf have been cleaned. The cooks prep table, a wall shelf with cooking spices, and the lower shelf food prep table have been cleaned. First floor pantry and second floor pantry refrigerators freezer ice built up was defrosted and the bottom of the refrigerators have been cleaned. Both microwaves in the pantries have been cleaned. The ice scoop has been placed in the ice scoop bin and the shelf has been cleaned. The bath blanket has been removed from below the sink in the second floor pantry.
2. To identify other areas with the potential to be affected, NHA/designee conducted an audit of the kitchen and any other identified areas have been addressed as needed. NHA/designee conducted an audit on labeling and dating of food and food items and any items identified have been corrected or discarded. NHA/designee reviewed and updated kitchen cleaning schedules and adjusted as needed.
3. To prevent this from reoccurring, NHA has educated Dietary manager on cleaning and dating procedures. Dietary Manager will educate kitchen staff on cleaning and dating procedures.
4. Ongoing monitoring for compliance, NHA will conduct weekly kitchen audits for three months to ensure compliance.
5. Results will be reviewed and revised as needed during monthly QAPI.

483.90(i) REQUIREMENT Safe/Functional/Sanitary/Comfortable Environ:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.90(i) Other Environmental Conditions
The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.

Observations:

Based on observation, it was determined that the facility failed to provide a safe, sanitary, and comfortable environment on two of four nursing units.(1st floor low side, 2nd floor high side)

Findings include:

Observation throughout the facility January 27 through 29, 2026, from 10:00 a.m. to 2:45 p.m., revealed the following:

A tube feeding pole in room 115 had a dried brown substance on it.

There was a displaced floor tile in room 115 by bed 1.

A mechanical lift (used to transfer residents from surface to surface) was observed with dirty wheels with knotted/intertwined thick tufts of hair and debris.

A sit to stand lift (used to assist a resident to a standing position) was observed with dirty wheels with knotted/intertwined thick tufts of hair and debris and dirt and debris on the foot boards.

The large shower chair back had a built up brown and pink substance on it.

The shower room ceiling exhaust fan had heavy dust on it.

A dried brown substance was observed on a tube feeding pole, bedside table, and privacy curtain in room 217. Dust, debris, a hair ball and a dried brown substance were observed behind the oxygen concentrator and fall mat on the left side of the bed.

The privacy curtain in room 229 was stained with a dark yellow substance and dust, crumbs and lint were observed on the left fall mat.

28 Pa. Code 201.14(a) Responsibility of licensee.

28 Pa. Code 201.18(b)(3) Management.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:

Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to provide adequate supervision to prevent a fall for one of nine sampled residents. (Resident 8)

Findings include:

Clinical record review revealed that Resident 8 had diagnoses that included dementia, end stage renal disease, and muscle weakness. Review of the Minimum Data Set assessment dated January 26, 2026, indicated that Resident 8 was cognitively impaired and fully dependent on staff for assistance getting in and out of the shower and bathing. Review of Resident 8's care plan revealed that the resident had a problem with mobility and in his ability to perform activities of daily living such as bathing and required assistance with bathing. Review of facility documentation revealed that on January 8, 2026, at 4:00 p.m., Resident 8 was being assisted with a shower by a nurse aide (NA 1). During the shower, NA 1 left the shower room with no other staff present. During that time Resident 8 slipped out of the shower chair onto the floor.

In an interview on January 29, 2026, at 1:34 p.m., the Director of Nursing and Administrator confirmed that a staff member should have been in the shower room throughout Resident 8's shower.

28 Pa. Code 211.12(d)(1)(5) Nursing services.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.71 and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Observations:

Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to implement enhanced barrier precautions and the use of personal protective equipment (PPE) to prevent the spread of infection for two of 22 sampled residents. (Residents 10 and 53)

Findings include:

Review of the facility policy entitled, "Enhanced Barrier Precautions," last reviewed June 2, 2025, revealed that enhanced barrier precautions were to be used with any "high-risk resident" with a wound or indwelling device during "high contact care activities" even when exposure to body fluids and blood is not anticipated, including during wound care, the care of feeding and tracheostomy tubes, providing hygiene, and changing briefs and linens. Standard precautions such as hand hygiene always apply and precautions include the use of protective gowns and gloves during high-risk activities.

Clinical record review revealed that Resident 10 had diagnoses that included paraplegia and a pressure ulcer of the lower back region related to a recurrent abscess (an area under the skin where pus (infected fluid) collects). The Minimum Data Set (MDS) assessment dated November 26, 2025, revealed that Resident 10 had a chronic left ischial (part of left hip bone) stage four pressure ulcer and was dependent on toileting and personal hygiene. On January 26, 2026, the wound nurse noted the reopening of the abscess. Observations on January 28, 2026, at 10:10 a.m. revealed a nurse aide (NA 2) entered Resident 10's room without wearing a protective gown prior to changing the resident's briefs.

Clinical record review revealed that Resident 53 had diagnoses that included traumatic brain injury, quadriplegia, neurogenic bladder, and gastronomy status. Resident 53 required devices including a suprapubic catheter and an enteral feeding tube according to the MDS assessment dated December 15, 2025. Observations on January 28, 2026, at 10:00 a.m. revealed a physical therapist (PT 1) performed leg stretches on Resident 53 without wearing a protective gown.

On January 29, 2026, at 1:00 p.m., the Director of Nursing confirmed that staff did not follow the facility infection control policy.

28 Pa. Code 211.10(d) Resident care policies.

28 Pa. Code 211.12(d)(1)(5) Nursing services.

§ 201.19(4) LICENSURE Personnel policies and procedures.:

(4) A determination by a health care practitioner that the employee, as of the employee's start date, is free from the communicable diseases or conditions listed in § 27.155 (relating to restrictions on health care practitioners).

Observations:

Based on a review of employee files, facility policy review, and staff interview, it was determined that the facility failed to follow Centers for Disease Control and Prevention (CDC) recommendations and facility policy for baseline tuberculosis (TB) screening and testing for one of five newly hired employees. (Employee 5)

Findings include:

According to the CDC's recommendations entitled, "Baseline Tuberculosis Screening and Testing for Health Care Personnel," last updated December 19, 2023, all United States health care personnel should be screened for TB upon hire. This process includes a risk assessment, symptom evaluation, and either a one-step interferon-gamma release assays (IGRA) blood test, a two-step Mantoux tuberculin skin test, or documentation of a negative chest x-ray with prior positive (TB) test. Per facility policy, entitled "Tuberculosis Screening Policy", last reviewed October 10, 2025, an employee may submit documentation of a previous negative TB test result or chest x-ray completed less than 12 months prior to their start date.

A review of Employee 5's employee file revealed that she started work at the facility as a nurse aide on November 5, 2025. A chest x-ray was completed on November 14, 2025, after Employee 5's start date. There was no documented evidence of a TB screen for Employee 5.

In an interview on January 31, 2026, at 11:45 a.m., the Director of Nursing confirmed that a current negative TB test or chest x-ray had not been collected and documented in the file for Employee 5 before their start date.

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum nurse aide (NA) to resident ratios for six of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from July 28 through August 3, 2025, December 22 through 28, 2025, and January 23 through 29, 2026, revealed the following:

The facility failed to meet the minimum NA to resident ratio of one NA for 15 residents on night shift (11:00 p.m. to 7:00 a.m.) on December 22 and 28, 2025, and January 23, 24, 25, and 26, 2026.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:

Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum licensed practical nurse (LPN) to resident ratios for one of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from July 28 through August 3, 2025, December 22 through 28, 2025, and January 23 through 29, 2026, revealed the following:

The facility failed to meet the minimum LPN to resident ratio of one LPN for 25 residents on day shift (7:00 a.m. to 3:00 p.m.) on December 28, 2025.

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:

Based on a review of nursing time schedules, it was determined that the facility failed to provide a minimum of 3.2 hours of direct care for each resident for six of 21 days reviewed.

Findings include:
Review of nursing schedules for 21 days from July 28 through August 3, 2025, December 22 through 28, 2025, and January 23 through 29, 2026,revealed the following total nursing care hours below minimum requirements:

Sunday, August 3, 2025: 3.09 care hours per resident.
Monday, December 22, 2025: 3.15 care hours per resident.
Friday, December 26, 2025: 3.19 care hours per resident.
Sunday, December 28, 2025: 3.14 care hours per resident.
Sunday, January 25, 2026: 2.98 care hours per resident.
Monday, January 26, 2026: 2.99 care hours per resident.

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