Inspection Reports for Silver Stream Nursing and Rehabilitation Center
905 Penllyn Pike, Spring House, PA 19477, PA, 19477
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
18 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
283% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Deficiencies: 1
Jul 1, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with pharmaceutical service requirements, specifically to determine if the facility provided necessary pharmaceutical services to residents as ordered by physicians.
Findings
The facility failed to provide necessary pharmaceutical services for one of five residents reviewed, as medications ordered for Resident R1 on May 28, 2025, were not administered due to unavailability caused by delayed pharmacy delivery.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide necessary pharmaceutical services for Resident R1 as ordered by physicians, due to medications not being available. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Resident count reviewed: 5
Medication dosage: 500
Date of physician order: May 28, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding medication availability and pharmacy delivery delays |
Inspection Report
Complaint Investigation
Deficiencies: 1
Apr 1, 2025
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to ensure that breathing treatments were prescribed upon admission and that medications were administered as ordered by the physician for one of fourteen residents reviewed (Resident R1).
Findings
The facility failed to obtain physician's orders for oxygen or breathing therapy upon admission for Resident R1 and failed to administer prescribed medications (Bromide inhalation and Albuterol inhalation solution) as ordered. Resident R1 was admitted to the hospital emergency room due to shortness of breath and change in mental status related to inadequate use of prescribed breathing treatments.
Complaint Details
The complaint investigation found substantiated failure to obtain supplemental oxygen therapy and continuous breathing therapy orders for Resident R1 upon admission, and failure to administer prescribed medications as ordered. Interviews with the Director of Nursing confirmed these findings.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure breathing treatments were prescribed upon admission and medications administered as ordered for Resident R1. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 14
Respiratory rate: 32
Normal respiratory rate range: 10-20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed and confirmed failure to obtain orders and administer medications for Resident R1 |
Inspection Report
Complaint Investigation
Deficiencies: 12
Dec 12, 2024
Visit Reason
The inspection was conducted due to complaints regarding mismanagement of resident personal funds, abuse/neglect, inadequate discharge planning, failure to provide safe adaptive equipment, medication errors, infection control issues, and other regulatory concerns at Silver Stream Nursing and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to maintain accurate accounting of resident personal funds, failure to protect a resident from verbal abuse by staff, inadequate discharge planning for several residents, failure to provide appropriate adaptive equipment for mobility, medication administration errors including missed opioid addiction treatment and wrong medication administration, failure to maintain proper infection control practices related to wound care, lack of an effective antibiotic stewardship program, failure to maintain safe food service equipment resulting in cold and unsatisfactory meals, and failure to maintain an effective pest control program.
Complaint Details
The visit was complaint-related, triggered by allegations of mismanagement of resident funds, abuse, inadequate discharge planning, medication errors, infection control issues, and other concerns. Substantiation status is not explicitly stated.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 12
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to maintain a complete, separate, and accurate accounting of each resident's personal funds entrusted to the facility for one resident (R28). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to protect one resident (R25) from verbal abuse and neglect by a licensed practical nurse. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to evaluate and implement individualized discharge plans for three residents (R11, R34, R46). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide safe and comfortable adaptive equipment to ensure activities of daily living were maintained for one resident (R34). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide timely opioid addiction treatment and adequate assessment for two residents (R56 and R61) and failed to provide proper bowel care for one resident (R81). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide necessary pharmaceutical services for two residents (R56 and R61) related to medication shortages and delays. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to use, monitor, and assess psychotropic drug use appropriately for one resident (R88). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure two residents (R69 and R64) were free from significant medication errors including wrong dosing and wrong medication administration. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain proper infection control practices related to wound care for one resident (R47). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain an effective antibiotic stewardship program including monitoring antibiotic use and providing feedback. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to keep essential food service equipment working safely, resulting in cold and unsatisfactory food temperatures for many residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain an effective pest control program to prevent and deal with common household pests and rodents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 24
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee E1 | Nursing Home Administrator | Interviewed regarding resident R28 personal funds issue |
| Employee E2 | Director of Nursing | Involved in resident R28 funds issue and abuse investigation of resident R25 |
| Employee E4 | Business Office Manager | Interviewed regarding resident R28 personal funds receipts |
| Employee E18 | Licensed Practical Nurse | Involved in verbal abuse incident with resident R25 |
| Employee E17 | Social Work Staff | Confirmed lack of discharge planning for residents R11, R34, and R46 |
| Employee E12 | Licensed Practical Nurse | Interviewed regarding mobility care needs of resident R34 |
| Employee E13 | Nursing Assistant | Interviewed regarding mobility care needs of resident R34 |
| Employee E16 | Physical Therapist | Interviewed regarding wheelchair needs of resident R34 |
| Employee E5 | Registered Nurse / Infection Preventionist | Interviewed regarding wound care and antibiotic stewardship program |
| Employee E10 | Director of Dietary Services | Interviewed regarding food service equipment failures |
| Employee E8 | Registered Dietitian | Interviewed regarding food service equipment failures |
| Employee E14 | Director of Maintenance | Interviewed regarding kitchen flooring and plumbing |
Inspection Report
Routine
Deficiencies: 19
Feb 27, 2024
Visit Reason
The inspection was a routine regulatory survey of Silver Stream Nursing and Rehabilitation Center to assess compliance with state and federal regulations.
Findings
The facility was found deficient in multiple areas including failure to notify residents of care plan meetings, failure to account for residents' personal belongings, failure to notify physicians of resident falls, late completion of resident assessments, failure to notify state authorities of significant mental health changes, inadequate assistance with activities of daily living, improper administration of medications including IV nutrition, inadequate pain management, improper medication storage and labeling, food safety violations, improper garbage disposal, incomplete nursing competencies, and insufficient nurse aide training hours.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 19
Deficiencies (19)
| Description | Severity |
|---|---|
| Failed to ensure a resident was notified in advance of care plan meetings to participate. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to account for personal belongings of three residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to notify physician of a resident fall incident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete comprehensive assessments every 12 months for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete quarterly assessments at least every 3 months for six residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to notify state mental health or intellectual disability authority of significant change in resident's mental health status. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide adequate assistance with activities of daily living including haircuts and shaving for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide timely foot care for one resident with fungal toenail infection. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure adequate supervision during medication administration for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to administer intravenous nutrition according to physician orders and professional standards for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide sufficient nursing staff to complete resident assessments timely for eight residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure licensed nursing staff had proper competencies for IV catheter care, trach care, and TPN administration. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to store, label, and dispense drugs according to professional standards for one resident medication observation. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure food was stored, prepared, distributed, and served in accordance with professional food safety standards. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly dispose of garbage and refuse. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure complete and accurate documentation in medical records for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to establish an antibiotic stewardship program including monitoring and tracking antibiotic use for seven months. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide safe, appropriate pain management consistent with physician orders for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure nurse aides received at least 12 hours of annual training for two nurse aides. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 21
Nurse aides reviewed: 6
Months antibiotic stewardship data missing: 7
Medication doses missed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee E8 | Social Worker | Confirmed no notification to state mental health authority and no documentation of resident care plan meeting notification |
| Employee E12 | Housekeeping Director | Confirmed no inventory sheet for resident's personal belongings |
| Employee E25 | Regional Housekeeping Director | Confirmed no inventory sheet for resident's personal belongings |
| Employee E3 | Regional Administrator/Chief Operating Officer | Discussed resident clothing concerns and staffing for assessments |
| Employee E27 | Confirmed medication was given to resident to self-administer without supervision | |
| Employee E2 | Director of Nursing | Confirmed multiple findings including late assessments, medication administration issues, antibiotic stewardship data missing, medication labeling, and nursing competencies |
| Employee E7 | MDS Coordinator | Confirmed late completion of resident assessments due to workload |
| Employee E24 | Licensed Practical Nurse | Observed administering medication from unlabeled container |
Inspection Report
Annual Inspection
Deficiencies: 2
Jan 25, 2024
Visit Reason
The inspection was conducted as part of an annual survey to assess compliance with regulatory requirements related to resident dignity and respiratory care.
Findings
The facility failed to ensure resident dignity for one out of seven residents reviewed, as Resident R1 had untrimmed facial hair and long fingernails with dark substance under the nails. Additionally, the facility failed to provide appropriate respiratory care for Resident R1 by not administering oxygen at the prescribed rate and not changing the oxygen tubing as ordered.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights, evidenced by untrimmed facial hair and long fingernails with dark substance under the nails for Resident R1. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide safe and appropriate respiratory care for Resident R1, including administering oxygen at 3.5 liters per minute instead of 4 liters per minute and not changing oxygen tubing since September 2023 as ordered. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 7
Oxygen flow rate ordered: 4
Oxygen flow rate observed: 3.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee E5 | Licensed Nurse | Confirmed observation of oxygen tubing not changed as ordered |
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 31, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to implement a system of records for receipt and disposition of controlled drugs between shifts, which led to discrepancies in narcotic counts and missing signatures on shift-to-shift narcotic counts.
Findings
The facility failed to maintain accurate records and accountability for controlled drugs across four medication carts, with multiple missing nurse signatures on shift-to-shift narcotic counts from September to October 2023. An incident of narcotic discrepancy involving six missing Oxycodone 5 mg tablets for a resident was confirmed, and the facility's narcotic count sheets did not match the actual narcotic cards present.
Complaint Details
The complaint investigation revealed missing nurse signatures on shift-to-shift narcotic counts on multiple dates between September 1, 2023, and October 31, 2023. A narcotic discrepancy incident in September 2023 involved six missing tablets of Oxycodone 5 mg for Resident R1. The outgoing overnight nurse failed to count narcotics with the incoming day shift nurse on September 24, 2023, contributing to the discrepancy.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to implement a system of records of receipt and disposition of all controlled drugs between shifts to enable accurate reconciliation and accountability for medication carts. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Missing Oxycodone tablets: 6
Narcotic cards not signed out: 53
Narcotic cards counted: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee E2 | Director of Nursing | Aware of narcotic discrepancy incident and has the investigation record; confirmed missing Oxycodone tablets. |
| Employee E3 | Second floor unit manager | Confirmed medication cart details, narcotic storage system, and narcotic discrepancy incident. |
| Employee E4 | Licensed nurse | Revealed missing signatures on the Second-floor front narcotic book shift-to-shift count. |
| Employee E5 | Licensed nurse | Revealed missing signatures on the Second-floor back narcotic book shift-to-shift count. |
| Employee E6 | Licensed nurse | Revealed missing signatures on the First floor back hall narcotic book and explained narcotic card counting procedures. |
| Employee E7 | Licensed nurse | Revealed missing signatures on the First-floor front hall narcotic book and confirmed narcotic count discrepancies. |
| Employee E1 | Confirmed that the outgoing overnight nurse left without counting narcotics with the incoming day shift nurse. |
Inspection Report
Complaint Investigation
Deficiencies: 1
May 4, 2023
Visit Reason
The inspection was conducted based on a complaint regarding the facility opening residents' mail without their consent.
Findings
The facility failed to ensure residents' privacy by opening mail addressed to residents without their consent for two of 20 residents reviewed. Interviews with residents and staff confirmed that mail was delivered opened, contrary to facility policy.
Complaint Details
Complaint investigation found that mail addressed to residents was opened without consent, affecting two residents (Resident R76 and Resident R19).
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure the rights of residents' privacy by opening residents' mail without resident consent for two of 20 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Activities Director | Activities Director | Interviewed regarding opened mail delivered to Resident R76; stated she did not open any mail. |
| Administrator | Administrator | Interviewed regarding mail delivery policy stating residents' mail should be delivered unopened. |
Inspection Report
Routine
Census: 88
Deficiencies: 14
May 4, 2023
Visit Reason
The inspection was a routine regulatory survey of Silver Stream Nursing and Rehabilitation Center to assess compliance with state and federal regulations related to resident care, dietary services, infection control, and quality assurance.
Findings
The facility was found deficient in multiple areas including delayed meal delivery and substitutions without resident notification, failure to maintain resident dignity during meals, inadequate care planning for pain management and mobility, failure to ensure resident privacy with mail, inadequate bowel and bladder assessments, lack of culturally competent trauma-informed care, failure to monitor adverse effects of medications, failure to follow up on dental care, insufficient dietary staffing and equipment, failure to maintain food temperature and palatability, ineffective quality assurance program, and lapses in infection control practices.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 14
Deficiencies (14)
| Description | Severity |
|---|---|
| Failure to promote resident dignity and respect during meal service with delayed meal delivery and residents waiting hungry. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure resident privacy by opening residents' mail without consent. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement individualized care plans for pain management prior to medication administration. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide assistance to maintain or improve range of motion with mobility device for a resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to assess bowel and bladder continence and develop care plan for resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide culturally competent, trauma-informed care addressing PTSD and triggers. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to monitor for adverse effects of anticoagulant medication as recommended by pharmacy consultant. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to follow up with dental recommendations for resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to employ sufficient dietary staff to effectively carry out food and nutrition services. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure menus were followed as planned with substitutions and omissions without resident notification. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to serve food and drink palatable, attractive, and at safe and appetizing temperatures. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to sustain an effective Quality Assurance and Performance Improvement (QAPI) program for resident falls and psychotropic medication use. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain effective infection control program including proper cleaning of medical equipment and hand hygiene during wound and tracheostomy care. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to keep essential kitchen equipment working safely including dish machine and hot holding equipment. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Resident census: 88
Residents with falls in last 90 days: 17
Residents with dementia: 32
Residents receiving psychoactive drugs: 64
Residents receiving antipsychotic drugs: 31
Residents receiving antianxiety drugs: 25
Residents receiving antidepressants: 56
Resident falls requiring hospital transfer: 12
Percentile for antipsychotic medication use: 95
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed lack of pain care plans and bowel/bladder assessment | |
| Activities Director | Interviewed regarding mail opening | |
| Administrator | Confirmed mail policy and QAPI program changes | |
| Director of Dietary Services | Reported staffing shortages, equipment issues, and meal delivery delays | |
| Licensed Practical Nurse (LPN) | Observed improper cleaning of medical equipment during medication administration | |
| Charge Nurse (LPN) | Observed improper wound and tracheostomy care techniques | |
| Nursing Supervisor | Confirmed lack of dental follow-up |
Inspection Report
Annual Inspection
Deficiencies: 1
Mar 20, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning requirements, specifically regarding the development and implementation of a comprehensive person-centered care plan for residents using oxygen and CPAP therapy.
Findings
The facility failed to develop and implement a complete care plan with measurable objectives for one of three residents (Resident R1) who required continuous oxygen and CPAP therapy. Observations, clinical record reviews, and staff interviews confirmed the lack of care plan interventions related to these therapies.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured, specifically related to oxygen and CPAP machine usage for Resident R1. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Physician's order oxygen flow rate: 4
CPAP setting: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee E10 | Nursing Assistant | Confirmed Resident R1 required continuous oxygen and CPAP machine use |
| Director of Nursing | Confirmed Resident R1 required continuous oxygen and CPAP machine use and lack of care plan |
Inspection Report
Complaint Investigation
Deficiencies: 2
Feb 6, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding inadequate monitoring of a resident's voiding schedule and failure to provide residents with accessible water on one of the nursing units.
Findings
The facility failed to ensure that one resident's voiding schedule was monitored according to physician's orders, and failed to provide water accessible to residents on the second-floor nursing unit. Observations and interviews confirmed missing documentation of voiding monitoring and lack of water at bedside tables for multiple residents.
Complaint Details
The complaint investigation found substantiated deficiencies related to inadequate monitoring of a resident's voiding schedule and failure to provide accessible water to residents on the second floor nursing unit.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure resident's voiding schedule was monitored in accordance with physician's order for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide residents with water accessible on one of two nursing units observed (Second floor). | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 19
Residents observed: 13
Observation time: 125
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Provided urinary continence record and confirmed lack of monitoring | |
| Licensed nurse Employee E3 | Made aware of resident's request for water | |
| Licensed nurse Employee E4 | Responded to resident's request for water and obtained water | |
| Nursing Home Administrator | Confirmed some residents did not have water on their bedside |
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