Pennsylvania Soldiers And Sailors Home

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital for three of three residents reviewed (Residents R1, R5, and R9).Findings include: Review of facility policy entitled Transfers and Discharge dated 2/2/26, revealed For a transfer/discharge to another provider, for any reason, the following information must be provided to the receiving provider:Contact information of the practitioner who was responsible for the care of the resident,Resident representative information.Advance directive information.All other information necessary to meet the residents needs, which includes, but may not be limited to:Resident status, including baseline and current mental, behavioral, and functional status, reason for transfer, recent vital signs.Diagnoses and allergies.Medications (including last received); andMost recent relevant labs, other diagnostic tests, and recent immunizations.All special…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of an as needed (PRN) psychotropic (mind altering) medication for one of five residents reviewed (Resident R100).Review of facility policy entitled Psychotropic Medication Use & GDR Process dated 2/2/26, indicated Residents who use psychotropic medications shall also receive non-pharmacological interventions to facilitate reduction or discontinuation of the psychotropic drugs. And non-pharmacological interventions will be utilized and documented in the EMAR [electronic medication administration record]. Review of Resident R100's clinical record revealed an admission date of 4/18/25, with diagnoses that included dementia (a disease that affects short term memory and the ability to think logically), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policy and clinical records, observations, and staff interviews, it was determined that the facility failed to ensure adequate safety measures were implemented per physician's orders by not attaching leg rests (supportive device attached to a wheelchair for the feet to rest upon) to the wheelchair during transport for four residents reviewed (Residents R45, R73, R75, and R101).Findings include: Review of facility policy entitled Medical Provider Orders dated 2/2/26, revealed .the written physician orders are to provide the essential care needs to the resident, consistent with their mental and physical status.physician orders are administered and carried out in accordance with the written or verbal orders of the attending medical provider. Review of Resident R45's clinical record revealed an admission date of 10/3/25, with diagnoses that included muscle spasm, hypothyroidism (a condition where the thyroid gland does not produce enough hormones causing a slow metabolism), and pain.Review of Resident R45's clinical record revealed a physician's order for B…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policy and clinical record and staff interview, it was determined that the facility failed to ensure recommendations made from the consultant pharmacist were acted upon for one of five residents reviewed (Resident R66).Review of facility policy entitled Medication Regimen Review [MRR] dated 2/2/26, indicated The MRR includes review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities., The pharmacist shall communicate any irregularities to the facility., The facility shall provide the licensed pharmacist. answers to the previous month's pharmacy recommendations. and Facility staff shall act upon all recommendations. Review of Resident R66's clinical record revealed an admission date of 9/29/25, with diagnoses that included diabetes (a health condition that is caused by the body's inability to produce enough insulin), Parkinson's (a chronic and progressive movement disorder that causes shaking, slows a person's ability to move and worsens over time), and anxiety (a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to provide oxygen according to physician's orders and failed to promote cleanliness and help prevent the spread of infection for three of five residents reviewed regarding respiratory care equipment (Residents R6, R30, and R38). Findings include: A facility policy dated 3/3/25, entitled Supplemental Oxygen Therapy revealed Turn the Flow Meter to the prescribed setting. DO NOT select a different setting unless the Provider has prescribed a change and The Nursing staff shall be responsible to clean filters (located at the back / side of the concentrators), wipe down machine, change all tubing, distilled water canisters (if applicable) and bags weekly. Resident R6's clinical record revealed an admission date of 6/5/15, with diagnoses that included Chronic obstructive pulmonary disease (COPD - when your lungs do not have adequate air flow), high blood pressure, and anxiety (a condition that causes a person to be nervous, uneasy, or worried about…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policy and clinical record review, and staff interview, it was determined that the facility failed to ensure that a PRN (as needed) anti-anxiety psychotropic (any drug that affects brain activities associated with mental processes and behavior) medication had clinical rationale identified for the use beyond the limitation of 14 days for one of 23 residents reviewed (Resident R4). Findings include: A facility policy entitled Resident Care/Pharmacy Services dated 3/2023, revealed that PRN orders for psychotropic medications (antipsychotic, anxiolytic, antidepressant and sedative/hypnotic) will be limited to 14 days unless the physician identifies the rationale to extend the medication beyond 14 days. Resident R4's clinical record revealed an admission date of 4/28/18, with diagnoses that included dementia (a disease of the brain that affects decision making, memory, mood and behavior), aneurysm of iliac artery (a bulge or dilation in the wall of the iliac arteries, located in the pelvis), benign neoplasm of colon (a non-cancerous growth that originated in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in a resident pantry in one of two refrigerators reviewed (Unit A pantry). Findings include: Review of facility policy entitled Resident Rights; Visitation dated 3/3/25, indicated Perishable food . brought in will be permitted to be placed in the unit refrigerator for 24 hours. The food must be labeled with resident's name date and time. Perishable items not of a leftover nature, may be placed in the unit refrigerator/freezer up through package expiration date. Observations on 3/5/25, at 11:40 a.m. of a refrigerator in the Unit A pantry used for residents revealed three zip lock bags containing snap peas, two of the zip lock bags had a date of 1/21/25, and the third zip lock bag lacked a date. Observation of one of the zip lock bags revealed the snap peas were soft and there was a liquid substance in the bottom of the zip lock bag. Further observations revealed a plastic container of blackberries…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policy and infection control records, and staff interviews, it was determined that the facility failed to ensure measures were in place to monitor and prevent legionella in the facility water. Findings include: A facility policy entitled, Prevention of Healthcare-Associated Legionella Disease, dated 3/03/25, revealed The State Veterans' Homes 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. Prevention of Healthcare-Associated Legionella (L. pneumophila) Disease - If environmental testing detects L. pneumophila then the environmental actions in this sub-paragraph are required. Any amount of L. pneumophila detected in a sample is considered a positive result. Implement remedial action using the criteria below. This remedial action approach uses a graded response for addressing L. pneumophila-positive samples detected through routine water testing. After environmental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, facility documentation and clinical record, and resident and staff interviews, it was determined that the facility failed to ensure that one of 22 residents reviewed was free of neglect during care. (Resident R11) Findings include: Review of facility policy entitled Administrative Services dated 3/2/24, revealed Neglect: The failure of the home, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of facility policy entitled Clinical Care dated 3/2/24, revealed Basic Elements of Lift, Gait Belts, and Slider Boards Use, 1.maintains a no manual body lift directive to minimize risk of injury to the resident . Review of Resident R11's clinical record revealed an admission date of 7/2/19, with diagnoses that included Alzheimer's disease (brain disorder that slowly destroys memory, thinking skills, and, over time the ability to carry out the simplest tasks),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to review and/or revise resident care plans for two of 22 residents reviewed (Residents R27 and R57). Findings include: Review of a facility policy dated 3/2/24, entitled Comprehensive Care Plans (Nursing Care) indicated that the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS (Minimum Data Set - federally mandated standardized assessment conducted at specific intervals to plan resident care) assessment. Resident R27's clinical record revealed an admission date of 5/9/14, with diagnoses that included paraplegia (injury to your spinal cord or brain causes paralysis to your lower body), high blood pressure, and diabetes (condition of improper insulin/blood sugar levels). Review of Resident R27's comprehensive care plan with a problem category of Pressure Ulcer / Injury revealed an outstanding target date (a date that the resident's care plan must be updated by) of 3/14/24. Resident R57's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.