Southeastern Pennsylvania Veteran's Center

Based on a review of job descriptions, clinical records, it was determined that the Commandant and Director of Nursing did not effectively manage the facility to make certain that all direct staff were educated and trained with facility's policy and procedure regarding safe heating/re-heating of food and beverages to prevent resident from getting burns. Findings include: A review of the job description of the Commandant revealed the following: Responsible for managing and controlling all health-related activities and management functions of the facility; Establish and maintain a safe environment for residents and staff by operating safety programs that is in conformance with agency, state, and federal standards to protect the health and safety of the residents. A review of the job description of the Director of Nursing revealed the following: Directs all nursing care activities and participates in the administration of the multidisciplinary and non-clinical aspects of the resident's extended care facility's overall operation; In conjunction with multidisciplinary team, plan, direct,…

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 a review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to timely notify the physician of a significant weight change for one of the 35 residents reviewed (Resident 63). Findings include: A review of the facility's policy titled Weight Policy, last revised on June 23, 2020, revealed routine weights will be done to monitor or detect any changes that would adversely affect the resident's health. A weight will be obtained upon admission and/or readmission, then weekly times four weeks. A weight loss or gain of 5% in one month will require a reweight. Dietitians will evaluate weekly weights and monthly weights to determine if additional interventions are needed. If there is a significant weight change, the Dietitian will notify the physician. A review of Resident 63's diagnosis list includes Congestive Heart Failure (CHF-A weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs), Chronic Kidney Disease (CKD-Gradual loss of kidney functions which can result in renal…

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 upon review of facility policy and procedure, clinical record review, and staff interview it was determined the facility failed to follow physician orders for fluid restriction and administration of medication for one of one resident reviewed (Resident 52). Findings include: Review of facility policy and procedure titled Hydration Policy revealed Residents on fluid restriction will receive fluids as per Provider Order. Review of Resident 52's diagnosis list revealed diagnoses including congestive heart failure (CHF - excessive body/lung fluid caused by a weakened heart muscle), Diabetes Mellitus (DM - failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment), urinary retention (bladder does not completely empty) and chronic obstructive pulmonary disease (COPD - disease process that causes decreased ability of the lungs to perform). Review of Resident 52's physician orders dated October 16, 2024, revealed 2000 cc Fluid Restriction. Total Dietary 680 cc, Total Nursing 1340 cc, (7-3 shift: dietary 480 cc, nursing 480 cc), (3-11…

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 clinical records review and staff interview, it was determined that the facility failed to ensure medications necessary for residents with kidney disease were administered as ordered for one of the two residents reviewed (Resident 46). Findings include: A review of Resident 46 diagnosis list includes End Stage Renal Disease (ESRD- Where kidney function has declined to the point that the kidneys can no longer function on their own). Clinical records review revealed resident goes to Dialysis (A process of purifying the blood of a person whose kidneys are not working normally) every Monday, Wednesday, and Friday, pickup time at 9:30 a.m. A review of Resident 46 physician's order dated November 9, 2025, revealed an order for Renvela (A medication used to control phosphorus levels for people with chronic kidney disease) 800 mg two tablets three times a day. The medications were scheduled at 8:00 a.m., 12 noon and 5:00 p.m. A review of the April 2025, Medication Administration Record revealed Renvela's medication was not administered at 12 noon on the following dates: April 2,…

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 and clinical record review, it was determined that the facility failed to timely assess the need for an indwelling urinary catheter for one of seven residents reviewed for urinary tract infections (UTI) (Resident 61). Findings include: Review of facility policy, Urinary Catheter Procedures, last revised December 30, 2022, revealed that A resident who enters the [facility] with an indwelling urinary catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident ' s clinical condition demonstrates that catheterization is necessary .Residents identified with an indwelling urinary catheter will be assessed by utilizing the Indwelling Catheter Observation Form in the Electronic Health Record (EHR). This observation form will be completed when the catheter is present on admission/readmission, when a catheter is inserted, and quarterly as long as the catheter remains in place .Attempts will be made to remove the catheter as soon…

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 clinical record review and staff interview, it was determined that Southeastern Pennsylvania Veterans' Center failed to ensure that one of 24 residents reviewed did not have an oncology consult timely (Resident R1). Findings include: Review of Resident R1's clnical record revealed the resident was admitted to the facility in November 2023 with a diagnosis of cancer. Review of Resident R1's clinical record revealed Certified Registered Nurse Practitioner assessed the resident on November 2, 2023 with a notation of cancer as a diagnosis. Review of Resident R1's clinical record revealed a liver biopsy was scheduled for January 31, 2024 and an oncology (physician that specializes in treatment of cancer disorders) appointment scheduled for February 23, 2024. Review of Resident R1's clinical record failed to reveal any documented evidence that the resident's cancer was assessed by an oncologist or course of treatment identified. Interview on March 14, 2024 at approximately 11:45 p.m. with the Director of Nursing, confirming the above information. Pa 28 211.12(a)(c)(d)(3)(5)…

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 facility policy, clinical record reviews, and staff interview, it was determined that the facility failed to to ensure that the drug regimen of each resident was reviewed monthly by a licensed pharmacist for four of five residents reviewed (Residents 23, 48, 138, and 145) and failed to act on the pharmacy recommendations in a timely way for two of five residents (Residents 23 and 132). Findings include: Review of facility policy Drug Regimen & Medical Chart Review revised June 19, 2019, indicated that at least once a month the resident's medical record will be reviewed concurrently with the drug regimen review (DRR) by a licensed pharmacist. The pharmacist will report any irregularities to the attending physician or CRNP (certified registered nurse practitioner), medical director and director of nursing for follow up with seven days. The attending physician or CRNP will document in the resident's medical record that the identified irregularity has been reviewed and acted upon. If the provider disagrees with the recommendation the provider must document in the clinical…

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 Pennsylvania's Nursing Practice Act, facility policy, and clinical records, it was determined that the facility failed to provide services that met professional standards of practice regarding medication administration for one of 34 residents reviewed (Resident 20). Findings include: According to Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, section 21.145. Functions of the LPN (Licensed Practical Nurse), subsection (a), The LPN is prepared to function as a member of the health-care team by exercising sound nursing judgment based on preparation, knowledge, experience in nursing and competency. Review of facility policy, Medication Administration - General, dated May 2015, revealed: Residents are identified before medication is administered. Methods of identification include: A. Checking identification band B. Checking photograph attached to medical record C. Calling resident by name d. If necessary, verifying resident identification with other facility personnel. Review of Resident 20's quarterly MDS (Minimum Data Set…

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 clinical record review, it was determined that the facility failed to correctly administer medications for two of 34 residents reviewed (Resident 20 and Resident 103). Findings include: Review of Resident 20's quarterly MDS (Minimum Data Set - periodic assessment of resident care needs) dated March 22, 2023, revealed the resident had a BIMS (Brief Interview for Mental Status) score of 05, indicating cognitive impairment. Further review of Resident 20 ' s MDS revealed the resident did not have a diagnosis of diabetes mellitus (failure of the body to produce insulin to enable sugar to pass from the blood stream to the cells for nourishment). Review of Resident 20's physician's orders failed to reveal any orders for insulin (medication used to lower blood sugar). Review of Resident 20's progress notes revealed a nurse's note from licensed nurse Employee E1 dated April 27, 2023, at 10:49 p.m. which stated: At [8:30 p.m.] this nurse was distracted and administered medication to wrong patient. This nurse called resident other name and resident replied. Administering Lantus [(long…

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 clinical record review and staff interview it was determined the facility failed to perform wound treatment on a newly found pressure ulcer for one of 2 residents reviewed (Resident 24) Findings Include: Review of Resident 24's Progress Notes revealed a nursing entry dated August 11, 2023 at 3:30 p.m. stating New area of concern reported by CNA(certified nursing assistant) during toileting. Reported to wound team for further evaluation. Further review of Resident 24's progress notes revealed a nursing entry date August 12, 2023 at 6:19 p.m. stating Resident to start Dakin's (a diluted solution bleach and other stabilizing ingredients, traditionally used as an antiseptic) solution to wound on back in am. Review of Resident 24's physician orders revealed at order with a start date of August 13, 2023 to cleanse the lower back ulcer with Normal Saline Solution (sterile salt water), pack wound with Daikin's soaked gauze and apply foam dressing. Review of Resident 24's Medication Administration Record revealed there was no evidence a treatment was placed on the wound until August…

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 policy and procedure, clinical record reviews, and staff interview it was determined the facility failed to provide interventions to prevent elopement for one of 2 residents reviewed. (Resident 164) Findings Include: Review of policy and procedure titled Wandering and Elopement last revised May 20, 2014 revealed a flight risk assessment will be completed upon admission, quarterly, annually, and change in condition as needed for episodes of wandering, A flight Risk Assessment score of 12 or greater indicates the need for an electronic monitoring device (EMD) to be placed on the resident's wrist or ankle. If an AMD is applied, the residents name and photo will be placed in the master photo book locate at the front desks and the nurse's station on each unit. Each resident will be reassessed as needed, and the EMD will be removed at the discretion of the interdisciplinary team following the reassessment. Further review of facility policy and procedure Wandering and Elopement defined elopement risk behavior as any behaviors including but not limited to; (1) resident is…

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.