Southeastern Pennsylvania Veteran's Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission Minimum Data Set assessments were completed in the required time frame for one of 42 residents reviewed (Resident 10).Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2025, indicated that an admission MDS assessment was to be completed no later than 14 days (admission date + 13 calendar days) following admission.A comprehensive admission MDS assessment for Resident 10, dated January 15, 2026, revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on January 15, 2025, which was 28 days after admission.An…

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 the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's assessment was transmitted within 14 days of completing the assessment for one of 42 residents reviewed (Resident 179).Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2025, indicated that a quarterly MDS assessment was to be transmitted no later than 14 days (completion date + 14 calendar days).A review of the electronic health record for Resident 179 revealed the completion date for the required quarterly assessment was April 24, 2026, however the assessment had not been transmitted. Its status in the electronic health record was in process.An interview with the Registered Nurse Assessment Coordinator (Employee 3) on July 9, 2026, at approximately 11:45 a.m. confirmed…

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 Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for one of 42 residents reviewed (Residents 10).Findings include:The Long-Term Care Facility RAI User's Manual, which provides guidance and instructions for the completion of Minimum Data Set (MDS) assessments (a mandated assessment of a resident's abilities and care needs), dated October 2025, revealed that Section I was to be coded for diseases that have a direct relationship to the resident's current functional status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. Review of Resident 10's initial psychiatric evaluation, dated December 18, 2025, revealed Visit summary - Schizoaffective disorder, bipolar type - historic diagnosis. Alternative diagnosis of bipolar disorder charted - more likely schizoaffective based on history of precedence of psychotic symptoms (disorganized behavior, unusual affect, etc.) with mood symptoms secondary.…

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 observation, interview, and review of facility policy and records, it was determined that the facility failed to ensure the resident environment was free of accidents and hazards by failing to perform a complete investigation to determine the cause and pattern of the accident for one out of 43 residents reviewed (R191).Findings include: Review of facility policy Temperature Monitoring: Reheating of Food/Beverages, dated Jun 11, 2025 revealed: The purpose of this protocol is to provide guidance.regarding temperature monitoring for foods/beverages that are reheated for resident palatability; while minimizing the risk for unsafe food temperatures coupled with the mitigating of scalding and burn risk.Allow enough standing time for food and beverages to cool to prevent burns/scalds.Review of Resident 191's quarterly MDS (Minimum Data Set - a mandatory assessment of a resident's physical condition and care needs) dated April 30, 2026, revealed that Resident 191 was moderately cognitively impaired. Resident 191 required setup with eating and was dependent on facility staff to…

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 and observation, it was determined that the facility failed to ensure insulin vials were labeled with open and expiration dates for one of six medication carts reviewed (4 CLC B Medication Cart).Findings include:Review of facility policy and procedure titled Medication Labels, revised March 18, 2024, revealed Each prescription medication label includes resident's first and last name, specific directions for use, including route of administration, medication name, strength of medication, prescriber's name, date dispensed, quantity of medication and expiration date of medication. Observation of the 4 CLC B Medication Cart on July 9, 2026, at 12:18 p.m. revealed one open and undated vial of Lispro (long acting) Insulin (a hormone produced by the pancreas that regulates blood sugar levels by allowing cells to absorb glucose from the bloodstream) , one open and undated vial of Novolog (short acting) insulin and two opened and undated vials of Lantus (long acting) Insulin. The above information was conveyed to the Director of Nursing on…

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 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.