Pennsylvania Soldiers and Sailors Home

In the surveyor’s words

From the most serious findings on record at Pennsylvania Soldiers and Sailors Home, in the surveyor’s own words.

• Immediate jeopardy, patternF689May 16, 2023

  Based on review of clinical records, facility documentation, policy and procedures, and staff interviews, it was determined that the facility failed to safely administer electrical stimulation (E-Stim- sends mild electrical pulses through the skin to help stimulate injured muscles or manipulate nerves to reduce pain) during therapy that resulted in second degree burns (includes blisters, a darker tone and a shiny, moist appearance) to two of 11 residents (Resident R1, R2), and failed to remove faulty equipment from service and created an Immediate Jeopardy situation for nine other residents (Residents R3-R11) for E-Stim therapy. […]

• No harm, potential for more than minimal, patternF628Mar 13, 2026

  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… […]

• No harm, potential for more than minimal, patternF835May 16, 2023

  Based on review of facility records and job descriptions, it was determined that the Commandant (Nursing Home Administrator) and Director of Nursing (DON) failed to effectively manage the facility to make certain that proper safety procedures were implemented by staff to prevent actual harm/injury to residents during the administration of electrical stimulation (e-stim- sends mild electrical pulses through the skin to help stimulate injured muscles or manipulate nerves to reduce pain) during therapy. […]

• No harm, potential for more than minimal, isolatedF605Mar 13, 2026

  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]. […]

• No harm, potential for more than minimal, isolatedF684Mar 13, 2026

  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. […]