Southeastern Pennsylvania Veteran's Center

In the surveyor’s words

From the most serious findings on record at Southeastern Pennsylvania Veteran's Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689May 9, 2025

  Based on observation, review of the facility's policy and procedures, facility documentation, clinical records, and staff interviews, it was determined the facility failed to ensure direct care staff were educated on the safe food heating/reheating process. This failure resulted in Immediate Jeopardy situation when it was determined a licensed nurse whom the facility failed to educate regarding safe food heating protocol failed to check the temperature of ramen soup after heating it in a microwave resulting in Resident 78 sustaining a second-degree burn to the chest. Failure of the facility to provide education to all direct care staff regarding safe food heating resulted in a situation that jeopardized the health and safety of Resident 78. […]

• Actual harm, isolatedF760Oct 7, 2025

  Based on a review of the facility's policy, observation, and interviews with residents and staff, it was determined that the facility failed to ensure the resident was administered the correct medications for one of three residents reviewed (Resident 1). The error resulted in harm and hospitalization due to the medications' side effects. This was a past non-compliance.Findings include: A review of the facility's policy and procedure titled Medication Administration, dated May 1, 2025, revealed that the licensed nurse preparing the medications for administration will follow the six rights of medication administration: right resident, right medication, right dose, right route, right time, and right documentation. […]

• Actual harm, isolatedF600Jul 1, 2025

  Based on facility policy and procedure review, staff and resident interviews, facility documentation review, and clinical record review it was determined the facility failed to ensure that one of 55 residents was free from neglect during care resulting in actual harm causing skin laceration, subdural hematoma, and cervical fractures requiring hospitalization. This deficiency is cited as past noncompliance. (Resident 1) Findings Include: Review of facility policy and procedure titled, Freedom form Abuse, Neglect Exploitation and Misappropriation revised May 7, 2025, revealed the definition of Neglect as the failure of the home, its employees or service providers to provide goods and services to a resident that are necessary to avoid physician harm, pain, mental anguish, or emotional… […]

• Actual harm, isolatedF760Mar 22, 2023

  Based on review of facility policy, clinical record, and interview; it was determined that the facility failed to ensure resident was free from significant medication error by administering heart medication outside of physician directed parameters which resulted in harm of hospitalization for one of ten residents reviewed (Resident R1). Findings include: Review of facility policy titled Medication Administration-General, with revision date of May 2015, indicated on page 2, section B(2) Medication are administered in accordance with written orders of the attending Medical provider. […]

• Actual harm, isolatedF689Dec 14, 2022

  Based on policy review, clinical record review and interviews with the staff, it was determined that the facility failed to provide supervision for one resident (Resident R1) for hot liquids sustaining a burn which is being cited as past non-compliance. Findings include: Review of the facility policy titled Food/Beverage Reheating Process revealed temperatures of any hot food/beverage items are to be at least 140 degrees F (Fahrenheit) and not exceed 165 degrees F. If the temperature is above 165 degrees F, the beverage should stand until cooling has occurred below the 165 degrees F temperature. […]