Pennsylvania Department of Health
SOUTHWESTERN VETERANS CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

SOUTHWESTERN VETERANS CENTER
Inspection Results For:

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SOUTHWESTERN VETERANS CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an abbreviated survey in response to one complaint and one event, completed on August 19, 2026, it was determined that Southwestern Veterans Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:

This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.

§483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Observations:

Based on review of facility policy, facility and clinical record documentation, and staff interviews, it was determined that the facility failed to ensure that one of two residents reviewed (Resident R2) was free of neglect during care which resulted in actual harm of a laceration (tear in the skin and underlying tissue) to the left forehead requiring five sutures (specialized threads or strands used to stitch together tissues following an injury or surgical procedure). This deficiency is cited as past non-compliance.

Findings include:

Review of facility policy "Freedom from Abuse, Neglect, Exploitation and Misappropriation of Resident Property" dated 1/16/26, indicated the purpose of protocol is to give guidance to provide protections for the health, safety, welfare, and rights of each resident residing in the facility by prohibiting and preventing abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, involuntary seclusion and any physical or chemical restraints not required to treat a resident's medical condition. The facility shall thoroughly investigate all allegations and include training for staff. The facility shall identify, correct and intervene in situations in which abuse, neglect, exploitation or misappropriation of resident property is more likely to occur. Identify, provide ongoing assessment, monitor and care plan appropriate interventions for residents with needs and behaviors which might lead to conflict or neglect.

Review of facility policy "Incident and Accident - Resident (Fall)" dated 1/16/26, indicated this protocol is to provide guidance to assist with maintaining the resident's safety and prevention of serious injury to the extent possible and to ensure a consistent and effective approach to the management and review of the fall itself.

A review of the Resident Assessment Instrument 3.0 User's Manual effective October 2025 indicated that a Brief Interview for Mental Status ("BIMS", a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions:
13-15: cognitively intact
8-12: moderately impaired
0-7: severe impairment

Review of Resident R2's admission record indicated that Resident R2 was admitted to the facility 6/9/26.

Review of Resident R2's Minimum Data Set (MDS - an assessment tool used to facilitate the management of care) assessment dated 6/15/26, indicated diagnoses of heart failure, heart disease, and lymphedema (condition characterized by swelling caused by an accumulation of fluid in the body's tissues). Further review of MDS indicated that Resident R2 is partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds, or supports truck and limbs, but provides less than half the effort. Further review of MDS indicated BIMS score of 15 "cognitively intact".

Review of physician orders indicated that on date 6/9/26, Resident R2 was ordered one assist for transfer with FWW (front-wheeled walker - mobility aid designed to provide support and stability for individuals who need assistance while walking), discontinued 8/2/26.

Review of Resident R2's plan of care with an Approach start date of 6/9/26, indicated that he/she is a 1-assist for transfers with FWW, edited 8/3/26, to transfer - STS (sit-to-stand lift - device designed to help individuals with reduced mobility who can still perform specific tasks by themselves or with limited staff assistance), sling size - large.

Review of Resident Roster (an easy reference of resident care needs for the nursing assistants to reference), indicated that on 7/3/26, Resident R2 is a 1-assit for transfers with FWW.

Review of Resident R2's clinical progress note dated 7/8/26, at 7:26 a.m., by Registered Nurse Supervisor (RNS) Employee E11, revealed that around 7:00 a.m., unit Registered Nurse (RN) reported that resident (R2) was on the floor in his room. Resident (R2) was lying face down to the right of his nightstand on the window side of his bed, feet towards the bed. There is a moderate amount of blood under his head area, and he has a towel. He is alert and verbally responding to questions. CRNP (Certified Registered Nurse Practioner) arrived and assessed resident (R2). There was no increased pain with movement. There was no deformity lengthening, or outward rotation of any extremities. He has a laceration above his left eye that now is no longer bleeding. 911 arrived and we transferred him to the stretcher. Resident (R2) off unit at around 7:23 a.m.

Further review of Resident R2's clinical progress note dated 7/8/26, at 8:38 a.m., by Certified Registered Nurse Practioner (CRNP) Employee E12, revealed resident (R2) evaluated today s/p (status post) accidental fall. On arrival to resident's (R2) room, he was lying on the floor face down. Alert and able to answer questions. Reports pain to left hip. No increased pain with palpitation. No deformity or instability on exam. Resident (R2) denied head, neck, or back pain. Was able to be rolled onto back with no increased pain. Laceration to forehead open but bleeding controlled. Assessment/Plan: 1. Fall with injury, 2. Longterm use of anticoagulation. Send to hospital for evaluation.

Further review of Resident R2's clinical progress note dated 7/8/26, at 7:45 p.m., revealed resident (R2) returned from the emergency department with discharge instructions indicating a laceration to the left outer forehead repaired with five non-absorbable sutures. No active bleeding was noted upon return. Monitor for healing progress and prepare for suture removal as recommended on day seven, unless otherwise directed by the provider.

Review of facility provided event report documentation dated 7/8/26, revealed Summary of Findings: Resident (R2) had a witnessed fall with a laceration to his head. Resident (R2) was being transferred with the assistance of one Nurse Aide (NA) but did not have his wheeled walker with him. He became unsteady and fell.

Review of facility provided investigation witness statement revealed Nurse Aide (NA) Employee E1 was interviewed by Assistant Director of Nursing (ADON) Employee E2 on 7/8/26, regarding care NA Employee E1 provided Resident R2 on 7/8/26, at time of fall. Witness statement revealed that NA Employee E1 admitted to using the Resident Roster, but when questioned about being aware that Resident R2 has a transfer order that includes a front-wheeled walker (FWW), NA Employee E1 responded "No." ADON Employee E2 further questioned NA Employee E1 as follows:
- "If you were using the roster, please explain why you didn't use the front-wheeled walker with transfer?" NA Employee answered, "I don't know."
- " Did you use a FWW when transferring this resident (R2) from bed to chair scale and when attempting to move him from the chair scale to the PWC (power wheelchair)?" Na Employee E1 answered, "No, I did not."

Review of documentation submitted by the facility dated 7/13/26, revealed that the facility initiated an investigation, regarding resident neglect on 7/8/26. Further review of submitted documents revealed that NA Employee E1, by her own admission, failed to utilize the proper transfer modality of the front-wheeled walker during the transfer which likely was a direct contributor to the fall, which resulted in the resident (R2) being sent to the emergency room for sutures. Allegation of neglect is substantiated. NA Employee E1 was an agency NA and her contract was terminated immediately.

During an interview on 8/19/26, at 3:30 p.m., with the Nursing Home Administrator (NHA), Assistant Nursing Home Administrator (ANHA) Employee E10, Quality Assurance (QA) Employee E3, and ADON Employee E4, information was disseminated that NA Employee E1 failed to implement the use of a FWW when transferring Resident R2 from chair scale to PWC on 7/8/26, resulting a fall and a laceration to Resident R2 forehead requiring sutures.

The facility failed to ensure that Resident R2 was free of neglect during care which resulted in actual harm of a laceration to the left forehead requiring five sutures.

This deficiency is cited as past non-compliance.

On 7/8/26, the facility initiated an investigation into a witnessed fall of Resident R2, resulting in a forehead laceration. Facility identified that Resident R2's Resident Roster and care plan contained the correct transfer status of assist times 1 with FWW. When Resident R2 returns from the hospital, his care plan will be reviewed and updated with any new interventions. NA Employee E1 was identified as the perpetrator and their agency contract was terminated upon completion of investigation.

Residents who utilize one person assist with FWW for transfers had their Resident Rosters and care plans reviewed for accuracy. Residents were interviewed to determine if they have any concerns with their ordered transfer status.

All nursing staff to include Registered Nurses (RN's), Licensed Practical Nurse (LPN's) and NA's were re-educated on how to implement correct resident transfer orders and on what constitutes abuse/neglect when failing to follow the residents designated care plan.

Random audits were initiated of residents requiring FWW for transfers to ensure the correct transfer method is being utilized. Audits are to be completed by the Registered Nurse Supervisor (RNS) or designee daily times seven days, week times 4 weeks, and monthly times 2 months. Audits will be forwarded to the QAPI committee for review and recommendations. Ad hoc QAPI committee meeting held on 7/9/26, and quarterly QAPI meeting held 7/16/26.

Interviews conducted with NA Employees E5, E6, E7, E8, and E9, confirmed that the facility initiated education on 7/9/26, which included how to implement correct resident transfer orders, locations of resident transfer status, and on what constitutes abuse/neglect when failing to follow the residents designated care plan.

During an interview with the NHA, ANHA Employee E10, QA Employee E3, and ADON Employee E4 on 8/19/26, at 3:30 p.m., and review of the facility's immediate actions, education, audits, and QAPI monitoring process to sustain solutions, it was verified that the facility had implemented a plan of correction to ensure residents are free from neglect during care and had achieved substantial compliance as of 7/17/26.

28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1)(e)(1) Management
28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 09/01/2026

Past noncompliance: no plan of correction required.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:

Based on review of facility policy, facility and clinical record documentation, and staff interviews, it was determined that the facility failed to provide adequate supervision and implement effective transfer interventions as per physician order to promote resident safety, resulting in a preventable accident and actual harm when the resident received a laceration (tear in the skin and underlying tissue) to the left forehead requiring five sutures (specialized threads or strands used to stitch together tissues following an injury or surgical procedure), for one of two residents reviewed (Resident R2). This deficiency is cited as past non-compliance.

Findings include:

Review of facility policy "Incident and Accident - Resident (Fall)" dated 1/16/26, indicated this protocol is to provide guidance to assist with maintaining the resident's safety and prevention of serious injury to the extent possible and to ensure a consistent and effective approach to the management and review of the fall itself.

A review of the Resident Assessment Instrument 3.0 User's Manual effective October 2025 indicated that a Brief Interview for Mental Status ("BIMS", a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions:
13-15: cognitively intact
8-12: moderately impaired
0-7: severe impairment

Review of Resident R2's admission record indicated that Resident R2 was admitted to the facility 6/9/26.

Review of Resident R2's Minimum Data Set (MDS - an assessment tool used to facilitate the management of care) assessment dated 6/15/26, indicated diagnoses of heart failure, heart disease, and lymphedema (condition characterized by swelling caused by an accumulation of fluid in the body's tissues). Further review of MDS indicated that Resident R2 is partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds, or supports truck and limbs, but provides less than half the effort. Further review of MDS indicated BIMS score of 15 "cognitively intact".

Review of physician orders indicated that on date 6/9/26, Resident R2 was ordered one assist for transfer with FWW (front-wheeled walker - mobility aid designed to provide support and stability for individuals who need assistance while walking), discontinued 8/2/26.

Review of Resident R2's plan of care with an Approach start date of 6/9/26, indicated that he/she is a 1-assist for transfers with FWW, edited 8/3/26, to transfer - STS (sit-to-stand lift - device designed to help individuals with reduced mobility who can still perform specific tasks by themselves or with limited staff assistance), sling size - large.

Review of Resident Roster (an easy reference of resident care needs for the nursing assistants to reference), indicated that on 7/3/26, Resident R2 is a 1-assit for transfers with FWW.

Review of Resident R2's clinical progress note dated 7/8/26, at 7:26 a.m., by Registered Nurse Supervisor (RNS) Employee E11, revealed that around 7:00 a.m., unit Registered Nurse (RN) reported that resident (R2) was on the floor in his room. Resident (R2) was lying face down to the right of his nightstand on the window side of his bed, feet towards the bed. There is a moderate amount of blood under his head area, and he has a towel. He is alert and verbally responding to questions. CRNP (Certified Registered Nurse Practioner) arrived and assessed resident (R2). There was no increased pain with movement. There was no deformity lengthening, or outward rotation of any extremities. He has a laceration above his left eye that now is no longer bleeding. 911 arrived and we transferred him to the stretcher. Resident (R2) off unit at around 7:23 a.m.

Further review of Resident R2's clinical progress note dated 7/8/26, at 8:38 a.m., by Certified Registered Nurse Practioner (CRNP) Employee E12, revealed resident (R2) evaluated today s/p (status post) accidental fall. On arrival to resident's (R2) room, he was lying on the floor face down. Alert and able to answer questions. Reports pain to left hip. No increased pain with palpitation. No deformity or instability on exam. Resident (R2) denied head, neck, or back pain. Was able to be rolled onto back with no increased pain. Laceration to forehead open but bleeding controlled. Assessment/Plan: 1. Fall with injury, 2. Longterm use of anticoagulation. Send to hospital for evaluation.

Further review of Resident R2's clinical progress note dated 7/8/26, at 7:45 p.m., revealed resident (R2) returned from the emergency department with discharge instructions indicating a laceration to the left outer forehead repaired with five non-absorbable sutures. No active bleeding was noted upon return. Monitor for healing progress and prepare for suture removal as recommended on day seven, unless otherwise directed by the provider.

Review of facility provided event report documentation dated 7/8/26, revealed Summary of Findings: Resident (R2) had a witnessed fall with a laceration to his head. Resident (R2) was being transferred with the assistance of one Nurse Aide (NA) but did not have his wheeled walker with him. He became unsteady and fell.

Review of facility provided investigation witness statement revealed Nurse Aide (NA) Employee E1 was interviewed by Assistant Director of Nursing (ADON) Employee E2 on 7/8/26, regarding care NA Employee E1 provided Resident R2 on 7/8/26, at time of fall. Witness statement revealed that NA Employee E1 admitted to using the Resident Roster, but when questioned about being aware that Resident R2 has a transfer order that includes a front-wheeled walker (FWW), NA Employee E1 responded "No." ADON Employee E2 further questioned NA Employee E1 as follows:
- "If you were using the roster, please explain why you didn't use the front-wheeled walker with transfer?" NA Employee answered, "I don't know."
- " Did you use a FWW when transferring this resident (R2) from bed to chair scale and when attempting to move him from the chair scale to the PWC (power wheelchair)?" Na Employee E1 answered, "No, I did not."

Review of documentation submitted by the facility dated 7/13/26, revealed that the facility initiated an investigation, regarding resident neglect on 7/8/26. Further review of submitted documents revealed that NA Employee E1, by her own admission, failed to utilize the proper transfer modality of the front-wheeled walker during the transfer which likely was a direct contributor to the fall, which resulted in the resident (R2) being sent to the emergency room for sutures. Allegation of neglect is substantiated. NA Employee E1 was an agency NA and her contract was terminated immediately.

During an interview on 8/19/26, at 3:30 p.m., with the Nursing Home Administrator (NHA), Assistant Nursing Home Administrator (ANHA) Employee E10, Quality Assurance (QA) Employee E3, and ADON Employee E4, information was disseminated that NA Employee E1 failed to implement the use of a FWW when transferring Resident R2 from chair scale to PWC on 7/8/26, resulting a fall and a laceration to Resident R2 forehead requiring sutures.

The facility failed to ensure that Resident R2 received adequate supervision and implement effective transfer interventions as per physician order, resulting in actual harm when the resident fell and received a laceration to the left forehead requiring five sutures from an improper transfer which required a FWW.

This deficiency is cited as past non-compliance.

On 7/8/26, the facility initiated an investigation into a witnessed fall of Resident R2, resulting in a forehead laceration. Facility identified that Resident R2's Resident Roster and care plan contained the correct transfer status of assist times 1 with FWW. When Resident R2 returns from the hospital, his care plan will be reviewed and updated with any new interventions. NA Employee E1 was identified as the perpetrator and their agency contract was terminated upon completion of investigation.

Residents who utilize one person assist with FWW for transfers had their Resident Rosters and care plans reviewed for accuracy. Residents were interviewed to determine if they have any concerns with their ordered transfer status.

All nursing staff to include Registered Nurses (RN's), Licensed Practical Nurse (LPN's) and NA's were re-educated on how to implement correct resident transfer orders and on what constitutes abuse/neglect when failing to follow the residents designated care plan.

Random audits were initiated of residents requiring FWW for transfers to ensure the correct transfer method is being utilized. Audits are to be completed by the Registered Nurse Supervisor (RNS) or designee daily times seven days, week times 4 weeks, and monthly times 2 months. Audits will be forwarded to the QAPI committee for review and recommendations. Ad hoc QAPI committee meeting held on 7/9/26, and quarterly QAPI meeting held 7/16/26.

Interviews conducted with NA Employees E5, E6, E7, E8, and E9, confirmed that the facility initiated education on 7/9/26, which included how to implement correct resident transfer orders, locations of resident transfer status, and on what constitutes abuse/neglect when failing to follow the residents designated care plan.

During an interview with the NHA, ANHA Employee E10, QA Employee E3, and ADON Employee E4 on 8/19/26, at 3:30 p.m., and review of the facility's immediate actions, education, audits, and QAPI monitoring process to sustain solutions, it was verified that the facility had implemented a plan of correction to ensure residents are free from accidents/incidents regarding transfer status of residents and had achieved substantial compliance as of 7/17/26.

28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1)(e)(1) Management
28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 09/01/2026

Past noncompliance: no plan of correction required.

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