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 findings of an abbreviated event survey completed on September 24, 2025, 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 documentation and clinical record, and resident and staff interviews, it was determined that the facility failed to ensure that one of two residents reviewed (Resident R1) was free of neglect during care which resulted in actual harm of a fracture of left femur (thigh bone).

Findings include:

Review of facility policy "Freedom from Abuse, Neglect, Exploitation and Misappropriation of Resident Property" dated 1/16/25, 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 "Transfer Devices" dated 1/16/25, indicated this protocol is to provide guidance for the facility regarding enhancing the residents'' quality of life, with the increased development of culture change, to the best abilities possible with resident agreement and tolerance by encouraging safe resident transfer independence while decreasing potential for injury to residents and staff. For the safety of the resident and staff, the facility incorporates the use of mechanical lifts, sliding boards, and other safety devices as ordered and when necessary, to assist with transfers to assist the resident with maintaining and achieving their highest practical level of care. Definition: Full Body Lift (Mechanical lift; Electric lift): Devices used to move residents who are unable to stand on their own or complete a transfer with staff assistance safely. Lift completes resident transfer from one surface to another. The facility maintains a no manual lift directive to minimize risk of injury to the resident and staff. When a resident has total dependance or requires extensive assistance of staff for transfers, a full body mechanical lift is the safest device for the resident and staff to utilize. Full body mechanical lifts with corresponding lift slings will be operated according to referenced manufacturer's guidelines.

A review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019 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 R1's admission record indicated that Resident R1 was admitted to the facility 6/26/24.

Review of Resident R1's Minimum Data Set (MDS - an assessment tool used to facilitate the management of care) assessment dated 6/19/25, indicated diagnoses of diabetes mellitus (chronic condition characterized by high blood sugar levels due to the body's inability to produce or effectively use insulin), end stage renal disease (final stage of chronic kidney disease, where kidneys can no longer function adequate, requiring dialysis or a kidney transplant for survival), and hepatitis C (viral infection that causes liver inflammation which could lead to liver damage). Further review of MDS indicated that Resident R1 is dependent for chair/bed-to-chair transfers in which helper does all of the effort; resident does none of the effort to complete the activity; Or the assistance of two or more helpers is required for the resident to complete the activity. Further review of MDS indicated BIMS score of 13 "cognitively intact".

Review of physician orders indicated that on date 6/28/24, Resident R1 was ordered Transfers: Full mechanical lift.

Review of Resident R1's care plan with an Approach start date of 11/4/21, indicated the he/she is a two person transfer with mechanical lift.

Review of Resident Roster (an easy reference of resident care needs for the nursing assistants to reference), indicated that on 8/11/25, Resident R1 is to be transferred using a HOYER (a device that helps caregivers transfer patients with limited mobility from one place to another) 2 assist with large sling.

Review of Resident R1's clinical progress note dated 8/9/25, at 5:07 p.m., revealed resident (R1) complained 10/10 pain to his left stump that is unrelieved by PRN (as needed) Tylenol. Residents left stump warm to touch and swelling noted. MD (doctor) called to inform of resident's condition, and gave verbal telephone order to send resident to the emergency room for evaluation.

Further review of clinical nursing progress note dated 8/11/25, at 6:30 p.m., revealed Resident R1 returned from hospital via stretcher at 6:07 p.m.

Further review of clinical physician services progress note dated 8/12/25, at 8:02 a.m., revealed that Resident R1 was found to have an acute comminuted (type of bone fracture where the bone is broken in three or more pieces) impacted and angulated (type of bone fracture that when a bone breaks and the ends of the bone fragments are not aligned) fracture of the distal left femur.

Review of facility provided investigation witness statement revealed Nurse Aide (NA) Employee E1 was interviewed by Assistant Director of Nursing (ADON) Employee E2 on 8/11/25, regarding care NA Employee E1 provided Resident R1 on 8/9/25. Witness statement revealed that NA Employee E1 admitted to physically picking Resident R1 up from his bed and placed him into his wheelchair. When asked by ADON Employee E2 if a Hoyer lift was used with a second person, NA Employee E1 stated "No".

Review of documentation submitted by the facility dated 8/14/25, revealed that the facility initiated an investigation, regarding resident neglect on 8/11/25. Further review of submitted documents revealed NA Employee E1 admitted that she failed to transfer Resident R1 utilizing the ordered transfer method (mechanical lift) and instead transferred him manually (by picking him up). Further review revealed that the facility cancelled NA Employee E1's contract because she did not follow facility policy when transferring a resident from his bed to his wheelchair.

During an interview on 9/24/25, at 10:35 a.m., Quality Assurance (QA) Employee E3 confirmed that NA Employee E1 failed to transfer a resident properly who required a full body mechanical lift with a Hoyer device.

During an interview on 9/24/25, at 3:15 p.m. with the Nursing Home Administrator (NHA) and DON it was confirmed that the facility failed to ensure that Resident R1 was free of neglect during care which resulted in actual harm of a fracture of left femur (thigh bone).

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) Nursing services
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 10/23/2025

R1's resident roster and care plan did contain accurate information for his transfer status utilizing a mechanical lift. C.N.A had all required trainings and competencies completed prior to working on the floor in facility. C.NA involved in incident was suspended pending investigation. ERS/APS/PB22 were completed. C.N.A contract was cancelled and no longer works at facility.

Like residents who utilize a mechanical lift for transfer will be interviewed using a question from the CMS abuse critical pathway. Residents who cannot be interviewed will have a skin assessment completed and documented

Directed in-services will be completed by contracted vendor/designee on F600 Free from abuse and neglect with facility wide staff. Directed inservices are scheduled for 10/15/25 and 10/16/2025 by Affinity Health Services

Random audits will be completed of 5 residents requiring a mechanical lift for transfers to ensure the correct transfer method is being utilized. Audits will be completed by the RNS/designee weekly x4 weeks and monthly X2 months.

Random audits will be completed on 5 residents using a question from the CMS abuse critical pathway for those resident who are interviewable or a skin assessment for those resident who are non interviewable. Audits will be completed by the RNS/designee weekly x4 weeks and monthly X2 months.

Audits will be forwarded to the QAPI committee for review and recommendations

Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, of professional malpractice or for purposes of any judicial or administrative proceeding.

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, clinical records, facility 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 fracture of the left femur, for one of two residents reviewed (Resident R1). This deficiency is cited as past non-compliance.

Findings include:

Review of facility policy "Transfer Devices" dated 1/16/25, indicated this protocol is to provide guidance for the facility regarding enhancing the residents' quality of life, with the increased development of culture change, to the best abilities possible with resident agreement and tolerance by encouraging safe resident transfer independence while decreasing potential for injury to residents and staff. For the safety of the resident and staff, the facility incorporates the use of mechanical lifts, sliding boards, and other safety devices as ordered and when necessary, to assist with transfers to assist the resident with maintaining and achieving their highest practical level of care. Definition: Full Body Lift (Mechanical lift; Electric lift): Devices used to move residents who are unable to stand on their own or complete a transfer with staff assistance safely. Lift completes resident transfer from one surface to another. The facility maintains a no manual lift directive to minimize risk of injury to the resident and staff. When a resident has total dependance or requires extensive assistance of staff for transfers, a full body mechanical lift is the safest device for the resident and staff to utilize. Full body mechanical lifts with corresponding lift slings will be operated according to referenced manufacturer's guidelines.

A review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019 indicated that a Brief Interview for Mental Status ("BIMS", a screening test that aids 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 R1's admission record indicated that Resident R1 was admitted to the facility 6/26/24.

Review of Resident R1's Minimum Data Set (MDS - an assessment tool used to facilitate the management of care) assessment dated 6/19/25, indicated diagnoses of diabetes mellitus (chronic condition characterized by high blood sugar levels due to the body's inability to produce or effectively use insulin), end stage renal disease (final stage of chronic kidney disease, where kidneys can no longer function adequate, requiring dialysis or a kidney transplant for survival), and hepatitis C (viral infection that causes liver inflammation which could lead to liver damage). Further review of MDS indicated that Resident R1 is dependent for chair/bed-to-chair transfers in which helper does all of the effort; resident does none of the effort to complete the activity; Or the assistance of two or more helpers is required for the resident to complete the activity. Further review of MDS indicated BIMS score of 13 "cognitively intact".

Review of physician orders indicated that on date 6/28/24, Resident R1 was ordered Transfers: Full mechanical lift.

Review of Resident R1's care plan with an Approach start date of 11/4/21, indicated he/she is a two person transfer with mechanical lift.

Review of Resident Roster (an easy reference of resident care needs for the nursing assistants to reference), indicated that on 8/11/25, Resident R1 is to be transferred using a HOYER (device that helps caregivers transfer patients with limited mobility from one place to another) 2 assist with large sling.

Review of Resident R1's clinical progress note dated 8/9/25, at 5:07 p.m., revealed resident (R1) complained 10/10 pain to his left stump that is unrelieved by PRN (as needed) Tylenol. Residents left stump warm to touch and swelling noted. MD (doctor) called to inform of resident's condition and gave verbal telephone order to send resident to the emergency room for evaluation.

Further review of clinical nursing progress note dated 8/11/25, at 6:30 p.m., revealed Resident R1 returned from hospital via stretcher at 6:07 p.m.

Further review of clinical physician services progress note dated 8/12/25, at 8:02 a.m., revealed that Resident R1 was found to have an acute comminuted (type of bone fracture where the bone is broken in three or more pieces) impacted and angulated (type of bone fracture that when a bone breaks and the ends of the bone fragments are not aligned) fracture of the distal left femur.

Review of facility provided investigation witness statement revealed Nurse Aide (NA) Employee E1 was interviewed by Assistant Director of Nursing (ADON) Employee E2 on 8/11/25, regarding care NA Employee E1 provided Resident R1 on 8/9/25. Witness statement revealed that NA Employee E1 admitted to physically picking Resident R1 up from his bed and placed him into his wheelchair. When asked by ADON Employee E2 if a Hoyer lift was used with a second person, NA Employee E1 stated "No".

Review of documentation submitted by the facility dated 8/14/25, revealed that the facility initiated an investigation, regarding resident neglect on 8/11/25. Further review of submitted documents revealed NA Employee E1 admitted that she failed to transfer Resident R1 utilizing the ordered transfer method (mechanical lift) and instead transferred him manually (by picking him up). Further review revealed that the facility cancelled NA Employee E1's contract because she did not follow facility policy when transferring a resident from his bed to his wheelchair.

During an interview on 9/24/25, at 10:35 a.m., Quality Assurance (QA) Employee E3 confirmed that NA Employee E1 failed to transfer a resident properly who required a full body mechanical lift with a Hoyer device and two staff members.

The facility failed to ensure that Resident R1 received adequate supervision and implemented proper transfer interventions resulting in actual harm of a fracture of the distal left femur from the improper transfer which required the use of a full body mechanical lift.

This deficiency is cited as past non-compliance.

On 8/11/25, facility was notified that Resident R1 was diagnosed with left femur fracture. Investigation was initiated. Facility identified that Resident R1's Resident Roster and care plan reflected correct transfer status utilizing a mechanical lift. Resident R1 to be re-evaluated on readmission to facility. NA Employee E1 was identified as potential perpetrator and facility suspended her/him pending investigation outcome.

Residents who utilize mechanical lifts for transfers had their Resident Rosters and care plans reviewed for accuracy. Physician orders, Resident Rosters, and care plans were updated accordingly based on review.

All nursing staff to include Registered Nurses (RN'S), Licensed Practical Nurse (LPN's) and NA's were re-education on how to implement correct patient transfer status, and what constitutes neglect when failing to follow the patients designated plan of care. Education provided required posttest completion for accuracy of understanding.

Random audits were initiated to ensure the correct transfer method is being utilized for residents requiring mechanical lift for transfer. 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.

Interviews with RN Employee E4 and E5, LPN Employee E6, and NA Employees E7, E8, and E9 on 9/24/25, confirmed that the facility-initiated education on 8/11/24, which included reporting abuse, neglect, and exploitation timely, following proper transfer protocols, and how to check a residents current transfer status.

During an interview with the Nursing Home Administrator (NHA) and DON on 9/24/25, at 3:15 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 8/14/25.

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) Nursing services
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 10/09/2025

Past noncompliance: no plan of correction required.

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