Pennsylvania Soldiers And Sailors Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Erie, Pennsylvania.
- Location
- 560 East Third St, Erie, Pennsylvania 16512
- CMS Provider Number
- 39A434
- Inspections on file
- 20
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Pennsylvania Soldiers And Sailors Home during CMS and state inspections, most recent first.
The facility failed to follow physician's orders for oxygen administration and did not maintain cleanliness of respiratory equipment for three residents. A resident received oxygen at a higher rate than prescribed, while two residents had dusty oxygen concentrators, indicating a lack of adherence to maintenance protocols.
A facility failed to document a clinical rationale for extending a PRN anti-anxiety psychotropic medication beyond the 14-day limit for a resident with multiple diagnoses, including dementia. The facility's policy requires such documentation, but the Nursing Home Administrator confirmed its absence for the resident's Xanax prescription.
The facility failed to properly store food in a resident pantry on Unit A, as observed in one of the two refrigerators reviewed. Several food items, including snap peas, blackberries, pepper rings, and mixed vegetables, were found improperly labeled or beyond their use-by dates. Staff interviews confirmed these deficiencies, highlighting a failure to adhere to the facility's food storage policy.
The facility failed to monitor and prevent Legionella in its water system. A positive result for Legionella non-pneumophila species was found in a kitchenette faucet, but no further testing was conducted after the initial finding. Interviews confirmed that necessary follow-up testing was not performed to ensure water safety.
The facility failed to ensure that a resident with Alzheimer's disease, anxiety, and essential tremor was transferred using the prescribed knee lift. Instead, a nurse aide physically lifted the resident, contrary to the care plan and physician's orders. This incident was confirmed by the Nursing Home Commandant, and the aide was suspended pending investigation.
The facility failed to review and/or revise care plans for two residents with multiple diagnoses, including paraplegia, dementia, and diabetes. The care plans, covering various problem categories, had outstanding target dates, and this was confirmed by the Registered Nurse Assessment Coordinator.
Failure to Adhere to Oxygen Orders and Equipment Cleanliness
Penalty
Summary
The facility failed to provide oxygen according to physician's orders and did not maintain cleanliness of respiratory care equipment for three residents. Resident R6, diagnosed with COPD, high blood pressure, and anxiety, had a physician's order for oxygen at 2 liters per minute (lpm) via nasal cannula as needed for shortness of breath. However, an observation revealed that the oxygen concentrator was set at 4 lpm, contrary to the physician's order. This discrepancy was confirmed by an LPN during an interview. Additionally, Residents R30 and R38, both with COPD and other health conditions, were observed with dusty oxygen concentrators and filters, indicating a failure to adhere to the facility's policy of weekly cleaning. Resident R30's concentrator had a gray dusty substance on the filter and a dried white substance on the concentrator itself. Similarly, Resident R38's concentrator was dusty with dried white and brown substances. These observations were confirmed by staff interviews, highlighting a lack of adherence to prescribed maintenance protocols for respiratory equipment.
Failure to Document Clinical Rationale for Extended PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a PRN anti-anxiety psychotropic medication had a clinical rationale identified for use beyond the 14-day limitation for one resident. The facility's policy, dated March 2023, mandates that PRN orders for psychotropic medications be limited to 14 days unless a physician provides a rationale for extending the medication. Resident R4, who has diagnoses including dementia, aneurysm of the iliac artery, benign neoplasm of the colon, and benign prostatic hyperplasia, had a physician's order for Xanax 0.25 mg by mouth every one-hour PRN for anxiety or shortness of breath, dated July 29, 2024. During an interview, the Nursing Home Administrator confirmed the absence of documented clinical rationale by the physician for extending Resident R4's PRN Xanax usage beyond the 14-day limit.
Improper Food Storage in Resident Pantry
Penalty
Summary
The facility failed to ensure proper food storage in a resident pantry, specifically in one of the two refrigerators reviewed on Unit A. The facility policy requires that perishable food brought in by residents be labeled with the resident's name, date, and time, and stored in the unit refrigerator for no more than 24 hours unless it is not a leftover, in which case it can be stored until the package expiration date. However, during an observation, it was found that three zip lock bags containing snap peas were improperly stored; two bags were dated 1/21/25, and one lacked a date. One of the bags contained snap peas that were soft with a liquid substance at the bottom. Additionally, a plastic container of blackberries lacked a name and date, a jar of pepper rings had a date of 9/9/24 with no expiration date, and a jar of mixed vegetables lacked both a date and an expiration date. Interviews with staff confirmed these deficiencies. A Nursing Assistant acknowledged that the snap peas were beyond their use-by date and that the blackberries, pepper rings, and mixed vegetables were not properly labeled or dated. The Director of Nursing also confirmed that food items in the resident refrigerator should be labeled with a resident's name and opened date and should be discarded by their use-by date. These findings indicate a failure to adhere to the facility's food storage policy, potentially compromising food safety.
Failure to Monitor and Prevent Legionella in Water System
Penalty
Summary
The facility failed to ensure proper monitoring and prevention measures for Legionella in its water system. A review of the facility's policy on the prevention of healthcare-associated Legionella disease indicated that any positive detection of L. pneumophila requires immediate remedial action and subsequent retesting to confirm the effectiveness of the remediation. However, the facility's water management records revealed a positive result for Legionella non-pneumophila species in the kitchenette faucet on Unit B's first floor. Despite this finding, there was no evidence of further testing conducted after the initial positive result. Interviews with the Facility and Grounds Director and the Nursing Home Administrator confirmed that the facility did not perform the necessary follow-up testing after the positive Legionella result. The Facility and Grounds Director acknowledged that the water system was flushed with a bleach/water solution, but no subsequent testing was conducted to ensure the safety of the water. The Nursing Home Administrator also confirmed that testing should have been completed promptly to ensure the water's safety for all facility users.
Failure to Follow Transfer Protocols Resulting in Neglect
Penalty
Summary
The facility failed to ensure that Resident R11 was free from neglect during care. Resident R11, who has Alzheimer's disease, anxiety, and essential tremor, was dependent on staff for transfers and had an active physician order for transfers using a knee lift with a medium sling. However, on 4/20/24, Nurse Aide (NA) Employee E2 physically lifted Resident R11 from the chair without using the knee lift as ordered. This action was confirmed by the Nursing Home Commandant during an interview on 4/25/24. The facility's investigation revealed that NA Employee E2 transferred Resident R11 by placing one arm under the resident's knees and one arm behind the resident's back, which was against the care plan. The facility initiated an investigation on 4/20/24 and suspended NA Employee E2 pending the investigation. The Nursing Home Commandant confirmed that the resident should have been transferred using the knee lift as per the care plan and physician's orders.
Failure to Review and Revise Care Plans
Penalty
Summary
The facility failed to review and/or revise resident care plans for two residents, R27 and R57, as required by their policy. Resident R27, who has diagnoses including paraplegia, high blood pressure, and diabetes, had an outstanding target date for the review of their pressure ulcer care plan. Similarly, Resident R57, with diagnoses including dementia, diabetes, and congestive heart failure, had 22 out of 24 care plans with outstanding target dates. These care plans covered various problem categories such as ADL function, communication, psychosocial well-being, cognitive loss, behavioral symptoms, mood state, psychotropic drug use, pain, falls, and urinary incontinence. During an interview, the Registered Nurse Assessment Coordinator confirmed that the care plans for both residents were not reviewed and/or revised as required. This failure to update the care plans was in violation of the facility's policy, which mandates that comprehensive care plans be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Facility staff failed to follow dialysis care policies and the care plan for a resident with diabetes mellitus, chronic kidney disease, and an upper extremity hemodialysis fistula. Despite clear directions to avoid using the arm with the dialysis access for any treatment, including blood pressure measurement, staff repeatedly documented taking blood pressure on that arm over multiple months. The DON later confirmed that the resident’s blood pressure had been measured on the arm containing the dialysis access.
A resident admitted with PTSD, depression, polyneuropathy, and insomnia, and assessed as having no cognitive impairment but needing substantial assistance with ADLs, was not evaluated for PTSD-related symptoms or triggers. The care plan did not address the resident’s trauma history, identify triggers, or include specific interventions to minimize triggers or re-traumatization. The DON confirmed that no PTSD assessment or related care planning had been completed, resulting in a deficiency in required nursing services.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Improper Blood Pressure Measurement on Dialysis Access Arm
Penalty
Summary
Facility staff failed to provide appropriate dialysis-related care by not adhering to policy and the resident’s care plan regarding protection of a hemodialysis access site. The facility’s policy on hemodialysis external catheter evaluation and maintenance, last reviewed February 24, 2026, directed staff to avoid taking blood pressure from an arm with a dialysis access device. The resident, who had diabetes mellitus with chronic kidney disease and required ongoing hemodialysis, had a care plan initiated November 11, 2021 and last reviewed December 17, 2025 that instructed staff to monitor the left upper extremity fistula for bleeding and to avoid using that arm for any treatment to prevent complications related to dialysis access. Despite these directives, clinical record review showed that staff documented taking the resident’s blood pressure on the left arm 10 times in January 2026, 10 times in February 2026, 14 times in March 2026, and four times in April 2026. In an interview on April 17, 2026, the Director of Nursing confirmed that the documentation showed the resident’s blood pressure had been measured on the left arm containing the dialysis access. These findings were cited under 28 Pa. Code 211.10(d) Resident care policies and 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
Failure to Assess and Care Plan for Resident with PTSD
Penalty
Summary
Surveyors identified that the facility failed to provide trauma-informed, person-centered care for a resident with a documented diagnosis of post-traumatic stress disorder (PTSD). The resident was admitted with PTSD, depression, polyneuropathy, and insomnia, and a Minimum Data Set assessment showed no cognitive impairment, a need for substantial assistance with activities of daily living, and a confirmed PTSD diagnosis. Despite this, the clinical record contained no documentation that the resident had been assessed for PTSD-related symptoms or triggers, and the resident’s care plan lacked any measures addressing the history of trauma, identifying triggers, or specifying interventions to minimize triggers or re-traumatization. In an interview, the Director of Nursing confirmed that the resident had not been assessed or care planned for PTSD, in violation of 28 Pa. Code 211.12(d)(3)(5) regarding nursing services.
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