Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pennsylvania Soldiers And Sailors Home during CMS and state inspections, most recent first.
Failure to Send Required Transfer Information to Hospital: The facility did not ensure that required clinical information was communicated to the receiving provider when three residents were transferred to the hospital. The records for residents with diagnoses including HTN, chronic pain, heart disease, HLD, and hypothyroidism lacked evidence that key transfer details such as resident status, meds, allergies, labs, precautions, and care plan goals were sent with them, and the NHA confirmed the missing documentation.
A resident with dementia and anxiety had a PRN lorazepam order for anxiety, but the MAR lacked evidence that non-pharmacological interventions were attempted before four administrations of the medication. The NHA confirmed the record did not show these interventions were tried before the PRN psychotropic was given, despite facility policy requiring non-pharmacological interventions to be used and documented in the EMAR.
Wheelchair transport occurred without ordered leg rests for four residents. Clinical records showed each resident had an order for leg rests for transport, but surveyors observed them being pushed in wheelchairs without the leg rests attached and with their feet dragging on the ground. The DON confirmed the leg rests should have been in place per MD orders, and the Director of Rehab stated it is unsafe to transport a resident this way.
Pharmacist MRR recommendations for a resident with DM, Parkinson's disease, and anxiety were not reviewed or addressed by the physician. The consultant pharmacist recommended changes to Meloxicam, Lorazepam, Melatonin, and Carbidopa/Levodopa, but the record lacked evidence of physician follow-up, and the NHA confirmed the recommendations were not addressed.
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 Send Required Transfer Information to Hospital
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider when three residents were transferred to the hospital. Facility policy required that transfer information include the practitioner’s contact information, resident representative information, advance directive information, resident status, reason for transfer, recent vital signs, diagnoses, allergies, medications, relevant labs and diagnostic tests, special instructions, precautions, and care plan goals. However, the clinical records for Residents R1, R5, and R9 did not contain evidence that this required information was sent with them upon transfer. Resident R1 had diagnoses including hypertension, chronic pain, and heart disease, and progress notes documented multiple hospital transfers. Resident R5 had diagnoses including hypertension, hyperlipidemia, and chronic pain, and progress notes documented hospital transfers as well. Resident R9 had diagnoses including hypertension, hyperlipidemia, and hypothyroidism, and progress notes documented a hospital transfer. During interview, the Nursing Home Administrator confirmed that the records lacked evidence that the necessary clinical information was provided to the receiving health care provider and stated that clinical information should have been provided at the time of transfer.
Failure to Document Non-Pharmacological Interventions Before PRN Psychotropic Use
Penalty
Summary
The facility failed to provide evidence that non-pharmacological interventions were attempted before administering PRN lorazepam for one resident. Facility policy titled Psychotropic Medication Use & GDR Process stated that residents who use psychotropic medications shall receive non-pharmacological interventions to facilitate reduction or discontinuation of the drugs, and that these interventions will be utilized and documented in the EMAR. Review of the resident’s record showed diagnoses including dementia, anxiety, and diabetes, and a physician order for lorazepam 0.5 mg by mouth every four hours PRN for anxiety. Review of the March 2026 MAR showed the PRN lorazepam was administered on 3/7/26, 3/8/26, and twice on 3/9/26, and the record lacked evidence that non-pharmacological interventions were attempted before four of those administrations. During an interview on 3/12/26, the NHA confirmed that the resident’s clinical record lacked evidence of non-pharmacological interventions being attempted prior to administering the PRN lorazepam and confirmed that such interventions should be attempted before psychotropic medication is given.
Wheelchair transport occurred without ordered leg rests
Penalty
Summary
The facility failed to ensure adequate safety measures were implemented per physician orders when four residents were transported in wheelchairs without leg rests attached. Facility policy stated that physician orders are to provide the essential care needs to the resident and are to be carried out in accordance with the written or verbal orders of the attending medical provider. Clinical record review showed that Resident R45 had an order for bilateral leg rests for transport only, Resident R73 had an order for bilateral leg rests to PRN wheelchair for transport only, Resident R75 had an order for leg rest for transport, and Resident R101 had an order for leg rest for transport. On 3/11/26, surveyors observed Resident R45, Resident R101, Resident R73, and Resident R75 being pushed in wheelchairs without leg rests, with their feet dragging on the ground during transport to the hallway and dining room. The DON confirmed that the wheelchair leg rests should have been in place per physician orders to ensure safe transport for these residents, and the Director of Rehab confirmed that it is unsafe for a resident to be transported in a wheelchair without leg rests with their feet dragging on the ground.
Pharmacist MRR Recommendations Not Addressed
Penalty
Summary
The facility failed to ensure that consultant pharmacist recommendations from the monthly medication regimen review were reviewed and addressed by the physician for one resident, R66. The facility policy stated that the medication regimen review includes review of the medical record to prevent, identify, report, and resolve medication-related problems or irregularities, that the pharmacist shall communicate irregularities to the facility, that the facility shall provide the pharmacist answers to the previous month's pharmacy recommendations, and that facility staff shall act upon all recommendations. Resident R66 was admitted on 9/29/25 with diagnoses including diabetes, Parkinson's disease, and anxiety. The pharmacist's medication regimen review dated 11/18/25 recommended changing Meloxicam from PRN to routine daily, extending and increasing Lorazepam, adding Melatonin, and evaluating the continued need for Carbidopa/Levodopa. The record lacked evidence that these recommendations were reviewed or addressed by the physician. The pharmacist confirmed this during interview, and the NHA also confirmed that the recommendations were not addressed by the physician.
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.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Erie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nightingale Nursing And Rehab Center | 1.6 mi | ★★★★★ | 9 | 0 |
| Lecom At Village Square, Llc | 1.6 mi | ★★★★★ | 3 | 0 |
| Sarah Reed Senior Living | 1.6 mi | ★★★★★ | 4 | 0 |
| Lecom At Elmwood Gardens, Llc | 2.8 mi | ★★★★★ | 1 | 0 |
| Twinbrook Healthcare And Rehabilitation Center | 3.1 mi | ★★★★★ | 20 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.