Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Southeastern Pennsylvania Veteran's Center during CMS and state inspections, most recent first.
A nurse administered another resident's medications to a cognitively intact resident with multiple chronic conditions after only verbally confirming the last name, without using other required identification methods. The resident developed symptoms including nausea, vomiting, and near syncope, requiring hospital admission for observation and treatment of medication side effects.
A resident with hemiplegia and hemiparesis, dependent on two-person assistance for bed mobility, was left in the care of a single staff member during incontinence care. The staff member did not follow the care plan, and while distracted, the resident fell from a high bed, sustaining multiple serious injuries including cervical fractures and a subdural hematoma.
A resident with diabetes and peripheral vascular disease sustained a second-degree burn after a nurse, who had not been educated on the facility's safe food heating policy, failed to check the temperature of reheated ramen soup before serving it. The incident occurred when the resident spilled the overheated soup on their chest, and documentation confirmed that required temperature checks were not performed. The Nursing Home Administrator acknowledged that direct care staff had not been trained on the safe food heating procedure, leading to an Immediate Jeopardy situation.
The Commandant and DON did not ensure that all direct care staff received education and training on safe heating and reheating of food and beverages, as required by facility policy and state regulations. This lack of training placed residents in Immediate Jeopardy due to the risk of burns from improperly handled food and beverages.
A resident with heart failure and kidney disease experienced a significant weight gain over five days, but was not reweighed or assessed promptly, and the physician was not notified until several days after the change was identified, contrary to facility policy.
A resident with multiple chronic conditions did not receive care in accordance with physician orders, as staff failed to enforce a prescribed fluid restriction and administered Midodrine despite blood pressure readings above the ordered threshold. These lapses were confirmed by facility leadership and documented through clinical record review.
A resident with ESRD who attended dialysis missed multiple scheduled doses of Renvela because they were out of the facility during medication times. The missed doses were documented as 'resident unavailable,' and the physician was not notified of these omissions. The DON confirmed the medication was not given due to the resident's absence for dialysis and that the physician was not informed.
A resident returned from the hospital with a Foley catheter and instructions for a void trial, but the facility failed to assess the catheter's necessity or conduct the trial. Despite documented catheter care, the resident developed a UTI, which was diagnosed after being sent to the hospital for hyponatremia. The facility did not complete the required observation form upon readmission.
A resident admitted with a cancer diagnosis did not receive a timely oncology consultation. Despite being assessed by a CRNP and having a liver biopsy and oncology appointment scheduled, there was no documented evidence of an oncologist's assessment or identified treatment course. This was confirmed by the DON.
Significant Medication Error Resulting in Hospitalization
Penalty
Summary
A significant medication error occurred when a licensed nurse administered another resident's medications to a resident with diagnoses including diabetes, hypertension, prostate cancer, and congestive heart failure. The nurse, who was not the resident's regular caregiver, entered the room where multiple residents were present. Upon calling out the resident's last name, the resident responded, and the nurse proceeded to give the medications without further verification. The medications administered included several drugs not prescribed to the resident, such as Bisacodyl, Chlorpromazine, Diltiazem, Duloxetine, Loratadine, Oxybutynin, Pantoprazole, Senna Plus, Tramadol, and Vraylar. Following the administration, the resident initially denied any immediate ill effects but was later reported by family to be pale, nauseated, and had vomited. The resident's vital signs were assessed, and after further symptoms developed, the physician was notified and ordered the resident to be transferred to the hospital. Hospital records indicated the resident was admitted for observation due to medication side effects, including near syncope, nausea, vomiting, and transient bradycardia, likely related to the medications received in error. The facility's policy required verification of resident identity using multiple methods, such as checking identification bands, reviewing photographs, and confirming with other staff if necessary. However, these procedures were not fully followed during the medication pass, leading to the error. The incident was documented in nursing progress notes and confirmed through staff statements and facility investigation records.
Failure to Follow Two-Person Assist Care Plan Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with hemiplegia and hemiparesis following a cerebral infarction, who required two-person assistance for bed mobility, was left in the care of a single non-licensed staff member during incontinence care. The resident's care plan and Minimum Data Set (MDS) both specified the need for two staff members to assist with bed mobility, but this protocol was not followed. During the care, the staff member attempted to manage soiled linens and clean the resident alone, despite the resident's repeated attempts to roll and complaints of hip pain. While the staff member was distracted by picking up a sheet that had fallen to the floor, the resident rolled off the bed and fell onto the floor. The bed was in a high position at the time to facilitate incontinence care. The fall resulted in significant injuries, including a closed displaced fracture of the first and second cervical vertebrae, a cervical compression fracture, a subdural hematoma, and a scalp laceration, all of which required hospitalization. Facility documentation and interviews confirmed that the staff member did not follow the resident's care plan, which mandated two-person assistance for bed mobility. The incident was substantiated as neglect, as the failure to provide the required level of assistance directly led to the resident's injuries.
Failure to Educate Staff on Safe Food Heating Results in Resident Burn
Penalty
Summary
The facility failed to ensure that direct care staff were educated on the safe process for heating and reheating food, as required by facility policy. The policy specified that food and beverages must be heated, stirred, temperature-checked, stirred again, and re-checked before being served to residents, with temperatures maintained between 140°F and 165°F to minimize the risk of burns. However, a licensed nurse who had not received this education prepared instant ramen soup for a resident and did not check the temperature before serving it. The resident involved had diagnoses of diabetes and peripheral vascular disease, was cognitively intact, and required set-up assistance with feeding. After the soup was served, the resident spilled it on their chest, resulting in a second-degree burn. Observations and clinical documentation confirmed the presence of a significant burn area on the resident's chest and abdomen, and the resident reported pain following the incident. Progress notes and wound care consults documented the extent and treatment of the burn. Interviews and facility documentation revealed that the nurse did not follow the required procedure for checking food temperature, and there was no evidence of temperature documentation for the soup. The Nursing Home Administrator confirmed that the staff member had not been trained on the safe food heating policy, and further acknowledged that all direct care staff, including nurses and nursing assistants, had not received this education. This lack of staff education and failure to follow policy led to an Immediate Jeopardy situation when the resident sustained a burn from overheated food.
Removal Plan
- Education was provided to the staff
- A whole house audit was conducted to check all microwaves in the facility had thermometers attached to it
- All residents were assessed to ensure no other residents received a burn from re-heated food items
- Process signage for re-heating food in the microwave were attached to the microwaves
- House-wide education developed and implemented for all facility staff on re-heating process, education was implemented and presented during the new hire and agency orientation
- Dietary performed audits to ensure thermometers are present and functioning on all microwaves in resident areas
- Audits were completed and ongoing
- The outcome of audits will be reviewed at the QA meeting
Failure to Train Staff on Safe Food and Beverage Heating Procedures
Penalty
Summary
The facility failed to ensure that all direct care staff were properly educated and trained on the facility's policy and procedure regarding the safe heating and reheating of food and beverages. This failure was attributed to the inactions of the Commandant and the Director of Nursing (DON), who did not fulfill their job responsibilities to manage and control health-related activities and ensure a safe environment for residents and staff. The Commandant was responsible for operating safety programs in accordance with agency, state, and federal standards, while the DON was responsible for communicating and ensuring understanding and implementation of facility policies and procedures among nursing staff. A review of job descriptions and clinical records revealed that the Commandant and DON did not provide the necessary education and training to direct care staff on safe food and beverage heating practices. As a result, residents were placed in Immediate Jeopardy due to the risk of burns from improperly heated food and beverages. The report cites specific state regulations that were not followed, highlighting the failure of facility management to ensure compliance with required safety and training standards.
Failure to Timely Notify Physician of Significant Weight Gain
Penalty
Summary
The facility failed to timely notify a physician of a significant weight change in a resident with diagnoses of congestive heart failure and chronic kidney disease. According to the facility's policy, significant weight changes require prompt reweighing and physician notification. The resident had a physician's order to be weighed three times a week to monitor for weight gain due to edema. A review of the resident's records showed a 20-pound (9.22%) weight gain over five days, but the resident was not reweighed until five days after this significant change was identified. Additionally, there was no documentation that the resident was assessed upon identification of the significant weight gain, nor was there evidence that the physician was notified until several days later. The Director of Nursing confirmed that the physician was not notified in a timely manner regarding the resident's significant weight gain, which was contrary to facility policy and regulatory requirements.
Failure to Follow Physician Orders for Fluid Restriction and Medication Administration
Penalty
Summary
The facility failed to follow physician orders regarding fluid restriction and medication administration for a resident with multiple diagnoses, including congestive heart failure, diabetes mellitus, urinary retention, and chronic obstructive pulmonary disease. The physician had ordered a strict 2000 cc fluid restriction, with specific allocations for dietary and nursing shifts. However, clinical record review showed that on multiple dates, the resident's fluid intake exceeded the ordered restriction, with daily totals ranging from 2090 cc to 2960 cc, surpassing the prescribed limit on numerous occasions. Additionally, the facility did not adhere to the physician's order for the administration of Midodrine, a medication intended to be held if the resident's systolic blood pressure was greater than 120 mmHg. Medication administration records revealed that the resident received Midodrine on several occasions when their systolic blood pressure was above the specified threshold. These findings were confirmed during interviews with the Nursing Home Administrator and Director of Nursing, who acknowledged that physician orders for both fluid restriction and medication administration were not being followed for this resident.
Failure to Administer Ordered Medication and Notify Physician for Dialysis Resident
Penalty
Summary
A resident with End Stage Renal Disease (ESRD) who attends dialysis three times weekly had a physician's order for Renvela 800 mg, to be administered two tablets three times daily at 8:00 a.m., 12 noon, and 5:00 p.m. Review of the Medication Administration Record for April 2025 showed that the 12 noon dose of Renvela was not administered on multiple dates, with documentation indicating the resident was unavailable due to being out of the facility for dialysis. There was no evidence in the clinical records that the resident's physician was notified about the missed doses. The Director of Nursing confirmed that the medication was not given because the resident was at dialysis and that the physician was not informed of the missed administrations. The facility failed to ensure that ordered medications were administered as prescribed to a resident receiving dialysis, and did not notify the physician when doses were missed.
Failure to Assess Catheter Necessity Leads to UTI
Penalty
Summary
The facility failed to timely assess the need for an indwelling urinary catheter for a resident who was readmitted from the hospital. The resident, who had been hospitalized for a fractured hip, returned to the facility with a Foley catheter and instructions to conduct a void trial as ambulation improved. However, the facility did not complete the required Indwelling Catheter Observation Form upon the resident's readmission, nor did they attempt the void trial as instructed. The resident's clinical record indicated that catheter care was documented every shift, but there were signs of potential complications, such as cloudy urine with sediment and confusion, which were noted in the progress notes. Despite these observations, the catheter remained in place until the resident was sent to the hospital for hyponatremia and was subsequently diagnosed with a UTI. The facility's failure to assess the necessity of the catheter and to follow the hospital's discharge instructions contributed to the resident's condition.
Failure to Ensure Timely Oncology Consultation
Penalty
Summary
Southeastern Pennsylvania Veterans' Center failed to ensure timely oncology consultation for one of the 24 residents reviewed. The resident was admitted in November 2023 with a diagnosis of cancer. A Certified Registered Nurse Practitioner assessed the resident on November 2, 2023, noting the cancer diagnosis. A liver biopsy was scheduled for January 31, 2024, and an oncology appointment was scheduled for February 23, 2024. However, the clinical record did not show any documented evidence that the resident's cancer was assessed by an oncologist or that a course of treatment was identified. This information was confirmed by the Director of Nursing during an interview on March 14, 2024.
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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 Spring City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parkhouse Rehabilitation And Nursing Center | 3.5 mi | ★★★★★ | 8 | 0 |
| Sanatoga Center | 4.4 mi | ★★★★★ | 0 | 0 |
| Manatawny Center For Rehabilitation And Nursing | 4.4 mi | ★★★★★ | 7 | 0 |
| Phoenix Center For Rehabilitation And Nursing,the | 4.7 mi | ★★★★★ | 4 | 1 |
| Kadima Rehabilitation & Nursing At Pottstown | 6.6 mi | ★★★★★ | 6 | 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.