Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 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.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 137 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Pennsylvania Soldiers And Sailors Home.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.