Inspection Reports for
Emmanuel Home
800 PRIESTLY AVENUE,, NORTHUMBERLAND, PA, 17857
Back to Facility Profile23 Reports
Inspection Report — Apr 9, 2026
Renewal
Date: Apr 9, 2026
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing regulations for Emmanuel Home.
Findings
The inspection identified multiple deficiencies including late incident reporting, failure to conduct required fire drills during sleeping hours, unsecured medications, missing medications, and staff training deficiencies related to insulin administration. Plans of correction were accepted and implemented by early June 2026.
Citations (5)
PA Code 2600.16.c requires incident reporting within 24 hours. The facility failed to notify the Department timely for medication errors and an unwitnessed fall, repeating a prior violation.
PA Code 2600.132.e requires a fire drill during sleeping hours every 6 months. The facility's most recent drill was 9/26/25, exceeding the 6-month requirement.
PA Code 2600.183.b requires medications and syringes to be locked. A medication blister pack was found unlocked and accessible in a resident's room.
PA Code 2600.185.a requires safe storage and availability of medications. A resident's prescribed Preparation H cream was not available at inspection.
PA Code 2600.190.b requires staff administering insulin to have current training. Staff person A's diabetic training expired, yet they administered insulin beyond that date.
Report Facts
Residents Served: 18
Total Daily Staff: 18
Waking Staff: 14
Current Hospice Residents: 1
Inspection Report — Apr 23, 2025
Renewal
Date: Apr 23, 2025
Visit Reason
The inspection was conducted as a renewal inspection of Emmanuel Home to review compliance with licensing regulations.
Findings
The inspection found several deficiencies including late reporting of a medication error, an incomplete quality management plan, expired medications, missing PRN medications, and medication administration training issues. Plans of correction were submitted and fully implemented by July 7, 2025.
Citations (5)
Late reporting of a medication error where Resident #2 received incorrect insulin dose and the incident was reported two days late.
Quality Management Plan did not address reportable incidents, complaint procedures, staff training, licensing violations, and resident or family councils.
Expired Nitroglycerin tablets found for Resident #1 with expiration dates 11-12-24 and 12-10-24.
Resident #2's PRN medications (Diabetic Tussin, Loperamide HCI, Magnesium Hydroxide Oral Suspension) were not available at the time of inspection.
Medication administration training deficiencies where two staff persons administered medications without passing the Department-approved medication administration test initially.
Report Facts
Residents Served: 27
Staffing Hours: 27
Waking Staff: 20
Medication Expiration Dates: 2
Medication Administration Test Passing Scores: 90
Medication Administration Test Scores: 100
Medication Administration Test Scores: 99
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in multiple findings related to medication errors, quality management, medication storage, and medication administration training. |
| Administrator | Administrator | Named in multiple findings related to incident reporting, quality management, and medication administration training. |
Inspection Report — Oct 31, 2024
Complaint Investigation
Date: Oct 31, 2024
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial inspection on 10/31/2024.
Complaint Details
The inspection was complaint-driven and unannounced. The submitted plan of correction was fully implemented and accepted.
Findings
The inspection found deficiencies related to fire drill procedures and support plan documentation. The facility did not conduct a sleeping hour fire drill with only regularly scheduled staff, and a resident's support plan was not updated to reflect mobility assistance needs. Both issues were corrected with plans of correction implemented by 11/19/2024.
Citations (2)
Fire drills were not held on different days and times as required; a sleeping hour drill included additional staff not regularly scheduled on that shift.
Resident support plan was not updated to reflect the need for two-person assistance for safe transfers and wheelchair use.
Report Facts
Residents Served: 26
Total Daily Staff: 38
Waking Staff: 29
Sleeping Hour Fire Drill Date: Sep 20, 2024
Corrected Fire Drill Date: Nov 18, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person A | Director of Nursing | Named in fire drill deficiency for participating in a sleeping hour drill when not scheduled. |
| Administrator | Responsible for correcting fire drill procedures and ensuring compliance. | |
| Director of Nursing | Director of Nursing | Responsible for correcting support plan documentation deficiencies. |
Inspection Report — Jul 18, 2024
Complaint Investigation
Date: Jul 18, 2024
Visit Reason
The inspection was conducted as a complaint investigation at Emmanuel Home on 07/18/2024.
Complaint Details
The inspection was complaint-related, but no deficiencies were found and no follow-up was required.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 28
Current Residents in Hospice: 2
Total Daily Staff: 28
Waking Staff: 21
Inspection Report — Apr 24, 2024
Plan of Correction
Date: Apr 24, 2024
Visit Reason
The inspection was a partial, unannounced follow-up review conducted on 04/24/2024 to verify the implementation of a previously submitted plan of correction related to an incident.
Findings
The submitted plan of correction was determined to be fully implemented, specifically addressing an incomplete Resident Assessment and Support Plan where the Behavioral & Cognitive section was left blank. The Director of Nursing corrected the issue and will ensure future plans are thoroughly completed.
Citations (1)
Resident Assessment and Support Plan was incomplete with the Behavioral & Cognitive section left blank.
Report Facts
Residents Served: 21
Total Daily Staff: 21
Waking Staff: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named as responsible for correcting the incomplete Resident Assessment and Support Plan and ensuring future compliance |
| Administrator | Administrator | Will make periodic reviews of Resident Assessment and Support Plans moving forward |
Inspection Report — Jun 8, 2023
Renewal
Date: Jun 8, 2023
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 06/08/2023 to review compliance with licensing requirements.
Findings
The facility was found to have multiple deficiencies including failure to report a medication error, breach of record confidentiality, inadequate staff training, uncovered resident equipment, failure to meet evacuation time requirements, outdated medical evaluations, medication storage and administration issues, and failure to report medication errors. Plans of correction were accepted and implemented by 07/11/2023.
Citations (9)
Medication error for Resident 1 was not reported to BHSL.
Licensing Inspection Summary from 7/6/2022 was posted with privacy code attached revealing names of residents.
Direct Care Staff Member A was not trained in required topics including self-administering medications and care for residents with dementia in 2022.
Resident 2 had an uncovered enabler bar on their bed with an opening of 10 inches by 12 inches.
The home failed to evacuate in under 2 minutes and 30 seconds on all fire drills from 4/2022 through 5/2023 and lacked a letter from a fire safety expert indicating maximum evacuation time.
The DME for Resident 3 was not updated to reflect change in mobility to minimal mobility need.
Resident 4's medication ordered every 6 hours as needed was not available at time of inspection.
Resident 1's prescribed eye drops were not available and not administered as prescribed; medication was documented in error on MAR.
No notification was made to the prescriber that Resident 1 was not administered prescribed eye drops 2 times per day for a specified period.
Report Facts
Residents Served: 21
Total Daily Staff: 21
Waking Staff: 16
Uncovered enabler bar opening: 10
Uncovered enabler bar opening: 12
Evacuation time limit: 150
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Verrol Soleyn | Administrator | Responsible for ensuring privacy coding removal and compliance with Licensing Inspection Summary postings. |
| Unnamed Former Director of Nursing | Director of Nursing | Replaced by new Director of Nursing; responsible for deficiencies related to medication errors and documentation. |
| Unnamed New Director of Nursing | Director of Nursing | Responsible for correcting medication errors, staff training, medication storage, and ongoing compliance monitoring. |
| Unnamed Maintenance Supervisor | Maintenance Supervisor | Assisted in covering uncovered enabler bars and ensuring compliance with equipment safety. |
| Unnamed Fire Chief | Fire Chief of The Northumberland Fire Department | Provided updated fire and safety letter indicating maximum evacuation time. |
Inspection Report — Jul 6, 2022
Complaint Investigation
Date: Jul 6, 2022
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 07/06/2022.
Complaint Details
The visit was complaint-related, with a follow-up plan of correction submission required and accepted. The complaint was substantiated by findings of deficiencies in resident assessments and support plans.
Findings
The inspection found deficiencies related to incomplete or untimely resident assessments and support plan revisions, including failure to document medical care services such as chair alarms. Plans of correction were accepted and implemented to address these issues.
Citations (3)
The most recent Resident Assessment of Resident 1 was not completed as required annually.
The Resident Support Plan for Resident 1 was not revised within 30 days upon completion of the annual assessment or changes in needs.
The Resident Support Plan for Resident 2 did not document the use of a chair alarm due to numerous falls.
Report Facts
Residents Served: 19
Total Daily Staff: 22
Waking Staff: 17
Residents with Mobility Need: 3
Inspection Report — Mar 8, 2022
Follow-Up
Date: Mar 8, 2022
Visit Reason
The visit was a follow-up review conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing to verify that the submitted plan of correction for previous deficiencies at Emmanuel Home was fully implemented.
Findings
The submitted plan of correction was determined to be fully implemented, with compliance maintained in areas including posting of the license inspection summary, carbon monoxide detector battery dating, completion of a supervised fire drill, and medication technician training for staff.
Citations (4)
The License Inspection Summary (LIS) dated 03/30/2021 was not posted in the home as required.
The batteries for the carbon monoxide monitor installed in the kitchen were not dated when installed.
The home did not have a fire drill supervised by a fire safety expert completed by 12/31/21 as required.
Staff persons A, B, and C did not have annual practicum completed for medication technician training in 2021.
Report Facts
Completion Date: May 16, 2022
Plan of Correction Update Date: May 27, 2022
Plan of Correction Completion Date: Jun 22, 2022
Inspection Date: Mar 8, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Verrol Soleyn | Head Administrator | Responsible for posting Licensing Inspection Summary and monitoring compliance monthly |
| Unnamed Northumberland Fire Chief | Fire Chief | Supervised the fire drill conducted on 03/08/2022 |
| Unnamed Medical Care Manager | RN | Responsible for fixing medication technician training deficiencies and monitoring ongoing compliance |
Inspection Report — Aug 12, 2021
Routine
Date: Aug 12, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report — May 25, 2021
Renewal
Date: May 25, 2021
Visit Reason
The document is a renewal license issued in response to the facility's renewal application submitted on February 16, 2021, to operate the Personal Care Home pursuant to Title 55, PA Code, Chapter 2600.
Findings
A regular license is being issued for Emmanuel Home. The Department will conduct an onsite inspection within the next twelve months to ensure compliance with applicable laws and regulations, and will take enforcement action if noncompliance is found.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal license letter and certificate |
Inspection Report — Mar 30, 2021
Renewal
Date: Mar 30, 2021
Visit Reason
The inspection was conducted as a renewal inspection of Emmanuel Home to review compliance and verify the implementation of the submitted plan of correction.
Findings
The inspection found that the submitted plan of correction was fully implemented. Deficiencies included failure to submit emergency procedures to the local emergency management agency, issues with glucometer readings and storage procedures, and incomplete documentation of a resident's physical therapy in the support plan. All deficiencies were corrected with documented plans of correction and follow-up submissions.
Citations (3)
The home did not review or submit the home's written emergency procedures for the year 2020 to the area's Emergency Management Agency.
Resident #1's glucometer readings were inconsistent and prior readings for Resident #2's glucometer were unable to be reviewed; the home's policy omitted auditing procedures for glucometers.
Resident #3's Residents Assessment and Support Plan did not include the resident's current physical therapy.
Report Facts
Residents Served: 28
Total Daily Staff: 29
Waking Staff: 22
Notice — Feb 26, 2021
Date: Feb 26, 2021
Visit Reason
The document serves to notify Emmanuel Home that their request for a waiver of the requirement for direct care staff to have a high school diploma, GED, or active registry status is granted temporarily due to anticipated high school graduation on May 26, 2021.
Findings
The waiver is granted under specific conditions including documentation of educational qualifications to be kept on file and the waiver being effective from February 26, 2021 through May 26, 2021, after which full compliance is expected.
Report Facts
Waiver effective period: 89
Notice — Feb 11, 2020
Date: Feb 11, 2020
Visit Reason
This document serves as a renewal notification for the license to operate Emmanuel Home as a Personal Care Home and informs that an annual inspection will be conducted within the next twelve months.
Findings
No inspection findings are reported in this document; it is a license renewal notice with an attached certificate of compliance.
Report Facts
Inspection Report — Mar 13, 2019
Renewal
Date: Mar 13, 2019
Visit Reason
The inspection was a renewal visit conducted by the Department’s Bureau of Human Services Licensing to assess compliance with 55 Pa. Code Chapter 2600 for Personal Care Homes.
Findings
Multiple violations of state regulations were found, including issues with resident confidentiality, carbon monoxide detector placement, staff training, medication administration documentation, and resident record completeness. Plans of correction were submitted and partially implemented with adequate progress noted.
Citations (7)
Regulation 2600.17: Resident records were not kept confidential as a resident's name was not removed from a posted violation document.
Regulation 2600.18: A carbon monoxide detector was not installed at least 15 feet from the home's three gas fired dryers as required.
Regulation 2600.65(a): Staff person hired on 9/10/2018 did not receive required orientation training until 9/13/2018.
Regulation 2600.182(b): Staff person B's medication training practicum for 2018 was incomplete and not dated when recertified.
Regulation 2600.183(e): The Breo inhaler for resident #1 was not dated when opened for use.
Regulation 2600.185(a): Resident #2's blood glucose reading was documented incorrectly, and another resident's blood sugar was erroneously recorded on Resident #2's log.
Regulation 2600.252: Resident #4's record did not include the resident's height.
Report Facts
Number of Residents Served: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert J. Delbo | Administrator | Named as responsible for preventing future violations in multiple plans of correction. |
| Kimberly A. Delbo | MSN, RN, CSN, CDP, Director of Nursing Services and Innovation | Named as responsible for preventing future violations related to medication administration and record keeping. |
Notice — Feb 5, 2019
Date: Feb 5, 2019
Visit Reason
This document serves as a renewal notification and license issuance for Emmanuel Home to operate as a Personal Care Home under Pennsylvania regulations.
Findings
The Department has approved the renewal application and issued a regular license. An onsite inspection will be conducted within the next twelve months as required by state law.
Report Facts
Notice — Dec 21, 2018
Date: Dec 21, 2018
Visit Reason
The document is a waiver approval letter extending a waiver for a direct care staff person at Emmanuel Home related to qualifications under 55 Pa.Code § 2600.54(a)(2).
Findings
The waiver is granted with conditions including continued education attendance, submission of GED documentation, and compliance with personal care home regulations. The waiver expires on March 27, 2019, and will be reviewed annually during inspections.
Report Facts
Waiver expiration date: Mar 27, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline L. Rowe | Director | Signed the waiver approval letter. |
Notice — Jul 9, 2018
Date: Jul 9, 2018
Visit Reason
The document is a letter granting a waiver for qualifications of a direct care staff person at Emmanuel Home personal care home.
Findings
The waiver is granted under specific conditions including continued education and documentation requirements. The waiver will be reviewed annually during the facility's annual inspection.
Report Facts
Waiver expiration date: Dec 27, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline L. Rowe | Director | Signed the waiver approval letter. |
Inspection Report — Mar 22, 2018
Renewal
Date: Mar 22, 2018
Visit Reason
The inspection was conducted as an annual licensing inspection combined with a renewal and complaint investigation for Emmanuel Home.
Complaint Details
The inspection included a complaint investigation component. Specific complaint substantiation status is not stated.
Findings
Violations were found related to food storage labeling and medication administration record keeping. Plans of correction were submitted addressing these issues with partial implementation progress noted.
Citations (2)
Regulation 55 Pa.Code §2600-103(e): Two clear plastic bags of frozen chicken cutlets were found in the home's freezer, unlabeled and not dated.
Regulation 55 Pa.Code §2600-187(b),(13),(14): Medication administration time and date were not recorded correctly for resident #1, and the MAR was incorrectly initialed.
Report Facts
Number of Residents Served: 28
Total Daily Staff: 30
Waking Staff: 23
Number of Current Hospice Residents: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert J. Delbo | Administrator | Named as responsible for preventing future violation in food labeling. |
| Kimberly A. Delbo | RN, Resident Care Manager | Named as responsible for preventing future violation in medication administration. |
Inspection Report — Feb 13, 2018
Renewal
Date: Feb 13, 2018
Visit Reason
The document is a renewal license issued to Emmanuel Home to operate as a Personal Care Home. The Department of Human Services will conduct an annual onsite inspection within the next twelve months as required by regulation.
Findings
This document does not report inspection findings but confirms issuance of a regular license renewal for Emmanuel Home. It states that future inspections will be conducted to ensure compliance with applicable laws and regulations.
Report Facts
Inspection Report — Feb 27, 2017
Renewal
Date: Feb 27, 2017
Visit Reason
The inspection was a renewal licensing inspection conducted by the Pennsylvania Department of Human Services on February 27, 2017.
Findings
The facility was found to have multiple violations related to carbon monoxide detector placement, background checks for direct care staff, food refrigeration temperature monitoring, fire drill scheduling, and incomplete medical evaluations. Plans of correction were submitted and partially implemented as of April 7, 2017.
Citations (5)
55 Pa.Code 2600-18: Carbon monoxide detectors were installed in each resident bedroom but not placed 15 feet or more from fossil-fuel burning devices as required.
55 Pa.Code 2600-51: A direct care staff person was hired without a timely Pennsylvania State Police Criminal Background Check.
55 Pa.Code 2600-103(f): The freezer did not contain a thermometer to ensure food was stored at proper temperature.
55 Pa.Code 2600-132(g): Fire drills were not routinely held at different times of day and night or on different days of the week and month.
55 Pa.Code 2600-141(a)(2): Medical evaluations for two residents did not include the resident's height or Medical Professional License number.
Report Facts
Total Daily Staff: 28
Waking Staff: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert J. Delbo | Administrator | Named as responsible party for preventing future violations and signer of plans of correction. |
Inspection Report — Feb 7, 2017
Renewal
Date: Feb 7, 2017
Visit Reason
This document is a renewal application and license issuance for Emmanuel Home, a Personal Care Home, confirming the facility's authorization to operate and stating that an annual onsite inspection will be conducted within the next twelve months.
Findings
No inspection findings are reported in this document. It serves as a license renewal notification and includes the facility's maximum capacity.
Report Facts
Notice — Feb 23, 2016
Date: Feb 23, 2016
Visit Reason
The document serves as a renewal notice and license issuance for Emmanuel Home, a Personal Care Home, following receipt of a renewal application and notification of upcoming annual inspection requirements.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license and states that an onsite inspection will be conducted within the next twelve months as required by regulation.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matthew J. Jones | Director | Signed the renewal notice letter. |
| Robert E. Robinson | Issuing Officer | Signed the certificate of compliance. |
Inspection Report — Feb 3, 2016
Renewal
Date: Feb 3, 2016
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing inspection and renewal process for Emmanuel Home.
Findings
The inspection found violations related to the incorrect posting of the Personal Care Home Complaint Hotline number in several areas of the facility. A plan of correction was submitted and approved to address the issue.
Citations (1)
55 Pa.Code 2600-91 requires posting emergency and complaint hotline numbers on or by each telephone with an outside line. The Personal Care Home Complaint Hotline number was posted incorrectly in the North Hallway, Activity Room, and resident rooms 109, 118, and 127.
Report Facts
Number of Residents Served: 30
Total Daily Staff: 30
Waking Staff: 23
Number of Current Hospice Residents: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert J. Delbo | Administrator | Named in relation to the violation and plan of correction. |
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