Inspection Reports for
Franciscan Manor
71 Darlington Rd, Beaver Falls, PA 15010, United States, PA, 15010
Back to Facility Profile15 Reports
Inspection Report — May 27, 2026
Complaint Investigation
Date: May 27, 2026
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection of the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 87
Current Residents in Hospice: 13
Residents Age 60 or Older: 87
Residents Diagnosed with Mental Illness: 19
Residents with Mobility Need: 10
Inspection Report — Mar 16, 2026
Follow-Up
Date: Mar 16, 2026
Visit Reason
The visit was an interim full inspection conducted as a follow-up to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the plan of correction with multiple deficiencies addressed, including staff qualifications, training, medical evaluations, medication administration, and resident assessments.
Citations (9)
54a - Direct care staff persons A and B did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
65b - Staff persons B and C completed their 40th scheduled work hour but did not complete training on emergency medical plan, mandatory abuse reporting, and reportable incident procedures.
65d - Direct care staff person B provided unsupervised ADL services without completing and passing the Department-approved direct care training course and competency test.
66b - The 2026 staff training plan did not include the name, position, duties, required courses, or scheduled training details for each direct care staff person.
141a - Resident #1's medical evaluation did not indicate special health or dietary needs; these sections were blank.
187b - Resident #4’s March 2026 Medication Administration Record lacked initials of the staff person who administered Vitamin D3 on 2/8/26 at 8:00 AM.
224a - Resident #2’s preadmission screening form did not include a determination that the resident's needs can be met by the home’s services.
225a - An initial assessment was not completed for resident #2, and resident #3’s assessment did not include the prescribed pureed diet.
227a - Resident #2’s initial support plan was not completed within 30 days of admission.
Report Facts
Residents Served: 89
Current Hospice Residents: 14
Residents 60 Years or Older: 89
Residents Diagnosed with Mental Illness: 23
Residents with Mobility Need: 12
Total Daily Staff: 101
Waking Staff: 76
Inspection Report — Jan 20, 2026
Complaint Investigation
Date: Jan 20, 2026
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection of the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 91
Current Hospice Residents: 13
Inspection Report — Oct 10, 2025
Original Licensing
Date: Oct 10, 2025
Visit Reason
The inspection was conducted due to a change in legal entity and as part of the initial licensing process for the newly licensed facility.
Findings
The facility was found to be in substantial compliance with applicable regulations, but the inspection was partial and incomplete due to the new legal entity status. A re-inspection is scheduled within three months to ensure full compliance.
Citations (4)
42y - Health Care Choice: The facility did not use the resident's preferred pharmacy from 12/26/24 through 1/31/25 despite the resident's right to choose their own pharmacy.
85e - Trash Outside Home: A large garbage container was full and uncovered, with the lid leaning against the wall, allowing potential insect and rodent penetration.
187b - Date/Time of Medication Admin.: Medications were recorded as administered at 8:00 p.m. but were actually taken by the resident at approximately 9:00 p.m.
225a - Assessment 15 Days: A resident's increased falls and resulting tibial fracture were not documented in the resident's assessment within 15 days of admission.
Report Facts
Residents Served: 89
Current Hospice Residents: 12
Staffing Hours: 96
Waking Staff: 72
Inspection Report — May 14, 2025
Follow-Up
Date: May 14, 2025
Visit Reason
The inspection was conducted as a partial, unannounced follow-up visit triggered by a complaint and incident review to verify correction of previous deficiencies.
Complaint Details
The inspection was complaint-related and incident-driven. The submitted plan of correction was reviewed and found fully implemented. No substantiation status was explicitly stated.
Findings
The facility was found to have fully implemented the submitted plan of correction related to medication administration errors, incident reporting, and resident assessments. No new reportable incidents were identified during the follow-up.
Citations (3)
Regulation 16c: The home failed to report a medication error incident to the Department within 24 hours as required. The Assistant Director of Health and Wellness who submitted the late report is no longer employed.
Regulation 187d: The home did not follow prescriber's orders by failing to administer prescribed medication to a resident on multiple dates due to medication unavailability. This was a repeat violation.
Regulation 225c: The resident's most recent additional assessment was not completed as required. The annual assessment was completed on 05/14/2025 during the inspection.
Report Facts
Residents Served: 87
Hospice Current Residents: 10
Resident Age 60 or Older: 87
Residents with Mental Illness: 1
Residents with Mobility Need: 11
Inspection Report — May 14, 2025
Complaint Investigation
Date: May 14, 2025
Visit Reason
The inspection was conducted as a partial, unannounced visit due to a complaint and incident at the facility.
Complaint Details
The visit was complaint-related and incident-based. The submitted plan of correction was fully implemented as of 06/18/2025.
Findings
The inspection found deficiencies related to medication administration errors, failure to report incidents timely, and incomplete resident assessments. Plans of correction were accepted and implemented by mid-June 2025.
Citations (3)
The home failed to report a medication error incident to the Department within 24 hours as required.
The home did not follow prescriber's orders by failing to administer prescribed medication to a resident on multiple dates due to medication unavailability.
Resident assessments were not completed as required, with the most recent assessment missing prior to the inspection.
Report Facts
Residents Served: 87
Total Daily Staff: 98
Waking Staff: 74
Current Hospice Residents: 10
Residents Age 60 or Older: 87
Residents with Mental Illness: 1
Residents with Mobility Need: 11
Inspection Report — Oct 4, 2022
Renewal
Date: Oct 4, 2022
Visit Reason
The inspection was a full, unannounced renewal inspection conducted over three days from 10/04/2022 to 10/06/2022 to assess compliance with licensing requirements.
Findings
The facility had multiple deficiencies including locked exit doors requiring keys, missing exit signage, incomplete medical evaluations for residents, medication administration record omissions, improper medication administration, and failure to report medication errors promptly. Plans of correction were accepted and implemented by April 6, 2023.
Citations (7)
123.a Exit doors were locked with a key on 10/4/22, preventing residents from easily opening them from inside. The doors are no longer used as an exit and have been blocked by furniture.
133.1 Exit signs were missing over the large double wooden doors used as egress for 82 residents. The doors are no longer used as an exit and have been blocked by furniture.
141a Medical evaluations for four residents lacked required height, weight, or temperature information in their documentation.
187a Medication record was missing for Resident #1's prescribed Omeprazole 20 mg daily for GERD.
187b Medication administration times were documented prematurely for Resident #5, showing medications administered on 10/6/22 before that date.
187d Resident #2 was administered a lower dose of Potassium Chloride (10 MEQ) than prescribed (20 MEQ) from 10/1/22 to 10/4/22.
188b Medication error for Resident #6 where prescribed medications were not administered on 10/3/22 and 10/4/22, and the prescribing physician was not notified promptly.
Report Facts
Residents Served: 82
Current Hospice Residents: 12
Staff Count: 88
Waking Staff: 66
Residents with Mobility Need: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Debra Bianchin | Certified DHS Medication Administration Instructor | In-serviced staff on proper medication administration documentation and procedures |
Inspection Report — Mar 11, 2022
Renewal
Date: Mar 11, 2022
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.
Notice — Sep 22, 2021
Date: Sep 22, 2021
Visit Reason
This document serves as a license renewal approval and certificate of compliance for Franciscan Manor, a Personal Care Home, confirming the facility's authorized capacity and informing about the upcoming annual inspection requirement.
Findings
The Department issued a regular license in response to the renewal application and advised that an onsite inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the license renewal approval letter |
Inspection Report — Sep 21, 2021
Renewal
Date: Sep 21, 2021
Visit Reason
The inspection was a renewal inspection conducted as a full, unannounced visit to assess compliance with licensing regulations.
Findings
Multiple deficiencies were identified including improper use and sanitation of glucometers, unsanitary conditions, inoperable bedside lamps, blocked egress, incomplete or missing medical evaluations and assessments, unsecured medications, improper medication labeling, untrained medication administration staff, and failure to follow prescriber's orders. Plans of correction were accepted and implemented with follow-up audits and staff training.
Citations (14)
85.a Sanitary conditions: The home used house glucometers for multiple residents and glucometers had blood stains, risking cross-contamination.
85.a Sanitary conditions: Multiple crumbs and food particles were found in the microwave and dirty dishes were left in a resident's room for an extended time.
101.j7 Lighting: Resident #3 did not have an operable bedside lamp that could be turned on or off.
121.a Unobstructed egress: A bench was blocking the front door exit from the stairs to the front lawn.
141.b.1 Annual medical evaluation: Residents #2 and #12 lacked documentation from their primary care physicians allowing postponement of medical evaluations.
183.b Medications and syringes locked: Unsecured medications were found on resident #13’s bedside table and bathroom sink.
184.a Labeling OTC/CAM: Resident #2’s insulin injector pen lacked a prescription label and medication labels did not match prescribed dosages.
190.a Medication course completion: Staff person administered medications without completing the required Department-approved medication administration course.
225.a Assessment within 15 days: Residents #8 and #11 had initial assessments missing diagnoses indicated in their medical evaluations.
225.c Additional assessments: Resident #3’s assessment did not include all diagnoses indicated in the medical evaluation.
225.c Additional assessments: Resident #2’s annual assessment was late, with the previous assessment completed over a year prior.
227.g Support plan signatures: Residents #8 and #11’s initial support plans were not signed by the residents nor documented as declined or unable to sign.
185.a Implement storage procedures: Multiple glucometer readings were inconsistent with medication administration records and glucometers were improperly stored and calibrated.
187.d Follow prescriber's orders: Resident #14 received incorrect insulin doses inconsistent with prescribed sliding scale orders.
Report Facts
Residents Served: 77
Current Hospice Residents: 5
Residents with Mental Illness: 2
Residents with Mobility Need: 7
Staff Total Daily: 84
Staff Waking: 63
Inspection Report — Dec 23, 2020
Complaint Investigation
Date: Dec 23, 2020
Visit Reason
The inspection was conducted as a complaint investigation at Francsican Manor on 12/23/2020.
Findings
No regulatory citations or deficiencies were identified during this complaint investigation inspection.
Report Facts
Residents Served: 58
Hospice Current Residents: 5
Total Daily Staff: 62
Waking Staff: 47
Residents Age 60 or Older: 58
Residents with Mobility Need: 4
Notice — Nov 18, 2020
Date: Nov 18, 2020
Visit Reason
The document serves as a renewal notification and license issuance for Franciscan Manor, a Personal Care Home, following receipt of the renewal application dated September 11, 2020.
Findings
The Department advises that an onsite inspection will be conducted within the next twelve months as required by regulation. No findings or deficiencies are reported in this document.
Report Facts
Inspection Report — Oct 9, 2020
Complaint Investigation
Date: Oct 9, 2020
Visit Reason
The inspection was conducted as a complaint investigation at Francsican Manor on 10/09/2020.
Findings
No regulatory citations or deficiencies were identified during this complaint investigation inspection.
Report Facts
Residents Served: 89
Current Hospice Residents: 7
Residents with Mobility Need: 10
Residents Age 60 or Older: 89
Inspection Report — Feb 19, 2020
Complaint Investigation
Date: Feb 19, 2020
Visit Reason
The inspection was conducted as a complaint investigation due to an incident reported at the facility.
Complaint Details
The visit was complaint-related due to an incident involving medication administration errors for Resident #1. The submitted plan of correction was fully implemented as of 3/23/2020.
Findings
The investigation found multiple medication administration and documentation violations involving Resident #1, including missing blood glucose readings, failure to initial medication administration records, incorrect medication dosages, and incomplete support plans. The facility submitted and implemented plans of correction for all deficiencies.
Citations (4)
185a - The home failed to document blood glucose readings for Resident #1 on 12/14/19 at 4:00 p.m. as required.
187b - Staff did not initial the medication administration record for Resident #1's Lantus insulin doses on multiple dates in December 2019.
187d - Staff administered an incorrect dose of Lantus insulin to Resident #1 on 2/5/20, exceeding the prescribed amount.
227c - The annual support plan for Resident #1 did not indicate the care and frequency of home health and rehabilitation therapy services provided.
Report Facts
Residents Served: 102
Current Residents Hospice: 7
Total Daily Staff: 111
Waking Staff: 83
Diagnosed with Mental Illness: 2
Have Mobility Need: 9
Are 60 Years of Age or Older: 102
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rex Pagani | Executive Director | Signed plans of correction and named as Administrator |
Document — Dec 31, 2019
Date: Dec 31, 2019
Visit Reason
Issuance of a new license certificate for Franciscan Manor as a Personal Care Home and notification of a forthcoming inspection within 3 months of the license effective date.
Findings
The facility was found to be in substantial compliance with applicable regulations under 55 Pa.Code Chapter 2600 for Personal Care Homes at the time of policy review.
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