Inspection Reports for Emmanuel Home
800 PRIESTLY AVENUE,, NORTHUMBERLAND, PA, 17857
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
5.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
15% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
71% occupied
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 27
Capacity: 38
Deficiencies: 5
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.
Deficiencies (5)
| Description |
|---|
| 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
License Capacity: 38
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
Complaint Investigation
Census: 26
Capacity: 38
Deficiencies: 2
Oct 31, 2024
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial inspection on 10/31/2024.
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.
Complaint Details
The inspection was complaint-driven and unannounced. The submitted plan of correction was fully implemented and accepted.
Deficiencies (2)
| Description |
|---|
| 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
License Capacity: 38
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
Complaint Investigation
Census: 28
Capacity: 38
Deficiencies: 0
Jul 18, 2024
Visit Reason
The inspection was conducted as a complaint investigation at Emmanuel Home on 07/18/2024.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies were found and no follow-up was required.
Report Facts
License Capacity: 38
Residents Served: 28
Current Residents in Hospice: 2
Total Daily Staff: 28
Waking Staff: 21
Inspection Report
Plan of Correction
Census: 21
Capacity: 38
Deficiencies: 1
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.
Deficiencies (1)
| Description |
|---|
| Resident Assessment and Support Plan was incomplete with the Behavioral & Cognitive section left blank. |
Report Facts
License Capacity: 38
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
Renewal
Census: 21
Capacity: 38
Deficiencies: 9
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.
Deficiencies (9)
| Description |
|---|
| 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
License Capacity: 38
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
Complaint Investigation
Census: 19
Capacity: 38
Deficiencies: 3
Jul 6, 2022
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 07/06/2022.
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.
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.
Deficiencies (3)
| Description |
|---|
| 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
License Capacity: 38
Residents Served: 19
Total Daily Staff: 22
Waking Staff: 17
Residents with Mobility Need: 3
Inspection Report
Follow-Up
Deficiencies: 4
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.
Deficiencies (4)
| Description |
|---|
| 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
Routine
Deficiencies: 0
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
Renewal
Capacity: 38
Deficiencies: 0
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
Maximum capacity: 38
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal license letter and certificate |
Inspection Report
Renewal
Census: 28
Capacity: 38
Deficiencies: 3
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.
Deficiencies (3)
| Description |
|---|
| 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
License Capacity: 38
Residents Served: 28
Total Daily Staff: 29
Waking Staff: 22
Notice
Deficiencies: 0
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
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