Inspection Reports for Our Home of Hope
223-225 CHERRY STREET,, COLUMBIA, PA, 17512
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
15 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
219% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
87% occupied
Based on a June 2025 inspection.
Census over time
Inspection Report
Renewal
Census: 26
Capacity: 30
Deficiencies: 12
Date: Jun 16, 2025
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 06/16/2025 to review compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including privacy violations due to video recording without proper signage and resident notification, insufficient administrator annual training hours, safety hazards with bath rugs, food contamination and temperature issues in freezers, fire safety inspection and drill timing issues, incomplete medical evaluations and preadmission screening forms, medication storage and availability problems, and missing resident signatures on support plans. Plans of correction were accepted with proposed completion dates mostly by 07/31/2025 and implementation verified by 08/14/2025.
Deficiencies (12)
Multiple cameras recorded entrances, exits, and interior corridors without signage or resident notification; a camera recorded a resident's bedroom.
Administrator completed only 8 hours of Department-approved training in 2024, less than the required 24 hours.
Bath rugs in bathrooms near resident rooms #106, #204, and #208 slid on the floor creating a fall hazard.
Food spillage and crumbs found inside openings of freezers #2, #3, #4 in basement and kitchen refrigerator/freezer.
Freezer temperatures were above required levels: freezer #3 at 28°F and 25°F; dining room freezer at 18°F and 8°F.
Fire safety inspection and drill were conducted late; last inspection on 5/19/25 with previous on 4/30/24.
Fire drill during sleeping hours was overdue; last conducted on 2/27/25 with previous on 3/29/24.
Resident #2's initial medical evaluation was not completed within required timeframe.
Resident #3's annual medical evaluation was not completed on or before the previous evaluation date.
Resident #4's prescribed medications (Naphcon drops and Ondansetron 4 mg) were not available in the home on 6/16/25.
Resident #2's preadmission screening form was not completed within 30 days prior to admission.
Resident #3 participated in support plan development but did not sign the support plan.
Report Facts
License Capacity: 30
Residents Served: 26
Staffing Hours: 26
Waking Staff: 20
Administrator Training Hours: 8
Freezer Temperature: 28
Freezer Temperature: 25
Freezer Temperature: 18
Freezer Temperature: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Named in findings related to annual training deficiency, medical evaluation audits, fire drill compliance, medication storage, and preadmission screening compliance. | |
| Maintenance Staff Member | Changed camera position and placed signage related to privacy violation. | |
| Cook | Responsible for cleaning food spillage and monitoring freezer temperatures. | |
| Clinical Nurse Supervisor LPN | Visited resident to obtain support plan signature and involved in medication cart audits. |
Inspection Report
Complaint Investigation
Census: 25
Capacity: 30
Deficiencies: 1
Date: Apr 24, 2025
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial inspection on 04/24/2025.
Complaint Details
The inspection was complaint-related and unannounced. The plan of correction was accepted and fully implemented as of 05/23/2025.
Findings
The submitted plan of correction was determined to be fully implemented. A food safety violation was found involving unlabeled and undated leftover food items in the pantry, which was corrected immediately with staff re-education and monitoring plans put in place.
Deficiencies (1)
Unlabeled and undated container of pasta, undated bag of brown sugar, and unlabeled and undated zip log bag of chow mein noodles found in the pantry.
Report Facts
License Capacity: 30
Residents Served: 25
Staffing Hours - Total Daily Staff: 25
Staffing Hours - Waking Staff: 19
Residents Receiving Supplemental Security Income: 16
Residents Age 60 or Older: 20
Residents Diagnosed with Mental Illness: 13
Residents Diagnosed with Intellectual Disability: 7
Residents with Physical Disability: 1
Inspection Report
Follow-Up
Census: 26
Capacity: 30
Deficiencies: 9
Date: Sep 17, 2024
Visit Reason
The inspection was an unannounced partial interim review conducted on 09/17/2024 to verify the full implementation of the submitted plan of correction for the facility.
Findings
The facility was found to be in compliance with the submitted plan of correction, which addressed previous deficiencies related to record confidentiality, criminal background checks, fire safety orientation, fire drill documentation, exit signage, medication labeling, medication storage procedures, and adherence to prescriber's orders.
Deficiencies (9)
Resident records were observed unlocked, unattended, and accessible in the kitchen/medication area.
A criminal history check had not been completed for a staff member.
Staff Person B did not complete the first day fire safety orientation training until after hire date.
Fire drill records did not document simulation of blocked exits and did not specify AM or PM for a drill time.
An exit sign was missing at an exit used by 26 residents.
Prescription medications were not properly labeled or had incorrect pharmacy labels inconsistent with current orders.
Discrepancies were observed between blood sugar readings on glucometer and medication administration records (MAR).
Resident did not have blood sugar testing completed on several dates as ordered.
Medications were not administered as prescribed on multiple occasions due to unavailability or omission.
Report Facts
License Capacity: 30
Residents Served: 26
Total Daily Staff: 26
Waking Staff: 20
Residents Receiving Supplemental Security Income: 15
Residents Diagnosed with Mental Illness: 16
Residents Diagnosed with Intellectual Disability: 6
Residents Aged 60 or Older: 7
Residents with Physical Disability: 3
Inspection Report
Renewal
Census: 27
Capacity: 30
Deficiencies: 16
Date: Jun 12, 2024
Visit Reason
The inspection was conducted as a full, unannounced renewal inspection with additional reasons including complaint and incident review.
Findings
The inspection identified multiple deficiencies including failure to post required regulations, delayed incident reporting, failure to offer interest-bearing accounts for resident funds, abuse by staff, incomplete criminal background checks, lack of certified first aid staff during certain hours, incomplete staff training, evidence of bedbug infestation, outdated emergency procedures, incomplete fire drill documentation, failure to post menus timely, medication storage and administration issues, and failure to follow prescriber's orders.
Deficiencies (16)
2600 regulations were not posted in a conspicuous and public place in the home on 06/12/2024.
Delayed reporting of possible resident financial abuse to the Department.
Failure to offer assistance in establishing interest-bearing accounts for residents holding more than $200 for over 2 consecutive months.
Staff Person B committed financial abuse by transferring resident funds to personal account and was terminated.
Criminal background checks were not requested timely for Staff Person A and Staff Person C.
No staff certified in First Aid were present from 2:00PM-6:00AM on 06/06/2024 to 06/08/2024.
Direct care Staff Person D did not receive required annual training on medication self-administration, resident needs, and personal care service needs.
Live bedbugs were observed in resident rooms 206 and 208.
Written emergency procedures had not been reviewed, updated, or submitted to local emergency management agency since October 2022.
Fire drill records lacked accurate documentation including discrepancies in time, resident counts, and missing staff participation data.
Residents did not always evacuate to designated meeting places during fire drills; one resident refused to participate on 01/31/2024.
Menus for the current and following week were not posted on 06/12/2024.
Loose medication pill found in medication drawer; medication administration and storage procedures not properly followed.
Medications prescribed to residents were not available or discrepancies existed between glucometer readings and medication administration records.
Failure to follow prescriber's orders for insulin administration and medication dosage for Resident 9.
Staff Person A, the Train-the-Trainer and practicum observer, had not completed the Department-approved medication administration training.
Report Facts
License Capacity: 30
Residents Served: 27
Total Daily Staff: 27
Waking Staff: 20
Residents with Supplemental Security Income: 24
Residents 60 Years or Older: 21
Residents Diagnosed with Mental Illness: 14
Residents Diagnosed with Intellectual Disability: 6
Residents with Physical Disability: 3
Residents with Mobility Need: 0
Evacuation Time: 188
Evacuation Time: 158
Evacuation Time: 188
Residents Present During Fire Drill: 28
Residents Present During Fire Drill: 29
Residents Present During Inspection: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person A | Train-the-Trainer and Practicum Observer | Named in findings related to delayed incident reporting, incomplete criminal background check, medication administration without approved training, and abuse reporting. |
| Staff Person B | Named in abuse finding involving unauthorized transfer of resident funds. | |
| Staff Person C | Named in finding related to delayed criminal background check. | |
| Staff Person D | Direct Care Staff | Named in finding related to incomplete annual training. |
| Administrator | Administrator | Named throughout report as responsible for corrective actions and compliance. |
| Clinical Nurse Supervisor | Clinical Nurse Supervisor | Named in medication administration and audit corrective actions. |
Inspection Report
Renewal
Census: 25
Capacity: 30
Deficiencies: 9
Date: May 2, 2023
Visit Reason
The inspection was conducted as a renewal visit to review the facility's compliance with licensing requirements.
Findings
The facility was found to have multiple deficiencies related to fire drills, medication administration, record keeping, and staff training. The submitted plan of correction was determined to be fully implemented with continued compliance required.
Deficiencies (9)
An unannounced fire drill was not held during the months of November and December of 2022.
The home does not have a maximum safe evacuation time specified in writing within the past year by a fire safety expert; evacuation times exceeded limits during drills.
The home has not conducted a fire drill during sleeping hours within the last 6 months.
Prescribed medications for Resident 3 were in the home's medication cart but not included in the resident's medication administration record (MAR).
Discrepancies observed between Residents 1 and 2's electronic medication administration records (eMAR) and glucometer readings.
Medication doses administered to Residents 2 and 3 were not entered in their medication administration records (MAR).
Resident 3’s medication administration record did not include the initials of the staff person who administered certain medications on 04/14/23 at 8 pm.
Staff persons administered insulin and performed glucose monitoring without completing required Department-approved diabetes patient education within the last 12 months.
Records for Residents 1 and 4 do not include the color of hair, color of eyes, and identifying marks.
Report Facts
License Capacity: 30
Residents Served: 25
Total Daily Staff: 25
Waking Staff: 19
Residents Receiving Supplemental Security Income: 24
Residents Diagnosed with Mental Illness: 17
Residents Diagnosed with Intellectual Disability: 4
Residents Aged 60 or Older: 8
Residents with Physical Disability: 2
Inspection Report
Renewal
Census: 27
Capacity: 30
Deficiencies: 13
Date: Nov 9, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
The inspection identified multiple deficiencies including failure to report medication errors, lack of quality management plan, insufficient staffing with medication administration training, lack of CPR and First Aid trained staff during certain shifts, excessively high hot water temperatures, lack of documentation to the fire department, incomplete medical evaluations, unsecured refrigerated medications, incomplete medication records, failure to follow prescriber's orders, incomplete medication administration training, and incomplete resident support plans.
Deficiencies (13)
Failure to report medication errors to the Department within 24 hours.
Lack of an established and implemented quality management plan.
No staff with medication administration training working overnight shifts on specified dates.
No staff with current CPR and First Aid certification working during specified shifts.
Hot water temperature exceeded 120°F in multiple bathrooms.
No documentation of written notification to local fire department regarding home address, bedroom locations, and evacuation assistance.
Resident medical evaluation not signed by physician and missing key health information.
Resident medical evaluations not completed annually as required.
Medications refrigerator not locked and accessible to anyone in the home.
Medication administration records missing diagnosis or purpose for prescribed medications.
Medications not administered as prescribed due to unavailability in the home.
Staff person administering medications had not received medication administration observations within the past 2 years.
Resident support plans missing documentation for medical, dental, vision, hearing, mental health, or behavioral care services and other needs.
Report Facts
License Capacity: 30
Residents Served: 27
Total Daily Staff: 27
Waking Staff: 20
Hot Water Temperature: 149
Hot Water Temperature: 145
Hot Water Temperature: 124
Notice
Capacity: 30
Deficiencies: 0
Date: Jun 13, 2021
Visit Reason
The document serves as a renewal notification and issuance of a regular license for the Personal Care Home 'Our Home of Hope' pursuant to Title 55, PA Code, Chapter 2600. It also advises that an annual onsite inspection will be conducted within the next twelve months.
Findings
The Department has approved the renewal application and issued a regular license. The document does not report any inspection findings but states that enforcement action will be taken if noncompliance is found during future inspections.
Report Facts
Maximum capacity: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter |
Viewing
Loading inspection reports...
