Inspection Report
Complaint Investigation
Census: 24
Capacity: 56
Deficiencies: 0
Oct 14, 2025
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection on 10/14/2025.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
Residents Served: 24
License Capacity: 56
Current Residents in Hospice: 2
Residents Receiving Supplemental Security Income: 4
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 5
Residents Age 60 or Older: 23
Residents Diagnosed with Intellectual Disability: 1
Residents with Physical Disability: 0
Inspection Report
Renewal
Census: 27
Capacity: 56
Deficiencies: 7
May 14, 2025
Visit Reason
The inspection was conducted as part of a renewal, complaint, and provisional review of the Reformed Presbyterian Home. The visit included licensing inspections on May 14, 2025 and May 30, 2025.
Findings
The facility was found to be in compliance with Title 55, PA Code, Chapter 2600 after corrections were made. Several deficiencies were identified including medication errors, lack of CPR/first aid certified staff during certain shifts, incomplete fire drill records, inadequate staff communication systems, and incomplete staff training. Plans of correction were accepted and implemented by early July 2025.
Deficiencies (7)
| Description |
|---|
| Failure to report a medication error incident to the Department within 24 hours. |
| No staff trained in first aid and certified in obstructed airway techniques and CPR present during night shifts on multiple dates. |
| Direct care staff did not receive required training in Emergency Medical Plan and Reporting of Reportable Incidents within 40 hours of employment. |
| Lack of a system or method of communication enabling staff to immediately contact others for emergency assistance. |
| Fire drill records were incomplete or inaccurate regarding number of residents evacuated during drills. |
| Medication container label did not match the prescribed dosage and instructions. |
| Failure to follow prescriber's orders regarding medication administration, resulting in medication errors. |
Report Facts
License Capacity: 56
Residents Served: 27
Staffing Hours: 33
Waking Staff: 25
Residents with Mental Illness: 15
Residents with Mobility Need: 6
Residents with Physical Disability: 1
Residents Receiving SSI: 2
Residents Age 60 or Older: 25
Hospice Residents: 4
Medication Errors: 1
Fire Drill Evacuations: 9
Fire Drill Evacuations: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed licensing letter and certificate of compliance. |
| Resident Care Director | Named in medication error finding, responsible for re-education and audits related to medication administration and incident reporting. | |
| Staff person A | Resident Care Director | Notified about medication error on 5/14/25. |
| Staff persons C and D | Medication Technicians | Interviewed regarding medication administration errors. |
| Director of Facilities | Involved in correction and re-education related to fire drill record deficiencies. | |
| PCHA | Involved in multiple corrective actions, audits, and education related to deficiencies. |
Inspection Report
Follow-Up
Census: 26
Capacity: 56
Deficiencies: 1
Mar 14, 2025
Visit Reason
The visit was a partial, unannounced follow-up inspection conducted due to a fine, to review the submitted plan of correction for compliance.
Findings
The inspection found that the submitted plan of correction related to additional resident assessments was fully implemented. The facility updated resident assessment dates and diagnoses as required, and ongoing audits and education were established to maintain compliance.
Deficiencies (1)
| Description |
|---|
| Resident assessments were not completed annually as required, with missing diagnoses and outdated assessment dates. |
Report Facts
License Capacity: 56
Residents Served: 26
Total Daily Staff: 33
Waking Staff: 25
Residents Receiving Supplemental Security Income: 20
Residents Age 60 or Older: 23
Residents Diagnosed with Mental Illness: 16
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 7
Residents with Physical Disability: 0
Inspection Report
Renewal
Census: 27
Capacity: 56
Deficiencies: 14
Aug 22, 2024
Visit Reason
The inspection was conducted as a renewal and provisional licensing inspection of the Reformed Presbyterian Home to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
Multiple violations were found including failure to post current license inspection summaries, incomplete staff orientation and training, unlocked poisonous materials accessible to residents, inadequate lighting at bedside, improper food storage and temperature control, lint accumulation in laundry area, obstructed emergency exits, incomplete fire drill records, failure to evacuate residents to designated meeting places during fire drills, incomplete resident education on rights, and incomplete resident assessments and medical evaluations. Plans of correction were directed with specific deadlines.
Deficiencies (14)
| Description |
|---|
| License inspection summaries were not posted in a conspicuous and public place in the home. |
| Direct care staff person did not receive orientation on emergency medical plan and reporting of reportable incidents. |
| Direct care staff persons did not receive required annual training on medication self-administration and care for residents with mental illness or intellectual disability. |
| Numerous poisonous materials were unlocked and accessible to residents. |
| Residents did not have operable lamps or lighting within reach at bedside. |
| Food requiring refrigeration was stored above required temperatures. |
| Food was stored uncovered in the kitchen cooler. |
| Accumulation of lint covering floor, ductwork, and wall behind washer and dryer in laundry room. |
| Emergency exit doors were locked or obstructed, preventing easy egress. |
| Fire drill records were incomplete, missing exit routes used and evacuation details. |
| Residents were not evacuated to designated meeting places during fire drills. |
| Menus were not posted one week in advance in a conspicuous and public place. |
| Residents were not educated on their right to refuse or question medication. |
| Resident assessments and medical evaluations were incomplete or inconsistent with diagnoses. |
Report Facts
License Capacity: 56
Residents Served: 27
Staffing Hours: 35
Waking Staff: 26
Fine Amount: 145
Census at Inspection: 29
Total Daily Staff: 30
Waking Staff: 23
Inspection Report
Renewal
Census: 27
Capacity: 56
Deficiencies: 13
Aug 22, 2024
Visit Reason
The inspection was conducted as a renewal provisional licensing inspection of the Reformed Presbyterian Home to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
The inspection identified multiple violations including failure to post current license inspection summaries, incomplete staff orientation and training, unlocked poisonous materials accessible to residents, inadequate lighting at bedside, improper food storage and refrigeration temperatures, obstructed emergency exits, incomplete fire drill records, failure to educate residents on medication refusal rights, and incomplete resident assessments and medical evaluations. Plans of correction were directed with specific deadlines.
Deficiencies (13)
| Description |
|---|
| License inspection summaries were not posted in a conspicuous and public place in the home. |
| Direct care staff person did not receive orientation on emergency medical plan and reporting of reportable incidents. |
| Direct care staff persons did not receive required annual training on medication self-administration, resident needs, and care for residents with mental illness or intellectual disability. |
| Poisonous materials were unlocked and accessible to residents. |
| Resident bedside lamps were not operable or not within reach. |
| Food requiring refrigeration was stored above required temperatures. |
| Food was stored uncovered in the kitchen cooler. |
| Accumulation of lint covering floor, ductwork, and wall behind washer and dryer. |
| Emergency exit doors were locked or obstructed. |
| Fire drill records did not include exit routes used and residents were not evacuated to designated meeting places during drills. |
| Menus were not posted one week in advance in a conspicuous and public place. |
| Residents were not educated on their right to refuse medication. |
| Resident assessments and medical evaluations were incomplete or inconsistent with diagnoses. |
Report Facts
License Capacity: 56
Residents Served: 27
Staffing Hours: 35
Waking Staff: 26
Fine Amount: 145
Fine Per Resident Per Day: 5
Census at Inspection: 29
Inspection Report
Follow-Up
Census: 28
Capacity: 56
Deficiencies: 2
Mar 27, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 03/27/2024 to review the facility's plan of correction related to a previous incident.
Findings
The facility was found to have fully implemented the submitted plan of correction regarding resident abuse reporting and staff education. The report details abuse incidents involving staff and residents, with corrective actions including staff re-education, ongoing monitoring, and termination of a staff member involved in abuse.
Deficiencies (2)
| Description |
|---|
| Failure to immediately report suspected verbal and physical abuse of a resident to the local Area Agency on Aging. |
| Resident was physically abused by staff who forcefully pushed the resident back into a chair, causing discomfort. This was a repeat violation. |
Report Facts
License Capacity: 56
Residents Served: 28
Current Hospice Residents: 2
Residents Age 60 or Older: 28
Residents with Mobility Need: 5
Inspection Report
Enforcement
Census: 29
Capacity: 56
Deficiencies: 35
Nov 14, 2023
Visit Reason
The inspection was conducted as a renewal and complaint investigation of the Reformed Presbyterian Home.
Findings
The facility was found to have multiple violations including failure to comply with regulations related to resident safety, medication administration, staff training, sanitary conditions, and documentation. A provisional license was issued due to failure to submit and comply with an acceptable plan of correction. Fines are pending if violations are not corrected by the mandated dates.
Complaint Details
The inspection included a complaint investigation triggered by allegations of noncompliance with regulations related to resident safety, medication administration, and staff training. The complaint was substantiated based on multiple violations found.
Deficiencies (35)
| Description |
|---|
| Failure to properly implement emergency procedures for a missing resident resulting in delayed discovery and return of the resident. |
| Failure to report resident death incident to the Department within 24 hours. |
| Operating boilers without inspection, approval, or certificate of operation. |
| Resident #1 elopement incident with inadequate staff response and supervision. |
| Resident #3's resident-home contract was not signed by the resident. |
| Resident #3's record lacked a signed statement acknowledging receipt of resident rights and complaint procedures. |
| Staff person C accused of racist behavior and causing trouble; reprimanded and counseled. |
| Facility policies and contracts did not specify residents' right to receive visitors for minimum 12 hours daily, 7 days per week. |
| Direct care staff hired without required criminal background checks and orientation training. |
| Staff person C did not receive orientation on emergency procedures and medical plan. |
| Sanitary conditions not maintained; soiled washcloths found in resident bathrooms. |
| Trash receptacles uncovered and overflowing in multiple common and resident bathrooms. |
| Bathroom lacked operable ventilation fan; ceiling tiles damaged by water. |
| Closet doors missing in shared resident bedrooms. |
| Residents lacked operable lamps or lighting at bedside. |
| Fire drill records incomplete; missing evacuation times and participant counts. |
| Resident medical evaluations incomplete or missing for multiple residents. |
| Medication administration errors including unqualified staff administering injections and incomplete medication records. |
| Medications discontinued but not removed from medication carts; expired medications stored in resident rooms. |
| Medication orders not followed; medications not administered as prescribed. |
| Residents not educated on right to refuse medication. |
| Resident assessments incomplete or missing. |
| Support plans incomplete or not revised timely. |
| Resident record entries contained errors and corrections without proper documentation. |
| Direct care staff lacked required qualifications and documentation of education. |
| Staff failed to complete required orientation and emergency preparedness training. |
| Fire drills not conducted properly or documented accurately. |
| Resident medications not properly labeled or documented. |
| Sanitary conditions in resident bathrooms were poor with heavy soiling and inadequate cleaning. |
| Trash receptacles uncovered and overflowing in multiple areas. |
| Fire drill records incomplete and inaccurate. |
| Residents lacked timely medical evaluations and follow-up. |
| Medication administration documentation incomplete and inaccurate. |
| Prescriber orders not followed; medications not administered as prescribed. |
| Resident initial assessments and support plans incomplete or not timely. |
Report Facts
Fine amount per violation: 145
Number of violations listed for fine: 8
Total daily staff: 46
Waking staff: 35
Residents served: 29
License capacity: 56
Inspection Report
Enforcement
Census: 29
Capacity: 56
Deficiencies: 25
Nov 14, 2023
Visit Reason
The inspection was conducted as a complaint and renewal investigation of the Reformed Presbyterian Home to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
Multiple violations were found including failure to follow emergency procedures for missing residents, incomplete incident reporting, lack of proper medical evaluations, medication administration errors, inadequate staff training, unsanitary conditions, and deficient fire drill records. A provisional license was issued with a plan of correction required.
Complaint Details
The inspection was complaint-related and substantiated with multiple violations found, including failure to report incidents, medication errors, and inadequate staff training and documentation.
Deficiencies (25)
| Description |
|---|
| Failure to follow emergency procedure for missing resident; resident was found offsite without staff awareness. |
| Failure to report resident death incident to the Department within 24 hours. |
| Operating boilers without inspection, approval, or certificate of operation since 10/7/22. |
| Resident #1 elopement plan and protocol not properly implemented or updated. |
| Resident #3's resident-home contract was not signed by the resident. |
| Resident #3's record lacked signed statement acknowledging receipt of resident rights and complaint procedures. |
| Staff person C accused of racist behavior and causing trouble; reprimanded. |
| Resident visitation rights not specified for minimum 12 hours daily, 7 days per week. |
| Direct care staff person D hired without timely criminal background check. |
| Staff person C did not receive orientation on emergency procedures and fire drills. |
| Sanitary conditions deficient with soiled washcloths and trash in resident bathrooms. |
| Trash receptacles uncovered and overflowing in multiple common and resident bathrooms. |
| Bathroom fan and ventilation not operable in resident room #224. |
| Ceiling tiles in resident room #224 bathroom missing or severely water damaged. |
| Closet doors missing in shared resident bedrooms. |
| Residents #3, #5, and #6 lacked access to operable bedside lighting. |
| Fire drills not conducted during sleeping hours as required; records incomplete. |
| Resident #3 and others had incomplete or missing medical evaluations and documentation. |
| Resident #7 prescribed medication administered by unqualified staff. |
| Discontinued medications not removed from medication carts; medication carts not properly audited. |
| Resident #10's medication not administered as prescribed on multiple days. |
| Medication errors and documentation deficiencies; lack of timely notification to prescribers. |
| Resident education on right to refuse medication not documented. |
| Resident #3's initial assessment and support plan incomplete or missing. |
| Resident #8's hospice care services not documented in support plan. |
Report Facts
Fine amount per violation: 145
Number of violations listed for fine: 8
Resident census: 29
Total licensed capacity: 56
Staff total daily hours: 46
Waking staff hours: 35
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary, Office of Long-term Living | Signed enforcement letter regarding provisional license and fines. |
| Staff person A | Named in missing resident incident and staff training deficiencies. | |
| Staff person B | Named in missing resident incident and staff training deficiencies. | |
| Staff person C | Named in staff training deficiencies and resident interaction incident. | |
| Staff person D | Named in criminal background check violation. |
Inspection Report
Follow-Up
Census: 30
Capacity: 56
Deficiencies: 3
Nov 7, 2023
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident involving resident #1 eloping from the facility.
Findings
The facility was found to have deficiencies related to resident #1 exiting the home unattended due to a non-functional wander guard system and inadequate supervision. The facility implemented a plan of correction including staff retraining, new wander guard bracelet issuance, daily maintenance checks, and updated resident assessments. Additional deficiencies included incomplete annual medical evaluation documentation for resident #1.
Deficiencies (3)
| Description |
|---|
| Resident #1 exited the home unattended and unsupervised due to a non-functional wander guard bracelet and lack of proper monitoring of exit doors. |
| The home failed to provide necessary physical site accommodations and equipment to ensure resident safety, specifically related to wander guard system installation and door alarms. |
| Resident #1's most recent annual medical evaluation lacked required information including evaluation date, medical professional's signature, and license number. |
Report Facts
License Capacity: 56
Residents Served: 30
Staffing Hours: 46
Waking Staff: 35
Current Hospice Residents: 5
Residents Age 60 or Older: 29
Residents with Mobility Need: 16
Inspection Report
Complaint Investigation
Census: 33
Capacity: 56
Deficiencies: 1
Oct 18, 2021
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 10/18/2021.
Findings
The inspection found a violation where on 9/30/2021, during resident dinner, two staff members left the home simultaneously for approximately 10 minutes, leaving no direct care staff present. The submitted plan of correction was fully implemented and compliance was maintained.
Complaint Details
The visit was complaint-related and the plan of correction was submitted and fully implemented. The complaint involved lack of direct care staff presence during resident dinner on 9/30/2021.
Deficiencies (1)
| Description |
|---|
| On the evening of 9/30/21, during resident dinner, staff member A and staff member B went outside to smoke for approximately 10 minutes, leaving no direct care staff present in the home. |
Report Facts
License Capacity: 56
Residents Served: 33
Current Hospice Residents: 3
Staffing Hours: 34
Waking Staff: 26
Supplemental Security Income Recipients: 1
Residents 60 Years or Older: 32
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 1
Residents with Physical Disability: 0
Notice
Capacity: 56
Deficiencies: 0
Jul 30, 2021
Visit Reason
The document serves as a renewal notification and issuance of a regular license for the Reformed Presbyterian Home Personal Care Home, confirming receipt of the renewal application and advising of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document; it confirms the issuance of a regular license and outlines the Department's plan to conduct an inspection within the next year.
Report Facts
Total licensed capacity: 56
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
| Jason Dolby | Administrator | Recipient of the renewal notification letter |
Inspection Report
Renewal
Deficiencies: 0
Jul 8, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 07/08/2021.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report
Renewal
Census: 27
Capacity: 56
Deficiencies: 18
Apr 5, 2021
Visit Reason
The inspection was conducted as a renewal and complaint investigation of the Reformed Presbyterian Home to assess compliance with applicable regulations and licensing requirements.
Findings
The inspection identified multiple deficiencies including failure to properly label medications, incomplete medical evaluations, inadequate emergency preparedness postings, sanitary condition issues, communication system deficiencies, and medication administration errors. Plans of correction were accepted and implemented for all findings.
Complaint Details
Complaint investigation was part of the inspection due to issues reported by resident #5 regarding theft of personal items through shared bathroom access. The complaint was addressed with installation of locks and resident education.
Deficiencies (18)
| Description |
|---|
| Carbon monoxide detectors outside boiler room and kitchen lacked date of battery replacement. |
| Written receipts for cash disbursements to residents were incomplete and copies were not maintained. |
| Resident #5 reported theft of personal items due to unsecured access through shared bathroom. |
| Criminal background check for staff person B was not completed prior to transfer to personal care department. |
| Staff person A did not receive required fire safety and emergency preparedness orientation on first day. |
| Multiple feces stains found in resident lounge bathroom and resident #1's toilet. |
| No verbal communication system for staff to immediately contact others in emergency; only pendant alert system. |
| Emergency telephone numbers not posted by telephones in activity room and resident #2's bedroom. |
| Leaking pipe under resident #1's bathroom sink. |
| Resident #1 and #3 did not have operable bedside lamps within reach. |
| Emergency preparedness plans were not posted in a public and conspicuous place. |
| Resident #1's annual medical evaluation lacked assessment of medication self-administration and provider identification. |
| Menus posted were outdated and not current for the inspection week. |
| First aid kits on home’s bus and van lacked required items such as thermometer, eye coverings, breathing shield, tweezers, and gloves. |
| Vehicle registrations for bus and van were expired at time of inspection. |
| Resident #3's insulin medication label only included sliding scale instructions, not scheduled doses; Resident #4's medication lacked pharmacy label. |
| Resident #3's blood sugar readings were incorrectly documented on medication administration record. |
| Resident #3 was administered insulin despite blood sugar reading below prescribed threshold. |
Report Facts
License Capacity: 56
Residents Served: 27
Staff Total Daily: 33
Waking Staff: 25
Deficiencies cited: 17
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