Deficiencies (last 4 years)
Deficiencies (over 4 years)
40 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
751% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
36
27
18
9
0
Census
Latest occupancy rate
43% occupied
Based on a October 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 24, 2025
Visit Reason
The inspection was conducted due to complaints regarding neglect and inadequate supervision resulting in harm to residents, including an incident involving Resident R2 during transfer and an elopement incident involving Resident R1.
Complaint Details
The complaint investigation found substantiated neglect related to inadequate supervision during resident transfers and failure to prevent elopement. Resident R2 was injured during a transfer when a mechanical lift tilted and the resident was lowered to the floor. Resident R1 eloped from the facility for approximately seven hours before being safely returned by staff assistance.
Findings
The facility failed to ensure residents were free from neglect by not providing adequate supervision and assistance during transfers for Resident R2, resulting in injury. Additionally, the facility failed to provide adequate supervision that resulted in an elopement of Resident R1, who left the premises unsupervised for several hours before being safely returned.
Deficiencies (2)
Failure to protect Resident R2 from neglect by not ensuring adequate supervision and assistance during transfers, resulting in a fall and injury.
Failure to ensure adequate supervision to prevent accidents, resulting in an elopement of Resident R1.
Report Facts
Residents reviewed for neglect: 3
Residents affected by elopement: 1
Duration of elopement: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E1 | Nurse Aide (NA) | Named in the finding related to Resident R2's transfer incident. |
| Employee E2 | Laundry Worker (LW) | Assisted Resident R1 in returning to the facility after elopement. |
| Employee E3 | Licensed Practical Nurse (LPN) | Confirmed details regarding Resident R1's elopement. |
Inspection Report
Complaint Investigation
Census: 24
Capacity: 56
Deficiencies: 0
Date: Oct 14, 2025
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection on 10/14/2025.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
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
Complaint Investigation
Deficiencies: 12
Date: Jun 18, 2025
Visit Reason
The inspection was conducted to investigate complaints related to resident confidentiality, neglect, failure to communicate necessary resident information during transfers, care plan deficiencies, inadequate assistance with activities of daily living, pressure ulcer care, colostomy care, respiratory care, pharmaceutical services, medication regimen reviews, medication storage, and food safety and sanitation.
Complaint Details
The visit was complaint-related, investigating multiple allegations including failure to maintain confidentiality, neglect, inadequate care, and improper facility practices. Substantiation status is not explicitly stated.
Findings
The facility was found to have multiple deficiencies including failure to maintain residents' confidential records, neglect in care practices, inadequate communication during resident transfers, failure to update care plans, insufficient assistance with activities of daily living, inadequate pressure ulcer care, improper colostomy care, failure to maintain respiratory equipment, missed medication administrations, lack of monthly medication regimen reviews, improper medication storage, and failure to monitor food temperatures and maintain kitchen sanitation.
Deficiencies (12)
Failed to maintain residents' confidential personal and medical records for one of five residents (Resident R7).
Failed to maintain an environment free of neglect and provide necessary goods and services for one of four sampled residents (Resident R26).
Failed to make certain that necessary resident information was communicated to the receiving health care provider for one out of two residents sampled with facility-initiated transfers (Resident R34).
Failed to ensure that a resident's care plan was updated and revised to reflect the resident's specific care needs for one of six residents (Resident R197).
Failed to provide Activity of Daily Living (ADL) assistance for one out of two residents (Resident R34).
Failed to ensure residents were assessed, and provided necessary treatment and services, consistent with professional standards of practice, for a pressure ulcer for one of five residents (Resident R147).
Failed to make certain that appropriate treatments and services were provided for the use of a colostomy as required for one of three residents (Resident R20).
Failed to provide appropriate respiratory care and maintain oxygen equipment for one of three sampled residents (Resident R17).
Failed to implement pharmaceutical services to ensure availability and administration of prescribed medications for one of three sampled resident records (Closed Resident Record CR145).
Failed to provide documentation of medication regimen reviews (MRR) completed at least monthly for two of three sampled resident records (Resident R4 and R20).
Failed to properly store medications for one of four residents (Resident R34).
Failed to properly monitor food temperatures and failed to properly maintain kitchen equipment in a sanitary condition creating the potential for cross contamination in the main kitchen of the facility.
Report Facts
Missed medication doses: 5
Meals served with no recorded food temperatures: 41
Medication regimen reviews missing: 6
Medication regimen reviews missing: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse | Employee E1 confirmed observations related to confidentiality breach and oxygen line dated 6/1/25. | |
| Nursing Home Administrator | Notified of multiple deficiencies including confidentiality breach, neglect, and failure to communicate resident information. | |
| Director of Nursing | Confirmed multiple deficiencies including pharmaceutical services failure and medication regimen review documentation failure. | |
| Registered Nurse | Employee E2 confirmed failure to document showers and medication regimen reviews. | |
| Director of Food Service | Employee E6 confirmed failure to maintain kitchen equipment and monitor food temperatures. | |
| Registered Nurse Assessment Coordinator | Employee E5 confirmed failure to update care plan for Resident R197. |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jun 18, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to pressure ulcer care and pharmaceutical services in the facility.
Findings
The facility failed to ensure appropriate assessment and treatment of a pressure ulcer for one resident and failed to implement pharmaceutical services to ensure availability and administration of prescribed medications for another resident.
Deficiencies (2)
Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for Resident R147.
Failed to implement pharmaceutical services to ensure availability and administration of prescribed medications for Closed Resident Record CR145.
Report Facts
Residents affected: 5
Residents affected: 3
Missed medication doses: 5
Skin assessment dates missed: 3
Pressure injury size: 1.5
Pressure injury size: 1.5
Pressure injury size: 0.1
MASD size: 1
MASD size: 1.5
MASD size: 0.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | NHA | Confirmed failure to ensure Resident R147 was assessed and treated for pressure ulcer |
| Director of Nursing | DON | Confirmed failure to implement pharmaceutical services for Closed Resident Record CR145 |
Inspection Report
Renewal
Census: 27
Capacity: 56
Deficiencies: 7
Date: 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)
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
Date: 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)
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
Complaint Investigation
Deficiencies: 1
Date: Feb 27, 2025
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to protect residents from neglect, specifically concerning Resident R1 who was found unattended outside the facility.
Complaint Details
The complaint investigation found that Resident R1 was observed outside the facility unattended due to a door not latching properly. The maintenance employee who worked on the door failed to secure it and did not inform staff, leading to neglect. The Nursing Home Administrator confirmed these findings and the maintenance employee was written up.
Findings
The facility failed to protect Resident R1 from neglect when an employee entrance door was not properly secured, allowing the resident to leave the facility unattended. Maintenance staff failed to repair the door and did not inform others that the door was unsecured, resulting in Resident R1 being found outside the facility.
Deficiencies (1)
Failure to protect residents from neglect, allowing Resident R1 to be unattended outside the facility due to an unsecured employee entrance door.
Report Facts
Residents affected: 3
Time of door issues: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E1 | Maintenance | Responsible for fixing the employee entrance door but failed to secure it and inform staff |
| Employee E4 | Registered Nurse | Administered medication to Resident R1 and later assessed Resident R1 for injury after resident was found outside |
| Employee E7 | Licensed Practical Nurse | Found Resident R1 outside by employee entrance in upper parking lot |
| Nursing Home Administrator | Confirmed maintenance employee failed to inform staff about unsecured door |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 22, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure resident safety and prevent an elopement incident involving Resident R1, and failure to complete a thorough investigation after the incident.
Complaint Details
The complaint investigation found that Resident R1 eloped from the facility on 11/2/24 without staff knowledge or supervision. The facility did not have a documented whole house re-education on elopement prevention following the incident. Resident R1 was found outside at a bus stop and returned by staff. The investigation was incomplete, missing statements from some staff and updated risk postings.
Findings
The facility failed to prevent Resident R1 from leaving the premises unaccompanied and did not conduct a complete investigation following the incident. Resident R1 exited the building without staff supervision, and the facility lacked documented whole house re-education on elopement prevention. Staff interviews and video review confirmed the incident and gaps in supervision and follow-up.
Deficiencies (2)
Failure to ensure resident safety and prevent an elopement.
Failure to complete a thorough investigation after the elopement incident.
Report Facts
Residents sampled: 7
Wander risk score: 2
Date of incident: Nov 2, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E1 | Nurse Aide (NA) | Provided interview about Resident R1's behavior and re-education |
| Employee E2 | Registered Nurse (RN) Supervisor | Reported on incident and communication with Nursing Home Administrator |
| Employee E3 | Registered Nurse (RN) | Observed and assisted in returning Resident R1 to the facility |
| Employee E4 | Registered Nurse (RN) | Provided interview about Resident R1's activities and re-education |
| Employee E5 | Occupational Therapist | Observed Resident R1 outside and notified staff and administration |
| Employee E6 | Licensed Practical Nurse (LPN) | Assisted in returning Resident R1 and assessed for injuries |
| Employee E7 | Activity Aide | Mentioned in investigation as missing statement |
| Director of Nursing (DON) | Director of Nursing | Confirmed lack of whole house re-education and was notified of incident |
| Nursing Home Administrator (NHA) | Nursing Home Administrator | Notified of the elopement incident and investigation findings |
Inspection Report
Renewal
Census: 27
Capacity: 56
Deficiencies: 14
Date: 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)
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
Date: 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)
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
Routine
Deficiencies: 11
Date: Aug 14, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, medication management, infection control, and staff competencies at the Reformed Presbyterian Home.
Findings
The facility was found deficient in multiple areas including failure to document notification of changes in resident condition, failure to maintain a safe and homelike environment, incomplete care plans, inadequate pressure ulcer care, improper respiratory equipment maintenance, incomplete dialysis communication, lack of staff competency training on new medical devices, incomplete nurse aide performance evaluations, failure to provide appropriate mental health services, improper medication storage and labeling, and failure to implement infection control practices.
Deficiencies (11)
Failed to document notification of changes in one of three residents reviewed (Resident R36) regarding elevated glucose levels.
Failed to provide a clean, safe, comfortable, and homelike environment for one of five resident rooms (Resident R55).
Failed to develop and implement comprehensive care plans to meet care needs for two of four residents (Resident R9 and R15).
Failed to accurately monitor and provide comprehensive assessments of a pressure area for one of three residents (Resident R17).
Failed to maintain sanitary conditions of respiratory equipment for one of three residents (Resident R49).
Failed to provide consistent and complete communication with the dialysis center for one resident receiving hemodialysis (Resident R15).
Failed to ensure nursing staff have the specific competencies and skill sets necessary to provide care for residents with FreeStyle Libre 3 glucose monitoring system (Residents R9 and R15).
Failed to complete annual performance evaluations for two nurse aides (Employees E8 and E9).
Failed to provide appropriate treatment and services for highest practicable mental and psychosocial services for one resident (Resident R28).
Failed to properly store medical supplies and biologicals in medication rooms and carts, failed to secure medications, and failed to date open medications.
Failed to implement infection control practices to prevent cross contamination during dressing change for one resident (Resident R17) and during administration of eye drops for another resident (Resident R261).
Report Facts
Residents reviewed: 3
Resident rooms observed: 5
Residents with incomplete care plans: 2
Residents with pressure ulcer assessment issues: 1
Residents with respiratory equipment issues: 1
Residents receiving hemodialysis: 1
Nurse aides with missing evaluations: 2
Residents with mental health service deficiencies: 1
Medication carts observed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E6 | Registered Nurse Unit Manager | Confirmed failure to document notification of elevated glucose and lack of staff in-service on FreeStyle Libre system |
| Employee E3 | Licensed Practical Nurse | Confirmed environmental issues, respiratory equipment issues, dialysis communication issues, medication storage issues, and infection control failures |
| Employee E5 | Registered Nurse / Infection Control Preventionist | Confirmed care plan deficiencies and pressure ulcer assessment failures |
| Employee E2 | Registered Nurse | Confirmed respiratory equipment and medication storage issues, and infection control failures |
| Employee E7 | Registered Nurse | Observed failing to perform hand hygiene during dressing change |
| Employee E11 | Social Service | Confirmed failure to provide mental health services for Resident R28 |
| Employee E10 | Director of Human Resources | Confirmed missing annual performance evaluations for nurse aides |
| Employee E4 | Licensed Practical Nurse | Confirmed medication storage violations in medication room and carts |
Inspection Report
Follow-Up
Census: 28
Capacity: 56
Deficiencies: 2
Date: 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)
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
Complaint Investigation
Deficiencies: 1
Date: Mar 9, 2024
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to provide appropriate care and service for pressure ulcers for one of three residents reviewed.
Complaint Details
Based on facility policy and procedure review, clinical record review, and staff interview, it was determined the facility failed to provide care and service for pressure ulcers for one of three residents reviewed (Resident 1).
Findings
The facility failed to provide adequate pressure ulcer care, as evidenced by Resident 1 having multiple pressure ulcers including a new stage 3 ulcer that was not documented timely. The wound was first discovered during weekly wound rounds by the Wound CRNP but should have been documented earlier by staff.
Deficiencies (1)
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing.
Report Facts
Pressure ulcer dimensions: 7
Pressure ulcer dimensions: 3
Pressure ulcer dimensions: 0.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Employee E3 | Interviewed regarding wound documentation and discovery | |
| Wound CRNP (Certified Registered Nurse Practitioner) | Performed weekly wound rounds and discovered the new pressure ulcer |
Inspection Report
Enforcement
Census: 29
Capacity: 56
Deficiencies: 35
Date: Nov 14, 2023
Visit Reason
The inspection was conducted as a renewal and complaint investigation of the Reformed Presbyterian Home.
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.
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.
Deficiencies (35)
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
Date: 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.
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.
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.
Deficiencies (25)
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
Date: 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)
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
Deficiencies: 7
Date: Sep 29, 2023
Visit Reason
The inspection was conducted based on complaints and concerns regarding resident rights, care planning, medication administration, hearing and vision services, infection control, and compliance with Medicaid/Medicare notification requirements.
Complaint Details
The visit was complaint-related, triggered by allegations of failure to honor resident rights, failure to provide required notices, inadequate care planning, medication errors, failure to provide hearing services, and infection control deficiencies. Substantiation status is not explicitly stated.
Findings
The facility was found deficient in multiple areas including failure to offer residents the opportunity to vote, failure to provide Medicaid/Medicare advanced beneficiary notices timely, lack of comprehensive care plans for residents, medication administration errors including administering medication from another resident's card, failure to provide hearing assistive devices and services, failure to maintain updated COVID-19 policies and proper hand hygiene, and failure to maintain medication error rates below 5%.
Deficiencies (7)
Failed to offer residents the opportunity to vote for five of thirteen residents.
Failed to provide Skilled Nursing Facility Advanced Beneficiary Form (SNF ABN CMS 10055) within 48 hours before services ended for one resident.
Failed to develop comprehensive care plans for one of twelve residents reviewed.
Failed to provide care and services to meet accepted standards of practice for one of four residents, including administering another resident's medication.
Failed to provide hearing assistive devices, treatment and services to one of two residents reviewed.
Medication error rate exceeded 5 percent for two of four residents.
Failed to maintain and implement updated COVID-19 policies and failed to perform hand hygiene for one of four residents.
Report Facts
Residents affected: 5
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Medication error rate: 7.69
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E3 | Social Services | Confirmed failure to provide SNF ABN CMS-10055 form within 48 hours |
| Employee E7 | Licensed Practical Nurse (LPN) | Administered medication from another resident's card and failed to administer Senna medication properly |
| Employee E6 | Licensed Practical Nurse (LPN) | Failed to perform hand hygiene and wear gloves during insulin administration |
| Nursing Home Administrator | Confirmed multiple deficiencies including failure to offer voting opportunity, medication errors, lack of care plans, failure to provide hearing services, and infection control policy deficiencies | |
| Director of Nursing (DON) | Confirmed outbreak status and failure to maintain updated COVID-19 policies and hand hygiene standards |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Apr 28, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to review and revise resident care plans, failure to follow physician orders related to Wanderguard placement, and failure to ensure resident safety resulting in elopement.
Complaint Details
The complaint investigation was substantiated as the facility failed to revise care plans, follow physician orders for Wanderguard placement, and prevent elopement, resulting in Immediate Jeopardy for Resident R1.
Findings
The facility failed to review and revise a resident care plan to reflect current status and needs, failed to follow physician orders to ensure Wanderguard placement for an elopement risk resident, and failed to prevent the elopement of a resident resulting in an Immediate Jeopardy situation. Corrective actions including updated assessments, care plans, staff education, and policy revisions were implemented.
Deficiencies (3)
Failed to review and revise a resident care plan to reflect current status and needs for one of six residents (Resident R1).
Failed to follow physician orders as required to ensure a Wanderguard device was in place for one of six elopement risk residents (Resident R2).
Failed to ensure resident safety and to prevent the elopement of a resident which resulted in an Immediate Jeopardy situation for one of 55 residents (Resident R1).
Report Facts
Residents affected: 1
Residents affected: 1
Total residents at risk for elopement: 5
Staff training completion: 93
Residents with elopement screening completed: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed care plan and resident specific interventions for Resident R1 were not revised after elopement | |
| Registered Nurse Supervisor Employee E5 | Observed Resident R2 without Wanderguard and confirmed failure to follow physician orders | |
| Nursing Home Administrator | Reported facility had five residents at elopement risk and confirmed Immediate Jeopardy situation | |
| Nursing Assistant Employee E2 | Reported Resident R1 removed Wanderguard and commented on staffing difficulties during evening care | |
| Registered Nurse Employee E4 | Reported Resident R1 kept removing Wanderguard and verbalized wanting to leave | |
| Registered Nurse Employee E3 | Reported Resident R1 was savvy and knew how to trigger alarm and leave during PM care |
Inspection Report
Complaint Investigation
Census: 33
Capacity: 56
Deficiencies: 1
Date: Oct 18, 2021
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 10/18/2021.
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.
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.
Deficiencies (1)
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
Date: 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
Date: 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
Date: 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.
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.
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.
Deficiencies (18)
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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