Inspection Reports for
Reformed Presbyterian Home

The facility was found to have fully implemented the submitted plan of correction. Deficiencies related to resident abuse reporting, treatment of residents, privacy violations due to video surveillance, outdated medical evaluations and assessments, and confidentiality of resident records were addressed with corrective actions and staff education.

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.

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.

The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.

No regulatory citations or deficiencies were identified as a result of this inspection.

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.

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.

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.

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.

The invoice details the total balance due of $2,842.00, with no current charges and payments since the last invoice totaling $2,842.00. No inspection findings or deficiencies are reported.

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.

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.

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.

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.

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.

The invoice details the balance due, payments made, and total charges for the facility's licensing assessment. No inspection findings or compliance information is included.

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.

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.

The facility was found to have uncorrected violations of 55 Pa. Code Chapter 2600 sections 184a and 187a, resulting in assessed fines totaling $2,610 for the period from April 24, 2024 to May 2, 2024.

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.

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).

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.

The inspection was complaint-related and substantiated with multiple violations found, including failure to report incidents, medication errors, and inadequate staff training and documentation.

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.

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.

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.

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%.

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.

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.

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.

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.

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.

No regulatory citations were identified as a result of this inspection.

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.

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.

The submitted plan of correction was determined to be fully implemented. The facility maintained compliance with regulations related to resident treatment and direct care staff training.

No inspection findings are reported in this document. It confirms the issuance of a regular license and states that the Department will conduct an inspection within the next twelve months.

Multiple violations of 55 Pa. Code Chapter 2600 were found, including issues with resident records access, quality management plan, staff lists, fire safety training, sanitary conditions, emergency phone postings, medication management, resident assessments, and fire evacuation procedures. Plans of correction were submitted and partially or fully implemented by August 15, 2019.

The inspection was complaint-driven. The complaint was substantiated as violations were found regarding resident rights and medication administration.

Violations of 55 Pa.Code Chapter 2600 were found related to resident rights and medication administration. Staff failed to provide prescribed Tylenol to a resident and did not treat the resident with dignity and respect as required.

No inspection findings are reported in this document. It is an administrative notice confirming license renewal and outlining future inspection requirements.

Multiple violations of 55 Pa. Code Chapter 2600 were found, including issues with resident contracts, staff training, emergency preparedness, medication administration, fire safety, and record keeping. Plans of correction were submitted with partial implementation progress noted.

The Department acknowledges receipt of the renewal application and states that an onsite inspection will be conducted within the next twelve months as required by law. No findings or deficiencies are reported in this document.

Multiple violations were found related to posting of licenses, resident privacy, staff training, water temperature, emergency telephone numbers, medication labeling and administration, resident assessments, and documentation. Plans of correction were submitted and partially implemented as of June 2017.

No regulatory violations were identified as a result of this inspection.

No inspection findings are reported in this document. It only confirms the license renewal and outlines the Department's inspection requirements.

Multiple violations of 55 Pa.Code Chapter 2600 were found, including deficiencies in staff training, sanitary conditions, lighting, fire drill evacuation times, medication administration records, and resident support plan documentation. Plans of correction were submitted for each violation with partial implementation noted as of August 12, 2016.

No inspection findings are reported in this document. It serves as a license renewal notification with a reminder of the upcoming annual inspection requirement.

The invoice details the balance due, payments made, and total charges for the facility's licensing assessments. No inspection findings or compliance information is included.