Inspection Reports for Shenango Presbyterian Home
238 SOUTH MARKET STREET,, PA, 16142
Back to Facility ProfileDeficiencies per Year
16
12
8
4
0
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Follow-Up
Census: 39
Capacity: 46
Deficiencies: 3
May 12, 2025
Visit Reason
The inspection was an unannounced partial review conducted due to an incident, with follow-up reviews related to a submitted plan of correction.
Findings
The facility was found to have deficiencies related to resident abuse reporting, verbal abuse by staff, and failure to follow prescriber's medication orders. The submitted plan of correction was accepted and determined to be fully implemented as of the follow-up review.
Deficiencies (3)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident as required by regulations. |
| Resident was verbally abused by staff who yelled at the resident after an aggressive incident. |
| Medication prescribed to a resident was not administered due to unavailability in the home. |
Report Facts
License Capacity: 46
Residents Served: 39
Secured Dementia Care Unit Capacity: 14
Secured Dementia Care Unit Residents Served: 13
Current Hospice Residents: 2
Residents Age 60 or Older: 39
Residents with Mental Illness: 2
Residents with Mobility Need: 20
Inspection Report
Renewal
Census: 36
Capacity: 46
Deficiencies: 5
Nov 18, 2024
Visit Reason
The inspection was a renewal review conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, to assess compliance and verify the submitted plan of correction.
Findings
The inspection identified multiple deficiencies including unsecured heat sources accessible to residents, undated food items, outdated food in storage, medication labeling errors, and incorrect posted codes for key-locking devices. All deficiencies had corrective plans accepted and were implemented with ongoing monitoring scheduled.
Deficiencies (5)
| Description |
|---|
| Steam table in an unsecured cabinet in the secured dementia care unit's kitchen with an outside temperature of approximately 164°F accessible to residents. |
| Multiple zip lock bags of vegetables and a container of peaches in the secured dementia care unit's refrigerator were not dated. |
| Multiple undated food items including cookie pucks, mixed vegetables, and diced peppers located in the main kitchen's walk-in freezer. |
| Prescription medications had labels inconsistent with prescribed dosages, including one medication labeled for two soft gel tablets daily when prescribed one capsule daily. |
| Magnetically locked exit had an incorrect posted magnetic lock code that could not be used to operate the locking mechanism. |
Report Facts
License Capacity: 46
Residents Served: 36
Secured Dementia Care Unit Capacity: 14
Secured Dementia Care Unit Residents Served: 10
Current Hospice Residents: 2
Resident with Mobility Need: 20
Resident Age 60 or Older: 36
Total Daily Staff: 56
Waking Staff: 42
Inspection Report
Complaint Investigation
Census: 34
Capacity: 46
Deficiencies: 7
Jul 30, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation following allegations of resident abuse and other regulatory concerns.
Findings
The inspection found multiple violations including delayed reporting of suspected resident abuse, failure to suspend or supervise the alleged perpetrator, incomplete medical evaluations, outdated resident assessments, and unsigned resident support plans. The facility submitted plans of correction which were accepted and later fully implemented.
Complaint Details
The visit was complaint-related, triggered by allegations of resident abuse involving staff. The complaint was substantiated with findings of delayed reporting and inadequate supervision of the alleged perpetrator.
Deficiencies (7)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident to the local Area Agency on Aging. |
| Failure to submit a plan of supervision or notice of suspension for the affected staff person after abuse allegation. |
| Failure to report the incident or condition to the Department within 24 hours as required. |
| Direct care staff provided unsupervised ADL services without completing Department-approved training and competency test. |
| Medical evaluation not documented on a Department-specified form within required timeframe. |
| Resident assessment not updated to reflect significant changes in condition. |
| Resident support plan was not signed by the resident nor documented reasons for lack of signature. |
Report Facts
License Capacity: 46
Residents Served: 34
Staff Working Hours: 44
Waking Staff Hours: 33
Residents in Secured Dementia Care Unit: 10
Capacity of Secured Dementia Care Unit: 14
Residents Age 60 or Older: 34
Residents Diagnosed with Mental Illness: 19
Residents with Mobility Need: 10
Dates Staff Person B Worked Post-Allegation: 10
Inspection Report
Follow-Up
Census: 40
Capacity: 46
Deficiencies: 4
Jan 23, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit to review the submitted plan of correction for the facility.
Findings
The submitted plan of correction was determined to be fully implemented as of the inspection dates. Deficiencies related to staff training records, medication administration documentation, additional resident assessments, and support plan signatures were corrected with ongoing monitoring and education planned.
Deficiencies (4)
| Description |
|---|
| The home's record of staff training did not include the date and length of training for staff trainings completed between 11/1/23 and 12/31/23. |
| Resident medication administration record did not include the initials of the staff person who administered the medication at the prescribed time. |
| Resident's most recent assessment of care needs on record was incomplete or had incorrect dates. |
| Resident's most recent support plan was completed but signatures by the resident and assessor were delayed. |
Report Facts
License Capacity: 46
Residents Served: 40
Secured Dementia Care Unit Capacity: 14
Residents Served in Dementia Unit: 14
Hospice Residents: 3
Staffing Hours: 60
Waking Staff: 45
Inspection Report
Renewal
Census: 38
Capacity: 46
Deficiencies: 15
Oct 19, 2023
Visit Reason
The inspection was conducted as a renewal and incident review of Shenango Presbyterian Home on 10/19/2023, 10/20/2023, and 10/27/2023 to verify compliance and implementation of the submitted plan of correction.
Findings
The inspection identified multiple deficiencies related to staff training, safety protocols, medication administration, and documentation. The facility submitted plans of correction for all violations, which were accepted and later determined to be fully implemented by the report date.
Deficiencies (15)
| Description |
|---|
| Staff person A did not receive training in medication self-administration or instruction on meeting residents' needs during training year 1/1/22 - 12/31/22. |
| Staff persons A and B did not receive required annual training in fire safety, emergency preparedness, resident rights, and the Older Adult Protective Services Act during training year 1/1/22 to 12/31/22. |
| The home's record of staff training for staff persons A and B did not include source, content, or length for training year 1/1/22 - 1/31/22. |
| Poisonous materials were found unlocked and accessible to residents in the secured dementia care unit kitchenette. |
| Trash receptacles in kitchens and bathrooms were uncovered or had holes in lids, allowing penetration of insects and rodents. |
| Emergency telephone numbers were not posted by telephones in the pantry kitchenette and ground floor staff dining room. |
| A used and unlabeled bar of soap was found in the 2nd floor spa room. |
| No thermometer was present in the refrigerator section of the 2nd floor kitchenette refrigerator. |
| Fire extinguishers in multiple locations had not been inspected by a fire safety expert since June 2022. |
| Resident #2's medication label did not include the correct prescribed dosage instructions. |
| Staff person C was found with 11 resident medication packets and loose pills in their car, off the facility's property, and had signed medication administration records falsely indicating administration. |
| Staff person D administered medication prescribed for resident #11 to resident #10. |
| Resident #12's preadmission screening form did not include a determination that the resident's needs could be met by the home. |
| Resident #2's support plan was not signed by the assessor or resident, nor did it indicate the resident was unable or declined to sign. |
| Staff person C completed a modified medication administration training course but did not complete the standard course prior to 7/31/23. |
Report Facts
Inspection dates: 3
Residents served: 38
License capacity: 46
Staff training hours: 61
Waking staff hours: 46
Secured dementia care unit capacity: 14
Secured dementia care unit residents served: 13
Hospice residents: 2
Residents with mental illness: 5
Residents with mobility need: 23
Residents aged 60 or older: 38
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in deficiencies related to lack of training and incomplete training records | |
| Staff person B | Named in deficiencies related to lack of training and incomplete training records | |
| Staff person C | Named in medication administration violations including medication packets found offsite and falsified records; also noted for incomplete medication training | |
| Staff person D | Named in medication administration error administering medication to wrong resident | |
| Director of Personal Care | Responsible for audits and reporting findings at quarterly QAPI meetings | |
| Director of Environmental Services | Responsible for correcting environmental safety issues such as poisonous materials and trash receptacles | |
| Director of Dining Services | Responsible for ensuring refrigerator thermometers and temperature audits | |
| Personal Care Home Administrator | Responsible for education, audits, and oversight of compliance with regulations |
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 23, 2022
Visit Reason
The document confirms that the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, reviewed the facility's submitted plan of correction on 08/23/2022 and 08/24/2022.
Findings
The submitted plan of correction was determined to be fully implemented, and continued compliance must be maintained.
Notice
Capacity: 46
Deficiencies: 0
Sep 7, 2021
Visit Reason
The document serves as a renewal notification and license issuance for Shenango Presbyterian 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; the document confirms issuance of a regular license and advises that enforcement action will be taken if noncompliance is found during future inspections.
Report Facts
Maximum capacity: 46
Secure Dementia Care Unit capacity: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
Inspection Report
Renewal
Census: 34
Capacity: 46
Deficiencies: 5
Aug 10, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the Shenango Presbyterian Home to assess compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including lack of carbon monoxide alarms near gas dryers, improper refrigerator/freezer temperatures, unsealed food storage, improperly stored medications, and inadequate posting of key-locking device operation instructions. All deficiencies had plans of correction accepted and were addressed either on-site or through follow-up submissions.
Deficiencies (5)
| Description |
|---|
| No carbon monoxide alarms near the 2 commercial gas dryers in the laundry room. |
| Refrigerator/freezer temperatures were above required levels and missing thermometers in some freezers and refrigerators. |
| Food items were opened and unsealed in various storage locations including freezer and pantry. |
| Resident #1's medication was opened but not marked with the date it was opened, violating manufacturer instructions. |
| Directions for operating the Secure Dementia Care Unit locking mechanism were not conspicuously posted near the door. |
Report Facts
License Capacity: 46
Residents Served: 34
Secured Dementia Care Unit Capacity: 14
Secured Dementia Care Unit Residents Served: 13
Hospice Residents: 4
Total Daily Staff: 57
Waking Staff: 43
Residents with Mobility Need: 23
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