Deficiencies (last 4 years)
Deficiencies (over 4 years)
6.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
45% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
50% occupied
Based on a September 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Census: 94
Capacity: 188
Deficiencies: 1
Date: Sep 16, 2025
Visit Reason
The visit was a partial, unannounced follow-up inspection conducted on 09/16/2025 to review the submitted plan of correction related to an incident involving medication storage.
Findings
The submitted plan of correction was determined to be fully implemented. The deficiency involved a punctured blister pack on slot nine found in the medication cart, which was immediately addressed by wasting the exposed medication and re-educating staff. Weekly medication cart audits and staff education were initiated to ensure ongoing compliance.
Deficiencies (1)
A blister pack had a puncture on slot nine and was observed on the medication cart during inspection.
Report Facts
Residents Served: 94
License Capacity: 188
Secured Dementia Care Unit Capacity: 23
Secured Dementia Care Unit Residents Served: 18
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 43
Residents 60 Years of Age or Older: 94
Residents with Physical Disability: 1
Total Daily Staff: 137
Waking Staff: 103
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jun 27, 2025
Visit Reason
The inspection was conducted based on complaints and concerns regarding resident rights violations, grievance accessibility, care plan accuracy, safety hazards, and staff training compliance at Philadelphia Protestant Home.
Complaint Details
The complaint investigation revealed that staff forcibly put a resident to bed without permission, violating resident rights. Bruising was noted on the resident's arms. The grievance process was found inaccessible to residents. Care plans were not updated to address inappropriate resident behavior. Unsafe medication storage and incomplete staff training were also identified.
Findings
The facility was found to have multiple deficiencies including failure to honor resident self-determination rights, lack of accessible grievance forms on nursing units, failure to revise care plans for inappropriate resident behavior, unsafe medication storage practices, and incomplete annual training for nurse aides.
Deficiencies (5)
Failed to ensure one resident exercised the right to go to bed at the time of their choosing; resident was forcibly put to bed without permission resulting in bruising.
Failed to ensure grievance forms were available and accessible to residents on three nursing units.
Failed to revise a resident's care plan related to inappropriate sexual behavior.
Failed to provide a safe environment; medication capsule found unsecured in pantry area near resident tables.
Failed to ensure two nurse aides completed required annual 12-hour in-service training.
Report Facts
Residents reviewed: 23
Grievances logged: 1
Nurse aides missing training: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E7 | Licensed Nurse | Named in resident rights violation for transferring resident without permission |
| Employee E8 | Nurse Aide | Named in resident rights violation for transferring resident without permission |
| Employee E3 | Licensed Nurse | Verified medication capsule found unsecured in pantry area |
| Employee E4 | Social Worker | Conducted facility tour revealing lack of accessible grievance forms |
| Employee E5 | Director of Social Services | Interviewed regarding grievance process and form accessibility |
| Employee E9 | Nurse Aide | Did not complete required annual 12-hour in-service training |
| Employee E10 | Nurse Aide | Did not complete required annual 12-hour in-service training |
Inspection Report
Renewal
Census: 97
Capacity: 188
Deficiencies: 6
Date: May 28, 2025
Visit Reason
The inspection was conducted as a renewal inspection of the Philadelphia Protestant Home facility to review compliance with licensing requirements.
Findings
The inspection found multiple deficiencies including failure to report suspected resident abuse incidents timely, breaches in record confidentiality, improper sanitary conditions during medication administration, improper food storage, and failure to post menus as required. The facility submitted and implemented a plan of correction addressing these issues.
Deficiencies (6)
Failure to immediately report suspected abuse of a resident on 10/29/2024 and other incidents to the Department as required.
Resident records were unlocked, unattended, and accessible in the memory care nurse station on 5/28/2025.
Two treatment carts were left open and unattended in the hallway near the personal care dining room on 5/28/2025.
Staff person was observed using bare, ungloved fingers to remove medication from blister cards during medication pass on 5/29/2025.
Food items in the walk-in freezer were opened and unsealed on 5/28/2025, including roasted garlic loaf, frozen waffles, and sausage links.
Menus for the week of May 25, 2025, and the upcoming week were not posted in memory care and personal care dining hall.
Report Facts
License Capacity: 188
Residents Served: 97
Secured Dementia Care Unit Capacity: 23
Secured Dementia Care Unit Residents Served: 18
Staffing Hours - Total Daily Staff: 144
Staffing Hours - Waking Staff: 108
Residents with Mobility Need: 47
Residents 60 Years or Older: 97
Residents Diagnosed with Mental Illness: 1
Inspection Report
Census: 103
Capacity: 188
Deficiencies: 0
Date: Mar 13, 2025
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 103
License Capacity: 188
Secured Dementia Care Unit Capacity: 23
Residents Served in Secured Dementia Care Unit: 18
Resident Support Staff: 0
Total Daily Staff: 150
Waking Staff: 113
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 0
Residents with Mobility Need: 47
Residents with Physical Disability: 3
Residents Age 60 or Older: 103
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Sep 19, 2024
Visit Reason
The inspection was conducted to investigate complaints related to inadequate supervision and failure to use assistive devices to prevent elopement for Resident R108, improper use of psychotropic medication orders for Resident R21, and failure to ensure binding arbitration agreements contained required regulatory language for residents.
Complaint Details
The complaint investigation focused on Resident R108's elopement incident on May 18, 2024, where the resident exited the facility without a wander-guard device and was found outside the building. The investigation also included review of PRN psychotropic medication orders for Resident R21 and the facility's binding arbitration agreements for residents.
Findings
The facility failed to adequately supervise Resident R108 who eloped from the nursing unit without an alarm device, failed to limit PRN psychotropic medication orders to 14 days with documented rationale for Resident R21, and failed to include required regulatory language in binding arbitration agreements for 102 residents.
Deficiencies (3)
Failed to adequately supervise one resident and use assistive devices to prevent elopement (Resident R108).
Failed to ensure PRN orders for psychotropic drugs are limited to 14 days without documented rationale (Resident R21).
Failed to ensure binding arbitration agreements contained required regulatory language for 102 residents.
Report Facts
Residents reviewed for elopement: 23
Residents reviewed for medication regimen: 5
Residents signed arbitration agreement: 102
Residents refused arbitration agreement: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E1 | Nursing Home Administrator | Interviewed regarding elopement incident and arbitration agreement deficiencies |
| Employee E2 | Director of Nursing | Interviewed regarding elopement incident and wander-guard device usage |
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Nov 3, 2023
Visit Reason
The inspection was conducted to investigate complaints and allegations related to resident care, medication errors, infection control, emergency transfers, rehabilitation services, food safety, and immunization practices at Philadelphia Protestant Home.
Complaint Details
The visit was complaint-related, triggered by allegations of inadequate investigation of resident injury, failure to notify ombudsman of emergency transfers, medication errors, improper food storage, lack of rehabilitation services assessment, infection control deficiencies, antibiotic stewardship failures, and immunization lapses.
Findings
The facility was found deficient in multiple areas including failure to conduct thorough investigations of resident injuries, failure to notify the State Long-Term Care Ombudsman of emergency transfers, medication error rates exceeding 5%, improper food storage, failure to assess need for specialized rehabilitation services, inadequate infection prevention and control program, ineffective antibiotic stewardship program, and failure to ensure residents received pneumococcal vaccinations.
Deficiencies (8)
Failed to conduct a complete and thorough investigation of a resident injury sustained during transfer.
Failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges for three residents.
Medication error rate was 8%, exceeding the 5% threshold, including errors in medication preparation and patch application.
Food was stored improperly with opened, unlabeled items and expired products in the walk-in refrigerator and freezer.
Failed to assess the need for specialized occupational therapy services for a resident with severe shaking affecting eating.
Failed to implement appropriate tracking and surveillance of infections for seven months.
Failed to maintain an effective antibiotic stewardship program including monitoring antibiotic usage for seven months.
Failed to ensure residents received pneumococcal immunizations or documented evidence of vaccination or refusal for three residents.
Report Facts
Medication administration opportunities observed: 25
Residents reviewed for emergency transfers: 22
Residents reviewed for immunization concerns: 5
Months of infection control and antibiotic stewardship data reviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E7 | Nursing Aide | Named in resident injury transfer investigation. |
| Employee E2 | Director of Nursing | Confirmed lack of statements and investigation details; confirmed lack of infection surveillance and antibiotic stewardship program. |
| Employee E8 | Licensed Practical Nurse | Observed medication errors during administration. |
| Employee E4 | Director of Dining | Confirmed food storage deficiencies. |
| Employee E5 | Dietary Manager | Participated in dietary department tour. |
| Employee E9 | Director of Therapy | Confirmed failure to assess need for occupational therapy. |
| Employee E10 | Dietician | Requested occupational therapy screen for resident. |
| Employee E11 | Registered Nurse | Confirmed resident tremors and lack of therapy screen. |
| Employee E3 | Infection Control Nurse | Confirmed lack of infection tracking and pneumococcal vaccination documentation. |
Inspection Report
Renewal
Census: 120
Capacity: 188
Deficiencies: 4
Date: Mar 29, 2023
Visit Reason
The inspection was conducted as a renewal visit to review the facility's compliance and the submitted plan of correction.
Findings
The facility was found to have several deficiencies related to fire extinguisher maintenance, medication storage and transcription errors, and medication record keeping. All deficiencies were addressed with corrective plans and were fully implemented by the time of the report.
Deficiencies (4)
Fire extinguisher W-3 in the Webb wing was overcharged and replaced immediately.
Incorrect transcription of accu check results into electronic medical records by staff.
PRN medication was not available in the medication cart but was corrected immediately.
Incorrect transcription of date on narcotic medication record; medication was administered twice without proper signature documentation.
Report Facts
Residents Served: 120
License Capacity: 188
Secured Dementia Care Unit Capacity: 23
Secured Dementia Care Unit Residents Served: 22
Hospice Current Residents: 2
Residents 60 Years or Older: 120
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 76
Total Daily Staff: 196
Waking Staff: 147
Notice
Capacity: 188
Deficiencies: 0
Date: Oct 14, 2021
Visit Reason
The document serves as a renewal notification and license issuance for Philadelphia Protestant Home, a 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 is an administrative notice confirming license renewal and outlining future inspection requirements.
Report Facts
Maximum capacity: 188
Secure Dementia Care Unit capacity: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter. |
Inspection Report
Renewal
Census: 123
Capacity: 188
Deficiencies: 0
Date: Sep 20, 2021
Visit Reason
The inspection was conducted as a renewal licensing inspection of the Philadelphia Protestant Home.
Findings
No regulatory citations or deficiencies were identified as a result of this unannounced full renewal inspection conducted on 09/20/2021 and 09/22/2021.
Report Facts
Residents Served: 123
License Capacity: 188
Secured Dementia Care Unit Capacity: 23
Residents Served in Secured Dementia Care Unit: 22
Hospice Current Residents: 4
Residents Age 60 or Older: 123
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 53
Residents with Physical Disability: 1
Inspection Report
Complaint Investigation
Census: 122
Capacity: 188
Deficiencies: 0
Date: May 7, 2021
Visit Reason
The inspection was conducted as a complaint investigation, with an unannounced partial inspection on 05/07/2021.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were substantiated.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 188
Residents Served: 122
Secured Dementia Care Unit Capacity: 23
Secured Dementia Care Unit Residents Served: 22
Hospice Current Residents: 5
Residents with Mobility Need: 55
Residents 60 Years or Older: 122
Residents with Physical Disability: 2
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