Pennsylvania Department of Health
REFORMED PRESBYTERIAN HOME
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

REFORMED PRESBYTERIAN HOME
Inspection Results For:

There are 118 surveys for this facility. Please select a date to view the survey results.

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REFORMED PRESBYTERIAN HOME - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an Abbreviated Survey in response to a complaint, completed on January 22, 2026, it was determined that Reformed Presbyterian Home was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Observations:

Based on review of facility policies, clinical records, facility documents and staff interviews, it was determined that the facility failed to ensure residents were assessed, and provided necessary treatment and services, consistent with professional standards of practice, for a pressure ulcer (PU/PIs- injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for one of three residents (CRR2).

Findings include:

Review of facility policy "Wound Management Program", last reviewed 7/15/25, indicated the facility is committed to providing a comprehensive wound management program to promote the resident's highest level of functioning and well-being and to minimize the development of in-house acquired pressure injuries, unless the individuals' clinical condition demonstrates they are unavoidable. Any resident with a wound receives treatment and services consistent with the resident's goals of treatment. Typically, the goal is one of promoting healing and prevention of infection unless a resident's preferences and medical condition necessitates palliative care as the primary focus. A commitment to the Wound Management Program is demonstrated byimplementation of the processes founded on accepted standards of practice, research-driven clinical guidelines, and interdisciplinary involvement. A visual skin assessment is completed by the nurse upon admission, re-admission and as needed by the nurse aide / therapy report or nurse identification. Results are documented in the Nursing Admission Screening and/or Skin Observation Tool in Point Click Care.

Review of the clinical record revealed that Resident CRR2 was admitted to the facility on 9/1/24.

Review of Resident CRR2's Minimum Data Set (MDS, periodic assessment of resident care needs) dated 11/30/25, indicated diagnoses of anxiety, depression, and adult failure to thrive (a state of decline that may be caused by chronic disease and functional impairment).

Review of Resident CRR2's physician order dated 8/23/24, indicated Skin assessment weekly (from head to toe) at bedtime every Thursday.

Review of Resident CRR2's clinical record on 1/22/26, failed to indicate documentation that the skin observation tool was completed between 9/15/25, through 12/20/25.

Review of Resident CRR2's physician orders dated 12/20/25, at 8:26 a.m. indicated sacrum wound: Clean with normal saline, apply Medi honey, calcium alginate and boarder gauze one time a day. Furtherreview of Resident CRR2's December treatment administration record indicated that the dressing was not documented completed until 12/22/25.

Review of Resident CRR2's physician orders dated 12/22/25, at 3:14 p.m. indicated treatment to sacrum: Cleanse wound with soap &; water and cover with dry dressing daily and as needed every night shift for wound care. Further review of Resident CRR2's December treatment administration record indicated that the dressing was not documented as completed on 12/30/25.

During an interview completed on 1/22/26, at 2:25 p.m. the Director of Nursing (DON) confirmed that Resident CRR2's skin observation tool was not completed between 9/15/25, through 12/20/25, and that a treatment ordered on 12/20/25, was not documented as completed until 12/22/25. The DON also confirmed that the treatment orders dated 12/22/25, for Resident CRR2 were also not documented as completed on 12/30/25, and that the facility failed to ensure residents were assessed, and provided necessary treatment and services, consistent with professional standards of practice, for a pressure ulcer (PU/PIs- injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for one of three residents (CRR2).

28 Pa. Code 201.18 (b)(1) Management.
28 Pa. Code 211.10 (c)(d) Resident care policies.
28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services.

Plan of Correction - To be completed: 03/20/2026

1) Skin Assessments not able to be completed for Residents CRR2 as discharged from the facility.

2) All residents audited to ensure scheduling of weekly skin assessments in place. Audit on file with NHA

3) Weekly Audits of skin assessments for 50% of resident population will be completed to ensure completed. Will complete weekly until 100% compliance and then will move to monthly audits

4) Nurses re-educated to policy to complete skin assessments. Director of Nursing to provide education and on file with NHA.

5) Quality Assurance Committee will receive update and audits compliance on file with QAPI.

483.70(n)(1)-(4) REQUIREMENT Hospice Services:

§483.70(n) Hospice services.
§483.70(n)(1) A long-term care (LTC) facility may do either of the following:
(i) Arrange for the provision of hospice services through an agreement with one or more Medicare-certified hospices.
(ii) Not arrange for the provision of hospice services at the facility through an agreement with a Medicare-certified hospice and assist the resident in transferring to a facility that will arrange for the provision of hospice services when a resident requests a transfer.

§483.70(n)(2) If hospice care is furnished in an LTC facility through an agreement as specified in paragraph (o)(1)(i) of this section with a hospice, the LTC facility must meet the following requirements:
(i) Ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services.
(ii) Have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC facility before hospice care is furnished to any resident. The written agreement must set out at least the following:
(A) The services the hospice will provide.
(B) The hospice's responsibilities for determining the appropriate hospice plan of care as specified in §418.112 (d) of this chapter.
(C) The services the LTC facility will continue to provide based on each resident's plan of care.
(D) A communication process, including how the communication will be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day.
(E) A provision that the LTC facility immediately notifies the hospice about the following:
(1) A significant change in the resident's physical, mental, social, or emotional status.
(2) Clinical complications that suggest a need to alter the plan of care.
(3) A need to transfer the resident from the facility for any condition.
(4) The resident's death.
(F) A provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided.
(G) An agreement that it is the LTC facility's responsibility to furnish 24-hour room and board care, meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs.
(H) A delineation of the hospice's responsibilities, including but not limited to, providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary, and bereavement); social work; providing medical supplies, durable medical equipment, and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions.
(I) A provision that when the LTC facility personnel are responsible for the administration of prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care, the LTC facility personnel may administer the therapies where permitted by State law and as specified by the LTC facility.
(J) A provision stating that the LTC facility must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by hospice personnel, to the hospice administrator immediately when the LTC facility becomes aware of the alleged violation.
(K) A delineation of the responsibilities of the hospice and the LTC facility to provide bereavement services to LTC facility staff.

§483.70(n)(3) Each LTC facility arranging for the provision of hospice care under a written agreement must designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff. The interdisciplinary team member must have a clinical background, function within their State scope of practice act, and have the ability to assess the resident or have access to someone that has the skills and capabilities to assess the resident.
The designated interdisciplinary team member is responsible for the following:
(i) Collaborating with hospice representatives and coordinating LTC facility staff participation in the hospice care planning process for those residents receiving these services.
(ii) Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family.
(iii) Ensuring that the LTC facility communicates with the hospice medical director, the patient's attending physician, and other practitioners participating in the provision of care to the patient as needed to coordinate the hospice care with the medical care provided by other physicians.
(iv) Obtaining the following information from the hospice:
(A) The most recent hospice plan of care specific to each patient.
(B) Hospice election form.
(C) Physician certification and recertification of the terminal illness specific to each patient.
(D) Names and contact information for hospice personnel involved in hospice care of each patient.
(E) Instructions on how to access the hospice's 24-hour on-call system.
(F) Hospice medication information specific to each patient.
(G) Hospice physician and attending physician (if any) orders specific to each patient.
(v) Ensuring that the LTC facility staff provides orientation in the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to LTC residents.

§483.70(n)(4) Each LTC facility providing hospice care under a written agreement must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, as required at §483.24.

Observations:

Based on a review of resident clinical records, and staff interview, it was determined the facility failed to ensure the coordination of hospice services (a special model of care for patients who are in the late phase of an incurable illness and wish to receive end-of-life care) with facility services to meet the needs for end of life care for one of two residents (Resident CRR2).

Findings include:

Review of the clinical record revealed that Resident CRR2 was admitted to the facility on 9/1/24.

Review of Resident CRR2's Minimum Data Set (MDS, periodic assessment of resident care needs) dated 11/30/25, indicated diagnoses of anxiety, depression, and adult failure to thrive (a state of decline that may be caused by chronic disease and functional impairment). Section O- Special treatments, procedures and programs section K1 coded yes for hospice services while a resident.

Review of Resident CRR2's physician order dated 9/13/24, indicated assessment and admitted to hospice. Further review of Resident CRR2's physician orders failed to include a diagnosis for the hospice care and indicate which hospice provider was providing this service and the hospice providers contact information.

Review of Resident CRR2's current comprehensive care plan failed to indicate a plan of care by the facility that displayed the coordination of hospice services by failing to include contact information for the hospice agency and how to access the hospice's 24 hour on-call system.

During an interview on 1/22/26, at 2:25 p.m. the Director of Nursing confirmed that the facility failed to include a diagnosis for hospice care and contact information for the hospice agency and how to access the hospice's 24 hour on-call system and that the facility failed to ensure the coordination of hospice services with facility services to meet the needs of Residents CRR2.

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 211.12(d)(3) Nursing services.

Plan of Correction - To be completed: 03/20/2026

1) Resident CRR2 discharged from the facility - unable to update records.

2) Records of all residents on hospice services audited and updated with information in physician orders and care plan as specified. Audit on file with NHA

3) Monthly audits of all residents on hospice to ensure orders and care plan include diagnosis, Hospice company.

4) Policy and Procedure updated

5) Nurses and social services re-educated by Director of Nursing to policy and procedure.

6) QA Committee will be updated to compliance and results of Audits on file with QAPI.

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