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 112 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 a complaint survey completed on February 27, 2025, 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:

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:

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.

§483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Observations:

Based on review of facility policy, facility documentation, clinical record review, and staff interview it was determined that the facility failed to protect residents from neglect for one of three residents reviewed (Resident R1).

Findings include:

Review of facility policy "Prevention of Abuse and Response" dated 7/30/24, indicated "Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect occurs on an individual basis when a resident does not receive care in one or more areas."

Review of the clinical record revealed Resident R1 was admitted to the facility 8/14/24.

Review of the clinical record MDS (minimum data set - a periodic assessment of resident needs) indicated diagnosis of dementia with other behavioral disturbances and cerebral infraction.

Review of facility submitted documentation dated 2/9/25, indicated Resident R1 was observed by staff outside of the facility (unattended without staff) by an employee entrance.

Review of facility documentation indicated the following:

12:55 p.m. - alarm bracelet on ankle checked on Resident R1 and in working order
4:05 p.m. - alarm bracelet on ankle checked on Resident R1 and in working order.
5:05 p.m. - Employee E1 maintenance fixing door for employee entrance - door not latching.
5:12 p.m. - Employee E1 maintenance leaves the door not fixed - not latching
7:00 p.m. - Resident R1 sitting in common area /tv lounge, calm no unusual behaviors
8:00 p.m. Employee E2 NA (Nurse Aide) reports seeing resident R1 sitting in common area.
8:00 p.m. Employee E3 NA reports seeing Resident R1 walking down hallway.
8:30 p.m. Resident R1 received medication from Employee E4 RN (registered nurse)
9:00 p.m.- Employee E4 saw Resident R1 walking in hallway
9:15 p.m. - Employee E5 NA saw Resident R1 in the community.
9:30 p.m. Employee E6 NA saw Resident R1 in the hallway.
9:50 p.m. - Employee E7 LPN found Resident R1 outside by employee entrance in upper parking lot.
9:55 p.m. Employee E4 completes last rounds - does not see Resident R1 goes to find Employee E4 RN to report Resident R1 is missing - Employee E4 RN I s outside assessing Resident R1 for injury. Resident R1 brought back into facility and new alarm bracelet is placed on ankle.

Review of Employee E1 maintenance indicated: On Thursday evening (2/6/25), I was approached by a member of nursing staff about the rear door not closing all the way, as I looked at it, I noticed it wasn't closing all the way due to the magnet not being attached to the door making it stay open. One of the nursing staff and I were trying to put it back in place and we noticed that some of the screws were missing as well. The nurse returned to his patients as I said I'll take care of it. I was asked by my supervisor if the door was secured so that he could inform staff , I told him it was, but was unable to repair the door at that time and I placed the parts in a box and I placed it outside my supervisor door."

During an interview on 2/25/25, at 4:15 p.m. Nursing Home Administrator confirmed that Employee E1 maintenance did work on the door, but failed to inform anyone that evening that the door was not secure and locking properly, Employee E1 was written up over the indicate and the facility failed to prevent Resident R1 from neglect with allowing access to an outside door.

28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18 (b)(1)( e) (1)Management.

Plan of Correction - To be completed: 04/10/2025

1) E1 was re-educated on proper response/reporting failed safety equipment and abuse/neglect. Signature of training on file with NHA

2) All staff will be reeducated to resident rights (free of abuse/neglect) as well as responsibilities on prevention, response and reporting of abuse/neglect. Training tracking completion to be on file with NHA.

3) Monthly Employee Newsletter provided to staff on March 7th to include prevention and reporting of abuse/neglect. On file with NHA.

4) Allegation of Abuse reported to DOH and AAA on 2/27/25. Event on file with NHA

5) NHA will audit daily all events/accidents to identify if employee action should be reported as abuse/neglect. Audit results in file with NHA.

6) QAPI to be provided tracking and report of events. On file with NHA.

7) Facility Services will conduce door alarm/entrance checks daily to ensure working properly. Audits to be forwarded to NHA and QAPI for review.

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