Pennsylvania Department of Health
REFORMED PRESBYTERIAN HOME
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

REFORMED PRESBYTERIAN HOME
Inspection Results For:

There are 116 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


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, and two incidents completed on November 24, 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 submitted documents, clinical records and staff interviews, it was determined that the facility failed to make certain each resident was free from neglect by not ensuring adequate supervision and assistance for transfers for one of three residents reviewed (Resident R2).

Findings include:

Review of facility policy "Prevention of Abuse and Response" dated 7/15/25, indicated neglect is the failure of the facility, its employees or service providersto 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 (e.g., absence of frequent monitoring for a resident known to be incontinent, resulting in being left to lie in urine or feces).

Review of the clinical record indicated Resident R2 was admitted to the facility on 10/2/25.

Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/6/25, indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fats in the blood), and arthritis (inflammation of one or more joints, causing pain and stiffness).

Review of a physician order dated 10/2/25, indicated to transfer resident with full body lift (a mechanical lift).

Review of Resident R2's Kardex (a snapshot of resident care needs) dated 10/8/25, indicated the resident transfers with Hoyer/full lift and assist of two staff.

Review of a progress note dated 10/8/25, stated, "Resident was being transferred to bed to the w/c (wheelchair). During the transfer the Hoyer lift tilted so the CNA (Certified Nurse Aide) had to lower her to the floor. Resident was assessed. She states that she hit her head and left shoulder. When her husband came in she requested to go to the ER (emergency room) for head pain. Physician and DON (Director of Nursing) notified."

Review of a witness statement dated 10/8/25, completed by Nurse Aide (NA) Employee E1 stated, "On October 8th around 1:30 p.m. I got Resident R2 all cleaned up changed to get her up in the Hoyer. She was holding on and when I went to turn it towards her chair it tilted and it was falling, so I held it to slowly lower to ground.

During an interview on 11/24/25, at 1:11 p.m. the Nursing Home Administrator (NHA) stated, "Resident R2's spouse was pressuring NA Employee E1 to get the resident into her chair because they wanted to go outside to smoke."

During an interview on 11/24/25, at 2:15 p.m. the NHA and DON confirmed that the facility failed to make certain each resident was free from neglect by not ensuring adequate supervision and assistance for transfers for Resident R2.

28 Pa. Code: 201.14(a) Responsibility of licensee
28 Pa. Code: 201.18(b)(1) Management.
28 Pa. Code: 211.10(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 01/06/2026

1) Employee involved was re-educated to facillity policy and disciplinary action provided. Employee no longer works for this facility.

2) All CNAs ad Nurses were re-educated on mechanical lift requirements - of two people and that all resident shall be transferred via their care plan. Education completed by Director of Nursing and Nursing Home Administrator. Proof of education on file with NHA.

3) Mechanical Lift Policy developed and approved by QAPI. Policy on file with NHA.

4) Observations of resident transfer will occur 5 times weekly to monitor for compliance with care plan and facility policy. Audits to be completed by Director of Nursing, Supervisors. Results on file with NHA.

5) Audit results to be provided to QAPI Committee.

6) All resident care plan/orders reviewed for accuracy of transfer status. Audit completed by Director of Nursing and Rehab Director and on file with NHA

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:

Based on review of facility documents, facility policy, clinical records, resident interview, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement (leaving an area without permission) for one of 55 residents (Resident R1).

Findings include:

Review of facility policy "Elopement Prevention Guidelines" last reviewed 7/15/25, indicated that the facility strives to promote resident safety and protect the rights and dignity of the residents. The facility maintains a process to assess all residents for risk of elopement; implement prevention strategies for those identified as elopement risk and follow a missing resident protocol. A situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision, if necessary, would be considered an elopement.

Risk prevention includes:
The nurse or designee will complete an elopement risk assessment for every resident upon admission, quarterly, annually, and as needed.The staff will regularly monitor the resident's whereabouts at mealtimes, medication administration and every two hours with nursing rounds.The staff will report to the Supervisor on duty, when he/she has observed resident behavior which is consistent with elopement (i.e., pacing, verbalizations of leaving the building, increased confusion, etc.).

Review of Resident R1's admission record indicated she was admitted to the facility on 7/25/25.

Review of Resident R1's clinical record revealed an Elopement Evaluation dated 7/25/25, that did not identify resident to be at risk for elopement,

Review of Resident R1's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 7/29/25, included diagnoses of high blood pressure, dysphagia (difficulty swallowing), and malnutrition (lack of nutrients in the body).

Review of clinical record revealed a nursing progress note dated 11/1/25, at 5:15 p.m. that stated the following: "At 17:15 (5:15 p.m.) staff noticed resident missing from her room during supper. Staff searched Dining Room and nearby bathrooms and not found. Elopement protocol initiated and nursing and one kitchen staff member searched every level of interior of building and outside front and back.
17:33 (5:33 p.m.) Notified administrator.

17:37 (5:37 p.m.) Called 911 and reported resident missing and answered questions about the resident's previous addresses, friends, family, possible whereabouts.

18:11 (6:11 p.m.) Notified resident's son and received info re. [regarding] resident's prior conversations with her son as well as prior addresses where she lived.

18:30 (6:30 p.m.) Police arrived and officer spoke with staff as well as resident's roommate then left building after they were completed.

18:49 (6:49 p.m.) Received recent photos via email from resident's son.

19:07 (7:07 p.m.) Called 911 and shared info re. prior addresses and info received from son.

19:29 (7:29 p.m.) Received call from police asking if resident had a cell phone which she doesn't or if she does have one is not functioning.

20:35 (8:35 p.m.) Resident returned to building assisted by laundry staff member (Laundry Worker (LW) Employee E2) who spotted resident downtown and aided her by getting on bus with her and bringing her back here. Notified 911 of resident's return and other staff notified Administrator as well as resident's son.

20:40 (8:40 p.m.) Notified doctor's group and spoke with Certified Registered Nurse Practitioner who OK'd sending resident to ER [Emergency Room] for medical evaluation to make sure no injury occurred while she was away from facility today. Went back to get resident who absolutely refused to go. Police returned at this point and witnessed that resident denied having any pain or injury and refused to go to ER. After police left this nurse checked resident from head to toe and found no bruises, no swelling and all skin noted to be intact. Offered resident food/fluids and nurse aide will be assisting resident to bed when resident was ready to go to bed".

Review of facility document "Summary of Events" dated 11/1/25, stated the following:
"17:55 (5:55 p.m.) Administrator confirms resident left the building using camera system. Resident ambulating safely and with recommended device (standard wheeled walker)"
Details of the camera system revealed the following
"13:14 (1:14 p.m.) Resident witnessed getting on the elevator from 3rd floor
13:14 (1:14 p.m.) Resident was observed in main reception
13:16 (1:16 p.m. Resident observed leaving out the front entrance ambulating with wheeled walker. Resident gets on Bus 6357 8 downtown".

Review of a written statement from LW Employee E2 dated 11/1/25, stated "Resident was downtown. She got on the number 8 bus. To the best of my knowledge, she was headed back (to the facility). She was unsure of her directions, so I decided to get off the bus together and escort her back into (the facility) from the bus stop up to the 3rd floor".

During an interview on 11/24/25, at 10:40 a.m. Resident R1 confirmed that she had left the facility on 11/1/25, and asked "Are they still talking about that? I went to my apartment to get shoes and jacket. I got them then I got confused on how to get back. Then I saw [LW Employee E2] who got me on the right bus and brought me back.

During an interview on 11/24/25, at 10:48 a.m. Licensed Practical Nurse (LPN) Employee E3 stated that he was working the day of the elopement, and confirmed that Resident R1 had been gone about four hours before staff knew she was missing, stating "She was here for lunch, and they couldn't find her at dinner. She didn't say anything to me that indicated that she was going to leave the facility". LPN Employee E3 confirmed that Resident R1 had been gone from the facility for approximately seven hours before her safe return.

During an interview on 11/24/25, at 2:11 p.m. the Nursing Home Administrator confirmed that the facility failed to make certain each resident received adequate supervision that resulted in an elopement for (Resident R1).

28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(1)(3) Management.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Plan of Correction - To be completed: 01/06/2026

1) Staff assigned to resident were re-educated and disciplined for failure to comply with facility policy to complete rounds and report.

2) All nursing staff re-educated to facility policy for rounds and change of shift report and elopement prevention. Re-education completed by NHA and DON. Signatures on file with NHA.

3) Rounding Policy and Procedure Initiated and approved by QAPI Committee.

4) Shift to Shift Procedure Policy and Procedure updated. Approved by QAPI committee.

5) Weekly audits of change of shift to occur to observe that change of shift report and rounding are occurring. To be completed by DON and Supervisors. Audits will continue weekly until 100% compliance consec. months and then will move to monthly.

6) Compliance Audit results to be reported to QAPI Committee and on file with NHA

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations: Based on review of nursing time schedules and staff interviews it was determined that the facility administrative staff failed to provide a minimum of one nurse aide per ten residents during the day shift for two of 21 days (10/26/25, and 10/7/25), and failed to provide a minimum of one nurse aide per 15 residents on the night shift for two of 21 days (10/625, and 11/3/25). Findings include: Review of facility census data, and nursing time schedules from 10/5/25 through 10/11/25, and 10/26/25 through 11/8/25, revealed the following nurse aide staffing shortages. Day shift: Date Census Full time equivalents (FTE) required FTE present 10/26/25 54 5.40 4.88 10/27/25 52 5.20 4.81 Night shift: Date Census FTE required FTE present 10/6/25 53 3.53 2.97 11/3/25 55 3.67 3.38 During an interview on 11/24/25, at 1:24 p.m. the Director of Nursing confirmed that the facility failed to provide a minimum of one nurse aide per 10 residents during the day, and one nurse aide per 15 residents on the night shift, with no additional excess higher-level staff to compensate for this deficiency.

Plan of Correction - To be completed: 01/06/2026

1) Review staffing requirements with nurse supervisors. Education to be completed by Director of Nursing. Proof of education on file with NHA.

2) Review planned schedule in advance an ensure staffing as regulated. DON to review daily staffing sheets in advance of the day.

3) NHA will track staffing ratios and report compliance with staffing ratios to QAPI Committee.

4) Turnover is less than 10% and we have 90% position full - Recruitment and retention are not of concern. Continue to monitor attendance and address thru disciplinary action. Attendance actions on file with HR. Open position also filled using agency agreement.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement