Reformed Presbyterian Home: Resident Missing 7 Hours - PA
The resident at Reformed Presbyterian Home, a woman identified in inspection records only as Resident R1, walked out the front door of the facility on her own at 1:16 p.m. on a day in late October 2025. She had a wheeled walker. She knew where she was going, at least at first.
Camera footage later reviewed by inspectors showed the sequence clearly. At 1:14 p.m., she stepped onto the elevator on the third floor. Thirty seconds later, she appeared in the main reception area. By 1:16, she was out the front entrance and gone, boarding a Port Authority bus, the Number 8, headed downtown.
She told inspectors later that she had a reason for going. "I went to my apartment to get shoes and jacket," she said during an interview on November 24. "I got them then I got confused on how to get back."
She was downtown, alone, confused about how to return, when a facility employee happened to find her.
The employee, identified in records as LW Employee E2, submitted a written statement dated November 1 describing what happened. The resident was on the Number 8 bus. The employee recognized her, understood she was unsure of her directions, and made a decision. "I decided to get off the bus together and escort her back into the facility from the bus stop up to the 3rd floor," the employee wrote.
That is how Resident R1 came home. Not because anyone at the facility noticed she was gone. Because someone happened to be on the same bus.
When inspectors interviewed the resident on November 24, she confirmed the account and seemed more bemused than alarmed. "Are they still talking about that?" she asked.
The Licensed Practical Nurse working that day, Employee E3, told inspectors he had no warning she intended to leave. "She was here for lunch, and they couldn't find her at dinner," he said. "She didn't say anything to me that indicated that she was going to leave the facility."
He confirmed she had been gone approximately seven hours before she was safely back.
Four of those hours passed before staff even knew she was missing.
The gap between her departure at 1:16 p.m. and the moment anyone recognized she was absent is the core of what inspectors cited. The facility's own camera system captured her leaving through the front entrance in plain view. She walked out with a standard wheeled walker, passed through reception, and boarded a city bus. No alarm was raised. No search was initiated. The afternoon passed.
The facility's administrator, interviewed on the afternoon of November 24, did not dispute any of it. The administrator confirmed that the facility failed to make certain Resident R1 received adequate supervision, and that the failure resulted in her elopement.
Federal inspectors tagged the violation as F0689, citing potential for actual harm, with few residents affected. The citation covers the failure to ensure adequate supervision to prevent accidents.
What the records don't answer is what the hours between 1:16 and dinner looked like inside the facility. Whether anyone checked on her. Whether her absence registered at any point before staff gathered residents for the evening meal and found her seat empty.
Resident R1 got her shoes and jacket. She got on the Number 8 bus. She got confused. She got lucky.
She was 84 years old, or 74, or some age the inspection report doesn't give. The report gives only this: she used a wheeled walker, she ambulated safely, and she spent most of an afternoon somewhere in Pittsburgh while the people responsible for her care did not know where she was.
"Are they still talking about that?" she asked the inspectors.
They were.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Reformed Presbyterian Home from 2025-11-24 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
REFORMED PRESBYTERIAN HOME in PITTSBURGH, PA was cited for violations during a health inspection on November 24, 2025.
She knew where she was going, at least at first.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.