Inspection visit

Health inspectionNovember 1, 2023

Presbyterian Homes-PresbyCMS #39553011 citations on this visit

11 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 11 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that meals were served in a manner that maintained or enhanced each resident's dignity by feeding residents while standing for three of 26 residents reviewed (Residents 7, 32, 40). Findings include: The facility's policy regarding assisting resident meals, dated January 26, 2023, revealed that the residents may require different levels of assistance with meals based on their cognitive and/or physical needs. A basic guideline for assisting residents with meals included to sit at eye level with the residents. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated September 20, 2023, revealed that the resident was rarely/never understood, could rarely/never understand, required extensive assistance from staff for her daily care tasks including with eating, and had diagnoses that included Alzheimer's. A care plan, dated April 12, 2023, revealed that Resident 7 has impaired functional status with her bed mobility, transfers, walking, toileting, locomotion, eating, grooming/personal hygiene, and bathing; that the resident was totally dependent on staff with eating; and that the resident had a potential risk for altered nutritional status and/or weight loss and needed to be fed by staff. A quarterly MDS assessment for Resident 32, dated September 7, 2023, revealed that the resident was rarely/never understood, could rarely/never understand, required extensive assistance from staff for his daily care tasks, required limited assistance from staff for eating, and had diagnoses that included Alzheimer's and stroke. A care plan for the resident, dated September 6, 2023, revealed that the resident has impaired functional status with her bed mobility, transfers, walking, toileting, locomotion, eating, grooming/personal hygiene, and bathing, and required set-up assistance with eating. A significant change MDS assessment for Resident 40, dated September 12, 2023, revealed that the resident was usually understood, could usually understand, required extensive assistance from staff for her daily care tasks, including with eating, and had diagnoses that included dementia. A care plan for the resident, dated September 20, 2023, revealed that the resident has impaired functional status with bed mobility, transfers, toileting, locomotion, grooming/personal hygiene, and bathing, and required the assistance of one staff for eating. The resident's dietary needs are sufficient at this time related to stable intake and weight, and staff was to assist the resident with eating. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 15 Event ID: 395530 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395530 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Presbyterian Homes-Presby 220 Newry Street Hollidaysburg, PA 16648 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0550 Level of Harm - Minimal harm or potential for actual harm Observations during the lunch meal on October 30, 2023, at 12:13 p.m. revealed that Residents 7, 32, and 40 were seated together at a dining table in the dining room on the second floor. Nurse Aide 1 was standing to the right of Resident 7 feeding the resident her lunch, Nurse Aide 2 was standing to the right of Resident 32 feeding the resident his lunch, and Nurse Aide 3 was standing to the right of Resident 40 feeding the resident her lunch. Residents Affected - Some Interview with Nurse Aide 1 on October 30, 2023, at 12:39 p.m. confirmed that she was standing while feeding Resident 7 her lunch. She indicated that sometimes she will stand depending on how many people are at the table. Interview with Nurse Aide 2 on October 30, 2023, at 12:34 p.m. confirmed that she was standing while feeding Resident 32 his lunch. She indicated that she likes to stand and feed him and her preference is to stand because he leans forward, so it is easier to feed him while standing. Interview with Nurse Aide 3 on October 30, 2023, at 12:58 p.m. confirmed that she was standing while feeding Resident 40 her lunch. She indicated that she chooses to stand because it is easier since they are down so low. Interview with the Director of Nursing on October 31, 2023, at 11:33 a.m. confirmed that staff should not be standing when feeding residents their meals. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 211.12(d)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395530 If continuation sheet Page 2 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395530 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Presbyterian Homes-Presby 220 Newry Street Hollidaysburg, PA 16648 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to make ongoing efforts to resolve a grievance regarding serving food at a palatable and appropriate temperature. Findings include: The facility's policy regarding grievances, dated January 26, 2023, revealed that resolution of the grievance was desired within three to five working days from the date the concern was filed. Resident council meeting minutes, dated July 2023, indicated that the residents were frustrated with receiving melted ice cream on their meal trays. Resident council meeting minutes, dated August 2023, indicated that the food had been served cold and undercooked. A meeting with a group of residents on October 30, 2023, at 1:30 p.m. revealed that the residents were receiving food that was cold, unappetizing and unpalatable. A lunch tray on October 31, 2023, at 12:23 p.m. revealed that the coffee was 65 degrees Fahrenheit (F) and tasted cold, the mashed potatoes were 106 degrees F and tasted cold, the ground beef was 115 degrees F and tasted cold, and the Swedish meatballs were 114 degrees and tasted cold. Interview with the Assistant Director of Nursing on November 1, 2023, at 10:30 a.m. revealed that temperature audits were being done prior to plating and serving food to residents and no issues were revealed during the temperature audits; however, she stated that the residents' grievances regarding cold food should have been resolved to their satisfaction and they were not. 28 Pa. Code 201.29(i) Resident rights. 28 Pa. Code 211.12(d)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395530 If continuation sheet Page 3 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395530 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Presbyterian Homes-Presby 220 Newry Street Hollidaysburg, PA 16648 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on review of the Resident Assessment Instrument User's Manual and residents' clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for two of 26 residents reviewed (Residents 32, 47). Residents Affected - Few Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, revealed that if the resident received hospice (end-of-life) services during the assessment period, then Section O0100K2 was to be checked. Physician's orders for Resident 32, dated June 1, 2023, included an order for the resident to receive hospice services. A care plan for Resident 32, dated September 6, 2023, revealed that the resident had chosen to receive Hospice services. A nursing note for Resident 32, dated June 5, 2023, revealed that the resident was admitted to Hospice services on June 3, 2023, with a diagnosis of Alzheimer's and dementia. A quarterly MDS assessment for Resident 32, dated September 7, 2023, revealed that Section O0100K2 was not checked, indicating that the resident did not receive hospice services. Interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on October 31, 2023, at 2:25 p.m. confirmed that Resident 32's MDS assessment of September 7, 2023, was not accurate and should have been checked to indicate that the resident received hospice services. The (RAI) User's Manual, dated October 2019, revealed that Section N0410F (Antibiotic Medications medications used to treat infections) was to be coded with the number of days the resident received an antibiotic medication during the seven-day assessment period. An admission MDS for Resident 47, dated September 20, 2023, revealed that section N0410F was coded (7), indicating that the resident received antibiotic medication for seven days during the look-back assessment period. Physician's orders for Resident 47, dated September 15, 2023, included an order for the resident to receive 100 milliliters (ml) of Meropenem (antibiotic) every eight hours for 84 doses. Resident 47's Medication Administration Record (MAR) for Resident 47 for September 2023 revealed that the resident received antibiotics on six of the seven days in the look-back period. Interview with the Assistant Director of Nursing on November 1, 2023, at 10:03 a.m. confirmed that Resident 47's MDS was coded incorrectly. 28 Pa. Code 211.5(f) Medical records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395530 If continuation sheet Page 4 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395530 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Presbyterian Homes-Presby 220 Newry Street Hollidaysburg, PA 16648 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included specific and individualized interventions for two of 26 residents reviewed (Residents 14, 52). Findings include: The facility's care plan policy, dated January 26, 2023, indicated that each resident's care plan was to be reviewed, updated and/or revised based on changing goals, preferences, and needs of the resident, in order to promote their highest level of functioning. The plan of care should meet the resident's medical, nursing, mental and psychosocial needs. A comprehensive MDS assessment for Resident 14, dated August 17, 2023, indicated that the resident was severely cognitively impaired, required extensive assistance for all care needs, and was not ambulatory. A diagnosis record for Resident 14, dated August 14, 2023, included anxiety, atrial fibrillation (irregular heart rhythm), and depression. Physician's orders for Resident 14, dated September 19, 2023, included an order for the resident to receive oxygen at 2 liters per minute continuously. There was no documented evidence in the resident's clinical record to indicate that a care plan was developed for the use of oxygen. Interview with the Nursing Home Administrator on October 31, 2023, at 12:30 p.m confirmed that a care plan for Resident 14's oxygen was not developed and that it should have been. A quarterly MDS assessment for Resident 52, dated March 30, 2023, indicated that the resident was severely cognitively impaired, required extensive assistance for all care, and was not ambulatory. A diagnosis record for Resident 52, dated June 14, 2023, included dementia, high blood pressure, and dysphagia (difficulty swallowing). A dietician note for Resident 52, dated October 24, 2023, indicated that she was on a regular diet with ground meats and thin liquids, and her appetite was fair. She requires assistance from staff with meals and will occasionally try to feed herself. Her husband, who lives in personal care, usually comes to lunch to help feed her. Observations in the second floor dining room on October 31, 2023, at 12:10 p.m. revealed Resident 52's husband attempting to assist his wife with her lunch. The resident was refusing to eat, and the husband stated he was going to smack her if she did not eat. He roughly wiped her face and continued to scold his wife for not eating. Interview with Licensed Practical Nurse 6 on October 31, 2023, at 12:15 p.m. revealed that her husband lives in the personal care unit, that he has confusion and can get upset with his wife for not eating. Interview with the Nursing Home Administrator on October 31, 2023, at 2:37 p.m. revealed that she has spoken to the husband in the past regarding his interactions/frustrations with his wife for not wanting to eat. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395530 If continuation sheet Page 5 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395530 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Presbyterian Homes-Presby 220 Newry Street Hollidaysburg, PA 16648 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with Nurse Aide 7 on October 31, 2023, at 3:57 p.m. revealed that she has seen Resident 52's husband get upset with his wife when he is trying to help her and she does not cooperate. Interview with Licensed Practical Nurse 8 on October 31, 2023, at 4:00 p.m. revealed that he has heard Resident 52's husband become verbally gruff with his wife while he was attempting to help her with her meals. There was no documented evidence in Resident 52's clinical record to indicate that a care plan was developed regarding the husband's interactions toward his wife. Interview with the Nursing Home Administrator on November 1, 2022, at 11:45 a.m confirmed that there was no care plan in place to address the husband's current interactions toward his wife, and that it should have been developed. 28 Pa. Code 211.11(d) Resident care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395530 If continuation sheet Page 6 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395530 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Presbyterian Homes-Presby 220 Newry Street Hollidaysburg, PA 16648 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on clinical records and interviews with staff, it was determined that the facility failed to ensure that a resident's care plan was updated for three of 26 residents reviewed (Resident 37) who refused care and who had anticoagulant medication discontinued (Residents 25, 26) . Findings: The facility policy for care planning, dated January 26, 2023, indicated that resident care plans are to be updated as needed and should include person-centered care needs. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated August 12, 2023, indicated that the resident was cognitively impaired and that she required extensive assistance from staff for daily care needs. Physician's order's for Resident 25, dated January 19, 2022, included an order for the resident to receive 5 milligrams (mg) Eliquis (blood thinner) twice daily until it was discontinued on October 7, 2023. Resident 25's care plan, dated August 9, 2023, revealed that the resident was medicated with a blood thinner for history of a deep vein thrombosis (blood clot). A review of Resident 25's Medication Administration Record (MAR), dated October 2023, revealed that the resident's Eliquis was discontinued on October 7, 2023. An interview with the Assistant Director of Nursing on November 1, 2023, at 10:29 a.m. confirmed that Resident 25's care plan was not updated to reflect the discontinuation of the blood thinner. A significant change MDS for Resident 26, dated August 27, 2023, indicated that the resident was cognitively impaired and required extensive assistance from staff for daily care needs. Physician's order for Resident 26, dated August 24, 2023, was for the resident to receive 30 mg/0.3 milliliters (ml) Enoxaparin (blood thinner) daily for 21 days. Resident 26's care plan, dated August 24, 2023, revealed that the resident was receiving Enoxaparin for deep vein thrombosis prevention. Resident 26's MAR, dated September 2023, revealed that the Enoxaparin was discontinued on September 13, 2023. Interview with the Assistant Director of Nursing on November 1, 2023, at 12:43 p.m. revealed that Resident 26's care plan was not updated to reflect the discontinuation of the blood thinner. The diagnosis record for Resident 37, dated Febraury 3, 2023, upon admission included anxiety, polyneuropathy (pain associated with nerve damage), depression, morbid obesity, and muscle weakness. A quarterly minimum data set (MDS) assessment (mandated to assess the resident abilities and care needs), dated September 29,2023, indicated that she was alert and oriented; required extensive assistance of two for bed mobility, transfers, and hygiene; was non-ambulatory; and had no rejection of care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395530 If continuation sheet Page 7 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395530 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Presbyterian Homes-Presby 220 Newry Street Hollidaysburg, PA 16648 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm The plan of care for Resident 37, dated October 4, 2023, indicated that she required two assist with use of a full body mechanical lift for transfers and she was not ambulatory. The occupational therapy note for Resident 37, dated October 16, 2023, indicated that education was provided for the resident on the importance of being out of bed, with poor follow through. Residents Affected - Few The physician progress notes, dated July 18, September 15, and October 17, 2023, indicated that the resident refused to get out of bed. The nurse aide documentation for the Resident 37's transfers for the month of October 2023 indicated that the activity did not occur for 14 of the 31 days. There was no documented evidence that Resident 37's care plan was revised to reflect that she refused to get out of bed. Interview with the Nursing Home Administrator and Director of Nursing on October 31, 2023 at 1:07 p.m. confirmed that the resident care plan was updated regarding her refusals to get out of bed and that staff just documented that the activity did not occur when a resident refuses. 28 Pa. Code 211.11(d) Resident care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395530 If continuation sheet Page 8 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395530 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Presbyterian Homes-Presby 220 Newry Street Hollidaysburg, PA 16648 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that physician's orders regarding obtaining laboratory samples were followed for one of 26 residents reviewed (Resident 25) resulting in a delay of treatment. Residents Affected - Some Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated August 12, 2023, indicated that the resident was cognitively impaired, required extensive assistance from staff for daily care needs, and had a urinary catheter (a tube inserted directly into her bladder). Physician's orders for Resident 25, dated September 4, 2023, included an order for the resident have a urine sample obtained and tested for an infection. Nursing note for Resident 25, dated September 5, 2023, revealed that a urine sample was obtained and sent to the lab. A nursing note, dated September 6, 2023, revealed that the urine sample obtained from Resident 25 was never picked up by the lab courier, so a new sample was obtained on that date. A nursing note, dated September 8, 2023, revealed that the resident had a urinary tract infection and that the physician ordered an antibiotic for ten days. Interview with the Director of Nursing on October 31, 2023, at 11:43 a.m. confirmed that Resident 25's urine sample was not sent to the lab when it was ordered and that the failure to send the urine sample to the lab resulted in a delay in treatment for the resident. 28 Pa. Code 211.12(d)(1)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395530 If continuation sheet Page 9 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395530 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Presbyterian Homes-Presby 220 Newry Street Hollidaysburg, PA 16648 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that central venous catheters were flushed per facility policy for one of 26 residents reviewed (Resident 47). Residents Affected - Some Findings include: The facility's policy regarding flushing central venous catheters (a thin tube inserted into a vein and used long-term for the administration of fluids and/or medications), dated January 26, 2023, indicated that the catheter was to be flushed before and after it was used to administer medication. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 47, dated September 20, 2023, revealed that the resident was cognitively intact, needed limited assistance for daily care needs, and had a diabetic foot ulcer (a wound to the foot due to a complication of diabetes (a disease caused by high blood sugar levels). Physician's orders for Resident 47, dated September 15, 2023, included an order for the resident's peripherally-inserted central catheter (PICC - a type of central venous catheter) to receive 100 milliliters (ml) of Meropenem (an antibiotic medication) every eight hours for left foot infection. Physician's orders for Resident 47, dated August 1, 2023, included an order for the resident's PICC line to be flushed with 10 ml of Normal Saline Solution every eight hours before and after medication administration. There was no documented evidence in the clinical record that Resident 47's PICC line had been flushed per facility policy before and after the administration of IV Meropenem from October 17, 2023, through 12:00 a.m. and 8:00 a.m. on October 30, 2023. An interview with the Assistant Director of Nursing on October 31, 2023, at 1:50 p.m. confirmed that there was no documented evidence that Residents 47's PICC line was flushed as per facility policy. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395530 If continuation sheet Page 10 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395530 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Presbyterian Homes-Presby 220 Newry Street Hollidaysburg, PA 16648 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on clinical records reviews and staff interviews, it was determined that the facility failed to obtain the correct medication for one of 26 residents reviewed (Resident 25). Residents Affected - Some Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated August 12, 2023, indicated that the resident was cognitively impaired, required extensive assistance from staff for daily care needs, and had a urinary catheter (a tube inserted directly into her bladder). Physician's order, dated February 16, 2022, included an order for the resident to receive AZO Cranberry (supplement used to reduce the risk of urinary tract infections), one tablet everyday. A nursing note for Resident 25, dated October 14, 2023, revealed that nursing staff noticed that the resident's urine was orange. When the nurse reviewed the resident's medications she noticed that the AZO Cranberry was not the correct medication. The resident was receiving AZO Cranberry with Pyridium (used to treat painful urination and turns the urine orange) instead of plain AZO Cranberry as ordered by the physician. A review of the pharmacy order history for Resident 25, undated, revealed that the resident's AZO Cranberry was filled on September 30, 2023, and on October 2, 2023, the resident received AZO Cranberry with Pyridium. Resident 25's Medication Administration Records (MAR's) for October 2023 revealed that the resident received the AZO Cranberry with Pyridium from October 5, 2023, through October 14, 2023, when the error was noticed. Interview with the Director of Nursing and Nursing Home Administrator on October 31, 2023, at 1:05 p.m. confirmed that Resident 25's AZO Cranberry was entered into the Electronic Health Record order system as AZO 99.5, instead of AZO 99, and therefore the pharmacy sent the AZO with Pyridium and the resident received the medication. The Director of Nursing stated that the medication was scanned into the system as the correct medication, so staff were not aware that they were giving Resident 25 the wrong medication until her urine changed color. 28 Pa. Code 211.12(d)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395530 If continuation sheet Page 11 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395530 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Presbyterian Homes-Presby 220 Newry Street Hollidaysburg, PA 16648 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observations, as well as resident and staff interviews, it was determined that the facility failed to serve food items that were palatable and at an acceptable temperature. Residents Affected - Some Findings include: An interview with Resident 1 on October 30, 2023, at 11:54 a.m. revealed that the food tasted awful, was cold, and that he did not like it. An interview with Resident 37 on October 30, 2023, at 12:50 p.m. revealed that the chicken was hard and the food was served cold. Observations in the kitchen on October 31, 2023, at 12:21 p.m. during the lunch meal service revealed that a test tray left the kitchen and arrived on the nursing unit at 12:21 p.m. The lunch meal on October 31, 2023, consisted of country fried steak, mashed potatoes, peas with mushrooms, Swedish meatballs, and an ambrosia salad. Trays were passed to the residents in their rooms and the last resident was served and eating at 12:23 p.m. The test tray on October 31, 2023, at 12:23 p.m. revealed that the coffee was 65 degrees Fahrenheit (F) and cold to taste, the mashed potatoes were 106 degrees F and cold to taste, the country fried steak was 115 degrees F and cold to taste, and the Swedish meatballs were 114 degrees F and cool to taste. Interview with the Dietary Manager on October 31, 2023, at 12:23 p.m. confirmed that the foods were not served at an acceptable temperature and were not palatable. 28 Pa. Code 201.18(b)(1)(2)(e) Management. 28 Pa. Code 211.6(c) Dietary services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395530 If continuation sheet Page 12 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395530 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Presbyterian Homes-Presby 220 Newry Street Hollidaysburg, PA 16648 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to serve food in accordance with professional standards for food service safety, by failing to ensure that dietary staff wore hair coverings that completely covered their hair during food handling. Findings include: The facility's dietary policy regarding personal hygiene, dated January 26, 2023, revealed that staff were to wear a hat or hairnet and wear hair away from face. Observations in the kitchenette on the first floor on October 30, 2023, at 9:05 a.m. revealed dietary staff preparing meal trays for delivery to the units for the residents' breakfast. Breakfast was served from 7:30 a.m. to 9:30 a.m. The dietary aide was observed with approximately two to three inches of hair falling onto her forehead, not contained within her hairnet. Interview with the Dietary Director on October 30, 2023, at 9:25 a.m. confirmed that the dietary aide did not have all her hair covered with a restraint and that she should have. 28 Pa. Code 211.6(f) Dietary services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395530 If continuation sheet Page 13 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395530 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Presbyterian Homes-Presby 220 Newry Street Hollidaysburg, PA 16648 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of correction for a State Survey and Certification (Department of Health) survey ending December 14, 2022, as well as a complaint survey ending July 28, 2023, revealed that the facility developed plans of correction that included development and implementation of care plans, quality of care, palatable food, and food procurement/storage/preperation under sanitary conditions. The results of the current survey, ending November 1, 2023, identified repeated deficiencies related to development and implementation of care plans, quality of care, palatable food, and food procurement/storage/preperation under sanitary conditions. The facility's plan of correction for a deficiency regarding development and implementation of care plans, cited during the survey ending December 14, 2022, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F656, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding development and implementation of care plans. The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending December 14, 2022, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding quality of care. The facility's plan of correction for a deficiency regarding palatable food, cited during the survey ending July 28, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F804, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding palatable food. The facility's plan of correction for a deficiency regarding food procurement/storage/preperation under sanitary conditions, cited during the survey ending July 28, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F812, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding food procurement/storage/preperation under sanitary conditions. Refer to F656, F684, F804, F812. 28 Pa. Code 201.14(a) Responsibility of licensee. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395530 If continuation sheet Page 14 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395530 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Presbyterian Homes-Presby 220 Newry Street Hollidaysburg, PA 16648 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 28 Pa. Code 201.18(e)(1) Management. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395530 If continuation sheet Page 15 of 15

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Citations

11 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0550GeneralS&S Epotential for harm
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
0585GeneralS&S Dpotential for harm
F585 - Grievances
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
0694GeneralS&S Epotential for harm
F694 - Parenteral Fluids
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
0755GeneralS&S Epotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0804GeneralS&S Epotential for harm
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
0812GeneralS&S Epotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0867GeneralS&S Dpotential for harm
F867 - Program feedback, data systems and monitoring
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
0641GeneralS&S Dpotential for harm
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
0684GeneralS&S Epotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0656GeneralS&S Dpotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0657GeneralS&S Dpotential for harm
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

FAQ · About this visit

Common questions about this visit

What happened during the November 1, 2023 survey of Presbyterian Homes-Presby?

This was a inspection survey of Presbyterian Homes-Presby on November 1, 2023. The surveyor cited 11 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at Presbyterian Homes-Presby on November 1, 2023?

Yes, 11 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

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Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·November 1, 2023