Health inspection·August 26, 2024

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 a comprehensive care plan that included specific and individualized interventions to address the care needs of residents for one of three residents reviewed (Resident 3). Findings include: The facility's policy regarding care planning, dated February 8, 2024, indicated that the facility will comprehensively evaluate and re-evaluate a resident's need for service and develop a plan to promote their highest practicable level of functioning as set forth by their Mission Statement as well as State and Federal guidelines. The overall care plan should be oriented towards involving the resident, the resident's family, and other resident representatives as appropriate. The facility's policy regarding change in medical condition, dated February 8, 2024, indicated that the facility must consult with a competent resident and notify the physician, appropriate facility staff, responsible party or designated person if applicable, significant other, and/or power of attorney (POA - a legal document that gives someone the authority to act on behalf of another person) following accidents/incidents involving the resident; when significant changes in the resident's physical, mental, or psycho-social status occurs; when there is a need to significantly alter treatment plans of the resident; and a decision to transfer or discharge the resident from the facility. A significant change in status Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated May 19, 2024, revealed that the resident was understood, could understand others, and had a diagnoses that included aphasia (loss of ability to understand or express speech), stroke, and dementia. A care plan for the resident, dated May 15, 2024, revealed that the resident had impaired decision making related to dementia. A care plan, dated May 15, 2024, revealed that the resident had impaired functional status with her bed mobility, transfers, walking, toileting, locomotion, grooming, personal hygiene, and bathing. Staff were to call the resident's daughter when the resident refused her showers. A nursing note for Resident 3, dated May 11, 2024, revealed that the writer talked to the resident's son. He would like him and his sister to be made aware of any information regarding the resident. A nursing note for Resident 3, dated May 30, 2024, entered as a late entry for May 26, 2024, revealed that the resident's son called the Nursing Home Administrator and explained that he would like to give his sister POA and that he doesn't have time to deal with this anymore. Page 1 of 2 395530 395530 08/26/2024 Presbyterian Homes-Presby 220 Newry Street Hollidaysburg, PA 16648

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A nursing note for Resident 3, dated May 27, 2024, revealed that the resident's daughter was the first contact person, and that if her mother ever had to go to the hospital, the facility was to call the local ambulance service as she was a member. There was no documented evidence that a care plan was developed to address Resident 3's individual care needs related to the resident's daughter being notified first when an accident/incident involved the resident; when significant changes in the resident's physical, mental, or psycho-social status occurred; when there was a need to significantly alter treatment plans of the resident; or a decision to transfer or discharge the resident from the facility. Interview with the Nursing Home Administrator on August 26, 2024, at 10:30 a.m. confirmed that a care plan to address Resident 3's daughter being notified first was not developed and should have been. 28 Pa. Code 211.12(d)(5) Nursing Services. 395530 Page 2 of 2