Inspection visit

Health inspectionSeptember 5, 2024

Presbyterian Homes-PresbyCMS #3955309 citations on this visit

9 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 9 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

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 review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in residents' care needs for two of 23 residents reviewed (Residents 4, 49). Findings include: The facility's policy regarding care plans, dated February 8, 2024, indicated that the facility would 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. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated June 21, 2024, revealed that she was cognitively intact, was dependent on staff for activities of daily living, and had a colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall). A care plan for Resident 4, dated June 19, 2024, indicated that the resident was to have her colostomy emptied when the bag is one-third full and to have colostomy care completed by staff. Review of the Treatment Administration Record for Resident 4, dated August and September 2024, revealed no documented evidence that the resident had colostomy care completed by staff or had the colostomy bag emptied when it was one-third full. Interview with Resident 4 on September 4, 2024, at 2:09 p.m. revealed that the resident does all the care for her colostomy herself, and that she will also empty and change the bag as needed. Interview with Licensed Practical Nurse 1 on September 4, 2024, at 9:49 a.m. confirmed that Resident 4 does all care for the colostomy herself, including changing and emptying the bag. Interview with the Director of Nursing on September 4, 2024, at 2:34 p.m. revealed that Resident 4 was no longer requiring help from staff for her colostomy care, including changing and emptying her bag, and that her care plan should have been revised to reflect that. A significant change MDS assessment Resident 49, dated June 2, 2024, revealed that she was cognitively intact, was dependent on staff for activities of daily living, and had diagnoses that included having a heart failure, atrial fibrillation. (irregular heartbeat), and high blood pressure. A care plan for Resident 49, dated July 25, 2024, indicated that the resident was receiving Digoxin therapy for a diagnosis of atrial fibrillation. (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 10 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 09/05/2024 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 Review of the Medication Administration Record for Resident 49, dated September 2024, revealed no documented evidence that the resident received any Digoxin medication. Interview with the Assistant Director of Nursing on September 5, 2024, at 3:15 p.m. revealed that Resident 49 was no longer taking Digoxin and her care plan should have been revised to reflect that; however, it was not. 28 Pa. Code 201.24(e)(4) admission Policy. 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 10 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 09/05/2024 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were obtained for the care and to maintain the patency of an intravenous access device for one of 23 residents reviewed (Resident 4). Residents Affected - Few Findings include: The facility's policy for intravenous device care, dated February 8, 2024, indicated that orders for flushing and care of intravenous device will be obtained to maintain device and prevent obstruction. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated June 21, 2024, revealed that the resident was cognitively intact and required assistance from staff for his daily care needs. A nurse's note for Resident 4, dated July 24, 2024, at 7:53 p.m., revealed that the right port flush was completed and had a good blood return. The next port flush will be in three months. Observations on September 3, 2024, at 11:48 a.m. revealed that Resident 4 had a Mediport (intravenous access device that allows for long-term intravenous (IV) treatments and blood draws) in her right chest area. There was no documented evidence in Resident 4's clinical record to indicate that a physician's order was obtained for the care and maintenance of the Mediport per the facility's policy. Interview with the Director of Nursing on September 4, 2023, at 12:07 p.m. confirmed that a physician's order for a port flush to be completed every three months was not obtained and should have been. 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 3 of 10 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 09/05/2024 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 review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for one of 23 residents reviewed (Resident 38). Residents Affected - Few Findings include: A facility policy for hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar), dated February 8, 2024, revealed that if a resident had a blood glucose (sugar) reading of 350 mg/dL or greater, the physician would be notified. If the blood glucose was less than 70 mg/dL and the resident was able to swallow without symptoms, offer three to four glucose tablets or four to five saltine crackers and may repeat in 15 minutes if glucose remains low. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 38, dated June 21, 2024, revealed that the resident was cognitively intact, was dependent on staff for daily care needs, and received insulin (medication that lowers blood sugar levels). Physician's orders for Resident 38, dated February 2, 2023, included an order for the resident to have her blood sugar checked four times a day and to notify the doctor if her blood sugar is above 350 mg/dL. Resident 38's Medication Administration Record (MAR) for July and August 2024 revealed that on July 11, 2024, at 8:00 p.m. the resident's blood sugar was 360 mg/dL; on August 15, 2024, at 8:00 p.m. it was 371 mg/dL; and on August 17, 2024, at 8:00 p.m. it was 361 mg/dL. There was no documented evidence that the physician was notified about the resident's blood sugar being above 360 mg/dL on these dates and times. Interview with the Director of nursing on September 5, 2024, at 10:44 a.m. confirmed that there was no documented evidence that the physician was notified about Resident 38's elevated blood sugars per physician's orders. Physician's orders for Resident 38, dated February 2, 2023, included an order for the resident to have hypoglycemia protocol initiated if resident had a blood sugar less than 70 mg/dL. A review of the MAR for Resident 38 for September 2024 revealed that on September 1, 2024, at 6:31 a.m. the resident's blood sugar level was 69 mg/dL. There was no documented evidence that the hypoglycemia protocol was initiated for the resident on the above date and time. 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 4 of 10 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 09/05/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on a review of policies and clinical records, observations, and staff interviews, it was determined that the facility failed to ensure that residents received proper care for indwelling urinary catheters for one of 23 residents reviewed (Resident 9). Findings include: The facility's policy regarding catheter care, dated February 8, 2024, indicated that catheter care will be performed with morning and evening care and as needed after incontinence or bowel movements. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated July 10, 2024, revealed that the resident was cognitively impaired and required extensive assistance from staff for all care. A care plan for Resident 9, dated July 6, 2024, revealed that the resident had an indwelling foley 16 French, 10 cc balloon catheter (a thin flexible tube inserted into the bladder to drain urine). Observations of Resident 9 on September 4, 2024, at 11:35 a.m. revealed that the resident was in bed and the indwelling foley that was in place was a 16 French, 10 cc balloon catheter. There was no documented evidence in Resident 9's clinical record to indicate that staff provided care for the resident's indwelling urinary catheter from July 6, 2024, to September 4, 2024. Interview with the Director of Nursing on September 4, 2024, at 11:26 a.m. confirmed that there was no documented evidence that staff provided care for the resident's indwelling urinary catheter from July 6, 2024, until September 4, 2024. 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 5 of 10 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 09/05/2024 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 0695 Provide safe and appropriate respiratory care 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 observations and staff interviews, it was determined that the facility failed to ensure that oxygen therapy was provided as ordered for one of 23 residents reviewed (Resident 38). Residents Affected - Few Findings include: The facility's policy regarding oxygen administration, dated February 8, 2024, indicated that a physician's order for oxygen was to include the liter flow and method of administration. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 38, dated June 8, 2024, revealed that the resident was cognitively intact, required substantial assistance with care needs, used supplemental oxygen, and had diagnoses that included respiratory failure. Physician's orders for Resident 38, dated August 31, 2024, included an order for the resident to receive continuous oxygen at a flow rate of 3 liters per minute via nasal canula (tubes that deliver oxygen into the nostrils) for hypoxia (low levels of oxygen in body tissues). Observations of Resident 38 in her room on September 3, 2024, at 9:08 a.m. and September 4, 2024, and at 10:57 a.m. revealed that the resident was receiving supplemental oxygen continuously at a flow rate of 4.5 liters per minute via nasal canula. Interview with Registered Nurse 2 on September 4, 2024, at 11:00 a.m. confirmed that Resident 38's oxygen was set at a flow rate of 4.5 liters per minute via nasal cannula. Interview with the Director of Nursing on September 4, 2024, at 12:58 p.m. confirmed that Resident 38's oxygen was not being administered at the correct flow rate. 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 6 of 10 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 09/05/2024 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 Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications (drugs with the potential to be abused) for one of 23 residents reviewed (Resident 57). Findings include: The facility's policy regarding destroying medications, dated February 8, 2024, indicated that medications included in the Drug Enforcement Administration classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility in accordance with federal and state laws and regulations. Physician's orders for Resident 57, dated July 1, 2024, included an order for the resident to receive 5 milligrams (mg) (0.25 milliliters) of morphine sulfate (a controlled narcotic pain medication) orally every 2 hours for pain, and 5 mg of Oxycodone (a controlled narcotic pain medication) orally every 6 hours for pain. A discharge summary for Resident 57, dated July 4, 2024, revealed that the resident ceased to breathe on that date; however, there was no documented evidence of the disposition of the morphine sulfate and oxycodone. Interview with the Assistant Director of Nursing on September 5, 2024, at 10:54 a.m. confirmed that there was no documented evidence that a disposition of Resident 57's morphine sulfate or Oxycodone was completed as required. 28 Pa. Code 211.9(h) Pharmacy Services. 28 Pa. Code 211.12(d)(1) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395530 If continuation sheet Page 7 of 10 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 09/05/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to label medications with the date they were opened in one of eight medication carts reviewed (split cart), and failed to ensure the narcotic box was permanently affixed inside the refrigerator. Findings include: The facility's policy regarding the storage of medications dated February 8, 2024, revealed that schedule (II-V) medications (medications with a greater potential to be abused) are to be stored in a permanently affixed and double locked compartment separate from all other medications. Observations in the 500 hall medication room refrigerator on September 4, 2024, at 9:40 a.m. revealed a clear, unlocked box containing an unopened 30 milliliter (ml) bottle of lorazepam 2 mg/ml (a schedule IV medication for anxiety). The box was secured to the shelf; however, the shelf was able to be removed. Interview with Licensed Practical Nurse 3 on September 4, 2024, at 9:43 a.m. confirmed that the narcotic box should have been locked and permanently affixed to the inside of the refrigerator. An interview with the Director of Nursing on September 4, 2024, at 12:07 p.m. confirmed that the narcotic box should have been locked and permanently affixed to the inside of the refrigerator. The facility's policy regarding the storage of medications, dated February 8, 2024, indicated that once opened, the nurse shall place a date opened sticker on the medication. An undated package insert for Lispro Insulin (used to treat diabetes) revealed that once entered/opened, the vial was to be discarded after 28 days. Observations in the split-cart Medication cart on September 4, 2024, at 9:53 a.m. revealed that an opened vial of Lispro Insulin was not properly labeled with the date it was opened. An interview with Licensed Practical Nurse 3 on September 4, 2024, at 9:53 a.m. confirmed that the opened vial of Lispro Insulin was not properly labeled with the date it was opened. An interview with the Director of Nursing on September 4, 2024, at 12:07 p.m. confirmed that the opened vial of Lispro Insulin was not properly labeled with the date it was opened, and it should have been. 28 Pa. Code 211.9(a)(1)(k) Pharmacy Services. 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 8 of 10 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 09/05/2024 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that food was discarded after it was outdated. Residents Affected - Some Findings include: The facility's policy regarding labeling and dating food, dated February 8, 2024, revealed that food was to be discarded past the use-by or expiration date. Observations in the kitchen on September 3, 2024, at 9:15 a.m. revealed three half-gallons of half and half creamer that were expired. Observations in the cooler revealed two large containers of expired sour cream and two large containers of expired ricotta cheese. Observations in the dry storage room revealed two cartons of expired apple juice and five cartons of apple juice with no manufacturer's expiration date. Interview with the Dietary Manager on September 3, 2024, at 9:43 a.m. confirmed that all items should be thrown out when they expire and should not be used. Observations in the first floor kitchenette on September 5, 2024, at 2:12 p.m. revealed a large container of cottage cheese, opened and in use, that had expired on September 2, 2024. There were also 10 cartons of frozen Nutrijuice in the freezer that were expired. Interview with Kitchen Aide 4 on September 5, 2024, at 2:12 p.m. confirmed that the expired items should have been thrown away and not used. 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 9 of 10 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 09/05/2024 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 plan of corrections for an annual survey ending November 1, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending September 5, 2024, identified repeated deficiencies related to a failure to revise care plans, failure to provide quality care, failure to have accountability for controlled medications, and failure to ensure that food was stored and served properly. The facility's plan of correction for a deficiency regarding revision of care plans, cited during the survey ending November 1, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F657, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure that resident's care plans were revised timely. The facility's plan of correction for a deficiency regarding providing quality care, cited during the survey ending November 1, 2023, revealed that the facility would complete audits and report 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 that resident's received quality care. The facility's plan of correction for a deficiency regarding accountability of controlled medications, cited during the survey ending November 1, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F755, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure that controlled medications were accounted for. The facility's plan of correction for a deficiency regarding storing and serving food, cited during the survey ending November 1, 2023, revealed that the facility would complete audits and report 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 that food was stored and served properly. Refer to F657, F684, F755, F812. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395530 If continuation sheet Page 10 of 10

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Citations

9 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.

0684GeneralS&S Dpotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0695GeneralS&S Dpotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0755GeneralS&S Dpotential 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.
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.
0658GeneralS&S Dpotential for harm
F658 - Comprehensive Care Plans
Ensure services provided by the nursing facility meet professional standards of quality.
0761GeneralS&S Dpotential for harm
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
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.
0690GeneralS&S Epotential for harm
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

FAQ · About this visit

Common questions about this visit

What happened during the September 5, 2024 survey of Presbyterian Homes-Presby?

This was a inspection survey of Presbyterian Homes-Presby on September 5, 2024. The surveyor cited 9 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at Presbyterian Homes-Presby on September 5, 2024?

Yes, 9 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."

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·September 5, 2024