Health inspection·November 5, 2024

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 Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to transcribe physician's orders related to medication changes for one of seven residents reviewed (Resident 1). Residents Affected - Few Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated August 30, 2024, indicated that the resident was cognitively impaired, required partial/moderate assist for transfers, and had a diagnosis that included dementia. Review of clinical records for Resident 1 revealed diagnoses that included a history of falls, adjustment disorder with anxiety and depression, and generalized anxiety disorder. Progress notes for Resident 1, dated October 18, 2024, at 3:53 p.m. indicated that the social worker and the Certified Registered Nurse Practitioner (CRNP) with Psychogeriatric Services called the resident's daughter to review medications. The daughter indicated that she did not have any concerns with the medications that the resident was on, but felt adjustments needed to be made to help the resident get more rest at night. The CRNP discussed increasing the resident's trazodone (an antidepressant used to help with sleep) and melatonin (a medication used to help with sleep) if appropriate, and the daughter was in agreement. Psychogeriatric consult notes for Resident 1, dated October 18, 2024, indicated that the resident was increasingly anxious, depressed, and agitated after family visits and had difficulty sleeping at night. The CRNP recommended to increase the trazadone to 75 milligrams (mg) at bedtime and to increase the melatonin to 10 mg at bedtime. Documentation in the resident's clinical record revealed that the psychogeriatric consult notes and recommendations were reviewed and initialed by the nurse and by the resident's physician on October 22, 2024. Nurse's notes for Resident 1, dated October 25, 2024, at 10:38 a.m., indicated that the interdisciplinary team reviewed the resident after a fall that occurred on October 25, 2024, at 12:01 a.m., indicating that the resident's trazodone and melatonin were increased during the consult with psychogeriatric services. (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 2 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 11/05/2024 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)