Health inspection·February 5, 2025

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 clinical records and staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for one of six residents reviewed (Resident 3). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated November 4, 2024, indicated that the resident was cognitively intact and had a history of falls. The care plan, dated December 22, 2024, through February 1, 2025, for Resident 3 revealed that the resident was non-compliant and at risk for falling and had the following interventions in place: provide environment free of clutter, keep call bell light in reach at all times, keep personal items and frequently used items within reach, kid cushion to the night stand, gripper socks on while in bed, reminder signs to ring for assistance, non-skid strips to the right side of the bed, bed height marked on the wall for bed height, anti-roll back devices to wheelchair, offer to lie down after breakfast and lunch, perimeter mattress to bed, reminder sign placed on bathroom door to remind resident of location, reminder sign on wall beside bed to remind resident to ring for assistance, reflective tape to wheelchair and walker, attempt to walk resident with front-wheeled walker if she appears restless, motion activated night light at foot of bed, walker at bedside, dycem (anti-slip material) to wheelchair cushion, offer to toilet if resident seems restless, family agreeable to soft helmet when it arrives, offer fidget dog, offer stuffed animal if resident seems restless, large face alarm clock when it arrives. A nursing note, dated February 2, 2025, at 9:00 p.m. revealed that Resident 3 had an unwitnessed fall in her room. Upon entering the room the resident was noted to be lying flat on her back with her legs extended straight in front of her. She had a bump noted on the back of her head that was painful to touch. She was transferred to the hospital for further evaluation and was admitted with a subdural hematoma (collection of blood on the brain). There was no documented evidence that the resident's care plan was updated to include the intervention of calling the resident's son when she was restless. A nursing note, dated February 2, 2025, at 7:45 p.m., revealed that Resident 3 had an unwitnessed fall in her room. Upon entering the room the resident was noted to be lying flat on her back with her legs extended straight in front of her, with her head towards the bed and legs toward the door. There were no injuries noted. A fall investigation, dated February 1, 2025, revealed that the resident was restless at the time of the fall and the care plan was followed. A witness statement from Licensed Practical Nurse 3, dated February 1, 2025, revealed that following the fall the resident's son (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 8 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 02/05/2025 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)