HOLLIDAYSBURG, PA - Federal inspectors identified failures in providing proper dining assistance and adaptive equipment to cognitively impaired residents at Presbyterian Homes-Presby during a February 5, 2025 complaint investigation, potentially affecting residents' nutritional intake and safety.
Failure to Follow Specialized Dining Protocols
The facility failed to provide appropriate dining accommodations for a severely cognitively impaired resident, despite clear documentation in multiple care planning documents specifying the exact feeding methods required. During the February 5 lunch service, inspectors observed Resident 1 eating from a standard plate containing pork, mashed potatoes and sauerkraut, directly contradicting the resident's care plan requirements.
The resident's individualized care plan, dated November 27, 2024, explicitly stated that all food items must be served in separate bowls and presented one at a time. This same requirement was reinforced in speech therapy clinical notes from December 21, 2024, and appeared on the resident's meal ticket the day of the inspection. Instead, staff served the meal on a single plate with all items mixed together.
A quarterly Minimum Data Set assessment from November 9, 2024, documented that this resident was severely cognitively impaired but capable of eating independently once properly set up. This classification makes proper meal presentation critical for maintaining the resident's ability to self-feed successfully.
Medical Significance of Adaptive Dining Equipment
For residents with severe cognitive impairment, the method of food presentation directly impacts their ability to maintain adequate nutrition and hydration. Serving food in separate bowls one at a time helps prevent overwhelming confusion that can occur when multiple food items are presented simultaneously. This approach reduces the cognitive load required for meal consumption and helps maintain focus on eating.
When cognitively impaired residents become confused or overwhelmed during meals, they may stop eating prematurely, mix inappropriate food combinations, or experience increased agitation. The sequential presentation method allows residents to concentrate on one food item at a time, improving overall consumption and reducing meal-related stress.
The facility's own policy regarding adaptive feeding devices, dated January 30, 2025, emphasized providing residents "the most independent and safe way of eating." The observed practice directly contradicted this stated commitment by failing to implement the documented accommodations that support independent eating for cognitively impaired residents.
Breakdown in Care Plan Implementation
The violation revealed a concerning disconnect between documented care requirements and actual practice. Multiple sources - the care plan, speech therapy notes, and the daily meal ticket - all contained the same specific instructions for bowl presentation. This redundancy in documentation suggests the facility recognized the importance of this accommodation yet failed to ensure consistent implementation.
When interviewed on February 5, 2025, at 2:46 p.m., the Nursing Home Administrator confirmed that "Resident 1's food should have been served in separate bowls one bowl at a time, as care planned." This acknowledgment from facility leadership indicates awareness of the proper protocol but highlights a failure in staff training or supervision to ensure compliance.
Industry Standards for Cognitive Support During Dining
Standard nursing home practice requires strict adherence to individualized care plans, particularly for residents with cognitive impairments who cannot advocate for their own needs. Speech therapy recommendations for dining modifications represent professional clinical judgments based on comprehensive swallowing and cognitive assessments. These modifications are not optional preferences but essential accommodations for safe and adequate nutrition.
Federal regulations mandate that facilities provide special eating equipment and utensils for residents who need them, along with appropriate assistance. This requirement extends beyond physical adaptive devices to include presentation methods that accommodate cognitive limitations. The sequential bowl presentation method represents a form of cognitive adaptive equipment, structuring the dining experience to match the resident's processing capabilities.
Regulatory Citations and Compliance Requirements
Inspectors cited the facility under F810, which requires nursing homes to provide special eating equipment and utensils for residents who need them and appropriate assistance. The violation was classified as causing "minimal harm or potential for actual harm" and affected few residents. Additionally, the facility was cited under Pennsylvania state regulations 28 Pa. Code 211.12(d)(3)(5) regarding nursing services standards.
While classified as minimal harm in this instance, such violations can escalate if residents experience weight loss, dehydration, or increased confusion during meals due to improper accommodation. The facility must now submit a plan of correction addressing how they will ensure consistent implementation of documented dining accommodations for all residents requiring specialized presentation methods.
The inspection findings underscore the importance of translating documented care requirements into consistent daily practice, particularly for vulnerable residents with cognitive impairments who depend on staff to provide appropriate accommodations for maintaining nutrition and independence.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Presbyterian Homes-presby from 2025-02-05 including all violations, facility responses, and corrective action plans.
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