The resident representative filed a grievance on July 24 after discovering the woman's glasses were missing. What they didn't know was that facility staff had already arranged an optometry visit, ordered replacement glasses through a consultant service called 360 care, and failed to document any family notification about the appointment or new eyewear.
That same day, the resident's skin condition had deteriorated significantly.
A wound note from July 16 described an intact blister on the woman's left lower leg, roughly three by four centimeters in diameter. The surrounding skin appeared pink and warm with some fluid seepage. Eight days later, medical staff documented that the blister was no longer intact and had informed the medical director.
The facility's physician ordered 500 milligrams of Cephalexin twice daily for seven days to treat cellulitis, a bacterial skin infection that can become serious if left untreated.
Nobody called the family about the infection or the antibiotic prescription.
State inspectors found no documented evidence that the resident representative received notification about the vision consultation, the worsening skin condition, or the new medication order. The facility's own policy, updated January 30, specifically required timely notification to families and resident representatives about changes in medical conditions.
The Director of Nursing confirmed during three separate interviews on September 10 that no documentation existed showing family notification about the antibiotic medication. She acknowledged that the family should have been notified about consultant appointments but wasn't.
A quarterly assessment from August 5 revealed the extent of the resident's cognitive impairment. She was severely impaired but usually understood communication and could sometimes understand others. She required assistance with her care needs and carried a dementia diagnosis.
The facility had no established process for notifying families when residents received services from 360 care's vision consultants, despite the company providing in-house optometry visits and ordering prescription eyewear.
The missing glasses grievance exposed a broader communication breakdown. While staff arranged medical care and vision services for a vulnerable resident who couldn't advocate for herself, her designated representative remained unaware of significant health developments unfolding over more than a week.
The skin infection case illustrated particular concern given the resident's cognitive limitations. Cellulitis can spread rapidly and lead to serious complications, especially in elderly patients with dementia who may not be able to communicate symptoms effectively.
Federal regulations require nursing homes to immediately notify residents, their doctors, and family members about situations that affect the resident, including injuries, medical changes, and room assignments. The facility's January policy acknowledged these requirements and committed to consistent compliance with resident choice considerations.
The inspection revealed that Presbyterian Homes-Presby failed to follow both federal standards and its own written procedures for a resident who depended entirely on staff and family coordination for her medical care decisions and advocacy.
The woman's representative discovered the missing glasses issue independently, raising questions about what other medical developments might have occurred without family knowledge. The bacterial infection requiring antibiotic treatment represented exactly the type of condition change that regulations mandate families must learn about promptly.
State inspectors classified the violation as causing minimal harm with few residents affected, but noted the facility's systematic failure to maintain required communication protocols for vulnerable residents who cannot speak for themselves.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Presbyterian Homes-presby from 2025-09-10 including all violations, facility responses, and corrective action plans.