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Presbyterian Homes-Presby: Dietary Care Violations - PA
Instead, staff served the meal on a single plate with all items mixed together....
Latest reports, citations, and penalties from CMS data
Instead, staff served the meal on a single plate with all items mixed together....
However, documentation revealed this critical recommendation was never implemented....
Despite the first elopement incident, facility staff failed to develop any care plan to prevent future occurrences....
Proper nutritional monitoring in nursing homes requires regular weight checks, laboratory assessments of protein levels, and documentation of food intake....
Three residents experienced significant medication errors that could have resulted in serious medical complications....
On March 24, inspectors found the resident sitting in his wheelchair with a nasal cannula connected to a portable oxygen tank that **was not turned on**....
When staff couldn't locate the resident at 6:00 PM, they initiated a facility-wide search and contacted local police....
The inspection narrative documents that three residents were subjected to this treatment during this extended period....
Two days later, the same resident fell again while attempting to stand without assistance in their room....
Additionally, inspectors found a bag labeled "Promethegan" with concerning documentation issues....
This lapse in reporting protocols represents a significant breakdown in the resident protection system that nursing homes are required to maintain....
In the 100 hall shower room, staff had stored an electric razor filled with gray hair stubble without any resident identification label....
The federal requirements governing medication administration encompass multiple safeguards....
The inspection narrative documented the resident's progression from complete continence to frequent incontinence between July 2024 and October 2024....
The nurse stated the resident was on "regular standard precautions," unaware of the enhanced requirements....
This marks the third inspection in less than a year where surveyors documented the same fundamental deficiency....
This qualification gap becomes particularly significant when considering the scope of responsibility involved in dietary management....
The resident had been switched to the injectable form due to refusal of oral medications and worsening behavioral symptoms....
The resident experienced severe pain for approximately 15 hours before receiving the appropriate pain medication....
The incident came to light over a weekend when supervisory nursing staff became aware of the situation....