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Complaint Investigation

Presbyterian Homes-presby

Inspection Date: February 5, 2025
Total Violations 1
Facility ID 395530
Location HOLLIDAYSBURG, PA
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Inspection Findings

F-Tag F689

Harm Level: Minimal harm or 19102
Residents Affected: Few to ensure that staff provided assistive devices to eat in accordance with the resident's care plan for one of six

F-F689 on January 19, 2025.

28 Pa. Code 201.14(a) Responsibility of Licensee.

28 Pa. Code 201.18(b)(1)(e)(1) Management.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 8 395530 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395530 B. Wing 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)

F 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Level of Harm - Minimal harm or 19102 potential for actual harm Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed Residents Affected - Few to ensure that staff provided assistive devices to eat in accordance with the resident's care plan for one of six residents reviewed (Resident 1).

Findings include:

The facility's policy regarding adaptive feeding devices, dated January 30, 2025, indicated that the facility would provide the resident with the most independent and safe way of eating.

A quarterly Minimum Data Set (MDS) assessment for Resident 1, dated November 9, 2024, indicated that

the resident was severely cognitively impaired and was independent with eating after set up. The resident's care plan, dated November 27, 2024, and speech therapy clinical notes, dated December 21, 2024, indicated that her food was to be provided in bowls and given to her one at a time.

Observations of Resident 1 during the lunch meal on February 5, 2025, at 11:50 p.m. revealed that the resident was at a dining room table eating her meal, and her pork, mashed potatoes and sauerkraut were served on a plate. The resident's meal ticket, dated February 5, 2025, indicated that the resident was to have her food served in separate bowls, one at a time.

Interview with the Nursing Home Administrator on February 5, 2025, at 2:46 p.m. confirmed that Resident 1's food should have been served in separate bowls one bowl at a time, as care planned.

28 Pa. Code 211.12(d)(3)(5) Nursing Services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 8 395530

📋 Inspection Summary

Presbyterian Homes-Presby in HOLLIDAYSBURG, PA inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in HOLLIDAYSBURG, PA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Presbyterian Homes-Presby or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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