Presbyterian Homes-presby

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