Presbyterian Homes-presby
Presbyterian Homes-Presby in HOLLIDAYSBURG, PA — inspection on September 10, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident representative was notified timely about a change in condition for one of three residents reviewed (Resident 2).Findings include:The facility's policy regarding changes in condition, dated January 30, 2025, indicated that the facility would provide timely notification to families, resident representatives, powers of attorney, physicians, and staff of changes in resident medical conditions consistent with regulation and resident choice.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated August 5, 2025, revealed that the resident was severely cognitively impaired, usually understood, could sometimes understand, required assistance with care needs, and had diagnoses that included dementia.A grievance filed by the resident representative on July 24, 2025, revealed that Resident 2's glasses were missing.
The glasses were replaced by 360 care.
The investigation determined that the resident representative was not notified of optometry visit in house or that new glasses were ordered.
There was no process in place to notify families when residents are seen for new glasses by 360 (consult vision services). A skin/wound note dated July 16, 2025, for Resident 2, revealed that she was noted to have intact edema blister on left medial lower extremity, approximately three by four centimeters (cm) in diameter.
Surrounding skin pink and warm to the touch with some weeping present. A skin/wound note dated July 24, 2025, for Resident 2, revealed that the blister was no longer intact and the medical director was aware.
Physician's orders for Resident 2, dated July 24, 2025, included an order for the resident to receive 500 milligrams (mg) of Cephalexin (antibiotic medication) twice a day for cellulitis (bacterial infection of the skin) for seven days.There was no documented evidence that the resident's representative was notified about the Resident 2's appointment with a consult for vision services, changes in a skin alteration, or a new ordered antibiotic medication.Interview with Director of Nursing on September 10, 2025, at 4:45, 5:03, and 5:21 p.m. confirmed that there was no documented evidence of notification to the resident's representative about a new medication and confirmed that the family should have been notified of any consult appointments, but was not.28 Pa.
Code 211.12(d)(1)(3)(5) Nursing Services.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
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