Presbyterian Homes-presby
Inspection Findings
F-Tag F0580
F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
Presbyterian Homes-Presby in HOLLIDAYSBURG, PA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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.