Presbyterian Homes-Presby

In the surveyor’s words

From the most serious findings on record at Presbyterian Homes-Presby, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Feb 1, 2022

  Based on review of policies, clinical records, and facility reports, as well as observations and staff interviews, it was determined that the facility failed to ensure that the residents' environment remained free of accident hazards for residents not identified as an elopement risk for one of three residents reviewed (Resident 2) and failed to develop and implement new interventions to prevent the elopement of residents not identified as an elopement risk, placing the safety of current residents not identified as a risk for elopment in Immediate Jeopardy. […]

• Actual harm, isolatedF689Feb 5, 2025

  Based on review of facility policies, clinical records, and facility investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that assistance devices to prevent accidents or injury were in place as care planned for one of six residents reviewed (Resident 2) who was at risk for falls, resulting in a fall with multiple fractures. This deficiency was cited as past non-compliance. Findings include: The facility's fall management policy, dated January 30, 2025, indicated that the facility would provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurred. The facility would ensure the resident environment remained as free of accident hazards as possible. […]

• Actual harm, isolatedF600Jul 22, 2024

  Based on review of policies, investigative reports, and residents' clinical records, as well as staff and family interviews, it was determined that the facility failed to ensure that residents were free from neglect caused by a failure to follow the facility's policy for obtaining temperatures of hot liquids for one of two residents reviewed (Resident 1), resulting in the resident spilling her coffee and causing a burn. This deficiency was cited as past noncompliance. Findings include: The facility's policy regarding resident abuse, dated February 8, 2024, revealed that each resident is provided a safe environment where they are not subjected to mental, physical, verbal, and sexual abuse. […]

• Actual harm, isolatedF689Jul 22, 2024

  Based on review of policies, clinical records, and facility investigation reports, as well as staff interviews, it was determined that the facility failed to provide an environment that was free of accident hazards by serving hot coffee in a cup without a lid to one of two residents (Resident 1) without first obtaining a temperature to ensure that it was not greater than 140 degrees Fahrenheit, resulting in third degree burns when it was spilled on the resident. This deficiency was cited as past non-compliance. Findings include: The facility's policy regarding reheating of hot food/beverages, dated February 8, 2024, revealed that when serving hot beverages the maximum temperature should not be greater than 140 degrees Fahrenheit (F). […]

• Actual harm, isolatedF689Jul 28, 2023

  Based on review of clinical records and facility investigation reports, as well as staff interviews, it was determined that the facility failed to provide an environment that was free of accident hazards for residents who were at risk for falls by failing to follow care-planned interventions for one of three residents reviewed (Resident 1), resulting in a fall with a hip fracture. This deficiency was cited as past non-compliance. Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated June 20, 2023, revealed that the resident was understood, could understand, required extensive assistance from staff for her daily care tasks including with her bed mobility and transfers, was not steady and only… […]