Presbyterian Village North Special Care CTR

In the surveyor’s words

From the most serious findings on record at Presbyterian Village North Special Care CTR, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 12, 2025

  Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistive devices to prevent accidents for one of six residents (Resident #1) reviewed for accidents and supervision. CNA A failed to transfer Resident #1 in accordance with her care plan and facility protocol when she independently transferred Resident #1 via mechanical lift (a mechanical device used to safely transfer individuals with limited mobility, typically those who are unable to bear weight or have difficulty moving independently, from one place to another, such as a bed, chair, or wheelchair). […]

• Immediate jeopardy, isolatedF578May 16, 2024

  47030 Based on interviews and record reviews, the facility failed to ensure residents had the right to request, refuse, and/or discontinue treatment, and to formulate an advance directive for 1 (Resident #71) of 10 residents reviewed for advanced directives. Resident #71 was administered CPR by LVN H on [DATE], in not honoring the resident's advance directives. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 4:48PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of more than minimal harm that is not immediate jeopardy and a severity level of isolated because the facility was continuing to implement their Plan of Removal. […]

• Actual harm, isolatedF689Oct 18, 2022

  Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 4 residents reviewed for accidents. The facility did not remain in Resident #1's room after assisting her to the restroom as trained. As a result, Resident #1 fell as she transferred unassisted in her room sustaining an abrasion to her left elbow and laceration to her head. This failure could place all residents, who required transfer assistance, at risk for accidents and injuries. […]

• No harm, potential for more than minimal, widespreadF812Feb 2, 2022

  Based on observation, interview, and record review, the facility failed to prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen. 1. The facility failed to ensure that dietary staff were ensuring that food was meeting the appropriate temperature before serving. 2. The facility failed to ensure that hot food was kept on the steam table prior to servicing. 3. The facility failed to ensure that the Dietary Manager used appropriate hand hygiene when serving ready to eat foods in the kitchen. […]

• No harm, potential for more than minimal, patternF761May 16, 2024

  Based on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals used in the facility are labeled in accordance with professional standards, including expiration dates and with appropriate accessory and cautionary instructions for 2 (Resident #22 and Resident # 323) of 8 residents reviewed for storage of drugs and Biologicals. The facility failed to ensure that MA D secured Resident # 22's medication before walking away from the medication cart. The facility failed to ensure that Resident #323's self-administration medications were secured and not left on the bedside table after administration. […]