Presidential Post-Acute

In the surveyor’s words

From the most serious findings on record at Presidential Post-Acute, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 23, 2026

  Number of residents sampled: Number of residents cited: Based on medical record review, observations, staff interviews, review of the mechanical lift manufacturer's instructions, review of the Hoyer sling owner's manual, review of the facility's investigation including witness statements, review of the Emergency Medical Services (EMS) report, review of hospital documentation, review of the death certificate, and review of the facility policies, the facility failed to ensure Resident #96 was transferred safely with a mechanical lift. This resulted in Immediate Jeopardy when Resident #96 suffered serious life-threatening injuries on [DATE] when Resident #96 was transferred using a mechanical lift and the top two straps supporting Resident #96's upper body simultaneously broke. […]

• Actual harm, isolatedF689Oct 20, 2025

  Based on review of a self-reported incident (SRI), record review, facility investigation, policy review, and resident and staff interviews, and radiologist interview, the facility failed to ensure Resident #7 received proper assistance during transfers to prevent accidents. Actual Harm occurred on 07/11/25 when Resident #7 sustained a left rib fracture following an improper transfer by facility staff. This affected one (#7) of six residents reviewed for accidents. The facility census was 91.Findings include: Review of Resident #7's medical record revealed an admission date of 04/08/25. Diagnoses included chronic obstructive pulmonary disease, weakness, spinal stenosis of the lumbar region with neurogenic claudication, and adult failure to thrive. […]

• No harm, potential for more than minimal, patternF921Mar 23, 2026

  Based on observation, staff interview, and review of the facility policy, the facility failed to ensure a homelike environment. This affected four (#53, #4, #8, and #90) residents reviewed for physical environment and had the potential to affect all residents. The facility census was 89.Observation on 03/09/26 at 9:37 A.M. of Resident #53's bedroom revealed behind the bed a large, discolored area behind the bed frame with chipped paint. Further observation of Resident #4's bedroom revealed a wall with pealing wallpaper and chipped paint. Additional observation of Resident #8's bedroom revealed a large area on the wall with dry wall chipped and missing paint. […]

• No harm, potential for more than minimal, patternF812May 8, 2024

  Based on observation, interviews, and policy review, the facility failed to properly store chemicals in the kitchen to prevent cross contamination. This had the potential to affect 74 of 76 residents who received food from the kitchen. The facility identified two residents (Resident #7 and Resident #42) who did not receive food from the kitchen. The facility census was 76. Findings include: Observation on 05/05/24 at 8:49 A.M. with Cook #293 revealed comet bleach powder and dawn dish detergent were stored on the kitchen preparation sink. Interview on 05/05/24 at 08:49 A.M. with Cook #293 revealed the sink is used to prepare food such as dicing up peppers, onions, slicing tomatoes, and cleaning lettuce. […]

• No harm, potential for more than minimal, patternF755Jan 13, 2023

  Based on observation, staff interview, and policy review, the facility failed to ensure resident medications were prepared at the time of administration. This affected 21 residents (#05, #07, #12, #13, #16, #18, #19, #28, #32, #36, #40, #41, #43, #45, #47, #54, #56, #57, #59, #71 and #77) who receive medication on the unit. The facility census was 77. Findings include: Observation on 01/12/23 at 7:32 A.M. revealed Licensed Practical Nurse (LPN) #302 was standing next to her medication cart with multiple plastic medication cups stacked upon one another. The cups had multiple loose pills located in each cup and initials written on the cups. […]