United Presbyterian Home

In the surveyor’s words

From the most serious findings on record at United Presbyterian Home, in the surveyor’s own words.

• Actual harm, isolatedF600Jul 14, 2022

  Based on clinical record review, staff interview, resident interview, and facility policy review the facility failed to protect residents from resident to resident altercations which included sexual gestures, physical touching, grabbing, and attempted hitting by Resident #51 for four of five residents reviewed for abuse (Resident #1, Resident #4, Resident #17, Resident #37), and also unidentified residents. The facility reported a census of 49 residents. Findings include: The Admission Minimum Data Set (MDS) assessment for Resident #51 dated 11/12/21 revealed the resident scored 3 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated the resident had severely impaired cognition. […]

• No harm, potential for more than minimal, patternF812Aug 22, 2024

  Based on observation, policy review, and staff interview, the facility failed to maintain adequate kitchen sanitation for 2 of 2 kitchen areas and failed to carry out sanitary food handling for 2 of 2 meals observed. The facility reported a census of 42 residents. Findings include: The initial kitchen tour, conducted on 8/19/24 at 9:51 a.m., revealed a fan near the dishwasher with thick dust particles on the fan covering. The fan blew toward a rack containing clean metal pans. A follow-up tour of the kitchen on 8/20/24 at 9:30 a.m. revealed the following concerns: a. Thick dust particles remained on the fan covering. The fan blew toward a rack which contained two water pitchers, trays, and tongs. b. Dust particles hung from the spigots of the fire suppression system. […]

• No harm, potential for more than minimal, patternF804Nov 28, 2023

  Based on observation, clinical record review, policy review, resident interview, and staff interview, the facility failed to provide foods at an appetizing temperature for 1 of 1 meals observed. The facility reported a census of 51 residents. Findings Include: 1. The Quarterly Minimum Data Set (MDS) assessment tool, dated 8/23/23, listed Resident #8's Brief Interview for Mental Status (BIMS) score as 13 out of 15, which indicated intact cognition. On 11/13/23 at 12:27 p.m., Resident #8 stated that in the evenings the soup was not hot. 2. The Quarterly MDS assessment tool, dated 8/30/23, listed Resident #33's BIMS score as 15 out of 15, which indicated intact cognition. On 11/13/23 at 1:13 p.m., Resident #33 stated lunch was cold half the time. 3. […]

• No harm, potential for more than minimal, patternF812Nov 28, 2023

  Based on observation, staff interview and facility policy the facility failed to maintain sanitary surfaces on the counter used for cutting meat to prevent possible cross-contamination of food for 14 of 36 residents served the meat option. The facility reported a census of 51. Findings include: On 11/14/23 at 11:45 AM start of lunch service observation, Cook, Staff F, placed individual resident paper menus on the counter in front of the steam table for review of resident individual choices circled on their menu's. Staff F moved the paper menus and proceeded to retrieve and cut the eight-ounce meat patty option in half on the same counter location the paper menus were placed. Staff repeated this process, looked at the menus and then cut the meat patty for those choosing the meat option. […]

• No harm, potential for more than minimal, patternF725Jul 14, 2022

  Based on review of clinical record, the facility assessment, call light logs, resident council meeting minutes and facility policy, and staff interview, the facility failed to assure sufficient staff available at all times to provide nursing and related services to meet the residents' needs for 2 of 24 residents reviewed (Residents #38 and #45). The facility reported a census of 49 residents. Findings. 1. The MDS (Minimum Data Set) Assessment tool, dated 5/11/22 listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident required limited assistance of 1 staff for personal hygiene, and extensive assistance of 1 staff for bathing. […]