Presbyterian Village

Based on observations, staff interviews, and review of facility policies titled, Mechanically Altered Diets and Thickened Liquids and How to Puree Foods, the facility failed to ensure dietary staff followed standardized pureed food recipes for nine of nine residents receiving pureed diets. This deficient practice had the potential to result in inconsistent nutritional intake and unsafe food consistency. Findings include:Review of the facility policy titled Mechanically Altered Diets and Thickened Liquids, issued on 05/01/2019, under the section titled Procedure, revealed, Mechanically altered diets are planned, prepared, and served with supervision or consultation from a registered dietitian.Review of the facility policy titled How to Puree Foods under the section titled Preparation Steps revealed, Depending on the resident's dietary restrictions, follow the proper recipes.Observation and interview on 01/26/2026 at 11:03 AM revealed [NAME] CC preparing pureed green beans for approximately 10 residents. The cook stated the consistency he was looking for was medium and that each…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review, staff interviews, and review of the facility's policies titled, Labeling Food Product and Food Storage, the facility failed to ensure food items were properly labeled, dated, sealed, and discarded when expired in the pantry, freezer, cooler, and resident refrigerator. This deficient practice had the potential to affect all 62 residents who receive food orally and increased the risk of foodborne illness.Findings include:Review of the facility policy titled Labeling Food Product, reviewed on 01/02/2023, revealed under Policy: All prepared foods, leftovers and opened products stored for later use will be labeled according to food safety standards. Under Procedures: .3. a. All labels will contain the complete name of the product, the date the product was prepared or opened, the date the product must be utilized by, and the name of the individual creating the label.Review of the facility policy titled Food Storage revealed under Procedure: All products shall be dated upon receipt or when they are prepared. Under Dry Storage revealed: .Any opened…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, and review of the facility policy titled, Environmental Services Policy - Cleanliness and Homelike Environment, the facility failed to maintain a clean and homelike environment related to a stained wall surface in one of eight rooms (Room F8) located on F Hall. This deficient practice had the potential to negatively impact the residents' right to reside in a safe, clean, and homelike environment. Findings include:A review of the facility policy titled Environmental Services Policy - Cleanliness and Homelike Environment reviewed on 08/28/2025, under the section titled Procedure, stated, Residents' rooms, bathrooms, and common areas will be cleaned and sanitized regularly per facility schedule and infection control practices. The policy further stated, Routine inspections of residents' rooms and common areas will be conducted to ensure compliance with cleanliness and homelike standards. The policy additionally stated, All staff are responsible for maintaining a clean and dignified environment. Spills, trash, or hazards should be reported…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, and review of the facility policy titled, Storage of Medications, the facility failed to ensure medications and biologicals were stored at proper temperatures to maintain their integrity. Specifically, one of two medication refrigerators in the first-floor medication room was not maintained within the required temperature range. Additionally, temperature monitoring was not completed daily in a second medication refrigerator located in the second-floor medication room. This deficient practice had the potential for residents to receive medications with compromised effectiveness.Findings include:Review of the undated facility policy titled Storage of Medications revealed the Policy states, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. The Policy Interpretation and Implementation section further indicated: 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls.7. Medications requiring refrigeration are stored in a refrigerator…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, and review of facility policy titled, Medication Administration Policy, the facility failed to ensure infection prevention and control practices were maintained during medication administration when food was present on one of four medication carts.Findings include:Review of the facility policy titled Medication Administration Policy revised on 01/29/2026, documented under section titled, Medication Cart Cleanliness and Prohibited Items, the policy applies to all licensed nursing staff and is intended to ensure safe and sanitary medication administration practices. Medication carts shall be maintained in a clean, organized, and professional manner at all times. The policy further stated, Medication carts are to be used exclusively for medication storage and medication administration supplies. The presence of food or beverages on or within the medication cart is strictly prohibited. Under the section titled Medication Cart Cleanliness, the policy stated, Medication carts must be clean, uncluttered, and free from visible dirt, spills, or debris,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review , staff interviews, and review of the facility policies/documents titled, Infection Prevention and Control Program, Infection Prevention and Control Committee, Surveillance Plan, Help Keep Our Residents Safe-Enhanced Barrier Precautions In Nursing Homes, Enhanced Barrier Precautions (EBP) Implementation-Observations Tool, and Wound Care, the facility failed to provide proper surveillance and monitoring for infections and communicable diseases for 71 of 71 residents (R) residing in the facility. In addition, the facility failed to ensure Enhanced Barrier Precautions signs were on residents' doors for 15 of 15 (R) on enhanced barrier precautions. Furthermore, the facility failed to provide wound care following appropriate technique to prevent spread of infection for one of eight sampled (R) (R19), and to ensure staff practiced infection prevention techniques relating to shared equipment use cleaning. These deficient practices had the potential to cause the spread of infection.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review, staff interviews, and review of the facility policy titled, Antibiotic Stewardship Policy, the facility failed to establish and maintain an antibiotic stewardship facility-wide monitoring system (line listing) for residents on antibiotics. The deficient practice had the potential to affect all 71 residents residing in the facility. Findings include: Review of the facility policy titled Antibiotic Stewardship Policy not dated, documented under section titled, Governance of Antimicrobial Stewardship, as part of the Infection Prevention and Control Program (IPCP), the facility has established a committee to oversee antimicrobial stewardship functions. The Infection Preventionist (IP), who is responsible for the overall IPCP, is an integral part of the committee. The Antibiotic Stewardship Committee will meet at least quarterly and review this policy annually and as needed. Under Composition: 1. An Antibiotic Stewardship Committee has been established and is composed of the following personnel: a. Infection Preventionist (IP), b. Director or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interview, and review of the facility policy titled, Antibiotic Stewardship Policy, the facility failed to employ a certified Infection Preventionist (IP) and experienced a lapse in infection prevention leadership. The deficient practice had the potential to affect all 71 residents residing in the facility. Findings include: Review of the undated facility policy titled Antibiotic Stewardship Policydocumented under section titled, Governance of Antimicrobial Stewardship, as part of the Infection Prevention and Control Program (IPCP), the facility has established a committee to oversee antimicrobial stewardship functions. The Infection Preventionist (IP), who is responsible for the overall IPCP, is an integral part of the committee. Under Composition revealed in 2. The IP will incorporate antibiotic stewardship into their current activities and will allocate dedicated time (10 hours/week) specifically for antimicrobial stewardship activities. The IP is required to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, record review, and review of the facility policy titled, Activities of Daily Living (ADLs) Policy, the facility failed to ensure activities of daily living relating to fingernail care and grooming were provided for five of 18 sampled residents (R) (R33, R42, R28, R55 and R31). The deficient practice had the potential to cause risk for unmet needs and a diminished quality of life. Findings include: Review of the policy titled Activities of Daily Living (ADLs) Policy revised October 2024 revealed under Policy Statement: Residents are provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. Under Policy Interpretation and Implementation: 1. Care will be provided unless clinically inappropriate. 2. Services that will be provided which include grooming, mobility, elimination during dining, and communication. 5. Residents are clinically assessed to determine the amount of assistance needed for tasks and any…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility's policy titled, Use of Psychotropic Medication, the facility failed to implement a stop date for a PRN (as needed) psychotropic medication for one of five Residents (R) (R53) reviewed for unnecessary medications. The deficient practice had the potential to affect the resident's highest practicable mental, physical, and psychosocial well-being. Findings include: Review of the facility's policy titled Use of Psychotropic Medication revised 7/2024 revealed under Policy: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Under Policy Explanation and Compliance Guidance: . 9. PRN [as needed] orders for all psychotropic drugs shall be used only when the medication is necessary to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, and review of the facility policy titled, Storage of Medications, the facility failed to ensure medications were secured for one of two medication carts on one of two Halls (Hall B). The deficient practice had the potential for residents, visitors, and staff to access medications that may cause illness or injury. The facility census was 71. Findings include: Review of the policy titled Storage of Medications dated 3/1/2024 revealed under Policy Statement: All drugs and biologicals will be stored in a safe secure and orderly manner. Under Policy Interpretation and Implementation: 1. Drugs are stored in locked compartments stored in their packaging as received from pharmacy. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. 9. Unlocked medication carts are not left unattended. Observation on 11/13/2402 at 8:19 am of medication administration on Hall B, Licensed Practical Nurse (LPN) EE was preparing for medication administration for R8 and walked down the hall…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interviews and review of facility policies titled Activities and Social Services and Activities Attendance, the facility failed to provide an ongoing program of activities based on resident representative input and/or activity preference assessments for four of 24 sampled residents (R) (R#42, R#40, R#53, R#38) reviewed for the activities. Findings include: 1. During an observation and interview with R#42 on 7/12/22 at 10:15 a.m., she stated that she would like to participate in activities but there are no group activities being offered. She stated that she is extremely frustrated because she has obeyed all the rules, took all four of her COVID shots and boosters. She stated, I am sick and tired of the staff blaming COVID for everything Resident was observed coloring with markers in adult coloring books and had puzzles at her bedside. She stated, All I do is either color or do puzzles and I want to do something else. A review of Electronic Medical Records (EMR) for R#42…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.