ElderGrade

Inspection citations at Presbyterian Homes-Presby

40 citations on record, 4 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2025 12 1
2024 13 2
2023 15 1
D November 20, 2025 Tag F0849 Corrected Dec 2025

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

No actual harm, potential for more than minimal harm

D November 20, 2025 Tag F0684 Corrected Dec 2025

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D November 20, 2025 Tag F0628 Corrected Dec 2025

Resident Rights Deficiencies

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

No actual harm, potential for more than minimal harm

D November 20, 2025 Tag F0600 Corrected Dec 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

No actual harm, potential for more than minimal harm

E November 20, 2025 Tag F0880 Corrected Dec 2025

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

E November 20, 2025 Tag F0812 Corrected Dec 2025

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

E November 20, 2025 Tag F0641 Corrected Dec 2025

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

No actual harm, potential for more than minimal harm

D September 10, 2025 Tag F0580 Complaint investigation Corrected Sep 2025

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

No actual harm, potential for more than minimal harm

D February 5, 2025 Tag F0810 Complaint investigation Corrected Feb 2025

Nutrition and Dietary Deficiencies

Provide special eating equipment and utensils for residents who need them and appropriate assistance.

No actual harm, potential for more than minimal harm

D February 5, 2025 Tag F0657 Complaint investigation Corrected Feb 2025

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

No actual harm, potential for more than minimal harm

E February 5, 2025 Tag F0684 Complaint investigation Corrected Feb 2025

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

G February 5, 2025 Tag F0689 Complaint investigation Corrected Jan 2025

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Actual harm to a resident

D November 5, 2024 Tag F0658 Complaint investigation Corrected Nov 2024

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

No actual harm, potential for more than minimal harm

D September 5, 2024 Tag F0867 Corrected Sep 2024

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

No actual harm, potential for more than minimal harm

D September 5, 2024 Tag F0761 Corrected Sep 2024

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

No actual harm, potential for more than minimal harm

D September 5, 2024 Tag F0755 Corrected Sep 2024

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

No actual harm, potential for more than minimal harm

D September 5, 2024 Tag F0695 Corrected Sep 2024

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

No actual harm, potential for more than minimal harm

D September 5, 2024 Tag F0684 Corrected Sep 2024

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D September 5, 2024 Tag F0658 Corrected Sep 2024

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

No actual harm, potential for more than minimal harm

D September 5, 2024 Tag F0657 Corrected Sep 2024

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

No actual harm, potential for more than minimal harm

E September 5, 2024 Tag F0812 Corrected Sep 2024

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

E September 5, 2024 Tag F0690 Corrected Sep 2024

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

No actual harm, potential for more than minimal harm

D August 26, 2024 Tag F0656 Complaint investigation Corrected Sep 2024

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

G July 22, 2024 Tag F0689 Complaint investigation Corrected Jul 2024

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Actual harm to a resident

G July 22, 2024 Tag F0600 Complaint investigation Corrected Jul 2024

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Actual harm to a resident

D November 1, 2023 Tag F0867 Corrected Dec 2023

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

No actual harm, potential for more than minimal harm

D November 1, 2023 Tag F0657 Corrected Dec 2023

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

No actual harm, potential for more than minimal harm

D November 1, 2023 Tag F0656 Corrected Dec 2023

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

D November 1, 2023 Tag F0641 Corrected Dec 2023

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

No actual harm, potential for more than minimal harm

D November 1, 2023 Tag F0585 Corrected Dec 2023

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

No actual harm, potential for more than minimal harm

E November 1, 2023 Tag F0812 Corrected Dec 2023

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

E November 1, 2023 Tag F0804 Corrected Dec 2023

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

No actual harm, potential for more than minimal harm

E November 1, 2023 Tag F0755 Corrected Dec 2023

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

No actual harm, potential for more than minimal harm

E November 1, 2023 Tag F0694 Corrected Dec 2023

Quality of Life and Care Deficiencies

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

No actual harm, potential for more than minimal harm

E November 1, 2023 Tag F0684 Corrected Dec 2023

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

E November 1, 2023 Tag F0550 Corrected Dec 2023

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

No actual harm, potential for more than minimal harm

E July 28, 2023 Tag F0812 Complaint investigation Corrected Aug 2023

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

E July 28, 2023 Tag F0804 Complaint investigation Corrected Aug 2023

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

No actual harm, potential for more than minimal harm

E July 28, 2023 Tag F0557 Complaint investigation Corrected Aug 2023

Resident Rights Deficiencies

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

No actual harm, potential for more than minimal harm

G July 28, 2023 Tag F0689 Complaint investigation Corrected Jul 2023

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Actual harm to a resident

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.