Pennsylvania Department of Health
WESTMINSTER WOODS AT HUNTINGDON
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

WESTMINSTER WOODS AT HUNTINGDON
Inspection Results For:

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WESTMINSTER WOODS AT HUNTINGDON - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and Civil Rights Compliance survey completed on May 16, 2024, it was determined that Westminster Woods at Huntingdon was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.45(c) Drug Regimen Review.
§483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

§483.45(c)(2) This review must include a review of the resident's medical chart.

§483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

§483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.

Observations:

Based on review clinical records, as well as staff interviews, it was determined that the facility failed to ensure that monthly pharmacy medication reviews were completed for two of 31 residents reviewed (Residents 3, 14).

Findings include:

The facility policy regarding Consultant Pharmacist report, dated March 26, 2024, indicated that the comments and recommendations concerning medication therapy were to be communicated in a timely fashion. The timing of these recommendations should enable a response prior to the next medication regimen review. Recommendations were to be acted upon and documented by the facility staff and/or prescriber. If the prescriber does not respond to recommendations directed to him/her within 30 days from the date the facility receives the recommendations, the Director of Nursing and/or the consultant pharmacist may contact the Medical Director.

Review of the clinical records for Resident 3 and Resident 14 revealed no documented evidence that the monthly review of medications by the pharmacist were addressed by the physician or designee in December 2023 and January 2024.

Interview with the Director of Nursing on May 16, 2024, at 2:57 p.m. confirmed that there was no documented evidence that the December 2023 and January 2024 monthly medication reviews for Residents 3 and 14 were addressed by the medical provider.

28 Pa. Code 211.9(a)(1) Pharmacy Services.

28 Pa. Code 211.12(d)(3) Nursing Services.

Plan of Correction - To be completed: 06/11/2024

Medical Director reviewed consultant pharmacist report for residents 3 and 14.

Current residents April consultant pharmacist report reviewed for recommendations.

Administrator educated Director of Nursing and Medical Director on Consultant Pharmacist Report policy specific to the time requirements for consultant pharmacist report reviews.

Director of Nursing and/or designee will audit timely completion of consultant pharmacist report monthly for 3 months. The results of these observations will be brought to the Quality Assurance and Performance Improvement Committee for further analysis.

483.10(h)(1)-(3)(i)(ii) REQUIREMENT Personal Privacy/Confidentiality of Records:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.10(h) Privacy and Confidentiality.
The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

§483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

§483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.

§483.10(h)(3) The resident has a right to secure and confidential personal and medical records.
(i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws.
(ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law.

Observations:

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to provide confidentiality of residents' personal health information during medication administration for one of 31 residents reviewed (Resident 48).

Findings include:

The facility policy regarding privacy of health information, dated March 26, 2024, indicated that the facility was to protect the confidentiality of a resident's health information.

Observations during medication administration on May 14, 2024, at 8:21 a.m. revealed that Licensed Practical Nurse 3 walked away from her medication cart to take the blood pressure of Resident 48 without securing her computer screen. Resident 48's personal health information was visible on the computer screen, which was facing the hallway. Upon return to the cart after obtaining the blood pressure, Licensed Practical Nurse 3 retrieved medication to administer to Resident 48 and again left the computer screen unsecured with Resident 48's personal health information visible and facing the hallway.

Interview with Licensed Practical Nurse 3 on May 14, 2024, at 8:27 a.m. confirmed that she should have covered Resident 48's personal information on the computer screen when leaving the medication cart.

Interview with the Director of Nursing on May 16, 2024, at 8:41 a.m. confirmed that the computer screen with residents' personal health information should have been covered when the nurse was not attending the medication cart.

28 Pa. Code 211.5(b) Clinical Records.

Plan of Correction - To be completed: 06/11/2024

Computer screen was secured.

Other medication cart computers observed to be in the secured position.

Director of Nursing and/or designee will educate current nursing team on HIPAA (Health Insurance Portability and Accountability Act) policy specific to licensed team members securing computer screen to protect the confidentiality of a resident's health information.

Director of Nursing and/or designee will audit medication carts utilizing med cart compliance audit tool 1x weekly for 1 month, monthly for 2 months. The results of these observations will be brought to the Quality Assurance and Performance Improvement Committee for further analysis.

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards:

§483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.

Observations:

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide care and treatment in accordance with professional standards of practice by failing to further assess an elevated blood pressure for one of 31 residents reviewed (Resident 29).

Findings include

The facility's policy regarding vital signs, dated March 26, 2024, revealed that vital signs are a measure of a resident's condition that assist in providing necessary services. The American Medical Association, Best Practice guidelines for blood pressure, dated December 2018, revealed that providers need to be aware of blood pressures that are out of range so they can act rapidly to intervene as appropriate.

An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 29, dated March 26, 2024, revealed that the resident was moderately cognitively impaired, usually understood and understands, and had diagnoses that include chronic kidney disease and primary hypertension (high blood pressure). Physician orders for Resident 29, dated April 10, 2024, included an order for the resident to receive 20 milligrams (mg) of Lisinopril (used to treat high blood pressure) twice a day and 6.25 mg of Carvedilol (used to treat high blood pressure) twice a day for hypertension.

A physician's assistant note for Resident 29, dated April 22, 2024, indicated that the resident was currently being followed for both orthostatic hypotension (low blood pressure when standing quickly) and essential hypertension (abnormally high blood pressure), in addition to syncopal (fainting) episodes and related falls.

Review of Resident 29's clinical record for May 12, 2024, indicated that at 8:40 p.m. her blood pressure was 139/94 millimeters of mercury (mm/Hg) and at 8:51 a.m. her blood pressure was recorded as 197/86 mm/Hg.
The American College of Cardiology and the American Heart Association determined that a normal blood pressure is 120/80 mm/Hg.

There was no documented evidence in Resident 29's clinical record for May 13, 2024, that the elevated blood pressure of 197/86 mm/Hg was reassessed.

Interview with Registered Nurse 1 on May 16, 2024, at 10:20 a.m. confirmed that Resident 29 has variable blood pressures; however, an elevated pressure of 197/86 mm/Hg would warrant a recheck and evaluation of the resident. Further assessment would include, rechecking the blood pressure with a different type of cuff, administering blood pressure meds as ordered and then rechecking the blood pressure with in an hour, alerting the MD as needed, and documentation in the residents progress notes.

Interview with Licensed Practical Nurse 2 on May 16, 2024, at 12:01 p.m. confirmed that she works with Resident 29 and if she obtained a blood pressure reading of 197/86 mm/Hg she would immediately retake the pressure with a different type of cuff or an automatic style cuff and if it was still elevated, she would alert the registered nurse to call the doctor and document any findings in the resident's progress notes.

Interview with the Director of Nursing on May 16, 2024, at 3:30 p.m. confirmed that Resident 29 had an elevated blood pressure that warranted further assessment, which was not done, and should have been.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Plan of Correction - To be completed: 06/11/2024

Medical Director reviewed documented blood pressures for Resident 29 and determined no change in treatment.

Current resident blood pressures documentation reviewed to verify in accordance with professional standards.

Director of Nursing and/or designee will re-educate current nursing team on Vital Signs policy specific to adult vital signs parameters and reporting process.

Director of Nursing and/or designee will audit blood pressure readings 1x weekly for 1 month, monthly for 2 months. The results of these observations will be brought to the Quality Assurance and Performance Improvement Committee for further analysis.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that the residents' environment remained as free of accident hazards as possible by transporting a resident without leg rests for one of 31 residents reviewed (Resident 47).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 47, dated March 29, 2024, revealed that the resident was cognitively impaired, required moderate assistance for all of her care, and used a wheelchair.

Observations on May 13, 2024, at 11:44 a.m. revealed that Registered Nurse 4 pushed Resident 47 in a wheelchair without any leg/foot rests from her room through the hallway and into the dining room while the resident elevated her feet. The leg/foot rests were not on the resident's wheelchair.

An interview with Registered Nurse 4 on May 13, 2024, at 11:47 a.m. revealed that she was aware that leg rests were to be used when transporting Resident 47 in her wheelchair.

An interview with the Director of Nursing on May 13, 2024, at 2:34 p.m. confirmed that staff, agency staff, and hospice staff should be using leg/footrests on wheelchairs when residents are being transported in their wheelchairs.

28 Pa. Code 211.12(d)(5) Nursing Services.

Plan of Correction - To be completed: 06/11/2024

Resident 47 was assessed by Registered Nurse to reveal no ill effects or injury.

Director of Nursing educated Hospice personnel on Transferring a Resident policy specific to leg rest presence.

Director of Nursing and/or designee will re-educate current team members on Transferring a Resident policy specific to leg rest presence.

Director of Nursing and/or designee will perform random weekly audits for 1x weekly for 1 month, monthly for 2 months. The results of these observations will be brought to the Quality Assurance and Performance Improvement Committee for further analysis.

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use:

§483.45(e) Psychotropic Drugs.
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

§483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

§483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Observations:

Based on facility policy, federal regulations, and clinical record reviews, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary medications for one of 31 residents reviewed (Resident 14).

Findings include:

The facility policy regarding Consultant Pharmacist report, dated March 26, 2024, indicated that comments and recommendations concerning medication therapy would be communicated in a timely fashion. The timing of these recommendations should enable a response prior to the next medication regimen review. Recommendations were to be acted upon and documented by the facility staff and/or prescriber. If the prescriber does not respond to recommendations directed to him/her within 30 days from the date the facility receives the recommendations, the Director of Nursing and/or the consultant pharmacist may contact the Medical Director.

Federal Regulations require that as-needed orders for psychotropic drugs be limited to 14 days. Except when the attending physician or prescribing practitioner believes that it is appropriate for the as-needed order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the as-needed order.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 14, dated November 6, 2023, revealed that the resident was severely cognitively impaired, required assistance with daily care needs, and had diagnoses that included depression and dementia.

Physician's orders for Resident 14, dated December 14, 2023, included an order for the resident receive a 5 milligram (mg) injection of Zyprexa (an antipsychotic) daily as needed for combativeness. There was no documented evidence that the order was discontinued after 14 days.

A January 2024 medication administration record for Resident 14 revealed that the resident was administered a
5 mg injection of Zyprexa on January 1 and 24, 2024.

A review of clinical records, including physician progress notes and consultant pharmacist recommendations to the physician for December 2023 and January 2024, for Resident 14 revealed no documented rationale for the long-term use of Zyprexa as needed, as required by federal regulations.

An interview with the Director of Nursing on May 16, 2024, at 3:30 p.m. confirmed that there was no documented rationale for the long-term use of as-needed Zyprexa by the attending physician or by a psychiatric consultant.

28 Pa. Code 211.12(d)(5) Nursing Services.

Plan of Correction - To be completed: 06/11/2024

Zyprexa for resident number 14 was discontinued.

Current PRN (Pro re nata - as needed) Psychotropic medication orders reviewed for documentation.

Administrator educated Director of Nursing and Medical Director on 483.45(c)(3)(e)(1-5) in relation to PRN (Pro re nata - as needed) orders for Psychotropic drugs and these requirement.

Director of Nursing and/or designee will audit PRN (Pro re nata - as needed) Psychotropic medication orders 1x weekly for 1 month, monthly for 2 months. The results of these observations will be brought to the Quality Assurance and Performance Improvement Committee for further analysis.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Observations:

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly secured in the medication cart, failed to ensure that controlled medications were stored in a separately locked, permanently-affixed compartment in one of two medication refrigerators reviewed (Main), failed to label medications with the date they were opened in one of two medication rooms reviewed (Main Medication Room) and in one of two medication carts reviewed (200 hall).

Findings include:

The facility's policy regarding the security of the medication cart, dated March 26, 2024, indicated that the nurse was to secure the medication cart during the medication pass to prevent unauthorized entry, and the medication cart was to be securely locked at all times when out of the nurse's view.

Observations on May 14, 2024, at 8:21 a.m. revealed that a medication cart in the hallway was unlocked and unattended by Licensed Practical Nurse 3 when she went into Resident 47's room to take his blood pressure and again at 8:25 a.m. when she took medications to the resident.

Interview with Licensed Practical Nurse 3 on May 14, 2024, at 8:27 a.m. confirmed that her medication cart should have been locked when unattended.

Interview with the Director of Nursing on May 16, 2023, at 8:01 a.m. confirmed that the medication cart should have been locked when unattended by Licensed Practical Nurse 3.

The facility's policy regarding medication storage, dated March 26, 2024, indicated that medications and biologicals are to be stored safely, securely and properly.

Observations of the Main medication room refrigerator on May 15, 2024, at 3:49 p.m. revealed that there was a narcotic storage box containing five (2mg/ml) bottles of Ativan (a controlled medication used to treat anxiety) that was not permanently affixed inside the refrigerator.

An interview with Registered Nurse 5 on May 15, 2024, at 4:00 p.m. confirmed that the narcotic storage box was not permanently affixed inside the refrigerator.

An interview with the Assistant Director of Nusing on May 15, 2024, at 4:51 p.m. confirmed that the narcotic storage box was not permanently affixed inside the refrigerator, and it should have been.

The facility's policy regarding medication administration, dated March 26, 2024, revealed that once opened, a multi-dose vial was to have the date it was opened recorded on the container.

An undated package insert for Tubersol (used to test for tuberculosis - a bacterial infection) revealed that once entered/opened, the vial was to be discarded after 30 days.

Observations in the Main medication room refrigerator on May 15, 2024, at 3:52 p.m. revealed that an opened vial of Tubersol was not properly labeled with the date it was opened.

An interview with Registered Nurse 5 on May 15, 2024, at 4:00 p.m. confirmed that the opened vial of Tubersol was not properly labeled with the date it was opened.

An interview with the Assistant Director of Nursing on May 15, 2024, at 4:51 p.m. confirmed that an opened vial of Tubersol was not properly labeled with the date it was opened, and it should have been.

An undated package insert for Insulin Lispro (a medication used to treat diabetes) revealed that once opened, the pen was to be discarded after 28 days.

Observations in the Medication Cart for 200 Hall on May 14, 2024, at 11:19 a.m. revealed that an opened Insulin Lispro pen for Resident 65 was not properly labeled with the date it was opened.

An interview with Licensed Practical Nurse 2 on May 15, 2024, at 11:25 a.m. confirmed that the opened Insulin Lispro pen for Resident 65 was not properly labeled with the date when it was opened, and it should have been.

An interview with the Assistant Director of Nursing on May 16, 2024, at 8:01 a.m. confirmed that an opened Insulin Lispro pen should have been dated when opened and discarded after 28 days.

28 Pa. Code 211.9(a)(1)(k) Pharmacy Services.

28 Pa. Code 211.12(d)(5) Nursing Services.

Plan of Correction - To be completed: 06/11/2024

Medication cart secured. Narcotic storage box permanently affixed inside refrigerator. Tubersol discarded.

Refrigerator log updated to include narcotic storage box verification.

Director of Nursing and/or designee re-educated current licensed nursing team on Medication Administration policy and Medication Storage in the Facility specific to medication cart security, medication labeling and affixed narcotic lock box.

Director of Nursing and/or designee will audit medication carts utilizing med cart compliance audit tool 1x weekly for 1 month, monthly for 2 months. Director of Nursing and/or designee will perform random medication refrigeration audits for labeling and storage. The results of these observations will be brought to the Quality Assurance and Performance Improvement Committee for further analysis.

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