Pennsylvania Department of Health
HUNTINGDON SKILLED NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

HUNTINGDON SKILLED NURSING AND REHABILITATION CENTER
Inspection Results For:

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HUNTINGDON SKILLED NURSING AND REHABILITATION CENTER - 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 a Civil Rights Compliance survey completed on February 29, 2024, it was determined that Huntingdon Skilled Nursing and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. 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.

§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Observations:

Based on facility policy review, observation, and staff interview, it was determined that the facility failed to properly store food and maintain sanitary conditions in the dietary department.

Findings include:

Review of the facility's policy entitled, "Use-By Dating Guidelines," last reviewed May 1, 2023, revealed that prepared foods should be discarded within 72 hours.

Review of the facility's policy entitled, "Refrigerated/Frozen Storage," last reviewed May 1, 2023, revealed that all foods were to be labelled with a "use-by" date once opened, refrigeration units were kept clean and organized, and if a food was removed from the original container, the food was to be labeled with a "use-by" date.

Observation during the kitchen tour on February 27, 2024, at 10:06 a.m., revealed the following:

In the dry storage area, there was an open bag of pasta that was not dated. In the walk-in cooler, there were two bins of individual packets of butter and creamer that were removed from the original containers and were not dated. There were two containers of opened sour cream and parmesan cheese and a box of grapes that had dried white food and liquid on the outside. There were three opened bags of bread that were not dated. There were two packages of lettuce removed from the original container that were not dated.

In the freezer, there were two opened packages of beef patties and garden burgers that were not dated. There was a package of pie shells removed from the original container that was not dated. In the trayline area, there was an opened bottle of cooking oil that was not dated.

In the cooks' preparation station, there were multiple small fruit flies. The can opener blade had dried food debris on it and there was an uncovered container of thickener. The garbage disposal was uncovered and had food debris and liquid exposed to air. There was a foul odor in the area. Several flies were observed by the floor drain.

In the cooks' cooler, there was a soiled and sticky thermometer. There was a sandwich dated February 21, 2024. A baked potato was not dated. There was dried food and liquid on the inside wall and bottom of the cooler.

The wall by the tray line had a large hole.

In an interview on February 27, 2024, at 11:00 a.m., the Dietary Manager confirmed that the food items should have been dated and the expired items should have been removed.

CFR 483.60(i) Food Safety Requirement
Previously cited 3/30/23.

28 Pa. Code 201.14(a) Responsibility of licensee.

Plan of Correction - To be completed: 04/08/2024

The following was completed as corrective action for those refrigerators found to have been affected by the alleged deficient practice. The identified areas were cleaned to correct these concerns: sour cream, parmesan cheese, and grapes were cleaned off, and anything that was not dated was thrown out, the can opener was cleaned, cook's cooler was cleaned. Completion of the alleged deficiencies was done by April 8th.
NHA or designee will educate staff and residents that if a pest is viewed to report it and have housekeeping to clean the room or area. Pest control will continue with 2x/month visits to the center and share findings with NHA and Environmental Services. Identified areas to be treated.
Food Service Director or designee will review the kitchen refrigerators, freezers, and coolers weeks x 3 to ensure that they are kept clean and organized. If a food was removed from the original container, the food was to be labeled with a "use-by" date.
NHA or designee will review audit findings at QAPI monthly X 2 months.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

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.

§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for five of 32 sampled residents. (Residents 29, 32, 57, 68, and 70)

Findings include:

Clinical record review revealed that Resident 29 had a Minimum Data Set (MDS) assessment completed on August 4, 2023. According to the assessment, the resident was occasionally incontinent of urine. According to the "Care Area Assessment" (CAA) summary from that assessment, the facility identified that urinary continence was a problem area for the resident and should have been included on the resident's comprehensive care plan. Review of the care plan revealed that the facility did not develop interventions to address this care area.

Clinical record review revealed that Resident 32 had an MDS assessment completed on February 21, 2024. According to the assessment, the resident had impaired vision. According to the CAA summary from that assessment, the facility identified that vision impairment was a problem area for the resident and should have been included on the resident's comprehensive care plan. Review of the care plan revealed that the facility did not develop interventions to address this care area.

Clinical record review revealed that Resident 57 had an MDS assessment completed on April 28, 2023. According to the assessment, the resident had a communication impairment. According to the CAA summary from that assessment, the facility identified that the communication impairment was a problem area for the resident and should have been included on the resident's comprehensive care plan. Review of the care plan revealed that the facility did not develop interventions to address this care area.

Clinical record review revealed that Resident 68 had an MDS assessment completed on February 3, 2024. According to the assessment, the resident had impaired vision. According to the CAA summary from that assessment, the facility identified that vision impairment was a problem area for the resident and should have been included on the resident's comprehensive care plan. Review of the care plan revealed that the facility did not develop interventions to address this care area.

Clinical record review revealed that Resident 70 had an MDS assessment completed on February 14, 2024. According to the assessment, the resident had cognitive impairment. According to the CAA summary from that assessment, the facility identified that cognitive impairment was a problem area for the resident and should have been included on the resident's comprehensive care plan. Review of the care plan revealed that the facility did not develop interventions to address this care area.

In an interview on February 29, 2024, at 1:00 p.m., the Director of Nursing confirmed that the care plans did not include the areas of potential concern identified in the comprehensive assessments.

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

Plan of Correction - To be completed: 04/08/2024

Residents 29, 32, 57, 68, 70 care plans updated.
Director of Nursing or designee will reeducate MDS coordinators and Interdisciplinary team on the development of comprehensive person centered care planning.
MDS coordinators to print out the Outcome Summary Report daily on completed residents and discuss triggered areas in morning clinical meetings for any care plan updates needed.
DON or Designee to complete a house wide audit to identify and correct residents with current CAA summary concerns that have not been addressed on the care plan and are not yet due for an assessment.
DON or Designee to complete random weekly audits for 3 weeks for 3 residents reviewing any triggered items identified on the MDS to ensure care plans are in place.
All findings and education to be discussed during the QAPI meeting x 3 months..

483.25 REQUIREMENT Quality of Care:

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.

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure physician's orders were implemented for two of 20 sampled residents. (Residents 49 and 68)

Clinical record review revealed that Resident 49 had diagnoses that included hypertension (high blood pressure). A physician's order dated November 8, 2023, directed staff to administer a medication (hydralazine) twice a day for hypertension. Staff was not to administer the medication if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is the highest) was less than 120 millimeters of mercury (mmHg). Review of Resident 49's medication administration record (MAR) revealed that staff documented that this medication was given six times in January 2024, and six times in February 2024, when the resident's SBP was less than 120 mmHg.

In an interview on February 29, 2024, at 12:46 p.m., the Director of Nursing confirmed that the medication should have been held if the SBP was less than 120 mmHg as per physician's order.

Clinical record review revealed that Resident 68 had diagnoses that included high blood pressure from chronic kidney disease and diabetes. On September 6, 2023, a physician ordered that staff administer 25 milligrams (mg) of a diuretic medication (hydrochlorothiazide) one time a day, and to hold the medication if the blood pressure reading was less than 110/65 mmHg. Review of Resident 68's MAR revealed that staff administered this medication twenty-nine times from February 1 to 29, 2024, with no documented blood pressures at the time of administration.

In an interview on February 29, 2024, at 1:25 p.m., the DON confirmed that there were no documented blood pressure measurements when the medication was given.

CFR 483.25 Quality of Care
Previously cited 3/30/23

28 Pa. Code 211.12(d)(1)(5)Nursing services.

Plan of Correction - To be completed: 04/08/2024

Residents 49 and 68 orders were reviewed to ensure the order had supplemental documentation for vital signs to be recorded and parameters identified in the physician order.
The Director of Nursing or designee will conduct education to licensed nursing staff to ensure that all directions of medication are being followed through and recorded correctly.
The Director of Nursing or designee will conduct an Initial audit to be completed on all patients with parameters to ensure accuracy of documentation.
Director of Nursing or designee to conduct Random audits of 5 MARs to be completed weekly x 3 weeks to ensure nursing staff is recording proper documentation of parameters as ordered.
The director of Nursing or designee will report all findings to be discussed in the QAPI meeting x 3 months.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.

Observations:
Based on observation, it was determined that the facility failed to provide a clean, homelike, and comfortable environment on two of two nursing units. (Garden and Upper)

Findings include:

During tours of Garden and Upper nursing units on February 27, 2024, between 10:45 a.m. and 12:20 p.m., the following were observed:

The wallpaper in rooms 131 and 134 was peeling.

In room 28, there was an area of loose wall molding, peeling wallpaper, and two tan stained ceiling tiles in the back right corner of the bedroom area. In the bathroom, a towel rack was absent from the wall, a white substance covered the sink faucet, and a black substance was observed on the floor behind the toilet.

In room 29, the bottom drawer was missing from the end table next to bed B.

In room 32, the bottom drawer was missing from the end table next to bed B. There was loose molding and a stained ceiling tile in the corner of the bedroom. In the bathroom, wallpaper was missing from the wall under the sink and two ants were seen on the floor.

In room 33, there was loose wallpaper and a loose towel rack in the bathroom.

In room 36, there was a black substance on the wall near the window and on the floor of the bathroom under the sink.

The wall near the sink in room 37's bathroom was dirty.

In room 39, there was detached molding at the bottom of the wall. In the bathroom, there was more detached molding, the toilet grab bar was loose, and there was cracked plaster. Also in the bathroom, a towel bar was missing.

There was detached molding and chipped paint in room 40. There were black stains on the floor in the bathroom.

28 Pa. Code 201.18(b)(1)(e)(2.1) Management.

Plan of Correction - To be completed: 04/08/2024

The following was completed as corrective action for those resident rooms found to have been affected by the alleged deficient practice. The identified rooms were corrected to include but are not limited to replacing racks, deep cleaning on floors, replacing molding, fixing wallpaper, removing black substances, and replacing drawers. The rooms were assessed for environmental concerns that needed to be contracted out and were identified and initiated. Resident rooms that were identified as needing larger renovations that require an empty room will be completed once the patient is discharged or they are moved to a different location in the building. Completion of the alleged deficiencies will be done by April 8th
NHA or Designee to educate all staff on components of a Homelike environment and process for notification if areas needing repaired identified.
NHA or designee will educate staff and residents that if a pest is viewed to report it and have housekeeping to clean the room or area. Pest control will continue with 2x/month visits to the center and share findings with NHA and Environmental Services. Identified areas to be treated.
The maintenance Director or designee will audit 5 rooms monthly x 3 to ensure the identification of any environmental concerns in need of repair.
Maintenance Director or Designee to review findings of the audit at the monthly QAPI meeting.

§ 211.12(f.1)(2) LICENSURE Nursing services. :

(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:
Based on a review of nursing time schedules and staff interview, it was determined that the facility failed to meet the minimum nurse aide (NA) to resident ratios for nine of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from October 1 to 7, 2023, January 1 to 7, 2024, and February 22 to 28, 2024, revealed the following:

The facility failed to meet the minimum NA to resident ratio of one NA for 12 residents on day shift (7:00 a.m. to 3:00 p.m.) on October 7, 2023, and February 24 and 25, 2024.

The facility failed to meet the minimum NA to resident ratio of one NA for 12 residents on evening shift (3:00 p.m. to 11:00 p.m.) on October 5 and 7, 2023, January 4 and 7, 2024, and February 23, 2024.

The facility failed to meet the minimum NA to resident ratio of one NA for 20 residents on night shift (11:00 p.m. to 7:00 a.m.) on January 1, 4, and 5, 2024.

In an interview on February 29, 2024, at 2:40 p.m., the Administrator confirmed that the facility did not meet minimum nurse aide to resident ratios on the identified dates.

Plan of Correction - To be completed: 04/08/2024

No residents were adversely impacted due to the unmet nurse-aide ratios.

The administrator or designee will re-educate the DON, scheduler, nursing supervisors, and any members of the nursing administration to ensure minimum nurse-aide ratios are met.

DON or designee will conduct daily audits to ensure nurse-aide ratios for 4 weeks.

DON or designee will review audit findings at QAPI X 2 months to ensure appropriate staffing

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:

Based on a review of nursing time schedules and staff interview, it was determined that the facility failed to meet the minimum licensed practical nurse (LPN) to resident ratios for 16 of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from October 1 to 7, 2023, January 1 to 7, 2024, and February 22 to 28, 2024, revealed the following:

The facility failed to meet the minimum LPN to resident ratio of one LPN for 25 residents on day shift (7:00 a.m. to 3:00 p.m.) on October 2, 2023, January 2 to 7, 2024, February 22, and 26, 2024.

The facility failed to meet the minimum LPN to resident ratio of one LPN for 30 residents on evening shift (3:00 p.m. to 11:00 p.m.) on October 5, 2023, and February 22, 26, 27, and 28, 2024.

The facility failed to meet the minimum LPN to resident ratio of one LPN for 40 residents on night shift (11:00 p.m. to 7:00 a.m.) on October 1 to 6, 2023, January 2 to 7, 2024, February 22, 26, and 27, 2024.

In an interview on February 29, 2024, at 2:40 p.m., the Administrator confirmed that the facility did not meet minimum licensed practical nurse to resident ratios on the identified dates.

Plan of Correction - To be completed: 04/08/2024

No residents were adversely impacted due to the unmet LPN ratios.

Administrator or designee will re-educate DON, scheduler, nursing supervisors, and any members of nursing administration to ensure minimum LPN ratios are met.

DON or designee will conduct daily audits to ensure LPN ratios for 4 weeks.

DON or designee will review audit findings at QAPI X 2 months to ensure appropriate staffing

§ 211.12(i)(1) LICENSURE Nursing services.:

(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.

Plan of Correction - To be completed: 04/08/2024

No residents were adversely impacted due to the HPPD.
Daily staffing meetings between the DON, NHA, and scheduler are taking place to make sure that the HPPD is following state regulations. Random audits will be conducted once a month x 3 to ensure compliance. The scheduler or designee will complete and report these audit results during the monthly QAPI meeting.

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