Huntingdon Health & Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services for residents with percutaneous endoscopic gastrostomy (PEG) tubes (a plastic tube inserted into the stomach to administer medications, supplements and liquid food) when staff failed to ensure the enteral feeding (liquid nourishment) and the flush solution (water used to flush the peg tube) were replaced in a timely manner and properly labeled for 1 of 2 (Resident #28) sampled residents reviewed for enteral feedings. The findings include: 1. Review of the facility policy titled, Feeding Tubes, dated 10/15/2024, revealed .Feeding tubes will be maintained in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible . 2. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE], with diagnoses including Gastrostomy Status, Diabetes, Seizures, and Dementia. Review of the quarterly Minimum Data Set…

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 policy review, medical record review, observation, and interview, the facility failed to obtain and follow Physician's Orders for the use of oxygen for 2 of 3 (Resident #42 and #62) sampled residents reviewed for respiratory care. The findings include: 1.Review of the facility policy titled, Oxygen Administration, dated 6/23/2025, revealed .Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences.Oxygen is administered under orders of a physician.Infection control measures include.Change oxygen tubing and mask/cannula weekly and as needed. 2. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Interstitial Pulmonary Disease, Atrial Fibrillation, and Dependence on Supplemental Oxygen. Review of the Physician's Order dated 4/3/2025, revealed .Oxygen: RUN @ [at] [2]L/MIN…

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 policy review, medical record review, observation, and interview, the facility failed to ensure medications were properly stored and secured when a medication was left in residents rooms for 2 of 2 (Resident #217 and #267) sampled residents, and failed to ensure that all medications were labeled and dated for 2 of 11 (Nurse's Station 1 Medication Room and Nurse's Station 2 Medication Cart) medication storage areas. The findings included: 1. Review of the facility's policy titled Medication Administration, dated 1/17/2023, revealed .Medications are administered .as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection .Wash hands prior to administering medications .Observe resident consumption of medication . Review of the facility's policy titled Medication Storage, dated 1/30/2024, revealed .During a medication pass, medications must be under the direct observation of the person administering medications .all medication…

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 facility policy review, observation, and interview, the facility failed to calibrate the thermometer, failed to ensure resident's food was labeled and dated in 2 of 2 resident nourishment refrigerators, and failed to ensure staff beverages were not stored in 1 of 2 resident nourishment refrigerators. The facility had a census of 64 residents with 63 of those residents receiving a meal tray from the kitchen. The findings included: 1. Review of the facility's undated policy titled, State Food Safety Resources revealed .A thermometer that is even five degrees off can lead you to .serve food that is not safe to eat .You can only rely on a thermometer if you calibrate it . Review of the facility policy titled Food: Preparation, dated 9/2017, revealed .All foods will be held at appropriate temperatures .Temperatures for TCS [Time/Temperature Control for Safety] foods will be recorded at time of service, and monitored periodically during meal service . Review of the facility's policy titled Use and Storage of Food Brought in by Family or Visitors dated 1/1/2022, revealed .All food…

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 policy review, observation, and interview, the facility failed to ensure that residents were treated with dignity and respect as evidenced by 1 of 63 (Resident #62) residents not receiving their meal tray timely with the other residents seated at the table in the main dining room. The findings included: 1. Review of the facility's policy titled, Resident Meal Service dated 1/1/2022, revealed .Each resident shall receive the correct diet .shall receive prompt meal service and appropriate .assistance .Nursing personnel will ensure that residents are served the correct food tray .Nursing personnel will evaluate food .intake in residents with, or at risk for, significant nutritional problems . 2. Review of the medical record revealed Resident #62 was admitted to the facility on [DATE], with diagnoses including Severe Protein-Calorie Malnutrition and Neurocognitive Disorder. Review of the Care Plan dated 3/20/2024, revealed .Resident is at risk for altered nutritional status related to low body mass index,…

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 policy review, observation, and interview, the facility failed to provide effective housekeeping to maintain a sanitary and comfortable environment as evidenced by a floor in a resident's room had 2 straws, white powdery substance and torn salt packet on the floor in 1 of 7 (Resident #8 ) resident rooms, and 3 dried dark brown spots on the floor, dried brown substance on the outside of the toilet, back of the toilet tank and on the door frame in 1 of 4 (Resident #12) observed bathrooms. The findings include: 1. Review of the facility's undated policy titled, 7-Step Daily Washroom Cleaning, revealed, .Clean and Sanitize Commode .includes the tank, the seat, the bowl and the base .Spot Clean the Walls .Damp Mop the Floor . Review of the facility's undated policy titled, 5-Step Daily Room Cleaning, revealed .Dust Mop .entire floor .especially behind dressers and beds .All corners and along the baseboards must be dust mopped to prevent buildup .Damp Mop .most important area .to disinfect is the floor . 2. Observation and interview on 7/17/2024 at 7:58 AM, Resident #12 asked…

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 policy review, medical record review, observation, and interview, the facility failed to ensure Activities of Daily Living (ADL) assistance was provided related to incontinent care, bathing, and grooming for 3 of 3 sampled residents (Resident #8, #47 and #57) reviewed for ADL care. The findings included: 1. Review of the facility's policy titled, Activities of Daily Living (ADLs), revised date of 12/28/2023 revealed, .The facility takes measures to minimize the loss of residents functional abilities, including activities of daily living .A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . 2. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses including Diabetes, Arthritis, Depression, and Anxiety. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Brief Interview for Mental Status (BIMS) score of 14, which…

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 policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained for 1 of 1 sampled residents (Resident #34) reviewed for transmission- based precautions, failed to provide a clean barrier while administering medications for 4 of 9 residents, (Resident #13, #16, #21 and #32) and used a contaminated alcohol wipe to clean a resident's cheek (Resident #13), and failed to observe Enhanced Barrier Precautions for 1 of 2 (Resident #32) sampled residents. The findings include: 1. Review of the facility's policy titled Transmission-Based (Isolation) Precautions, dated 12/27/2023, revealed .The facility will have PPE [Personal Protective Equipment] readily available near the entrances of the resident's room. Staff .will don appropriate PPE before or upon entry into the environment of a resident on transmission-based precautions .Contact Precautions .Intended to prevent transmission of pathogens that are spread…

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 Centers for Disease Control and Prevention (CDC) guidelines, policy review, medical record review, daily working schedule, employee time detail reports, employee screening logs, observation, and interview, 2 of 4 staff members (Licensed Practical Nurse (LPN) #2 and #8) failed to perform hand hygiene for 2 of 4 sampled residents (Resident #4 and #21) observed during medication pass and 28 of 75 staff members (Licensed Practical Nurse (LPN) #1, #2, #3, #4, and #5, Certified Nurse Assistant (CNA) #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, and #12, Dietary Staff #1, #2, #3, #4, #5, #6, Housekeeping Staff #1, and #2, and Therapy Staff #1, #2 and #3) failed to complete the screenings log for COVID-19 prior to working 9 of 9 days (9/11/2021-9/19/2021) reviewed. This could have affected the 61 residents residing in the facility. The findings include: Review of the facility's policy titled, Hand Hygiene, revised 5/7/2021, revealed .Hand Hygiene Table .Between resident contact .After handling contaminated objects .Before applying and after removing personal protective equipment…

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 policy review, medical record review, and interview, the facility failed to notify the Ombudsman of emergency transfers for 3 of 3 sampled residents (Resident #19, #26, and #52) reviewed for hospitalization. The findings include: Review of the facility's policy titled, Transfer and Discharge (including AMA [Against Medical Advice]), dated 7/28/2020, revealed .A copy of the notice shall be provided to a representative of the Office of the State Long-Term Care Ombudsman . Review of the medical record, revealed Resident #19 was admitted to the facility on [DATE] with diagnoses of Bipolar Disorder, Chronic Obstructive Pulmonary Disease, Alzheimer's Disease, Depression, Dementia with Behavioral Disturbance, and Hypertension. Review of the Progress Notes dated 6/7/2021, revealed .Resident left facility for [Named Hospital]-emergency room [ER] at 1600 [4:00 PM] via [by] EMS [Emergency Medical Services]/ambulance . Review of the medical record, revealed Resident #26 was admitted to the facility on [DATE] and…

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 policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served in a sanitary manner when 3 of 9 staff members (Certified Nursing Assistant (CNA) #10, #13, and #14) failed to don appropriate Personal Protective Equipment (PPE), failed to perform hand hygiene, placed dirty meal trays on the cart with unserved trays, and failed to clean bedside tables for 9 of 61 sampled residents (Resident #4, #5, #6, #10, #14, #31, #32, #48, and #159) during dining observations. The findings include: Review of the facility's policy titled, Hand Hygiene, revised 5/7/2021, revealed .Hand Hygiene Table .Between resident contact .After handling contaminated objects .before applying and after removing personal protective equipment (PPE), including gloves .before and after handling clean or soiled linens .When in doubt . Observation in the resident's room [ROOM NUMBER]/27/2021 at 11:49 AM, revealed after meal tray setup, CNA #14 exited Resident #48's room and placed the dirty…

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 policy review, observation, and interview, the facility failed to ensure 2 of 9 staff members (Certified Nursing Assistant (CNA) #1 and #2) provided care for a resident in a manner that maintained or enhanced the resident's dignity for 2 of 6 residents (Resident #1 and #6) observed during dining. The findings include: Review of the facility's policy titled, Promoting/Maintaining Resident Dignity, revised 10/30/2020, revealed .All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights . Observation in Resident #1's and Resident #6's room on 9/27/2021 at 12:15 PM, revealed both CNA #1 and CNA #2 stated, .we have one more feeder on the cart in [Named Room number] . Observation in the common area on the Memory Care Unit on 9/28/2021 at 6:13 PM, revealed CNA #1 stated, .we have 3 feeders left . During an interview on 9/28/2021 at 6:18 PM, CNA #1 stated, .I never been trained on what to say .all I know is feeders .I have always heard feeders . During an interview on 9/29/2021 at 11:08 AM, CNA #2 confirmed she…

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 policy review, medical record review, observation, and interview, the facility failed to accurately assess a pressure injury for 1 of 2 sampled residents (Resident #58) reviewed for pressure ulcers. The findings include: Review of the facility's policy titled, Wound Treatment Management, dated 1/1/2021, revealed .Characteristics of the wound .Pressure injury stage .Size .Condition of the tissue in the wound bed .The effectiveness of treatments will be monitored through ongoing assessment of the wound . Review of medical record, revealed Resident #58 was admitted to the facility on [DATE] and had diagnoses of Benign Neoplasm, Schizoaffective Disorder, Diabetes, Mood Disorder, COVID-19, Hypertension, and Alzheimer's Disease. Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed Resident #58 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident was cognitively impaired for decision making and the resident was not coded for pressure ulcers. Review…

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 policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured in 3 of 8 medication storage areas (Unit 1 Cart, D Hall Cart, and the Treatment Cart) when internal and external medications were stored together, and Medication and Treatment Carts were unlocked and unattended. The findings include: Review of the facility's policy titled, Storage of Medication, revised 10/30/2020, revealed .All drugs and biologicals will be stored in locked compartments .During a medication pass, medication must be under the direct observation of the person administering medications or locked in the medication storage area/cart .External Products: Disinfectants and drugs for external use are stored separately from internal .Internal Products: Medication to be administered by mouth are stored separately from other formulation . Observation of the Unit 1 Medication Cart on 9/27/2021 at 10:16 AM, revealed a bottle of hand sanitizer, 3 boxes of rivastigmaine transdermal patches, and a bottle of melatonin 3 milligrams (mg) tablets in the top…

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.