Every finding on record at Huntingdon Skilled Nursing and Rehabilitation Cent

Based on facility policy review, staff interview, and observation, it was determined that the facility failed to monitor dish machine sanitizing solution to ensure that food was served in a sanitary manner. Findings include:Review of the facility policy entitled, Machine Warewashing and Sanitizing, dated March 31, 2026, revealed that for a low temperature dish machine, the appropriate amount of chlorine sanitizing solution is 50 parts per million (PPM). Staff were to record the sanitizer PPM at a minimum of daily on the Dish Machine Daily Temperature Record Log. In an interview during the kitchen tour on April 1, 2026, at 10:14 a.m., the Dietary Manager (DM) stated that the dish machine required a chemical solution to sanitize the dishware. Observation of the dish machine revealed the chemical solution was connected to it during the dishware washing service for breakfast. There were no chemical test strips available in the dietary department for staff to monitor the concentration of the sanitizing solution in the dish machine. Review of the March 2026 Dish Machine Daily Temperature Record Log revealed there was no documented evidence that staff were monitoring the sanitizer PPM daily. In an interview on April 1, 2026, at 2:25 p.m., the DM confirmed that there was no documented evidence that the PPM was being checked daily by staff and it should have been documented on the Daily Temperature Log. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure physicians' orders were implemented for four of 20 sampled residents. (Residents 5, 8, 83, and 98)Findings include: Review of the facility policy entitled, Medication Administration General Guidelines, last reviewed March 31, 2026, revealed that staff were to obtain and record vital signs, if necessary, prior to medication administration and document necessary information in the Medication Administration Record (MAR). Clinical record review revealed that Resident 5 had diagnoses that included heart disease and hypertension (high blood pressure). A physician's order dated July 26, 2025, directed staff to administer a medication (metoprolol tartrate) one time a day to treat hypertension. Staff were to hold the medication if the resident's heart rate was below 60 beats per minute. Review of Resident 5's February and March 2026 MAR revealed no documented evidence that the heart rate was taken prior to the medication being administered. Clinical record review revealed that Resident 8 had diagnoses that included dementia and constipation. A physician's order dated January 21, 2026, directed staff to administer a bisacodyl suppository rectally every 24 hours as needed if no bowel movement in two days. Physician's orders dated November 25, 2025, directed staff to administer 17 grams of MiraLax in four to eight ounces of fluid and to administer 30 milliliters of Milk of Magnesia (MOM) as needed at bedtime if the resident has not had a bowel movement in three days. Review of bowel movement tracking documentation for Resident 8 revealed that there were no bowel movements recorded from March 6, 2026, at 9:29 p.m., through March 10, 2026, at 1:49 p.m., and March 27, 2026, at 2:59 p.m., to April 1, 2026, at 9:06 p.m. Review of the MAR for March 2026, revealed that the resident was not provided with any as needed medications for constipation until MOM was provided on night shift April 1, 2026. For both time periods, Resident 8 did not have a bowel movement for at least three days. Clinical record review revealed that Resident 83 had diagnoses that included hypertension. A physician's order dated March 4, 2026, directed staff to administer a blood pressure medication (metoprolol) two times a day. The physician ordered that staff were 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 at its highest) was lower than 110 millimeters of mercury (mm/Hg) or if the heart rate was less than 60 beats per minute. Review of Resident 83's MAR for March 2026 revealed that the staff administered Metoprolol three times when Resident 83's SBP was lower than 110 mm/Hg. Clinical record review revealed that Resident 98 was admitted to the facility on [DATE], following a hospitalization with diagnoses that included shortness of breath, pneumonia, and a new diagnosis of lung cancer. Resident 98's discharge instructions from the hospital dated January 22, 2026, noted the presence of metastatic lung cancer, indicated that an oncologist had been consulted, and the resident needed imaging studies completed that included a position emission tomography (PET) scan to determine the staging of the lung cancer. Resident 98 was to follow up with the oncologist after imaging studies were completed. A letter from the hospital dated January 21, 2026, confirmed that Resident 98 was scheduled for a PET Scan on February 4, 2026, at 9:15 a.m. A physician's progress note dated January 28, 2026, noted the facility was aware that Resident 98 had metastatic lung cancer and needed an outpatient PET scan to be completed per oncology's recommendation. A general progress note dated February 5, 2026, indicated a PET scan was re-scheduled for February 13, 2026, at 1:45 p.m. A physician's progress note, dated February 9, 2026, confirmed that Resident 98's appointment for the PET scan had been rescheduled. There was lack of evidence to support that the facility transported the resident to the scheduled appointment for the PET scan on February 13, 2026. There was no indication that the appointment was rescheduled prior to the resident's emergency transfer to the hospital on February 19, 2026. In interviews on April 2, 2026, at 11:09 a.m., 11:45 a.m., and 12:24 p.m., and on April 3, 2026, at 12:16 p.m., the Regional Clinical Director confirmed there was no documented evidence that the blood pressure and heart rate were taken prior to medication administration per physician's order for Resident 5, that none of the as needed medications for constipation were administered to Resident 8 and should have been, that Resident 83 received the medication outside of the ordered parameters, and that Resident 98 did not get the PET scan as scheduled on February 13, 2026, and the appointment was not rescheduled. CFR 483.25 Quality of CarePreviously cited 7/28/25 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that residents were free from potential chemical restraints for one of five sampled residents who were ordered psychotropic medications. (Resident 8)Findings include:Clinical record review revealed that Resident 8 had diagnoses that included anxiety and dementia. On January 21, 2026, a physician ordered staff to administer an anti-anxiety medication (lorazepam) every six hours as needed for end-of-life anxiety and terminal agitation. The order did not include a date to indicate when staff were to stop administering the as needed medication. Review of Resident 8's Medication Administration Record revealed that staff had administered the lorazepam 14 times in February 2026 and five times in March 2026. There was no documented evidence that the physician had reevaluated continued use beyond 14 days of the as needed anti-anxiety medication. In an interview on April 2, 2026, at 11:08 a.m., the Regional Clinical Director confirmed that the physician's order did not include when staff were to stop administering the as needed anti-anxiety medication. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to complete an accurate Minimum Data Set (MDS) assessment for two of 20 sampled residents. (Residents 11 and 67)Findings include: Clinical record review revealed that Resident 11 had diagnoses that included Parkinson's disease (a progressive, incurable neurological disorder) with dyskinesia (involuntary, erratic, writhing, or jerky movements caused by long term use of medication to treat Parkinson's disease), dementia, and repeated falls. A review of nurses' notes indicated that the resident had falls on December 24, 2025, December 25, 2025, December 29, 2025, and January 26, 2026. A review of Resident 11's MDS assessment dated [DATE], incorrectly indicated in Section J (falls since admission/entry or reentry, or prior assessment whichever is more recent) that the resident had not fallen since the prior assessment which had been completed on November 24, 2025. Clinical record review revealed that Resident 67 had diagnoses that included Alzheimer's disease and anxiety. A physician's order dated December 30, 2025, ordered staff to apply a wander guard bracelet (a wearable device designed to prevent residents from unsafe wandering) to the resident's left ankle. A review of Resident 67's MDS assessment dated [DATE], section P (alarms not used, used less than daily, or used daily) incorrectly indicated that a wander alarm was not used. Observation on March 31, 2026, at 2:00 p.m. revealed a wander guard bracelet on the resident's left ankle. In an interview on April 2, 2026, at 2:28 p.m., the Regional Clinical Director confirmed that Resident 11's MDS completed on February 17, 2026, was inaccurate and should have captured four falls and that Resident 67's MDS completed on February 12, 2026, should have indicated that a wander alarm was used daily.

Based on clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to provide services to maintain adequate grooming and hygiene for one of 20 sampled residents. (Resident 5)Findings include: Clinical record review revealed that Resident 5 had diagnoses that included cerebral palsy, muscle weakness, and depression. A Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident 5 required maximum assistance with hygiene and self-care and had no cognitive impairment. Review of the care plan revealed that staff were to assist the resident with hygiene and self-care. On March 31, 2026, at 1:20 p.m., the resident was observed in his room. His nails were long and dirty. In an interview at that time, he stated that he would like his nails cleaned and that he would not refuse nail care on his bath day since his nails were dirty. Documentation revealed that Resident 5 was last bathed by staff on March 30, 2026, and he had not refused care. On April 1, 2026, at 10:45 a.m., the resident was observed in his bed. His nails remained long with dirt underneath them. In an interview on April 2, 2026, at 11:07 a.m., the Regional Clinical Director confirmed that nail care was to be done on shower days as needed. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide restorative nursing services to increase or prevent a reduction in range of motion for one of 20 sampled residents. (Resident 6)Findings include:Clinical record review revealed that Resident 6 had diagnoses that included quadriplegia (paralysis of all four limbs), muscle weakness, and left-hand contracture (a condition where the tissues of the hand stiffen and tighten and limits hand mobility). The Minimum Data Set assessment dated [DATE], indicated that the resident was severely cognitively impaired, was dependent on staff for personal hygiene, and had a loss of range of motion in the upper extremities. On January 27, 2026, the occupational therapist had recommended a palm guard splint due to left hand contracture management. A physician's order dated January 27, 2026, directed that staff were to apply a left palm guard splint after morning care was provided and then remove it after evening care was provided every day. On March 26, 2026, a restorative nursing note stated that the resident continued to require the left palm splint. Observations on April 1, 2026, at 9:44 a.m., and April 2, 2026, at 10:35 a.m., revealed that Resident 6 was lying in bed with his left hand in a clenched fist without a left palm guard splint in place. Morning care had previously been provided to the resident at the time of both observations. In an interview on April 2, 2026, at 10:40 a.m., Registered Nurse (RN) 1 confirmed that Resident 6 was to have the left palm guard splint and could not locate it in his room.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on facility policy review, review of facility documentation, clinical record review, and staff interview, it was determined that the facility failed to implement adequate interventions to prevent falls for one of 20 sampled residents. (Resident 11)Findings include: Review of the facility policy entitled, Accidents/Incidents, last reviewed March 31, 2026, revealed that an appropriate intervention would be implemented based on the conclusion of an accident or incident investigation. Clinical record review revealed that Resident 11 had diagnoses that included Parkinson's disease (a progressive, incurable neurological disorder) with dyskinesia (involuntary, erratic, writhing, or jerky movements caused by long term use of medication to treat Parkinson's disease), dementia, and repeated falls. The Minimum Data Set assessment dated [DATE], indicated that the resident was cognitively impaired and dependent on staff for transfers. A review of facility documentation and nurse's notes dated December 25, 2025, indicated that the resident had a witnessed fall in the dining room. There was a lack of documentation to support the resident was assessed for any new interventions or that any additional measures were implemented following the fall. A review of Resident 11's care plan revealed that the resident was at risk for falls, had previous falls, but did not indicate that an intervention was implemented after the resident 's fall on December 25, 2025. The resident had additional falls on December 29, 2025, and January 26, 2026. In an interview on April 3, 2026, at 9:32 a.m., the Director of Nursing confirmed that there was no documented evidence that an additional intervention was implemented after Resident 11's fall on December 25, 2025. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, observation, and staff interview, it was determined that the facility failed to ensure staff implemented infection control policies to prevent the spread of infection for three of 20 residents sampled. (Residents 36, 53, and 99) Review of the facility policy entitled, Medication Administration, last reviewed March 31, 2026, revealed that staff were to complete appropriate hand hygiene prior to preparing or administering medications to the residents. On April 1, 2026, at 8:18 a.m., Licensed Practical Nurse (LPN) 1, was observed administering medications to Residents 36, 53, and 99. The LPN did not perform hand hygiene prior to administering medications to the residents. In an interview on April 3, 2026, at 9:40 a.m., the Director of Nursing confirmed that LPN 1 should have completed hand hygiene prior to administering medications to Residents 36, 53, and 99. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, it was determined that the facility failed to develop and/or implement a baseline care plan that addressed individual resident needs for three of 20 sampled residents. (Residents 10, 13, 19)Findings include: Clinical record review revealed that Resident 10 was admitted to the facility on [DATE], with diagnoses that included diabetes, heart failure, and muscle weakness. The baseline care plan dated July 16, 2025, noted that the resident was incontinent of bowel. There was no evidence that the care plan included interventions and goals to address Resident 10’s incontinence. Clinical record review revealed that Resident 13 was admitted to the facility on [DATE], with diagnoses that included diabetes and dysphagia (difficulty swallowing). There was no documented evidence that the facility developed a baseline care plan following admission. Clinical record review revealed that Resident 19 was admitted to the facility on [DATE], with diagnoses that included depression and diabetes. On July 22, 2025, a nurse noted that the resident had a language barrier and had difficulty communicating. On July 23, 2025, the social worker documented that the resident's family was required to translate due to a language barrier. There was no documented evidence that the resident's language barrier was addressed in the baseline care plan. In an interview on July 28, 2025, at 4:15 p.m., the Director of Nursing confirmed there was no documented evidence that the care areas were addressed in the resident's baseline care plan. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan that addressed individualv resident needs as identified in the comprehensive assessment for one of 20 sampled residents. (Resident 18) Findings include: Clinical record review revealed that Resident 18 was admitted to the facility on [DATE], and had diagnoses that included diabetes, heart failure, and dementia. The Minimum Data Set assessment and Care Area Assessment summary dated July 21, 2025, noted that the resident's urinary incontinence, dental care, self-care, mobility, and pressure ulcer were to be addressed in the care plan. There was no evidence that interventions to address Resident's 18 urinary incontinence, dental care, self-care, mobility, and pressure ulcer were included in the care plan. In an interview on July 28, 2025, at 4:00 p.m., the Director of Nursing confirmed there was no documented evidence that the care areas were addressed in the care plan. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, 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 1, 16) Findings include: Review of the policy entitled, Medication Administration, last reviewed July 25, 2025, revealed staff were to obtain vital signs as necessary prior to medication administration and document physician indicated medication administration information. Clinical record review revealed that Resident 16 had diagnoses that included hypertension (high blood pressure), heart failure, anemia (blood disorder), and kidney disease. On July 18, 2025, the physician ordered staff to administer a blood pressure medicine (hydralazine HC1) twice a day and once at bedtime. Staff was not to administer the medication if the resident's systolic blood pressure (the first measurement of blood pressure when the heart beats and the pressure is at its highest) was less than 100 millimeters of mercury (mmHg). Review of Resident 16’s July 2025 Medication Administration Record revealed that staff administered the medication 28 out of 29 times with no documented evidence that the blood pressure was assessed prior to medication administration per the physician's order. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), atrial fibrillation (irregular heartbeat), and dysphagia (difficulty swallowing). On July 14, 2025, the physician ordered for staff to obtain the resident's weight daily. There was no documented evidence that staff obtained Resident 1's weight on July 16, 18, 25, or 26, 2025. In an interview on July 28, 2025, at 4:15 p.m., the Director of Nursing confirmed there was no documented evidence Resident 16's blood pressure was taken prior to medication administration, and that Resident's 1's weight was taken daily as per physician's order. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, it was determined that the facility failed to dispose of trash and refuse properly. Findings include: Observation of the dumpster area on July 28, 2025, at 10:30 a.m., revealed three full trash bags outside the dumpster and a used disposable glove on the ground. The top lid of the garbage dumpster was open and it was full of trash bags. 28 Pa Code 201.18(b)(3) Management.

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 [DATE], revealed that prepared foods should be discarded within 72 hours. Review of the facility's policy entitled, Refrigerated/Frozen Storage, last reviewed [DATE], 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 [DATE]. 28 Pa. Code 201.14(a) Responsibility of licensee.

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.

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.

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 [ROOM NUMBERS] was peeling. In room [ROOM NUMBER], 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 [ROOM NUMBER], the bottom drawer was missing from the end table next to bed B. In room [ROOM NUMBER], 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 [ROOM NUMBER], there was loose wallpaper and a loose towel rack in the bathroom. In room [ROOM NUMBER], 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 [ROOM NUMBER]'s bathroom was dirty. In room [ROOM NUMBER], 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 [ROOM NUMBER]. There were black stains on the floor in the bathroom. 28 Pa. Code 201.18(b)(1)(e)(2.1) Management.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to provide treatment and services for enteral hydration as per physician's order in a timely manner for one of four sampled residents who had enteral hydration. (Resident 1) Findings include: Review of the facility policy entitled, Enteral Feeding: Administration by Pump, dated February 1, 2023, revealed that the enteral feed pump was to be set with the flow rate of feed and water to be administered to the resident as ordered by the physician. Clinical record review revealed that Resident 1 had diagnoses that included malignant neoplasm of the tongue, tracheostomy (airway placed in the throat), and gastrostomy tube (a surgical creation of a gastric opening through the abdominal wall for the purpose of introducing food and water into the stomach). The Minimum Data Set assessment dated [DATE], indicated that the resident required extensive assistance with most activities of daily living and required staff assistance for nutrition and hydration. On October 18, 2023, the physician ordered for staff to administer Glucerna 1.5 enteral feed to infuse at 65 milliliters (mls) per hour (hr) and to flush the feed with 55 mls of water every one hour during the pump infusion. The resident's care plan revealed that staff was to administer the tube feeding formula, hydration, and flushes per the physician's order. Physician's documentation dated, January 4, 2024, indicated that the resident had not been getting 55 mls of water as ordered. Review of a nursing progress note dated January 9, 2024, at 11:30 a.m., revealed that the resident's enteral feeding infusion pump was observed to be set at 30 ml/hr for water flushes and not the physician ordered 55 ml/hr. During an interview on January 21, 2024, at 2:00 p.m., the Administrator confirmed that the physician's order and policy were not followed. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on observation, it was determined that the facility failed to ensure that a safe, clean, and comfortable environment was maintained on one of two nursing units. (The Garden) Findings include: Observations during the environmental tour of the second floor nursing unit (The Garden) on July 26, 2023 revealed the following: There was a strong pervasive musty odor throughout the unit. At the end of the corridor, after rooms [ROOM NUMBERS], the wall had exposed drywall with clusters of black spots throughout the bottom half of the wall. There was also black spots under the windowsill. There was black spots on the bottom portion of the wall where the baseboard was missing between rooms [ROOM NUMBERS]. CFR 483.90(i) Other Environmental Conditions Previously Cited 03/30/2023 28 Pa. Code 207.2(a) Administrator responsibility.

Based on observation and interview, it was determined that the facility failed to store and serve food under sanitary conditions in the kitchen. Findings include: Observation of the main kitchen on March 28, 2023, at 10:34 a.m., in the food preparation area, revealed a mop bucket with dirty water and a mop stored in the water. There were various particles of debris on the meat slicer. There was a small, black, winged insect above the food. Observation revealed a cart with an unidentified liquid on the bottom shelf of the cart. Clean coffee cups were on that cart. There was a dented can of peaches and a can of pineapples in dry storage. There were clean dishes stored on a rolling cart with various non-food related items. In an interview, the Director of Dining Services stated that the clean dishes should be stored on the clean dish cart. The clean dish cart was observed with various particles of debris on the cart and dishes. In the walk in refrigerator, there was a package of ham stored on a tray with raw, ground beef. 28 Pa. Code 201.18(b)(3) Management.

Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive assessment of a significant change in status for one of 18 sampled residents. (Resident 79) Findings include: Clinical record review revealed that Resident 79 was admitted to the facility with diagnoses that included Alzheimer's disease and dementia. On January 21, 2023, the resident was admitted to hospice services. There was no Minimum Data Set assessment completed to reflect the significant change in the resident's condition. In an interview on March 30, 2023, at 9:39 a.m., the Director of Nursing confirmed that a comprehensive significant change in status assessment was not completed upon change in the resident's condition. 28 Pa. Code 211.5(f) Clinical records.

Based on review of clinical records, review of facility documentation and interviews with staff, it was determined that the facility failed to follow physician orders [REDACTED]. Findings include: Review of the clinical record for Resident CL1 revealed that the resident had been admitted to the facility on [DATE], with diagnoses, including but not limited to, high blood pressure and end stage [MEDICAL CONDITION] ( [MEDICAL CONDITION]- kidney failure) for which the resident was receiving peritoneal [MEDICAL TREATMENT] (medical procedure by which toxins and fluids are removed from the blood stream through a tube inserted into the abdomen) treatments. An initial Minimum Data Set, (MDS-periodic assessment of needs) dated August 21, 2015, revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 14 which indicated that the resident was alert and oriented (aware of person, place and time and responded appropriately to external stimuli). Further review of the clinical record revealed nurse practitioners' progress notes dated September 15, 2015, at 2:49 p.m. which indicated that the resident had been nauseated and vomiting for four days. The note further indicated that the resident had stated that he had noted bloody urine the other day. On September 16, 2015, at 6:52 a.m., the resident had been noted with a fever of 100.0 (normal temperature is 98.6) degrees fahrenheit for which the resident's physician was notified. Further nurse practitioners' progress notes dated September 16, 2015, at 9:44 a.m., revealed that the resident had an acute fever this morning 101.0 now 102.9 . It further indicated that the resident was now complaining of cough and wheezing. The progress note indicated that the nurse practitioners' [DIAGNOSES REDACTED]. The nurse practitioner planned on obtaining blood work, urine culture and a chest Xray. The nurse practioner further noted the resident's status as Unstable. Physician orders [REDACTED]. Nurses notes dated September 16, 2016, at 12:20 p.m., revealed that the resident continued with a fever of 101.3 degrees. Further nursing documentation indicated that the nurse practitioner had ordered stat (stat-medical term used to indicate the need to be completed emergently) laboratory work which included Blood Cultures (tests for growth of bacteria in the blood stream) times two, CBC (complete blood count) BMP (BMP-basal metabolic panel- blood chemistry) and a urine culture (tests for the presence of bacteria in the urine). Additionally, the nursing notes indicated that the nurse practitioner had ordered intravenous normal saline solution (a salt solution) be started on the resident. Nursing documentation at 3:25 p.m., on September 16, 2015, indicated that the resident had been seen by the resident's attending physician and started on [MEDICATION NAME] (used to treat serious infections), [MEDICATION NAME] (anti-infective used to treat pneumonia) and Cefepine (Cephalosporin used to treat infections) for [MEDICAL CONDITION] (infection of the blood stream), PNA (pneumonia) and UTI (urinary tract infection). laboratory results dated [DATE], indicated that a CBC, blood cultures and a BMP had been drawn on Resident CL1 at 1:15 p.m. Further review of the laboratory results indicated that the resident's WBC (white blood cell count- levels used to determine the presence of an acute infection) was at a critical value of 40.7. The laboratory results also indicated that the normal range for WBC was 3.8 to 10.6. Documentation on the laboratory studies further indicated that the results for the WBC were called to the facility at 4:26 p.m. on September 16, 2015, greater than 3 hours after the laboratory drew the blood sample. Further review of nursing notes dated September 16, 2015, revealed no documentation that nursing staff had monitored and/or reassessed the resident's medical condition until 9:36 p.m., approximately six hours after the doctor had indicated that the resident might be septic and five hours after receiving notification of the resident's critical lab values. Nursing documentation on September 16, 2015, indicated that Resident Cl1's attending physician was aware of the laboratory results at 9:36 p.m At 10:46 p.m. on September 16, 2015, nurses note the resident as weak and very pale looking with decreased breath sounds to bases (bottom of lungs) and with scattered wheezes present. At 10:57 p.m., approximately ten minutes later, nurses note that the resident was having periodic episodes of shortness of breath and that they had started the resident on supplemental oxygen at two liters via a nasal cannula (placed inside the nostrils). Further nursing documentation at 10:57 p.m., indicated that nursing staff had called the resident's physician and were waiting for a call back. Further review of nursing documentation on September 16, 2015, at 11:49 p.m., revealed that the resident had increased shortness of breath and restlessness. The resident's physician was made aware and the resident was subsequently transferred to the hospital via 911 (emergency ambulance transport). A review of additional clinical documentation indicated that resdient Cl1 was admitted to the hospital's medical intensive care unit [MEDICAL CONDITIONS] (low blood pressure) and pneumonia. Interview with the administrator on February 6, 2016, at 1:20 p.m. revealed that the facility has a contracted laboratory service which can perform lab work on an urgent basis. Further interview with the administrator confirmed that the facility has not established an expected response time for laboratory studies that have been ordered to be done stat. The administrator further indicated that the lab's ability to respond to the facility's requests for stat labs was limited based on the labs availability. The facility failed to ensure that one resident who had exhibited signs and symptoms of an acute change in condition, with critical lab values, and signs and symptoms [MEDICAL CONDITION] was transferred to the hospital in a timely manner resulting in actual harm to the resident and failed to administer medications as ordered by the physician . 483.25 Provide Care and Services. previously cited 8/20/15 and 9/19/14. 28 Pa Code: 211.12 (d)(1)(5) Nursing services.