Huntingdon Health & Rehabilitation Center

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on facility policy review, medical record review, hospital documentation review, observation and interview, the facility failed to protect the resident's right to be free from sexual abuse for 2 of 4 sampled residents (Resident #1 and Resident #2) reviewed. On [DATE] during group activities, the Former Activities Director (FAD) observed Resident #1 display unwanted behaviors towards Resident #4, leaning against him during conversation, putting her arms around him and touching him affectionately. The FAD intervened and reported the inappropriate behaviors to the Staff Development Coordinator (SDC). The SDC notified Medical Doctor (MD) T on [DATE] and obtained orders for medication to be given for hypersexual behaviors. There were no interventions implemented to monitor Resident #1's hypersexual behaviors pending medication administration with evaluation of medication effectiveness. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to ensure there was at least one Cardiopulmonary Resuscitation (CPR) certified staff member on each shift to perform CPR for 1 of 3 sampled residents (Resident #161) reviewed as full code status (residents that could require CPR). The facility failed to have at least one current CPR certified licensed staff member working on each shift, which had the potential to affect the 36 full code status residents residing in the facility. The facility's failure resulted in Immediate Jeopardy (IJ) when Resident #161 was found without a pulse or respirations and CPR uncertified staff members performed CPR. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. [...]

Inspectors wroteBased on policy review, job description review, and interview, the facility Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain and maintain the highest practicable well-being of the residents. Administration failed to provide oversight to monitor and evaluate Cardiopulmonary Resuscitation (CPR) certification status when licensed staff members' CPR certifications had expired. The failure of the facility to ensure each shift had CPR trained personnel placed 1 of 3 sampled residents (Resident #161) in Immediate Jeopardy when Resident #161 was found unresponsive, without a pulse, and untrained and uncertified staff members provided CPR. The facility's failure could have affected the 36 full code status residents (residents that could require CPR) residing in the facility. [...]

Inspectors wroteBased on policy review, job description review, nursing schedule review, Quality Assurance (QA) meeting sign in sheet review, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program that identified opportunities for improvement related to nursing staff maintaining a Cardiopulmonary Resuscitation (CPR) certification. Failure of the QAPI committee to ensure the CPR certifications remained current allowed the facility to operate without at least one CPR certified staff member working on each shift. Resident #161 went into Cardiopulmonary Arrest, CPR uncertified staff members performed CPR, and Resident #161 expired. The facility's failures could have affected the 36 full code status residents (residents that could require CPR) residing in the facility. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.