Huntingdon Skilled Nursing And Rehabilitation Cent
Inspection history, citations, penalties and survey trends for this long-term care facility in Huntingdon Valley, Pennsylvania.
- Location
- 3430 Huntingdon Pike, Huntingdon Valley, Pennsylvania 19006
- CMS Provider Number
- 395913
- Inspections on file
- 16
- Latest survey
- July 28, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Huntingdon Skilled Nursing And Rehabilitation Cent during CMS and state inspections, most recent first.
The facility did not develop or implement baseline care plans that addressed the specific needs of three residents, including bowel incontinence, dysphagia, and a language barrier, as required upon admission. The DON confirmed these omissions in the care plans.
A resident with diabetes, heart failure, and dementia was admitted and assessed as needing interventions for urinary incontinence, dental care, self-care and mobility, and pressure ulcer. The facility failed to include these areas in the care plan, and the DON confirmed the omissions during interview.
The facility did not ensure that physician's orders were followed for two residents. One resident received blood pressure medication without documented evidence that blood pressure was checked prior to administration, as required. Another resident did not have daily weights documented on several days, despite a physician's order. The DON confirmed the lack of required documentation.
Surveyors observed that trash bags were left outside the dumpster, a used disposable glove was on the ground, and the dumpster lid was open with the container full, indicating improper disposal of garbage and refuse.
Failure to Develop and Implement Baseline Care Plans Addressing Individual Needs
Penalty
Summary
The facility failed to develop and implement baseline care plans that addressed the individual needs of three residents upon admission. For one resident admitted with diabetes, heart failure, and muscle weakness, the baseline care plan noted bowel incontinence but did not include interventions or goals to address this issue. Another resident admitted with diabetes and dysphagia did not have a baseline care plan developed at all following admission. A third resident, admitted with depression and diabetes, was documented by nursing staff and a social worker as having a language barrier that required family members to translate. However, there was no evidence that this communication barrier was addressed in the baseline care plan. The Director of Nursing confirmed that these care areas were not documented in the residents' baseline care plans.
Plan Of Correction
F 0655 Residents 10, 13, and 19 care plans were updated to accurately reflect the resident's initial plan of care and families were made aware. All the residents have the potential to be affected by the deficient practice. All other residents in the facility were audited to ensure that baseline care plans are initiated within 48 hours of admission. All the pertinent departments will be educated on the policies and policies relating to the proper initiation of baseline care plan and accurate reflection of the baseline plan of care. Audits will be completed by the DON/Designee once a week for at least 3 residents for 3 months to ensure that the care plans are done for all new admissions within 48 hours of admission. All findings will be reported and reviewed by the QAPI committee monthly. Date of Compliance: 08/26/2025
Failure to Develop Comprehensive Care Plan for Resident with Multiple Needs
Penalty
Summary
A deficiency was identified when a facility failed to develop and implement a comprehensive care plan for a resident with multiple medical conditions, including diabetes, heart failure, and dementia. The resident was admitted on July 15, 2025, and the Minimum Data Set assessment and Care Area Assessment summary dated July 21, 2025, indicated that the resident's urinary incontinence, dental care, self-care and mobility, and pressure ulcer required care plan interventions. However, a review of the clinical record revealed that there was no evidence these care areas were addressed in the resident's care plan. During an interview, the Director of Nursing confirmed that there was no documented evidence that the identified care areas were included in the care plan for this resident. This lack of documentation and failure to address the resident's assessed needs in the care plan constituted noncompliance with the requirement to develop and implement a comprehensive, person-centered care plan based on the resident's comprehensive assessment.
Plan Of Correction
NotSpecified Resident 18 was updated to accurately reflect the goals of admission, preference for and potential for future discharge, discharge plan, and services provided in the facility. Resident's updated care plan included interventions for the following: to address Resident 18's urinary incontinence, dental care, self-care, mobility, and pressure ulcer. All residents have the potential of being affected by the deficient practice. All other residents were audited to ensure that the care plans are comprehensive and reflective of the goals of admission, preferences for and potential for future discharge, as well as discharge plans. Comprehensive care plans will be reviewed within days of the resident's RAI assessment. All pertinent disciplines will be educated on the policies and procedures that reflect care plans which are reflective of the goals of admission, potential for future discharge, and the discharge plans. An audit will be completed by the DON/Designee once a week for at least 3 residents for 6 weeks to ensure an accurate plan of care for residents that is reflective of the goals of admission, preferences/potential of discharge, and discharge plans. All findings will be reported and reviewed by the QAPI committee monthly. Date of Compliance: 08/26/2025
Failure to Follow Physician Orders for Medication Administration and Monitoring
Penalty
Summary
The facility failed to ensure that physician's orders were implemented for two residents. For one resident with diagnoses including hypertension, heart failure, anemia, and kidney disease, a physician ordered blood pressure medication to be administered twice daily and at bedtime, with the stipulation that the medication should not be given if the systolic blood pressure was less than 100 mmHg. However, documentation showed that staff administered the medication 28 out of 29 times without recording any evidence that the resident's blood pressure was assessed prior to administration, as required by the physician's order. Another resident, admitted with hypertension, atrial fibrillation, and dysphagia, had a physician's order for daily weight monitoring. The clinical record lacked documentation that the resident's weight was obtained on several specified days. The Director of Nursing confirmed that there was no documented evidence that the required assessments and monitoring were performed according to the physician's orders for both residents.
Plan Of Correction
Physicians' orders were reviewed for all antihypertensive medications to ensure orders reflect parameters prior to medication administration. Physicians' orders were also reviewed for all weights to ensure that orders are carried out and reported as ordered. All residents with antihypertensive medication and daily weights orders have the potential to be affected by the deficient practice. All other residents were audited to ensure that parameters are documented before medication administration and weights are documented and reported to accurately reflect the doctor's orders. Nursing staff will be re-educated on the policies and procedures of medication administration and documentation to accurately reflect the doctor's orders. An audit will be completed by the DON/Designee on all new admissions once a week for at least 3 residents for 6 weeks to ensure that physician's orders are accurately reflected on the MAR/TARS. All findings will be reported and reviewed by the QAPI committee monthly for 3 months. Date of Compliance: 08/26/2025
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse as required. During an observation of the dumpster area, three full trash bags were found outside the dumpster, and a used disposable glove was observed on the ground. Additionally, the top lid of the garbage dumpster was open and the dumpster itself was full of trash bags. These findings indicate that trash and refuse were not contained or disposed of in accordance with regulations at the time of the observation.
Plan Of Correction
Based on observation during a Jul 28, 2025 survey tour, it was determined that the facility failed to dispose of trash and refuse properly. 1. The facility staff disposed of the trash and refuse immediately after the surveyor made the leadership team aware of the alleged deficiency on July 28, 2025. 2. No residents were affected by this alleged deficient practice. An initial audit was completed by the Facility Administrator or designee on Jul 28, 2025. 3. Re-education was provided to the facility leadership staff, the Dietary Department, Maintenance Department, and the Housekeeping department. The facility will conduct audits to ensure trash and refuse is disposed of properly. 4. The Facility administrator will conduct random weekly audits for 3 months. The Administrator will report findings to the Quality Assurance Performance Improvement Committee monthly for three months. The Performance Improvement Committee will evaluate and determine the effectiveness of the plan to ensure compliance is achieved and determine if further monitoring and evaluation is required. Date of Compliance: 08/26/2025
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
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