Health inspection·April 10, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on review of facility policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that staff reported an allegation of verbal abuse in a timely manner for one of 34 residents reviewed (Resident 5). Findings include: The facility's abuse policy, dated January 9, 2025, indicated that staff would report any incidents of suspected abuse immediately to administration. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated January 17, 2025, indicated that the resident was cognitively impaired, required assistance from staff with daily care tasks, and had diagnoses that included hydrocephalous (excess of fluid on the brain). Facility investigation documents, dated January 10, 2025, revealed that Nurse Aide 1 was assisting Nurse Aide 2 transfer Resident 5 to her wheelchair on January 5, 2025, at breakfast. Nurse Aide 1 heard Nurse Aide 2 yelling loudly at Resident 5. The resident asked the nurse aide if she could have her shoes on and she overheard Nurse Aide 2 tell the resident, No you cannot have your shoes on with the way you were acting getting ready, you don't deserve your shoes. Interview with the Nursing Home Administrator on April 10, 2025, at 10:35 a.m. confirmed that Nurse Aide 1 did not immediately report the allegation of abuse on January 5, 2025. She stated that she was not notified of the incident until January 10, 2025, and immediately suspended the Nurse Aide 2 to rule out abuse. 28 Pa. Code 201.18(e)(1) Management. Page 1 of 9 395297 395297 04/10/2025 Embassy of Huntingdon Park 1229 Warm Springs Avenue Huntingdon, PA 16652

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for one of 34 residents reviewed (Resident 20), failed to administer insulin per manufacturer's instructions for one of 34 residents reviewed (Resident 78), and failed to follow wound recommendations for one of 34 residents reviewed (Resident 80). Residents Affected - Some Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 20, dated March 3, 2025, indicated that the resident was cognitively intact, received insulin, and had diagnoses that included diabetes. Physician's orders for Resident 20, dated March 19, 2025, included an order for the resident to receive 17 units of Humalog (fast acting insulin) subcutaneously with meals for diabetes. The insulin was to be held if the resident's blood sugar was less than 100 milligrams/deciliter (mg/dL) The Medication Administration Record (MAR) for Resident 20 for January, March, and April 2025 revealed that the resident received 17 units of Humalog insulin at 7:30 a.m. on January 2 for a blood sugar of 89 mg/dL; on January 3 for a blood sugar of 91 mg/dL; on March 4 for a blood sugar of 99 mg/dL; on March 17 for a blood sugar of 96 mg/dL; at 11:30 a.m. on March 31 for a blood sugar of 99 mg/dL; at 4:30 p.m. on January 2 for a blood sugar of 84 mg/dL; on January 20 for a blood sugar of 96 mg/dL; and on April 1 for a blood sugar 92 mg/dL. Interview with the Director of Nursing on April 9, 2025, confirmed that Resident 20's Humalog insulin should have been held on the dates and times mentioned above. A quarterly MDS assessment for Resident 78, dated March 12, 2025, revealed that the resident was cognitively intact, required assistance with care needs, received insulin, and had a diagnosis of diabetes. Physician's orders for Resident 78, dated October 31, 2024, included an order for the resident to receive Humalog insulin (a fast-acting medication used to lower blood sugar) to be administered per a sliding scale (dose is based on a person's blood sugar) before meals. Review of the resident's Medication Administration Record (MAR) for March and April 2025 revealed that the resident's blood sugar was scheduled to be taken at 7:00 a.m., 11:00 a.m., and 4:00 p.m. with insulin to be administered per the sliding scale. Manufacturer's instructions for Humalog insulin, dated March 2013, indicated that Humalog insulin should be given within 15 minutes before a meal or immediately after a meal. Resident 78 is scheduled to receive her breakfast tray between 7:30 and 7:35 a.m., her lunch tray between 11:30 and 11:35 a.m. and her supper tray between 4:30 and 4:35 p.m. A review of Resident 7's MAR for March and April 2025 revealed that the resident's blood sugars were checked, and she received Humalog insulin on the following dates and times: March 2 at 3:03 p.m.; March 4 at 3:13 p.m.; March 6 at 3:13 p.m.; March 7 at 3:58 p.m.; March 8 at 3:58 p.m.; March 9 at 3:35 p.m.; March 10 at 3:11 p.m.; March 12 at 10:42 a.m.; March 13 at 10:47 a.m.; March 16 at 3:34 395297 Page 2 of 9 395297 04/10/2025 Embassy of Huntingdon Park 1229 Warm Springs Avenue Huntingdon, PA 16652

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some p.m.; March 17 at 6:41 a.m.; March 17 at 10:38 a.m.; March 18 at 6:37 a.m.; March 18 at 10:39 a.m.; March 18 at 3:27 p.m.; March 19 at 3:59 p.m.; March 20 at 3:20 p.m.; March 21 at 6:21 a.m.; March 21 at 10:51 a.m.; March 21 at 3:17 p.m.; March 22 at 6:37 a.m.; March 22 at 3:35 p.m.; March 23 at 10:42 a.m.; March 23 at 3:42 p.m.; March 24 at 3:51 p.m.; March 25 at 3:49 p.m.; March 26 at 10:20 a.m.; March 27 at 10:29 a.m.; March 27 at 3:38 p.m.; March 28 at 3:49 p.m.; March 29 at 3:33 p.m.; April 1 at 3:31 p.m.; April 2 at 6:54 a.m.; April 2 at 10:43 a.m.; April 2 at 3:20 p.m.; April 5 at 3:31 p.m.; and April 7 at 3:26 p.m. Interview with the Nursing Home Administrator on April 9, 2025, at 1:16 p.m. confirmed that Resident 78's Humalog insulin was not being administered as per the manufactures instructions. The facility's wound treatment policy, dated January 9, 2025, revealed that to promote wound healing of various types of wounds, it was the policy of the facility to provided evidence-based treatments in accordance with current standards of practice and physician orders. Wound treatments would be provided in accordance with physician orders, and in the absence of treatment orders, the licensed nurse would notify the physician to obtain treatment orders. An admission MDS assessment for Resident 80, dated January 15, 2025, indicated that the resident was cognitively impaired, had an infection to his foot, and had diagnoses that included Alzheimer's dementia. A wound consult, dated January 16, 22, and 30, 2025, revealed that Resident 20 had frost bite wounds to his first and second toes on the left and right feet. It was recommended that betadine (antiseptic solution) be placed on the wound bed on the first and second toes of the left and right feet twice a day and left open to air. Physician's orders, dated January 16, 2025, included orders for betadine be applied to the wound base of the first and second toes of the right foot. Review of Resident 80's Treatment Administration Records for January and February 2025 revealed that there was no documented evidence that the treatment of betadine to the resident's left first and second toes was completed twice a day as recommended by the wound consultant. Interview with the Director of Nursing on April 9, 2025, at 12:13 p.m. confirmed that Resident 80's treatments to the left toes were not applied as recommended by the wound consultant. 28 Pa. Code 211.12(d)(1)(5) Nursing Services. 395297 Page 3 of 9 395297 04/10/2025 Embassy of Huntingdon Park 1229 Warm Springs Avenue Huntingdon, PA 16652

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to follow pressure ulcer treatment recommendations from a wound consultation for one of 34 residents reviewed (Resident 11). Residents Affected - Some Findings include: The facility's wound treatment policy, dated January 9, 2025, revealed that to promote wound healing of various types of wounds, it was the policy of the facility to provided evidence-based treatments in accordance with current standards of practice and physician orders. Wound treatments would be provided in accordance with physician orders, and in the absence of treatment orders, the licensed nurse would notify the physician to obtain treatment orders. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated March 12, 2025, indicated that the resident was cognitively impaired, required assistance for her care needs, and had a Stage 3 pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle is not exposed). A wound consultation for Resident 11, dated January 15, 22, and 30, 2025, revealed that the resident had a Stage 3 (full thickness tissue loss) pressure sore on her coccyx (lower end of the spine) and the plan was to apply collagen (helps wounds heal by attracting new skin cells to the wound) to the base of the wound and zinc (used to treat minor skin irritation) to the peri-wound (skin surrounding the wound) daily. Review of Resident 11's Treatment Administration Records for January and February 2025 revealed that the treatments to the coccyx did not include the application of collagen to the wound bed daily from January 15 through February 5, 2025. A wound consultation for Resident 11, dated February 19, 2025, revealed that the resident had a Stage 3 pressure sore on her coccyx, and the plan was to apply bacitracin ointment and collagen to the base of the wound daily. Review of Resident 11's Treatment Administration Records for February 2025 revealed that there was no treatment applied to the coccyx from February 20 through 26, 2025. Interview with Director of Nursing on April 9, 2025, at 12:13 p.m. confirmed that the treatments to Resident 11's coccyx on the mentioned dates above were not being completed as recommended by the wound consultant and should have been. 28 Pa. Code 211.12(d)(5) Nursing Services. 395297 Page 4 of 9 395297 04/10/2025 Embassy of Huntingdon Park 1229 Warm Springs Avenue Huntingdon, PA 16652

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to obtain laboratory studies as ordered by the physician for one of 34 residents reviewed (Resident 27). Findings include: A facility policy related to anticoagulation therapy, dated January 9, 2025, indicated that the facility will implement the procedure for the treatment/management of residents receiving anticoagulation therapy (i.e. low molecular weight heparin or warfarin/coumadin). The facility in collaboration with the physician will provide therapeutic coagulation for the resident while attempting to decrease the potential morbidity and mortality associated with anticoagulation therapy. The charge nurse will obtain an order from the physician for any pertinent labs for monitoring of the anticoagulation therapy. The nurse will notify the physician and document the results of the prothrombin time and international normalized ratio (PT/INR-blood tests that determine how long it takes the blood to clot). A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 27, dated March 17, 2025, revealed that the resident was cognitively impaired, required assistance with care needs, was taking an anticoagulant medication (a medication that thins the blood), and had diagnoses that included atrial fibrillation (an abnormal heart rhythm) and a history of cerebral infarction (lack of blood supply to the brain resulting in brain death to parts of the brain). A nursing note for Resident 27, dated February 7, 2025, at 9:00 a.m. revealed that the resident had a critically high PT/INR (body takes longer to form blood clots and increases the risk for bleeding). The results were sent to the Certified Registered Nurse Practitioner (CRNP) and new orders were obtained to give 10 milligrams (mg) of Vitamin K (used to reverse the effects of coumadin resulting in critically high PT/INR results) and continue to hold the coumadin (an anticoagulant) and repeat the PT/INR the following a.m. A nursing note for Resident 27, dated February 8, 2025, at 2:39 p.m. revealed that the resident had her PT/INR completed. The CRNP was notified, and orders were obtained to restart the resident's coumadin dose of 4.5 mg daily. Physician's orders for Resident 27, dated February 8, 2025, included an order for the resident to receive 4 mg and 0.5 mg of warfarin (coumadin) daily for a total of 4.5 mg daily. Physician's orders for Resident 27, dated February 8, 2025, included an order for the resident to have an INR blood test on Wednesday, February 12, 2025. There was no documented evidence that the INR blood test was completed on February 12, 2025, as ordered by the physician. Interview with Nursing Home Administrator on April 10, 2025, at 11:30 a.m. confirmed that Resident 27's INR was not completed on February 12, 2025, as ordered by the physician. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services. 395297 Page 5 of 9 395297 04/10/2025 Embassy of Huntingdon Park 1229 Warm Springs Avenue Huntingdon, PA 16652

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Findings include: The facility's policy regarding food safety, dated January 9, 2025, indicated that all food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption, and all food should be covered labeled and dated with the date it was opened. Observations in the walk-in cooler on April 7, 2025, at 9:20 a.m. revealed that there were five trays of chicken and five trays of broccoli that were covered with plastic wrap and not dated with the date they were prepared. Observations in the walk-in freezer on April 7, 2025, at 9:30 a.m. revealed that there were opened bags of carrots, green beans, corn and dinner rolls not secured and not labeled with the date they were opened. Observations in the main kitchen on April 7, 2025, at 9:43 a.m. revealed that the scoop for the flour was stored inside the bin with the flour, and the scoop for the rice was stored inside the bin with the rice. Interview with the Dietary Manager on April 7, 2025, at 9:45 a.m. confirmed that all food items should be covered, labeled and dated with the date they were opened or prepared and the scoops for the flour and rice should not be stored in the bins with the flour and rice. The facility's policy regarding uniform dress code for the food service worker, dated January 9, 2025, revealed that all hair should be clean and hair nets should cover all hair at all times. Observations in the main kitchen on April 9, 2025, at 11:20 a.m. during the lunch service revealed that Dietary Worker 3 was plating food and her hair was not completely covered with a hair net. Dietary Worker 5 was placing covers on the plates and silverware on the trays and her hair was not completely covered with a hair net. Dietary Worker 4 was making sandwiches in the food prep area and her hair was not completely covered with a hair net. The facility's policy regarding cleaning of food contact and non-food contact surfaces, dated January 9, 2025, indicated that non-food contact surfaces should be cleaned as often as necessary to be kept free from an accumulation of dust, dirt, food particles and other debris. Observation in the main kitchen on April 9, 2025, at 1:00 p.m. revealed that there was a blower fan on a kitchen cart that was blowing air in the kitchen. The fan was coated with dust and debris on the inside and outside surfaces. Observation in the main kitchen on April 9, 2025, at 1:34 p.m. revealed that a shelving unit where pans and cookie sheets where stored was covered with dust and debris. 395297 Page 6 of 9 395297 04/10/2025 Embassy of Huntingdon Park 1229 Warm Springs Avenue Huntingdon, PA 16652

F 0812 Level of Harm - Minimal harm or potential for actual harm Interview with the Dietary Manager on April 9, 2025, at 1:45 p.m. confirmed that dietary workers should be wearing hair nets that cover all of their hair and that all food and non-food contact surfaces should be cleaned as often as necessary to be kept free from an accumulation of dust, dirt, food particles and other debris. Residents Affected - Some 28 Pa. Code 211.6(f) Dietary Services. 395297 Page 7 of 9 395297 04/10/2025 Embassy of Huntingdon Park 1229 Warm Springs Avenue Huntingdon, PA 16652

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of established infection control guidelines, facility policy, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for one of 34 residents reviewed (Resident 41). Residents Affected - Few Findings include: CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance effective April 1, 2024. The recommendations now include the use of EBP during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply. The facility's policy regarding EBP, dated January 9, 2025, indicated that EBP's referred to the use of gown and gloves for the use during high contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with chronic wounds). An order for EBP's will be obtained for residents with any of the following: 1.) Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers), and/or indwelling medical devices (e.g. central lines, hemodialysis catheters, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO and 2.) Infection or colonization with any resistant organisms targeted by the CDC and epidemiologically important MDRO when contact precautions do not apply. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 41, dated February 13, 2025, indicated that the resident was admitted to the facility on [DATE], was cognitively intact, required assistance with care needs, had an indwelling catheter (a thin, flexible tube inserted into the bladder to drain urine from the bladder), a wound infection, a Stage 4 pressure ulcer (pressure wound with full thickness tissue loss with exposed bone, tendon or muscle) present on admission, and had a diagnosis of neurogenic bladder (bladder lacks control due to nerve or muscle problems) and a Stage 4 pressure ulcer. Physician's orders for Resident 41, dated December 3, 2024, included an order for the resident to have a urinary (foley) catheter (an indwelling catheter) for neurogenic bladder. Physician's orders for Resident 41, dated April 4, 2025, included an order for staff to apply saline wet-to-dry dressing to the buttocks wound with nystatin powder crusting to the peri wound, apply xtrasorb dry dressing (a dressing used to a wound with a high amount of drainage), and hold in place with medipore tape (cloth medical tape) in the evening. A care plan for Resident 41, dated November 15, 2024, revealed 395297 Page 8 of 9 395297 04/10/2025 Embassy of Huntingdon Park 1229 Warm Springs Avenue Huntingdon, PA 16652

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that the resident had an indwelling foley catheter for neurogenic bladder. A care plan for Resident 41, dated November 14, 2024, revealed that the resident had a pressure ulcer to her sacrum. care plan for Resident 41, dated January 16, 2025, revealed that the resident required EBPs for wounds and catheter. There was no documented evidence that EBP were implemented for Resident 41 until January 16, 2025. Interview with the Assistant Director of Nursing/Infection Preventionist on April 9, 2025, at 10:22 a.m. indicated that Resident 41 was on EBP when she was admitted ; however, there was no documented evidence that she was on EBP when she was admitted . She indicated there was no order and the care plan was initiated after she came off contact precautions (used to prevent the spread of infection passed through direct contact with an infected person or their environment) for an MDRO in January 2025. The Director of Nursing indicated that she was treated for an MDRO in January and when the contact precautions were discontinued, they continued the EBP. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing Services. 395297 Page 9 of 9