Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Envive Of Huntington during CMS and state inspections, most recent first.
The facility failed to consistently review and revise fall care plans with individualized interventions for four residents with severe cognitive impairment and mobility limitations who experienced multiple falls. For one resident, repeated falls related to confusion, attempts to stand and walk independently, and sliding from a wheelchair were documented, yet the fall care plan remained limited to a generic intervention without added specific strategies. Another resident with hemiplegia and a history of falls continued to fall while ambulating without a walker, moving clothing, and from an unlocked wheelchair, and although staff documented education and added a non‑slip pad to the wheelchair, these interventions were not incorporated into the care plan or CNA assignment sheets. A third resident on multiple high‑risk medications fell several times from a recliner and in the bathroom, with staff identifying issues such as improper footwear, worn nonskid strips, and failure to use the call light, but the resulting individualized interventions were not added to the care plan, and fall risk assessments sometimes showed her as not at risk. A fourth resident with severe dementia, agitation, and wandering fell from a wheelchair after scooting on a slippery cushion while barefoot at night; staff documented use of dycem under the cushion and noted increased nighttime confusion, but this intervention was not added to the care plan. Interviews confirmed that fall interventions were often communicated verbally or via CNA tools that sometimes lacked specific interventions, leading to care plans that did not accurately reflect current, individualized fall‑prevention measures.
Dietary staff failed to use required hair and beard coverings during meal prep and service. The Dietary Manager was observed in the kitchen and plating 43 meals without a hair cover or beard net, despite a posted sign requiring hair nets beyond that point. He stated he did not know the coverings were required because his hair was short, and the Administrator later confirmed he should have worn both coverings.
A resident council group reported that mail was not delivered on Saturdays and was routinely held until Monday. The ADON/Activities Director stated the weekend mail worker was no longer employed, and residents had not received Saturday mail for about a month and a half, despite a facility policy requiring mail delivery within 24 hours, including Saturdays.
Loose pills were found in two medication carts, including multiple unidentified tablets and capsules in the drawers and bottom of the carts. Two opened eye drop containers also lacked open dates. RNs, an LPN, and the DON confirmed that loose pills should be destroyed and that eye drops should have open dates, and the DON stated the carts were used for medications for 46 residents total.
Hypodermoclysis Infusion Rate and Solution Expiration Not Followed: A resident with syncope, weakness, kidney disease, and heart failure received NS hypodermoclysis at 150 mL/HR instead of the ordered 60 mL/HR, and the bag was marked as a second bag infused after being punctured beyond the expected use period. The MAR was missing the second bag administration time, and staff gave conflicting statements about how long a punctured NS bag remained usable.
A resident with vascular dementia, hearing impairment, and dependence on staff for personal care and toileting was subjected to undignified treatment by a CNA. Multiple staff reported hearing the CNA speak in a loud, angry tone and tell the resident to stop using the call light because staff were busy and had other residents to care for. Staff also reported that the CNA stated she would not change or toilet the resident, and another CNA ultimately responded to the call light and assisted the resident to the bathroom. The facility’s abuse policy defined such deprivation of necessary care and failure to acknowledge requests for assistance as abuse.
A resident in COVID-19 isolation was the subject of multiple staff reports that a CNA yelled at her, used an angry tone, told her not to keep using the call light because staff were busy, and stated she would not take the resident to the bathroom. Another CNA later assisted the resident to the bathroom after hearing this exchange outside the closed door. The facility’s initial incident report to the State Agency described the situation mainly as the CNA raising her voice so the resident could hear through PPE and advising her not to use the call light unless needed, and it omitted the allegation that the CNA threatened to withhold toileting care, resulting in a failure to timely and accurately report the full abuse and neglect allegations.
The facility posted photographs of two residents on social media without obtaining the required written consent as outlined in facility policy. One resident with cognitive impairment and another who was cognitively intact were both pictured in online posts, but neither had a signed social media release form in their records. Staff and administration confirmed the absence of proper consent, despite the facility's policy mandating explicit written approval before releasing resident images for such purposes.
Staff transferred a resident with Parkinson's disease and mobility impairment without using a gait belt or assistive device, contrary to facility policy and the resident's care plan. Both CNAs involved acknowledged the omission, and nursing leadership confirmed that a gait belt was required for such transfers.
A CNA provided incontinence care to a resident with Parkinson's disease and, without removing gloves or performing hand hygiene, touched the resident's call light and bed controls before discarding gloves. Interviews with staff and review of facility policy confirmed that gloves should have been removed and hand hygiene performed before touching environmental surfaces, resulting in a breach of infection control practices.
A facility failed to notify the Ombudsman of a resident's multiple hospital transfers due to serious medical conditions, including diabetic ketoacidosis and hypertension. The Social Services Director misunderstood notification requirements, and the facility lacked a policy for Ombudsman notification.
The facility failed to update care plans for two residents, leading to discrepancies in dialysis scheduling and lack of documented management for a pressure injury. One resident's care plan did not align with actual dialysis days, while another resident's care plan was not updated to include interventions for a pressure ulcer upon returning from the hospital. Staff interviews confirmed that care plans should be updated with significant changes, but this was not done in these cases.
A resident with multiple health conditions received incorrect administration of Midodrine due to improperly written medication orders. The orders instructed staff to hold the medication based on incorrect blood pressure parameters, leading to administration when the resident's systolic blood pressure was above the specified threshold. Interviews with the DON and NP confirmed the error in the medication order, which was not properly reviewed and signed electronically.
A facility failed to follow physician orders for administering an anti-hypotensive medication to a resident with a history of liver disease and hypertension. The medication was given despite the resident's blood pressure being outside the prescribed parameters, and there were multiple instances where the medication was held without proper documentation of vital signs. Staff interviews revealed inconsistencies in documentation practices.
A facility failed to ensure a resident did not receive antipsychotic medication without proper indication. The resident, with a history of bipolar disorder and other mental health issues, was receiving antipsychotic medication despite inconsistent documentation of a psychotic disorder. Care plans included monitoring for side effects, but the resident exhibited behaviors not clearly linked to medication use. Staff interviews indicated the resident's tearfulness was often random, suggesting inadequate justification for the medication.
A resident was subjected to inappropriate and sexually-toned conversations by an employee, DE5, through Facebook Private Messenger. Despite the resident reporting the issue to the Social Services Director, no action was taken by the previous administration to investigate or address the situation. The new administrator discovered the issue through an anonymous tip, leading to an investigation and the suspension of DE5. The facility failed to adhere to its policies on abuse and social media use, leaving the resident unprotected.
A facility failed to report an allegation of sexual abuse involving a resident and a dietary employee. The resident reported inappropriate messaging to the Social Services Director, but no action was taken. The Dietary Manager was also aware and informed the previous administrator, who dismissed the concerns. The issue was not addressed until a new administrator received an anonymous tip and suspended the employee. Facility policies on abuse reporting and investigation were not followed.
A facility failed to promptly investigate allegations of inappropriate messaging between a resident and a dietary employee. Despite the resident's report to the Social Services Director and the Dietary Manager's awareness, no action was taken by the previous administrator. The situation was only addressed months later by a new administrator following an anonymous tip, leading to the employee's suspension.
The facility failed to ensure proper hand hygiene was performed by staff before and after resident contact. A Restorative Aide and the Activities Director were observed assisting residents without performing hand hygiene, despite acknowledging the requirement and having hand sanitizer available. The DON and Nurse Consultant confirmed the expectation for staff to follow hand hygiene protocols.
Failure to Update and Individualize Fall Care Plans After Repeated Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to review and revise fall care plans with appropriate, individualized interventions after multiple falls for four residents identified as at risk for accidents. For Resident B, who had severe cognitive impairment, used a wheelchair, and required extensive assistance with ADLs, the care plan listed only a generic intervention to anticipate and meet needs. Despite a series of documented falls on multiple dates, associated with confusion, attempts to stand and walk independently, and sliding from his wheelchair, the fall care plan was not updated with specific, individualized interventions to mitigate further falls. Fall risk assessments repeatedly identified him as at risk, and nursing and IDT notes documented education to call for assistance, but these interventions were not incorporated into the written care plan. Resident C had severe cognitive impairment, hemiplegia/hemiparesis, used a wheelchair, and required varying levels of assistance with mobility and ADLs. His care plan identified him as at risk for falls due to decreased mobility, history of falls, and high‑risk medications, with interventions such as non‑skid strips, encouraging gripper socks/shoes, and use of a wheelchair for locomotion. However, after multiple falls—while walking without a walker in his room, while attempting to move clothing from plastic to wooden hangers, and from his wheelchair when the brakes were not locked—newly identified interventions and circumstances were not consistently added to the care plan. IDT notes referenced education on fall precautions, use of ambulation devices, and the need to call for assistance with daily activities, and an intervention to add a non‑slip pad to his wheelchair cushion was documented, but this intervention was not added to the resident’s care plan. The CNA assignment sheet also lacked documentation of fall interventions and indicated he walked, despite the care plan specifying wheelchair use for all locomotion/transfers. Resident D, who had severe cognitive impairment, used a wheelchair, and was on multiple high‑risk medications, had a care plan listing general fall‑risk interventions such as ensuring assistive devices were within reach, non‑skid socks, nonskid strips to chair, and wearing Crocs during transfers. She experienced several falls, including sliding from an elevated electric recliner while wearing soft, non‑grip socks; missing her recliner when attempting to sit; and falls in the bathroom when not using her call light and when urine was on the floor. Immediate and IDT notes identified specific issues and responses, such as replacing worn nonskid strips, educating her on proper footwear, reminding her to feel for the chair behind her knees before sitting, and encouraging call‑light use for ADLs, but these individualized interventions were not incorporated into the care plan. At times, fall risk assessments even indicated she was not at risk for falls despite recent incidents. Resident E had severe dementia with agitation, wandering, and required extensive assistance with mobility and ADLs. Her care plan identified her as at risk for falls due to history of falls, need for assist with transfers, and cognitive impairment, with general interventions such as anticipating needs, ensuring call light and personal items were within reach, maintaining clear pathways, and therapy screening. She had an unwitnessed fall from her wheelchair in a conference room at night after scooting herself in the chair; she was barefoot, reported that her feet were hot so she removed her socks, and stated that the pillow under her was slippery and caused her to slide to the floor. An IDT note documented that she had dementia with increased confusion at night and that dycem was placed under her cushion, but this new, individualized intervention was not added to the care plan. Interviews with CNAs and an LPN confirmed that fall interventions were often communicated verbally, in a CNA book, Kardex, or assignment sheets, and that CNA sheets sometimes lacked specific interventions, while the Administrator stated that interventions discussed in clinical meetings were intended to be added to care plans and CNA sheets. Despite this, the documented care plans for these four residents were not consistently reviewed and revised to reflect individualized fall‑prevention measures after repeated falls. Overall, the deficiency centers on the facility’s failure to ensure that fall care plans for four residents at risk for accidents were reviewed and revised with appropriate, individualized interventions following each fall event. Although falls were assessed, documented, and discussed by nursing and IDT staff, and immediate or situational interventions were sometimes implemented, these measures were not reliably incorporated into the formal care plans. Additionally, there were inconsistencies between care plans, CNA assignment sheets, and actual resident status or practices, such as residents walking when care plans called for wheelchair use, or CNA sheets lacking fall interventions, contributing to the lack of a clear, updated, and individualized fall‑prevention plan for each resident.
Dietary Manager Failed to Wear Required Hair and Beard Coverings
Penalty
Summary
The facility failed to ensure dietary staff used hair coverings during meal preparation and service. During breakfast service, the Dietary Manager was observed walking throughout the kitchen without a hair cover or beard cover and then plated 43 plates of food without wearing either covering. When interviewed, the Dietary Manager stated he was unaware he needed to wear a hair cover or beard net because his hair was so short. A posted sign on the kitchen door stated that hair nets must be worn beyond that point, and the Administrator later confirmed that the Dietary Manager should have worn both a hair net and beard net while in the kitchen. The facility policy titled Culinary Personal Hygiene stated that all culinary employees must wear a clean hair restraint that effectively covers all hair and that employees with facial hair must also wear a beard restraint.
Delayed Saturday Mail Delivery
Penalty
Summary
The facility failed to provide residents with Saturday mail delivery, despite a policy stating that mail and packages would be delivered to residents within 24 hours of delivery on premises or to the facility's post office box, including Saturday deliveries. During a Resident Council group interview, regular attendees reported that mail was not delivered within the facility on Saturdays. Residents 6, 14, 15, 16, 24, 36, and 37 confirmed that mail received on Saturdays was routinely held until Monday before being distributed. The Activities Director stated that the staff member who had previously handled weekend mail delivery was no longer employed, and as a result residents had not received mail on Saturdays for approximately the past month and a half. The Administrator stated that mail was supposed to be delivered within the facility on Saturdays.
Loose Pills and Undated Eye Drops Found in Medication Carts
Penalty
Summary
Medications were found stored improperly in two medication carts during survey observations. In the 200-hallway medication cart, a white round pill inscribed 54/27, a blue round pill, a clear oval capsule, a white round pill inscribed 40, a white round pill inscribed EP 117, and a white round pill inscribed B05 were found in the drawers. RN 3 stated the pills should be destroyed in the drug buster and indicated the carts were cleaned out during third shift. Two eye drop containers were also observed opened without open dates written on the container or box, and RN 8 stated eye drop containers should have an open date written on them. In the 100-hallway medication cart, a white round pill inscribed PH 020 and a white oblong pill inscribed ZF 41 were found at the bottom of the cart. LPN 4 stated the pills should be destroyed in the drug buster solution and was unsure how often medication carts were cleaned out. The DON later stated that eye drop containers should have an opened date written on them and that medication carts should be cleaned out every shift. The DON also stated that 21 residents received medications from the 100-hallway medication cart and 25 residents received medications from the 200-hallway medication cart. The facility policy on Medication Labeling and Storage stated nursing staff are responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.
Hypodermoclysis Infusion Rate and Solution Expiration Not Followed
Penalty
Summary
The facility failed to ensure safe, appropriate administration of hypodermoclysis for Resident 20 by not following the physician-ordered infusion rate and by allowing normal saline to be administered after the bag had been punctured beyond the expected time frame. Resident 20 had diagnoses including syncope and collapse, difficulty walking, adult failure to thrive, muscle weakness, bradycardia, kidney disease, and heart failure. The current physician order directed hypodermoclysis at 60 mL/HR for two liters of normal saline, with discontinuation after the second bag was finished. However, during observation on 3/16/26, the resident was seen with a bag of normal saline infusing at 150 mL/HR, and the bag was marked 3/14 as the second bag infused. When the infusion was observed again with the DON and LPN present, the LPN adjusted the tubing and the dial knob was then shown at 60 mL/HR, matching the order. The MAR did not document the administration time for the second bag, and the record showed the first bag began on 3/12/26 at 3:17 p.m. Facility staff gave conflicting information about how long a punctured normal saline bag remained usable, with the Administrator stating there was no policy, the RN and pharmacist stating 24 hours, and the DON stating the facility followed a 24-48 hour policy. The facility policy titled Hypodermoclysis required review of the order and included the rate of infusion as part of the order.
Failure to Treat Resident With Dignity and Respect When Requesting Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was treated with dignity and respect when requesting assistance. The resident had vascular dementia, was cognitively intact per the most recent MDS, was hard of hearing, and required assistance with personal care, transfers, and mobility using a walker and wheelchair. Her care plan included interventions to allow adequate time for responses, minimize environmental stimuli, and provide clear, simple instructions due to impaired communication and psychosocial wellbeing concerns related to negative interactions with others. On the day of the incident, staff in the activity area heard a staff member speaking in a very loud and angry tone. The Activity Director and Activity Assistant reported hearing a CNA tell the resident that she could not keep pushing her call light if she did not need something because there were other people to take care of and the CNA did not have time to keep coming into her room. When they looked to see where the yelling was coming from, they saw the CNA exiting the resident’s room, which was in isolation for COVID-19. Another staff member later reported that the same CNA also told the resident that she would not change her because she was too busy. Additional staff interviews corroborated that the CNA told the resident to stop putting on her call light and stated she was not going to take the resident to the bathroom. One CNA reported standing outside the closed door and hearing the CNA tell the resident to stop using the call light and that she would not take her to the bathroom; when the resident turned on her call light again, this CNA assisted her to the bathroom. The resident’s roommate confirmed that the CNA told the resident not to turn on her call light unless she needed something. The facility’s abuse policy defined abuse to include deprivation of goods and services necessary to maintain physical, mental, and psychosocial well-being, including when staff have the knowledge and ability to provide care but choose not to do so or fail to acknowledge a resident’s request for assistance, resulting in care deficits.
Failure to Timely and Accurately Report Allegations of Verbal Abuse and Neglect
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of verbal abuse and neglect involving one resident. On a specific date, the Activity Director heard someone yelling loudly while in the activity room and heard a staff member state that the resident could not keep pushing the call light unless something was needed because there were other people to care for. When the Activity Director stepped out, she saw a CNA exiting the resident’s room. A similar account was documented by the Activity Assistant, who heard an aide using a very loud and angry tone and heard the aide tell the resident not to keep pushing the call light if she did not need something, because there were other people to take care of and there was no time to keep coming into the room. These observations were reported to the Administrator. The Administrator and DON later entered the resident’s room, donning PPE due to the resident being in COVID-19 isolation, and questioned the resident about any trouble with staff. The resident reported that the CNA had told her she could not turn on her call light because staff were busy, but stated she did not feel abused. The resident’s roommate also reported that the CNA told the resident not to turn on her call light unless she needed something and denied that the resident needed to use the restroom at that time. Another CNA reported that, while standing outside the resident’s closed door, she heard the CNA tell the resident to stop putting her call light on and that she was not going to take her to the bathroom; this CNA later assisted the resident to the bathroom after the call light was turned on again. Despite these multiple staff reports and statements describing yelling, an angry tone, and a statement that the CNA would not toilet the resident, the facility’s initial incident report and follow-up documentation characterized the event primarily as the CNA raising her voice because the resident could not hear through PPE and telling the resident not to turn on the call light unless she needed something. The incident report did not include the allegation that the CNA threatened to withhold services, specifically refusing to toilet the resident. The facility’s policy required immediate reporting of abuse allegations to the Administrator and authorities within two hours and removal of any accused employee from resident contact during investigation, but the CNA continued to work after the initial allegation, and the allegation of refusal to toilet the resident was not accurately reflected in the initial report to the State Agency.
Failure to Obtain Written Consent Before Posting Resident Photos on Social Media
Penalty
Summary
The facility failed to protect resident dignity and rights by not obtaining written consent, as required by facility policy, before posting photographs of two residents on social media platforms. For one resident with dementia, depression, and mild cognitive impairment, a photograph was posted during an arts and crafts activity, but the only consent on file was for photographs intended for medical records and activities, not for social media use. The resident was aware of the photos being taken and posted but had not provided explicit written consent for social media release. For another resident, who was cognitively intact and had diagnoses including diabetes, bipolar disorder, and heart failure, photographs were posted online showing the resident at a lake during a meal, but there was no signed photography or video consent release form in the admission packet. Interviews with the Administrator confirmed that neither resident had a signed social media release form on file, and the Director of Nursing verified that both residents appeared in the facility's social media posts. The facility's current policy explicitly requires written consent from the resident or representative before images or recordings are taken or released for any purpose other than specific exceptions, such as investigations or emergencies. The lack of proper written consent prior to posting these images constituted a failure to honor the residents' rights to dignity and self-determination.
Failure to Use Assistive Device During Resident Transfer
Penalty
Summary
Staff failed to follow facility policy regarding the use of assistive devices during the transfer of a physically dependent resident diagnosed with Parkinson's disease, muscle weakness, tremors, and difficulty walking. The resident was documented as cognitively intact but had upper and lower extremity impairment on one side and required extensive assistance from two staff members for transfers. The care plan specified that transfers required two staff and that a mechanical lift could be used as needed. However, during observed transfers, two CNAs moved the resident between a recliner and bed without using a gait belt or any assistive device, instead lifting the resident by placing their arms under the resident's armpits and cueing the resident to move his feet. Both CNAs acknowledged during interviews that they should have used a gait belt for the transfer, and this was confirmed by an RN and the DON, who stated that a gait belt was required for this resident during transfers. The facility's policy on safe lifting and movement of residents required staff to incorporate resident safety and to be trained in the use of manual and mechanical lifting devices. The failure to use a gait belt or assistive device during the transfer was directly observed and confirmed by staff interviews, constituting a failure to implement the facility's policy for safe resident transfers.
Failure to Follow Infection Control Protocols During Incontinence Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to follow proper infection control practices during incontinence care for a resident diagnosed with Parkinson's disease, diabetes, muscle weakness, and tremors. The resident was cognitively intact but dependent on staff for toileting due to upper and lower extremity impairment on one side. During an observed care episode, the CNA washed her hands and donned gloves before providing incontinence care for a small bowel movement. After completing the care and redressing the resident, the CNA, still wearing the same gloves, touched the resident's call light and bed controls before removing her gloves and performing hand hygiene. Interviews with the CNA, a registered nurse (RN), and the director of nursing (DON) confirmed that gloves should have been removed and hand hygiene performed before touching any items in the resident's environment after providing incontinence care. The facility's current hand hygiene policy also required all personnel to follow handwashing procedures to prevent the spread of infections. The failure to remove gloves and perform hand hygiene before touching environmental surfaces constituted a breach of infection control protocols.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide timely notification to the Office of the State Long-Term Care Ombudsman regarding the transfer or discharge of a resident, specifically Resident 21, who was hospitalized multiple times throughout the year. Resident 21's clinical record indicated several hospitalizations due to serious medical conditions, including diabetic ketoacidosis, refusal of dialysis and medications, hypertension, hyperglycemia, and hyperkalemia. Despite these transfers, the facility did not notify the Ombudsman for the months of March, May, October, and December 2024. The Social Services Director indicated that a monthly report of transfers and discharges was typically sent to the Ombudsman via email. However, the facility's system did not notify her of hospitalizations if a resident was on bed-hold status, leading to a misunderstanding that notification was only necessary if a resident's return was not anticipated. Additionally, the facility lacked a policy addressing the notification of the Ombudsman, as confirmed by the Administrator during an interview.
Failure to Update Care Plans for Dialysis and Pressure Injury Management
Penalty
Summary
The facility failed to review and revise care plan interventions for dialysis management for Resident 21. The resident's clinical record indicated a discrepancy between the scheduled dialysis days and the care plan. The care plan, initiated on March 7, 2024, stated that the resident was to attend dialysis on Tuesday, Thursday, and Saturday, while physician orders and staff interviews confirmed that dialysis was scheduled for Monday, Wednesday, and Friday. This inconsistency was not addressed in the care plan, leading to a lack of alignment between the resident's care plan and actual treatment schedule. For Resident 27, the facility did not update the care plan to include the management of a pressure injury upon the resident's return from the hospital. The resident was admitted with an unstageable pressure ulcer on the left buttock, but the care plan was not revised to reflect this condition or to include goals and interventions for wound management. Despite the presence of a pressure injury and the need for specific interventions, the care plan remained unchanged until January 17, 2025, several months after the resident's return from the hospital. Interviews with facility staff, including the DON and Social Services, revealed that care plans were expected to be updated when there was a significant change in a resident's condition or upon readmission from a hospital stay. However, this protocol was not followed for Resident 27, resulting in a lack of documented care strategies for the pressure injury. The facility's policy required care plans to be reviewed and updated in response to significant changes, but this was not adhered to in the cases of Residents 21 and 27.
Incorrect Administration of Anti-Hypotensive Medication
Penalty
Summary
The facility failed to ensure that an anti-hypotensive medication, Midodrine, was ordered and administered correctly for a resident with multiple health conditions, including anoxic brain damage, type 1 diabetes mellitus, end-stage renal disease, bipolar disorder, and hypertension. The resident's medication orders were incorrectly written, leading to the administration of Midodrine 2.5 mg when the resident's systolic blood pressure was 126 mmHg, contrary to the order to hold the medication if the systolic blood pressure was greater than 120 mmHg. Interviews with the Director of Nursing (DON) and a Nurse Practitioner (NP) revealed that the medication order for Midodrine 5 mg was also incorrectly written, instructing staff to hold the medication if the systolic blood pressure was less than 120 mmHg, instead of greater than 120 mmHg. This error was acknowledged by the NP, who admitted to the oversight in reviewing and signing the electronic orders. The incorrect orders led to the improper administration of the medication, potentially affecting the resident's blood pressure management.
Failure to Follow Physician Orders for Anti-Hypotensive Medication Administration
Penalty
Summary
The facility failed to adhere to physician orders regarding the administration of an anti-hypotensive medication for a resident. The resident, who had a history of alcoholic cirrhosis of the liver, muscle weakness, dysphagia, essential hypertension, and alcoholic polyneuropathy, was prescribed midodrine 10 mg to be taken twice daily for decreased blood pressure, with instructions to hold the medication if blood pressure exceeded 120/80 mmHg. However, on December 28, 2024, the medication was administered despite the resident's blood pressure being 148/89, which was outside the prescribed parameters. Further review of the January 2025 Medication Administration Record (MAR) revealed that the medication was held on several occasions without documentation of the resident's blood pressure in the MAR, vital signs tab, or progress notes. Interviews with facility staff, including a QMA, RN, LPN, and the DON, indicated inconsistencies in documenting vital signs and medication administration. The facility's policy on administering medications required adherence to prescriber orders, including any specified time frames, which was not followed in this instance.
Failure to Justify Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that a resident did not receive antipsychotic medication without proper indication related to targeted behavior expressions and mental health diagnoses. The resident in question, who had a history of bipolar disorder, mild intellectual disabilities, paranoid personality disorder, delusional disorder, and major depressive disorder, was receiving antipsychotic medication. However, the resident's quarterly Minimum Data Set (MDS) assessments initially indicated no psychotic disorder, which later changed to indicate a psychotic disorder other than schizophrenia. The care plans for the resident included the use of antipsychotic and anti-anxiety medications, with interventions to monitor and document side effects and effectiveness. Despite these interventions, the resident exhibited behaviors such as tearfulness, withdrawal, agitation, and restlessness, which were not consistently linked to the use of the medications. The facility's policy required that residents only receive antipsychotic medications when necessary to treat specific conditions, but the documentation and observations did not clearly support the continued use of these medications for the resident. Interviews with staff members revealed that the resident's understanding of conversations varied, and she could become tearful and upset easily. The resident's tearfulness was often random and not prompted by specific events, suggesting that the use of psychotropic medications may not have been adequately justified. The facility's failure to ensure that the resident did not receive unnecessary antipsychotic medication without clear indication and documentation of targeted behaviors and mental health diagnoses led to the deficiency.
Failure to Protect Resident from Sexual Abuse by Employee
Penalty
Summary
The facility failed to protect a resident from sexual abuse perpetrated by an employee, identified as DE5, who engaged in inappropriate and sexually-toned conversations with Resident B. The interactions began as friendly exchanges on Facebook Private Messenger but escalated to flirty and inappropriate messages, including DE5 sending pictures of herself in pajamas and messages indicating she was wearing only a bra and panties. Resident B, who was cognitively intact, reported feeling uncomfortable with the nature of the conversations and ended the relationship, but not before informing the Social Services Director (SSD) about the situation. Despite Resident B's report to the SSD, no further action was taken by the facility's previous administration to investigate or address the issue. The SSD advised Resident B to stop messaging DE5 but did not document the incident or follow up with the resident. The Dietary Manager (DM) was also aware of the inappropriate messaging and reported it to the previous administrator, who dismissed the concerns, stating that action could only be taken if there was evidence of sexual activity. No documentation or investigation was conducted by the previous administration regarding the allegations. The issue came to light when the new administrator received an anonymous call about the inappropriate relationship and initiated an investigation. The investigation confirmed the inappropriate nature of the messages, leading to the suspension of DE5. The facility's policies on abuse and social media use were not adhered to, as the previous administration failed to report or investigate the allegations, leaving Resident B unprotected from potential abuse.
Failure to Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the Indiana Department of Health when the concern was initially identified for a resident. The issue began when the resident, identified as Resident B, reported to the Social Services Director (SSD) that a Dietary Employee (DE5) was engaging in inappropriate messaging with him via Facebook Private Messenger. The messages included flirty content and photos, with one message indicating the employee was in her bra and panties. Despite Resident B informing the SSD about the situation, no further action was taken by the SSD or the previous administrator to investigate or report the incident. The Dietary Manager (DM) was also aware of the inappropriate messaging and had informed the previous administrator about the situation. However, the previous administrator dismissed the concerns, stating that the facility could not take action unless there was evidence of sexual activity. The DM did not document any of the reports or take further action to address the issue. The inappropriate messaging continued until the new administrator received an anonymous call about the relationship and initiated an investigation, which led to the suspension of DE5. The facility's policies on abuse and neglect require immediate reporting of such allegations to the state licensing agency and a thorough investigation. However, these procedures were not followed by the previous administration, resulting in a failure to report the incident in a timely manner. The lack of documentation and follow-up by the SSD and DM further contributed to the deficiency, as the situation was not addressed until months later when the new administrator took action.
Delayed Investigation of Staff-Resident Misconduct
Penalty
Summary
The facility failed to conduct a timely and thorough investigation into allegations of sexual misconduct involving a staff member and a resident. Resident B reported to the Social Services Director (SSD) that a dietary employee, DE5, was engaging in inappropriate messaging with him via Facebook Private Messenger. Despite Resident B's disclosure in May, the SSD only advised him to stop messaging DE5 and did not document the incident or follow up. The Dietary Manager (DM) was also aware of the situation and reported it to the previous administrator, who took no documented action. The inappropriate relationship continued, with DE5 sending messages and photos that crossed professional boundaries. DE5 admitted to sending a photo of herself in pajamas and a message indicating she was in her bra and panties. Despite being aware of the situation, the previous administrator did not initiate an investigation or document any actions taken. It was not until an anonymous call in September that the new administrator became aware of the situation and began an investigation, suspending DE5 and collecting evidence from Resident B. The facility's policies on abuse and neglect require immediate reporting and thorough investigation of such allegations, which were not followed in this case. The lack of documentation and follow-up by the previous administrator and other staff members resulted in a significant delay in addressing the allegations, leaving the resident without proper support and the staff member without appropriate oversight.
Failure to Perform Hand Hygiene Before and After Resident Contact
Penalty
Summary
The facility failed to ensure proper hand hygiene was performed by staff before and after moments of resident contact. During a random observation, a Restorative Aide was seen assisting a resident in a wheelchair and adjusting his foot pedals without performing hand hygiene after exiting the resident's room. The Restorative Aide admitted to sometimes delaying hand hygiene until she returned to her work room, especially if she encountered another resident needing therapy. Similarly, the Activities Director was observed assisting a resident with oxygen tubing and then distributing crafting supplies to other residents without performing hand hygiene before or after these activities. The Activities Director acknowledged that she was supposed to perform hand hygiene before and after entering a resident's room but did not always do so, despite having hand sanitizer available in her pocket and work room. The Director of Nursing (DON) and Nurse Consultant confirmed that staff were expected to perform hand hygiene before and after entering resident rooms where care was performed. The facility's current policy, dated February 2022, also stipulated that healthcare workers should use hand hygiene before and after direct physical contact with residents. These observations and interviews indicate a failure to adhere to the facility's hand hygiene policy, potentially compromising infection prevention and control measures.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Huntington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Waters Of Huntington Skilled Nursing Facility, The | 0.3 mi | ★★★★★ | 18 | 1 |
| Hickory Creek At Huntington | 0.3 mi | ★★★★★ | 6 | 0 |
| Heritage Pointe Of Huntington | 2.5 mi | ★★★★★ | 15 | 0 |
| Markle Health & Rehabilitation | 9.9 mi | ★★★★★ | 1 | 0 |
| Heritage Pointe Of Warren | 13.2 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.