Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Waters Of Huntington Skilled Nursing Facility, The during CMS and state inspections, most recent first.
A resident with full code status experienced a medical emergency with worsening oxygen saturation, stopped breathing, and had no detectable heartbeat. An LPN started a breathing treatment, then began CPR, but stopped compressions after contacting the NP by phone and did not call EMS. The record lacked documentation of physician notification and EMS notification, and the LPN and QMA involved did not have current CPR certification consistent with professional standards.
An LPN and QMA failed to respond appropriately when a resident with COPD and other serious diagnoses deteriorated while full code. The LPN initiated a nebulizer treatment without a physician order, the QMA administered albuterol from another resident despite scope limits, EMS was not called, and CPR was stopped by the LPN without indication after the resident stopped breathing and lost a pulse.
Dishwasher Did Not Reach Proper Sanitizing Temperature: The facility failed to ensure the high-temp dishwasher reached the required sanitizing temperature. During kitchen observation, the wash temperature was 126 degrees F instead of 160 degrees F or higher. The Dietary Mgr said a pink chemical sanitizer was added and a strip later showed improper sanitization, while the Maintenance Dir said he replaced the thermostat but did not verify the machine reached the proper temp.
Restriction of Cognitively Intact Residents’ Scooter Use Without Documented Assessment: The facility restricted two cognitively intact residents from taking their motorized scooters off the property after reported scooter-related incidents and community complaints, but staff lacked documentation of the events and did not document an assessment of the residents’ ability to make this decision. One resident said she had been told to sign a form and would need supervision to leave, while the other said she bought the scooter to go to nearby places and signed an agreement while upset without understanding it. The facility policy stated cognitively intact residents with a documented medical reason for a motorized vehicle would be allowed to use it, with therapy assessment for safe operation ability.
Failure to Assess Residents for Self-Administration of Medications: An LPN left medication cups and an inhaler in residents’ rooms for later use, even though the residents were not care-planned or assessed for self-administration. One resident said staff left meds for him because he waited until after breakfast, another took whatever staff gave him and could not identify the pills, and a third said staff left meds in her room for when she woke up and she did not know what she took. The records lacked physician orders and self-administration assessments, and MDS data showed cognitive impairment for two of the residents.
A resident with multiple serious diagnoses, including DM with kidney complications, AFib, and a prior stroke, was transferred to the hospital after declining hemoglobin levels. The record showed staff spoke with the resident’s representative and arranged transport, but there was no documentation that the resident or representative received the required written transfer/discharge appeal rights or bed hold policy. Interviews with LPN, ADON, and DON confirmed the facility used transfer paperwork, but the resident’s chart lacked evidence that the required notices were provided.
A resident with poor vision and documented need for an eye exam did not receive timely vision services. He had signed ancillary service forms for eye care, but the initial consent had the wrong last name, and the SSD could not locate an appointment or confirm he was on the optometry caseload. Staff believed he would be seen when the optometrist next came to the facility, but no appointment had been scheduled, and the resident was transported for an eye visit that did not occur.
A resident with dementia, severe cognitive impairment, daily wandering, and a history of physical aggression was not effectively monitored or managed for wandering and behavior expressions. The record showed repeated episodes of resident-to-resident aggression, combative behavior with staff, and entering other residents’ rooms, while observations found him wandering hallways, standing at exit doors, and entering a room without consistent staff intervention or diversion. Staff reported using doorway banners to keep him out of rooms, but he could pull them away and go inside, and the DON stated the facility did not have a policy specifically addressing wandering.
A resident with major depressive disorder, dementia, and HTN had a pharmacy med regimen review in which the provider agreed to discontinue PRN ondansetron and PRN Imodium, but the ondansetron order remained active in the chart. The ADON stated the medication had never been discontinued, and the DON said the orders should have been discontinued after the pharmacy recommendation was signed.
A resident with major depressive disorder and dementia received duplicate escitalopram orders when a GDR from 10 mg to 5 mg daily was entered but the 10 mg order was not discontinued right away. As a result, the EMAR showed both the 5 mg and 10 mg doses were administered together for several days, and the DON later acknowledged the duplicate administration.
Unlabeled and Improperly Stored Medications: A resident's hydrocodone-acetaminophen tablets returned from LOA were found in a sleeve without the medication name, and the Controlled Substance Record lacked resident identification. On the secured unit cart, unlabeled bottles of acetaminophen, acidophilus, Vitamin D3, and opened nystatin powder were found in resident-specific areas, and staff stated medications should be labeled with the resident's name and order information.
Two residents with severe cognitive impairment and high fall risk experienced repeated falls and injury due to the facility's failure to consistently implement and communicate fall prevention interventions. Despite care plans outlining specific measures such as safety checks, anti-tippers, and floor mats, these were often missing or not in place, and staff were unclear about responsibilities and interventions, leading to inadequate supervision and preventable accidents.
Two residents experienced documented falls that were not accurately reflected in their MDS assessments, as progress notes described multiple incidents of residents being found on the floor, but the corresponding MDS assessments indicated no falls since the prior assessment. The MDS Coordinator relied only on active risk management reports and was unaware of how to access historical data, and there was no specific facility policy for MDS assessments.
The facility did not complete required assessments for three residents with respiratory illness and falls. One resident with COPD and other conditions did not have documented respiratory assessments or vital signs after starting treatment for an infection. Two residents with cognitive impairment and multiple unwitnessed falls had incomplete neurological checklists, with missing entries and no documentation of refusals or reasons for missed checks. Staff and DON interviews confirmed that assessments and documentation were not completed as required by facility policy.
The facility failed to maintain a clean and homelike environment, with stained and worn carpeting, unclean floors, and bathrooms with brown matter around toilets. The Administrator acknowledged the unclean conditions, and the Housekeeping Director was developing a new cleaning plan. Observations indicated that cleaning procedures were not effectively implemented.
A facility failed to conduct weekly skin assessments for a resident at risk for skin breakdown, as required by their care plan and facility policy. The resident, with multiple diagnoses including dementia and hypertension, had not received a skin assessment since March, despite being identified as at risk for pressure ulcers. The care plan and facility policy both mandated weekly assessments, which were not performed, as confirmed by the ADON and MDS Coordinator.
A facility failed to immediately report a resident-to-resident altercation involving two residents with dementia, leading to a delayed submission to the Indiana Department of Health. The incident occurred when one resident, agitated, entered another's room, resulting in a physical confrontation. Staff interviews revealed a failure to follow the facility's abuse reporting policy, as the incident was not reported to the Administrator until weeks later.
The facility failed to implement individualized non-pharmacological interventions for two residents with dementia, leading to incidents of wandering, agitation, and aggression. Despite behavior monitoring orders, care plans lacked specific interventions, and staff were uncertain about documentation responsibilities. The facility's policy on behavior management was not adequately followed.
A cognitively impaired resident at high risk for falls was inadequately supervised, with room doors often closed, impairing staff's ability to monitor. Despite multiple unwitnessed falls, some resulting in injury, the care plan was not updated with new interventions. Staff interviews revealed a lack of communication and awareness of the resident's fall history and interventions, and post-fall monitoring reports were incomplete.
A resident with type 2 diabetes mellitus received expired Humalog insulin from a medication cart in an LTC facility. The insulin, opened on May 1st, was administered multiple times after its expiration on May 29th. Despite nightly checks, the expired insulin was not removed, and the facility's policy on insulin expiration was not followed.
The facility did not ensure that daily nurse staffing data was complete and available at the beginning of each shift. Observations showed that the posted information lacked the number of hours worked per shift for RNs, LPNs, and CNAs, as well as the resident census. Interviews confirmed that these details were filled out the following day, contrary to facility policy.
A resident with dementia was moved to a memory care unit without proper notification or involvement in the decision-making process, leading to confusion and distress. The facility cited a non-existent flood as the reason for the move, failing to follow its own policy on room changes and neglecting to document the necessity of the move in the resident's clinical record.
Failure to Provide Appropriate CPR and Emergency Response
Penalty
Summary
The facility failed to ensure a resident with a known full code status received appropriate emergency services during a medical event that ended in death. Resident B had diagnoses including abdominal aortic aneurysm, COPD, emphysema, hypertension, anorexia, vascular implants, and chronic kidney disease. The resident’s record showed a physician order for full code status, the most current MDS indicated the resident was cognitively intact, and the care plan documented that the resident elected to be a full code. According to the progress note, Resident B’s oxygen saturation dropped from 82% to 75% while a breathing treatment was being given. The resident’s mouth was open, the resident was very pale, then stopped breathing and no heartbeat could be heard. Chest compressions were started while the QMA lowered the head of bed, and time of death was documented after two rounds of chest compressions. The clinical record lacked documentation that the physician or nurse practitioner was notified of the change in condition, and it also lacked documentation that emergency services were notified. During interviews, LPN 1 stated she started a breathing treatment because that was what the NP usually did, then called the NP. She said the resident stopped breathing, she performed CPR, and later stopped compressions after speaking with the NP by phone. She also stated she should have called emergency services. The NP stated she received text messages about the resident’s decline and that the resident was not being sent to the hospital, but she did not give an order to stop CPR. QMA 2 stated she administered an albuterol treatment without an order because the nurse told her to, and she observed that the resident had no rise or fall of the chest before CPR was started. Review of CPR certifications showed LPN 1 and QMA 2 did not have current CPR certification consistent with professional standards.
Improper emergency response and scope-of-practice violations during resident decline
Penalty
Summary
Nursing staff failed to provide care within their scope of practice and failed to respond appropriately to a resident’s change in condition. Resident B had diagnoses including abdominal aortic aneurysm, COPD, emphysema, hypertension, anorexia, vascular implants, and chronic kidney disease. The resident was cognitively intact, had a physician order for full code status, and had elected to be full code in the care plan. The clinical record did not document notification of the physician or nurse practitioner regarding the resident’s change in condition, and it did not document that emergency services were notified. According to the progress note and staff interviews, Resident B developed labored breathing and low oxygen saturation. LPN 1 documented that the resident’s oxygen saturation was 82%, a breathing treatment was started, and the saturation dropped to 75% during the treatment. The resident became pale, stopped breathing, and no heartbeat could be heard. Chest compressions were started, and time of death was documented at 1:55 a.m. after two rounds of compressions. A later event note written by LPN 1 stated that three rounds of compressions were completed, the funeral home was called, and the nurse practitioner and DON were notified. During interviews, LPN 1 stated she started a breathing treatment because that was what the NP usually did, then called the NP. She said she was preparing paperwork to send the resident to the hospital when the resident stopped breathing, and she later stopped CPR after the NP told her to stop. The NP stated she received text messages from LPN 1 about the resident’s condition and was unaware the resident did not already have an order for breathing treatments. The NP said she did not give an order to stop CPR. QMA 2 stated LPN 1 told her to get a breathing treatment, so she obtained a nebulizer machine and albuterol ampule from another resident because there was no order for albuterol, and she administered the treatment. QMA 2 then found no chest rise or fall and told LPN 1 they needed to start CPR. LPN 1 began compressions, felt or heard a rib crack, asked if that was the resident’s last breath, and then said she was going to call it and stopped the compressions. The report also states the QMA administered a nebulizer treatment despite the scope of practice prohibiting QMAs from administering inhalation treatments, and that staff failed to initiate EMS and LPN 1 made the determination to end CPR without indication.
Dishwasher Did Not Reach Proper Sanitizing Temperature
Penalty
Summary
The facility failed to ensure the high-temperature dishwasher functioned at a level that maintained proper sanitization requirements. During an initial kitchen tour, the dishwasher’s washing temperature was observed at 126 degrees Fahrenheit instead of the required 160 degrees Fahrenheit or higher. This concern was identified in the kitchen area and applied to the facility’s meal service operations for 58 of 58 residents who received meals from the kitchen. During interview, the Dietary Manager stated the thermostat had been replaced on Friday and, despite the wash temperature being below the indicated temperature, she believed it was safe to use because she was pouring sanitizing chemical into the dishwasher. She poured a small cup of pink chemical sanitizer into the dishwasher before running the machine, and after it ran, she tested the water with a chemical strip that indicated improper sanitization was completed. The Maintenance Director stated he replaced the thermostat on Friday and thought it was preset, but he did not run the dishwasher to verify that it reached the appropriate temperature. The facility policy titled, Dishwashing: Machine, stated to check that wash and rinse cycles achieve proper temperature per manufacturer guidelines and, if a chemical sanitizer is used, to check the concentration using the correct strip and not proceed if acceptable temperatures or sanitizing concentration are not met.
Restriction of Cognitively Intact Residents’ Scooter Use Without Documented Assessment
Penalty
Summary
The facility failed to promote residents’ rights to make choices regarding leaving the facility property on their motorized scooters and failed to assess the residents’ ability to make those decisions before restricting off-property use for 2 cognitively intact residents. Resident 1 had diagnoses including type 2 diabetes mellitus, anxiety disorder, hypertension, overactive bladder, osteoarthritis, GERD, and muscle weakness, and a quarterly MDS dated 7/10/25 indicated she was cognitively intact. Resident 34 had diagnoses including hypertension, hypernatremia, COPD, and anemia, and a quarterly MDS dated 5/19/24 indicated she was cognitively intact. Both residents owned motorized scooters and were able to make their own decisions, according to staff interviews and the residents’ statements. During interviews, the SSD stated there had been incidents involving the scooters, including Resident 1 going to a nearby Dairy Queen and gas station and community members calling to report residents on scooters were almost hit by cars. The SSD also stated the sidewalks were uneven and Resident 1 almost tipped over, but she lacked documentation about the incidents and did not have interviews with community members. The DON also stated she did not have documentation of where or when the incidents occurred. Resident Council minutes showed both residents were educated about safety concerns and, effective 7/2/25, motorized scooters were no longer allowed off the facility property. Resident 1 stated she was no longer able to leave the facility property on her scooter after being asked to sign a form and being told she would need supervision to leave. She said she had crossed the road to go to Dairy Queen and had once gotten stuck on the sidewalk, with police helping her get unstuck. Resident 34 stated she bought the scooter so she could leave the premises and go to nearby restaurants or stores, that she was her own person and made her own health decisions, and that she had been told she could no longer take the scooter off the property because it was a liability and not allowed by the State. She said she signed the agreement while upset and did not know what she had signed. The facility policy stated cognitively intact residents with a documented medical reason for a motorized vehicle would be allowed to use it, with therapy assessment for safe operation ability and removal only if safety concerns were identified.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to assess residents for self-administration of medications for 3 of 3 residents reviewed. Resident 12 was observed with morning medications left at his bedside table on multiple occasions, and he stated nurses left his medications with him each day because he preferred to wait until after breakfast. During an interview, an LPN said he was not care-planned to self-administer medications, but staff felt comfortable leaving his pills with him because he was alert and oriented. His record showed diagnoses including type 2 diabetes mellitus, major depressive disorder, benign prostatic hyperplasia, and cardiomyopathy, and the clinical record lacked both a physician’s order for self-administration and a self-administration assessment. Resident 49 was observed with a medication cup containing multiple pills left on his table, and later he was seen taking the medications himself after becoming distracted and forgetting to take them. He stated he was unsure what most of the medications were and that he took whatever staff gave him. On another observation, medication remained in a cup on his table while he was in his room. His record included diagnoses of hypertension, diabetes, and atrial fibrillation, and a quarterly MDS indicated moderately impaired cognitive status. The clinical record also lacked a physician’s order to self-administer medication and a self-administration assessment. Resident 8 was observed asleep in bed while a medication cup containing multiple pills and a Trelegy inhaler sat on her bedside table across the room. She stated staff left medications in her room for her to take when she woke up, and she did not know what medications she took. Her record included bipolar disorder, dysphagia, and cognitive communication deficit, and the quarterly MDS indicated moderately impaired cognitive status. An LPN later stated she left medications in Resident 42 and Resident 8’s rooms because they were alert and oriented and liked their medications available when ready, but the clinical record lacked a physician’s order and self-administration assessment for Resident 8.
Missing Written Transfer/Discharge Appeal Rights and Bed Hold Notice
Penalty
Summary
The facility failed to ensure that Resident 58 and the resident’s representative were notified in writing of the transfer/discharge appeal rights and the bed hold policy when the resident was transferred to the hospital. Resident 58’s record showed diagnoses including type 2 diabetes with diabetic kidney complications, paroxysmal atrial fibrillation, abnormal findings on diagnostic imaging of the heart and circulation, and cerebral infarction due to occlusion or stenosis of a small artery. A progress note documented that the facility spoke with the resident’s representative because the resident’s hemoglobin continued to decrease, and the resident was sent to the hospital after the representative said the family would transport the resident to the regional hospital. The clinical record contained an e-Interact SBAR summary indicating the resident was sent to the hospital, but it lacked evidence that the transfer/discharge appeal rights and bed hold policy were provided in writing to the resident and/or the resident’s representative. During interviews, LPN 6 stated that when a resident was transferred, a face sheet, code status, medication list, and bed hold form were sent, but she was unsure what else was sent. The ADON and DON stated the required transfer/discharge and bed hold forms were on the computer and would pop up when a resident was transferred or discharged, but the DON also stated that when Resident 58 was transferred, paper copies were used and the transfer was unusual. The facility policy stated that before transferring a resident to a hospital, the nursing facility would provide information about the bed-hold policy and, for an emergency transfer, explain the transfer and send the original State Transfer/Discharge/Bedhold notice with the resident and/or responsible party.
Failure to Provide Timely Vision Services
Penalty
Summary
The facility failed to ensure vision services were provided for one resident who had documented eye care needs and had requested ancillary services. The resident was blind in the left eye and had poor vision in the right eye. He told staff he had not been seen by the facility eye doctor and had not heard anything about an appointment, despite having spoken with the Social Services Director about scheduling one. He later stated that his right-eye vision had become worse and blurrier and that he wanted to see an eye doctor as soon as possible. The resident’s record showed multiple references to the need for an eye exam, including physician progress notes stating he needed an eye doctor appointment for visual disturbances, complained of worsening vision, and wanted an eye exam. His care plan identified him as at risk for vision issues and noted he had asked to be placed on the list for ancillary services. Two signed ancillary services forms indicated he wanted audiology, eye care, and podiatry, although the initial form contained the wrong last name. The Social Services Director stated she could not locate documentation of an eye appointment, had emailed the optometry company, and learned the resident was not on their caseload. She said she believed he would be seen when the optometrist next came to the facility, so no appointment was scheduled. The DON stated the initial consent form had been filled out in error and that staff reviewed physician notes and daily events, but the practitioner did not inform staff that the resident needed an eye exam. The Administrator stated the ancillary services provider should have notified the facility that the resident could not be identified on their list. On the day of the interview, the resident was transported for an eye appointment that had not actually been scheduled, arrived before the office opened, and was later told the eye doctor was not in. He did not receive eye care services that day.
Failure to Manage Wandering and Aggressive Behaviors in a Resident with Dementia
Penalty
Summary
The facility failed to develop and implement effective interventions and monitoring for a resident with dementia who displayed known wandering and physical aggression. Resident 53 had diagnoses including dementia with behavioral disturbance, major depressive disorder, anxiety disorder, and insomnia. His record showed severe cognitive impairment, daily wandering, disorganized thinking, incoherent conversation, and unpredictability. Orders included a WanderGuard to the left ankle, behavior monitoring each shift, and care plan interventions for wandering, elopement risk, and aggressive behaviors. The resident’s care plans identified him as at risk for elopement, wandering into other residents’ rooms, resident-to-resident aggression, verbal and physical aggression, and non-compliance with care. Interventions listed in the record included redirecting him, offering food, drink, toileting, activities, and limiting the number of staff who redirected him when he became aggressive. The record also documented repeated episodes of aggression, including lunging at another resident, shoving a resident to the floor, being combative with staff, pushing a CNA against a wall, and attempting to choke a CNA during care. During observations, the resident wandered throughout hallways, stood at exit doors, entered other residents’ rooms, and was not consistently approached by staff. On one observation, he walked through multiple hallways, looked into rooms, and no staff offered him a snack, activity, or diversion. On another, he entered a resident’s room, got into the bed, and required repeated attempts before leaving after being offered a cookie. Staff interviews confirmed that banners were placed across doorways to keep him out of rooms, but he could pull them away and enter anyway. The DON stated the facility did not have a policy specifically addressing wandering.
Failure to Discontinue Medications After Pharmacy Review
Penalty
Summary
The facility failed to implement pharmacy recommendations and follow physician orders to discontinue medications for one resident reviewed for pharmacy recommendations. The resident had diagnoses of major depressive disorder, dementia, and hypertension, and a quarterly MDS dated 5/27/25 indicated the resident's cognitive status was severely impaired. A pharmacy medication regimen review dated 1/1/25 indicated the provider agreed to discontinue the resident's PRN ondansetron and PRN Imodium, but the clinical record showed the ondansetron was not discontinued. During interview, the ADON stated the ondansetron had never been discontinued, and the DON stated the ondansetron and Imodium orders should have been discontinued based on the pharmacy recommendation and that recommendations were given to the provider for review and signature before the ADON or DON changed orders accordingly.
Duplicate Escitalopram Orders Led to Excessive Antidepressant Dosing
Penalty
Summary
The facility failed to ensure Resident 24 did not receive an excessive dosage of escitalopram when physician orders were not followed for a gradual dose reduction. Resident 24 had diagnoses of major depressive disorder, dementia, and hypertension, and a quarterly MDS dated 5/27/25 indicated severely impaired cognitive status. A pharmacy medication regimen review dated 5/7/25 documented that a gradual dose reduction had been approved for escitalopram from 10 mg to 5 mg daily, and recommended discontinuing the 10 mg order so the reduction would be followed. The clinical record showed the 5 mg escitalopram order was entered on 5/1/25 to start on 5/2/25, but the 10 mg order was not discontinued until 5/12/25. This resulted in both the 5 mg and 10 mg orders being active at the same time, and the EMAR showed both doses were administered daily from 5/2/25 through 5/12/25. The DON stated the dose decrease had been discussed at a behavior meeting and that orders were usually entered by the ADON, while the ADON reviewed pharmacy recommendations and changed orders accordingly.
Unlabeled and Improperly Stored Medications
Penalty
Summary
The facility failed to ensure a narcotic medication was appropriately identified, labeled, and stored. During an observation of the South medication cart, four white oblong pills marked M365 were found in a plastic medication sleeve labeled with Resident 32's name and a.m./p.m., but the medication name was not written on the sleeve. QMA 7 stated Resident 32 had gone out on leave of absence with her representative and had been dispensed 10 hydrocodone-acetaminophen 5/325 mg tablets for the leave. When Resident 32 returned, four pills remained in the sleeve. The facility accepted the remaining pills, completed a Controlled Substance Record report, and placed the medication into the narcotic lock box. The Controlled Substance Record report did not include the resident's identification, and the DON stated the form should have been completed accurately with the resident's name and the medication should have been destroyed. LPN 8 stated she did not place a resident identifier on the report and did not verify the medication before accepting it into the narcotic lock box. The facility also failed to ensure medications were labeled on one of two medication carts observed. On the secured unit medication cart, unlabeled medications were found in resident-specific sections, including a bottle of extra strength acetaminophen tablets and a bottle of acidophilus probiotic tablets in Resident 27's section, an unlabeled bottle of Vitamin D3 2000 IU in Resident 43's section, and an opened bottle of nystatin powder about half full without a resident identifier in the treatment drawer. QMA 17 stated the bottles should be labeled with the resident's name, expiration date, and open date, and she did not know to whom the nystatin belonged. Review of Resident 27's record showed an order for acetaminophen 325 mg, two tablets daily, but no order for acidophilus probiotic. Resident 43's record showed an order for cholecalciferol 50 mcg daily. LPN 6 and the ADON stated medications should be labeled with the resident's name, physician's name, date opened, and the actual order.
Failure to Implement and Communicate Fall Prevention Interventions for High-Risk Residents
Penalty
Summary
The facility failed to provide adequate supervision and implement fall prevention interventions for two residents with known high fall risk, resulting in repeated falls and injury. One resident, with diagnoses including dementia, repeated falls, and severe cognitive impairment, experienced multiple falls over a period of time. Despite a care plan outlining numerous fall prevention interventions such as safety checks, anti-tippers for the wheelchair, non-skid footwear, and floor mats, these interventions were inconsistently implemented. After each fall, there was a lack of immediate new interventions to prevent further incidents, and required equipment such as anti-tippers and floor mats were often missing or on backorder. The resident sustained injuries including a left ankle fracture and a gash to the face, with documentation showing that staff and interdisciplinary team meetings did not result in timely or effective changes to the care plan or its implementation. Another resident, also with severe cognitive impairment and multiple comorbidities, was similarly identified as a high fall risk. The care plan for this resident included interventions such as anti-rollbacks for the wheelchair, floor mats, and non-skid strips. However, observations revealed that these interventions were not in place at the time of survey, and the resident experienced several falls, often found on the floor without the prescribed safety equipment. Staff interviews indicated confusion about who was responsible for implementing new interventions, and communication about fall interventions was inconsistent. Maintenance was sometimes responsible for installing equipment, but there was no clear process to ensure timely implementation. Throughout the report, staff interviews and observations highlighted a lack of awareness and understanding of the residents' fall interventions among CNAs, LPNs, and other staff. Communication about changes to care plans and interventions was primarily verbal during shift changes or huddles, and documentation was not always updated promptly. The facility's failure to ensure that fall prevention interventions were consistently implemented and that staff were adequately informed and trained contributed directly to repeated falls and injuries for residents at high risk.
Inaccurate Coding of Falls on MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for two residents. For one resident, multiple progress notes documented incidents where the resident was found on the floor, including being observed sitting or lying on the floor in his room or doorway, sometimes with minor redness noted but no significant injuries. Despite these documented falls, the resident's quarterly MDS assessment indicated that there had been no falls since the prior assessment. Similarly, another resident's record showed two separate incidents where the resident was found on the floor, one time after sliding out of a wheelchair and another after attempting to stand and losing balance. Both incidents were documented in progress notes, with no significant injuries reported. However, the resident's quarterly MDS assessment also indicated no falls since the prior assessment. Interviews with the MDS Coordinator revealed that she only reviewed active risk management reports and was unaware that historical reports could be accessed, while the DON clarified that prior reports were available under a different tab. The facility did not have a specific policy for MDS assessments.
Failure to Complete Required Assessments for Respiratory Illness and Falls
Penalty
Summary
The facility failed to ensure that appropriate assessments were completed for residents with respiratory illnesses and those who experienced falls. For one resident with chronic obstructive pulmonary disease (COPD), anemia, and hypertension, there was a lack of documented respiratory assessments and vital signs after the initiation of treatment for an upper respiratory infection. Despite physician orders for antibiotics and steroids, and a care plan that included monitoring for respiratory symptoms, there were no recorded assessments or temperature readings for an extended period, contrary to facility policy and staff expectations. For two other residents with cognitive impairment and mobility issues, there were multiple unwitnessed falls documented in their records. However, neurological checklists initiated after these falls were incomplete, with missing entries, blank spaces, and no documentation of refusals or reasons for missed assessments. In some cases, the checklists were not continued as required, and there were inconsistencies and illegible entries in the documentation. Staff interviews confirmed that neurological checks should be completed after unwitnessed falls or head injuries, and any missed assessments should be explained in the progress notes, which was not done. Facility policies required ongoing assessments for both respiratory illnesses and post-fall incidents, including specific monitoring and documentation protocols. The Director of Nursing acknowledged the missing documentation and incomplete neurological check forms for the affected residents. The deficiencies were identified through record review and staff interviews, and were related to complaints received by the facility.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, homelike environment for its residents, as observed during a facility tour. The carpeting in the hallways was stained and worn, and the floors in resident rooms and bathrooms were unclean, with dark debris and brown matter around the base of toilets. The bathrooms also had yellowish-brown stains on the outside surfaces of the toilets. The Administrator acknowledged the unclean conditions and noted that housekeeping was in the process of mopping floors and cleaning rooms. However, the Administrator was unsure of the last time the floors had been stripped, and the housekeeping supervisor had only been in the position for four days. During the tour, further observations revealed sticky bathroom floors, discolored baseboards, and dried brown matter inside and around toilets. The Housekeeping Director mentioned developing a new cleaning plan for the facility. A review of the facility's deep cleaning schedule indicated that at least one room was to be deep cleaned daily, in addition to normal cleaning tasks. The facility's cleaning policies outlined procedures for cleaning resident bathrooms and rooms, but the observed conditions suggested these procedures were not being effectively implemented.
Failure to Conduct Weekly Skin Assessments for At-Risk Resident
Penalty
Summary
The facility failed to provide weekly skin assessments for a resident identified at risk for skin breakdown, as outlined in their care plan. Resident D, who has diagnoses including depression, dementia, anxiety, hypothyroidism, delusions, hypertension, insomnia, and hypoglycemia, had not received a skin assessment since March 10, 2024. The most recent quarterly Minimum Data Set (MDS) assessment indicated that the resident was at risk for pressure ulcers and required assistance for transfers and repositioning. The care plan, dated November 10, 2023, specified that the resident was at risk for skin breakdown due to incontinence and required weekly skin assessments by a nurse. However, this was not adhered to, as confirmed by the Assistant Director of Nursing and the MDS Coordinator during an interview. The facility's policy, dated May 28, 2023, also required weekly skin assessments, which were not conducted for Resident D.
Delayed Reporting of Resident Altercation
Penalty
Summary
The facility failed to report a resident-to-resident altercation to the Administrator immediately, which delayed the submission of the incident to the Indiana Department of Health. The incident involved Resident B and Resident C, both diagnosed with anxiety, depression, and dementia. On the night of the altercation, Resident B was agitated and entered Resident C's room, leading to a physical confrontation. Despite the altercation occurring on 7/9/24, the Administrator was not made aware until 7/29/24, resulting in a late report to the health department. Interviews with staff revealed a lack of immediate reporting of the incident. LPN 3, who was notified of the altercation, did not report it because she did not witness it herself. The facility's policy requires immediate reporting of such incidents to the Administrator or the person in charge. However, the delay in reporting was attributed to the staff's failure to follow the chain of command and the facility's abuse reporting policy. The Administrator only became aware of the incident when it was reported to him on 7/29/24, which was the date he used for the self-reportable submission.
Failure to Implement Individualized Dementia Care Interventions
Penalty
Summary
The facility failed to develop and implement individualized non-pharmacological interventions for residents with dementia, specifically for Resident B and Resident C. During observations, Resident B was noted to wander around the unit, intruding into other residents' spaces, and was involved in incidents of agitation and aggression. Despite these behaviors, Resident B's care plan lacked specific interventions to address his increased agitation and aggression. Resident B's clinical record indicated diagnoses of depression, dementia, anxiety, and seizures, with medication orders including sertraline, memantine, Vimpat, lorazepam, and donepezil. Behavior monitoring was ordered for intrusive wandering, anxiety, non-compliance, and pacing, yet the care plan did not reflect these needs. Resident C, diagnosed with dementia with behavioral disturbances, major depressive disorder, and anxiety, was also involved in altercations with Resident B. Despite a history of aggression towards Resident B, Resident C's care plan lacked interventions related to his behavior. His clinical record showed medication orders for sertraline, lisinopril, and donepezil, with behavior monitoring for depressive mood, anxiety, agitation, and non-compliance. However, no behaviors were documented under the behavior monitoring order for July 2024, indicating a lack of proper documentation and intervention planning. Interviews with staff revealed confusion and inconsistency in documenting and addressing the residents' behaviors. LPNs and CNAs noted Resident B's wandering and Resident C's protective behavior towards female residents, yet there was uncertainty about who was responsible for documenting behavior monitoring. The Social Services Director acknowledged that the care plans should have been updated with new interventions, and the Administrator and DON confirmed the need for summarization in progress notes and updated care plans. The facility's Behavior Management Program policy emphasized the need for identifying causal factors and appropriate interventions, which were not adequately implemented in this case.
Inadequate Supervision and Fall Prevention for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure adequate supervision to prevent falls for a cognitively impaired resident, identified as Resident C. Observations revealed that Resident C's room door was often closed or slightly ajar, which impaired the ability of staff to provide proper supervision. The resident, who was cognitively impaired and at high risk for falls, was frequently found on the floor after unwitnessed falls. Despite the resident's repeated calls for assistance, staff response was delayed, and the resident's preference for an open door was not consistently honored. Resident C's medical history included unspecified dementia, polyneuropathy, and other conditions that contributed to her high fall risk. The resident required moderate to maximum assistance for transfers and mobility and was dependent on staff for certain activities of daily living. Despite these needs, the care plan was not updated with new interventions following multiple unwitnessed falls, some of which resulted in injuries, including a head injury that required an emergency room visit. Interviews with staff indicated a lack of communication and awareness regarding the resident's fall history and the interventions in place to prevent falls. The facility's policy required specific monitoring and documentation following falls, but the post-fall monitoring reports lacked detailed information, and there was no evidence of consistent monitoring. The deficiency was further highlighted by the facility's failure to update the care plan with new interventions after each fall, as required by their policy.
Expired Insulin Administered to Resident
Penalty
Summary
The facility failed to remove and destroy expired insulin from a medication cart, affecting one resident who received medications from this cart. During an observation, it was noted that a Humalog Kwikpen, which was opened and expired, was stored in the medication cart. The insulin had been opened on May 1st and expired on May 29th, yet it was administered to the resident on multiple occasions after its expiration date. The resident, who had a diagnosis of type 2 diabetes mellitus with diabetic nephropathy, received expired insulin doses on several dates, totaling six expired doses. The facility's policy and the manufacturer's instructions both indicated that the insulin should have been discarded 28 days after opening. Interviews with the LPN and ADON revealed that the expired insulin should have been disposed of during nightly checks and prior to administration. The Third Shift Insulin Expiration Review Sheets, which were supposed to ensure expired insulins were removed, were signed daily but failed to result in the removal of the expired insulin. The DON acknowledged that signatures on these sheets should have indicated that insulins were checked for expiration, but this was not effectively done. The facility's policy on insulin pens was not adhered to, leading to the administration of expired insulin to the resident.
Incomplete Daily Nurse Staffing Data Posting
Penalty
Summary
The facility failed to ensure that the posted daily nurse staffing data was completed at the beginning of each shift and was readily available for residents and visitors. During observations on three separate days, the posted staffing information in the main lobby lacked the number of hours worked per shift for each RN, LPN, and CNA, as well as the resident census for that day. The observations revealed discrepancies in the documentation, such as missing hours and census data, which were only completed the following day after calculating hours from timecards. Interviews with facility staff, including the Business Office Manager, Medical Records personnel, and the Administrator, confirmed that the staffing postings were incomplete. The Medical Records staff indicated that the resident census and nurse staffing hours were left blank initially and filled out the next day. The Administrator stated that the daily nurse staffing sheet was filled out according to facility policy, except for the resident census and nurse staffing hours, which were completed the following day. The facility policy required that the staffing data, including the total number of hours worked and the current census, be posted daily at the beginning of each shift.
Failure to Involve Resident in Room Change Decision
Penalty
Summary
The facility failed to involve Resident B in the decision-making process prior to a room change, which led to her experiencing anxiety about her personal belongings and confusion about her new environment. Resident B, who was diagnosed with major depressive disorder and unspecified dementia, was moved to a memory care unit after her previous room allegedly flooded. However, it was later revealed that there was no actual flood, and the move was initiated without proper notification or involvement of the resident or her representative. Resident B's clinical records indicated she was moderately cognitively impaired and had a history of wandering. Despite this, the facility did not provide prior written notice of the room change to her or her representative. Interviews with staff revealed that the decision to move Resident B was made hastily, with management informing her of a non-existent flood to justify the relocation. This lack of communication and transparency contributed to Resident B's confusion and distress, as she struggled to adjust to her new surroundings and missed her previous social interactions. The facility's policy on room changes requires that residents and their responsible parties be notified and oriented to new rooms prior to any change. However, this protocol was not followed in Resident B's case. The absence of a Notification of Room Change evaluation and the failure to document the necessity of the move in her clinical record further highlight the facility's oversight in managing the transition appropriately. Interviews with various staff members, including the ADON, DON, and Social Service Director, confirmed that the move was not handled in accordance with established procedures, leading to Resident B's unnecessary distress.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 234 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Huntington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hickory Creek At Huntington | 0 mi | ★★★★★ | 6 | 0 |
| Envive Of Huntington | 0.3 mi | ★★★★★ | 10 | 0 |
| Heritage Pointe Of Huntington | 2.5 mi | ★★★★★ | 15 | 0 |
| Markle Health & Rehabilitation | 9.7 mi | ★★★★★ | 1 | 0 |
| Heritage Pointe Of Warren | 13.1 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.