Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Huntington Health And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to maintain safe, comfortable room temperatures and a clean, homelike environment. Two residents reported being cold, with one and a family member observed wearing coats in a room measured at about 63°F, while staff stated room heat could not be individually adjusted and the boiler heat had been turned off despite a policy requiring 71–81°F. Multiple rooms had sticky substances on floors, debris along walls and under beds, trash on floors, trash cans without liners, excessive dust on A/C filters, and a damaged A/C unit with rust and peeling paint. Housekeeping was reported to appear only every other day, and staff did not recall recent maintenance visits. Pantries contained dirty microwaves and a soiled refrigerator, with unclear responsibility between housekeeping and dietary for cleaning them. Persistent odors of stagnant water, body odor, and urine were noted on one unit, reflecting ongoing environmental cleanliness problems.
Surveyors found that menus, recipes, and production sheets were not followed for multiple meals, including ziti with meat sauce and baked fish, resulting in improper ingredients, preparation methods, and portion sizes for various diet types (regular, CCD, and renal). A cook prepared ziti using ground hamburger, generic tomato sauce, and cheese without consulting the approved recipe, and a server used incorrect scoop sizes so that all observed trays were mis-portioned until corrected. On another day, breaded “pub style” fish was served to all diets instead of the specified baked, un-breaded fish, and both the regional dietary manager and the dietician acknowledged that the correct fish was not used for CCD and renal diets.
Surveyors found that the facility did not consistently provide palatable meals at safe and appetizing temperatures, nor did it always follow the posted menu. During observed lunches, residents were served non-breaded pork chops instead of the advertised breaded pork chops and reported the meat was tough and hard to chew; on another day, residents reported grilled chicken was rubbery and too tough to eat after it had been baked and then held in a steamer. Resident council minutes documented repeated complaints over several months about late meals and cold food. A tray line observation showed hot foods initially within required temperature ranges, but a test tray delivered to a unit later had hot items below 135°F and a cold item above 41°F. Multiple residents reported that their food was usually cold, unpalatable, and that requests for alternative items were not consistently honored.
Respiratory equipment was not properly labeled or stored for 3 residents reviewed. An RN observed oxygen tubing without a change date, and respiratory devices including a breathing treatment machine and CPAP mask were left out of bags in a resident room. Another RN confirmed the tubing was not dated and the equipment was not stored properly, despite physician orders requiring oxygen tubing to be changed and dated.
Controlled drug documentation was inaccurate when an LPN administered Ativan to a resident but did not sign it out on the controlled drug record, leaving the count inconsistent with the actual tablets in the cart. The facility also failed to meet a resident’s pharmaceutical needs when ordered Ritalin was repeatedly unavailable from pharmacy/Omnicell, MAR entries referenced progress notes instead of routine administration, and the controlled drug record showed extra sign-outs that did not match the MAR. The DON could not explain the missing medication supply and noted the provider should have been contacted when doses were not given.
Kitchen sanitation, food storage, and staff hygiene practices were not followed. Surveyors observed food debris, sticky residue, trash, and unclean equipment throughout the food prep and storage areas, along with open or improperly stored food, missing temp logs, ice buildup, and an unclean ice machine. Staff were also observed handling trash, touching their faces and clothing, and putting on gloves without proper hand hygiene; one employee was even observed without a beard guard.
A resident with multiple sclerosis, functional quadriplegia, and contractures, whose care plan required a touch call light, repeatedly had the call light lying on the floor and out of reach. Staff, including an RN, acknowledged that the resident could not move enough to reach the device and that it should be positioned on the resident’s chest, yet observations showed the call light remained inaccessible even after staff entered the room to provide care. The DON later acknowledged that the call light lacked a clip to attach it to the bed linens and that this problem had been ongoing.
Surveyors found that the facility did not revise a resident’s oral/dental care plan after all teeth were extracted, leaving the plan to reference natural teeth in poor repair despite the change in condition. In addition, another resident reported never being involved in a care plan meeting since admission, while the MDS coordinator stated the resident declined participation but could not provide documentation of this refusal. These issues demonstrate failures to update care plans after significant changes and to document resident choice regarding participation in care planning.
A resident with severe cognitive impairment was observed sitting in a day room in a hospital gown that was not tied in the back and without socks, slippers, or shoes. The resident remained dressed that way until the UM was notified, and was later seen in the hallway wearing pajamas.
A resident who preferred showers reported that staff often gave a bed bath at the last minute instead of honoring the scheduled shower, saying they had not had time and did not want to get the resident up in the lift. Record review showed the resident’s preference for showers was documented, but most bathing entries were bed baths, and the DON confirmed the resident had mostly received bed baths.
The facility failed to provide written transfer notices for two residents who were sent to the hospital for altered mental status. No notice forms were found in the EHRs, and the Administrator stated the facility does not do that, even though the notices were to include the reason for transfer, appeal rights, how to appeal, and Ombudsman contact info.
The facility failed to update PASARRs for two residents after new mental health diagnoses were documented. One resident had MDD, anxiety, and bipolar disorder added to the record, and another resident had PTSD noted on the MDS, but the EMR showed no evidence of updated PASARRs. The admission coordinator stated updated PASARRs had been resubmitted but could not provide proof.
PASARR screening was incomplete for 3 residents because documented psychiatric diagnoses were not reflected on the PASARR forms. One resident had later-added Major Depressive Disorder, anxiety, and Bipolar Disorder without evidence of an updated PASARR, another had PTSD on the MDS without a corresponding PASARR update, and a third resident’s Bipolar disorder was not indicated on the admission PASRR. The admission coordinator stated updated PASARRs had been resubmitted but could not provide evidence they were updated.
A resident with autism had an activity care plan that was not updated or personalized despite changes in preferences and participation, and staff confirmed the plan was based on a generic library rather than individualized interventions. Another resident had an order for bilateral quarter side rails to support bed mobility, but the comprehensive care plan did not address side rail use, and the DON confirmed it was not care planned.
Activities program did not meet a resident’s needs and interests. A resident with autism was observed in bed hollering with no stimulation in the room, while records showed a preference for being active, listening to music, watching TV, and sometimes coloring. Although the resident refused most group activities, the care plan was not updated with personalized interventions, and the activity record showed only one group activity and no documented 1:1 visits.
A facility failed to carry out ordered blood glucose monitoring for a resident receiving risperidone and also failed to give a scheduled Risperdal IM injection when due; the DON confirmed both omissions. The facility also did not adequately treat another resident’s hemorrhoid pain, as the resident reported constant pain for two weeks and said medication had been applied only once before an APRN order was later obtained for rectal cream.
A resident with a fistula in his left arm reported that staff did not take his BP in that arm, yet the medical record showed multiple BP readings documented as taken in the left arm by an LPN and an RN. The facility had a PIP addressing improper BP documentation for residents with limb restrictions, and the DON acknowledged an LPN was re-educated but still documented the resident’s BP in the wrong arm shortly afterward.
Incorrect Transmission-Based Precautions for Resident with MRSA: The facility failed to maintain an effective infection prevention and control program when a resident with a history of MRSA and active abscesses was placed on EBP instead of contact precautions. The resident had multiple recent antibiotic orders for the abscess, and the IP confirmed the resident should have been on contact precautions for MRSA-related wounds.
Surveyors found that several residents were unable to access their call lights when they needed assistance, with call lights discovered on the floor or out of reach in multiple rooms. Nursing staff confirmed the inaccessibility of the call lights, and residents reported being unable to request help for personal needs as a result.
Surveyors found that the facility did not document notification to residents, their representatives, or physicians when dietary orders and care instructions were changed for multiple residents. This failure to communicate changes as required by policy was confirmed by staff and affected a significant number of individuals.
The facility did not ensure accurate MDS assessments for two residents: one with a newly identified deep tissue injury to the heel that was not documented in the MDS, and another who had a recent UTI and related treatment, which was also omitted from the MDS. These omissions resulted in incomplete and inaccurate resident assessments.
Care plans were not updated for several residents after significant changes in their care, including the addition of safety checks for a resident with a fall history, discontinuation of dialysis and initiation of comfort care for another resident, and removal of opioid interventions for a resident no longer receiving those medications. These deficiencies were confirmed through record reviews and staff interviews with the DON and nursing staff.
Surveyors found that several residents did not receive scheduled showers or shaving assistance, with documentation confirming missed care and a lack of evidence for resident refusals. Some residents, including those with cognitive impairment, expressed distress over not receiving proper bathing or grooming, and the DON was unable to provide additional documentation to support that care was offered and declined.
The facility did not follow physician orders and care plans for several residents, including repeated blood pressure measurements from a restricted arm, inadequate assistance during transfers for a resident with fall risk, incomplete safety check documentation, and improper feeding techniques for a resident with aspiration precautions. These actions resulted in deficiencies related to the provision of appropriate treatment and care.
A resident reported receiving food portions that were too small, and observation of meal service confirmed that dietary staff were using a scoop that provided only about half the required portion size for main dishes. Staff lacked guidance on correct scoop sizes, and no portion size chart was posted in the kitchen.
Surveyors found that meals served were unappetizing, lacked flavor, and were not maintained at safe temperatures. Two residents reported the food was awful and cold, and surveyors observed gray, mushy vegetables, tasteless noodles, and cold chicken. Food temperature checks confirmed items were below recommended hot holding temperatures.
The facility did not deliver meals and snacks to residents at scheduled times, with meal trays arriving late and snacks remaining undelivered despite documentation stating otherwise. Staff and resident interviews confirmed delays, and observations showed that food service preparation was not completed on time, resulting in residents waiting for meals and not receiving ordered snacks.
Surveyors found that temperature logs for food and chemical test logs for the three-compartment sink were frequently incomplete, and food was not consistently reheated to required temperatures before being served to residents. These deficiencies were confirmed by the Administrator and DON, with specific instances of food being served at temperatures below facility policy.
Surveyors identified multiple instances of inaccurate and incomplete medical record documentation, including incorrect medication diagnoses, conflicting advanced directive orders, inconsistent documentation of a fracture site, an incomplete POST form regarding medically assisted nutrition, and an incorrect transfer date. These deficiencies were confirmed through record reviews and staff interviews.
Staff did not perform or offer hand hygiene to residents immediately before meal service, despite facility policy requiring hygiene assistance prior to meals. Hand sanitizer was used by staff but not provided to residents at the appropriate time, and interviews confirmed that residents were not offered hand hygiene before eating.
A resident in the assisted dining room waited twelve minutes longer than others at their table to receive a meal, as staff did not serve all residents at the same table at the same time, contrary to facility policy for meal service.
The facility did not ensure that two residents' rights regarding advance directives were upheld. In one case, a POST form was signed by a Power of Attorney instead of a resident with capacity, and in another, there was no documented attempt to obtain a timely signature from a Power of Attorney despite verbal consent.
A resident admitted from a hospital with a diagnosis of schizophrenia and prescribed Loxapine had a preadmission PASRR that failed to identify any major mental illness. The facility's policy required review of PASRRs for residents transferred from hospitals on antipsychotic medications, but the screening was incomplete and did not accurately reflect the resident's mental health status.
Two residents did not have complete or accurate care plans in place. One resident's care plan lacked interventions and goals for issues such as dialysis refusal, hygiene care refusal, and fall risk, and included an intervention for pain medication without a current order. Another resident's care plan did not reflect the need for Enhanced Barrier Precautions as ordered by a physician for ESBL resistance.
A resident receiving fortified pudding three times daily for weight loss did not have the amount consumed documented, despite the supplement being administered as ordered. The DON confirmed the lack of documentation during the survey.
A medication pass observed by surveyors revealed a 7% medication error rate when an LPN prepared to administer an extra dose of buspirone and omitted a scheduled dose of famotidine for a resident. The errors were identified before administration, and the facility's leadership was notified.
A resident with an order for a divided plate was served a meal on a regular plate, despite documentation in the care plan and tray card specifying the need for adaptive equipment. This was confirmed by observation and review with an LPN, in violation of facility policy requiring provision of special eating utensils and equipment as ordered.
Failure to Maintain Safe Temperatures and Clean, Homelike Environment
Penalty
Summary
The deficiency involves the facility’s failure to maintain comfortable and safe room temperatures and a clean, homelike environment as required by its own policies. One resident reported feeling cold at night when the temperature dropped and the heat was off, and another resident and his wife were observed wearing coats in the room, stating the room had been cold since the previous night. Staff told them there was no way to adjust the heat individually in rooms and that nothing had been done. The Maintenance Director measured the temperature in one resident’s room at 62.8°F and the hallway at 61.5°F, acknowledging that the boiler heat had been turned off and that it would take several hours to reheat the building, despite the facility policy specifying a comfortable temperature range of 71°F to 81°F. The facility also failed to maintain cleanliness and proper housekeeping in multiple resident rooms and common areas. Surveyors observed sticky substances on floors near beds, debris along wall edges and under beds, trash on floors, and trash cans without liners in several rooms. Air conditioner filters were found with excessive dust and debris, and one air conditioner had a cracked front cover that would not stay on, with rust and peeling paint along the wall. Staff, including nurse aides, reported that housekeeping usually came every other day, that they had not seen a housekeeper on the unit that day, and that they did not recall maintenance being in the rooms since February. A revisit showed that although rooms had been swept, grey sticky buildup remained along floor edges, rooms had an odor of stagnant water, and trash and sticky substances persisted on floors. Additional observations showed that pantries and equipment were not being adequately cleaned. Microwaves in the pantry contained a large amount of food debris and sticky substances, and a refrigerator had food debris and dried white sticky liquid on shelving. There was also a case of styrofoam cups left on the floor until a CNA picked it up. When questioned, the housekeeping manager stated they believed dietary was responsible for cleaning microwaves, while the dietary manager believed their staff only cleaned refrigerators, and no clear policy could initially be located to define responsibility for cleaning these items. Persistent odors on one unit, including stagnant water, human body odor, and urine, were also noted during observations, indicating ongoing environmental cleanliness issues contrary to the facility’s cleaning and disinfecting policy.
Failure to Follow Menus, Recipes, and Production Sheets for Therapeutic Diets
Penalty
Summary
The facility failed to ensure that menus, recipes, and production sheets were followed as required to meet residents’ nutritional needs. On day 11 of the menu cycle, the planned lunch menu specified ziti with meat sauce, Italian blend vegetables, and vanilla pudding (or diet vanilla pudding for CCD diets, and a hamburger on a bun for renal diets). The recipe for ziti with meat sauce included specific ingredients such as olive oil, penne pasta, garlic, onions, carrots, crushed and diced tomatoes, seasonings, sugar, and ground beef and pork. During observation of meal preparation, a cook reported that he ground hamburger, added some seasoning, poured tomato sauce over noodles, baked it, and added cheese at the end, and acknowledged he had not reviewed or used the recipe. The dietary manager confirmed that the recipe for ziti with meat sauce had not been followed. During tray line service for that same meal, the server did not use the correct scoop sizes specified on the production sheet, which required 8 oz and 12 oz portions, resulting in all 10 observed trays being portioned incorrectly until the manager intervened. On another observed meal service day (day 17 of the menu cycle), the menu and recipes called for baked fish, with specific side items varying by diet type, and the recipe for baked fish listed pangasius fish, margarine, black pepper, and paprika. Instead, a breaded “pub style” fish was prepared for all diets. When questioned, the regional dietary manager stated that residents preferred the pub style fish and acknowledged that un-breaded fish should have been used for CCD and renal diets. The facility dietician also stated she was not aware that un-breaded fish was not being used for these diets.
Failure to Provide Palatable Meals at Safe and Appetizing Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to provide meals that were palatable, matched the posted menu, and were maintained at safe and appetizing temperatures, as required by its own food temperature policy. The policy specified that hot foods must be cooked, held, and served at or above 135°F and cold foods at or below 41°F, with temperatures taken and recorded prior to service and monitored during holding, plating, and transport. During a lunch meal observation, residents were served non-breaded pork chops instead of the herbed breaded pork chops listed on the menu, and multiple residents reported the pork chops were tough, not breaded, and difficult to chew. The dietary manager confirmed that breaded pork chops were not prepared. On another observed lunch, the menu called for grilled chicken, smashed red potatoes, and cauliflower; residents reported the chicken was rubbery and too tough to chew, and a staff member stated that after baking the chicken, it was placed in a steamer to keep it warm and acknowledged that chicken breasts sometimes become tough. Additional observations and record reviews showed ongoing issues with food temperature and timeliness of meal service. Resident council minutes over several months documented repeated complaints about meals being late and food being served cold. During a tray line observation, pre-service temperatures of hot items were within the required range, but a test tray sent to a unit and checked later showed hot foods had fallen below 135°F (chopped fish at 122°F, greens at 130°F, sweet potatoes at 128°F) and a cold item (pineapple tidbits) was at 60°F, above the 41°F limit. Multiple residents reported that food was usually cold when received, that they did not like the taste, and that when they requested alternative items, they sometimes did not receive them. These observations, interviews, and temperature checks demonstrate that the facility did not consistently maintain food palatability, adherence to the menu, or safe and appetizing temperatures during preparation, holding, and delivery.
Respiratory Equipment Not Properly Labeled or Stored
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met when the facility failed to properly label and store respiratory equipment for 3 of 4 residents reviewed for respiratory compliance. For Resident #92, an oxygen concentrator was observed in the room with oxygen tubing on the resident, but neither the tubing nor the storage bag was dated; a breathing treatment machine was lying in a Geri chair with the mask not in a bag, and a CPAP machine had its mask lying on the nightstand, also not in a bag. During interview, RN #76 stated that Respiratory Therapy takes care of labeling and changing the bags and confirmed that the oxygen tubing was not labeled and the respiratory equipment was not stored properly. For Resident #1 and Resident #14, physician orders directed that oxygen tubing be changed and dated and that the filter be cleaned weekly, but observations showed oxygen tubing with no date indicating when it was changed, while the baggie on the concentrator had a date of 03/25/26; RN #45 verified that there was no date of change on the tubing for both residents.
Controlled Drug Records Not Kept Accurate and Ordered Medication Not Available
Penalty
Summary
The facility failed to record the disposition of all controlled drugs within accepted standards of practice. During inspection of the fourth floor A cart, LPN #88 had just completed a morning medication pass when the surveyor compared the Controlled Drug Administration Record with the actual contents of the locked controlled substance drawer. For Resident #62, the record showed 16 tablets of lorazepam (Ativan) 1 mg should have remained, but only 15 tablets were present. LPN #88 stated she had administered an Ativan tablet to Resident #62 that morning but had not signed it out on the controlled drug record, and the DON confirmed controlled substances should be signed out when removed for administration. The facility also failed to provide pharmaceutical services to meet the needs of Resident #62, who had an order for Ritalin (methylphenidate) 5 mg, three tablets twice daily for restlessness related to anxiety disorder related to dementia with psychotic disturbance. The MAR showed multiple administrations marked with a notation indicating to see a progress note, and the notes repeatedly documented that the medication was awaiting pharmacy supply, unavailable in Omnicell, or on order from pharmacy. The Controlled Drug Administration Records showed Ritalin was signed out twice on two dates when the MAR reflected only one administration each day. The DON stated she could not explain why the medication was not available on those dates and stated the provider should have been contacted when the medication was not given.
Poor kitchen sanitation, food storage, and hand hygiene practices
Penalty
Summary
Food sanitation and handling practices were not followed in the kitchen and food service areas. Survey observations and record review showed multiple areas with food debris, dried sticky residue, trash, and unclean equipment, including the dish room floor, tables, coffee maker area, microwave, warming unit, mixer table, slicer table, stove, reach-in refrigerator, walk-in refrigerator, walk-in freezer, ice cream freezer, meal delivery carts, and storage racks. The kitchen entrance door was repeatedly observed propped open with a broom, and the dietary manager stated it was generally left open because the kitchen was hot. Food storage and temperature monitoring were also incomplete. The ice cream freezer was observed with melted, sticky sherbet containers, one with a torn lid exposing the product to air, and temperature logs were missing PM entries for the freezer on multiple days. Food temperature logs were also missing dinner meal temperatures on multiple dates. In the walk-in freezer, cases of food were open to air, a bag of breaded meat had no dates, and ice buildup was present on shelves, the floor, and near the fan. The ice machine had dust, rust, broken pieces, and dried residue inside and along the edges. Employee hygiene and glove use were observed to be inconsistent with policy. A dietary employee without a beard guard was observed in the kitchen. During meal preparation, staff removed gloves, touched the trash can lid, wiped their faces and hands on clothing, scratched their arms, and then attempted to put on new gloves without washing hands. One employee washed hands but did not turn off the faucet with a clean, dry cloth and then wiped hands on clothing before returning to food service tasks. Meal service was also delayed when the tray line ran out of food and extra requested items were not prepared in advance.
Inaccessible Call Light for Functionally Quadriplegic Resident
Penalty
Summary
Failure to reasonably accommodate a resident’s needs occurred when a resident who was functionally quadriplegic and diagnosed with multiple sclerosis, contractures of the right elbow and left hand, and quadriplegia had an inaccessible touch call light on multiple observations. The resident’s care plan specified the need for a touch call light due to multiple sclerosis, and nursing staff stated that the call light needed to remain on the resident’s chest because the resident could not move enough to reach out. On one observation, the call light was found lying on the floor and missing the clip needed to attach it to the bed linens, and a registered nurse confirmed that the resident could not reach it and that it should be on the resident’s chest. On a subsequent observation, the resident again did not have access to the call light, which was on the floor out of reach. The resident reported not knowing where the call light was and stated a need for a nurse. After this was reported to an LPN, a follow-up observation showed the call light still on the floor, and the resident reported that staff had been in to provide eye care but had not restored access to the call light. Another registered nurse confirmed that the call light should be positioned on the resident’s chest near the chin and verified that it was on the floor at that time. During an interview, the DON acknowledged that there had been no clip to attach the call light to the linens and that the issue had been ongoing since earlier in the week.
Failure to Revise Care Plan After Tooth Extractions and Lack of Documented Resident Participation in Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to timely develop and revise comprehensive care plans and to provide residents the opportunity to participate in care plan conferences. For one resident, the oral/dental care plan documented that the resident had natural teeth in poor repair with caries and missing teeth, with a goal to remain free from dental complications; however, the care plan was not updated after the resident had all teeth extracted on 10/08/25, as confirmed by the Care Plan/MDS Coordinator during interview. For another resident, the resident reported not having been involved in any care plan since admission, while the MDS Coordinator stated that the resident did not want to participate in care planning but was unable to provide any documentation verifying that the resident had declined involvement, and no such evidence was available before survey exit. These findings show that the facility did not ensure care plans were revised following significant changes in a resident’s dental status and did not document a resident’s refusal to participate in care planning, resulting in noncompliance with requirements that care plans be developed, reviewed, revised, and conducted with resident participation or documented refusal.
Resident Observed Undressed in Day Room
Penalty
Summary
The facility failed to ensure a resident was dressed in a manner that promoted dignity. Resident #62, who was noninterviewable and had a BIMS score of 2 indicating severe cognitive impairment, was observed sitting in a wheelchair in the fourth-floor day room wearing a hospital gown that was not tied in the back and with no socks, slippers, or shoes. The resident continued to sit in the day room in only a hospital gown until the Unit Manager was notified. Afterward, the resident was observed wearing the gown tied in the back with socks, and later was seen in the hallway in a wheelchair wearing pajamas.
Failure to Honor Resident Bathing Preference
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by supporting resident choice regarding bathing for Resident #136. During interview, the resident stated a desire to take showers but reported that on the scheduled day, staff often came at the last minute and gave a bed bath instead, saying they had not had time and did not want to get the resident up in the lift. A review of the resident’s Activities Preference Evaluation showed that choosing between a tub bath, shower, bed bath, or sponge bath was very important to the resident, and that the resident preferred showers. Review of the bathing task record from 02/02/26 to present showed four showers and the remainder documented as bed baths, with one shower refusal noted. The DON confirmed that the resident preferred showering and had mostly received bed baths.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide a written discharge/transfer notice to the resident or resident representative for two residents who were transferred to the hospital for altered mental status. For Resident #24, the electronic health record showed transfer to the hospital on [DATE], but no notice of transfer form was located in the EHR; the Administrator stated, "We don't do that" when asked to provide the written notice, which was to include the reason for transfer or discharge, appeal rights and how to appeal, and the Ombudsman's contact information. For Resident #4, the EHR showed transfer to the hospital on [DATE] due to altered mental status, and the resident did not have capacity to make his own medical decisions; a progress note stated the resident was sent out with EMS and appropriate paperwork including bed hold policy, but no written notice of transfer form was located in the EHR, and the Administrator again stated, "We don't do that."
Failure to Update PASARRs for Residents With New Mental Health Diagnoses
Penalty
Summary
The facility failed to update PASARRs for two residents with new or documented mental health diagnoses. Resident #54 had an existing PASARR dated 04/24/16 that noted the resident would be able to be discharged in 3-6 months, but the EMR showed later diagnoses of Major Depressive Disorder added on 07/11/16, Anxiety added on 02/28/19, and Bipolar Disorder added on 05/12/20, with no evidence of an updated PASARR. Resident #150 had PTSD documented on the annual MDS with an ARD of 08/06/21, but the EMR contained no evidence that the PASARR was updated. During interview, the admission coordinator stated that updated PASARRs had been resubmitted but could provide no evidence that they had been updated for either resident.
PASARRs Missing Documented Psychiatric Diagnoses
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was incomplete for 3 of 9 residents reviewed because the facility did not include documented psychiatric diagnoses on the PASARR forms. Based on record review and staff interviews, Resident #54 had a PASARR dated 04/24/16, but later diagnoses of Major Depressive Disorder, anxiety, and Bipolar Disorder were added to the medical record without evidence of an updated PASARR. The admission coordinator stated that updated PASARRs had been resubmitted but could not provide evidence that they had been updated. Resident #150 had PTSD documented on the annual MDS, but the EMR did not show that the PASARR was updated to reflect that diagnosis. Resident #6 was admitted with a diagnosis of Bipolar disorder, and the PASRR dated 01/19/26 did not indicate Bipolar disorder in section 3, question 30. During interview, the admission coordinator confirmed that Bipolar disorder was not indicated on the admission PASARR.
Care Plans Not Individualized for Activities and Side Rail Use
Penalty
Summary
Failure to develop a resident-centered care plan was identified for activities for Resident #16 and for the use of side rails for Resident #13. Resident #16 had a diagnosis of autism and was observed lying in bed hollering out with no stimulation on in the room. The initial activities assessment noted that the resident enjoyed being up and active, even if unable to meaningfully participate, and that staff would involve the resident in group activities when up to a wheelchair and provide coloring materials and fidget toys for leisure stimulation. The quarterly activity assessment stated the resident refused most group activity invitations, preferred to spend leisure time in the room resting, watching TV, listening to music at times, and sometimes enjoyed coloring. The activity care plan remained unchanged since the initial assessment and included general interventions such as inviting the resident to group activities, providing materials for self-directed activities, and visiting regularly, but no new personalized interventions were added despite changes in participation and preferences. The Activity Director confirmed the care plan had not been updated and was not personalized. Resident #13 had a physician order for bilateral one-fourth side rails up at all times while in bed to promote independence with bed mobility, with placement checks every shift. Observation showed the resident had quarter side rails on both sides of the bed. However, the comprehensive care plan did not include a focus or interventions related to side rail use for bed mobility. The DON confirmed the resident was not care planned for side rail use.
Activities Program Did Not Meet Resident Needs
Penalty
Summary
The facility failed to provide an activities program that met the needs and interests of Resident #16, a resident with a diagnosis of autism. During observation, the resident was found lying in bed and hollering out, with no stimulation on in the room. The initial activities assessment noted that the resident enjoyed being up and active, even if unable to meaningfully participate, and that staff would involve the resident in group activities when up in a wheelchair and provide coloring materials and fidget toys for leisure stimulation. The quarterly activity assessment stated the resident refused most group activity invitations, preferred to spend leisure time in the room resting, watching TV, listening to music, and sometimes coloring, and that activities staff visited regularly to ensure leisure and social needs were being met. However, the activity care plan had no added interventions since the initial assessment and included only general interventions from admission, with no personalized changes despite the resident's changed participation. The MDS indicated the resident enjoyed doing things with groups of people, but the activity participation record showed only one group activity from 02/01/26 to present and no one-to-one visits. The Activity Director confirmed the care plan had not been updated with new interventions and that the participation record did not show one-to-one visits for the resident who was not attending group activities.
Missed Blood Glucose Monitoring, Delayed Antipsychotic Injection, and Inadequate Hemorrhoid Pain Relief
Penalty
Summary
Facility failed to provide care and services in accordance with professional standards of practice for Resident #62 by not implementing a physician’s order for monthly Accu-chek blood glucose monitoring ordered due to antipsychotic use. Review of the physician’s orders showed the monthly fingerstick blood glucose monitoring order written on 11/05/24, but no Accu-chek results were documented in the record. The DON confirmed on 04/08/26 that the monitoring had not been obtained as ordered and stated the order had been entered incorrectly and did not carry over to the MAR for implementation. The facility also failed to administer Resident #62’s Risperdal injection as ordered. The physician’s order called for Risperdal 25 mg IM every 14 days for bipolar disorder with psychotic features, and the injection was due on 04/01/26. The April MAR showed a notation indicating to see a progress note, and the progress note stated the facility was waiting for the pharmacy to deliver the medication. There was no documentation that the medication was ever administered, and the DON confirmed it had not been given as scheduled. For Resident #136, the facility failed to provide medication for hemorrhoid pain relief. The resident reported constant hemorrhoid pain for two weeks, stated the pain had become more frequent, and said only one application of medication had been provided. A later nursing note documented that the APRN was contacted and an order was received for hemorrhoid rectal cream three times daily for seven days, confirming the resident had hemorrhoids.
Inaccurate Blood Pressure Documentation for Resident With Limb Restriction
Penalty
Summary
The facility failed to maintain an accurate medical record for Resident #8 in the area of blood pressure documentation. During an interview, Resident #8 stated he has a fistula in his left arm and reported that no one ever tried to take his blood pressure in that arm. A review of the resident’s blood pressure summary showed multiple blood pressures documented as taken in the left arm in 2026, including entries by an LPN and an RN. The facility’s Performance Improvement Project dated 04/02/26 addressed improper blood pressure documentation on residents with limb restrictions, and the DON acknowledged that LPN #123 had been re-educated on 04/06/26 but still documented the resident’s blood pressure in the wrong arm two days later.
Incorrect Transmission-Based Precautions for Resident with MRSA
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections. During observation, record review, and staff interview, the facility did not implement the correct transmission-based precautions for a resident being treated for an active multidrug-resistant organism. Resident #182 was observed with an enhanced barrier precautions sign in the room, indicating gowns and gloves were required for high-contact care, and the resident had a physician order for Enhanced Barrier Precautions every shift for a history of MRSA. Record review showed the resident also had multiple recent antibiotic orders for an abscess, including cephalexin, doxycycline, and ceftriaxone injections, and a physician progress note documented a history of MRSA and multiple abscess/skin infections with a new abscess to the right shin. On interview, the Infection Preventionist confirmed the resident should have been on contact precautions instead of enhanced barrier precautions because of abscesses with a history of MRSA. The Infection Preventionist also stated the facility did not have a list of all conditions requiring contact precautions, although it followed CDC guidance. The resident was later ordered for Transmission Based (Contact) Isolation for MRSA in wounds.
Call Lights Found Inaccessible for Multiple Residents
Penalty
Summary
Surveyors identified that the facility failed to ensure call lights were within reach and accessible for multiple residents. During interviews and observations, several residents reported being unable to access their call lights when they needed assistance. In one instance, a resident stated she could not ring her call light for help because she did not know where it was, and it was found lying on the floor out of her reach. Another resident expressed the need to use the bathroom but could not locate her call light, which was also found on the floor. In a shared room, a second resident's call light was discovered wrapped around a chair arm with the button on the floor, similarly out of reach. Additionally, a resident reported being wet and needing to be changed, but her call light was found on the floor, out of her reach, and her water pitcher had also been knocked onto the floor. In each case, the inaccessibility of the call lights was confirmed by nursing staff. These findings demonstrate that the facility did not reasonably accommodate the needs and preferences of the residents by ensuring that call lights were accessible at all times.
Failure to Notify Residents and Representatives of Changes in Condition or Orders
Penalty
Summary
The facility failed to ensure that residents and/or their Power of Attorney (POA) were notified of changes in condition or physician orders, as required by facility policy. Record review and staff interviews revealed that for multiple residents, including those with dietary order changes such as removal of aspiration precautions, modifications to meal assistance, and adjustments to allowed utensils or food consistencies, there was no documentation that the residents, their representatives, or their physicians were informed of these changes. The facility's policy mandates prompt notification to the resident, physician/practitioner, and representative when there is a change in the resident's medical or mental condition or status. During the survey, the state surveyor requested documentation of notifications regarding these changes for several residents. No additional documentation was provided by the facility, and corporate staff confirmed the absence of such records. The lack of documentation affected a significant number of residents, as identified in the report, and was discovered as a random opportunity for discovery during the survey.
Inaccurate MDS Assessments for Pressure Injury and UTI
Penalty
Summary
The facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for two current residents and one closed record. For one resident, medical records indicated a new suspected deep tissue injury to the left heel was present upon return from the hospital, with wound care orders initiated. However, the corresponding MDS assessment did not document the presence of any unhealed pressure ulcers or injuries, resulting in an inaccurate assessment. For another resident, medical records showed a recent hospital discharge with diagnoses including urinary tract infection (UTI), chronic suprapubic catheter, and other comorbidities. The resident's urinalysis revealed significant infection indicators, and both intravenous and oral antibiotics were administered. Despite this, the MDS assessment failed to document that the resident had a UTI in the last 30 days, leading to an incomplete and inaccurate assessment.
Failure to Revise Care Plans Following Changes in Resident Care Needs
Penalty
Summary
The facility failed to revise and update care plans for several residents following significant changes in their care needs and physician orders. For one resident with a history of multiple falls, a physician's order was issued for safety checks every 30 minutes, but this intervention was not added to the resident's care plan. Another resident who decided to discontinue dialysis and transition to comfort care only did not have their care plan updated to reflect the cessation of dialysis and the initiation of comfort care. Additionally, the care plan for this resident contained an incorrect focus area regarding diuretic use, with missing diagnosis information. A third resident's care plan continued to list opioid administration as an intervention, despite the absence of a current physician's order for opioids and confirmation from the DON that the resident was not receiving opioid medication. These findings were confirmed through record reviews and staff interviews, indicating that the care plans were not consistently revised to reflect current physician orders and the residents' actual care needs.
Failure to Provide Scheduled ADL Care for Multiple Residents
Penalty
Summary
Surveyors identified that the facility failed to provide adequate assistance with activities of daily living (ADLs), specifically bathing and shaving, for four residents. Multiple residents reported not receiving scheduled showers, with documentation confirming that showers were either missed or not provided according to the facility's schedule. For example, one resident was observed to have greasy hair and expressed distress over not receiving a scheduled shower, with records showing only one shower in the past 30 days despite a twice-weekly schedule. Another resident reported not being shaved and still had facial hair days after requesting assistance, while others stated they had only received bed baths or no bathing at all, despite their care plans indicating a preference for scheduled showers or bed baths if showers were declined. The facility's documentation often lacked evidence of resident refusals for showers or bed baths, and the Director of Nursing was unable to provide additional documentation to support that care was offered and declined. Several residents had moderately impaired cognition and were not able to make their own medical decisions, further emphasizing the need for staff to ensure ADL care was provided as scheduled or properly documented if refused. The failure to provide or document essential ADL care, such as bathing and shaving, was confirmed through resident interviews, observations, and record reviews.
Failure to Follow Physician Orders and Resident Care Plans
Penalty
Summary
The facility failed to follow physician's orders and resident care plans for multiple residents, resulting in deficiencies related to treatment and care. For one resident with end stage renal disease and a permacath in the right arm, there was a standing physician's order prohibiting blood pressure measurements or lab draws from that arm. Despite this, blood pressure readings were repeatedly documented as being taken from the restricted right arm over several months, as confirmed by the Director of Nursing. Another resident with a history of multiple falls had specific transfer assistance orders requiring two-person extensive assist during the day and three-person assist at bedtime, with non-weight bearing to the left lower extremity. Documentation showed that on numerous occasions, the resident was transferred with only one-person assistance or supervision, contrary to the physician's orders. Additionally, this same resident had an order for safety checks every 30 minutes, but there were multiple instances where documentation of these checks was incomplete or missing. A third resident, who required full assistance with feeding and had aspiration precautions in place, was observed being fed in a gerichair at a 45-degree angle instead of the required 90 degrees upright. The nursing assistant did not alternate solids and liquids as ordered, and the resident was not positioned with a pillow behind the head for chin tuck, as specified in the care plan and recent speech therapy recommendations. The nursing assistant was unaware of the specific feeding and positioning requirements, and the resident's care did not align with the prescribed aspiration precautions.
Failure to Serve Correct Food Portions During Mealtimes
Penalty
Summary
The facility failed to ensure that proper food portions were served to residents during mealtimes. During an interview, a resident reported that the food portions provided were too small. An observation of lunch service revealed that the dietary staff were using a number ten scoop, which serves approximately 3.2 ounces, to serve lasagna and other main dishes, despite the menu specifying a six-ounce portion. The dietary aide stated that he used the scoops provided without specific knowledge of portion sizes and was unaware if the correct scoop was being used for the required portion. Further review found that there was no scoop size guide posted in the kitchen, and dietary employees could not identify where they received guidance on correct portion sizes. The facility's own scoop size chart confirmed that the scoop being used was only about half the size needed to meet the menu requirements. This deficiency had the potential to affect more than a limited number of residents, given the facility's census of 184.
Unpalatable and Improperly Tempered Meals Served
Penalty
Summary
Surveyors identified a deficiency in the facility's provision of meals that were not appetizing, palatable, or served at safe and appetizing temperatures. Two residents reported dissatisfaction with the food, describing it as awful, horrible, tasteless, and cold. During a test tray evaluation, surveyors observed that the broccoli was gray, mushy, and lacked flavor, the noodles were plain and tasteless, and the chicken strips were cold. All five surveyors agreed that the meal was not palatable or appetizing. Additionally, food temperatures taken after meal service showed the chicken at 101.8°F and green beans at 113°F, both below recommended hot holding temperatures, with bread served at room temperature. These findings were based on direct observation, resident interviews, and food temperature measurements, indicating a failure to ensure meals were palatable, attractive, and served at safe and appetizing temperatures.
Failure to Provide Timely Meal and Snack Service
Penalty
Summary
The facility failed to deliver meals and snacks to residents in a timely manner and did not ensure that snacks were provided as ordered. Observations revealed that meal service was consistently delayed, with lunch trays being delivered significantly later than the scheduled times on multiple days. Dietary staff were seen preparing for meal service late, with dishware still wet from washing being used immediately for tray assembly. Staff interviews confirmed that meal service often started behind schedule, and residents were observed expressing hunger while waiting for their meals past the expected delivery times. Additionally, snacks intended for residents were found unopened and still labeled in the nourishment room refrigerator the morning after they were supposed to be delivered. Despite this, documentation indicated that the snacks had been offered and accepted by the residents, which was confirmed by both the Administrator and DON. This discrepancy between documentation and actual delivery of snacks affected multiple residents, as evidenced by the presence of their labeled, untouched snacks in the refrigerator.
Incomplete Food Safety Logs and Improper Food Reheating
Penalty
Summary
The facility failed to maintain complete temperature logs for food and the chemical test log for the three-compartment sink, as well as to reheat resident food to appropriate temperatures before consumption. Review of dietary department temperature logs revealed multiple instances between 03/01/25 and 03/19/25 where logs were either partially completed or not completed at all, with specific dates and meals missing documentation. Similarly, the chemical test log for the three-compartment sink, which is required to be completed three times daily, was found to be incomplete on numerous occasions throughout March, with several days missing all entries. These deficiencies were confirmed during interviews with the Administrator and DON. Additionally, observations and log reviews indicated that food was not being reheated to the required temperatures before being served to residents. Specific instances were documented where reheated food items, such as biscuits, macaroni and cheese, dumplings, and roasted turkey, were served at temperatures significantly below the facility's policy requirements of 165 degrees for 15 seconds or 135 degrees for ready-to-eat foods. These findings were also confirmed in interviews with facility leadership, and the recorded temperatures were acknowledged as being too low for safe consumption.
Inaccurate and Incomplete Medical Record Documentation
Penalty
Summary
The facility failed to maintain accurate and complete medical records for five residents, resulting in multiple documentation errors. For one resident, the physician's order listed Eliquis as being prescribed for hypertension, when the resident's actual diagnosis was thrombosis and embolism, and Eliquis is primarily used as a blood thinner. Another resident's transfer form contained an incorrect date, and the diagnosis for Melatonin was inaccurately documented as insomnia instead of as a supplement. Additionally, a resident's advanced directive contained conflicting information, with the order stating 'Full Code' while the directive indicated 'Do Not Attempt Resuscitation' and 'Full Treatments.' Further deficiencies included a resident's progress note documenting a fracture to the right great toe, while all other records indicated the fracture was to the left great toe. In another case, a resident with multiple sclerosis and dysphagia, who lacked decision-making capacity, had a POST form that was incomplete regarding medically assisted nutrition, as none of the available options were selected to indicate the resident's or representative's wishes. These findings were confirmed through record reviews and staff interviews.
Failure to Provide Resident Hand Hygiene Before Meals
Penalty
Summary
Facility staff failed to perform hand hygiene for residents prior to meal service, as observed by the survey team during lunch on the 300 hallway and the South/Parkway side. Although a bottle of hand sanitizer was present on the delivery carts, it was only used by staff for their own hand hygiene. No residents were observed receiving hand hygiene before their meals were delivered. Interviews with two residents confirmed that staff did not offer hand hygiene prior to meal service. An interview with an LPN Unit Manager revealed that hand sanitizer had been offered to some residents over two hours before meal service began, rather than immediately prior to meals as required. The facility's policy states that staff will assist residents with appropriate hygiene before serving meals, but this was not followed during the observed meal services.
Failure to Provide Simultaneous Meal Service in Dining Room
Penalty
Summary
The facility failed to provide a home-like dining environment and did not serve residents seated at the same table at the same time or in order, as required by its Dining Experience policy. During observation in the Third Floor Assisted Dining Room, it was noted that one resident waited twelve minutes after all other residents in the dining room had been served before receiving their lunch tray. This practice was inconsistent with the facility's stated procedure, which directs that meal service should ensure residents at the same table are served simultaneously, similar to restaurant table service.
Failure to Ensure Resident Participation and Timely Signatures in Advance Directives
Penalty
Summary
The facility failed to honor residents' rights regarding advance directives for two out of fifty residents reviewed. In one instance, a resident who had capacity had their Portable Orders for Scope of Treatment (POST) form signed by their Power of Attorney instead of by the resident themselves. This was confirmed by a corporate registered nurse. In another case, there was no documentation of attempts to obtain a timely signature from a resident's Power of Attorney for the advanced directive/POST form, despite verbal consent having been given. These findings were based on record review and staff interviews.
Incomplete PASRR Screening for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure a complete and accurate Preadmission Screening and Resident Review (PASRR) was conducted for one resident who was reviewed for PASRR compliance. The facility's policy required that PASRRs be reviewed for residents transferred from a hospital who were already receiving antipsychotic medications. In this case, the resident was admitted from a hospital with a diagnosis of schizophrenia and was prescribed the antipsychotic medication Loxapine, which had been continued from the hospital. However, the PASRR completed prior to admission did not identify the resident's diagnosis of schizophrenia or any major mental illness. This discrepancy was confirmed by the facility's business manager, who acknowledged that the PASRR was incorrect and did not reflect the resident's actual mental health diagnosis.
Failure to Develop and Implement Complete Care Plans
Penalty
Summary
The facility failed to develop and implement complete care plans for two of five residents reviewed. For one resident, the care plan included focus areas such as refusal to attend dialysis, refusal of hygiene care, and risk for falls, but lacked specific interventions or goals for these issues. Additionally, the care plan listed an intervention to administer pain medication, despite the resident not having a current physician's order for any pain medication. For another resident, there was a physician's order for Enhanced Barrier Precautions every shift due to a history of ESBL resistance, but the care plan did not reflect that the resident was on these precautions. These deficiencies were confirmed by a registered nurse during staff interviews.
Failure to Document Nutritional Supplement Intake
Penalty
Summary
The facility failed to document the amount of nutritional supplement consumed by one resident who was receiving fortified pudding three times daily for weight loss, as ordered by the physician. Although the Medication Administration Record indicated that the resident received the supplement as prescribed, there was no record of how much of the fortified pudding was actually consumed. This lack of documentation was confirmed by the Director of Nursing during the survey. No additional information was provided regarding the resident's condition or further details about the incident.
Medication Error Rate Exceeds 5% During Medication Pass
Penalty
Summary
The facility failed to maintain a medication error rate below 5% during a medication administration observation, resulting in a 7% error rate. During the observed medication pass, an LPN was seen dispensing medications to a resident using blister packaging and multi-use bottles. The LPN dispensed two buspirone 10 mg tablets into the medication cup, despite the resident's order for buspirone 10 mg twice daily. The surveyor intervened before administration, and the LPN removed the extra tablet before giving the medications to the resident. Additionally, the resident did not receive a scheduled dose of famotidine 20 mg, which was ordered twice daily for gastro-esophageal reflux disease. The errors were identified during the observation of 28 medication administrations, with two errors noted: the attempted administration of an extra buspirone tablet and the omission of famotidine. The LPN confirmed the medication orders and acknowledged the errors when questioned by the surveyor. The facility's administrator and DON were informed of the findings, and no further information was provided during the survey process.
Failure to Provide Ordered Adaptive Eating Equipment
Penalty
Summary
A deficiency was identified when a resident who had an order for a divided plate was served a lunch meal on a regular plate instead. The resident's care plan specified the use of built-up utensils and a divided plate, and the tray card also indicated the need for a divided plate. This was confirmed during observation and through review with an LPN. Facility policy requires that adaptive devices, such as special eating equipment and utensils, be provided for residents who need or request them. Despite these documented requirements, the resident did not receive the ordered adaptive equipment during the observed meal service.
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.
Illustrative
What surveyors actually found near you
We read the 80 citations issued within 25 miles in the last 12 months — including the 3 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.
Illustrative
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) |
|---|---|---|---|---|
| Heritage Center | 0.8 mi | ★★★★★ | 32 | 0 |
| St. Mary's Hospital | 2 mi | ★★★★★ | 2 | 0 |
| Madison Park Healthcare | 2.3 mi | ★★★★★ | 4 | 0 |
| Riverview Post Acute | 5.8 mi | ★★★★★ | 5 | 0 |
| Wayne Healthcare Center | 11.8 mi | ★★★★★ | 4 | 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.