Inspection Reports for Huntington Health and Rehabilitation Center
WV, 25701
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 2, 2025, found the facility not in substantial compliance with Life Safety Code requirements related to fire safety, specifically sprinkler system installation, though it met Emergency Preparedness standards. Earlier inspections showed a pattern of deficiencies involving resident care issues such as meal service, medication errors, care planning, and infection control, as well as repeated fire safety and maintenance concerns including sprinkler system deficiencies and electrical equipment testing. Several complaint investigations were substantiated over the years, highlighting problems with nutrition, abuse reporting, infection control, and supervision, while many complaints were unsubstantiated. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history shows ongoing challenges, particularly with resident care and life safety compliance, with some corrective actions noted but recurring issues persisting over time.
Deficiencies (last 26 years)
Deficiencies (over 26 years)
16.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
87% worse than West Virginia average
West Virginia average: 9 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
97% occupied
Based on a June 2025 inspection.
Occupancy over time
Inspection Report
Life Safety
Census: 181
Capacity: 186
Deficiencies: 0
Date: Jun 2, 2025
Visit Reason
A comparative Federal Monitoring Survey for Emergency Preparedness and Life Safety Code was conducted by CMS on 4/24/2025 following a West Virginia Office of Health Facility Licensure and Certification survey conducted on 3/18/2025.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid participation requirements related to Life Safety from fire and the 2012 Edition of the NFPA 101 Life Safety Code, Chapter 19 Existing Health Care Occupancies. However, the facility was found in substantial compliance with Emergency Preparedness requirements.
Report Facts
Certified beds: 186
Census: 181
Diesel generators: 2
Inspection Report
Deficiencies: 0
Date: Apr 30, 2025
Visit Reason
The inspection was conducted to review the facility's compliance with applicable Federal, State, and local Emergency Preparedness requirements.
Findings
The facility was found to be in compliance with all applicable Federal, State, and local Emergency Preparedness requirements based on review of documentation and staff interview.
Inspection Report
Life Safety
Census: 181
Capacity: 186
Deficiencies: 1
Date: Apr 24, 2025
Visit Reason
A comparative Federal Monitoring Survey for Emergency Preparedness and Life Safety Code was conducted by CMS on 4/24/25 following a West Virginia Office of Health Facility Licensure and Certification survey on 3/18/25.
Findings
The facility was found not in substantial compliance with Life Safety Code requirements, specifically failing to install the sprinkler system according to NFPA 101 and NFPA 13 standards. Emergency water was stored within 18 inches of the sprinkler deflector, a condition confirmed by the Director of Maintenance. The facility was found in substantial compliance with Emergency Preparedness requirements.
Deficiencies (1)
Failed to install the sprinkler system in accordance with NFPA 101 - 2012 edition and NFPA 13 - 2010 edition requirements; emergency water was stored within 18 inches of the sprinkler deflector.
Report Facts
Certified beds: 186
Census: 181
Diesel generators: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Confirmed sprinkler system deficiency during exit conference |
Inspection Report
Annual Inspection
Census: 184
Deficiencies: 17
Date: Mar 24, 2025
Visit Reason
An unannounced annual recertification, annual relicensure, facility reported incident (FRI) and complaint investigation survey was conducted at Huntington Health and Rehabilitation Center from March 17-24, 2025.
Findings
The facility was found deficient in multiple areas including failure to ensure proper meal portions, failure to follow physician orders, incomplete care plan revisions, call lights not within reach, delayed meal delivery and nutritional supplementation, inaccurate assessments, failure to provide appetizing meals, medication errors, incomplete PASARR documentation, failure to provide showers and ADL assistance, incomplete and inaccurate resident records, failure to complete food temperature logs, and failure to perform hand hygiene before meals.
Deficiencies (17)
Failure to ensure proper meal portions served to residents during mealtimes.
Failure to follow physician's orders for residents' arm restrictions, transfer assistance, safety checks, and aspiration precautions.
Failure to revise care plans timely for safety checks, dialysis discontinuation, opiate discontinuation, and enhanced barrier precautions.
Call lights were not within reach and accessible to residents.
Failure to ensure timely meal delivery and nutritional supplementation.
Failure to develop and implement accurate comprehensive care plans including pain management and enhanced barrier precautions.
Failure to ensure residents' rights to participate in and sign advance directives in a timely manner.
Failure to notify residents or their representatives of changes in condition or orders.
Failure to provide appetizing and palatable meals at safe temperatures.
Failure to provide adaptive eating equipment as ordered.
Medication error rate exceeded 5%, with errors in administration of buspirone and famotidine.
Failure to ensure complete and accurate PASARR documentation for residents with mental illness.
Failure to provide assistance with activities of daily living including showers, bathing, and shaving.
Failure to maintain accurate and complete resident records including diagnoses, transfer dates, and code status.
Failure to complete food temperature logs, chemical test logs for three-compartment sink, and failure to reheat food to appropriate temperatures.
Failure to perform hand hygiene for residents before meals.
Failure to provide a home-like dining environment and serve residents at the same time in assisted dining room.
Report Facts
Facility census: 184
Medication error rate: 7
Number of residents reviewed: 50
Number of closed record reviews: 3
Number of residents interviewed for nutritional supplementation: 10
Number of residents interviewed for hand hygiene: 2
Number of residents interviewed for ADL assistance: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #76 | Licensed Practical Nurse | Involved in medication administration error for Resident #17 |
| RN #44 | Registered Nurse | Confirmed errors in care plans and diagnoses |
| Director of Nursing | Confirmed multiple findings and involved in corrective actions | |
| Corporate Registered Nurse #223 | Registered Nurse | Confirmed POST form errors |
| Social Worker #1 | Social Worker | Interviewed regarding POST form signatures |
| LPNUM #49 | Licensed Practical Nurse Unit Manager | Interviewed regarding hand hygiene practices |
| Dietary Aide #176 | Dietary Aide | Observed serving incorrect meal portions |
| Dietary Aide #177 | Dietary Aide | Observed food temperature taking |
| NA #156 | Nursing Assistant | Observed feeding Resident #7 without following aspiration precautions |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 24, 2025
Visit Reason
The inspection was conducted as an annual recertification, annual relicensure, facility reported incident (FRI), and complaint investigation survey.
Findings
The facility, Huntington Health & Rehabilitation Center, was found to be in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules based on review of plans of correction and credible evidence accepted in lieu of an onsite revisit.
Inspection Report
Routine
Census: 184
Deficiencies: 2
Date: Mar 18, 2025
Visit Reason
The inspection was conducted as a routine survey to assess compliance with NFPA 101 sprinkler system installation and electrical equipment testing and maintenance requirements.
Findings
The facility failed to ensure sprinkler heads were properly installed with adequate clearance from light fixtures in multiple janitor closets and a conference room closet, potentially affecting all residents, staff, and visitors. Additionally, the facility failed to maintain required annual testing and documentation for various electrical patient-care equipment, including centrifuge machines, suction pumps, nebulizers, whirlpool tubs, and air mattress pumps.
Deficiencies (2)
Sprinkler heads located less than twelve inches from light fixtures in janitor closets and conference room closet, exceeding allowable distance per NFPA 13.
Lack of annual testing and documentation for electrical resistance, leakage current, and touch current for multiple patient-care related electrical equipment.
Report Facts
Facility census: 184
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Plant Operations Director | Discussed sprinkler system deficiencies during inspection | |
| Administrator | Interviewed residents and educated maintenance department regarding deficiencies and corrective actions | |
| Maintenance Director | Performed corrective actions including relocating light fixtures and locking out/tagging out electrical equipment pending inspection |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 12, 2023
Visit Reason
The inspection was conducted as a complaint investigation survey, with a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.
Complaint Details
The complaint investigation survey concluded on 08/03/23, and the facility was found in substantial compliance with previously cited deficiencies.
Findings
The facility, Huntington Health & Rehabilitation Center, was found to be in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules, with previously cited deficient practices corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 18, 2023
Visit Reason
Follow-up survey conducted to verify correction of previously cited deficiencies.
Findings
All previously cited tags were corrected. The facility was found in compliance with all applicable Federal, State, and local Emergency Preparedness requirements.
Inspection Report
Complaint Investigation
Census: 173
Deficiencies: 3
Date: Sep 12, 2023
Visit Reason
An unannounced complaint investigation survey was conducted at Huntington Health and Rehabilitation Center on 09/12/23 based on complaint #28846.
Complaint Details
Complaint #28846 was unsubstantiated with unrelated deficiencies cited.
Findings
The facility was found deficient for failing to prepare and serve food in accordance with professional food service safety standards, including a dietary aide not wearing a beard guard and failure to record food temperatures. Additionally, the facility failed to post correct menus on the third and fourth floors. These deficiencies had the potential to affect all residents.
Deficiencies (3)
Dietary aide was not wearing a beard guard during food preparation.
Failure to record food temperatures after the dinner meal on 09/07/23.
Incorrect lunch menus posted on the third and fourth floors.
Report Facts
Facility census: 173
Deficiency count: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Aide #12 | Dietary Aide | Named in finding for not wearing a beard guard. |
| Certified Dietary Manager | Certified Dietary Manager | Interviewed regarding food safety deficiencies and menu posting. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 12, 2023
Visit Reason
The inspection was conducted as a complaint investigation survey to review previously cited deficient practices and verify compliance.
Complaint Details
The complaint investigation survey concluded on 09/12/2023 with the facility in substantial compliance and previously cited deficient practices corrected.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules based on review of plans of correction and credible evidence accepted in lieu of an onsite revisit.
Inspection Report
Annual Inspection
Census: 185
Deficiencies: 14
Date: Aug 3, 2023
Visit Reason
An unannounced annual recertification/licensure survey and complaint survey was conducted at Huntington Health and Rehabilitation from 07/31/23 to 08/03/23 to assess compliance with federal and state regulations.
Complaint Details
Complaint #28686 substantiated with related deficiencies at F925; Complaint #28402 substantiated with related deficiencies at F677; Complaint #28185 substantiated with related deficiencies at F925; Complaint #27764 substantiated with related deficiencies at F677; Complaint #27028 substantiated with related deficiencies at F925 and F814.
Findings
The facility was found out of substantial compliance with multiple deficiencies including failure to accurately complete assessments, ensure dignified care, maintain accurate care plans, provide proper pest control, timely meal delivery, and adequate supervision to prevent accidents.
Deficiencies (14)
Failed to complete an accurate Minimum Data Set (MDS) for skin conditions for one resident.
Failed to ensure residents were provided care in a dignified manner during meals.
Failed to invite residents to care plan meetings and revise care plans appropriately for five residents.
Failed to store garbage and refuse properly to prevent rodents and pests.
Failed to ensure discharge MDS assessments accurately reflected discharge location for one resident.
Failed to maintain complete, accurate, and confidential medical records for multiple residents.
Failed to procure, store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Failed to ensure accurate PASARR screening for mental disorder and intellectual disability for two residents.
Failed to develop and implement baseline care plan for a newly admitted resident.
Failed to provide necessary assistance with activities of daily living (ADLs) for dependent residents.
Failed to develop person-centered care plans for three residents.
Failed to maintain an effective pest control program to keep the facility free of pests and rodents.
Failed to provide meals at scheduled times to ensure no more than 14 hours between evening and morning meals.
Failed to assess pressure ulcers when first identified to receive appropriate care and treatment for one resident.
Report Facts
Facility census: 185
Deficiencies cited: 13
Audit frequency: 12
Meal delivery delay: 1
Scheduled showers: 2
Bed baths: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Verified inaccuracies in MDS and care plans, confirmed deficiencies and corrective actions. | |
| Administrator | Provided policy information, acknowledged pest control issues, and reported findings to Quality Assurance Committee. | |
| Licensed Practical Nurse #43 | Removed medication found in resident room that should not have been there. | |
| MDS Coordinator #94 | Confirmed inaccuracies in MDS assessments and coordinated corrections. | |
| Dietary Manager | Confirmed meal delivery delays and scheduled snack issues. | |
| Licensed Social Worker | Involved in care plan reviews and advance directive form follow-up. | |
| Infection Preventionist | Acknowledged lice treatment documentation issues. |
Inspection Report
Routine
Census: 185
Capacity: 186
Deficiencies: 4
Date: Aug 1, 2023
Visit Reason
The inspection was a routine survey conducted to assess compliance with NFPA 101 fire safety standards and other regulatory requirements for the nursing facility.
Findings
The facility was found deficient in multiple areas related to fire safety, including hazardous area enclosures, sprinkler system installation, smoke barrier doors, and electrical equipment testing and maintenance. Specific deficiencies included missing self-closing hardware on doors, missing sprinkler heads in pipe chase rooms, excessive gaps in smoke barrier doors, and lack of annual testing documentation for medical equipment.
Deficiencies (4)
Hazardous areas not protected and separated according to NFPA 101; missing self-closing hardware on multiple doors and door damage.
Facility not protected throughout by an approved automatic sprinkler system; missing sprinkler heads in pipe chase rooms.
Smoke barrier doors exceeded allowable gap at meeting edges and were not maintained according to NFPA 101.
Electrical equipment, including fixed and portable patient-care equipment, lacked documentation of required annual testing for electrical resistance, leakage, and touch current.
Report Facts
Facility census: 185
Total licensed capacity: 186
Deficiency completion date: Sep 5, 2023
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 18, 2022
Visit Reason
The visit was conducted as a complaint investigation survey to review previously cited deficient practices and assess the facility's compliance.
Complaint Details
The complaint investigation survey concluded with the facility in substantial compliance and previously cited deficient practices addressed.
Findings
The facility, Huntington Health and Rehabilitation Center, was found to be in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules based on review of plans of correction and credible evidence accepted in lieu of an onsite revisit.
Inspection Report
Annual Inspection
Census: 164
Deficiencies: 21
Date: Jun 21, 2022
Visit Reason
An unannounced annual recertification, annual relicensure, and complaint investigation survey was conducted at Huntington Health and Rehabilitation Center from June 21-23, 2022.
Complaint Details
Complaint #26972 was unsubstantiated with no related or unrelated deficiencies cited. Complaint #26629 was substantiated with related deficiencies cited at F558, F584, F809, F919, and F921. Complaint #26541 was substantiated with related deficiencies cited at F558, F600, F677, F697, and F741.
Findings
The facility was found deficient in multiple areas including resident rights, reasonable accommodations, survey results accessibility, advance directives, infection control, medication administration, environment maintenance, involuntary seclusion, abuse reporting, nutrition, pain management, staffing, and care planning. Several complaints were substantiated with related deficiencies cited.
Deficiencies (21)
Failed to ensure privacy covers on Foley catheter bags for residents #66, #108, #90, and #164.
Failed to provide a trapeze bar for resident #164 to maintain independent functioning.
Failed to ensure survey results were readily accessible to residents and visitors.
Failed to have signed POST forms for residents #57, #110, #56, #36, and #69.
Failed to maintain a safe, clean, comfortable, and homelike environment on the fourth floor including dirty air units, damaged walls, broken tiles, and unclean shower areas.
Failed to ensure residents were free from involuntary seclusion related to inappropriate use of transmission-based precautions for COVID-19 exposure.
Failed to report allegations of neglect timely and to appropriate agencies for Resident #170 and others.
Failed to investigate allegations of abuse and neglect for Resident #170.
Failed to maintain accurate records for controlled drugs for Resident #324.
Failed to develop and implement person-centered care plans reflecting resident or responsible party preferences for residents #68 and #69.
Failed to provide grooming and oral hygiene care for residents #68 and #69.
Failed to maintain call light system in working order for Resident #82.
Failed to maintain a safe, functional, sanitary, and comfortable environment including unsecured soiled utility room, medications left at bedside, fan in hallway, and bed cords improperly placed.
Failed to provide incontinence care in accordance with professional standards for Resident #84.
Failed to maintain acceptable nutritional status and notify physician, dietician, and responsible party of significant weight loss for residents #57 and #143.
Failed to label and date enteral feeding formula and supplies for residents #85, #69, and #143.
Failed to properly manage pain for residents #324, #155, and #144 including incomplete pain assessments and failure to honor resident's choice of pain control.
Failed to maintain accurate nurse staffing postings for multiple days.
Failed to ensure sufficient staff with appropriate competencies and skills to provide care including dignity bags on catheters, accurate POST forms, proper transmission-based precautions, reporting of incidents, environmental safety, incontinent care, nutrition, enteral feeding, pain management, and infection control.
Failed to provide timely meals to Resident #164 after re-admission resulting in a delay of breakfast tray delivery.
Failed to maintain infection prevention and control program including delayed use of appropriate PPE for symptomatic staff, improper handling of wastewater leak, and failure to clean contaminated areas timely.
Report Facts
Resident census: 164
Deficiencies cited: 22
Weight loss percentage: 14
Weight loss percentage: 11.9
Controlled drug doses missing: 11
Controlled drug doses missing: 14
Narcotic discrepancy investigation date: Jul 27, 2022
Weight: 177
Weight: 159.8
Weight: 161.4
Weight: 159.8
Hours per patient day: 2.4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #33 | Licensed Practical Nurse | Named in dignity bag deficiency and trapeze bar condition |
| DON | Director of Nursing | Named in multiple findings including narcotic discrepancy and infection control |
| ADON #149 | Assistant Director of Nursing | Confirmed catheter bag touching floor and unlabeled tube feeding |
| RN #46 | Registered Nurse | Noted poor oral care for Resident #69 |
| NA #32 | Nurse Aide | Observed missed breakfast tray for Resident #164 |
| Social Worker | Handled neglect concern for Resident #170 | |
| Administrator | Named in multiple findings and interviews | |
| Unit Manager #106 | Unit Charge Nurse | Named in suction canister deficiency |
| Maintenance Technician #168 | Named in wastewater leak cleanup deficiency | |
| Maintenance Technician #171 | Named in wastewater leak cleanup deficiency | |
| Dietary Manager | Named in missed meal tray deficiency | |
| RN UM #110 | Registered Nurse Unit Manager | Named in pain management deficiency |
| NP | Nurse Practitioner | Named in pain management deficiency |
Inspection Report
Routine
Census: 164
Deficiencies: 3
Date: Jun 21, 2022
Visit Reason
The inspection was conducted as a routine survey to assess compliance with federal and state regulations related to resident rights, fire safety, electrical systems, and facility maintenance.
Findings
The facility was found to have deficiencies including obstructions in means of egress, failure to conduct annual fuel quality testing for the emergency generator, and fire doors with damaged or non-rated hardware and penetrations. These issues were acknowledged by the facility's Maintenance Director and Administrator.
Deficiencies (3)
Obstructions in the corridor by the supply room including supply carts, boxes, and a wood pallet blocking means of egress.
Failure to conduct annual fuel quality test for the emergency generator as required by NFPA 110.
Fire doors had non-rated, damaged latching hardware, multiple penetrations to frames, and missing bottom latching hardware.
Report Facts
Facility census: 164
Deficiency count: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Facilities Maintenance Director | Verified findings related to means of egress obstructions, generator fuel testing, and fire door deficiencies | |
| Administrator | Acknowledged findings at exit interview |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 23, 2022
Visit Reason
The document is a plan of correction submitted in response to previously cited deficiencies, accepted in lieu of an onsite revisit for the survey concluding on 2022-01-12.
Findings
The facility, Huntington Health and Rehabilitation Center, is in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules, with previously cited deficient practices corrected as evidenced by the accepted plan of correction.
Inspection Report
Complaint Investigation
Census: 162
Deficiencies: 2
Date: Jan 12, 2022
Visit Reason
An unannounced complaint investigation and focused infection control survey was conducted at Huntington Health and Rehabilitation Center from January 11-12, 2022, based on observations, clinical record reviews, interviews, and other documentation.
Complaint Details
Complaint #26257 was substantiated with no related or unrelated deficiencies cited.
Findings
The facility failed to provide adequate nutrition and hydration to residents receiving early morning dialysis, resulting in significant weight loss and low albumin levels for two residents (#128 and #129). Additionally, the facility failed to ensure residents received at least three meals daily with no more than 14 hours between dinner and breakfast on dialysis days.
Deficiencies (2)
Failure to provide adequate nutrition and hydration to residents on dialysis, resulting in weight loss and low albumin levels.
Failure to ensure residents received at least three meals daily with no more than 14 hours between evening meal and breakfast.
Report Facts
Facility census: 162
Weight loss Resident #128: 13.4
Weight loss Resident #129: 6
Missed dialysis treatments Resident #128: 3
Shortened dialysis treatments Resident #128: 6
Missed dialysis treatments Resident #129: 1
Shortened dialysis treatments Resident #129: 4
Audit frequency: 3
Audit duration: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #144 | Registered Nurse | Named in findings related to nutrition and meal delivery issues for Residents #128 and #129 |
| Dietary Manager | Responsible for verifying dialysis times and educating dietary staff regarding nutrition on dialysis days |
Inspection Report
Complaint Investigation
Census: 172
Deficiencies: 0
Date: Oct 6, 2021
Visit Reason
An unannounced complaint investigation and focused infection control survey was conducted at Huntington Health and Rehabilitation Center on October 4-6, 2021.
Complaint Details
Complaint #25814, #25758, #25540, and #25443 were all unsubstantiated with no related or unrelated deficiencies cited.
Findings
The allegations were unsubstantiated with no related or unrelated deficient practices identified. The facility was in substantial compliance with applicable federal and state regulations.
Report Facts
Complaint count: 4
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 10, 2021
Visit Reason
The inspection was conducted as a complaint investigation survey related to complaint reference #25116, with review of plans of correction and credible evidence accepted in lieu of an onsite revisit.
Complaint Details
Complaint reference number 25116; the facility was found in substantial compliance following review of plans of correction and credible evidence without an onsite revisit.
Findings
Huntington Health and Rehabilitation Center was found to be in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules, with previously cited deficient practices corrected.
Inspection Report
Complaint Investigation
Census: 166
Deficiencies: 3
Date: Mar 23, 2021
Visit Reason
An unannounced complaint investigation was conducted at Huntington Health and Rehabilitation Center on March 23-25, 2021, to investigate multiple complaints, including complaint #25116 which was substantiated.
Complaint Details
Complaint #25116 was substantiated with related deficiencies cited at F695 and F726, and unrelated deficiencies cited. Complaints #25054, #24580, #25148, and #25253 were unsubstantiated with no related or unrelated deficiencies cited.
Findings
The facility was found not in substantial compliance with federal and state regulations, with deficiencies related to inadequate CPR policies and training, insufficient tracheostomy care and suctioning training, and insufficient nursing staff competencies. Specific issues included lack of CPR policy, inadequate staff training on tracheostomy care, and failure to ensure adequate nursing competencies.
Deficiencies (3)
Failure to ensure a system was in place to have adequate staff properly trained and certified in CPR, including lack of CPR policy and inadequate documentation of suctioning during CPR.
Failure to ensure all staff were trained to care for residents with tracheotomy, including lack of routine re-education and absence of facility policy for tracheotomy care.
Failure to ensure sufficient nursing staff with appropriate competencies and skill sets to provide nursing and related services, specifically related to tracheostomy care and CPR competency.
Report Facts
Resident census: 166
Oxygen saturation rate: 39
Heart rate: 89
Training audit frequency: 5
Training audit duration: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pulmonary Program Manager #78 | Pulmonary Program Manager | Interviewed regarding respiratory staff presence and training; provided education and training on tracheostomy care and suctioning |
| Registered Nurse #133 | Registered Nurse | Observed performing tracheostomy care; educated on tracheostomy care on 03/24/2021 |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding policies and training; provided education packets; responsible for audits and corrective actions |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding staff education and comfort with tracheotomy care |
Inspection Report
Complaint Investigation
Census: 142
Deficiencies: 0
Date: Jan 28, 2021
Visit Reason
An unannounced complaint investigation survey was conducted at Huntington Health from January 25 to January 28, 2021.
Complaint Details
Complaints #24944, #24686, and #24506 were unsubstantiated with no related or unrelated deficiencies cited.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia Nursing Home Licensure Rules. Complaints #24944, #24686, and #24506 were unsubstantiated with no related or unrelated deficiencies cited.
Report Facts
Census: 142
Inspection Report
Abbreviated Survey
Census: 131
Deficiencies: 0
Date: Dec 2, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency on December 2, 2020.
Findings
The facility was found in compliance with infection control regulations and CMS and CDC recommended practices to prepare for COVID-19. No deficiencies were cited.
Report Facts
Census: 131
Inspection Report
Routine
Census: 136
Deficiencies: 0
Date: Nov 10, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency.
Findings
The facility was found in compliance with infection control regulations and CMS/CDC recommended practices to prepare for COVID-19. No deficient practices were identified.
Report Facts
Positive COVID cases: 81
Inspection Report
Routine
Census: 161
Deficiencies: 0
Date: Oct 22, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency on October 22, 2020.
Findings
The facility was found in compliance with infection control regulations and CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Facility census: 161
Inspection Report
Routine
Census: 156
Deficiencies: 0
Date: Oct 21, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency on October 21, 2020.
Findings
The facility was found in compliance with infection control regulations and CMS and CDC recommended practices to prepare for COVID-19. No deficient practice was noted.
Report Facts
Census: 156
Inspection Report
Abbreviated Survey
Census: 180
Deficiencies: 0
Date: Jun 22, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency on June 22, 2020.
Findings
The facility was found in compliance with infection control regulations under 42 CFR 'a7483.80 and related requirements, as well as CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Census: 180
Inspection Report
Complaint Investigation
Census: 185
Deficiencies: 0
Date: Feb 18, 2020
Visit Reason
An unannounced complaint investigation was conducted at Huntington Health and Rehabilitation Center on 02/18/20 to 02/19/20.
Complaint Details
Complaint #23870 was unsubstantiated with no related or unrelated deficiencies cited.
Findings
The allegations were unsubstantiated with no related or unrelated deficient practices identified. The facility was in substantial compliance with applicable regulations.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Nov 26, 2019
Visit Reason
The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.
Findings
The facility was found to be in substantial compliance with the applicable federal and state regulations, with previously cited deficient practices corrected as evidenced by accepted plans of correction and credible evidence in lieu of an onsite revisit.
Inspection Report
Annual Inspection
Census: 182
Deficiencies: 15
Date: Oct 10, 2019
Visit Reason
An unannounced annual re-certification and annual re-licensure survey was conducted at Huntington Health and Rehabilitation Center from 10/07/19 through 10/10/19. The survey included observations, clinical record reviews, resident, family and staff interviews, and other facility documentation.
Findings
The facility was found deficient in multiple areas including failure to provide residents with dignity and privacy, incomplete and inaccurate Physician Orders for Scope of Treatment (POST) forms, unsafe and unsanitary environment conditions, failure to ensure residents were free from chemical restraints, medication administration errors including late and incorrect dosages, failure to notify Ombudsman of hospital transfers, incomplete physician order signatures, and poor food quality and palatability.
Deficiencies (15)
Failure to treat residents with dignity and privacy during care and dining.
Incomplete and inaccurate Physician Orders for Scope of Treatment (POST) forms.
Unsafe, unsanitary environment including fluid and debris under fall mats and unclean kitchen conditions.
Failure to ensure residents were free from chemical restraints.
Medication administration errors including incorrect dosages, routes, and late administration.
Failure to notify Ombudsman of resident hospital transfers.
Failure to provide resident or representative notice of bed hold policy upon hospital transfer.
Inaccurate resident assessments, including failure to correctly code catheterization status.
Failure to revise care plans timely and accurately to reflect resident needs and incidents.
Failure to ensure medication regimen review identified irregularities and acted upon them.
Failure to ensure residents were free from unnecessary medications.
Failure to provide palatable, attractive, and timely food to residents.
Failure to maintain kitchen and beverage service in a safe and sanitary manner.
Failure to maintain complete and accurate medical records including unsigned physician orders and incomplete commercial supplement orders.
Failure to develop and implement appropriate plans of action to correct identified quality deficiencies.
Report Facts
Facility census: 182
Medication doses: 51
Medication late administration: 8
Medication audit frequency: 5
Food committee meetings: 1
Test tray audits: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named in multiple findings including medication administration and care plan deficiencies | |
| Assistant Director of Nursing | Named in medication variance and education | |
| Licensed Practical Nurse #185 | Observed medication administration without privacy | |
| Licensed Practical Nurse #84 | Reported dialysis communication book issues | |
| Dietary Manager | Named in food quality and kitchen sanitation findings | |
| Health Information Coordinator | Named in failure to notify Ombudsman and unsigned physician orders |
Inspection Report
Routine
Census: 182
Deficiencies: 1
Date: Oct 7, 2019
Visit Reason
The inspection was conducted as a routine survey to assess compliance with smoking regulations and other facility requirements.
Findings
The facility failed to ensure compliance with NFPA 101 smoking regulations, including the absence of ashtrays of noncombustible material, metal containers with self-closing covers for ashtrays, and prohibiting smoking near oxygen storage and other hazardous areas. Observations included employees smoking near oxygen storage, cigarette butts near the generator, and cigarette ash in a restroom sink.
Deficiencies (1)
Failure to ensure smoking regulation provisions included ashtrays of noncombustible material and safe design and metal containers with self-closing cover devices in all smoking areas, and failure to prohibit smoking in areas where flammable liquids, combustible gases, or oxygen is stored.
Report Facts
Facility census: 182
Frequency of audits: 5
Frequency of audits: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Environmental Services Director | Verified findings related to smoking regulation deficiencies | |
| Administrator | Acknowledged findings at exit interview | |
| Maintenance Director | Purchased cigarette receptacles and responsible for auditing smoking areas | |
| Staff Development Manager | Responsible for educating staff on smoking area policies |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 3, 2019
Visit Reason
The visit was conducted as a complaint investigation survey related to complaint reference #22133.
Complaint Details
Complaint reference #22133; the facility was found in substantial compliance with previously cited deficient practices.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules. A review of plans of correction and credible evidence was accepted in lieu of an onsite revisit, concluding the complaint investigation.
Inspection Report
Complaint Investigation
Census: 182
Deficiencies: 3
Date: Mar 11, 2019
Visit Reason
An unannounced complaint survey was conducted at Huntington Health and Rehabilitation Center from 03/11/19 to 03/13/19 based on complaints #22133 and #21667. Complaint #22133 was substantiated with related deficiencies cited, while complaint #21667 was unsubstantiated.
Complaint Details
Complaint #22133 was substantiated with related deficiencies cited at F580 and F689. Complaint #21667 was unsubstantiated with no related or unrelated deficiencies cited.
Findings
The facility was found deficient in promptly notifying a resident's physician and responsible party of significant changes in condition and new orders upon return from the hospital, affecting one resident. Additionally, the facility failed to ensure call lights were within reach for two high fall risk residents as directed by their care plans, creating an environment not free from accident hazards.
Deficiencies (3)
Failure to promptly notify resident's physician and responsible party of significant changes and new orders upon return from hospital for Resident #1.
Failure to implement individualized care plan interventions related to high fall risks; call lights not within reach for Residents #3 and #4.
Failure to provide an environment free from accident hazards; call lights not within reach for high fall risk residents #3 and #4.
Report Facts
Facility census: 182
Residents reviewed for high fall risks: 5
Residents affected by call light deficiency: 2
Residents reviewed for notification deficiency: 5
Residents affected by notification deficiency: 1
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Oct 22, 2018
Visit Reason
The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.
Findings
The facility, Huntington Health and Rehabilitation Center, was found to be in substantial compliance with the applicable federal and state regulations based on a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.
Inspection Report
Annual Inspection
Census: 176
Deficiencies: 7
Date: Aug 23, 2018
Visit Reason
An unannounced annual re-certification and annual re-licensure survey was conducted at Huntington Health and Rehabilitation Center from 08/20/18 through 08/23/18.
Findings
The survey identified multiple deficiencies including failure to provide activities based on resident preferences, inadequate monitoring and documentation of oxygen therapy, failure to maintain effective communication with dialysis center, missing laboratory tests, a significant medication error involving insulin administration to the wrong resident, and infection control lapses including improper glove use and catheter bag positioning.
Deficiencies (7)
Failed to invite and provide activities of interest for two residents (#74 and #80) based on their care plans and preferences.
Failed to ensure oxygen therapy was monitored for need and effectiveness and failed to document respiratory signs and symptoms for resident #92.
Failed to maintain effective communication with dialysis center and follow-up on blood pressure medication changes for resident #32.
Consultant pharmacist failed to identify missing HgbA1C lab test for resident #84 during monthly drug regimen review.
Administered long acting insulin to resident #120 who was not diabetic, a significant medication error.
Failed to obtain ordered laboratory tests for vitamin D for resident #93.
Failed to maintain proper infection control practices including glove use during peri care and proper positioning of catheter bag for resident #92.
Report Facts
Residents in facility: 176
Survey sample size: 28
Insulin units administered in error: 30
Blood sugar levels: 108
Blood sugar levels: 91
Oxygen flow rate: 3.5
Audit frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #4 | Nurse | Administered insulin to wrong resident #120, acknowledged error and reported it |
| Nurse #113 | Unit Manager | On duty during insulin error, notified physician and monitored resident #120 |
| Activity Director #80 | Activity Director | Verified failure to invite residents #74 and #80 to activities and failure to follow care plans |
| Licensed Practical Nurse #55 | Unit Coordinator/LPN | Confirmed oxygen flow rate discrepancy and catheter bag touching floor for resident #92 |
| Licensed Practical Nurse #75 | LPN | Cared for resident #92 and confirmed oxygen saturation checks were not documented |
| Nurse #28 | Nurse | Reported missing HgbA1C lab for resident #84 |
| Consultant Pharmacist #167 | Consultant Pharmacist | Failed to identify missing HgbA1C lab during drug regimen review |
| Certified Nursing Assistant #44 | CNA | Failed to change gloves after peri care and touched multiple surfaces with contaminated gloves |
Inspection Report
Plan of Correction
Census: 176
Deficiencies: 1
Date: Aug 21, 2018
Visit Reason
The inspection was conducted to assess compliance with NFPA 10 standards for portable fire extinguishers and other regulatory requirements.
Findings
The facility failed to maintain fire extinguishers according to NFPA 10 standards, with extinguishers installed too high above the floor, potentially affecting all residents, staff, and visitors.
Deficiencies (1)
Fire extinguishers were installed with the top greater than five feet above the floor, violating NFPA 10 standards.
Report Facts
Facility census: 176
Number of fire extinguishers installed too high: 17
Plan of correction completion date: Oct 11, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Facilities Services Director | Verified findings during inspection | |
| Administrator | Verified findings at time of exit | |
| Maintenance Director/designee | Responsible for auditing fire extinguishers weekly and monthly |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 5, 2018
Visit Reason
The inspection was conducted as a complaint investigation, with a review of plans of correction and credible evidence accepted in lieu of an onsite revisit for complaint investigation(s) concluding on 2018-04-17.
Complaint Details
Complaint References: #20116. The facility was in substantial compliance with previously cited deficient practices based on review of plans of correction and credible evidence.
Findings
The facility, Huntington Health and Rehabilitation Center, was found to be in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules, with previously cited deficient practices corrected.
Inspection Report
Complaint Investigation
Census: 178
Deficiencies: 8
Date: Apr 17, 2018
Visit Reason
An unannounced complaint survey was conducted at Huntington Health and Rehabilitation Center on April 16-17, 2018, substantiating complaint #20116 with related and unrelated deficiencies cited.
Complaint Details
Complaint #20116 was substantiated with related and unrelated deficiencies cited. The complaint investigation included observations, resident and staff interviews, and record reviews. Nurse Aides #22 and #4 were suspended pending investigation for verbal abuse of Resident #8.
Findings
The facility was found deficient in multiple areas including resident rights violations (verbal abuse, dignity issues), failure to provide reasonable accommodations, privacy breaches, unsafe and unclean environment, failure to prevent abuse and neglect, inadequate quality of care (failure to follow care plans), infection control lapses, and unsecured handrails throughout the facility.
Deficiencies (8)
Resident rights were violated by staff yelling at a resident and uncovered catheter bags affecting residents #4 and #8.
Failure to provide reasonable accommodations such as accessible over-bed light cords and bathroom access affecting residents #10 and #11.
Breach of personal privacy due to medication reorder sheets left unattended with resident information visible affecting residents #20-#25.
Unsafe, unclean, and non-homelike environment including missing personal items, debris, and paint damage affecting residents #3, #4, and #8.
Residents were subjected to verbal abuse by Nurse Aide #22, who was suspended pending investigation; facility failed to ensure freedom from abuse and neglect.
Failure to provide care according to plan including not floating heels and missing fall mats affecting residents #1, #2, #4, #7, and #9.
Infection control failures including stained linens, improper isolation precautions, and undated oxygen/nebulizer tubing affecting residents #1, #2, #5, #7, #10, and #11.
Handrails throughout multiple halls were loose and not securely affixed, posing safety risks to residents.
Report Facts
Facility census: 178
Complaint sample size: 11
Residents affected by verbal abuse: 1
Residents affected by privacy breach: 6
Residents affected by care plan noncompliance: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide #22 | Nurse Aide | Named in verbal abuse finding for yelling at Resident #8 |
| Nurse Aide #4 | Nurse Aide | Suspended pending investigation related to abuse complaint |
| District Director of Clinical Services | Interviewed regarding abuse investigation and facility deficiencies | |
| Certified Nursing Assistant #1 | CNA | Failed to follow contact isolation procedures for Resident #5 |
| Licensed Practical Nurse #10 | LPN | Interviewed about medication reorder sheet privacy breach |
| Respiratory Therapist #50 | RT | Interviewed about oxygen tubing practices |
Inspection Report
Complaint Investigation
Census: 184
Deficiencies: 0
Date: Mar 14, 2018
Visit Reason
An unannounced complaint investigation was conducted at Huntington Health and Rehabilitation Center from March 12, 2018 to March 14, 2018 for Complaint Reference #19704 and #18718.
Complaint Details
The allegations were unsubstantiated and no related or unrelated deficient practices were identified.
Findings
The allegations were unsubstantiated and no related or unrelated deficient practices were identified. The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule.
Report Facts
Sample size: 19
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Oct 31, 2017
Visit Reason
The document is a plan of correction submitted in response to previously cited deficiencies during Quality Indicator and Licensure Surveys concluding on 09/07/2017.
Findings
The facility, Huntington Health and Rehabilitation Center, is in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules. The plan of correction and credible evidence were accepted in lieu of an onsite revisit, confirming substantial compliance with previously cited deficient practices.
Deficiencies (1)
Facility must inform residents orally and in writing of their rights, rules, services, and charges, including Medicaid-related information, prior to or upon admission and during their stay.
Inspection Report
Annual Inspection
Census: 180
Deficiencies: 23
Date: Sep 7, 2017
Visit Reason
Unannounced annual Quality Indicator, State Licensure Survey and three Complaint Investigations were conducted at Huntington Health and Rehabilitation Center from 08/28/2017 through 09/07/2017.
Complaint Details
Complaint Reference #17924 was substantiated with related deficiencies cited at F312 and F323. Complaint Reference #18500 was substantiated with related deficiencies cited at F309 and F325. Complaint Reference #18642 was substantiated with related deficiencies cited at F282.
Findings
The facility had multiple deficiencies including failure to identify the appointed Health Care Surrogate for Resident #84, failure to notify resident representatives of significant changes, failure to manage residents' personal funds properly, failure to report allegations of abuse and neglect timely and appropriately, failure to ensure proper medication administration and documentation, failure to provide care consistent with care plans, failure to maintain accurate medical records, and failure to provide a safe environment.
Deficiencies (23)
Failure to identify the appointed Health Care Surrogate for Resident #84 and continued notification to the wrong representative.
Failure to notify resident representatives of significant changes in condition or medication.
Failure to properly manage residents' personal funds and notify residents when funds approach Medicaid resource limits.
Failure to convey personal funds within 30 days of resident's death.
Failure to maintain a surety bond sufficient to cover residents' personal funds.
Failure to thoroughly investigate and report allegations of abuse and neglect, including failure to check WV CARES registry prior to employment.
Failure to notify residents and/or representatives of room or roommate changes prior to the move.
Failure to develop and revise comprehensive care plans to address significant weight loss and falls.
Failure to accurately complete Minimum Data Set (MDS) assessments, including diagnosis and weight loss documentation.
Failure to provide restorative therapy as ordered.
Failure to provide oral care for a resident with dentures, including failure to recognize presence of dentures.
Failure to provide appropriate toileting services to maintain bladder continence.
Failure to ensure resident environment is free from accident hazards, including loose grab bars and improper placement of over-bed tables on fall mats.
Failure to ensure expired medication was not administered.
Failure to identify and report irregularities in medication regimen review.
Failure to obtain informed consent prior to influenza vaccination for three residents.
Failure to provide sufficient nursing staff with appropriate competencies and skills to provide care.
Failure to ensure nurse aides demonstrate competency in skills and techniques necessary to care for residents' needs.
Failure to maintain accurate and up-to-date resident medical records, including responsible party information.
Failure to provide care and services to maintain or improve residents' highest practicable physical, mental, and psychosocial well-being.
Failure to provide sufficient dietary support personnel to safely and effectively carry out food and nutrition services, resulting in delayed meal delivery.
Failure to provide a safe, functional, sanitary, and comfortable environment, including broken heating/air conditioning unit vents.
Failure to maintain a functioning call light system for a resident.
Report Facts
Resident census: 180
Survey sample: 60
Residents with personal funds near Medicaid limit: 5
Residents with falls: 7
Weight loss percent: 13.1
Weight loss percent: 10.8
Medication administration errors: 10
Nurse aides without annual performance review: 2
Nurse aides without competency documentation: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #122 | Social Worker | Named in failure to identify Health Care Surrogate for Resident #84 |
| Employee #150 | Nurse Aide | Named in failure to report abuse allegations and WV CARES registry issue |
| Employee #116 | Registered Nurse Unit Manager | Named in medication administration and oral care findings |
| Employee #176 | Licensed Practical Nurse | Named in expired medication administration finding |
| Employee #40 | Licensed Nurse | Named in restorative therapy and incontinence care findings |
| Employee #87 | Registered Nurse | Named in meal delivery and oral care findings |
| Employee #131 | Licensed Practical Nurse | Named in meal delivery and nurse aide competency findings |
| Employee #183 | Human Resources Manager | Named in WV CARES registry issue |
| Employee #99 | Nurse Aide | Named in nurse aide competency findings |
| Employee #74 | Nurse Aide | Named in nurse aide competency findings |
| Employee #56 | Nurse Aide | Named in nurse aide competency findings |
| Employee #131 | Nurse Aide | Named in nurse aide competency findings |
Inspection Report
Annual Inspection
Census: 180
Deficiencies: 3
Date: Aug 29, 2017
Visit Reason
The inspection was conducted as an annual survey to assess compliance with NFPA 101 fire drills, electrical systems maintenance and testing, and electrical equipment testing and maintenance standards.
Findings
The facility failed to conduct fire drills at varied times as required by NFPA 101, failed to maintain electrical systems and conduct electrical safety checks on receptacles at patient bed locations, and failed to maintain patient-care related electrical equipment (PCREE) in accordance with NFPA 99 standards. These deficiencies were acknowledged by the Maintenance Supervisor and Administrator and corrective plans were submitted.
Deficiencies (3)
Failed to conduct fire drills at unexpected times at least quarterly on each shift as required by NFPA 101.
Failed to maintain electrical systems and conduct electrical safety checks of receptacles at patient bed locations in accordance with NFPA 99.
Failed to maintain patient-care related electrical equipment (PCREE) and conduct electrical safety checks on resident beds in accordance with NFPA 99.
Report Facts
Facility census: 180
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Discussed deficiencies related to fire drills and electrical safety | |
| Administrator | Discussed deficiencies and agreed corrections were needed | |
| Maintenance Director | Maintenance Director | Provided in-service education and responsible for audits and reporting to QAPI committee |
Inspection Report
Complaint Investigation
Census: 171
Deficiencies: 0
Date: Apr 12, 2017
Visit Reason
An unannounced complaint investigation was conducted at Huntington Health and Rehabilitation Center from 04/10/17 to 04/12/17 for Complaint Reference #17356 and #17523.
Complaint Details
The allegations were unsubstantiated and no related or unrelated deficient practices were identified.
Findings
The allegations were unsubstantiated and no related or unrelated deficient practices were identified. The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule.
Report Facts
Sample size: 6
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 10, 2017
Visit Reason
The inspection was conducted as a complaint investigation based on complaint reference #16793, with review of plans of correction and credible evidence accepted in lieu of an onsite revisit.
Complaint Details
Complaint investigation concluded on 12/20/16 with substantial compliance and acceptance of plans of correction in lieu of onsite revisit. Complaint reference #16793.
Findings
The facility, Huntington Health and Rehabilitation Center, was found to be in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules, with previously cited deficient practices corrected.
Inspection Report
Complaint Investigation
Census: 183
Deficiencies: 3
Date: Dec 18, 2016
Visit Reason
An unannounced off hours complaint survey was conducted at Huntington Health and Rehabilitation Center from December 18 to December 20, 2016, based on complaint #16793 which was substantiated with related deficiencies cited.
Complaint Details
Complaint #16793 was substantiated with related deficiencies cited based on observations, clinical record reviews, resident, family, and staff interviews, and other facility documentation.
Findings
The facility failed to consistently follow physician orders for administering PRN anti-hypertensive medication for Resident #81, failed to provide non-pharmacological interventions before administering PRN anti-psychotic medications for Residents #81, #149, and #72, and the physician failed to act upon pharmacist recommendations regarding unnecessary medications for Resident #81.
Deficiencies (3)
Facility failed to consistently administer Hydralazine 10 mg PRN for systolic blood pressure greater than 150 for Resident #81 as ordered by the physician.
Facility failed to provide non-pharmacological interventions before administering PRN anti-psychotic medications for Residents #81, #149, and #72.
Physician failed to act upon pharmacist recommendations regarding unnecessary medications for Resident #81, specifically regarding the use of Haldol.
Report Facts
Facility census: 183
Complaint sample size: 11
Days medication not administered as ordered: 20
Dates PRN Haldol administered: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed medication administration issues and lack of documentation of non-pharmacological interventions during interviews | |
| Nurse Educator | Initiated in-service education for licensed nursing staff on medication administration and non-pharmacological interventions | |
| Medical Director | Received education regarding unnecessary medications and medication regimen review regulations |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 28, 2016
Visit Reason
The inspection was conducted as a complaint investigation related to complaint reference #16278, with a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.
Complaint Details
Complaint investigation concluded on 2016-08-31 with substantial compliance and acceptance of plans of correction in lieu of onsite revisit. Complaint reference number #16278.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules, with previously cited deficient practices corrected as of the complaint investigation concluding on 2016-08-31.
Inspection Report
Complaint Investigation
Census: 171
Deficiencies: 2
Date: Aug 29, 2016
Visit Reason
An unannounced complaint survey was conducted at Huntington Health and Rehabilitation Center from August 29, 2016 to August 31, 2016 in response to Complaint #16278, which was found unsubstantiated with unrelated deficiencies cited.
Complaint Details
Complaint #16278 was unsubstantiated with unrelated deficiencies cited. The complaint sample consisted of 5 residents.
Findings
The facility was found to have unsecured cleaning supplies in the 400 Hall Shower Room, failure to follow proper hand hygiene during medication administration by a licensed practical nurse, and inadequate infection control practices. The facility implemented corrective actions including securing chemicals, staff education, and increased monitoring.
Deficiencies (2)
Facility failed to provide an environment free from accident hazards due to unsecured cleaning supplies in the 400 Hall Shower Room.
Failure to maintain infection control by not washing or sanitizing hands during medication administration affecting four residents.
Report Facts
Facility census: 171
Complaint sample size: 5
Residents affected by hand hygiene deficiency: 4
Frequency of audits/checks for unsecured chemicals: 14
Frequency of medication pass observations: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #134 | Licensed Practical Nurse | Named in hand hygiene deficiency during medication administration |
| 4th Floor Unit Manager | Registered Nurse | Interviewed regarding unsecured cleaning supplies in shower room |
| Director of Nursing | Interviewed regarding chemical storage and hand hygiene policies |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 21, 2016
Visit Reason
The document is a plan of correction related to a Quality Indicator and Licensure Survey concluding on 06/17/16, accepted in lieu of an onsite revisit.
Findings
The facility, Huntington Health and Rehabilitation Center, is in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules, with previously cited deficient practices corrected as evidenced by the accepted plan of correction.
Report Facts
Survey completion date: Jul 21, 2016
Previous survey date: Jun 17, 2016
Inspection Report
Annual Inspection
Census: 179
Deficiencies: 5
Date: Jun 14, 2016
Visit Reason
The inspection was conducted as a routine annual survey to assess compliance with NFPA 101 Life Safety Code standards and other regulatory requirements at Huntington Health and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas related to fire safety and electrical code compliance, including corridor doors not resisting smoke passage, hazardous storage area doors not latching, fire drills not conducted at varied times, sprinkler system maintenance issues, and electrical wiring deficiencies.
Deficiencies (5)
Facility failed to protect corridor openings with doors capable of resisting the passage of smoke; corridor doors had gaps and did not close or latch properly.
Hazardous storage area door near kitchen did not close and latch.
Fire drills were conducted at the same times and not varied as required.
Automatic sprinkler systems were not continuously maintained in reliable operating condition; wiring and tubing draped over sprinkler piping.
Electrical wiring and equipment deficiencies including missing cover plate on junction box and unsecured electrical panel.
Report Facts
Facility census: 179
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Discussed deficiencies related to doors, fire drills, sprinkler system, and electrical wiring | |
| Administrative Director | Discussed deficiencies related to doors, fire drills, sprinkler system, and electrical wiring |
Inspection Report
Annual Inspection
Census: 179
Deficiencies: 1
Date: Jun 13, 2016
Visit Reason
Unannounced annual Quality Indicator and State Licensure Surveys were conducted at Huntington Health and Rehabilitation Center from June 13, 2016 through June 15, 2016.
Findings
The facility failed to promote care for residents in a manner that maintains and enhances each resident's dignity, specifically by staff referring to residents requiring assistance with eating as 'feeders' and residents drinking milk directly from cardboard cartons without straws.
Deficiencies (1)
Facility failed to promote dignity and respect by staff referring to residents who require assistance with eating as 'feeders' and residents drinking milk directly from cardboard cartons without straws.
Report Facts
Census: 179
Survey sample residents: 37
Residents observed in dining room: 9
Residents served milk in cardboard cartons: 5
Residents eating in room served milk in cartons: 8
Residents served milk with one straw: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #90 | Licensed Practical Nurse | Interviewed about straw usage and meal service |
| Nurse Aide #101 | Nurse Aide | Referred to residents requiring assistance as 'feeders' during meal service |
| Nurse Aide #106 | Nurse Aide | Referred to residents requiring assistance as 'feeders' during meal service |
| Director of Nursing #100 | Director of Nursing | Verified staff should not address residents as 'feeders' and should provide straws for milk |
Inspection Report
Complaint Investigation
Census: 185
Deficiencies: 0
Date: Mar 30, 2016
Visit Reason
An unannounced complaint investigation was conducted March 29, 2016 to March 30, 2016 at Huntington Health and Rehabilitation Center for Complaint Reference 15310.
Complaint Details
Complaint Reference 15310 was investigated and found unsubstantiated with no deficient practices identified.
Findings
The allegations were unsubstantiated and no related or unrelated deficient practices were identified. The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule.
Report Facts
Sample size: 6
Inspection Report
Complaint Investigation
Census: 171
Deficiencies: 0
Date: Jul 15, 2015
Visit Reason
Unannounced complaint investigations were conducted at Huntington Health and Rehabilitation Center from July 13, 2015 to July 15, 2015 for Complaint References 13916 and 13970.
Complaint Details
The allegations were unsubstantiated and no related or unrelated deficient practices were identified.
Findings
The allegations were unsubstantiated and no related or unrelated deficient practices were identified. The facility was in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.
Report Facts
Sample size: 11
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 17, 2015
Visit Reason
Review of plans of correction and credible evidence was accepted in lieu of an onsite revisit for the Quality Indicator and Licensure Surveys concluding on 05/12/15.
Findings
Huntington Health and Rehabilitation Center is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule. The facility is in substantial compliance with the previously cited deficient practices.
Inspection Report
Life Safety
Census: 181
Deficiencies: 3
Date: Apr 21, 2015
Visit Reason
The inspection was conducted to evaluate compliance with NFPA 101 Life Safety Code standards, including fire alarm system testing, sprinkler system maintenance, and emergency generator maintenance.
Findings
The facility failed to inspect and test all components of the fire alarm system annually, maintain sprinkler system gauges according to NFPA 25 standards, and properly maintain the emergency generator battery by testing the specific gravity of electrolyte fluid weekly. These deficiencies were confirmed through document review, observation, and staff interviews.
Deficiencies (3)
Failed to inspect and test all components of the facility fire alarm system annually in accordance with NFPA 72.
Failed to maintain sprinkler system gauges in accordance with NFPA 25, including lack of evidence of testing or replacement.
Failed to maintain the emergency generator by not testing and recording the specific gravity of electrolyte fluid in the generator's batteries weekly as required by NFPA 110.
Report Facts
Facility census: 181
Smoke detectors: 64
Smoke detectors tested on 01/22/15: 30
Smoke detectors tested on 10/29/14: 31
Smoke detectors tested on 07/29/14: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Facility maintenance director | Discussed findings related to fire alarm system, sprinkler gauges, and generator maintenance |
Inspection Report
Annual Inspection
Census: 181
Deficiencies: 7
Date: Apr 20, 2015
Visit Reason
Unannounced annual Quality Indicator Survey, State Licensure Survey, and Complaint Investigation #12980 were conducted from April 20, 2015 through April 28, 2015, with an extended survey completed on May 12, 2015. Complaint #12980 was unsubstantiated with no related deficiencies.
Complaint Details
Complaint #12980 was investigated and found to be unsubstantiated with no related deficiencies.
Findings
The facility had multiple deficiencies including failure to maintain effective housekeeping and maintenance services, inaccurate resident assessments, failure to ensure employee background checks via fingerprinting, inadequate treatment and prevention of pressure sores, unsafe environment hazards such as broken elevator panels and improper use of cleaning chemicals, expired medications not discarded, and unlocked medication carts posing safety risks.
Deficiencies (7)
Failed to provide effective housekeeping and maintenance services for one of 37 resident rooms; cove molding pulled away from wall and broken electrical outlet cover in Room 45.
Failed to ensure one of 27 residents reviewed had an accurate Minimum Data Set (MDS) assessment; hospice care not identified for Resident #225.
Failed to ensure facility did not employ individuals without proper fingerprint-based criminal background checks; one employee (#42) worked 29 days before fingerprint results were obtained.
Failed to prevent development and provide treatment for pressure sores; Resident #156 had untreated wounds and pressure ulcer mis-staged, turning and repositioning care not consistently provided.
Failed to maintain a resident environment free from accident hazards; broken elevator panels with sharp jagged edges and unsafe use of bleach-based cleaning product on urine areas.
Failed to dispose of expired medications and ointments; expired petroleum jelly ointment and Heparin lock flush solution found in medication storage rooms.
Failed to ensure safe medication storage; medication cart found unlocked, unattended and out of nurse's sight.
Report Facts
Facility census: 181
Survey dates: 2015-04-20 to 2015-04-28
Extended survey completion date: May 12, 2015
Residents in survey sample: 27
Employee files reviewed: 5
Days employee #42 worked before fingerprint results: 29
Packets of expired petroleum jelly ointment: 45
Expired Heparin syringes: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #42 | Employee who worked 29 days before fingerprint background check results were obtained; facility failed to ensure proper background check. | |
| Resident Care Management Director #169 | Confirmed transcription error on MDS assessment for Resident #225 regarding hospice care. | |
| Maintenance Supervisor #157 | Verified repairs needed in Room 45 for broken molding and electrical outlet cover. | |
| LPN #10 | Wound Care Nurse | Acknowledged failure to identify, assess, and treat wounds on Resident #156. |
| Nurse Aide #187 | Interviewed regarding turning and positioning practices related to pressure ulcer prevention. | |
| Nurse Aide #177 | Provided care to Resident #156 and described pressure ulcer prevention measures. | |
| Housekeeping Staff #186 | Educated on safe use of cleaning products and acknowledged use of bleach-based Tilex on urine areas. | |
| Unit Manager #22 | Confirmed expired petroleum jelly ointment found in medication storage room. | |
| Unit Manager #105 | Confirmed expired Heparin syringes found in medication storage room. | |
| Unit Coordinator Registered Nurse #172 | Locked medication cart found unattended and unlocked in hallway. | |
| LPN #29 | Left medication cart unlocked and unattended; received final warning. | |
| Director of Nursing | Provided facility guidelines and confirmed expectations for medication storage and expired medication disposal. |
Inspection Report
Complaint Investigation
Census: 181
Deficiencies: 1
Date: Nov 11, 2014
Visit Reason
An unannounced complaint survey was conducted at Huntington Health and Rehabilitation Center from November 11 to November 13, 2014, based on complaint #12187 which was substantiated with unrelated deficiencies cited.
Complaint Details
Complaint #12187 was substantiated with unrelated deficiencies cited. The complaint sample consisted of 11 residents.
Findings
The facility failed to accurately assess a resident's functional status on the quarterly minimum data set (MDS) assessment, incorrectly coding the resident as having no impairment despite observed physical limitations. This affected one of twelve sampled resident assessments reviewed.
Deficiencies (1)
Failure to accurately assess the resident on the quarterly MDS assessment, incorrectly coding functional limitations in range of motion as no impairment.
Report Facts
Facility census: 181
Sample size: 12
Complaint sample size: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #109 | Nurse Aide | Reported resident's decreased range of motion and need for assistance |
| Assistant Director of Nursing | Assistant Director of Nursing | Confirmed resident's physical limitations and discussed MDS assessment discrepancies |
| Employee #20 | MDS Coordinator | Acknowledged resident's functional status had not changed and expressed uncertainty about coding instructions |
| MDS Nurse | MDS Nurse | Reviewed RAI instructions and agreed the MDS did not accurately reflect resident's functional status |
Inspection Report
Complaint Investigation
Census: 183
Deficiencies: 0
Date: Oct 1, 2014
Visit Reason
An unannounced complaint investigation was conducted from 09/29/14 to 10/01/14 at Huntington Health and Rehabilitation Center for Complaint Reference 12034.
Complaint Details
The allegations were unsubstantiated and no related or unrelated deficient practices were identified.
Findings
The allegations were unsubstantiated and no related or unrelated deficient practices were identified. The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule.
Report Facts
Sample size: 12
Inspection Report
Complaint Investigation
Census: 170
Deficiencies: 0
Date: Aug 20, 2014
Visit Reason
An unannounced complaint investigation was conducted from 08/18/14 to 08/20/14 at Huntington Health and Rehabilitation Center for Complaint Reference 11708.
Complaint Details
The allegations were unsubstantiated and no related or unrelated deficient practices were identified.
Findings
The allegations were unsubstantiated and no related or unrelated deficient practices were identified. The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule.
Report Facts
Sample size: 10
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 9, 2014
Visit Reason
The inspection was conducted as a complaint investigation, with a review of plans of correction and credible evidence accepted in lieu of an onsite revisit for the complaint investigation concluding on 2014-05-14.
Complaint Details
Complaint Reference: 10815. The facility was in substantial compliance with previously cited deficient practices based on review of plans of correction and credible evidence accepted instead of an onsite revisit.
Findings
The facility, Huntington Health and Rehabilitation Center, was found to be in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules, with previously cited deficient practices corrected.
Inspection Report
Complaint Investigation
Census: 179
Deficiencies: 0
Date: May 22, 2014
Visit Reason
An unannounced complaint investigation (#11316) was conducted at Huntington Health and Rehab from 05/19/14 to 05/22/14.
Complaint Details
Complaint investigation #11316 was unsubstantiated with no related or unrelated deficient practices identified.
Findings
The allegations were unsubstantiated and no related or unrelated deficient practices were identified. The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule.
Report Facts
Sample size: 8
Inspection Report
Complaint Investigation
Census: 182
Deficiencies: 1
Date: Apr 12, 2014
Visit Reason
An unannounced complaint investigation (#10816) was conducted at Huntington Health and Rehabilitation Center from 04/12/14 to 04/14/14 to investigate a complaint.
Complaint Details
The complaint investigation was unsubstantiated with an unrelated citation issued for medication timing errors.
Findings
The complaint was unsubstantiated but an unrelated medication timing deficiency was found. The facility failed to ensure medications ordered to be administered before meals were given after breakfast, resulting in a medication error rate of 7.6%.
Deficiencies (1)
Medications ordered to be administered before meals, on an empty stomach, were administered after breakfast for two residents (#89 and #54).
Report Facts
Facility census: 182
Survey dates: Survey conducted from 2014-04-12 to 2014-04-14
Medication error rate: 7.6
Survey sample size: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse identified as Employee #18 who administered medications incorrectly |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 18, 2013
Visit Reason
The inspection was conducted as a complaint investigation based on two complaint references: 9076 / 13266 and 9190 / 13284.
Complaint Details
Complaint Reference: 9076 / 13266 and Complaint Reference: 9190 / 13284 were both unsubstantiated with no related or unrelated citations.
Findings
Both complaint investigations were unsubstantiated with no related or unrelated citations found during the inspection.
Report Facts
Complaint Reference: 9076
Complaint Reference: 13266
Complaint Reference: 9190
Complaint Reference: 13284
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 6, 2013
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance for Huntington Health and Rehabilitation Center.
Findings
The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as well as providing written descriptions of legal rights.
Deficiencies (1)
Facility failed to inform residents orally and in writing of their rights, rules, services, and charges as required.
Report Facts
Deficiency ID: 156
Inspection Report
Annual Inspection
Census: 171
Deficiencies: 3
Date: Oct 31, 2013
Visit Reason
The inspection was conducted as part of a Quality Indicator and Licensure Survey to assess compliance with federal and state regulations for nursing facilities.
Findings
The facility was found to have deficiencies related to food storage and sanitation practices in the dietary department, and failure to act on pharmacist recommendations for medication dose reduction for one resident. These issues had the potential to affect resident safety and care.
Deficiencies (3)
Facility staff did not store all foods under sanitary conditions; items were removed from original containers without labeling the date opened, and incorrect test strips were used to check sanitizer concentration in the three-compartment sink.
Dietary staff stacked wet dishware, creating a moist environment conducive to bacterial growth.
Facility failed to ensure pharmacy recommendations for gradual dose reduction of Risperdal for Resident #254 were acted upon in a timely manner.
Report Facts
Census: 171
Residents reviewed for unnecessary medications: 5
Resident identifier: 254
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #186 | Dietary Supervisor | Named in findings related to food storage and sanitation |
| Director of Nursing | Interviewed regarding pharmacy recommendations and medication dose reduction | |
| Medical Director | Accepted pharmacist recommendation but initially failed to write medication order |
Inspection Report
Life Safety
Deficiencies: 1
Date: Oct 1, 2013
Visit Reason
The inspection was conducted to assess compliance with the NFPA 101 Life Safety Code Standard, specifically regarding electrical wiring and equipment in the facility.
Findings
The facility was found to be non-compliant with NFPA 70 Article 517 and Article 400.8 of the National Electric Code due to the use of relocatable power taps and flexible cords in patient rooms on the third floor to power TV sets mounted high on the walls.
Deficiencies (1)
Use of relocatable power taps and flexible cords in patient rooms is in violation of NFPA 70 Article 517 and Article 400.8 of the National Electric Code.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Discussed findings regarding non-compliance with the Maintenance Director. | |
| Maintenance Director | Discussed findings regarding non-compliance with the Administrator. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 19, 2013
Visit Reason
The inspection was conducted as a complaint investigation based on complaint reference 13225 / 8795.
Complaint Details
Complaint reference 13225 / 8795 was investigated and found to be unsubstantiated with no citations.
Findings
The complaint was found to be unsubstantiated and no citations were issued.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 23, 2013
Visit Reason
The inspection was conducted as a complaint investigation referenced by complaint number 13117 / 8157.
Complaint Details
Complaint Reference: 13117 / 8157. Unsubstantiated complaint record with no citations.
Findings
The complaint was found to be unsubstantiated with no citations issued.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: May 22, 2013
Visit Reason
This document is a Plan of Correction related to deficiencies identified during a prior inspection of Huntington Health and Rehabilitation Center.
Findings
The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b)(5)-(10).
Deficiencies (1)
Failure to inform residents orally and in writing of their rights, rules, services, and charges in a language they understand.
Inspection Report
Complaint Investigation
Census: 181
Deficiencies: 4
Date: Apr 10, 2013
Visit Reason
The inspection was conducted as a substantiated complaint investigation related to resident discharge practices, notice requirements, equal practices regardless of payment source, and clinical record completeness.
Complaint Details
Complaint Reference: 13066 / 7859. The complaint was substantiated with related deficiencies cited.
Findings
The facility failed to permit a resident to remain when discharge requirements were not met, failed to provide proper written discharge notices including appeal rights, discharged residents based on payment source, and did not maintain complete and accurate clinical records for a resident exhibiting behavioral changes.
Deficiencies (4)
Failed to permit a resident to remain in the facility when discharge requirements were not met.
Failed to provide proper written notice of discharge including required information and appeal rights.
Failed to maintain identical policies and practices regarding transfer, discharge, and provision of services regardless of payment source.
Failed to maintain complete, accurate, and accessible clinical records reflecting resident's condition and behaviors.
Report Facts
Facility Census: 181
Sampled discharged residents: 5
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #134 | Social Worker | Interviewed regarding resident discharge and transfer practices |
| Director of Nursing | Interviewed regarding discharge notice content and clinical record completeness |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 19, 2013
Visit Reason
The inspection was conducted in response to three complaint references: 7585 / 13017, 7666 / 13035, and 7704 / 13044.
Complaint Details
Complaint references 7585 / 13017, 7666 / 13035, and 7704 / 13044 were investigated and found to be unsubstantiated with no deficiencies.
Findings
All three complaints were found to be unsubstantiated with no deficiencies identified during the investigation.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 30, 2013
Visit Reason
This document is a Plan of Correction submitted by Huntington Health and Rehabilitation Center in response to deficiencies cited during a prior inspection.
Findings
The document includes a summary statement of deficiencies related to resident rights and notification requirements, specifically regarding informing residents of their rights, services, charges, and Medicaid benefits.
Deficiencies (1)
Failure to inform residents both orally and in writing of their rights, rules, services, and charges as required by regulation 483.10(b)(5)-(10), 483.10(b)(1).
Report Facts
Deficiency ID: 156
Inspection Report
Complaint Investigation
Census: 180
Deficiencies: 2
Date: Dec 12, 2012
Visit Reason
The inspection was conducted in response to a complaint regarding the facility's failure to allow Resident #108's children to visit him due to concerns about aggressive behavior and an ongoing adult protective services investigation.
Complaint Details
Complaint Reference: 7445 / 12271. The complaint was substantiated with citations related to visitation rights and PASRR requirements.
Findings
The facility failed to ensure Resident #108 was allowed visits from family members, citing aggressive behavior and an ongoing financial exploitation investigation. The facility also failed to update the resident's preadmission screening (PAS) assessment in a timely manner to determine continued eligibility for nursing home care.
Deficiencies (2)
Facility failed to allow Resident #108's children to visit due to aggressive behavior and ongoing adult protective services investigation.
Facility failed to ensure a resident's preadmission screening (PAS) was updated timely for continued nursing home care.
Report Facts
Facility census: 180
Resident count: 9
Complaint date: Sep 11, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker | Employee #138 who provided information about guardianship and APS investigation | |
| Director of Nursing (DON) | Employee #66 who provided information about complaint investigation and PAS update | |
| Administrator | Provided information about visitation restrictions and concerns about children's behavior | |
| Adult Protective Service Supervisor | Provided email stating APS did not prevent visitation |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 7, 2012
Visit Reason
The inspection was conducted as a complaint investigation based on complaint reference 12233 / 7375.
Complaint Details
Complaint reference 12233 / 7375 was unsubstantiated with no citations.
Findings
The complaint was unsubstantiated and no citations were issued during the investigation.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 23, 2012
Visit Reason
The document is a statement of deficiencies and plan of correction related to regulatory compliance for Huntington Health and Rehabilitation Center.
Findings
The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b).
Deficiencies (1)
Failure to properly inform residents of their rights, rules, services, and charges as required by regulation 483.10(b)(5)-(10), 483.10(b)(1).
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 12, 2012
Visit Reason
The inspection was conducted as a complaint investigation based on two complaint references: 12147 / 7190 and 12153 / 7198.
Complaint Details
Complaint Reference: 12147 / 7190 - Unsubstantiated complaint record with no citations. Complaint Reference: 12153 / 7198 - Unsubstantiated complaint record with no citations.
Findings
Both complaint investigations were unsubstantiated with no citations issued.
Inspection Report
Complaint Investigation
Census: 171
Deficiencies: 1
Date: Jul 9, 2012
Visit Reason
The inspection was conducted as a revisit and complaint investigation related to complaints #12147 and #12153.
Complaint Details
Complaint numbers #12147 and #12153 triggered the revisit and complaint investigation.
Findings
The report includes a statement of deficiencies and plan of correction related to resident rights and facility notification requirements. Specific deficiencies are cited under regulatory guidelines.
Deficiencies (1)
Failure to inform residents of their rights and all rules and regulations governing resident conduct and responsibilities during their stay.
Report Facts
Sample Size: 18
Inspection Report
Complaint Investigation
Census: 168
Deficiencies: 2
Date: Jun 15, 2012
Visit Reason
The inspection was conducted as a complaint investigation based on two unsubstantiated complaint references (12082 / 7063 and 12085 / 7067) with unrelated citations.
Complaint Details
Complaint references 12082 / 7063 and 12085 / 7067 were unsubstantiated but unrelated citations were found. The facility failed to report and investigate an allegation of abuse reported by Resident #21 regarding rough catheter insertion.
Findings
The facility failed to report and investigate an allegation of abuse involving Resident #21, and failed to maintain complete and accurate clinical records for Residents #21 and #167, including unsigned nursing notes and inaccurate medication administration documentation.
Deficiencies (2)
Failed to report and investigate an allegation of abuse where a nurse was reported to be unnecessarily rough pushing in a catheter for Resident #21.
Failed to maintain complete and accurate clinical records, including unsigned nursing notes and discrepancies in medication administration records for Residents #21 and #167.
Report Facts
Facility Census: 168
Sampled Residents: 9
Dates of Inspection: 2012-06-11 to 2012-06-15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Verified the facility had not reported or investigated the abuse incident involving Resident #21. | |
| Administrator | Discussed the abuse allegation and did not consider it reportable or investigable. | |
| Employee #73 | Verified lack of reporting and investigation of abuse incident and unsigned nursing notes. | |
| Employee #80 | Interviewed regarding circled initials on treatment records and documentation practices. |
Inspection Report
Routine
Deficiencies: 11
Date: May 18, 2012
Visit Reason
Quality Indicator Survey conducted from 05/13/12 to 05/18/12 to assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to provide appropriate liability notices, failure to notify responsible parties of significant changes, failure to resolve grievances related to missing personal property, failure to prohibit neglect resulting in injury, failure to provide activities meeting residents' interests and needs, failure to provide medically-related social services for discharge planning, failure to develop comprehensive care plans, failure to provide services by qualified persons per care plan, failure to provide care to maintain bladder function, failure to maintain a safe environment free of hazards, and failure to properly manage expired medications.
Deficiencies (11)
Failure to provide the Skilled Nursing Facility Advance Beneficiary Notice (CMS Form 10055) to resident #277 upon discontinuation of benefits.
Failure to notify responsible party of administration of intravenous antibiotics for resident #248.
Failure to resolve grievance related to missing personal property for resident #85.
Failure to implement written policies and procedures to prohibit neglect resulting in fracture for resident #28.
Failure to provide activities meeting interests and needs for residents #120 and #281.
Failure to provide medically-related social services in discharge planning for resident #177.
Failure to develop comprehensive care plans for residents #177 (discharge), #59 (dialysis medication administration), and #16 (pain).
Failure to provide services by qualified persons per care plan, including failure of employee #110 to follow resident #28's care plan for transfers and failure to implement activity plans for residents #120 and #281.
Failure to provide care and services to maintain bladder function and promote continence for residents #71 and #248 with decline in urinary continence.
Failure to ensure resident environment remains free of accident hazards and provide adequate supervision to prevent accidents; employee #110 terminated for neglect related to resident #28's fracture.
Failure to ensure expired medications were not available for resident use in two medication storage rooms; expired Acetaminophen and fiber powder found.
Report Facts
Deficiencies cited: 11
Residents sampled: 36
Residents identified with falls/fractures: 8
Residents with cognitive impairment sampled: 8
Residents sampled for community discharge: 3
Residents receiving dialysis: 5
Residents sampled for urinary incontinence: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #110 | Certified Nursing Assistant | Failed to follow resident #28's care plan for transfers and failed to report injury incident; terminated. |
| Employee #76 | Issued incorrect liability notice form for resident #277 and confirmed no care plan for pain for resident #16. | |
| Employee #170 | Licensed Practical Nurse | Assessed resident #28's foot after injury but did not receive report of foot caught in chair. |
| RN #32 | Registered Nurse | Verified family notification failure for resident #248's IV antibiotics and confirmed no toileting program for resident #71. |
| Social Worker #43 | Unaware of discharge planning follow-up for resident #177. | |
| Activity Director | Confirmed failure to provide activities and supplies for resident #120 and #281. | |
| RN #51 | Registered Nurse | Confirmed medication administration issues for resident #59 on dialysis days. |
| CNA #64 | Certified Nursing Assistant | Reported resident #248 rarely needs help to bathroom. |
| CNA #92 | Certified Nursing Assistant | Reported resident #71 incontinent sometimes and not on toileting program. |
Inspection Report
Routine
Census: 179
Capacity: 186
Deficiencies: 4
Date: May 16, 2012
Visit Reason
The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards and other regulatory requirements related to facility safety, emergency preparedness, and resident rights.
Findings
The facility was found deficient in multiple areas including failure to ensure a door to the soiled laundry area closed and latched, lack of required signage on delayed-egress doors, absence of no smoking signs in oxygen storage areas, and failure to maintain battery-powered emergency lighting in the generator transfer switch room.
Deficiencies (4)
Door to the soiled laundry area did not close and latch, compromising smoke barrier effectiveness.
Delayed-egress doors lacked required signage indicating door release within 15 seconds after applying pressure.
No smoking signs were not posted in areas where oxygen cylinders are stored or used.
Battery-powered emergency lighting in the generator transfer switch room was inoperable.
Report Facts
Facility census: 179
Total capacity: 186
Inspection date: May 16, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Acknowledged deficiencies related to doors and signage during inspection |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 2, 2012
Visit Reason
The inspection was conducted as a complaint investigation based on complaint reference 11283.
Complaint Details
Complaint Reference: 11283. The complaint was unsubstantiated with no deficiencies found.
Findings
The complaint was unsubstantiated and no deficiencies were identified during the investigation.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Oct 8, 2011
Visit Reason
This document is a Plan of Correction related to deficiencies identified during a prior inspection of Huntington Health and Rehabilitation Center.
Findings
The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b)(5)-(10).
Deficiencies (1)
Failure to properly inform residents of their rights, rules, services, and charges in writing and orally in a language they understand.
Inspection Report
Complaint Investigation
Census: 180
Deficiencies: 4
Date: Aug 22, 2011
Visit Reason
The inspection was conducted as a complaint investigation referenced by complaint #11196, which was found to be unsubstantiated but resulted in unrelated deficiencies being cited.
Complaint Details
Complaint reference #11196 was unsubstantiated but unrelated deficiencies were cited during the investigation.
Findings
The facility was found deficient in several areas including inaccurate resident weight documentation in the Minimum Data Set (MDS), failure to develop and revise comprehensive care plans based on assessments, incomplete and inaccurate clinical records especially related to skin condition and wound care, and failure to update care plans to reflect changes in resident nutritional status.
Deficiencies (4)
Failure to assure accuracy of resident weight recorded in the Minimum Data Set (MDS) for Resident #184.
Failure to develop a comprehensive care plan based on assessment results for Resident #185.
Failure to review and revise the care plan to reflect current nutritional status for Resident #184.
Failure to maintain complete and accurate clinical records including weekly skin assessments for Resident #184.
Report Facts
Facility census: 180
Resident weight discrepancy: 45
Care plan weight goal discrepancy: 46
Dates of missing skin assessments: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager (Employee #63) | Named in relation to errors in Minimum Data Set weight entry and failure to update care plans | |
| Registered Dietician | Disciplined for incorrect nutritional assessment and care plan development | |
| Director of Nursing (DON) | Interviewed regarding weight discrepancies and wound care documentation | |
| Wound Care Nurse | Re-educated for failure to complete weekly skin assessment on week of discharge |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 26, 2011
Visit Reason
The inspection was conducted in response to complaint references #11114 and #11115.
Complaint Details
Complaint references #11114 and #11115 were investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaint records were found to be unsubstantiated with no deficiencies cited.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Apr 15, 2011
Visit Reason
The document is a Plan of Correction related to deficiencies identified during a prior inspection of Huntington Health and Rehabilitation Center.
Findings
The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b)(5)-(10).
Deficiencies (1)
Failure to properly inform residents of their rights, rules, services, and charges in writing and orally in a language they understand.
Report Facts
Deficiency ID: 156
Inspection Report
Complaint Investigation
Census: 173
Deficiencies: 2
Date: Mar 7, 2011
Visit Reason
The inspection was conducted in response to complaints referenced #11056 and #11017, focusing on allegations of neglect and failure to report such allegations to State officials.
Complaint Details
Complaint references #11056 and #11017 were unsubstantiated but resulted in unrelated deficiencies being cited. The facility failed to report neglect allegations involving residents #177, #97, #108, and #51 to State officials as required.
Findings
The facility failed to report allegations of neglect involving four residents to State officials as required. Additionally, the facility did not promote resident dignity adequately, as evidenced by untimely meal service, improper positioning during meals, and unkempt hair among residents.
Deficiencies (2)
Failure to report allegations of neglect to State officials for residents #177, #97, #108, and #51.
Failure to promote care that maintains or enhances resident dignity, including untimely meal service, improper positioning, and unkempt hair for multiple residents.
Report Facts
Concern forms reviewed: 15
Residents involved in neglect allegations: 4
Facility census: 173
Residents observed with dignity issues: 11
Audit frequency: 5
Audit frequency: 4
Audit frequency: 1
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 17, 2010
Visit Reason
The inspection was conducted as a complaint investigation related to complaint reference #10289.
Complaint Details
Complaint reference #10289 was unsubstantiated with no deficiencies cited.
Findings
The complaint was found to be unsubstantiated and no deficiencies were cited during the investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 21, 2010
Visit Reason
The inspection was conducted in response to complaint reference #10104 to investigate allegations against the facility.
Complaint Details
Complaint reference #10104 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaint was found to be unsubstantiated and no deficiencies were cited during the investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 31, 2010
Visit Reason
The inspection was conducted in response to complaint references #10063 and #10067.
Complaint Details
Complaint references #10063 and #10067 were investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaint records were found to be unsubstantiated with no deficiencies cited during the investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 2, 2010
Visit Reason
The inspection was conducted in response to complaint references #9352 and #10029.
Complaint Details
Complaint references #9352 and #10029 were investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaint records were found to be unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 11, 2009
Visit Reason
The inspection was conducted in response to complaint references #9323 and #9327.
Complaint Details
Complaint references #9323 and #9327 were investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaint records were found to be unsubstantiated with no deficiencies cited.
Inspection Report
Life Safety
Deficiencies: 0
Date: Nov 10, 2009
Visit Reason
The inspection was conducted to review facility documentation, staff interviews, observations, and performance testing to determine compliance with NFPA 101, Life Safety Code, 2000.
Findings
The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2000.
Inspection Report
Annual Inspection
Census: 179
Deficiencies: 7
Date: Oct 29, 2009
Visit Reason
The inspection was conducted concurrently with a complaint investigation (complaint reference #9312) and the facility's annual Federal Medicare/Medicaid certification resurvey and State licensure inspection.
Complaint Details
Complaint reference #9312 was unsubstantiated with no related deficiencies cited. The complaint investigation was conducted concurrently with the annual certification resurvey and state licensure inspection.
Findings
The facility was found deficient in multiple areas including failure to develop comprehensive care plans for residents with specific needs (e.g., implanted pacemaker, constipation, incontinence), failure to initiate interventions for constipation, failure to provide care to restore bladder function, incomplete nurse staffing postings, serving food at improper temperatures, infection control violations related to artificial nails and wound care, and failure to provide the required roster/sample matrix timely to surveyors.
Deficiencies (7)
Failure to develop care plans addressing Resident #43's implanted cardiac pacemaker, Resident #78's constipation, and Resident #141's incontinence.
Failure to initiate interventions for treatment of constipation for four residents and failure to assess functionality of Resident #43's pacemaker.
Failure to provide care and services to restore normal bladder function for Resident #141 who was incontinent of bladder.
Failure to post daily nurse staffing information including actual hours worked by RNs, LPNs, and CNAs.
Failure to serve food at proper temperature affecting flavor and palatability.
Failure to maintain infection control standards: wound care nurse wore artificial nails and contaminated an open wound during dressing change.
Failure to provide the Roster / Sample Matrix (form CMS-802) within one hour after surveyors entered the facility, impeding the survey process.
Report Facts
Facility census: 179
Sampled residents: 25
Residents with constipation treatment failure: 4
Date survey completed: 2009
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #57 | Verified facility had not developed a plan for care of Resident #43's pacemaker | |
| Employee #68 | Verified no follow-up regarding Resident #43's pacemaker and coordinated follow-up plan | |
| Employee #151 | MDS coordinator who confirmed no care plan developed for Resident #141's incontinence | |
| Employee #178 | Nurse manager who confirmed no bladder continence assessment for Resident #141 | |
| Employee #126 | Dietary manager who confirmed food temperatures were too cold at point of service | |
| Employee #23 | Wound care nurse who wore artificial nails and contaminated an open wound during dressing change | |
| Employee #115 | Assisted Employee #23 during wound care |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Oct 5, 2009
Visit Reason
This document is a Plan of Correction submitted by Huntington Health and Rehabilitation Center in response to deficiencies cited during a prior inspection.
Findings
The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b)(5)-(10).
Deficiencies (1)
Failure to properly inform residents of their rights, rules, services, and charges in writing and orally in a language they understand.
Inspection Report
Complaint Investigation
Census: 176
Deficiencies: 2
Date: Sep 3, 2009
Visit Reason
The inspection was conducted as a complaint investigation based on complaint references #9248, #9250 (unsubstantiated) and #9257 (substantiated with deficiencies cited).
Complaint Details
Complaint references #9248 and #9250 were unsubstantiated with no deficiencies cited. Complaint reference #9257 was substantiated with deficiencies cited related to nursing practice and medical record keeping.
Findings
The facility failed to ensure that licensed practical nurses (LPNs) performed wound assessments and pressure ulcer evaluations within their scope of practice, as registered nurses (RNs) were not involved in these assessments. Additionally, the facility did not complete Braden Skin Assessments weekly for four weeks after admission for several residents, and medical records were incomplete and not readily accessible.
Deficiencies (2)
Tasks delegated to LPNs included wound assessments and pressure ulcer evaluations without RN involvement, which is outside the LPN scope of practice.
Failure to complete Braden Skin Assessments weekly for four weeks after admission and incomplete medical records for multiple residents.
Report Facts
Current number of pressure ulcers: 13
Facility census: 176
Number of sampled residents with incomplete Braden assessments: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #22 | LPN Treatment Nurse | Interviewed regarding wound measurements and treatment protocols; acknowledged lack of RN involvement in wound assessments. |
| Employee #147 | Interviewed regarding Braden Skin Assessments; confirmed assessments were to be done weekly for four weeks but were missing for several residents. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 31, 2009
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during a prior inspection of Huntington Health and Rehabilitation Center.
Findings
The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b)(5)-(10).
Deficiencies (1)
Failure to properly inform residents of their rights, rules, services, and charges in writing and orally in a language they understand.
Inspection Report
Complaint Investigation
Census: 173
Deficiencies: 5
Date: Jul 20, 2009
Visit Reason
The inspection was conducted as a complaint investigation referencing complaints #9181, #9203, and #9208, which were substantiated with deficiencies cited.
Complaint Details
Complaint references #9181, #9203, and #9208 were substantiated with deficiencies cited.
Findings
The facility failed to complete a comprehensive assessment after a significant change in a resident's status, failed to revise care plans for residents with scabies, failed to promptly identify and treat scabies in two residents, failed to provide adequate supervision to prevent accidents, and failed to maintain an effective infection control program to prevent the spread of scabies.
Deficiencies (5)
Failed to complete a comprehensive assessment after a significant change in resident #174's status.
Failed to revise care plans for residents #52 and #53 to address complaints of itching, rash, and scabies diagnosis.
Failed to promptly identify and treat residents #52 and #53 for scabies.
Failed to provide adequate supervision to prevent accidents; nine residents were left unsupervised during an evening meal.
Failed to establish and maintain an infection control program to investigate, control, and prevent infections, resulting in scabies outbreak without proper investigation or containment.
Report Facts
Facility census: 173
Residents left unsupervised: 9
Percentage of rash coverage: 70
Inspection Report
Complaint Investigation
Census: 174
Deficiencies: 4
Date: Feb 25, 2009
Visit Reason
The inspection was conducted as a complaint investigation based on multiple complaint references, including substantiated and unsubstantiated complaints.
Complaint Details
Complaint references #2-8342, #2-8357, #2-8359 were unsubstantiated with unrelated deficiencies cited. Complaint reference #9016 was substantiated with deficiencies cited.
Findings
The facility was found deficient in multiple areas including failure to immediately report and investigate an injury of unknown origin for a resident with bruises and a fracture, failure to maintain a safe, clean, and homelike environment for residents, failure to ensure proper application and monitoring of WanderGuard bracelets for residents at risk of elopement, and failure to handle soiled linens properly to prevent infection spread.
Deficiencies (4)
Failure to immediately report or thoroughly investigate an injury of unknown origin for a resident with bruises and a fracture.
Failure to maintain a safe, clean, comfortable, and homelike environment, including malodorous rooms and improper handling of medical equipment.
Failure to ensure residents at risk for elopement had WanderGuard bracelets applied and monitored every shift as ordered.
Failure to handle soiled linens properly, placing them on carpeted floors, risking spread of infection.
Report Facts
Facility census: 174
Number of sampled residents with deficiencies: 9
Number of residents with missing WanderGuard checks: 10
Number of shifts missing WanderGuard bracelet verification: 7
Inspection Report
Complaint Investigation
Census: 173
Deficiencies: 2
Date: Oct 22, 2008
Visit Reason
The inspection was conducted as a complaint investigation based on complaint reference #2-8259, which was substantiated with deficiencies cited. Other complaints (#2-8262 and #2-8292) were unsubstantiated with no related deficiencies.
Complaint Details
Complaint reference #2-8259 was substantiated with deficiencies cited. Complaints #2-8262 and #2-8292 were unsubstantiated with no related deficiencies.
Findings
The facility failed to promptly investigate and resolve grievances voiced by a resident and family member, failed to provide adequate supervision to prevent a resident at risk of elopement from leaving the facility unsupervised, and did not implement required care plans or interventions for identified risks. These deficiencies were substantiated for one of eight sampled residents.
Deficiencies (2)
Failure to fully investigate and make prompt efforts to resolve grievances voiced by a resident and family member, contrary to facility policy.
Failure to provide supervision and assistance devices to prevent accidents, specifically to prevent a resident at risk for elopement from leaving the facility unsupervised.
Report Facts
Facility census: 173
Sampled residents: 8
Residents with deficiencies: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #142 | Interviewed and unable to find evidence of a care plan for resident at risk of elopement |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 6, 2008
Visit Reason
The inspection was conducted in response to complaint reference #2-8252 to investigate the allegations made.
Complaint Details
Complaint reference #2-8252 was unsubstantiated with no related deficiencies cited.
Findings
The complaint was found to be unsubstantiated with no related deficiencies cited during the investigation.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Oct 2, 2008
Visit Reason
Paper revisit to review the facility's plan of correction following previous deficiencies.
Findings
The document contains a statement of deficiencies and the provider's plan of correction related to resident rights and notification requirements. No new deficiencies or severity levels are explicitly stated.
Deficiencies (1)
Failure to inform residents of their rights and all rules and regulations governing resident conduct and responsibilities during their stay.
Inspection Report
Annual Inspection
Census: 184
Deficiencies: 8
Date: Aug 14, 2008
Visit Reason
The inspection was conducted as a complaint investigation combined with the facility's annual Federal Medicare/Medicaid certification resurvey and State licensure inspection.
Complaint Details
Complaint reference #2-8208 was substantiated with deficiencies cited. Complaint references #2-8210 and #2-8213 were unsubstantiated with no related deficiencies cited.
Findings
The facility was found deficient in multiple areas including failure to notify physicians of significant resident changes, inadequate grooming services, inaccurate resident assessments, incomplete care plans, failure to complete required pre-admission screenings, failure to follow bowel protocols, inadequate pressure ulcer care, failure to prevent infection spread due to improper handwashing, and incomplete clinical record documentation.
Deficiencies (8)
Failure to notify physician of pressure ulcer and bowel movement issues for residents #12 and #112.
Failure to provide adequate grooming services for resident #155.
Failure to accurately document pressure ulcers in the Minimum Data Set (MDS) for resident #12.
Failure to develop comprehensive care plans addressing resident needs for residents #104 and #149.
Failure to complete required pre-admission screening (PAS) and Level II evaluations prior to admission for multiple residents.
Failure to follow bowel protocol and adequately assess skin alterations for residents #112, #102, and #113.
Failure of staff to wash hands properly between resident contacts, increasing risk of infection spread.
Incomplete and inaccurate clinical record documentation including unsigned physician orders and undated nursing notes.
Report Facts
Facility census: 184
Residents sampled: 25
Residents with PAS issues: 6
Residents with care plan issues: 2
Residents with pressure ulcers not documented in MDS: 1
Residents with inadequate grooming: 1
Residents with bowel protocol failure: 1
Residents with handwashing failures observed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #130 | Wound Care Nurse | Named in findings related to pressure ulcer treatment failure and handwashing deficiencies |
| Employee #83 | Director of Nursing | Interviewed regarding failure to notify physician and treatment of pressure ulcers |
| Employee #2 | Licensed Practical Nurse | Observed failing to wash hands properly during medication pass |
| Employee #205 | Registered Nurse Unit Manager | Interviewed regarding grooming and skin assessments |
| Employee #38 | Director of Nursing | Interviewed regarding bowel protocol failure |
| Employee #207 | Registered Nurse Unit Manager | Interviewed regarding skin assessments |
| Employee #146 | Licensed Practical Nurse | Assisted wound care nurse during observation of resident #104 |
| Employee #115 | Registered Nurse Unit Manager | Observed and confirmed additional open pressure ulcer areas on resident #104 |
Inspection Report
Life Safety
Census: 184
Deficiencies: 3
Date: Aug 14, 2008
Visit Reason
The inspection was conducted to evaluate compliance with NFPA 101 Life Safety Code standards, including fire alarm system maintenance, medical gas storage, and electrical equipment safety.
Findings
The facility failed to maintain the fire alarm system in accordance with NFPA 72, failed to store oxygen cylinders properly per NFPA 99, and failed to maintain electrical equipment per NFPA 70. Specific issues included failure of the fire alarm trouble signal, oxygen cylinders stored near combustible materials, and open drums of cooking oil near an electrical transformer.
Deficiencies (3)
Fire alarm system failed to send a trouble signal when primary and secondary phone lines were disconnected.
Oxygen cylinders stored within six to twelve inches of combustible material.
Electrical wiring and equipment not maintained in accordance with NFPA 70; two open drums of cooking oil located within four inches of an electrical transformer.
Report Facts
Facility census: 184
Oxygen cylinders observed: 13
Cooking oil drums: 2
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 12, 2008
Visit Reason
The document is a plan of correction related to a paper revisit survey of Huntington Health and Rehabilitation Center.
Findings
The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as well as providing written descriptions of legal rights.
Deficiencies (1)
Facility failed to properly inform residents of their rights, rules, services, and charges as required by regulation 483.10(b)(5)-(10), 483.10(b)(1).
Report Facts
Deficiency ID: 156
Inspection Report
Complaint Investigation
Census: 184
Deficiencies: 2
Date: Apr 23, 2008
Visit Reason
The inspection was conducted as a complaint investigation triggered by substantiated complaints regarding resident care and safety, specifically focusing on elopement incidents and individualized care plans.
Complaint Details
Complaint references #2-8022 and #2-8069 were unsubstantiated with no deficiencies cited. Complaint reference #2-8019 was substantiated with deficiencies cited related to individualized care plans and elopement investigations.
Findings
The facility failed to individualize comprehensive care plans for residents at risk of elopement, using pre-developed plans that did not address unique resident needs. Additionally, the facility failed to thoroughly investigate incidents of elopement for two residents, did not implement individualized interventions to prevent reoccurrence, and lacked evidence of proper follow-up investigations.
Deficiencies (2)
Failure to assure that each resident's comprehensive plan of care was individualized to prevent injury from elopement; care plans were pre-developed and not tailored to unique resident needs.
Failure to thoroughly investigate incidents of elopement when residents left the facility unsupervised and undetected, and failure to implement individualized interventions to prevent reoccurrence.
Report Facts
Facility census: 184
Residents sampled with elopement issues: 4
Residents with incomplete elopement investigations: 2
Safety check duration: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker | Acknowledged lack of individualized care plans and absence of further investigations for elopement incidents |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Nov 6, 2007
Visit Reason
This document is a plan of correction related to a paper revisit survey conducted at the facility.
Findings
The document references a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges, but no detailed findings or severity levels are provided.
Deficiencies (1)
Facility must inform residents orally and in writing of their rights, rules, services, and charges, including Medicaid-related information.
Inspection Report
Complaint Investigation
Census: 184
Deficiencies: 1
Date: Oct 11, 2007
Visit Reason
The inspection was conducted as a complaint investigation referenced as #2-7224, which was found to be unsubstantiated but resulted in unrelated deficiencies being cited.
Complaint Details
Complaint reference #2-7224 was unsubstantiated with unrelated deficiencies cited.
Findings
The facility failed to develop a comprehensive care plan that included Hospice services for Resident #56, despite the resident receiving Hospice care since 09/14/07. A care plan addressing Hospice services was subsequently formulated on the afternoon of 10/10/07 after review and interviews.
Deficiencies (1)
Failure to develop a care plan including Hospice services for Resident #56 who had been receiving Hospice care since 09/14/07.
Report Facts
Facility census: 184
Residents sampled: 5
Resident identifier: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Manager (Registered Nurse) | Interviewed and verified the care plan did not include Hospice services for Resident #56 | |
| Hospice Nurse (Registered Nurse - Nursing Home Team Manager) | Interviewed and confirmed Hospice services provided and care plan omission |
Inspection Report
Deficiencies: 1
Date: Oct 1, 2007
Visit Reason
The document is a paper revisit survey conducted at Huntington Health and Rehabilitation Center to review compliance and deficiencies.
Findings
The report includes a statement of deficiencies related to resident rights and notification requirements, with a focus on informing residents of their rights, services, and charges. The initial comments note this as a paper revisit.
Deficiencies (1)
Facility must inform residents orally and in writing of their rights, rules, services, and charges, including Medicaid-related information, prior to or upon admission and during the stay.
Inspection Report
Complaint Investigation
Census: 184
Deficiencies: 3
Date: Aug 21, 2007
Visit Reason
The inspection was conducted as a substantiated complaint investigation related to concerns about the cleanliness and care environment of the facility, specifically regarding odor and hygiene in a resident's room and adherence to physician orders for catheter care.
Complaint Details
Complaint reference #2-7170 was substantiated with deficiencies cited related to environmental cleanliness and catheter care.
Findings
The facility failed to maintain a clean and homelike environment in one resident's shared room, with persistent urine odor and soiled items on the floor. Additionally, the facility did not follow physician orders for timely catheter changes for two residents, and failed to keep a catheter drainage bag off the floor, potentially increasing infection risk.
Deficiencies (3)
Facility failed to provide a clean and homelike environment; strong urine odor and soiled items present in a resident's room.
Facility failed to follow physician orders to change indwelling urinary catheters every 30 days for two residents.
Catheter drainage collection bag was consistently kept on the floor, risking bacterial contamination and urinary tract infection.
Report Facts
Facility census: 184
Days catheter not changed: 41
Days catheter not changed: 58
Number of sampled residents with catheters: 7
Number of residents with catheter care deficiencies: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse (Employee #2) interviewed regarding catheter care and room cleanliness; unable to provide evidence of catheter changes and noted issues with drainage bag placement. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 9, 2007
Visit Reason
This document is a plan of correction related to a paper revisit survey conducted at the facility.
Findings
The document includes a summary statement of deficiencies related to resident rights and notification requirements, specifically regarding informing residents of their rights, services, charges, and Medicaid benefits.
Deficiencies (1)
Failure to inform residents both orally and in writing of their rights, rules, services, and charges as required by regulation.
Inspection Report
Life Safety
Census: 175
Deficiencies: 7
Date: Jun 27, 2007
Visit Reason
The inspection was conducted to evaluate the facility's compliance with NFPA 101 Life Safety Code standards, including fire safety, smoke barriers, fire alarm systems, means of egress, and emergency power systems.
Findings
The facility failed to maintain fire-rated smoke barriers and doors, failed to maintain self-closing hazardous room doors, had issues with delayed-egress locking devices and signage, failed to maintain all components of the fire alarm system including smoke detector testing, improperly stored soiled linen/trash receptacles, and failed to maintain battery-powered emergency lighting for the generator site.
Deficiencies (7)
Failed to maintain all portions of smoke barrier walls to a one-half hour fire rated construction.
Failed to maintain all facility smoke barrier doors to a twenty minute fire resistance rating.
Failed to maintain all hazardous room doors to be self-closing.
Failed to maintain all means of egress readily accessible; missing instructional signs on delayed-egress doors and multiple delayed-egress devices in one egress path.
Failed to maintain all components of the facility fire alarm system; incomplete smoke detector inspections and lack of sensitivity testing documentation.
Failed to store soiled linen/trash receptacles in accordance with capacity and space requirements.
Failed to maintain battery-powered emergency lighting at the generator site location; emergency lighting in generator transfer switch room was inoperable.
Report Facts
Facility census: 175
Smoke detectors installed: 63
Smoke detectors inspected: 28
Smoke detectors inspected: 27
Smoke detectors inspected: 30
Smoke detectors inspected: 30
Soiled linen/trash receptacles: 6
Space for soiled linen/trash receptacles: 50
Required space for receptacles: 384
Inspection Report
Annual Inspection
Census: 181
Deficiencies: 13
Date: Jun 14, 2007
Visit Reason
The inspection was conducted as an annual Federal Medicare/Medicaid certification survey and State licensure inspection, including a complaint investigation.
Complaint Details
Complaint reference #2-7122 was unsubstantiated with unrelated deficiencies cited. The complaint investigation was conducted concurrently with the annual survey.
Findings
The facility was cited for multiple deficiencies including failure to provide residents access to petty cash after hours, failure to report allegations of neglect, failure to provide medically-related social services for suicidal ideations, unsanitary environment in resident rooms and dietary areas, inaccurate resident assessments, medication errors including failure to administer prescribed diuretics, inadequate nurse staffing postings, failure to plan and serve appropriate diets, and incomplete clinical records.
Deficiencies (13)
Failed to provide residents access to petty cash after normal business hours and weekends affecting 114 residents.
Failed to report six of seven allegations of neglect to appropriate outside agencies.
Failed to provide medically-related social services after a resident voiced suicidal ideations.
Failed to maintain a clean, homelike environment; urine odor and soiled briefs found in resident room.
Failed to conduct accurate comprehensive assessments; medication administration inaccurately documented.
Failed to provide necessary care and services; diuretic medication not administered for 21 days.
Failed to ensure adequate supervision to prevent accidents; resident yelled for help and was ignored for 10 minutes.
Failed to post nurse staffing information correctly; missing census, hours worked, and staff titles.
Failed to plan a full liquid diet for three residents with physician orders for such diet.
Failed to prepare and serve food under sanitary conditions; gravy not cooked properly and pureed meat too thin.
Failed to maintain sanitary conditions in dietary department; cracked tiles, trapped moisture, expired foods, and dirty bowls observed.
Pharmacist did not review drug regimen for one resident due to unavailable chart.
Failed to maintain complete clinical records; narcotic medication administered but not recorded on medication administration record.
Report Facts
Residents affected by petty cash access: 114
Facility census: 181
Allegations of neglect not reported: 6
Residents with full liquid diet orders: 3
Days diuretic medication not administered: 21
Minutes resident yelled for help before response: 10
Medication administrations not recorded on MAR: 4
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 6, 2006
Visit Reason
Paper revisit to review the facility's plan of correction following a prior inspection.
Findings
The document contains a statement of deficiencies and the provider's plan of correction related to resident rights and notification requirements. No new deficiencies or severity levels are explicitly stated.
Deficiencies (1)
Failure to inform residents of their rights and services in writing and orally as required.
Inspection Report
Annual Inspection
Census: 70
Deficiencies: 2
Date: Jun 1, 2006
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident safety and rights.
Findings
The facility failed to ensure that safety and assistive devices were properly attached and functioning, affecting thirteen of seventy residents using alarms and safety devices. Multiple residents were observed with improperly applied or non-functioning alarms and safety devices, posing a risk for falls and injuries.
Deficiencies (2)
Failure to ensure safety and assistive devices were properly attached and/or in working order for residents using alarms and roll guards to prevent falls or injuries.
Failure to inform residents of their rights and rules governing resident conduct in a language they understand, including notice of Medicaid benefits and advance directives.
Report Facts
Residents affected: 13
Total residents using devices: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff members #73, #118, #165 mentioned in relation to safety device application and awareness |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 30, 2006
Visit Reason
The inspection was conducted in response to a complaint referenced as #2-6118.
Complaint Details
Complaint reference #2-6118 was unsubstantiated with no deficiencies cited.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.
Inspection Report
Complaint Investigation
Census: 20
Deficiencies: 3
Date: May 1, 2006
Visit Reason
The inspection was conducted as a complaint investigation referenced as #2-6101, which was found to be unsubstantiated but resulted in unrelated deficiencies being cited.
Complaint Details
Complaint reference #2-6101 was unsubstantiated; however, unrelated deficiencies were cited regarding medication administration documentation.
Findings
The facility failed to maintain complete and accurate medication administration records (MARs), specifically the MARs for the 'B' hall were not initialed for an entire medication pass on 04/29/06. Additionally, the facility did not follow proper documentation procedures for medication refusals, and some medications were not properly accounted for or destroyed according to policy.
Deficiencies (3)
Medication administration records (MARs) were not initialed for an entire medication pass on 04/29/06 for residents on the 'B' hall.
Failure to document medication refusal properly for Resident #114, including lack of explanatory notes on the MAR.
Medication sheet lacking resident identification contained administration records for Resident #12 with missing documentation for refused medications.
Report Facts
Residents affected: 19
Medications refused: 3
Medications refused: 6
Medications administered: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #2 | Interviewed and confirmed incomplete MAR documentation for the 9:00 a.m. medication pass on 04/29/06. | |
| Nurse #4 | Interviewed regarding medication refusal procedures and confirmed lack of proper documentation and destruction of refused medications. |
Inspection Report
Complaint Investigation
Census: 184
Deficiencies: 2
Date: Apr 25, 2006
Visit Reason
The inspection was conducted as a complaint investigation, substantiated with deficiencies cited related to housekeeping, maintenance, and infection control.
Complaint Details
Complaint reference #2-6050 substantiated with deficiencies cited related to housekeeping and infection control.
Findings
The facility failed to maintain a sanitary, orderly, and comfortable environment, with multiple resident rooms observed to have unsanitary conditions including soiled bedpans, urine and stool odors, stained and uncleaned equipment, and floors not properly cleaned or mopped. Infection control procedures were not followed, particularly regarding cleaning and sanitizing resident equipment and wet mopping floors daily.
Deficiencies (2)
Failure to provide housekeeping services necessary to maintain a sanitary, orderly and comfortable living environment in multiple resident rooms.
Failure to implement infection control measures to ensure resident equipment soiled with body waste and fluids was promptly sanitized and stored properly at the resident's bedside.
Report Facts
Facility census: 184
Residents affected: 74
Rooms identified: 12
Urine volume in bedpan: 100
Urine and stool volume in potty chair: 2000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Environmental Services | Accompanied surveyor during room observations and agreed on cleaning deficiencies | |
| Director of Nurses (DON) | Acknowledged failure to follow infection control policies and cleaning procedures |
Inspection Report
Complaint Investigation
Census: 181
Deficiencies: 17
Date: Mar 9, 2006
Visit Reason
Complaint investigation related to allegations of physical restraints, staff treatment of residents, dignity issues, and comprehensive assessments.
Complaint Details
Complaint reference 2-6045. Unsubstantiated complaint record with no related deficiencies cited.
Findings
The facility was found deficient in multiple areas including improper use of physical restraints, inadequate investigation of abuse allegations, failure to promote resident dignity, incomplete comprehensive assessments and care plans, improper medication administration, unsanitary food preparation conditions, and environmental safety issues.
Deficiencies (17)
Failure to assure resident's right to be free from physical restraints without medical justification.
Inadequate investigation of abuse allegations against staff.
Failure to promote care in a manner that maintains resident dignity and respect.
Comprehensive assessments not completed to include required additional assessment information for identified potential problem areas.
Resident assessments failed to accurately reflect resident status, including communication difficulties.
Care plans failed to include measurable objectives and individualized approaches to meet residents' needs.
Services provided did not meet professional standards of quality; LPNs delegated duties outside their scope of practice including care planning and assessment evaluation.
Nursing staff administered medications not in accordance with facility policy (medications not properly diluted for G-tube administration).
Resident with indwelling catheter did not receive appropriate treatment and services to prevent urinary tract infections.
Resident environment not free of accident hazards; side rails used without adequate indications and without interventions to prevent injury.
Resident call system components missing in original building shower room.
Facility failed to maintain a safe, functional, sanitary, and comfortable environment; including damaged floors, ceilings, and unsanitary kitchen conditions.
Facility failed to maintain and firmly secure corridor handrails.
Facility failed to maintain an effective pest control program; presence of ants in dietary pantry.
Facility failed to comply with state regulations: consultant pharmacist not registered, food service permit not updated, and staff not informed of abuse registry requirements.
Facility used hypnotic drug for excessive duration without assessment or dose reduction attempts.
Facility failed to ensure resident received adequate supervision and assistance devices to prevent accidents; resident alarm not properly used.
Report Facts
Facility census: 181
Residents affected: 17
Residents affected: 25
Residents affected: 4
Residents affected: 3
Residents affected: 1
Residents affected: 1
Staff files reviewed: 10
Inspection Report
Routine
Census: 181
Deficiencies: 10
Date: Mar 8, 2006
Visit Reason
The inspection was conducted as a routine facility survey to assess compliance with NFPA 101 Life Safety Code standards and other regulatory requirements.
Findings
The facility was found to have multiple deficiencies related to fire safety including failure to maintain exitway walls with proper flame spread rating, inadequate exit signage, obstruction of egress paths, insufficient illumination of exit signs, failure to conduct quarterly fire drills on all shifts, overdue maintenance of kitchen range hood extinguishing system, improper storage of soiled linen/trash receptacles, and failure to maintain emergency power system annunciator panel visibility and electrical receptacle safety.
Deficiencies (10)
Facility failed to maintain exitway walls with an interior finish that had a flame spread rating of Class A or Class B.
Facility failed to provide signs to identify all doors that were not a way of exit access but could be mistaken for an exit.
Facility failed to maintain corridor exit width in accordance with NFPA 101 Life Safety Code due to protruding notebook holders and shelf.
Facility failed to maintain all means of egress readily accessible; items such as linen carts, hampers, crates, beds, boxes, IV poles, and food carts were stored in egress paths.
Facility failed to maintain all facility exit signs to provide continuous illumination; five exit signs had only one of two bulbs illuminated.
Facility failed to conduct fire drills on each shift at least quarterly; no fire drill conducted on 3-11 shift for second quarter of 2005.
Facility failed to maintain the range hood extinguishing system; six year maintenance was past due and spray nozzles were improperly positioned.
Facility failed to store soiled linen/trash receptacles with capacities greater than 32 gallons in a room protected as a hazardous area and exceeded allowed capacity per square foot.
Facility failed to maintain emergency power system annunciator panel so that it was readily observable; papers obstructed the view.
Facility failed to maintain electrical wiring and wall receptacles in accordance with NFPA 70; multiple GFCI receptacles failed to trip when tested and an extension cord was in use in a resident room.
Report Facts
Facility census: 181
Number of clean linen carts: 6
Number of soiled linen/trash hampers: 9
Number of crates of bottled water: 53
Number of exit signs with only one bulb illuminated: 5
Fire drill missing: 1
Capacity of soiled linen/trash hampers: 32
Total capacity of soiled linen/trash hampers stored: 472
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 7, 2006
Visit Reason
The inspection was conducted in response to a complaint referenced as #2-5325.
Complaint Details
Complaint reference #2-5325 was unsubstantiated with no deficiencies cited.
Findings
The complaint was found to be unsubstantiated and no deficiencies were cited during the investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 21, 2005
Visit Reason
The inspection was conducted as a complaint investigation based on complaint reference #2-5272.
Complaint Details
Complaint reference #2-5272 was unsubstantiated with no deficiencies cited.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 6, 2005
Visit Reason
The inspection was conducted in response to complaint references #2-5242 and #2-5257.
Complaint Details
Complaint references #2-5242 and #2-5257 were investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaint records were found to be unsubstantiated with no deficiencies cited during the inspection.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jul 28, 2005
Visit Reason
The visit was a paper revisit to follow up on previous deficiencies.
Findings
The document is a statement of deficiencies and plan of correction related to resident rights and notification requirements. No specific findings or deficiencies beyond the initial comments are detailed.
Deficiencies (1)
Facility must inform residents of their rights and all rules and regulations governing resident conduct and responsibilities during their stay, including Medicaid-related notifications.
Report Facts
Provider/Supplier Identification Number: 515007
Inspection Report
Complaint Investigation
Census: 180
Deficiencies: 2
Date: Jun 15, 2005
Visit Reason
The inspection was conducted in response to complaint reference #2-5146, which involved allegations of neglect at the facility.
Complaint Details
Complaint reference #2-5146 involved allegations of neglect for residents #72 and #180. The facility's investigation was deemed inadequate and the allegations were unsubstantiated without sufficient evidence or interviews. Resident #102's significant condition changes were not assessed as required.
Findings
The facility failed to thoroughly investigate two allegations of neglect involving residents #72 and #180, including not interviewing key staff and lacking evidence to substantiate the allegations. Additionally, the facility failed to complete a significant change assessment for resident #102 despite multiple condition changes.
Deficiencies (2)
Failure to thoroughly investigate allegations of neglect for residents #72 and #180, including lack of interviews with responsible nursing staff and insufficient evidence to substantiate or refute the allegations.
Failure to complete a significant change assessment for resident #102 despite multiple condition changes requiring interdisciplinary review.
Report Facts
Facility census: 180
Weight loss: 11
Number of allegations investigated: 9
Number of new pressure ulcers identified: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Questioned about the investigation and failure to interview the nurse responsible for Resident #180's care | |
| Treatment Nurse | Provided written statements about marking bed pads and suspecting residents were not turned or changed | |
| Nursing Assistant | Provided statements regarding care of residents #72 and #180 and observations of care deficiencies | |
| Social Worker Assistant | Reviewed video tapes and provided statements about nursing assistant activities during the night shift |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 6, 2005
Visit Reason
The inspection was conducted in response to a complaint referenced as #2-5140.
Complaint Details
Complaint reference: #2-5140. The complaint was unsubstantiated with no deficiencies cited.
Findings
The complaint was found to be unsubstantiated with no deficiencies cited during the investigation.
Inspection Report
Deficiencies: 1
Date: Jun 1, 2005
Visit Reason
The visit was a paper revisit to review previous findings and compliance status.
Findings
The report contains a summary statement of deficiencies related to resident rights notification, but no new on-site findings are detailed.
Deficiencies (1)
Failure to inform residents of their rights and rules in a language they understand, including Medicaid-related notifications.
Inspection Report
Complaint Investigation
Census: 185
Deficiencies: 3
Date: Apr 19, 2005
Visit Reason
The inspection was conducted in response to complaint references #2-5057 and #2-5098 to investigate allegations related to resident neglect and other concerns.
Complaint Details
Complaint references #2-5057 and #2-5098 were investigated. The complaints were found to be unsubstantiated but unrelated deficiencies were cited.
Findings
The facility was found to have unsubstantiated complaints with unrelated deficiencies cited, including failure to report an allegation of neglect for Resident #52, inadequate supervision of Resident #148 who eloped three times in three months, and infection control issues related to dirty linen carts being left on floors during meal times.
Deficiencies (3)
Failure to report an allegation of neglect to the State survey and certification agency or Nurse Aide Registry for Resident #52.
Inadequate supervision of Resident #148 who eloped from the building three times in three months.
Failure to ensure dirty linen carts were not left on the floor during meal times, potentially affecting residents on the third and fourth floors.
Report Facts
Facility census: 185
Resident elopements: 3
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 8, 2005
Visit Reason
The inspection was conducted in response to complaint references #2-5002 and #2-5022.
Complaint Details
Complaint references #2-5002 and #2-5022 were investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaint records were found to be unsubstantiated with no deficiencies cited.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 14, 2005
Visit Reason
Paper revisit to review the facility's plan of correction following a prior inspection.
Findings
The document contains a statement of deficiencies and the provider's plan of correction related to resident rights and notification requirements. No new inspection findings are detailed beyond the plan of correction.
Deficiencies (1)
Failure to inform residents of their rights and all rules and regulations governing resident conduct and responsibilities during their stay, including Medicaid-related notifications.
Report Facts
Deficiency ID: 156
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 21, 2004
Visit Reason
The inspection was conducted as a complaint investigation referenced as #2-4389.
Complaint Details
Complaint reference #2-4389 was unsubstantiated with no deficiencies cited.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.
Inspection Report
Annual Inspection
Census: 181
Deficiencies: 8
Date: Dec 2, 2004
Visit Reason
The inspection was conducted as a comprehensive annual survey of Huntington Health and Rehabilitation Center to assess compliance with federal regulations regarding resident rights, quality of life, care, environment, dietary services, infection control, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to provide residents with choices regarding bathing, failure to return personal clothing after laundering, inadequate assistance with positioning for meals, incomplete and inaccurate fluid intake and output records for several residents, improper elevation of head of bed for residents with gastrostomy feedings, unsecured electrical breaker panels, unsanitary food storage practices, and improper infection control techniques during wound care and ice handling.
Deficiencies (8)
Failure to assure one resident was given choices regarding bathing, resulting in refusal of showers for over one month without alternatives offered.
Failure to ensure personal clothing was returned to residents after laundering.
Failure to assist residents into appropriate positions in bed to access food and eat meals comfortably.
Failure to accurately and completely record fluid intake and output for four residents requiring monitoring.
Failure to adequately elevate head of bed for three residents with gastrostomy feedings as ordered by physician.
Failure to provide a safe environment due to unsecured electrical breaker panel boxes in multiple locations.
Failure to ensure food in dry storage area was stored under sanitary conditions; measuring cup left inside powdered sugar container.
Failure to use proper infection control technique during wound dressing and ice handling, risking cross-contamination.
Report Facts
Facility census: 181
Residents sampled: 25
Residents with feeding tubes monitored for intake/output: 4
Residents observed with gastrostomy feeding issues: 3
Electrical breaker panels unsecured: 15
Inspection Report
Life Safety
Census: 181
Deficiencies: 2
Date: Dec 1, 2004
Visit Reason
The inspection was conducted to evaluate compliance with NFPA 101 Life Safety Code standards, including fire resistance of smoke barriers and proper storage of medical gases.
Findings
The facility failed to maintain smoke barrier walls to a one-half hour fire resistance rating due to unsealed penetrations, and failed to store oxygen cylinders in a secure, enclosed space as required by NFPA 99.
Deficiencies (2)
Facility failed to maintain all portions of smoke barrier walls to a one-half hour fire rated construction due to unsealed/incompletely sealed penetrations around conduits, wires, and ventilation ducts.
Facility failed to store oxygen cylinders in an enclosed space secure against unauthorized entry, violating NFPA 99 storage requirements.
Report Facts
Facility census: 181
Oxygen cylinders observed: 28
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 7, 2004
Visit Reason
The inspection was conducted as a complaint investigation referenced as #2-4295.
Complaint Details
Complaint reference #2-4295 was unsubstantiated with no deficiencies cited.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 25, 2004
Visit Reason
The inspection was conducted in response to complaint reference #2-4278.
Complaint Details
Complaint reference #2-4278 was unsubstantiated with no deficiencies cited.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 9, 2004
Visit Reason
The inspection was conducted as a complaint investigation referenced as #2-4249.
Complaint Details
Complaint reference #2-4249 was unsubstantiated with no deficiencies cited.
Findings
The complaint was found to be unsubstantiated and no deficiencies were cited during the investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 27, 2004
Visit Reason
The inspection was conducted in response to complaint reference #2-4216.
Complaint Details
Complaint reference #2-4216 was unsubstantiated with no deficiencies cited.
Findings
The complaint was found to be unsubstantiated and no deficiencies were cited during the investigation.
Inspection Report
Complaint Investigation
Census: 171
Deficiencies: 6
Date: May 30, 2004
Visit Reason
Complaint investigation related to substantiated complaints of missing resident property and other quality of care concerns including unsafe smoking practices and call light response issues.
Complaint Details
Complaint references #2-4177 and #2-4182 were substantiated with deficiencies cited related to missing resident property and other quality of care issues.
Findings
The facility failed to report alleged misappropriation of resident property to the state agency, did not ensure timely response to call lights, failed to offer alternative shower times when refused, lacked care planning for use of seclusion for aggressive behavior, and failed to adequately assess and supervise residents who smoked, resulting in immediate jeopardy for one resident. The facility also failed to maintain a smoke-free hallway environment near the smoking room.
Deficiencies (6)
Failed to report four complaints of missing resident property to the state surveying agency as alleged misappropriation of property.
Failed to ensure call lights were answered timely and not just turned off without assistance.
Failed to offer alternative shower times when residents refused weekly showers.
Failed to have a care plan for use of seclusion to address aggressive behavior of a resident.
Failed to adequately assess and supervise residents who smoked, including one resident found asleep with a burning cigarette, creating immediate jeopardy.
Failed to maintain a smoke-free hallway environment outside the smoking room.
Report Facts
Facility census: 171
Number of residents with smoking issues: 18
Number of residents observed with unsafe smoking practices: 5
Number of residents with missing property complaints: 4
Number of residents interviewed about call light delays: 7
Minutes call lights delayed: 30
Inspection Report
Annual Inspection
Census: 181
Deficiencies: 19
Date: Sep 5, 2003
Visit Reason
The inspection was conducted as a comprehensive annual survey of Huntington Health and Rehabilitation Center to assess compliance with federal regulations related to resident rights, quality of care, resident assessments, environment, dietary services, and administration.
Findings
The facility was found deficient in multiple areas including failure to update care plans and assessments, inadequate staff communication with residents, failure to investigate and report bruising of unknown origin, improper use of assistive devices, failure to offer substitute food when meals were refused, unsafe physical environment conditions, improper food temperature control, incomplete medical record management, and lack of effective quality assurance processes.
Deficiencies (19)
Failure to review and update the overall plan of care for a resident who regained capacity to make medical decisions.
Failure to report and investigate bruising of unknown origin for eleven residents.
Failure to provide care in a manner that maintains dignity and respect during feeding of a resident.
Failure to arrange furniture to allow wheelchair access for a resident.
Failure to complete accurate and complete Minimum Data Set (MDS) assessments for residents.
Failure to develop comprehensive and individualized care plans for residents, including failure to update care plans after multiple falls and significant changes.
Failure to revise care plan after significant decline in resident's communication ability.
Failure to accurately document resident's feeding ability and failure to provide assistive devices as ordered.
Failure to offer substitute food when resident refused meal, despite significant weight loss.
Failure to apply pressure prevention devices such as pillow and Spenco boot to resident.
Failure to initiate toileting program and restore bladder function for a resident with urinary incontinence.
Failure to apply prescribed left hand splint to prevent contractures.
Failure to apply bed alarms to residents at risk for falls; alarms were present but not connected to residents.
Failure to maintain cleanliness of lateral supports for a resident; supports were soiled with dried food.
Facility environment deficiencies including damaged furniture surfaces, damaged closet doors, excessive storage and clutter in resident rooms, damaged sink cabinet, damaged floor tiles, and lack of privacy in central toilets.
Unsafe courtyard patio and sidewalks with uneven and broken slabs causing standing water and safety hazards.
Failure to maintain cheese salad sandwiches at or below 41°F on serving line, risking foodborne illness.
Failure to maintain accurate medical records by not removing discontinued physician orders, leading to potential unnecessary lab tests.
Failure of quality assessment and assurance committee to analyze incident data and implement interventions to prevent recurring injuries.
Report Facts
Resident census: 181
Number of residents with bruising of unknown origin: 11
Number of falls for Resident #121: 30
Weight loss: 15
Temperature of cheese salad sandwiches: 47
Number of damaged over bed tables: 73
Number of damaged bedside tables: 38
Number of damaged beds: 8
Number of damaged HVAC units: 9
Number of falls for Resident #121: 30
Inspection Report
Life Safety
Census: 181
Deficiencies: 3
Date: Sep 4, 2003
Visit Reason
The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards, specifically focusing on smoke barrier doors, hazardous area doors, and fire rated and smoke resistant construction of emergency egress stairways.
Findings
The facility was found deficient in maintaining smoke barrier doors to close properly, corridor doors serving hazardous areas to latch securely, and fire rated and smoke resistant construction of emergency egress stairway doors. Specific issues included impeded smoke barrier doors, doors dragging floors, doors not latching in hazardous areas, and damaged latching assemblies on stairway doors.
Deficiencies (3)
Smoke barrier doors were impeded from closing by carts and dragging floors, preventing proper closure to resist smoke passage.
Corridor doors serving hazardous areas did not latch securely in their frames.
Fire rated and smoke resistant construction of emergency egress stairway door was deficient due to damaged latching assembly preventing secure latching.
Report Facts
Facility census: 181
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 7, 2003
Visit Reason
The inspection was conducted in response to complaint #2-3125.
Complaint Details
Complaint #2-3125 triggered the investigation.
Findings
The report includes a deficiency related to the facility's failure to properly inform residents of their rights, rules, services, and charges as required by regulation.
Deficiencies (1)
Failure to inform residents both orally and in writing of their rights, rules, services, and charges as required by 483.10(b)(5)-(10), including Medicaid-related notifications.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Apr 23, 2003
Visit Reason
This document is a Plan of Correction related to deficiencies identified during a prior inspection at Huntington Health and Rehabilitation Center.
Findings
The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b)(5)-(10).
Deficiencies (1)
Failure to properly inform residents of their rights, rules, services, and charges as required by regulation 483.10(b)(5)-(10).
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Mar 13, 2003
Visit Reason
The document is a Plan of Correction related to a previously conducted survey at Huntington Health and Rehabilitation Center, addressing deficiencies identified during the inspection.
Findings
The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulatory standards.
Deficiencies (1)
Failure to properly inform residents of their rights, rules, services, and charges in writing and orally in a language they understand.
Inspection Report
Deficiencies: 3
Date: Dec 5, 2002
Visit Reason
The inspection was conducted to assess compliance with life safety code standards and other regulatory requirements related to resident rights, fire safety, and safe handling of compressed oxygen cylinders.
Findings
The facility was found deficient in maintaining corridor doors to close and latch properly, maintaining the fire alarm system, and safe handling and storage of compressed oxygen cylinders. Specific issues included unlatched corridor doors, fire alarm zones not indicating fire location, ineffective corridor alarms, and unsecured compressed gas cylinders.
Deficiencies (3)
Corridor doors not latched in their frames, preventing secure closure.
Fire alarm system deficient: corridor alarms not providing alarm in two corridors and fire alarm annunciator panel not indicating fire zone location.
Deficient safe handling and storage of compressed oxygen cylinders, including unsecured cylinders and improper storage area.
Report Facts
Compressed oxygen cylinders: 13
Unsecured compressed oxygen cylinders: 3
Corridors with ineffective alarms: 2
Total corridors in old building: 3
Inspection Report
Annual Inspection
Census: 183
Deficiencies: 7
Date: Dec 4, 2002
Visit Reason
Annual inspection survey conducted to assess compliance with federal regulations for nursing facilities, including quality of care, resident rights, physical environment, dietary services, and clinical record accuracy.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during barber services, inaccurate resident assessments, inadequate assistance with feeding, unsanitary conditions of furniture and ice machine, and inaccurate clinical record documentation.
Deficiencies (7)
Facility failed to ensure sixteen male residents were provided care in a manner that maintained their dignity; residents were left unsupervised and lined up in the hallway awaiting barber services for extended periods.
Facility failed to accurately assess the functional capacity and health status of two residents, including incorrect cognitive status assessment.
One resident observed eating late lunch tray alone with food on face and hands; staff unaware of delay or reason.
One resident did not receive adequate assistance to feed himself despite physical limitations.
Twenty-three resident over-bed tables had missing, loose, or damaged laminate preventing proper cleaning.
Ice machine serving old building was soiled and required cleaning, posing risk to all residents served.
Clinical records of six residents contained inaccurate documentation including misplaced information, incorrect height, and discrepancies in minimum data set assessments.
Report Facts
Residents observed unsupervised awaiting barber services: 16
Residents sampled: 28
Residents sampled: 25
Resident room over-bed tables with damaged laminate: 23
Facility census: 183
Residents with inaccurate clinical records: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Instructed staff to apply denture adhesive and discussed MDS coding errors | |
| MDS Coordinator | Responsible for MDS assessments and corrections related to cognitive status and falls/fractures |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 6, 2002
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance for Huntington Health and Rehabilitation Center.
Findings
The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b)(5)-(10).
Deficiencies (1)
Failure to inform residents of their rights, rules, services, and charges in writing and orally in a language they understand.
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jan 31, 2002
Visit Reason
The inspection was conducted as a comprehensive annual survey of Huntington Health and Rehabilitation Center to assess compliance with federal regulations related to resident rights, quality of life, resident assessment, physical environment, and administration.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity and respect, inadequate accommodation of individual resident needs, incomplete resident oral assessments, unsanitary conditions in shower areas, and lack of proper contracts for dialysis services and nursing staffing agencies.
Deficiencies (5)
Failure to promote care in a manner that maintained dignity for residents #70 and #128, including use of a ripped lap buddy and inappropriate staff behavior during resident transfer.
Failure to ensure reasonable accommodation of individual needs regarding positioning for residents #70 and #98.
Failure to accurately assess resident #128 for oral problems; oral lesions and dryness were not documented or assessed routinely.
Facility failed to maintain a clean and sanitary environment; mold and mildew found in shower grout and caulking was failing.
Facility failed to have written contracts specifying responsibility for dialysis services for residents #171, #38, and #20, and lacked comprehensive contract with nursing staffing agency ensuring staff qualifications and background checks.
Report Facts
Sampled residents: 25
Residents receiving dialysis: 3
Facility census: 183
Central showers inspected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding lack of contracts for dialysis services and nursing staffing agency | |
| Registered Nurse | RN | Observed resident #128 and noted oral lesions; interviewed about oral assessments |
Inspection Report
Life Safety
Deficiencies: 1
Date: Jan 31, 2002
Visit Reason
The inspection was conducted to evaluate compliance with NFPA 101 Life Safety Code standards, specifically regarding the functionality of delayed egress locking systems on emergency exit doors.
Findings
The facility was found deficient in maintaining delayed egress locking systems that failed to unlock upon activation of the fire alarm system during a fire drill. Two emergency exit doors, located at the 4th floor stairway near room #430 and the 2nd floor stairway from the old building, did not unlock as required, compromising emergency egress.
Deficiencies (1)
Delayed egress locking systems on emergency exit doors failed to unlock upon activation of the fire alarm system.
Report Facts
Date of fire drill: Jan 31, 2002
Number of deficient doors: 2
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jan 10, 2002
Visit Reason
The visit was conducted as a follow-up survey to complaint number 21246, occurring from January 7, 2002 to January 10, 2002.
Complaint Details
Follow-up survey to complaint 21246 conducted from 1/07/02 to 1/10/02.
Findings
The document contains a statement of deficiencies related to resident rights and notification requirements, but no specific findings or deficiencies are detailed in the provided text.
Deficiencies (1)
Failure to inform residents of their rights and all rules and regulations governing resident conduct and responsibilities during their stay, including notification of Medicaid benefits and charges.
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Nov 2, 2001
Visit Reason
The inspection was conducted in response to Complaint ID 2-1246 to investigate allegations related to medication administration, transcription errors, supervision failures, and resident safety concerns.
Complaint Details
Complaint ID 2-1246 triggered the investigation. The complaint involved medication errors and inadequate supervision leading to resident safety risks. The findings substantiated multiple deficiencies including medication administration errors and failure to prevent resident elopement and injury.
Findings
The facility was found deficient in multiple areas including improper medication administration to Resident #102, incorrect transcription of medication orders for Residents #78 and #186, inadequate supervision leading to residents exiting the building unsupervised (Residents #105, #119, and #163), and failure to prevent injuries related to unsafe exits and door alarms not functioning properly.
Deficiencies (6)
One nurse did not follow standards of practice with medication pass for Resident #102, administering two consecutive puffs of Aerobid inhaler without waiting one minute and failing to have the resident rinse mouth after inhalation.
Incorrect transcription of medication orders for Resident #78, where Colace 100 mg was transcribed as PeriColace.
Incorrect transcription of Prednisone dosage for Resident #186, transcribed as 25 mg instead of 2.5 mg, resulting in a tenfold overdose for 38 days.
Failure to provide adequate supervision to prevent Resident #105 from exiting the building unsupervised multiple times.
Resident #163 exited the building in a wheelchair, rolled down stairs, and sustained injuries due to a malfunctioning door alarm and lack of preventive system.
Resident #119 found sitting on stairs near a door with a non-working alarm, posing potential for more than minimal harm.
Report Facts
Residents reviewed: 7
Residents with medication transcription errors: 2
Days resident #186 received incorrect Prednisone dose: 38
Safety check duration: 72
Safety check interval: 15
Date of first incident Resident #105 exited unsupervised: Jul 17, 2001
Date of second incident Resident #105 exited unsupervised: Jul 29, 2001
Date of third incident Resident #105 exited unsupervised: Sep 27, 2001
Date Resident #163 injured by falling down stairs: Aug 14, 2001
Date Resident #119 found on stairs near exit: Aug 11, 2001
Inspection Report
Plan of Correction
Deficiencies: 9
Date: Mar 22, 2001
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Huntington Health and Rehabilitation Center, detailing regulatory deficiencies identified during a survey completed on March 22, 2001.
Findings
The facility was cited for multiple deficiencies related to residents' rights, quality of life, environment, quality of care, infection control, physical environment, and clinical record maintenance. Deficiencies include failure to inform residents of their rights, inadequate programs for resident activities, unsafe or unclean environment, and incomplete clinical records.
Deficiencies (9)
Failure to inform residents of their rights and provide notice of services and charges in a language understood by the resident.
Failure to promote care that maintains or enhances each resident's dignity and respect.
Failure to provide an ongoing program of activities meeting residents' interests and well-being.
Failure to provide a safe, clean, comfortable, and homelike environment.
Failure to provide necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being.
Failure to assist residents in making appointments and arranging transportation for vision and hearing care.
Failure to provide designated rooms for resident dining and activities that are well lighted, ventilated, furnished, and spacious.
Failure to establish and maintain an infection control program including investigation, control, prevention, and record keeping.
Failure to maintain clinical records that are complete, accurately documented, readily accessible, and systematically organized.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Mar 22, 2001
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance for Huntington Health and Rehabilitation Center.
Findings
The report identifies a deficiency related to the NFPA 101 Life Safety Code Standard requiring vertical openings to be enclosed with two-hour construction, with exceptions for certain building types.
Deficiencies (1)
Vertical openings must be enclosed with two hour construction. Only one hour construction is required in one story buildings, sprinklered buildings three stories or less, and existing buildings.
Inspection Report
Annual Inspection
Deficiencies: 12
Date: Nov 16, 2000
Visit Reason
The inspection was conducted as a comprehensive annual survey of Huntington Health and Rehabilitation Center to assess compliance with federal regulations related to resident care, environment, infection control, and administrative requirements.
Findings
The facility was found deficient in multiple areas including failure to maintain residents' dignity during dining, inadequate activity programs for Alzheimer residents, poor environmental conditions such as strong urine odor and cigarette smoke exposure, failure to provide ordered assistive devices and vision care, improper linen handling, pest control issues, and incomplete clinical documentation.
Deficiencies (12)
Failure to provide care in the dining room to maintain or enhance residents' dignity and respect, resulting in delayed meal service to some residents.
Lack of ongoing activity programs designed to meet the needs of residents with Alzheimer disease on the fourth floor.
Failure to provide a clean, comfortable, and homelike environment due to strong ammonia-like urine odor in one wing.
Failure to provide ordered assistive devices (contracture guards, Spenco boots, hand splints, elbow pads) to residents, risking contractures and skin breakdown.
Failure to ensure residents received proper vision assistive devices and services, resulting in one resident not wearing glasses and having difficulty eating.
Deficient infection control related to improper handling, storage, and transportation of linens, risking spread of infection.
Failure to provide a well-ventilated, smoke-free environment for residents on oxygen therapy exposed to cigarette smoke in smoking areas.
Failure to maintain a safe, functional, sanitary, and comfortable environment including smoke odor in corridors and obstruction of handicapped access in resident toilet/shower rooms.
Failure to maintain an effective pest control program, evidenced by an unsealed gap in an exterior door allowing pest access.
Failure to maintain sanitary conditions during food distribution, with food carts placed near housekeeping carts and soiled linen containers.
Failure to maintain an infection control program to protect residents with tracheostomies from infection; tubing was observed lying on the floor.
Failure to maintain complete and accurate clinical records and documentation of treatments, including undocumented medication orders and premature documentation of treatment completion.
Report Facts
Residents on Alzheimer floor: 53
Residents sampled: 25
Residents with assistive device deficiencies: 3
Residents on oxygen therapy affected by smoke: 4
Smokers in OB area: 10
Unsealed door gap: 1.25
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Nov 16, 2000
Visit Reason
The inspection was conducted as a standard annual survey of Huntington Health and Rehabilitation Center to assess compliance with regulatory requirements including life safety code standards and resident rights notifications.
Findings
The facility was found deficient in multiple areas including failure of corridor doors to close and latch properly, vertical openings not enclosed with required fire-resistance rated construction, smoke barrier walls with unsealed penetrations, exit doors with malfunctioning magnetic locks, obstructed exit discharge paths, and failure to conduct required quarterly sprinkler system inspections and semi-annual kitchen range hood extinguishment system inspections.
Deficiencies (6)
Third and fourth floor clean linen storage room doors failed to close to latch due to bent screws in the striking plate.
Not all facility vertical openings are maintained enclosed with a one hour fire-resistance rated construction, including stairway between 3rd and 4th floor and 1st floor trash chute room.
Smoke barrier walls above lay-in ceiling had unsealed/incompletely sealed penetrations around wires reducing fire rated construction.
Exit doors with magnetic locking devices did not initiate alarm or release when pressure applied; exit discharge paths partially blocked by bush and storage boxes.
Facility automatic sprinkler system was not inspected and tested quarterly as required; last inspection was 8 months prior to survey.
Facility kitchen range hood extinguishment system was not inspected semi-annually; last inspections were 11 months apart.
Report Facts
Months since last sprinkler inspection: 8
Months between range hood inspections: 11
Number of boxes obstructing exit discharge path: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Plant Operations | Interviewed confirming last sprinkler system inspection date. |
Inspection Report
Follow-Up
Deficiencies: 9
Date: Mar 29, 2000
Visit Reason
Follow-up life safety code inspection to verify correction of previously cited deficiencies related to emergency exits and delayed egress locking systems.
Findings
The facility was found deficient in maintaining emergency exits with delayed egress locking systems readily accessible at all times. Several issues were corrected, including removal of magnetic locks and installation of delayed egress locks on exit doors. However, some deficiencies remained such as missing required signage and alarm notification issues on certain doors. A reduction in the scope and severity of the deficiency was recommended from level "F" to level "C" with a follow-up inspection required. Additionally, sprinkler system coverage was found obstructed by storage within 18 inches of sprinkler heads in two locations.
Deficiencies (9)
Corridor door serving medical records office lacked positive latching.
Rear door of first floor boiler room lacked positive latching, had an unsealed 2 inch hole, and door struck frame preventing closure.
Corridor door serving soiled side of laundry struck its frame when closing.
Two through-the-wall vents from medical supply storage room to corridor compromised required one hour fire/smoke resistant construction.
Employee lockers near room #7 not contained within one hour fire/smoke rated construction with proper door and latching.
Emergency exit door near smoking lounge had a sign stating 'This is not an exit door' which was removed.
Seven chairs stored in corridor near medical supply storage room obstructed emergency egress.
Magnetic locks on emergency egress doors did not meet delayed egress locking system requirements; replaced with delayed egress locks but missing required signage and alarm notification on some doors.
Storage within 18 inches of sprinkler heads in activity office and maintenance shop obstructed sprinkler coverage.
Report Facts
Inspection dates: 3
Storage clearance: 18
Delayed egress door unlock delay: 15
Inspection Report
Annual Inspection
Census: 177
Deficiencies: 7
Date: Dec 16, 1999
Visit Reason
The inspection was conducted as a comprehensive annual survey of Huntington Health and Rehabilitation Center to assess compliance with federal regulations regarding resident rights, quality of care, environment, infection control, dietary services, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to post the most recent survey results in accessible locations, improper use of physical restraints on a resident, failure to maintain resident dignity by leaving a resident wet in a public area, inadequate housekeeping in dining areas, failure to enforce proper handwashing protocols among staff, failure to provide snacks to all residents at bedtime, and unsanitary food storage and handling practices in the dietary department.
Deficiencies (7)
Failed to make the results of the most recent survey available for examination and failed to post it in a place readily accessible to residents.
Failed to ensure one resident's right to be free from physical restraints imposed for convenience; resident was restrained with a lap tray on wheelchair against her wishes.
Failed to promote care for one resident in a manner that maintains dignity by leaving the resident wet with urine in a public lobby.
Failed to provide effective housekeeping services for one of four dining areas; tables were littered and dirty during and after meals.
Failed to require staff to wash hands after each direct resident contact for which handwashing is indicated; observed in three instances.
Failed to offer snacks at bedtime daily to all residents not on specific diets requiring snacks.
Failed to store, prepare, distribute, and serve food under sanitary conditions; issues included improper handling of raw eggs, uncovered food, unlabeled and undated food items, and potential cross contamination of utensils.
Report Facts
Facility census: 177
Sampled residents: 24
Residents in group meeting: 12
Deficiencies cited: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses | Stated that the statement of deficiencies from the last survey had not been posted | |
| Licensed Practical Nurse (LPN) | Observed failing to wash hands properly and involved in medication administration and patient care violations |
Inspection Report
Life Safety
Deficiencies: 9
Date: Dec 16, 1999
Visit Reason
The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards, specifically focusing on hazardous area construction, emergency exit accessibility, and sprinkler system maintenance.
Findings
The facility was found deficient in maintaining required fire safety measures including lack of positive latching on corridor and boiler room doors, compromised fire/smoke resistant construction due to vents and locker placement, obstructed emergency exits, improper locking mechanisms on emergency egress doors, and storage obstructing sprinkler head coverage.
Deficiencies (9)
Corridor door serving the medical records office lacked positive latching.
Rear door of first floor boiler room lacked positive latching, had an unsealed 2 inch hole, and door struck frame preventing closure.
Corridor door serving soiled side of laundry struck its frame preventing proper closure.
Two through-the-wall vents compromised one hour fire/smoke resistant construction of second floor medical supply storage room.
Employee lockers near room #7 not contained within one hour fire/smoke rated construction with proper door and latching.
Emergency exit door near smoking lounge had a sign stating 'This is not an exit door' and was alarmed; sign was ordered removed.
Seven chairs stored in corridor near medical supply storage blocked unobstructed emergency egress.
Magnetic locks on emergency egress doors did not meet delayed egress locking system requirements.
Storage within 18 inches of sprinkler heads in activity office and maintenance shop obstructed sprinkler coverage.
Report Facts
Inspection dates: 3
Storage clearance: 18
Hole size: 2
Force for door release: 15
Maximum height for releasing mechanism: 48
Inspection Report
Deficiencies: 18
Date: Dec 15, 1999
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to the physical environment, resident rights, and sanitary conditions.
Findings
The facility was found to have multiple deficiencies including unlocked electrical panel boxes, lack of exhaust ventilation in smoking lounges, missing electrical outlet covers, unsafe door locks, malfunctioning GFI devices, unsecured cleaning chemicals, damaged and unsanitary conditions in various rooms, and missing or damaged fixtures and surfaces throughout the building.
Deficiencies (18)
Unlocked corridor electrical panel boxes allowing unauthorized access.
Smoking lounges lacked exhaust ventilation causing second-hand smoke odor in corridors.
Missing electrical outlet cover in resident room 322.
Missing shield on ceiling light fixture in pantry room.
Corridor doors with sliding bolt locks that do not allow egress if locked.
Ground Fault Circuit Interrupting (GFI) devices in multiple resident rooms failed to function properly.
Two gallon container of liquid disinfectant stored unsecured on the floor near men's shower tub area.
Employee lounge restroom commode out of order with strong offensive odor.
Cabinet doors in pantry room would not close properly; one cabinet door missing; countertop laminate missing.
Shower stall missing water supply handle.
Ceiling tiles water damaged or missing; exterior wall wallpaper peeling in waiting room.
Corridor wall damaged and handrail missing near room 402.
Hand sink missing from women's handicapped/training toilet.
Shower rooms with missing wall/floor tiles and mold/mildew accumulation.
Ice machines insufficiently clean inside.
Wall heating units in dining room with accumulation of food particles in air vents.
Wall cove base missing in multiple rooms preventing proper cleaning.
Exterior walls in resident rooms with peeling paint and unfinished plaster patches.
Report Facts
Deficiencies cited: 17
Inspection dates: 3
Resident rooms with non-functioning GFI devices: 9
Resident rooms with exterior wall issues: 5
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