Huntington Health Care & Rehabilitation Center

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute and serve food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure food stored the kitchen refrigerator was labeled, dated and not expired. 2. The facility failed to ensure food stored in the kitchen dry storage area was labeled, dated, and not expired. These deficient practices could place residents at risk for foodborne illness. During an observation on 7/15/2025 at 10:15 AM revealed the following: #2 refrigerator contained (2) 46-ounce containers of opened and undated thickened lemon water. #3 refrigerator contained (2) pies with a graham cracker crust and unknown white filling that was opened, unlabeled and undated. #4 Freezer contained (5) bags of French fries that were unlabeled and undated. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 8 residents (Resident #3 and Resident #14) and 3 of 7 staff (CNA D, CNA E and LVN G) reviewed for infection control. 1. The facility failed to ensure CNA D followed EBP (enhanced barrier precautions) for Resident #3 when providing care on 7/15/2025. 2. The facility failed to ensure the ice cooler's scoop compartment on hall 400 did not contain a towel with a black substance on 7/15/2025. 3. The facility failed to ensure LVN G washed or sanitized her hands during administration of IV medications to Resident #14 on 7/16/2025.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 1 of 4 resident hallways (Hallway 100) and the main dining room reviewed for environmental concerns. 1. The facility failed to ensure rooms 101, 103, 106, and 107 did not have soiled floors on 7/15/2025 and 7/16/2025. 2. The facility failed to ensure the floors on 100 hallway did not have soiled floors on 7/15/2025 and 7/16/2025. 3. The facility failed to ensure the dining room did not have soiled floors on 7/15/2025 and 7/16/2025. These failures could place residents at risk of a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to immediately inform the resident's physician when there was a significant change in resident's physical, mental, or psychosocial status for 1 of 6 residents (Resident #52) reviewed for notification of changes in that: The facility did not notify Resident #52's physician for a significant change in weight. (weight loss of 25.8 pounds in 30 days.) This deficient practice could place residents at risk of not having their physician notified of changes resulting in a delay in continuity of care.

Inspectors wroteBased on interviews and record review, the facility failed to complete a comprehensive MDS assessment within 14 days after a significant change in the resident's mental or physical condition for 1 of 4 residents (Resident #6) reviewed for assessments. The facility failed to reassess Resident #6 following a hospice admission (specific care for the sick or terminally ill) on 03/24/25. This failure could place residents at risk for not having their individual needs met due to inaccurate assessments.

Inspectors wroteBased on interviews and record review, the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change of condition for 1 of 4 Residents (Resident #6) reviewed for PASRR (Preadmission Screening and Resident Review Services). The facility failed to ensure Resident #6 had a new level 1 PASSR completed with a new diagnosis of psychotic disorder with delusions (a mental disorder in which a person has delusions, but with no accompanying prominent hallucinations, thought disorder, mood disorder, or significant flattening of affect) and major depressive disorder (a serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and a range of emotional and physical problems). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 1 of 4 residents (Resident #21) reviewed for PASRR Level I screenings. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #21. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnoses (bipolar disorder) were present upon Resident #21's admission date on 9/27/2024. This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needs.

Inspectors wroteBased on interview, and record review the facility failed to review and revise the comprehensive care plan after each assessment for 1 of 4 (Resident #6) residents reviewed for care plan revisions. The facility failed to update Resident #6's care plans for hospice status. These failures could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 2 of 8 residents (Resident #9 and Resident #20) reviewed for quality of care.1. The facility failed to remove worn and damaged mechanical lift slings from service for Resident #9 on 7/15/2025 and 7/16/2025.2. The facility failed to ensure a bottle of peri-wash was not left in Resident #20's room on 7/15/25. This failure could place residents at risk of injuries due to environmental hazards.

Inspectors wroteBased on observation, interviews and record reviews the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals and preferences for 1 resident (Resident #57) out of 2 residents observed for respiratory therapy. The facility failed to obtain physician orders for Resident #57's Bipap settings he used each night at the facility since his admission on [DATE]. This failure could place residents who reside at the facility at risk for inaccurate care and communication of health conditions to other providers. Record review of Resident #57's electronic medical record and face sheet dated 7/16/2025 reflected he was admitted to the facility on [DATE]. His diagnoses included: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services including procedures that assured the accurate acquiring, receiving, dispensing and administering for all drugs and biologicals to meet the needs of each resident for 1 of 12 months (May 2025). The facility failed to have a licensed pharmacist, 2 facility staff witnesses and sign the drug destruction log during drug destruction occurrence May 22, 2025. These failures could place residents at risk for misappropriation and drug diversion.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 4 residents (Resident #23) reviewed for storage of medications and for 1 of 4 medication carts (Nurse Cart L) reviewed for pharmacy services.1. The facility failed to ensure Resident #23's 10 ml sterile normal saline prefilled syringe and intravenous site dressing were not kept at the bedside and was unable to be accessed by unauthorized personnel or residents on 07/15/25. 2. The facility failed to ensure expired Tresiba (insulin degludec) for Resident #30 was not on the nurse medication cart on 7/16/25. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption for 1 of 2 resident personal refrigerators (Resident #57) reviewed for food safety. 1. The facility failed to ensure the refrigerator for Resident #57 was clean and contained food items that were labeled and dated. 2. The facility failed to ensure the refrigerator for Resident #57 did not contain expired milk or expired whipped cream. These failures could place residents at risk for food borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to provide documentation for transfer or discharge by resident's physician for 1 of 1 resident (Resident #1) reviewed for discharge requirements. The facility failed to provide a reason for Resident #1's discharge by the resident's physician and the specific resident needs the facility could not meet, the facility's efforts to meet those needs and the specific services the receiving facility would provide to meet the needs of the resident which could not be met at current facility. This failure could place residents at risk of not having the needed records when transferring care and services and causing a disruption in their care and/or services.

Inspectors wroteBased on record review and interviews the facility failed to ensure the arbitration agreement contained all the required elements for 1 of 1 facility reviewed for Arbitration Agreements. The facility did not ensure the arbitration agreement granted the resident or his/her representative the right to rescind the agreement within 30 calendar days of signing. The facility did not ensure the arbitration agreement allowed the resident or anyone else (e.g., resident's representative) to communicate with federal, state, or local officials such as federal and state surveyors, other federal or state health department employees, and representative of the Office of the State Long Term Care Ombudsman. This failure could place the residents or the residents' responsible parties in binding agreements not fully understood, have a loss of their legal rights, and cause negative psychological issues.

Inspectors wroteBased on record review and interviews the facility failed to ensure the Arbitration Agreement contained all the required elements for 1 of 1 facility reviewed for Arbitration Agreements. The facility failed to ensure the arbitration agreement included provision of a neutral arbitrator. The facility failed to ensure the arbitration agreement contained a section indicating the provision of a convenient venue. These failures could place the residents or the residents' responsible parties in binding agreements not fully understood, have a loss of their legal rights, and cause negative psychological issues.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow established policy regarding smoking areas, and smoking safety for 1 of 1 smoking area reviewed. The facility failed to empty ash trays and keep trash out of the ash trays in the designated smoking area on 5/29/2024. This failure could place residents who smoke at risk of physical harm and lead to an unsafe smoking environment.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for 3 of 12 residents reviewed for quality of care. (Resident #3, #33, and #38) The facility failed to remove worn and damaged mechanical lift slings from service. This deficient practice could result in a loss of quality of life due to injuries.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that residents requiring respiratory care are provided care, consistent with professional standards of practices for 3 of 7 residents reviewed for respiratory care (Residents #15, #29, and #1). The facility failed to ensure the external filters of Resident's #15, #29, and #1 oxygen concentrators were free of dust buildup on 5/28/2024. These failures could place residents who require respiratory care at risk for respiratory infections, breathing in dust and allergens, decreased effectiveness of oxygen concentrators, and exacerbation of respiratory distress.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the only kitchen. Temperature logs for the dishwasher, refrigerator 1, refrigerator 2, freezer 1, and freezer 2 were missing recorded temperatures. This failure could place residents who ate from the kitchen at risk of foodborne illness.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #116) and 3 of 8 staff (MDS nurse, CNA E, and CNA F) reviewed for infection control. MDS nurse failed to perform hand hygiene between residents during noon meal service on 5/28/2024. CNA E and CNA F failed to follow enhanced barrier precautions (EBP) when they provided foley catheter (a tube inserted into the bladder) care and incontinent care to Resident #116 on 5/28/2024. These failures could place residents at risk of exposure to communicable diseases and infections.

Inspectors wroteBased on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promoted resident independence and dignity while dining for one (1) of 24 residents reviewed for meal service. (Resident #53). LVN B stood beside Resident #53 while she assisted the residents to eat. This failure could place residents who need assistance with eating at risk for weight loss and a decreased quality of life.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure that the resident was free from physical or chemical restraints imposed for purposes of discipline or convenience and that were not required to treat the resident's medical symptoms for 1 of 10 residents (Resident #54) reviewed for physical restraints. The facility failed to obtain physician order and informed consent for Resident #54 before implementing a position change alarm. This failure could place residents in the facility at risk of decreased quality of life, injury and being subjected to restraints for purposes of convenience or discipline.

Inspectors wroteBased on interviews and record review, the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change of condition for 1 of 6 Residents (Resident #32) reviewed for PASSAR (Preadmission Screening and Resident Review Services). The facility failed to ensure Resident #32 had a new level 1 PASSAR completed with a new diagnosis of Post-Traumatic Stress Disorder (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations) and major depressive disorder (persistent feeling of sadness and loss of interest that interferes with daily life). [...]

Inspectors wroteBased on interviews and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 2 of 8 residents (Resident #48 and #64) reviewed for baseline care plans. The facility failed to complete a baseline care plan within 48 hours of admission on Resident # 48 and provide a care plan summary to the resident or representative. The facility failed to complete a baseline care plan within 48 hours of admission on Resident # 64 and provide a care plan summary to the resident or representative. These failures could place residents at risk of not receiving correct and/or necessary care or treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications for 1 of 1 medication rooms reviewed for medication administration. The facility failed to dispose of expired medications from the medication storage room. These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications, decreased quality of life, and hospitalization.

Inspectors wroteBased on observations and interviews the facility failed to provide food that was palatable, and at a safe and appetizing temperature for residents interviewed for food temperature and taste. (Resident #168) The facility failed to serve hot and palatable foods. Resident #168 complained the food was served cold and did not taste good. These failures could place residents at risk for weight loss, altered nutritional status, and diminished quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to be equipped to allow residents to call for staff through a communication system which relayed the call directly to a centralized staff work area for 2 of 12 residents reviewed for call lights. (Residents #44 & #55). The facility failed to ensure Resident #44's and Resident #55's emergency call lights in the bathroom were reachable from the floor. This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 3 medication carts (nurse cart 100 hall) and the medication storage room reviewed for labeling and storage. 1. The facility failed to remove expired insulin and glucose control solutions (high and low solutions) from the nurse medication cart on hall 100. 2. The facility failed to label and remove expired Tuberculin (TB) testing solution from the medication room refrigerator. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions in 1 of 1 kitchen reviewed for kitchen sanitation. Cook D had hair hanging out of the back of her hair net while washing dishes. The inside bin of the ice maker was dirty. Cook E laid the spoon used for stirring the pureed meat, on the three-compartment sink drainboard, then picked it up and continued to use it. These failures could place the residents at risk of foodborne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 2 of 15 residents (Residents #14 and #25) reviewed for care plans. The facility failed to ensure Resident #14 and Resident #25's care plans accurately reflected residents' PASRR positive status. This deficient practice could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible for 1 of 15 residents (Resident #43) reviewed for accident hazards. The facility failed to ensure an aerosol can of air freshener was not sitting on the bedside table of Resident #43's room. Label contained the phrase .KEEP OUT OF REACH OF CHILDREN AND PETS . This failure could place residents with dementia that may wander at risk of injury by ingestion or inhalation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 2 of 13 residents (Residents #16 and #28) reviewed for respiratory care. The facility failed to ensure Residents #16 and #28's nasal cannula tubing on the wheelchair was changed every 7 days and labeled. This deficient practice could place residents at risk of developing respiratory infections and complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for the lunch meal on 03/28/23 reviewed for food form and preparation. The facility failed to ensure the pureed turkey, prepared on 03/28/22 for the noon meal, was pureed to a smooth consistency without grainy, fibrous particles in it. This failure could place residents who received pureed or mechanically chopped meat at risk of consuming foods that could cause choking, decrease meal intake, and not having nutritional needs met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 3 resident personal refrigerators reviewed for food safety (Resident #25). The facility failed to ensure the refrigerator for Resident #25 did not contain expired diced peaches and box of coffee creamer singles. This failure could place resident at risk for food borne illnesses.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure services provided met professional standards of quality for 1 of 18 licensed staff (ADON) reviewed for valid nursing licenses. The facility failed to ensure the ADON's nurse license did not expire as of [DATE]. This failure could place residents at risk for not receiving nursing services by a licensed nurse.

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain medical records on each resident that were complete and accurate, in accordance with accepted professional standards and practices for 3 of 6 residents (Resident #17, Resident #28 and Resident #38) reviewed for accurate records. The facility failed to ensure Resident #17, Resident #28 and Resident #38's executed (signed by MD and resident representative) Consent for Antipsychotic or Neuroleptic Medication Treatment (Form 3713) was placed in the medical record per facility policy. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care and risk to safety.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain all mechanical, electrical, and patient care equipment, in safe operating condition, for 1 of 1 stove in the kitchen reviewed for food service. The facility did not ensure the gas stove was in working order. One of six gas stove burners did not light automatically, when the knob was turned. This failure could place residents who eat out of the kitchen at risk for injury and under cooked food.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to be equipped to allow residents to call for staff through a communication system which relays the call directly to a centralized staff work area for 2 of 12 residents reviewed for call lights. (Resident # 30 and Resident #48) The facility failed to ensure Resident #30 and #48's emergency call light in the bathroom would reach the floor. The call light cord was coiled up in a bundle above the support bar. This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS reviewed for administration (Fiscal year 2023 for the first quarter October 1, 2022 to December 31, 2022) The facility failed to submit PBJ staffing information to CMS for the 4th quarter of the fiscal year 2022. The facility's failure could place residents at risk for personal needs not being identified and met.