Waters of Huntington Skilled Nursing Facility, the

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were maintained for shared bathroom space, including toilets and bed pans, for 1 of 3 residents reviewed for infection control. (Resident B)

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident with a known full code status (cardiopulmonary resuscitation [CPR] to be performed) received the appropriate emergency services as evidenced by a nurse (LPN 1) with an expired CPR certification starting CPR without a physical assessment, ceasing CPR without a medical evaluation, and failing to notify emergency services when the resident was found not breathing and without a heart rate for 1 of 3 residents reviewed for death. (Resident B). This deficient practice resulted in the facility's failure to provide CPR for Resident B during a medical event that resulted in death. The immediate jeopardy began on [DATE] when the facility failed to provide CPR as indicated by professional standards to a resident with a full code status who experienced a medical event resulting in death. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff provided care within their scope of practice as evidenced by LPN 1 giving medication orders for a nebulizer (breathing) treatment to QMA 2 without a physician order, QMA 2 administered the nebulizer treatment, staff failed to initiate emergency medical services, and LPN 1 made the determination to end CPR activities without indication. (Resident B) This deficient practice resulted in a delay in emergency medical treatment for a resident experiencing a change in condition that resulted in death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the high-temperature dishwasher functioned at a level to maintain proper sanitization requirements. This deficient practice had the potential to impact 58 of 58 residents who received meals from the facility kitchen.

Inspectors wroteBased on interview and record review, the facility failed to promote residents' rights to make choices regarding taking leave of absence within the local community and failed to assess residents for their ability to make such determinations before restricting leave of absence for 2 of 2 residents reviewed for self-determination. (Residents 1 and 34). During a Resident Council group interview, on 7/24/25 at 1:33 p.m., Resident 34 indicated she had concerns and questions about why she and another resident were no longer allowed to leave the facility property on their motorized scooters. During an interview with the Administrator on 7/24/25 at 2:15 p.m., she indicated there was an incident with a resident on a motorized scooter. The resident(s) had done something they should not have and caused an incident. The incident happened before the Administrator was employed by the facility. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to assess residents for self-administration of medications for 3 of 3 residents reviewed for self-administration of medication. (Resident 8, Resident 12, and Resident 42)Findings Include: 1. During an observation and interview with Resident 12, on 7/21/25 at 10:51 a.m., the resident indicated his morning medications were left with him each day because he did not like to take his medications before he ate breakfast. On his bedside table was a medication cup which contained one medium round peach pill, one medium round beige pill, one small round pink pill, and half of a small oblong white pill. Nurses left his morning medications with him daily because they were aware he waited for breakfast to be served before he took the pills. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident and the resident's representative were notified in writing of the transfer/discharge appeal rights and the bed hold policy when a resident was transferred to the hospital for 1 of 3 residents reviewed for hospitalization (Resident 58).

Inspectors wroteBased on interview and record review, the facility failed to ensure vision services were provided for 1 of 3 residents reviewed for ancillary services. (Resident 33) Finding Includes:During an interview, on 7/21/25 at 10:00 a.m., Resident 33 indicated he had not been seen by the facility's eye doctor. He spoke with the Social Service Director two weeks ago and she was to schedule an eye appointment at the local supermarket. He had not heard anything regarding an appointment. He was blind in his left eye and had poor vision in right eye. Resident 33's clinical record was reviewed on 7/25/25 at 1:59 p.m. Diagnoses included benign prostatic hyperplasia (enlarged prostate), neuropathy (nerve damage), major depressive disorder, and anxiety. Current orders included Resident 33 may receive services including eye care, audiology, podiatry, and dental. (9/19/24). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement effective interventions for and monitoring of behavior expressions of known wandering and physical aggression for 1 of 1 residents reviewed for dementia care. (Resident 53)

Inspectors wroteBased on record review and interview, the facility failed to implement pharmacy recommendations and follow physician orders to discontinue medications for 1 of 5 residents reviewed for pharmacy recommendations. (Resident 24)

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident did not receive an excessive dosage than ordered of an antidepressant when physician orders were not followed for a gradual dose reduction for 1 of 5 residents reviewed for unnecessary medications. (Resident 24)

Inspectors wroteA. Based on observation and interview, the facility failed to ensure narcotic medication was appropriately identified, labeled and stored. This deficient practice had the potential to affect 1 of 58 residents who resided in the facility. B. Based on observation, record review, and interview, the facility failed to ensure medications were labeled for 1 of 2 medication carts observed. This deficient practice had the potential to affect 15 of 15 residents who received medications from the secured unit medication cart

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision for a resident with known fall risk and ensure the implementation of fall interventions to prevent repeated falls for 2 of 3 residents reviewed for falls. (Resident B and Resident D) This deficient practice resulted in Resident B sustaining a left ankle fracture during a fall.

Inspectors wroteBased on record review and interview, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately coded for 2 of 3 residents' MDS assessments reviewed. (Resident B and D)

Inspectors wroteBased on interview and record review the facility failed to ensure assessments were completed for 3 of 4 residents reviewed with respiratory illness and falls. (Resident J, Resident C and Resident D).

Inspectors wroteBased on observation and interview, the facility failed to ensure the facility was maintained in a clean, homelike manner for random observations of resident rooms, bathrooms, and common area hallways.

Inspectors wroteBased on record review and interview, the facility failed to provide weekly skin assessments for a resident identified at risk for skin breakdown according to their plan of care for 1 of 3 residents assessed for pressure injury. (Resident D)

Inspectors wroteBased on interview and record review, the facility failed to ensure staff reported a resident-to-resident altercation to the Administrator immediately, delaying the submission of the incident within the required timeframe to the Indiana Department of Health for 1 of 3 incidents reviewed. (Resident B and Resident C)

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement individualized non- pharmacological interventions for behaviors for residents with dementia for 1 or 3 residents reviewed for dementia care (Resident B and Resident C).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision to prevent falls for a cognitively impaired resident, 1 of 3 residents reviewed for accidents. (Resident C)

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove and destroy expired insulin from the medication cart for 1 of 2 medication carts reviewed for medication storage. (Center Unit Medication Cart) This affected 1 of 12 residents who received medications from this medication cart. (Resident 27)

Inspectors wroteBased on observation and interview, the facility failed to ensure the posted daily nurse staffing data was completed at the beginning of the shift and readily available for residents and visitors during 3 of 3 observations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to involve the resident prior to a room change, resulting in the resident worrying about her personal property being damaged, for 1 of 3 residents reviewed for quality of care. (Resident B)

Inspectors wroteBased on interview and record review, the facility staff failed to provide resident information to assure continuity of care for a resident's emergency transfer to an acute care hospital for 1 of 5 residents reviewed for hospitalization. (Resident 6)

Inspectors wroteBased on record review and interview, the facility failed to ensure a significant change Minimum Data Set (MDS) assessment was completed when hospice services were initiated for 1 of 4 residents reviewed for hospice services (Resident 42).

Inspectors wroteBased on record review and interview, the facility failed to assure collaborative communication with the hospice provider for 2 of 4 residents reviewed for hospice services. (Residents 14 and 15)

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions (EBP) for 1 of 3 residents reviewed for Transmission Based Precautions. (Resident 19)