Heritage Pointe of Huntington: 53 Falls, Missing Safety Tools - IN
The resident, identified in inspection records as Resident B, could not reliably tell staff when he needed to use the bathroom. He was totally dependent on caregivers for nearly everything except feeding himself. Staff knew to watch him for nonverbal cues because he couldn't consistently put his needs into words. He was described as often antsy. He was known to slide out of his bed onto his buttocks. He fell repeatedly trying to get up from his wheelchair or recliner.
Between April 26, 2025 and October 19, 2025, he fell 53 times.
A physician had ordered a concave mattress as one of the interventions meant to reduce his fall risk. By the time inspectors visited on October 20, the intervention had changed to a body pillow instead. But nobody had updated the care plan or discontinued the mattress order. The concave mattress was not in place. The care plan and the physician's orders did not match. A certified nursing assistant confirmed both facts to inspectors that afternoon.
The call light presented its own problem. Glow-in-the-dark tape had been identified as an intervention, something to help Resident B locate his call light in the dark and summon help before attempting to get up on his own. No such tape was on the call light. The CNA confirmed that too.
The director of nursing, interviewed at 4:46 p.m. on the day of the inspection, said she was unsure whether specialty tape like glow-in-the-dark tape had ever been used. She acknowledged the concave mattress order should have been discontinued when the intervention changed to a body pillow. She said physician orders were supposed to be followed and care plans were supposed to match those orders. She said Resident B needed more one-on-one attention to prevent falls. She offered an explanation for why the clinical record had not kept pace: the MDS nurse was on medical leave, and staff had been doing their best to implement interventions and update the documentation.
The facility's own fall prevention policy, provided by the administrator during the inspection, states that every resident will be assessed for fall risk and receive care in accordance with their individualized level of risk. The policy further requires that after any fall, staff review the care plan and update it as needed, and document all assessments and actions taken.
Fifty-three falls. Six months. The care plan still reflected an intervention that was no longer being used. The intervention that replaced it was in place, but the order for the old one had never been closed out. The new intervention meant to help him call for help before he tried to stand, the tape on the call light, was never applied at all.
The inspection was conducted in response to a complaint. Inspectors cited the violation at a level of minimal harm or potential for actual harm, affecting a small number of residents. That classification reflects the regulatory framework's language, not a judgment that 53 falls across six months represents an acceptable outcome for any person in any care setting.
Resident B could not reliably say when he needed help. He depended on staff to read his body language, to watch for the restlessness that preceded a fall, to make sure the things ordered to protect him were actually there when he reached for them in the dark.
Some of those things were not there.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Heritage Pointe of Huntington from 2025-10-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 24, 2026 · Our methodology
HERITAGE POINTE OF HUNTINGTON in HUNTINGTON, IN was cited for violations during a health inspection on October 20, 2025.
The resident, identified in inspection records as Resident B, could not reliably tell staff when he needed to use the bathroom.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.