Continuing Care at Highland Springs

Inspectors wroteBased on interview and record review the facility failed to ensure each resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 of 6 residents (Resident #1) reviewed for behavioral services. The facility failed to provide behavioral health care and services to Resident #1 who continued to express suicidal ideations and display signs and symptoms of depression after inpatient treatment for suicidal ideations at a behavioral health hospital stay from [DATE]-[DATE], resulting in Resident #1 ingesting a lethal dose of diphenhydramine (Benadryl) and expiring on [DATE]. An IJ was identified on [DATE] at 5:07 PM. The IJ template was provided to the facility on [DATE] at 5:25 PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive centered care plan for each resident that includes measurable objectives to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #1) of 6 residents reviewed for care plans. The facility failed to develop a care comprehensive care plan with interventions and actions the facility could take that were specific to Resident #1's suicidal ideations when she admitted to the facility from an in-patient behavioral health facility on [DATE]. On [DATE] Resident #1 ingested approximately a bottle and a half of Benadryl (Diphenhydramine) and expired at the local hospital. An IJ was identified on [DATE] at 5:07 PM. The IJ template was provided to the facility on [DATE] at 5:25 PM. While the IJ was removed on [DATE] at 4: [...]

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, and mental and psychosocial needs that were identified in the comprehensive assessment for three (Residents #5, #7, and #33) of six residents reviewed for care plans. The facility failed to ensure Residents #5, #7, and #33's comprehensive care plans addressed their use of psychotropic medications (drugs that affect the mind, emotions, and behavior) and related behavioral concerns as identified in their comprehensive assessments. This failure could place residents at risk of receiving inadequate interventions not individualized to their mental health care needs. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed ensure residents were free of any significant medication errors for one (Residents #27) of two residents reviewed for medications. The facility failed to ensure LNV A administered a medication as ordered to Resident #27 by crushing Aspirin ER (used to prevent cardiovascular events like heart attack and stroke in high-risk patients) and Potassium ER Chloride (mineral supplement prescribed by a doctor to treat or prevent hypokalemia (low potassium levels); medications that should not be crushed. This deficient practice placed residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure food was properly stored in the facility's freezer. These failures could place residents at risk for food-borne illnesses. Observation of the facility's freezer on 09/09/24 at 9:23 AM revealed: - 1 tub of ice cream with lid open and exposed to air; - 1 box of pie crust shells open and exposed to air; - 1 box of biscuits open and exposed to air; In an interview on 09/09/2025 at 9:45 AM, the Chef stated she had been unaware that some boxes were open and exposing food to air. She admitted she did not know how to address the issue and had not realized it was a problem. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 1 of 1 facility's reviewed for grievances. The facility failed to make information known to Resident's and their Representatives either individually or through postings in prominent locations throughout the facility on who the facility grievance official was, their contact information, how to file an anonymous grievance and their right to obtain a written decision related to their grievance. The facility failed to ensure Resident's #1,# 2, and# 3 had information known to them on how to file a grievance or concern, who the grievance official was, how to file an anonymous grievance, and their right to obtain a written decision related to their grievance. [...]

Inspectors wroteBased on interview, and record review, the facility failed to coordinate assessments with the Pre-admission Screening and Resident Review (PASARR) program for 4 (Resident #3, Resident #5, Resident #7, Resident #8) out of 4 residents reviewed for PASARR assessments. The facility failed to transcribe PL1s' (PASARR Level 1 Screenings) to the LTC Online Portal for 4 (Resident #3, Resident #5, Resident #7, Resident #8) out of 4 residents reviewed for PASARR assessments. This failure could place residents who are eligible for PASARR services at risk of not receiving needed services. Findings Include: Record Review of Resident #5's admission MDS with an ARD (Assessment Reference Date) of 03/16/2024 revealed she was an [AGE] year-old-female who admitted to the facility on [DATE]. Resident #5's active diagnoses included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately submit a PL1 (PASARR Level 1 Screening) screening when residents admitted with a diagnosis of Mental Illness, Intellectual Disability or Developmental Disability for 3 (Resident #5, Resident #7, Resident #8) out of 4 residents reviewed for PASARR screenings. The facility failed to submit a new PL1 screening when residents were diagnosed with a new diagnosis of Mental Illness, Intellectual Disability or Developmental Disability during their stay for 1 (Resident #3) out of 4 residents reviewed for PASARR screenings. The facility failed to ensure that Resident #5, Resident #7, and Resident #8 had accurate PL1's on admission. 1. The facility failed to submit a correct PL1 screening for Resident #5 when she admitted to the facility on [DATE] with an active diagnosis of Major Depressive Disorder. 2. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 2 (Pod 1 and Pod 2) out of 2 units reviewed for environment. 1. The facility failed to ensure that the mechanical lift on Pod 1 was locked and secured when not in use. 2. The facility failed to ensure that the mechanical lift on Pod 2 was locked and secured when not in use. 3. The facility failed to ensure a parked wheelchair in the common area on Pod 1 was locked and secured when not in use. 4. The facility failed to ensure that razors intended for shaving use were locked and secured. These failures could place residents at risk for falls and/or injury. Findings Include: Observation of the facility's Pod 1 Unit on 07/30/24 at 9:45 am revealed an unlocked and unsecured mechanical lift parked in front of a resident's room. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food that was palatable for two (lunch meal 08/01/24) of four meals reviewed for palatability. [NAME] L added water to the puree recipe on 07/31/2024 . The facility failed to serve pureed mashed potatoes, root vegetable soup, purred roast beef that was palatable. The facility failed to serve mechanical chopped roast beef or root vegetable soup that was palatable. These failures could affect residents by placing them at risk of weight loss, altered nutritional status and a diminished quality of life. Findings Included: Observation on 08/01/24 at 1:05pm of lunch test tray revealed the pureed lunch was served on a tray with a cover. The purred lunch tray revealed a white ceramic container with pureed mashed potatoes, pureed roast beef, both items were in the same container in round formations. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: The facility failed to ensure that food in the kitchen was labeled, dated and/or sealed. These deficient practices could affect 42 residents who received meals and/or snacks from the main kitchen and place them at risk for food borne illness. Findings Included: Observation of the kitchen on during the Initial Brief Tour on 07/30/2024 at 9:25 AM, revealed that inside the large freezer there was rack in the entry of the freezer that contained a silver pan of pink shrimp on a sheet pan. There was a piece of parchment paper covering the shrimp with a florescent green label dated 07/30. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences of 1 (Resident #1) of 4 residents reviewed for activities of daily living. 1. The facility failed to ensure that Resident #1 had a mobility device that was accessible and comfortable to her that promoted independence, activity involvement and psychosocial need. This failure could place residents at risk of increased isolation and depression. Findings Include: Record Review of Resident #1's Quarterly MDS with an ARD (Assessment Reference Date) of 06/26/2024, revealed an [AGE] year-old female who admitted to the facility on [DATE]. Resident #1's diagnoses included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #12) of 8 residents reviewed for quality of life. The facility failed to ensure Resident #12 was taken to the bathroom when he requested and did not have to soil himself. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for falls, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of three residents (Resident #1, #2, and #3) of 18 residents reviewed for medications and pharmacy services. The facility failed to ensure nurses were adequately counting narcotic cards and blister packs, narcotic count audits were conducted to prevent a drug diversion, and nurses were properly disposing of narcotics. Resident #1 and Resident #3 were missing narcotics. Resident #1, #2, and #3 had unexplained wasted (disposed) narcotics from May 2023 to December 2023. The noncompliance was identified as PNC. The noncompliance began on 05/16/23 and ended on 12/11/23. The facility had corrected the noncompliance before the survey began. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide or arrange services as outlined by the comprehensive care plan to meet professional standards for one (Residents #1) of 18 residents observed for medication administration. RN A and LVN B failed to report Resident #1 was missing one hydrocodone pill during narcotic count. RN A and LVN B failed to properly document Resident #1's missing hydrocodone pill during narcotic count. The noncompliance was identified as PNC. The noncompliance began on 12/01/23 and ended on 12/11/23. The facility had corrected the noncompliance before the survey began. These failures could affect residents by placing them at risk of not having their medications available as prescribed or possible drug diversions.

Inspectors wroteBased on interview and record review, the facility failed to assess each resident quarterly (every 3 months) using the MDS (minimum data set) form specified by the state and approved by CMS for one (Resident #33) of five residents reviewed for quarterly assessments. The facility failed to ensure Resident #33 had a quarterly MDS assessment . This failure could place residents at risk of not receiving necessary care or receiving inappropriate care for their conditions.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 6 residents (Residents #25) for care plan revisions, in that: The facility failed to ensure Resident #25's care plan was revised to include not using the gait belt during transfers These failures could place residents at risk of receiving inappropriate care.