Highland Springs Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure contact isolation precautions (define - steps used to stop the spread of germs by touch, requiring a private room, gloves, and a gown) were implemented in accordance with the policies and procedures, for one of four sampled residents who required contact isolation precautions (Resident 2), when the facility staff provided services to Resident 2 without the use of Personal Protective Equipment (PPE - refers to specialized clothing or gear worn by individuals to minimize exposure to hazards that cause serious workplace injuries, illnesses, or infections):This failure had the potential to increase the spread of scabies (a contagious, tiny mite infestation, skin condition) and cause serious bacterial infection and severe skin damage to individuals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, for one of four residents reviewed (Resident 1), was free from injury from an unwitnessed fall, when Resident 1's bed alarm was not responded to timely. This failure has the potential to place Resident 1 at risk for further falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed for four of six residents reviewed for weight loss (Residents 12, 11, 33, and 32) the following:1. For Resident 12, who was not on a planned weight loss program (an approach to losing and maintaining weight characterized by a reduced-calorie, nutritionally balanced eating plan, regular physical activity, and a behavior change component to promote sustained lifestyle habits), the facility failed to assess the continued weight loss from 153 pounds (lbs.-unit of measurement) to 131 lbs. since January 2025, and initiate interventions to prevent further loss. This failure resulted in Resident 12 losing weight since admission to the facility. Resident 12 lost 24 lbs. since admission. (admission weight 153, in January 2025, and was 129 lbs. in August 2025). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement and document non-pharmacological interventions (NPI), for four of four sampled residents (Resident 3, 9, 12, and 61) receiving psychotropic medications. In addition, for Resident 61, the facility failed to document the NPI were attempted prior to initiating psychotropic medications. These failures had the potential to place residents at risk of unnecessary psychotropic medication use and adverse side effects, such as sedation and falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure discontinued medications were not stored in the medication cart readily available for use. This failure has the potential for the residents to receive discontinued medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow its policy and procedure in preparation of pureed food by methods to conserve nutritive value, for 16 out of 16 residents who received pureed foods. This failure had the potential for the residents to receive food with inadequate nutritive value and could potentially place the residents at risk for compromised nutritional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a sanitary environment, prepare, and serve food in accordance with professional standards for food service safety when:1. The reach-in refrigerator ventilator had dust;2. The reach-in refrigerator storage shelves had chipping paint;3. Two opened food items were found unsealed in the freezer; and4. Hamburger buns were not stored according to manufacturer's guidelines. These failures had the potential to result in the spread of food borne illness within the facility due to the contamination and improper storage of food.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the proper maintenance of essential equipment, when the walk-in freezer had icicles built up. This failure had a potential risk to affect the quality of food stored in the walk-in freezer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an effective pest control program was in place, when house flies were observed flying and landing on a resident's meal during lunch in the dining room on August 25, 2025. This failure had the potential to spread food borne illness within the facility due to the contamination and inadequate pest control.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the resident's individualized needs, for two of 19 residents reviewed when:1. For Resident 31, the facility did not provide a wheelchair that was properly cleaned, comfortable, and safe to accommodate his needs. This failure resulted in Resident 31, not to have a full support of his buttocks during transfer from bed to wheelchair or from wheelchair to bed when the wheelchair seat was worn out and sagging (losing firmness and drooping) in the middle. In addition, the wheelchair had a built-in whitish stain embedded at the cloth material; and2. For Resident 86, the facility did not replace his rollaway walker when the seat cover had multiple tears and the middle vinyl seat cover had a large tear exposing the foam material from inside. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the licensed nurse followed the manufacturer's instructions for priming an insulin pen, for one of six residents observed during medication administration (Resident 30). This failure had the potential to result in inaccurate insulin dosing and adverse effects, such as poor glycemic control.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services for two of 19 residents reviewed (Residents 40 and 14) when:1. For Resident 40, the fingernails on both hands were long and had blackish materials embedded underneath the resident's nailbeds; and2. For Resident 14, had dried food debris on the mouth, beard, and chin. These failures had the potential to negatively impact the physiological and psychological well-being of Residents 40 and 14.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician order for oxygen administration, for one of 19 residents reviewed (Resident 13). This failure had the potential for Resident 13 to receive ineffective oxygen therapy, and had increased risk of hospitalization and adverse outcomes including death for Resident 13.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dental care services and follow up treatment was provided, for one of 19 residents reviewed (ResidentThis failure had the potential for pain, infection, poor nutrition, and further decline in oral health for Resident 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the appropriate food texture was provided, for one out of one resident reviewed (Resident 25), when Resident 25's meal was not fully pureed and had chunks in his meal during lunch on August 25, 2025. This failure had the potential for Resident 25 to aspirate and cause harm to Resident 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the infection prevention and control practices were implemented in accordance with its policy and manufacturer's instructions, when: 1. For Resident 67, a licensed nurse did not properly clean and disinfect the shared stethoscope before and after use, as required by the facility's policy; and 2. For Resident 30, a licensed nurse did not disinfect the rubber seal of an insulin pen prior to attaching a needle, in accordance with the manufacturer's instructions for use. These failures had the potential to cause the spread of infection, placing residents at risk, and compromise their health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, for one of three residents (Resident 1):1. The depakote (medication to treat mood disorder) dosage recommended by the general acute hospital (GACH) was carried out when Resident 1 was re-admitted back to the facility; and2. The facility psychiatry nurse practitioner (PNP- an advanced practice registered nurse specializing in mental health care) review the acute hospital assessment and medication adjustment recommendations. These failures had the potential to contribute to unmanaged behavior of Resident 1 and affect overall behavioral condition of the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for one of one residents (Resident 1) was appropriately monitored by their sitter in two instances when:Certified Nursing Assistant (CNA) 1 was not fully implementing a 1:1 (one sitter/staff member assigned to closely watch one resident) monitoring on Resident 1; andCNA 2 left Resident 1 unattended during 1:1 monitoring. These failures had the potential to cause harm to Resident 1 and to fellow residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a respiratory protection program (a program intended to establish practices for the selection, use, and care of respiratory protective equipment in the workplace) was implemented, when 47 out of 106 direct care staff (Certified Nursing Assistants [CNA] 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, Licensed Vocational Nurses (LVN) 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and Registered Nurses (RN) 1, 2, and 3) were fit tested with the use of N-95 filtering facepiece respirator, (FFR - filtering facepiece respirator - a disposable half-mask that covers the user's airway (nose and mouth) and offers protection from particulate materials), in accordance with the facility's policy and procedure and CDC guidelines. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents involved in multiple altercations (physical fight) (Residents 1 and 2) were separated and distanced away from each other as indicated in the care plan. This failure resulted in Resident 1 being grabbed and pulled out from a chair which led to a closed clavicle fracture (broken collarbone).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of eleven sampled residents' (Resident 4 and Resident 5) call lights were within reach. This failure has the potential for Resident 4 and Resident 5 to have unmet needs due to inability to be able to call for assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free from accident hazards for one of four residents reviewed for accidents (Resident 41), when the resident tripped on an in-ground planter (a garden bed or a space dug into the ground where plants are grown) that was approximately 3.25 to 3.5 inch deep above the ground level. This failure resulted for Resident 41 falling and hitting her head on the picnic table, resulting in a periorbital hematoma (black eye- swelling and discoloration around the eye area) and a fracture of the nasal septum (broken or cracked part inside the nose that separated the two sides).

Inspectors wroteBased on interview and record review, the facility failed to ensure the comprehensive assessments for six of 22 sampled residents (Residents 14, 34, 49, 51, 53, and 82) were completed within 14 calendar days after admission. This failure had the potential for residents to not receive resident centered care (care focusing on the needs of individuals) for Residents 14, 34, 49, 51, 53, and 82.

Inspectors wroteBased on observation, interview, and record review, the facility failed, for four of seven residents (Residents 46, 10, 40, and 76) to ensure: 1a. Resident 46 was provided privacy by Licensed Vocational Nurse (LVN) 1, when she assessed the resident for back pain; and 1b. Resident 10 was provided privacy by LVN 2, when he applied the Voltaren Cream (pain medication cream applied topically). These failured had the potential toi violate residents rights to privacy during medication administration. and 2a. Resident 40's narcotic medication Norco (brand name or narcotic pain medication) 5-325 milligrams (mg- unit of measurement) was documented as administered by the Licensed Nurse (LN) on June 18 and 27, 2024; and 2b. For Resident 76, the medication Ativan (anti-anxiety medication) was documented as administered by the LN on July 16 and 24, 2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure dietary staff could carry out the functions of food and nutrition services safely and effectively when [NAME] (CK) 1, Dietary Aide (DA) 3 and DA 4 were unable to accurately describe the cooldown process for hot food and ambient food temperatures. This failure had the potential to place residents at risk for food borne diseases (illness that result from ingestion of contaminated food) that can cause sickness and or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a sanitary environment, to prepare, and serve food in accordance with professional standards for food service safety when: 1. The toaster dial control had a build up of brown-yellowish grime. 2. Multiple cutting boards had yellowish discoloration, deep cuts, indentations, and damaged. 3. The left and right sides of the oven, the front inside surfaces of the left and right oven doors showed brown discoloration. (cross reference F908) 4. The front metal areas of two meal tray carts were stained with brown discoloration. (cross reference F908) These failures had the potential to place residents at risk for food borne diseases (illness that result from ingestion of contaminated food) that can cause sickness and or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, one toaster, two oven doors, the left and right sides of the oven and four meal tray carts were maintained in a safe operating condition. These failures had the potential to place residents at risk for food borne diseases (illness that result from ingestion of contaminated food) that can cause sickness and or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a comfortable homelike environment for one of eight residents (Resident 87) when multiple damaged window blinds were observed. This failure had the potential to disrupt the residents' daily living needs and environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure education and resources regarding Advance Directive (AD - written statement of a person's wishes regarding medical treatment) were provided to one of the three residents reviewed for AD (Residents 44), and or the Resident Representative (RP). This failure had the potential for Resident 44 and the RP to remain uneducated and uninformed about AD and could result in the facility being unable to know and honor the resident's wishes regarding medical treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for one of seven residents reviewed for environment (Resident 28) was provided with a clean, safe, and comfortable environment when: 1. The resident's call light button (a device that alerts healthcare staff for help in a facility) cord was damaged and cracked. In addition, the staff did not report the damaged and cracked call light button cord to maintenance for replacement. This failure had the potential to prevent Resident 28 from receiving assistance as needed. 2. The cabinet above the sink inside the bathroom had rust buildup on the bottom shelf. This failure had the potential to place Resident 28 at risk of living in an unkempt and un-homelike environment.

Inspectors wroteBased on interview and record review, the facility failed to notify the Office of the State Long-Term Care Ombudsman (LTC Ombudsman - an agency reponsible for advocating on behalf of residents) of a discharge for one of two residents (Resident 39) reviewed for closed records. This failure had the potential to result in the LTC Ombudsman not to be informed about Resident 39's plan of care and condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, Licensed Vocational Nurse (LVN) 1, administered the medication Nifedipine (brand name of medication used for high blood pressure) ER (extended release) 20 milligrams (mg - unit of measurement) as ordered by the physician for one of seven residents (Resident 10) observed for medication administration. This failure has the potential for the resident to not receive the full therapeutic effects of the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, an edema (swelling caused by too much fluid in the tissues) on the left upper and left lower extremity was appropriately assessed and a care plan was initiated and developed, for one of eight residents reviewed (Resident 24). This failure has the potential for the edema to not be monitored for complications and may also result to the delay in treatment of possible worsening symptoms.

Inspectors wroteBased on interview and record review, the facility failed for one of two residents (Resident 54), to address vision deficits when a recommendation for reading glasses was not followed up. This failure had the potential for Resident 54 to have a decline in his vision.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the following medications were not stored readiliy available for use in the medication cart and medication room: - One bottle of Nutricia UTI Stat Liquid 30 FL Oz (Fluid Ounce - unit of measurement) 887 milliliters (unit of measurement) with an expiration date of [DATE]; - Four acetaminophen suppositories 650 milligrams (mg-unit of measurement) labeled for use on a resident that expired [DATE]; and - One vial of Comimaly Intramuscular Suspension 30 MCG (micrgogram- unit of measurent)/0.3ml (type of Covid{(highly contagious type of respiratory infection}vaccine ) labeled for use on a resident that was discharged from the facility on [DATE]. This failure has ther potential for the residents to receive expired and/or ineffective medications.

Inspectors wroteBased on observation, interview, and record review, facility failed to provide assistive devices such as plate guard (equipment to prevent food from falling off the plate), for two of eight residents (Resident 13 and Resident 58) observed during mealtime. This failure had the potential for Resident 13 and 58 not meeting the daily nutritional needs, which could lead to weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe and sanitary storage of personal food for one of one resident (Resident 56) when two expired bags of marshmallows were found inside the resident's closet and were readily available for consumption. This failure had the potential to place Resident 56 at risk for foodborne diseases (illness that result from ingestion of contaminated food).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control practices were observed when: 1. Registered Nurse (RN) 2, did not perform the appropriate hand hygiene prior to, in between, and after a resident contact during a blood sugar check and administration of insulin (medication used for high blood sugar) for one of seven residents observed (Resident 4); and 2. For one of two residents (Resident 347), when a Physical Therapy Assistant (PTA) failed to perform hand hygiene and disinfect ankle weights used after providing care on the resident, who is on an enhanced barrier precautions (EBP - infection prevention and control practices that can help reduce the spread of infection). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of five residents reviewed for immunizations (Resident 58) was offered the pneumococcal vaccine (vaccines against the bacterium Streptococcus pneumoniae [bacteria that can cause pneumonia]). This failure had the potential for Resident 58 not fully protected against pneumonia (infection of lungs).

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents' (Resident 2) whereabout was being frequently monitored. This failure potentially could have contributed for Resident 2 to be able to wander to Resident 1's room and was found on top of the resident on April 27, 2024.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Physician's Orders for Life Sustaining Treatment (POLST-a legal document signed by the resident if with capacity to make decision or resident legal representative, and physician, that indicate a resident's preference for life sustaining treatment) was identifiable, accurate, and updated, for three of seven residents reviewed (Resident 2, 6, and 7). This failure had the potential for Residents 2, 6, and 7 to receive inappropriate or delayed treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident representative or surrogate decision maker (authorized individual to make healthcare decisions for the resident) was assigned for decision making, for one of seven residents reviewed (Resident 7). This failure had the potential to result in medical services to not be coordinated in accordance with the resident's needs due to the lack of appropriate decision- making capacity and advocacy for the resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident was monitored following an allegation of sexual abuse, for one of two sample residents (Resident 2). This failure had the potential to affect Resident 2 ' s physical, emotional, and psychosocial wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to ensure for one of three sampled residents (Resident B), treatments were completed, as ordered, for a right hip surgical wound. This failure had the potential to delay wound healing, increase the risk of complications and further infections for Resident B.

Inspectors wroteBased on interview and record review, the facility failed to ensure for two of three residents (Resident A, Resident B), the following: 1) Resident A, a care plan was developed with specific goals and interventions addressing the Resident A's dementia ; and 2) Resident B, monitoring of behaviors and non-pharmacological interventions were implemented prior to starting psychotropic medication. These failures had the potential to result in inconsistent and inadequate management of care for both residents.

Inspectors wroteBased on observation and interview, the facility failed to provide a clean and safe environment for the residents and visitors when one out of one dumpster garbage bin located outside the kitchen was overflowing with trash, and the deformed (bent) lid was not securely closed. This failure had the potential for an unsafe environment for the residents and the visitors due to possible pest infestation and spread of diseases in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Resident 31's closet space was free from belongings left by a resident who had been discharged . This failure had the potential to inhibit Resident 31's ability to have adequate closet space for her belongings.

Inspectors wroteBased on interview and record review, the facility failed to ensure proper behavior monitoring was implemented for the use of Provera (medication to treat behavior in men) medication for one of five residents (Resident 50) reviewed for unnecessary psychotropic medication (medication which affects behavior). This failure had the potential for Resident 50 to receive unnecessary psychotropic medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of twenty-nine opportunities observed during medication administration were free from a medication error rate of five percent or more when: 1. Lidoderm patch (medication for pain) was not removed as scheduled per the physician order; and 2. Albuterol inhaler (medication to help with breathing) was not administered as recommended by the manufacturer's instructions. These failures resulted in a mediation error rate of 6.9% and could potentially result in residents not receiving the full therapeutic effect of the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored according to the facility's policy and procedure and per state and federal requirements when: 1. Diclofenac gel (medication for pain) had the incorrect drug label on the medication when compared to the physician's order; and 2. Two multi-dose vials of Tuberculin for injection had an opened date that was expired. These failures had the potential for medication error to occur or medication to be used with less efficacy. 1. On [DATE], at 9:36 a.m., during medication administration observation, License Vocation Nurse (LVN) 1 was observed preparing diclofenac gel 1% for Resident 31. The diclofenac gel label indicated, .Apply 2 gm (gram- unit of measurement) topically to left shoulder . LVN 1 was observed to apply diclofenac gel to Resident 31's right shoulder. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu was followed during the lunch meal on January 24, 2023, when: 1. Resident 18, with CCHO (Controlled Carbohydrate Diet - a meal plan consisting of having the same amount of carbohydrates every day), low fat and low cholesterol diet (a diet that helps reduce the risk of heart disease), received one whole slice of wheat bread instead of half a slice of wheat bread; and 2. Resident 63, with regular low fat and low cholesterol diet, received regular chicken jambalaya with sausage, instead of the chicken jambalaya without sausage. These failures had the potential to result in compromising the medical and nutritional status of Residents 18 and 63.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper dishwashing procedure was completed when several various sized metal pans were stacked and stored wet. This failure had the potential to cause food-borne illnesses in a medically vulnerable population who consumed food in the facility. The facility census was 80.