Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Highland Springs Care Center during CMS and state inspections, most recent first.
Unplanned Weight Loss Not Properly Assessed or Managed: The facility failed to adequately assess and document interventions for residents with significant weight loss. One resident with dementia, dysphagia, and wandering behavior lost weight from 153 lbs. to 129 lbs. while staff noted weight loss may be beneficial but did not establish a clear weight goal or documented plan, and the resident was observed leaving meals while being fed. Another resident with dementia, dysphagia, and muscle wasting lost weight from 247 lbs. to 217 lbs.; although diet orders and care plan notes referenced weight management, the record did not show a planned weight loss program, a resident-centered nutrition care plan, or a documented assessment of the cause of the ongoing weight loss.
Failure to Document NPI for Residents on Psychotropics: Four residents with diagnoses including schizophrenia, dementia, mood disorder, psychosis, anxiety, and depression were ordered psychotropic meds such as antipsychotics, divalproex, and mirtazapine. The care plans and NP/PA notes referenced NPI and monitoring, but the MARs showed no documented evidence that NPI were implemented or monitored. For one resident, the psychotropic assessment also lacked documentation that behavior interventions were attempted before the meds were started.
Discontinued medications were found stored in a medication cart and readily available for use. During an observation, an LVN confirmed that hydroxyzine, Lidoderm patches, and ibuprofen for three residents had been discontinued but were still in the cart’s bottom drawer. The LVN stated these medications should have been removed, and the facility policy required discontinued drugs to be returned to the dispensing pharmacy or destroyed as indicated.
Pureed foods were prepared too early and held in the oven instead of being prepared as close as possible to lunch service time. A CDM and dietary staff were observed cooking regular menu items first, then scooping them out to make pureed items such as meatballs, zucchini, pasta, spinach, beef, and mashed potatoes. The RD confirmed this did not follow the facility’s food prep policy, and 16 residents were receiving a pureed diet.
Food service sanitation deficiencies were identified when dust was observed in the reach-in refrigerator ventilator, three refrigerator shelves had chipping paint, two opened food items in the walk-in freezer were left unsealed in their boxes, and hamburger buns were stored in the walk-in refrigerator despite the manufacturer’s room-temperature storage guidance. The CDM stated the dust and chipping paint were sanitation issues, and that open food items needed to be properly sealed.
The facility failed to maintain the kitchen walk-in freezer when icicles and ice were observed around a black pipe inside the unit, with food stored underneath. The CDM stated the buildup was not usual, and the RD later stated there should not be any icicles or ice in the freezer. The facility also did not have the manufacturer manual for the freezer, and its maintenance policy stated defective fixtures should be immediately repaired.
Flies were observed in the dining room during meal service, including one landing on a resident's drinking glass while staff assisted residents with meals. An LPN and a CNA stated the flies were unsanitary, and the IP reported a recent pest control issue with flies entering when residents go in and out and doors are left open. The facility's pest control policy stated it must maintain an effective program to keep the building free from insects and rodents.
Two residents were allowed to continue using damaged mobility equipment that did not match their needs. One resident with TBI, pneumonia, and unsteadiness of feet used a manual wheelchair with a sagging, stained seat and missing footrests, and staff used non-skid material on the seat for fall prevention. Another resident with a compression fracture and anxiety disorder used a rollaway walker with multiple tears and exposed foam in the seat cover, and staff acknowledged both devices needed replacement.
A nurse failed to follow the manufacturer’s instructions when priming an insulin pen for a resident with DM2. The nurse attached a new needle, selected 2 units to prime, and pressed the dose knob while holding the pen with the needle pointing downward instead of upright, then administered 4 units of Insulin Lispro. The nurse later confirmed the technique used was incorrect, and the IP and DON stated the pen should be primed with the needle facing up.
Failure to Provide Nail and Oral Hygiene Care: Two residents with significant care needs were observed without needed hygiene assistance. One resident with dementia and vascular disease had long fingernails with debris under the nailbeds, and staff acknowledged the nails were dirty and needed trimming. Another resident with Parkinsonism and Alzheimer’s disease was observed with dried food debris on the mouth, beard, and chin after a meal, and an LVN stated CNA staff should have provided oral care and cleared the food particles.
Failure to follow an oxygen order: A resident receiving continuous O2 therapy was observed on 3.5-4 L/min via mask/NC even though the physician order was for 2 L/min via NC, with titration up to 5 L/min only if O2 sats were below 93%. The resident’s O2 sats were documented at 95%-99%, and there was no documentation for the higher flow rate. The ADON stated the charge nurse was responsible for checking O2 sats each shift, verifying the flow rate against the order, and documenting any titration above 2 L/min.
A resident with chronic AFib, lack of coordination, and PVD was observed with a missing lower tooth and a blackened tooth remaining in the gums, and reported discomfort when chewing and uncertainty about his dental appointment status. The chart showed an oral/dental care plan and a dental consult order, but records reflected a long gap in dental assessment and treatment, and the ADON stated the teeth appeared decayed and should have been identified on admission, with oral pain, or during daily oral care.
A resident on a puree diet was observed eating food that contained chunks instead of a fully smooth texture. The resident spit out some of the chunks and said he did not know what they were. An LVN and the CDM both stated puree food should be smooth with no solids or chunks, and the resident’s record showed dysphagia, dementia, and a physician order for puree texture.
An LPN used a shared stethoscope on a resident and cleaned it with an alcohol swab pad instead of the EPA-registered disinfectant wipes kept in the med cart, even though the stethoscope had been placed directly on the resident’s skin. In a separate event, an LPN attached a new needle to an insulin lispro KwikPen without wiping the rubber seal with an alcohol swab first, then primed and administered insulin to a resident. The IP and ADON stated shared equipment should be disinfected with appropriate wipes and the insulin pen seal should be disinfected before needle attachment, consistent with facility policy and the manufacturer’s instructions.
A resident with a mental disorder, psychosocial adjustment difficulty, or a history of trauma and/or PTSD did not receive appropriate treatment and services, as the care plan lacked individualized interventions and documentation to address their specific needs.
A resident with dementia and anxiety disorder, placed on 1:1 sitter watch after an altercation, was left unsupervised on two occasions: once when a CNA was observed with eyes closed and not fully attentive, and again when another CNA left the resident alone to get supplies. Both actions were contrary to facility policy and expectations for continuous, close monitoring.
The facility failed to implement a respiratory protection program, resulting in 47 out of 106 direct care staff not being fit tested for N95 masks, as required by policy and CDC guidelines. This deficiency was discovered during an investigation of a COVID-19 outbreak, where 32 residents and 12 staff tested positive. Interviews revealed that fit testing was not prioritized, with some staff not tested since 2020. The Administrator confirmed the absence of a proper program, posing a risk to residents and staff.
A facility failed to separate two residents with a history of altercations, resulting in one resident pulling another from a wheelchair, causing a clavicle fracture. Despite care plans indicating the need for separation and redirection, staff did not prevent the interaction, leading to the incident.
The facility failed to ensure that call lights were within reach for two residents, potentially leading to unmet needs. One resident, with fluctuating decision-making capacity and self-care deficits, had her call light out of reach while sitting in her wheelchair. Another resident, with cognitive and communication deficits, also had her call light placed out of reach. A CNA confirmed the inaccessibility of the call lights, which contradicted the facility's policy requiring accessible call lights for residents.
A resident with dementia and schizophrenia, identified as high risk for falls, tripped on an in-ground planter in the patio area, resulting in a nasal fracture and periorbital hematoma. The planter, approximately 3.25 to 3.5 inches deep, posed a tripping hazard due to its unevenness. The facility's policy emphasized addressing environmental hazards, but the area was not maintained safely.
The facility failed to complete comprehensive assessments for six residents within the required 14 days after admission, as confirmed by the MDS nurse and DON. This delay in completing the Minimum Data Set (MDS) assessments, crucial for resident-centered care planning, was contrary to the facility's policy and federal guidelines.
A facility failed to ensure privacy for two residents during medication administration and did not properly document the administration of controlled medications for two other residents. An LVN assessed a resident for back pain and applied topical medication to another without closing doors or drawing privacy curtains. Additionally, narcotic and anti-anxiety medications were signed out for two residents, but there was no documentation in the eMAR to confirm administration, contrary to facility policies.
The facility failed to ensure dietary staff could safely and effectively carry out food cooling procedures. Staff members provided incorrect information about the cooldown process for hot and ambient temperature foods, which could risk foodborne diseases. The Registered Dietitian clarified the correct procedures, which were not followed by the staff, indicating a failure in training or adherence to facility policies.
The facility failed to maintain a sanitary kitchen environment, with grime on a toaster, damaged cutting boards, rust on oven surfaces, and corroded meal tray carts. These issues, acknowledged by the Dietary Manager and Registered Dietician, pose risks of cross-contamination and foodborne illnesses, contrary to facility policies and FDA Food Code standards.
The facility failed to maintain kitchen equipment, including a toaster, oven, and meal tray carts, in a safe condition, posing a risk for foodborne illnesses. Observations revealed chipped and peeled surfaces and rust, which could lead to contamination. The Dietary Manager and Registered Dietician acknowledged these issues, highlighting the potential for bacterial growth and cross-contamination.
A resident's room had multiple damaged window blinds, causing excessive brightness and discomfort. The resident used curtains to block the light. Both the Maintenance Supervisor and Facility Administrator were aware of the issue, acknowledging the need for repair or replacement to maintain a homelike environment, as per the facility's maintenance policy.
A facility failed to provide education and resources about Advance Directives (AD) to a resident with severely impaired cognitive skills and their representative. The Social Service Director admitted to not offering the necessary information, and the Director of Nursing confirmed that the facility's policy requires such education and documentation, which was not followed in this case.
A resident's environment was compromised due to a damaged call light cord and a rusted bathroom cabinet. The call light, essential for alerting staff, was cracked with exposed wires, and the issue was not reported to maintenance. Additionally, the bathroom cabinet had rust buildup, which was acknowledged by staff but not addressed. These deficiencies highlight lapses in maintaining a safe and homelike environment.
A facility failed to notify the LTC Ombudsman of a resident's discharge to an acute hospital, as required by policy. The resident had severe cognitive impairment due to dementia and Alzheimer's. Staff interviews revealed that the Social Service Director missed sending the notification, and both the Medical Records Director and Director of Nursing confirmed the oversight, emphasizing the importance of such notifications for resident safety and continuity of care.
A facility failed to ensure proper medication administration when an LVN did not check a resident's pulse rate before giving Nifedipine ER 20 mg, as required by the physician's order. The LVN lacked the necessary equipment to accurately measure the pulse rate, leading to a potential risk of the resident not receiving the full therapeutic effects of the medication.
A resident with a history of diabetes, COPD, heart disease, and liver cirrhosis experienced untreated edema in the left extremities. Despite complaints of pain and swelling, the facility failed to document an assessment or develop a care plan. The DON confirmed the lack of documentation and monitoring, indicating a deficiency in following facility policies.
A resident with dementia, capable of making his own decisions, did not receive recommended reading glasses due to the facility's failure to follow up on an optometrist's recommendation. Despite a physician's order for a vision consult and the resident's expressed need for glasses, the facility did not act on the recommendation, as confirmed by the SSD and DON. This oversight was not documented, contrary to the facility's policy on consultant services.
The facility failed to properly store medications, resulting in expired and discontinued drugs being readily available for use. A bottle of Nutricia UTI Stat Liquid and acetaminophen suppositories were found in a medication cart despite being expired, and a vial of Comimaly Intramuscular Suspension was stored in the medication refrigerator for a discharged resident. Both LVNs and the DON acknowledged these errors, which violated the facility's medication storage policy.
The facility failed to provide necessary assistive devices, such as plate guards, for two residents during mealtime, leading to difficulties in managing their food. Both residents were observed struggling to keep food on their plates, resulting in spillage. Staff interviews confirmed that these residents should have been evaluated and provided with assistive eating devices to meet their nutritional needs.
A resident with fluctuating decision-making capacity had two expired bags of marshmallows in their closet, which were gifts from the previous Christmas. The marshmallows were readily available for consumption, and both an LVN and a CNA acknowledged the potential for stomach upset if consumed. The DON stated that expired food should be discarded, as per facility policy, which was not followed in this instance.
The facility failed to ensure proper infection control practices when a nurse did not perform hand hygiene during a blood sugar check and insulin administration for a resident, and a physical therapy assistant did not disinfect ankle weights or perform hand hygiene after therapy on a resident with multidrug-resistant organisms. These actions were contrary to the facility's infection control policies.
A facility failed to offer a resident the second dose of the pneumococcal vaccine as per CDC guidelines. The resident, who has COPD, received the first dose (PPSV23) but was not documented as being offered the second dose (PCV20) after one year, as required. This deficiency was identified during an interview and record review with the Infection Preventionist.
A resident with dementia was inadequately monitored, allowing them to wander into another resident's room and engage in inappropriate behavior. Despite having a care plan that required frequent monitoring due to a risk of wandering, the resident's behavior was not documented or communicated to the DON, leading to a failure in supervision and intervention.
The facility failed to ensure that the POLST forms were identifiable, accurate, and updated for three residents, leading to potential inappropriate or delayed treatment. The discrepancies involved missing signatures, outdated POLST statuses, and lack of documentation for decision-making processes.
The facility failed to assign a surrogate decision maker for a resident with schizophrenia who lacked decision-making capacity. The resident was admitted without a completed POLST and Consent to Treat form, and there was no documented evidence that the IDT or Bioethics Committee had taken action to appoint a healthcare decision maker.
Unplanned Weight Loss Not Properly Assessed or Managed
Penalty
Summary
The facility failed to provide enough food and fluids to maintain residents’ health for four of six residents reviewed for weight loss. For Resident 12, who had diagnoses including dementia, oropharyngeal dysphagia, wandering, mood disorder, psychosis, and metabolic encephalopathy, the record showed progressive unplanned weight loss from 153 lbs. on admission to 129 lbs. in August 2025. Nutrition notes repeatedly stated that weight loss may be beneficial because the resident remained above ideal body weight, but there was no documented evidence that Resident 12 was placed on a planned weight loss program or that a weight goal was established. The resident was observed during lunch wandering away from the table while being fed, and staff redirected the resident back to the seat more than once. The record also showed the resident often left the seat during meals and ate irregularly, yet no nutrition intervention was documented between April and August to address the unplanned weight loss. Resident 12’s weight management documentation repeatedly described the resident as above ideal body weight and noted varying oral intake, but the IDT weight management notes did not document a clear goal weight or how much weight loss was intended. The physician progress notes reviewed did not address the weight loss as planned or desirable. During interview, an LVN stated she was unaware of Resident 12’s plan of care for weight change and said the IDT relied on the RD and DON to determine a goal weight. The RD later stated the significant weight loss was unplanned and undesirable, that the resident needed additional cueing and assistance during meals, and that snacks should have been provided. The MDS nurse verified there was no nutrition intervention found to address the unplanned weight loss during the reviewed period. For Resident 11, who had diagnoses including dementia, dysphagia, muscle wasting and atrophy, and anxiety, the record showed weight loss from 247 lbs. in February 2025 to 217 lbs. in August 2025. The resident had diet orders for CCHO, mechanical soft texture, thin consistency, fruit cup with meals, and non-fat milk for weight management. Nutrition assessments and IDT notes repeatedly described the resident as above ideal body weight and stated the resident may benefit from weight loss, but the record did not show that the resident was placed on a planned weight loss program or that a weight goal was set. The care plan addressed anticipated weight loss and change in condition, but it did not document a resident-centered nutrition care plan that explained how staff would implement and monitor interventions for the significant weight changes. Resident 11’s record also showed large weight fluctuations, including a 17-lb. gain in May 2025 followed by a 26-lb. loss by early June and continued loss through August. The RD notes and IDT weight management notes described the weight loss as possibly related to fluid shifts, altered diet, aging, and medical diagnoses, but the record did not show a further assessment to determine the root cause of the 26-lb. loss or a physician assessment addressing the cause of the significant weight loss. The care plan reports did not document how staff would implement and monitor interventions or evaluate their effectiveness for the resident’s weight changes.
Failure to Document Non-Pharmacological Interventions for Residents Receiving Psychotropic Medications
Penalty
Summary
The facility failed to implement and document non-pharmacological interventions (NPI) for four sampled residents who were receiving psychotropic medications. Resident 3 had diagnoses including schizophrenia, anxiety, and mild cognitive impairment and was ordered Mirtazapine for depression and Risperidone for grandiose delusions. Although the care plan and NP/PA progress notes referenced nonpharmacological intervention and monitoring of behavioral and weight changes, the August MAR contained no documented evidence that NPI were implemented or monitored for this resident. Resident 9 had diagnoses including schizophrenia, dementia, insomnia, bipolar disorder, major depressive disorder, and anxiety and was ordered Divalproex Sodium for mood disorder, Mirtazapine for depression with poor appetite, and Quetiapine for schizophrenia with behaviors including kicking, scratching, and spitting. The care plan and NP/PA progress notes stated that nonpharmacological interventions should be utilized and that the resident should be monitored closely for behavioral and weight changes, but the August MAR showed no documented evidence that NPI were implemented or monitored. Resident 12, who had dementia, mood disorder, and unspecified psychosis, was ordered Depakote Sprinkles for severe restlessness; the care plan directed staff to assess triggers, reduce or eliminate triggers if possible, and provide redirection as needed, but the August MAR contained no documented evidence of NPI implementation or monitoring. Resident 61 had vascular dementia, Alzheimer's disease, unspecified psychosis, mood disorder, and anxiety and was ordered Divalproex Sodium and Mirtazapine for mood disturbances and depression with poor appetite. The psychotropic assessment did not include any behavior interventions attempted prior to initiation of these medications, and the August MAR contained no documented evidence that NPI were implemented or monitored. During interview and record review, the MDS nurse confirmed there was no documented evidence that NPI were implemented for Residents 3, 9, 12, and 61, and the ADON confirmed there was no documented evidence that NPI were attempted prior to initiating Resident 61's psychotropic medications.
Discontinued Medications Left in Medication Cart
Penalty
Summary
The facility failed to ensure discontinued medications were removed from Medication Cart 1 and were not left stored in the cart and readily available for use. During an observation with concurrent interview and record review on August 27, 2025, LVN 3 stated that medications stored in the cart were readily available for use. In the bottom drawer of the cart, surveyors found 30 tablets of hydroxyzine HCl 25 mg for Resident 38, 14 Lidoderm patches for Resident 50, and 15 ibuprofen 600 mg tablets for Resident 55. In concurrent interviews, LVN 3 stated the hydroxyzine had been discontinued on July 30, 2025, the Lidoderm patch had been discontinued on May 30, 2025, and the ibuprofen had been discontinued on July 29, 2025. LVN 3 stated the discontinued medications should have been pulled out from the medication cart and that discontinued medications should not have been stored in the medication cart readily available for use. The facility policy titled, Storage of Medications, dated March 2023, stated discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destructed as indicated.
Pureed Foods Prepared Too Early and Held in Oven
Penalty
Summary
Food and drink were not ensured to be palatable, attractive, and at a safe and appetizing temperature because the facility did not follow its Food Preparation Policy for pureed foods. During observation in the kitchen, several serving pans of food were found holding inside the oven, and the CDM stated that pureed food items, including meat ball, zucchini, and pasta, had been finished for the lunch meal. The CDM also stated that regular food items were cooked first, stored inside the oven, and then scooped out to prepare the pureed foods. On a later observation, the same staff member was seen preparing pureed spinach for lunch and storing all cooked food items, including beef, mashed potatoes, and spinach, in the oven at holding temperature. The staff member stated he usually tried to complete all lunch meal preparation before 9:30 a.m., while the facility's serving time for lunch was 11:30 a.m. The RD confirmed the staff member did not follow the Food Preparation Policy, which required food to be prepared as close as possible to serving time to preserve flavor, freshness, and nutritional value. The Diet Type Report showed 16 residents were receiving a pureed diet.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain a sanitary environment and to prepare, store, and serve food in accordance with professional standards in the kitchen and food storage areas. During an inspection with the Certified Dietary Manager (CDM), dust was observed in the ventilator of the reach-in refrigerator, and three refrigerator storage shelves in that unit were observed to have chipping paint. The CDM stated that the dust in the ventilator was a sanitation issue and could get into food, and that the chipping paint on the shelves could contaminate food. The facility’s Kitchen Cleanliness and Sanitation Policy stated that equipment, surfaces, and food preparation areas must be cleaned and sanitized regularly, and that shelves and equipment must be in good working condition. In the walk-in freezer, two opened food items, honey wheat rolls and breadsticks, were observed in opened boxes and were not sealed or rewrapped inside the packaging. The CDM stated that open food items in the freezer need to be properly sealed and not exposed, and that improperly stored food items are a sanitation concern because exposed food can cause cross contamination and freezer burn. In the walk-in refrigerator, nine packs of hamburger buns were observed stored there, while the manufacturer’s label stated the bakery products retain their best quality if stored at room temperature. The CDM stated that the facility should follow the manufacturer’s guidelines for bread storage, and the facility’s Storage of Open Food Items policy stated that bread and baked goods should be labeled with the date opened and discard date per the manufacturer’s label or storage guidelines.
Walk-In Freezer Had Ice Buildup on Pipe
Penalty
Summary
The facility failed to ensure proper maintenance of essential equipment when the walk-in freezer in the kitchen had icicles and ice built up around the connection of a black pipe. During a concurrent observation and interview on August 25, 2025, icicles were seen around the pipe inside the freezer, and food was stored underneath it. The Certified Dietary Manager stated she had just noticed the icicles and that it was not usual to have icicles built up inside the walk-in freezer. Later that day, additional observation showed new icicles around the pipe connection and ice built up on the wall under the pipe. On August 26, 2025, Registered Dietitian 2 observed icicles on the black pipe and stated the facility did not have the manufacturer manual for the walk-in freezer. In a later interview, RD 2 stated there should not be any icicles or ice built up in the walk-in freezer and that her expectation was to contact the vendor to fix it. The facility policy titled, Maintenance Inspections, stated defective fixtures should be immediately repaired by the maintenance supervisor or appropriate service company.
Flies Observed in Dining Room During Meal Service
Penalty
Summary
The facility failed to ensure an effective pest control program was in place when house flies were observed in the dining room during lunch and one fly landed on the rim of Resident 45's drinking glass. Three flies were seen flying around table two, and flies continued to be observed around the same table while LVN 1 assisted Resident 46 with her meal. LVN 1 stated that flies should not be in the dining room and that it was unsanitary. CNA 4 was later observed swatting the flies away and stated that flies are unsanitary and an infection control issue. The Infection Preventionist stated there had been a recent pest control issue and that flies had been noticed, explaining that they come in when residents go in and out and do not keep the door closed. The Infection Preventionist also stated flies are not acceptable in the dining room and can land on dirty things, trash, and dog feces, and that they present a risk for infection, disease, and food contamination. The facility's undated Pest Control Policy stated the facility shall maintain an effective pest control program to keep the building free from insects and rodents.
Worn and Damaged Mobility Equipment Not Replaced
Penalty
Summary
The facility failed to accommodate the individualized needs of two residents by allowing them to continue using worn and damaged mobility equipment. Resident 31, who had diagnoses including traumatic brain injury, pneumonia, and unsteadiness of feet, was observed with a manual wheelchair at bedside that had faded cloth material, whitish stains, and a seat that was sagging in the middle. The resident stated the wheelchair had been the same one since admission, and a staff member had provided non-skid material to place on the seat to prevent him from slipping off. The wheelchair also did not have the resident’s name and room number. During observation and interview, CNA and nursing staff acknowledged that Resident 31’s wheelchair seat was drooping, worn out, and missing both footrests. The CNA stated she had not noticed the condition until then, and the LVN stated the wheelchair did not have a firm seat for support and that no work order had been received to replace it. The treatment nurse stated the non-skid material was being used as part of fall prevention and said the wheelchair needed to be replaced. The maintenance supervisor stated there had been no request from nursing staff to replace the wheelchair since admission, and the administrator acknowledged the wheelchair was not appropriate to accommodate the resident’s needs and needed replacement. Resident 86, who had diagnoses including compression fracture of the first vertebrae and anxiety disorder, was observed using a rollaway walker brought from home that had multiple tears in the seat cover and a large tear in the middle exposing the foam material. The resident stated he had asked staff multiple times for a new walker because the seat was torn and uncomfortable, but he did not know who to ask. CNA and treatment staff observed the torn cushion and acknowledged the walker needed replacement. The treatment nurse stated staff should have contacted the social service director to order a new walker, and the administrator acknowledged the resident needed a new walker.
Improper Insulin Pen Priming During Medication Administration
Penalty
Summary
The facility failed to ensure a licensed nurse followed the manufacturer’s instructions when priming an insulin pen for Resident 30. During medication administration observation, the nurse removed an Insulin Lispro KwikPen from the medication cart, attached a new needle without wiping the rubber seal with an alcohol swab, selected 2 units to prime the pen, and quickly pushed the dose knob while holding the pen with the needle pointing downward instead of upright. After priming, the nurse selected 4 units and injected the insulin into Resident 30’s abdomen. Resident 30 had a physician’s order dated August 20, 2025, for Insulin Lispro 4 units subcutaneously before meals for DM2, with instructions to hold if blood sugar was less than 70 mg/dL. The nurse later confirmed he held the pen downward during priming and stated he was unaware the manufacturer required the pen to be positioned upright. The IP and ADON also stated the pen should be primed with the needle facing upward, and the manufacturer’s package insert instructed that the pen be held with the needle pointing up while priming.
Failure to Provide Nail and Oral Hygiene Care
Penalty
Summary
The facility failed to provide necessary care and services for two residents who were unable to fully carry out activities of daily living. One resident, who had diagnoses including dementia, cerebral infarction, and peripheral vascular disease, was observed in bed with long fingernails on both hands and blackish material under the nailbeds. The resident stated he wanted his nails trimmed. On a later observation, the resident still had long fingernails. An LVN observed that the fingernails measured approximately 0.5 cm to 1 cm from the nailbed and stated the nailbeds were dirty. The Infection Preventionist also observed that the fingernails were long and needed to be trimmed and stated the dirt under the nailbeds could be a source of infection. The resident’s record included a physician order for podiatry care every two months and as needed, and the care plan identified the resident as at risk for not being treated related to refusing hand hygiene and nail care. The record also included a prior podiatric evaluation in which the fingernails were filed by the podiatrist per staff request, but there was no documented evidence that the fingernails were trimmed after that time. Facility policy required nailbeds to be cleaned, nails kept trimmed, and regular nail care provided. A second resident, who had diagnoses including Parkinsonism, lack of coordination, adult failure to thrive, and Alzheimer’s disease, was observed in bed with dried food debris around the mouth, beard, and chin after a meal. The resident was alert but not responding to simple questions. An LVN observed dried light brown and pink food particles on the mouth, beard, and chin and stated CNA staff should provide oral care and ensure the chin and beard were clear of food particles after each meal. The resident’s history and physical stated he did not have the capacity to understand and make decisions, and the care plan and MDS indicated self-care deficits and a need for partial/moderate assistance with oral hygiene.
Failure to Follow Oxygen Order
Penalty
Summary
The facility failed to follow the physician order for oxygen administration for one resident who was receiving continuous oxygen therapy. The resident was admitted with diagnoses including chronic atrial fibrillation, secondary hypertension, and anemia, and the history and physical indicated the resident had the capacity to understand and make decisions. The resident’s care plan directed staff to check oxygen flow every shift, monitor O2 saturation as ordered, and provide oxygen as ordered. The physician order dated August 9, 2024, directed staff to administer oxygen at 2 L/min via nasal cannula and titrate up to 5 L/min for O2 saturations less than 93% every shift. During observation, the resident was seen wearing an oxygen mask and receiving 3.5 L/min of oxygen, and the resident stated oxygen was used all the time, including during sleep. Record review showed the resident’s oxygen saturations from August 1, 2025, to August 26, 2025 ranged from 95% to 99%. On August 26, 2025, an LVN observed the oxygen flow meter at almost 4 L/min and verified that 4 L/min had been documented the prior day at 96%, with no documentation for the indication for 4 L/min on August 26, 2025. The ADON stated the charge nurse was responsible for monitoring oxygen saturation every shift, checking the oxygen liters against the physician order, and documenting oxygen saturation if it was below 93% and oxygen was titrated above 2 L/min. The facility policy also required review of the physician order, assessment of vital signs, and recording the rate of oxygen flow, route, and rationale.
Failure to Provide Timely Dental Assessment and Follow-Up
Penalty
Summary
Provide routine and 24-hour emergency dental care for each resident was not met for one resident reviewed. Resident 18 was observed with a missing left lower tooth and a partial, blackened tooth remaining in the gums, and stated he had discomfort chewing his food and wanted to know the status of his dental appointment. He also stated he could not recall the last time he saw the dentist. Resident 18 had diagnoses including chronic atrial fibrillation, lack of coordination, and peripheral vascular disease, and had a physician order for dental consult and treatment as needed for dental problems. Record review showed Resident 18’s care plan addressed altered oral/dental status, gum pain, and dentures not fitting properly, with interventions including notifying the MD of dental concerns and notifying the dentist for referral. Progress notes documented a dental-related diet change in July 2024, a call from the dental office in May 2025 regarding extractions and apixaban management, an inability to receive dental treatment in June 2025, and a dental visit in July 2025 where a full mouth X-ray was declined. Further review indicated there was no dental assessment and treatment by the dentist after July 2024 until June 2025. During interviews, the ADON stated the resident’s teeth looked bad and decayed, and that the condition should have been identified on admission, with oral pain, or during daily oral care; however, the chart contained no change-of-condition documentation for the left lower tooth.
Puree Diet Food Served With Chunks
Penalty
Summary
The facility failed to ensure that Resident 25 received food prepared in the correct puree texture. During a dining observation in the designated RNA Feeding Program Room, Resident 25 was observed eating puree food but was spitting out a few chunks of food onto his napkin. In a concurrent interview, Resident 25 stated that he did not know what the chunks were. The resident’s meal ticket indicated a puree diet, and an LVN who was seated next to the resident stated that puree food should be smooth with no solids or chunks. Resident 25’s record showed diagnoses including dysphagia and unspecified dementia, and a progress note indicated he could not make decisions. The physician order dated July 17, 2025, specified a puree texture. The CDM later stated that puree food should be completely smooth and that chunks place residents on puree diets at high risk for aspiration. The facility’s written regular pureed diet guidance also stated that the texture should be smooth and moist.
Infection Control Practices Not Followed for Shared Stethoscope and Insulin Pen
Penalty
Summary
A licensed vocational nurse used a shared blood pressure cuff and stethoscope to measure a resident’s blood pressure, disinfecting the cuff with Micro-Kill One Germicidal Wipes but wiping the stethoscope with a single alcohol swab pad before and after use. The stethoscope diaphragm had been placed directly on the resident’s skin, and the nurse then stored the stethoscope in the medication cart for use with other residents. During interview, the nurse confirmed the alcohol swab pad was used on the stethoscope instead of the EPA-registered disinfectant wipes kept in the medication cart. The Infection Preventionist stated that EPA-registered disinfectant wipes should be used to clean shared medical equipment, including stethoscopes, and that an alcohol swab pad is not an EPA-registered disinfectant and did not meet the facility’s policy for disinfecting shared stethoscopes. The ADON stated the expectation was for staff to follow the facility’s infection control policies and procedures, and that shared equipment such as stethoscopes should be sanitized before and after each resident use with appropriate wipes. The facility policy required reusable resident-care equipment, including stethoscopes, to be cleaned and disinfected according to current CDC recommendations and manufacturers’ instructions. A separate observation showed an LPN obtaining a blood sample from a resident and then removing an insulin lispro KwikPen from the medication cart, removing the pen cap, and attaching a new needle without disinfecting the rubber seal with an alcohol swab pad. The nurse then primed the pen and administered 4 units of insulin. The nurse stated he was unaware the manufacturer’s instructions required the rubber seal of the insulin pen to be disinfected before attaching a needle, and acknowledged it should have been disinfected. The manufacturer’s package insert instructed staff to wipe the rubber seal with an alcohol swab before selecting and attaching a new needle.
Failure to Provide Mental Health and Psychosocial Services
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident who displayed or was diagnosed with a mental disorder, psychosocial adjustment difficulty, or had a history of trauma and/or post-traumatic stress disorder. The deficiency was identified based on the lack of evidence that the resident received necessary care and interventions tailored to their mental health and psychosocial needs, as required by regulatory standards. Surveyors observed that the resident's care plan did not address their specific mental health diagnosis or trauma history, and there was no documentation of individualized interventions or services to support their psychosocial adjustment. This omission resulted in the resident not receiving the comprehensive care needed for their condition.
Failure to Maintain 1:1 Supervision for Resident on Sitter Watch
Penalty
Summary
The facility failed to ensure that a resident requiring 1:1 monitoring was appropriately supervised in two separate instances. In the first instance, a Certified Nursing Assistant (CNA) assigned as a sitter was observed with her eyes closed for several minutes while on duty, and was not paying full attention to the resident as required. The Director of Nursing (DON) confirmed that the sitter was expected to remain within arm's length of the resident at all times and to continuously monitor the resident to prevent harm. The facility's policy also required staff to make routine checks to maintain resident safety and well-being. The CNA admitted to resting her eyes but denied being asleep, and a guard who witnessed the event reported it to management. In the second instance, another CNA assigned to 1:1 monitoring left the resident unattended in her room while he went to get supplies. The CNA acknowledged that he should not have left the resident alone and should have asked for assistance from other staff members. At the time of both incidents, the resident had diagnoses of dementia and anxiety disorder and had been placed on 1:1 monitoring following an altercation with another resident. Observations confirmed that the resident was left without staff supervision, contrary to facility policy and the expectations outlined by the DON.
Failure to Implement Respiratory Protection Program
Penalty
Summary
The facility failed to implement a respiratory protection program, specifically regarding the fit testing of N95 respirators for its direct care staff. Out of 106 direct care staff, 47 were not fit tested for the use of N95 masks, which is a requirement according to the facility's policy and CDC guidelines. This deficiency was identified during an unannounced visit to investigate a COVID-19 outbreak, where 32 residents and 12 staff members tested positive for the virus. Interviews with staff members, including the Infection Preventionist (IP), revealed that fit testing was supposed to occur upon hire, annually, and when new N95 models were introduced. However, several staff members, including Registered Nurses (RNs), Licensed Vocational Nurses (LVNs), and Certified Nursing Assistants (CNAs), reported not being fit tested for several years, with some last tested in 2020. The IP admitted to not prioritizing fit testing due to focusing on vaccinations and managing the COVID-19 outbreak. The Administrator confirmed the absence of a Respiratory Protection Program that included fit testing for N95 masks. The facility's policy required fit testing at the time of initial assignment and annually thereafter, but this was not adhered to, as evidenced by the lack of current fit testing records for 47 staff members. This oversight had the potential to contribute to the spread of COVID-19 among residents and staff, posing a risk to those not yet affected by the virus.
Removal Plan
- The administrator provided a verbal consult to the IP regarding failure to follow N95 Fit Testing Policy and procedure, including fit testing upon hire and annually thereafter.
- The administrator posted an on-shift message to all staff and requested whoever has not completed a N95 test for the past 12 months must be tested before reporting to work.
- A list of employees not fit tested was posted on the timeclock to ensure that they could not clock in unless the fit testing is completed.
- The administrator, the DON, and the MDS nurse contacted all employees not fit tested, and instructed them to complete their N95 Fit testing.
- The administrator and DON conducted in-services regarding N95 Fit Testing guidelines.
- Two other IPs reported to the facility to assist the facility in N95 fit testing of affected employees.
- The facility added N95 Fit Testing to the annual in-service calendar to ensure that all employees will complete their annual fit tests every January.
- The facility will conduct follow up in-service for N95 Fit Testing monthly for 3 months.
- The administrator and the DON will check 5 randomly selected employee files each week for 3 months, followed by quarterly and as needed to ensure all employees were fit tested.
Failure to Separate Residents Leads to Injury
Penalty
Summary
The facility failed to ensure the separation and distancing of two residents involved in multiple altercations, as indicated in their care plans. This failure resulted in a physical altercation where one resident was pulled from a chair by another, leading to a closed clavicle fracture. The incident was investigated during an unannounced visit on October 2, 2024, following an allegation of physical abuse. Resident 2, diagnosed with schizophrenia and lacking decision-making capacity, had a history of aggressive behavior towards Resident 1. Previous incidents on September 13 and 14, 2024, involved Resident 2 pushing and hitting Resident 1. Both residents' care plans included interventions to keep them apart and provide redirection when needed. Despite these interventions, on September 30, 2024, Resident 2 pulled Resident 1 from a wheelchair, causing a fall and injury. Interviews with facility staff, including the Infection Preventionist and Dietary Manager, revealed awareness of the need to keep the residents apart. However, during the incident on September 30, 2024, staff failed to redirect the residents in opposite directions, leading to the altercation. The Director of Nursing confirmed the staff's awareness of the need to separate the residents and acknowledged the failure to prevent the incident, which resulted in Resident 1's injury.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights for two residents were within reach, which could lead to unmet needs due to their inability to call for assistance. During an unannounced visit, it was observed that Resident 4, who was sitting in her wheelchair on the right side of her bed, had her call light hanging above the right side of the head of the bed, making it unreachable. Resident 4 expressed the need for help to be changed but was unable to call for assistance due to the call light's position. Similarly, Resident 5 was observed sitting in her wheelchair at the foot of Resident 4's bed, with her call light placed in the center of the bed, out of her reach. An interview with a CNA confirmed that the call lights were not within reach for both residents. Resident 4's medical records indicated she was admitted with diagnoses including diabetes mellitus type 2, osteoarthritis, and peripheral vascular disease, and had fluctuating capacity to make decisions. Her care plan emphasized the need for the call light to be within reach due to her self-care deficits. Resident 5's medical records showed diagnoses of dementia, diabetes mellitus type 2, major depressive disorder, and a history of falling, with an inability to make decisions. Her care plan also highlighted the necessity for the call light to be accessible due to her extensive assistance needs. The facility's policy required that each resident have a means to call staff directly for assistance, which was not adhered to in these cases.
Resident Falls Due to Tripping Hazard in Patio Area
Penalty
Summary
The facility failed to provide an environment free from accident hazards for a resident who was at high risk for falls. The resident, who had dementia and schizophrenia and lacked decision-making capacity, tripped on an in-ground planter that was approximately 3.25 to 3.5 inches deep above ground level. This incident occurred in the outer patio area, where the resident fell and hit her head on a picnic table, resulting in a periorbital hematoma and a fracture of the nasal septum. The resident's fall risk assessment had previously indicated a high risk of falling, with a score of 18 or more. Observations and interviews revealed that the in-ground planter posed a tripping hazard due to its unevenness relative to the surrounding pavement. The Director of Nursing acknowledged that the fall could have been avoided if the planter had been fixed. The facility's policy on promoting safety and reducing falls highlighted the importance of addressing extrinsic factors, such as environmental hazards, to enhance residents' quality of life. However, the facility did not maintain the area around the buildings, including the patio, in a safe and orderly manner, as required by their policy.
Failure to Complete Timely Comprehensive Assessments
Penalty
Summary
The facility failed to complete comprehensive assessments for six residents within the required 14 calendar days after their admission. This deficiency was identified during a review of the Minimum Data Set (MDS) comprehensive assessments, which are crucial for evaluating residents' health status and developing a resident-centered care plan. The MDS nurse confirmed that the assessments for the affected residents were not completed on time, as mandated by federal and state guidelines. Interviews with the MDS nurse and the Director of Nursing (DON) revealed an acknowledgment of the importance of timely completion of these assessments to ensure appropriate care planning. The facility's policy, dated July 2017, and a document titled RAI OBRA-required Assessment Summary, reiterated the requirement for assessments to be completed no later than the 14th calendar day following a resident's admission. Despite these guidelines, the assessments for the six residents were delayed, potentially impacting the delivery of resident-centered care.
Privacy and Documentation Deficiencies in Medication Administration
Penalty
Summary
The facility failed to ensure privacy for two residents during medication administration. One resident, who was alert and interviewable, was assessed for back pain by an LVN without the door being closed or the privacy curtain being drawn, leaving the resident visible from the hallway. Another resident had a topical pain medication applied to her knee by an LVN, again without privacy measures being taken, as the door was left open and the resident was visible from the hallway. Both LVNs acknowledged the oversight in providing privacy during these procedures. The facility also failed to properly document the administration of controlled medications for two residents. For one resident, the narcotic medication Norco was signed out on two occasions, but there was no documentation in the electronic Medication Administration Record (eMAR) to confirm that the medication was administered. Similarly, for another resident, the anti-anxiety medication Ativan was signed out, but again, there was no documentation in the eMAR to confirm administration. The LVN interviewed confirmed that the documentation was missing and should have been completed. The facility's policies and procedures require that medication administration be documented immediately after administration, including the date, time, and signature of the administering nurse. The lack of documentation for the controlled medications could lead to delays in identifying drug discrepancies and potential medication diversion. The facility's failure to adhere to its own policies and procedures regarding privacy and documentation contributed to these deficiencies.
Deficiency in Food Cooling Procedures
Penalty
Summary
The facility failed to ensure that dietary staff could safely and effectively carry out the functions of food and nutrition services, specifically regarding the cooldown process for hot food and ambient food temperatures. During interviews, Dietary Aide (DA) 3 and DA 4, as well as Cook (CK) 1, were unable to accurately describe the correct procedures for cooling down hot and ambient temperature foods. DA 3 incorrectly stated that the cooldown process for hot food starts at 186 degrees and should reach 140 degrees after two hours, and 34 degrees after another two hours. DA 3, DA 4, and CK 1 also provided incorrect information regarding the cooldown process for ambient food temperatures, such as tuna salad, indicating a misunderstanding of the required procedures. The Registered Dietitian (RD) clarified that the correct process for cooling hot food is to cool from 140 degrees to 70 degrees within two hours, and then to 40 degrees within four hours, totaling six hours. For ambient food temperatures, the food should reach 40 degrees or less within four hours, and if not, it must be discarded. The facility's policy, dated 2019, aligns with the RD's explanation, indicating a failure in staff training or adherence to these policies. This deficiency had the potential to place residents at risk for foodborne diseases due to improper food handling and cooling procedures.
Sanitation Deficiencies in Kitchen Equipment
Penalty
Summary
The facility failed to maintain a sanitary environment in the kitchen, leading to potential risks of foodborne illnesses. During an inspection, a toaster was found with a brown-yellowish grime buildup on its dial control, which the Dietary Manager (DM) acknowledged as grime that should not have been present due to the risk of cross-contamination. Additionally, multiple cutting boards were observed with yellowish discoloration, deep cuts, and damage, which the DM confirmed could harbor bacteria and lead to foodborne illness. Further observations revealed that the left and right sides of the oven, as well as the front inside surfaces of the oven doors, had brown discoloration identified as rust. The DM stated that the rust could fall into food, causing cross-contamination. Meal tray carts were also found with brown discoloration and corrosion, which the Registered Dietician (RD) and Maintenance Assistant (MA) attributed to wear and corrosion, posing a risk of bacterial growth and cross-contamination. The facility's policies and procedures, as well as the FDA Food Code, emphasize the importance of maintaining clean and undamaged equipment to prevent the growth of microorganisms and ensure food safety. However, the facility failed to adhere to these standards, as evidenced by the presence of grime, rust, and damaged equipment in the kitchen, which could potentially lead to foodborne illnesses among residents.
Deficient Maintenance of Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment in a safe operating condition, which posed a risk for foodborne illnesses. During an inspection, it was observed that a toaster had a chipped and peeled plastic film on its dial, which the Dietary Manager acknowledged as a potential site for bacterial growth and cross-contamination. Additionally, the left and right sides of the oven, as well as the inside surfaces of the oven doors, were found to have chipped and peeled paint with brown discoloration, identified as rust. The Dietary Manager confirmed that the rust and peeled paint could fall into food, leading to contamination. Further observations revealed that four meal tray carts had chipped and peeled vinyl stickers, and two of the carts had brown discoloration on their metal areas, indicating corrosion. The Registered Dietician and Maintenance Assistant confirmed these findings, noting that the rust and deterioration could lead to bacterial growth and cross-contamination. The facility's policies and the FDA Food Code emphasize the importance of maintaining kitchen equipment in good repair to prevent such risks, but the facility failed to adhere to these standards.
Failure to Maintain Homelike Environment Due to Damaged Blinds
Penalty
Summary
The facility failed to provide a comfortable homelike environment for a resident due to multiple damaged window blinds in the resident's room. During an observation and interview, the resident expressed that the room was too bright and had to use curtains to block the light coming through the damaged blinds. The Maintenance Supervisor acknowledged awareness of the issue and stated that the blinds needed replacement. Similarly, the Facility Administrator was aware of the need for repair or replacement to maintain a homelike environment. The facility's policy, dated December 2009, requires the maintenance department to keep the building in good repair, which was not adhered to in this instance.
Failure to Provide Advance Directive Education and Documentation
Penalty
Summary
The facility failed to provide education and resources regarding Advance Directives (AD) to a resident and their representative. The resident, who was admitted to the facility, was documented as having severely impaired cognitive skills and was unable to make decisions. Despite this, there was no evidence in the medical record that education or information about AD was provided to the resident or their representative. The Social Service Director (SSD) acknowledged that she did not provide the necessary resources and education, which should have been documented in the resident's records. The Director of Nursing (DON) stated that upon admission, licensed nurses are responsible for screening residents regarding AD, and the SSD is expected to follow up. If a resident does not have an AD, the facility's policy requires that assistance in establishing ADs be offered, and the offer or decline of assistance should be documented in the medical record. However, in this case, the facility did not adhere to its policy, resulting in a deficiency related to the lack of education and documentation concerning AD for the resident and their representative.
Deficiencies in Resident Environment and Maintenance Reporting
Penalty
Summary
The facility failed to provide a clean, safe, and comfortable environment for a resident, identified as Resident 28, due to two specific deficiencies. Firstly, the resident's call light button cord was found to be damaged and cracked, with exposed wires, during an observation. The resident was unaware of the damage, which had not been reported to the maintenance department for replacement. Interviews with the Maintenance Supervisor and a Certified Nurse Assistant (CNA) revealed that there was no work order for the call light, and the staff had not informed maintenance about the issue, which could potentially prevent the resident from receiving timely assistance. Secondly, the cabinet above the sink in the resident's bathroom had rust buildup on the bottom shelf. This was observed during an inspection, and both the Maintenance Supervisor and the CNA acknowledged the rust, stating that the cabinet should not be in such a condition. The Director of Nursing (DON) confirmed that the cabinet should be clean and free of rust, and emphasized that staff should report maintenance needs to ensure resident comfort and safety. The facility's policy on maintenance service indicates that the maintenance department is responsible for keeping the building and equipment in safe and operable condition, which was not adhered to in this case.
Failure to Notify LTC Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman of a discharge for a resident, which was identified during a review of closed records. The resident, who had been admitted with dementia and Alzheimer's, was discharged to an acute hospital. Despite the facility's policy requiring notification to the LTC Ombudsman at the time of discharge, there was no documented evidence that this notification occurred for the resident. Interviews with facility staff, including the Social Service Director, Medical Records Director, and Director of Nursing, confirmed that the discharge notice was not sent to the LTC Ombudsman. The Social Service Director acknowledged the oversight, stating that she missed sending the notification. The Medical Records Director and Director of Nursing reiterated the importance of this notification for resident safety and continuity of care, and confirmed that the notification should have been sent within 72 hours of the discharge.
Failure to Follow Medication Administration Protocol
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN) administered the medication Nifedipine ER 20 mg as ordered by the physician for a resident with hypertension. During a medication administration observation, the LVN did not check the resident's pulse rate, which was a required parameter before administering the medication. The medication label instructed to hold the medication if the systolic blood pressure was below 110 mmHg or the pulse rate was below 60 beats per minute. The LVN was observed to lack the necessary equipment to accurately check the pulse rate and admitted to not obtaining an accurate reading before administering the medication. The Director of Nursing confirmed that the LVN should have checked the pulse rate prior to administering the medication, as per the physician's order. The facility's policy and procedure for medication administration also required vital signs to be taken just before medication administration by the medication nurse. The failure to follow these procedures had the potential to prevent the resident from receiving the full therapeutic effects of the medication.
Failure to Assess and Care Plan for Edema
Penalty
Summary
The facility failed to appropriately assess and develop a care plan for a resident experiencing edema in the left upper and lower extremities. On July 23, 2024, during an observation and interview, the resident was found with a swollen left arm and hand, which was not supported or treated. The resident confirmed that no treatment, such as elevation or icing, had been applied. The resident's medical history includes diabetes, chronic obstructive pulmonary disease, atherosclerotic heart disease, and cirrhosis of the liver. The resident's records revealed that on July 4, 2024, a licensed nurse noted the resident's complaint of pain and swelling in the left arm, with an edema grading of +6. However, there was no documented assessment of the size and appearance of the swelling, nor was there a care plan initiated to address the edema. On July 13, 2024, the resident's condition was noted to include a blister on the left upper arm, and a new order for Lasix was received, but again, no assessment or care plan was documented. The Director of Nursing confirmed the lack of documentation for an appropriate assessment and care plan for the resident's edema. The facility's policy on edema assessment and care planning was not followed, as there was no evidence of monitoring or documentation of the edema's progression or any care plan to address the resident's needs. This oversight in documentation and care planning represents a deficiency in the facility's compliance with its own policies and procedures.
Failure to Follow Up on Vision Care Recommendation
Penalty
Summary
The facility failed to address the vision needs of a resident, identified as Resident 54, who had a recommendation for reading glasses that was not followed up. Resident 54, who has dementia but retains the capacity to make his own decisions, expressed a desire for reading glasses to help him read better. Despite a physician's order for an eye-health and vision consult, and a subsequent recommendation from an optometrist for new reading glasses, the facility did not act on this recommendation. Interviews with the Social Service Director (SSD) and the Director of Nursing (DON) confirmed that the recommendation for reading glasses was not followed up, and there was no documentation indicating that the issue had been addressed. The SSD acknowledged the oversight and the potential for this lack of follow-up to lead to vision problems for the resident. The facility's policy on Ancillary/Consultant Physician Services requires that consultant recommendations be documented and acted upon, but this was not adhered to in this case.
Improper Storage of Expired and Discontinued Medications
Penalty
Summary
The facility failed to ensure that medications were stored properly, leading to the availability of expired and discontinued medications. During an inspection, it was observed that a bottle of Nutricia UTI Stat Liquid and acetaminophen suppositories were stored in a medication cart despite being expired. The Nutricia UTI Stat Liquid had an expiration date that had passed, and the acetaminophen suppositories were labeled for a resident who had been discharged. Licensed Vocational Nurse (LVN) 3 acknowledged that these medications should not have been readily available for use and should have been disposed of properly. Additionally, a vial of Comimaly Intramuscular Suspension was found in the medication refrigerator, labeled for a resident who had already been discharged. LVN 4 confirmed that this medication should have been removed and stored in a designated cabinet for discontinued medications. The Director of Nursing (DON) also stated that the expired and discontinued medications should have been pulled out and wasted to prevent potential medication errors. The facility's policy on medication storage was reviewed, indicating that discontinued or outdated drugs should be returned to the pharmacy or destroyed.
Failure to Provide Assistive Eating Devices
Penalty
Summary
The facility failed to provide necessary assistive devices, such as plate guards, for two residents during mealtime, which was observed by surveyors. Resident 13 was seen struggling to keep food on her plate, resulting in food spilling onto the floor. During an interview, the resident expressed difficulty in managing her food, and a Licensed Vocational Nurse (LVN) confirmed that a plate guard should have been provided to assist the resident. The Director of Nursing (DON) acknowledged that Resident 13 should have been evaluated for and provided with an assistive eating device to ensure her nutritional needs were met. Similarly, Resident 58 was observed having difficulty keeping food on her plate, with food spilling onto the overbed table. The resident expressed confusion about the location of her food, indicating a need for assistance. An Infection Preventionist (IP) noted the necessity of a plate guard for Resident 58 to prevent food from falling off the plate. The DON also confirmed that Resident 58 should have been evaluated and provided with an assistive eating device. The facility's policy on assistive devices, dated January 2020, states that specialized eating utensils and equipment should be provided to assist residents, but this was not adhered to in these cases.
Expired Food Storage in Resident's Room
Penalty
Summary
The facility failed to ensure the safe and sanitary storage of personal food for a resident, identified as Resident 56, when two expired bags of marshmallows were found in the resident's closet. The marshmallows, which were gifts from the previous Christmas, were readily available for consumption. Resident 56, who has a fluctuating capacity to understand and make decisions, admitted to occasionally snacking on the marshmallows. During observations and interviews, both a Licensed Vocational Nurse (LVN) and a Nursing Assistant (CNA) confirmed the presence of the expired marshmallows and acknowledged the potential for stomach upset if consumed. The Director of Nursing (DON) stated that expired food should have been discarded and not accessible to residents. The facility's policy on food storage specifies that expired items should be discarded, yet this was not adhered to in the case of Resident 56. The failure to discard the expired marshmallows posed a risk of foodborne illness to the resident, highlighting a lapse in the facility's adherence to its own food storage policies.
Infection Control Lapses in Hand Hygiene and Equipment Disinfection
Penalty
Summary
The facility failed to ensure proper infection control practices during a blood sugar check and insulin administration for a resident. A registered nurse did not perform hand hygiene before, in between, and after resident contact. The nurse was observed not washing hands before and after pushing the resident's wheelchair, checking blood sugar, and administering insulin. Despite wearing gloves, the nurse did not follow the facility's policy on hand hygiene, which requires washing hands before and after these procedures. In another instance, a physical therapy assistant did not perform hand hygiene or disinfect ankle weights after using them on a resident under enhanced barrier precautions. The resident had multidrug-resistant organisms and extended spectrum beta-lactamase in their urine, necessitating strict infection control measures. The assistant failed to wash hands and disinfect equipment after therapy, contrary to the facility's infection control policies. The infection prevention nurse confirmed the expectations for hand hygiene and equipment disinfection, emphasizing the importance of these practices to prevent infection spread. The facility's policies clearly outline the need for hand hygiene and disinfection of non-critical resident-care items, which were not adhered to in these cases.
Failure to Offer Second Pneumococcal Vaccine Dose
Penalty
Summary
The facility failed to ensure that a resident was offered the pneumococcal vaccine as per CDC guidelines. Resident 58, who is of advanced age and has a diagnosis of chronic obstructive lung disease (COPD), was admitted to the facility and had received one dose of the pneumococcal vaccine (PPSV23) in April 2023. According to the facility's policy and CDC guidelines, a second dose of pneumococcal vaccine (PCV20) should be offered one year after the initial dose. However, during an interview and record review, it was found that there was no documentation indicating that Resident 58 was offered the second dose of the vaccine after the one-year interval. This oversight was confirmed by the Infection Preventionist during the review of the resident's immunization record.
Inadequate Monitoring Leads to Resident Wandering Incident
Penalty
Summary
The facility failed to ensure adequate monitoring of a resident with dementia, leading to an incident where the resident wandered into another resident's room. Resident 2, who had a history of severely impaired cognition and was at risk for wandering due to dementia, was not frequently monitored as required by their care plan. This lack of supervision allowed Resident 2 to enter Resident 1's room, where they were found on top of Resident 1, who is non-verbal and unable to make decisions. Interviews with staff revealed that Resident 2 had previously exhibited behavior of entering other residents' rooms, but this was not documented or communicated to the Director of Nursing (DON) or other licensed staff. The DON was unaware of Resident 2's behavior until the incident occurred, indicating a breakdown in communication and documentation within the facility. The incident highlights the facility's failure to implement and follow through with the necessary interventions to prevent such occurrences, as outlined in Resident 2's care plan.
Failure to Update and Maintain Accurate POLST Documentation
Penalty
Summary
The facility failed to ensure that the Physician's Orders for Life Sustaining Treatment (POLST) were identifiable, accurate, and updated for three residents. Resident 2's POLST, dated March 4, 2024, indicated a Do Not Attempt Resuscitation (DNR) status, but during an Interdisciplinary Team (IDT) meeting on March 12, 2024, the resident's family member gave verbal consent for a full code status. However, the POLST was not updated, and the resident was transferred to an acute hospital with the incorrect DNR status. The Director of Nursing (DON) confirmed that the updated POLST should have been in the chart since March 12, 2024, and acknowledged the potential for serious adverse events due to this oversight. The Social Services Director (SSD) and a Registered Nurse (RN) also confirmed the discrepancy and the lack of an updated POLST in the resident's record. Resident 6's POLST, dated May 11, 2022, indicated full treatment but lacked the resident's or their representative's signature. The IDT met with the resident's responsible party on January 22, 2024, but the POLST was not updated to reflect this meeting. The DON confirmed that the POLST should have been updated and signed by the resident's assigned responsible party after the IDT meeting. There was no documented evidence explaining why the SSD/Bioethics committee had signed the POLST initially, and the updated POLST was missing from the resident's medical chart. Resident 7, who was admitted with severe cognitive impairment, did not have a completed and signed POLST or Consent to Treat form in their medical record. The SSD confirmed that the facility's process involved the Bioethics Committee acting as the healthcare decision-maker when no other decision-maker was available. However, there was no documented evidence of the IDT's determination or the Bioethics Committee's involvement in Resident 7's case. The facility's policies on POLST and the Bioethics Committee were reviewed, but the required documentation and updates were not present in the resident's records.
Failure to Assign Surrogate Decision Maker for Resident
Penalty
Summary
The facility failed to ensure a resident representative or surrogate decision maker was assigned for decision making for a resident diagnosed with schizophrenia who lacked the capacity to understand and make decisions. The resident was admitted without a completed and signed Physician's Orders for Life Sustaining Treatment (POLST) and Consent to Treat form. The Medical Records (MR) staff confirmed the absence of these documents and acknowledged the resident's lack of decision-making capacity. Despite the facility's policy requiring the Interdisciplinary Team (IDT) to appoint a decision maker, there was no documented evidence that the IDT or the Bioethics Committee had taken action to assign a healthcare decision maker for the resident. The Social Service Director (SSD) confirmed that the facility's process involves the IDT meeting to determine if the Bioethics Committee should be the appointed healthcare decision maker when no other decision maker is available. However, the SSD was unable to provide documented evidence that the IDT had reviewed the resident's case or that the Bioethics Committee had been involved in making healthcare decisions for the resident. The facility's policies on admission to a secured unit and the role of the Bioethics Committee were reviewed, but there was no documentation showing that these procedures had been followed for the resident in question.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 455 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Beaumont
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vista Real Post Acute | 1.6 mi | ★★★★★ | 1 | 0 |
| Sundance Creek Post Acute | 2 mi | ★★★★★ | 15 | 0 |
| Oak Glen Post Acute | 2.7 mi | ★★★★★ | 1 | 0 |
| Sunrise Post Acute | 3.6 mi | ★★★★★ | 30 | 0 |
| Yucaipa Hills Post Acute | 5.8 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Highland Springs Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.