Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Highland Ridge Care Center, Llc during CMS and state inspections, most recent first.
The facility failed to appropriately assess and intervene for two residents. One resident with dementia and bowel incontinence received multiple laxatives, had ongoing diarrhea and aggressive behavior during care, and then slipped and fell in the shower while staff were cleaning stool from the resident. Another resident with Alzheimer’s disease and a history of falls complained of hip pain after a fall, but the nurse did not promptly notify the physician or fully respond to the injury concerns, and the resident was later found to have a suspected fracture.
Failure to Provide Adequate Supervision to Prevent Falls: Two residents with dementia and fall risk were not adequately supervised. One resident, who was combative during care and needed 2 staff for showers, was left with insufficient help during a shower after bowel incontinence and slipped on a wet floor, sustaining a severe femur fracture. Another resident was left unattended in a wheelchair despite a care plan warning not to leave her alone, and she later fell to the floor with hip pain.
A resident with severe cognitive impairment, DM, Alzheimer’s disease, bone density disorder, and a history of falls was found on the floor after a fall and repeatedly showed pain with turning, lifting, and brief care. Staff documented right hip pain, crying out with movement, and pain ratings up to 6/10, but pain treatment and escalation were inconsistent, with one LPN stating Tylenol was not offered because the resident was sleeping. The resident later required Tylenol, and the family reported significant pain during later assessment, with the hospital giving morphine after a suspected fracture was identified.
Insufficient staffing and training for dementia care led to repeated unmet behavioral support needs for a resident with dementia, anxiety, depression, and hallucinations. A CNA reported being left alone or paired with inadequately trained staff while providing 2-person care for an aggressive resident who resisted showers, required extensive assistance with hygiene, and was incontinent of bowel and bladder. Staff interviews showed the dementia unit often relied on new CNAs training other new CNAs, with limited supervision and inconsistent awareness by nursing leadership when staffing was short or the resident became aggressive during care.
Failure to Provide Resident Privacy and Dignity: Staff repeatedly entered resident rooms without knocking or announcing themselves, including during personal care and wound care. A resident with Alzheimer's disease and another resident with intact cognition were observed being interrupted in their rooms, and one resident's bare buttocks were exposed to the hallway during care. A CNA also moved a seated resident's chair without warning, causing the resident to tip and startle.
Failure to notify the LTC Ombudsman of resident discharges: The facility did not document notification to the State LTC Ombudsman for three residents who discharged home. Records showed each resident’s discharge to home, but there was no evidence the required discharge notice was sent to the Ombudsman. The Administrator stated staff believed notification was only needed for hospital transfers, although facility policy required sending the discharge notice to the Ombudsman at the same time it was issued to the resident.
A resident with a documented shellfish allergy was served shrimp at lunch and ate one to two pieces before a CNA noticed and removed the tray. The resident had intact cognition and a history of hives with shellfish exposure. Staff did not immediately assess or notify the RN when the exposure occurred, and the record later noted mild hand itchiness, refusal of PRN Benadryl, and no SOB or dyspnea.
A resident with a documented shellfish allergy was served a meal containing coconut shrimp. Dietary staff set up the tray and a CNA placed it in front of the resident, who ate part of the shrimp before another CNA noticed the allergy and removed the tray. The resident’s record and food ticket both identified shellfish as an allergen, and the resident had a prior hx of hives with shellfish.
A resident with Alzheimer's and dementia was found with dried blood on his head due to scratching and picking at scabs. The facility failed to investigate the injury's origin, with inconsistent staff accounts and inadequate documentation. The DON acknowledged the need for thorough investigation but did not provide evidence of it in this case.
A resident with severely impaired cognition experienced multiple unwitnessed falls, but the facility failed to complete neurological assessments for 15 out of 16 falls, despite having a policy in place. Staff interviews indicated awareness of the policy, but the Director of Nursing noted that the policy did not differentiate based on cognitive status.
Failure to Assess and Respond to Bowel-Related Fall and Post-Fall Pain
Penalty
Summary
The facility failed to provide appropriate assessment and interventions for two residents, based on clinical record review, observation, and staff interviews. One resident had diagnoses including diabetes mellitus, kidney disease, dementia, anxiety, and depression, with severe cognitive impairment, incontinence of bowel and bladder, and dependence for toileting, bathing, grooming, and hygiene. After returning from a hospital stay for a urinary tract infection, the resident developed multiple loose stools and was receiving several bowel medications, including polyethylene glycol, lactulose, senna, and other laxatives/PRN bowel agents. The record showed duplicate polyethylene glycol orders and ongoing administration of laxatives during a period of repeated loose stools and aggressive behavior during care. On the day of the fall, the resident was being showered after being incontinent of stool. Staff reported the resident became combative, grabbed the grab bar, and slid on the wet shower floor. Point-of-care documentation showed repeated loose diarrhea and multiple showers over the preceding days, with staff noting the resident was aggressive during care and that interventions were not effective. The hospital record stated the resident had diarrhea since the prior hospital discharge due to multiple laxatives, and the daughter reported she was unaware the resident was receiving polyethylene glycol twice daily and that the resident had diarrhea for about a week before the fall. A second resident had diagnoses including type 2 diabetes mellitus, Alzheimer’s disease, bone density disorder, macular degeneration, and a history of falls, with maximum assistance needed for toileting, dressing, and showers. After a fall from the wheelchair area, the resident complained of right hip pain and initially could not move the right lower extremity due to pain, crying out with movement and during repositioning. Staff documented vital signs and noted the resident later moved extremities, but the fall follow-up form recorded no pain and no change in condition. Staff interviews showed the resident continued to have pain during care, yet the nurse did not call the physician and instead placed the report on the medical director’s clipboard. The resident’s daughter later reported the facility delayed obtaining the x-ray, and the hospital ultimately identified a suspected fracture.
Failure to Provide Adequate Supervision to Prevent Falls
Penalty
Summary
The facility failed to provide appropriate and sufficient supervision to ensure resident safety and prevent avoidable accidents for 2 of 3 residents reviewed for falls. One resident had diagnoses including diabetes mellitus, kidney disease, dementia, anxiety, depression, visual hallucinations, osteoarthritis, incontinence, and severe cognitive impairment, and her care plan identified fall risk, need for assistance with bathing, dressing, grooming, and hygiene, and behavioral issues including aggression during care. The record showed repeated aggressive behavior during showers and care, with staff documenting that redirection and reassurance were not effective on multiple occasions. On 10/29/25, the resident was incontinent of bowel and staff attempted to shower her. She became combative, grabbed the grab bar in the shower, stood up, and slipped on the wet floor. She was found on the shower floor with her left leg internally rotated and screaming in pain. The hospital record documented a ground-level fall in the shower, stool on the shower floor, and a severe left distal femur fracture with significant impaction and medial displacement. Interviews with CNA staff and other employees stated the resident did not like showers, was often aggressive, and required 2 staff for showers and care, but one CNA was left alone on the dementia unit and attempted to complete the shower without adequate assistance. A second resident had diagnoses including type 2 diabetes mellitus, Alzheimer's disease, bone density disorder, macular degeneration, and a history of falls. Her care plan directed staff to assist with transfers, ambulation, and to avoid leaving her unattended in a wheelchair. On 10/26/25, after being placed in her wheelchair in her room, she was left unattended and later found on the floor next to the wheelchair with her head resting on the wheel. She complained of right hip pain and cried out with movement, but staff and the family initially monitored her rather than obtaining immediate evaluation. Interviews showed staff knew she should not be left alone in the wheelchair, yet she was left unattended and subsequently fell. The facility assessment and policy cited staffing and supervision responsibilities, but the events described showed the residents were not adequately supervised at the times of the falls.
Failure to Provide Appropriate Pain Management After a Fall
Penalty
Summary
The facility failed to provide appropriate pain management for a resident with severe cognitive impairment, diabetes, Alzheimer’s disease, bone density disorder, macular degeneration, and a history of falls. The resident required a walker with one staff assist, a wheelchair, and extensive assistance with toileting, dressing, and showers. After a fall, the resident was found on the floor next to her wheelchair with her head resting on the wheel. Staff documented that she was alert and talkative, but she complained of right hip pain and cried out with attempted movement. She was assisted back to bed with a mechanical lift, and the daughter initially declined hospital evaluation. Following the fall, staff observations and documentation showed ongoing pain with movement and care. One nurse documented that when the resident was turned or repositioned, she yelled out in pain and reported pain from the right hip down to the right knee. Another nurse documented that the resident cried out when staff attempted to turn her for brief care and that she reported her right hip hurt pretty bad, with pain rated as 6/10 during transfer. Staff interviews confirmed that the resident screamed in pain during turning, lifting, and care, and that pain was noted when staff attempted to move her right leg or provide incontinence care. Despite these repeated pain complaints and movement-related distress, staff did not consistently treat or escalate the pain at the time it was observed. One LPN stated Tylenol was not offered because the resident was sleeping and was not alarmed. Another nurse stated she was told to monitor for pain after the fall, and staff described the resident as fine when she was not being moved. The resident later required Tylenol for pain, and the daughter reported that when she arrived later, the resident was in significant pain during assessment and movement, and the hospital later administered morphine after a suspected fracture was identified.
Insufficient staffing and training for dementia unit behavioral care
Penalty
Summary
The facility failed to ensure there was a sufficient number of direct care staff with the competencies and skills needed to meet the behavioral health needs of residents with dementia, mental, and psychosocial disorders. The report states the facility also failed to provide supervision and skills training for staff on how to approach residents who may be agitated, combative, verbally or physically aggressive, or anxious, and how and when to obtain assistance in managing behavior symptoms. The facility reported a census of 50 residents. Resident #1 had diagnoses of dementia, anxiety, depression, and visual hallucinations, required maximal assistance with toileting, showering or bathing, and personal hygiene, and moderate assistance with dressing. The resident was incontinent of bowel and bladder, had a BIMS score of 3 indicating severe cognitive impairment, rejected care on 3 of 5 days reviewed, and had physical behavior symptoms directed toward others. Point of care documentation showed repeated aggressive behavior during care on multiple shifts, with interventions such as redirection, conversation, and reassurance documented as not effective. Staff interviews described repeated staffing and training problems on the dementia unit. A CNA stated she was new, had limited training, and was left to work alone or with staff who were not certified to assist her with residents needing two-person care. She reported that on one occasion Resident #1 was left with BM on the body, became aggressive during a shower, and fell while she was trying to complete care without adequate help. Other CNAs and an RN stated the dementia unit typically required two CNAs, that new staff were being trained by other new staff, and that experienced staff were not consistently available. The activity assistant stated she was not certified to assist with resident care and could not count as the second staff member. The scheduler and charge nurse stated they were unaware that the unit was short-staffed at times or that the resident had fallen, while the administrator stated there should always be 2 certified staff in the dementia unit during day and evening shifts and 1 CNA on nights, but was unaware that this was not occurring.
Failure to Provide Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure staff provided care with dignity and respect for 4 of 33 residents reviewed. Resident #1 had moderately impaired cognition, a diagnosis of Alzheimer's disease, used a wheelchair, and was dependent on staff for toileting, transfers, and repositioning in bed. During an interview in the resident's room, staff entered without knocking or announcing themselves. The resident stated that staff just walk in. Later observations showed a CNA entering the room with breakfast and lunch without knocking or announcing herself. During wound care for Resident #1's sacral/coccyx wound, staff exposed the resident's bare buttocks while providing care. Another CNA entered the room without knocking or announcing herself, pushed a mechanical standing lift through the doorway, and exposed the resident's bare buttocks to the hallway while moving the lift into the room. Staff present did not comment when the CNA entered during care. Staff interviews indicated they had been taught to knock, announce themselves, and wait to enter until the resident was covered, but these actions were not followed during the observations. Resident #49 had severe cognitive impairment, dementia, and an anxiety disorder, and used a walker and wheelchair. While assisting the resident into the dining room, a CNA lifted the chair the resident was sitting in without voicing her intent, causing the resident's upper body to tip to the right; the resident startled and grabbed for the chair and table to balance herself. Resident #18, who had intact cognition, was observed with one CNA who knocked, announced herself, and entered with a mechanical lift, followed by another CNA who entered the room without knocking or announcing herself. Resident #31, who had a BIMS score indicating intact cognition, was also observed with a CNA walking into the room without knocking and walking up to the resident. The facility policy stated staff would provide privacy and dignity, cover body parts as needed, and knock and request permission before entering private space.
Failure to Notify LTC Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman of the discharge of 3 of 3 sampled residents who were discharged to home. Review of the facility discharge list dated 6/1/25 to 9/8/25 identified three residents discharged from the facility to home: Resident #56, Resident #58, and Resident #59. Clinical record review showed that Resident #56 had a discharge summary indicating a planned discharge home with home health services, Resident #58 had a progress note documenting discharge to home, and Resident #59 had a recapitulation of stay and discharge summary documenting discharge to home. For each of the three residents, the clinical record lacked documentation that the State LTC Ombudsman was notified of the discharge. On 9/10/25, the Administrator stated she believed the facility was only required to notify the LTC Ombudsman for hospital transfers, not discharges to home, and reported corporate staff were also unaware of the need to contact the LTC Ombudsman for residents discharged to home. The facility policy titled Discharge and Transfer Policy dated 3/2025 stated that staff must send a copy of the resident's discharge notice to the Office of the State Long Term Care Ombudsman at the same time the notice is issued to the resident.
Failure to Respond to Known Shellfish Allergy Exposure
Penalty
Summary
Nursing staff failed to assess and intervene after a resident with a documented shellfish allergy was served and ate shrimp at lunch. Resident #28 had intact cognition, a care plan directing staff to provide the ordered diet, and a documented allergy to shellfish with a history of hives after exposure. During lunch observation, dietary staff set up the meal, a CNA placed the tray in front of the resident, and the meal included breaded coconut shrimp. The resident ate one to two shrimp before another CNA noticed the shrimp on the plate and removed the meal. The resident reported that staff had not checked on her after she ate the shrimp and denied symptoms at the time of interview. The clinical record later documented a late-entry note stating the resident complained of itchiness in her hands, refused PRN Benadryl, denied shortness of breath or dyspnea, and had vital signs assessed. The nurse documented notifying the primary care physician by fax. The facility's food allergy policy stated food allergies were to be documented on admission and reviewed during care planning development.
Food Allergy Meal Service Error
Penalty
Summary
The facility failed to ensure that a resident with a documented shellfish allergy was not served shellfish during meal service. Resident #28 had intact cognition, a care plan directing staff to provide the resident’s diet as ordered, and the clinical record identified a food allergy to shellfish, including shrimp, crab, lobster, oysters, clams, mussels, and scallops. A history and physical also documented a prior allergic reaction of hives to shellfish. During lunch observation, dietary staff set up the resident’s meal and a CNA placed the tray in front of the resident. The meal included breaded coconut shrimp, and the resident ate part of the shrimp before another CNA noticed the allergy and removed the tray. The food service ticket for the meal listed coconut shrimp and printed in red that the allergen was shellfish. The resident later reported that shellfish previously caused itching and denied any throat or swallowing difficulty, and at the time of interview denied any allergic reaction symptoms.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident diagnosed with Alzheimer's disease, dementia with behavioral disturbance, and anxiety. The resident, who required partial to moderate assistance with daily activities, was observed with dried blood on his head due to scratching and picking at scabs. The clinical records lacked detailed assessment information, including the origin and size of the injury, and there was no documentation of provider notification. Staff interviews revealed inconsistent accounts of the incident, with some staff suggesting the resident might have fallen, while others believed the injury was due to scratching and picking behavior. The Director of Nursing (DON) acknowledged the need to investigate such incidents thoroughly but did not provide evidence of a comprehensive investigation in this case. The resident was observed resting in his room with the injury appearing healed. Staff interviews indicated that the resident had a history of falls and behavioral issues, but there was no clear documentation or investigation into the cause of the injury. The DON described the process for investigating unknown injuries, which involves assessing the resident's ability to answer questions, reviewing staffing patterns, and considering any changes in the resident's behavior or health status. However, the facility did not follow this process adequately, resulting in a failure to determine the cause of the resident's injury and ensure appropriate care and intervention.
Failure to Complete Neurological Assessments After Unwitnessed Falls
Penalty
Summary
The facility failed to complete neurological assessments after unwitnessed falls for a resident with severely impaired cognition. The resident, diagnosed with vascular dementia with psychotic disturbance, anxiety disorder, and insomnia, experienced multiple unwitnessed falls over a period of several months. Despite the facility's policy requiring neurological assessments for unwitnessed falls, the assessments were only completed for one of the 16 falls documented in the resident's progress notes. Interviews with staff revealed that they were aware of the policy to start neurological assessments after unwitnessed falls, especially for residents with cognitive impairments. However, the Director of Nursing indicated that the policy did not differentiate based on cognitive status and that staff took the residents' statements at face value. The facility's Fall Prevention and Management Program Policy, which was modified in April 2021, required neuro checks for three days following unwitnessed falls but lacked specific guidance for residents with impaired cognition.
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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.
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Nursing homes near Williamsburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rose Haven Nursing Home | 8.8 mi | ★★★★★ | 11 | 0 |
| English Valley Nursing Care Center | 10.8 mi | ★★★★★ | 3 | 0 |
| Colonial Manor Of Amana | 10.9 mi | ★★★★★ | 0 | 0 |
| Parkview Manor | 15.9 mi | ★★★★★ | 13 | 0 |
| Pleasantview Home | 19.6 mi | ★★★★★ | 6 | 0 |
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