Continuing Care at Highland Springs

In the surveyor’s words

From the most serious findings on record at Continuing Care at Highland Springs, in the surveyor’s own words.

• Immediate jeopardy, patternF740Jan 21, 2026

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

• Immediate jeopardy, isolatedF656Jan 21, 2026

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

• No harm, potential for more than minimal, widespreadF585Aug 1, 2024

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

• No harm, potential for more than minimal, widespreadF812Oct 13, 2022

  Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure the temperatures of food items were recorded. 2. The facility failed to ensure food items were properly labeled, dated, and stored in accordance with professional standards. These failures could place residents, who receive food from the kitchen, at risk for food contamination and food-borne illness. […]

• No harm, potential for more than minimal, patternF656Sep 11, 2025

  Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for three (Residents #5, #7, and #33) of six residents reviewed for care plans. The facility failed to ensure Residents #5, #7, and #33's comprehensive care plans addressed their use of psychotropic medications (drugs that affect the mind, emotions, and behavior) and related behavioral concerns as identified in their comprehensive assessments. This failure could place residents at risk of receiving inadequate interventions not individualized to their mental health care needs. […]