Highland Ridge Rehab Center

In the surveyor’s words

From the most serious findings on record at Highland Ridge Rehab Center, in the surveyor’s own words.

• Actual harm, isolatedF689May 19, 2022

  Based on staff interviews, clinical record review, and facility document reviews the facility staff failed to provide supervision and assistance devices to prevent injury during a bed transfer for 1 of 8 residents, Resident #3. For Resident #3, the facility staff failed to provide a 2-person assist or Hoyer lift during a transfer to the bed resulting in a broken arm. The findings were: Resident #3's admission record noted their diagnoses included, but were not limited to, transient cerebral ischemic attack (stroke), Alzheimer's disease (progressive disease destroying memory and other mental functions), dementia (impaired brain functions), [CONDITION(S)] (deteriorating cartilage at end of bones), muscle weakness, stiffness of unspecified joint, and dysphagia (difficulty swallowing). […]

• No harm, potential for more than minimal, widespreadF800Feb 26, 2026

  Based on observation, resident interview, staff interview, and facility document review, the facility staff failed to meet the daily nutritional and dietary needs of all residents that receive nutrition by oral means and the facility staff failed to maintain an overall system to manage and execute its food and nutritional services during a lapse in food service management. The findings included:Tray line was observed on 2/25/26 at 11:45 AM. The menu consisted of Swedish meatballs, egg noodles, and pacific blend vegetables. During observations of the tray-line, no special diets were noted to be called out other than regular diets, ground consistencies, and/or puree consistencies. […]

• No harm, potential for more than minimal, widespreadF812Feb 26, 2026

  Based on observations, staff interview, and facility document review, the facility staff failed to prepare, store, distribute, and serve food in accordance with professional standards for food service safety in the facility kitchen and in 4 of 4 unit pantries/nutrition rooms.The findings included:For the facility, the facility staff failed to discard out-of-date food items, failed to date and label perishable food items, failed to maintain clean dietary equipment, failed to store food under sanitary conditions, failed to utilize hair and beard restraints for dietary personnel, and failed to practice proper hand hygiene.An initial tour of the kitchen on 2/24/2026 at 10:51 AM was completed with the Registered Dietician (RD).Observation of the dry storage area revealed the following items:7… […]

• No harm, potential for more than minimal, widespreadF882Sep 5, 2025

  Based on observations, staff interview, and facility document review, the facility staff failed to employ an infection preventionist with the required training prior to assumption of the role.The findings included:On 9/5/25, members of the survey team made multiple observations of residents requiring EBP (enhanced barrier precautions) and/or TBP (transmission-based precautions) without proper notification/signage and PPE available to staff, residents and/or visitors. On 9/5/25 at 2:54 PM-surveyors met with interim administrator (ADM), interim director of nursing (DON), regional director of clinical services and licensed practical nurse #1 (LPN#1). […]

• No harm, potential for more than minimal, patternF655Feb 26, 2026

  Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to provide and/or review a baseline care plan (BCP) for 5 of 25 residents, Residents #6, #2, #13, #126, and #134 and failed to complete a BCP for 1 of 25 residents, Resident #84. The findings included:1. For Resident #6, the facility staff failed to provide the resident with a copy of their BCP. Resident #6's clinical record listed the resident as being their own responsible party. Diagnoses included sepsis and chronic pulmonary edema. […]