Highland Springs Care Center

In the surveyor’s words

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

• Immediate jeopardy, patternF880Nov 14, 2024

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

• Actual harm, isolatedF692Aug 29, 2025

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

• Actual harm, isolatedF600Oct 2, 2024

  Based on interview and record review, the facility failed to ensure the residents involved in multiple altercations (physical fight) (Residents 1 and 2) were separated and distanced away from each other as indicated in the care plan. This failure resulted in Resident 1 being grabbed and pulled out from a chair which led to a closed clavicle fracture (broken collarbone). Findings: On October 2, 2024 at 8:30 a.m., an unannounced visit to the facility was conducted to investigate an allegation of physical abuse (the intentional use of physical force to cause injury or harm to another person). On October 2, 2024, Resident 2's admission record was reviewed. […]

• Actual harm, isolatedF689Jul 25, 2024

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

• No harm, potential for more than minimal, widespreadF814Jan 26, 2023

  Based on observation and interview, the facility failed to provide a clean and safe environment for the residents and visitors when one out of one dumpster garbage bin located outside the kitchen was overflowing with trash, and the deformed (bent) lid was not securely closed. This failure had the potential for an unsafe environment for the residents and the visitors due to possible pest infestation and spread of diseases in the facility. Findings: During the kitchen initial tour on January 23, 2023, at 10:09 a.m., one dumpster bin located outside the facility's kitchen was observed overflowing with trash and the lid was not securely closed. In addition, the dumpster lid was observed deformed (bent) and would not close tightly to prevent rodents or pests from entry. […]