Not rated by CMS — ratings are suppressed for new or low-volume facilities.
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.
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.
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.
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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 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 | — | 14 | 0 |
| Oak Glen Post Acute | 2.7 mi | — | 0 | 0 |
| Sunrise Post Acute | 3.6 mi | — | 30 | 0 |
| Yucaipa Hills Post Acute | 5.8 mi | — | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.