A list of the most recent deficiencies for Highland Springs Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-16 | 2024-03-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-04 | 2023-12-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-15 | 2023-12-06 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-14 | 2023-08-28 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-07-17 | 2023-07-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-17 | 2023-07-27 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-10 | 2023-05-22 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-04 | 2023-04-11 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-01-30 | 2023-02-17 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-01-30 | 2023-02-17 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-01-30 | 2023-02-17 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-01-30 | 2023-02-17 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2023-01-30 | 2023-02-17 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-01-30 | 2023-02-17 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-01-30 | 2023-02-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-01-30 | 2023-02-17 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-01-30 | 2023-02-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-30 | 2023-02-17 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-01-26 | 2023-02-16 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-01-26 | 2023-02-16 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-01-26 | 2023-02-16 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-01-26 | 2023-02-16 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-01-26 | 2023-02-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-26 | 2023-02-16 | N |
| Dispose of garbage and refuse properly. | Health | 2023-01-26 | 2023-02-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-19 | 2022-11-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-01 | 2021-11-10 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-10-01 | 2021-11-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-11 | 2021-09-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-11 | 2021-09-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-04 | 2021-05-26 | Y |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-09-18 | 2019-10-07 | N |
| Establish methods for sharing information. | Fire Safety | 2019-09-18 | 2019-10-07 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-09-18 | 2019-10-07 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-09-18 | 2019-10-07 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-09-18 | 2019-10-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-09-18 | 2019-10-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-18 | 2019-10-07 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2019-09-18 | 2019-10-07 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-09-18 | 2019-10-07 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-08-22 | 2019-09-16 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-08-22 | 2019-09-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-22 | 2019-09-16 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-08-22 | 2019-09-16 | N |
| Provide or obtain dental services for each resident. | Health | 2019-08-22 | 2019-09-16 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-08-28 | 2019-01-30 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-11-19 | 2018-12-13 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-11-19 | 2018-12-13 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-08-28 | 2018-12-11 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-08-28 | 2018-11-05 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-08-28 | 2018-11-05 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-08-28 | 2018-11-05 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-08-28 | 2018-10-12 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-08-28 | 2018-10-12 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-08-28 | 2018-10-12 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2018-08-28 | 2018-10-12 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-08-28 | 2018-10-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-08-28 | 2018-10-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-08-28 | 2018-10-12 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2018-08-28 | 2018-10-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-08-28 | 2018-10-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-08-28 | 2018-10-12 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-08-28 | 2018-10-12 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-08-28 | 2018-10-12 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2018-08-28 | 2018-10-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-08-28 | 2018-10-12 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-08-28 | 2018-10-12 | N |
