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Deficiency Records for Highland Springs Care Center
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.
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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-08-22 | 2024-09-06 | Y |
| 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 | 2024-07-25 | 2024-08-16 | 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 | 2024-07-25 | 2024-08-16 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-07-25 | 2024-08-16 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-07-25 | 2024-08-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-07-25 | 2024-08-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-07-25 | 2024-08-16 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2024-07-25 | 2024-08-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-07-25 | 2024-08-16 | 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 | 2024-07-25 | 2024-08-16 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2024-07-25 | 2024-08-16 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2024-07-25 | 2024-08-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-07-25 | 2024-08-16 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2024-07-25 | 2024-08-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-07-25 | 2024-08-16 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-07-25 | 2024-08-16 | N |
| Keep all essential equipment working safely. | Health | 2024-07-25 | 2024-08-16 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-07-25 | 2024-08-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-25 | 2024-08-16 | Y |
| Establish policies and procedures for medical documentation. | Fire Safety | 2024-07-30 | 2024-08-16 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2024-07-30 | 2024-08-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-07-30 | 2024-08-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-07-30 | 2024-08-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-06-21 | 2024-06-28 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2024-05-09 | 2024-05-16 | Y |
| 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 | 2024-05-09 | 2024-05-16 | Y |
| 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 |
| 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 |
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