Federal inspectors cited the facility for multiple food safety violations during a July inspection, finding kitchen equipment covered in brown rust buildup and expired food readily available to residents.
The dietary manager acknowledged the problems when confronted by inspectors on July 22. "The toaster is old and needs to be replaced," she said, pointing to brown-yellowish grime buildup in the front dial control. She admitted the contamination "could cross-contaminate food and cause foodborne illness."
The kitchen's main oven showed extensive deterioration. Brown discoloration covered both sides of the oven and the front inside surfaces of both oven doors. The dietary manager identified the discoloration as rust and said it "can fall into the resident's food, causing cross-contamination and leading to food borne illness."
Cutting boards throughout the kitchen were scarred and stained. One blue cutting board had "multiple deep cuts, indentations, and damaged" surfaces with "parts of the plastic lifted." Two green cutting boards showed "yellowish discoloration, multiple deep cuts, and indentations" from food residue.
"The surface should be clean, smooth, and undamaged to prevent the growth of microorganisms that could cause cross contamination and food borne illness," the dietary manager told inspectors.
The meal delivery system was equally compromised. Four meal tray carts had chipped and peeled vinyl stickers on their sides. Cart #3's front right corner had been reinforced with different metal that showed brown discoloration. Cart #4 displayed similar rust patterns.
The registered dietician explained that the carts' surfaces were "not smooth" and had brown discoloration. She said meal tray carts "should have no rust, have a smooth surface, no chipping or peeling to prevent bacterial growth that could cause cross contamination."
A maintenance assistant confirmed the brown discoloration was "corrosion and deterioration."
Meanwhile, Resident 56 had been consuming expired marshmallows for months. During a room inspection on July 23, investigators found two bags of expired marshmallows in the resident's closet. One bag was opened and had hardened. The resident, who had "fluctuating capacity to understand and make decisions," told inspectors the marshmallows were "gifts from last Christmas" seven months earlier.
"I snack on them occasionally," Resident 56 said.
Licensed Vocational Nurse 5 found the expired marshmallows "readily available to eat" and warned they "could cause stomach upset" if consumed.
Nursing Assistant 1 agreed the expired marshmallows "should not have been there because they could cause stomachache if consumed."
The Director of Nursing said her expectation was "that expired food should have been discarded and not readily available for consumption by the resident."
Infection control practices also broke down during routine medical care. Registered Nurse 2 failed to perform proper hand hygiene while checking blood sugar and administering insulin to Resident 4 on July 24.
Inspectors observed the nurse pushing the resident's wheelchair without gloves or hand hygiene, then checking blood sugar and preparing insulin without washing hands between tasks. The nurse wore gloves during procedures but skipped hand washing before and after patient contact.
"I forgot to perform hand washing prior to and after checking Resident 4's blood sugar and prior to and after the administration of insulin," RN 2 told inspectors. She acknowledged she "should have washed her hands" at each step.
The Infection Preventionist confirmed that licensed nurses "should wash their hands before and after performing a blood sugar check and before and after administering insulin on a resident, even if gloves were worn during the procedure."
A Physical Therapy Assistant treating a resident on enhanced barrier precautions also violated infection control protocols. The resident was isolated due to multidrug-resistant organisms and extended spectrum beta-lactamase bacteria in his urine.
After applying ankle weights during therapy, the assistant left the isolation room without performing hand hygiene or disinfecting the equipment. She admitted she "should have performed hand hygiene and disinfected the weights before bringing them outside of the room because of infection control and the spread of germs to other residents and staff."
The facility also failed to offer required vaccinations. Resident 58, who had chronic obstructive pulmonary disease, received one pneumococcal vaccine dose in April 2023 but was never offered the required second dose a year later.
The Infection Preventionist said "there was no documentation that Resident 58 was offered the second dose of the pneumococcal vaccine after one year from the initial dose," despite CDC guidelines requiring the follow-up vaccination.
Physical environment problems extended beyond the kitchen. Resident 87 complained about multiple damaged window blinds in her room that made it "too bright." She resorted to using curtains to block light coming through the broken blinds.
Both the Maintenance Supervisor and Facility Administrator acknowledged awareness of the damaged blinds. The administrator said the blinds "should have been replaced or repaired to provide home like environment for the residents."
The facility's own policies required regular equipment maintenance and food safety protocols. The maintenance policy mandated that equipment be maintained "in a safe and operable manner at all times." Food storage policies required that "food items that are expired or beyond the best buy date are discarded."
Federal Food and Drug Administration guidelines specify that food-contact surfaces must have "smooth, easily cleanable surface" and be "resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition."
The registered dietician summarized the kitchen problems during her interview: "Rust, peeled paint, or any decomposition on any kitchen equipment should have not been there. Rust, peeled paint, vinyl or plastic is a food safety hazard that can fall into food and could cross contaminate and cause foodborne illness."
Highland Springs Care Center has 120 days to submit a plan of correction addressing the violations. The facility serves meals to dozens of residents daily using the compromised equipment while Resident 56 continues to live with expired food within easy reach.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Highland Springs Care Center from 2024-07-25 including all violations, facility responses, and corrective action plans.