Highland Ridge Rehab: Missed Muscle Relaxant Doses - VA
Highland Ridge Rehab Center failed to administer Cyclobenzaprine to Resident #6 on September 8, 2024, according to a complaint investigation completed this September. The muscle relaxant had been ordered three times daily to treat muscle spasms in a resident dealing with an extensive list of injuries and medical conditions.
The resident's diagnosis list read like a trauma case: encephalopathy, hemiplegia and hemiparesis, congestive heart failure, epilepsy, multiple rib fractures on the left side, fracture of nasal bones, fracture of left thumb, and fracture of the shaft of the left clavicle. Despite these serious conditions, staff skipped the 6:00 AM dose of the 10 mg medication without documentation or explanation.
Resident #6 remained cognitively intact throughout the ordeal. A mental status assessment from January scored 15 out of 15, indicating full cognitive function. The resident was aware of their condition and treatment needs.
The medication omission came to light when federal surveyors reviewed the September 2024 Medication Administration Record. The 6:00 AM slot for Cyclobenzaprine on September 8 remained unsigned, indicating the dose was never given. No notes explained why the medication was withheld or forgotten.
When surveyors confronted the Interim Administrator about the missing dose on September 5, 2025, her response revealed a troubling gap in medication oversight. She stated that because the medication wasn't signed off, "she would assume that meant it was not given." She offered no further information about the incident.
The administrator's assumption pointed to a fundamental breakdown in medication management. Staff are required to document when medications are given, held, or refused. An unsigned entry typically indicates an omission, but facilities are expected to investigate and document why prescribed medications weren't administered, especially for residents with serious medical conditions requiring pain and spasm management.
Cyclobenzaprine treats skeletal muscle conditions including pain and injury. For someone with multiple fractures across their ribs, clavicle, thumb, and nasal bones, missing doses could mean unnecessary suffering and delayed healing. The medication helps reduce muscle spasms that often accompany traumatic injuries.
The facility's casual response to the medication error raised questions about their oversight systems. Federal regulations require nursing homes to follow medical provider orders and ensure residents receive appropriate treatment according to their care plans. When medications are missed, facilities must investigate, document the reason, and take corrective action.
Highland Ridge's violation affected what inspectors classified as "few" residents, but the impact on Resident #6 was direct. Someone dealing with multiple fractures and neurological conditions like hemiplegia needed consistent medication management, not gaps in care followed by administrative assumptions.
The inspection report provided no indication that the facility had investigated the medication omission before surveyors discovered it nearly a year later. The interim administrator's matter-of-fact response suggested this wasn't treated as a serious care failure requiring immediate attention and correction.
Federal surveyors classified the violation as causing "minimal harm or potential for actual harm," but the finding highlighted broader concerns about medication administration oversight at the facility. When staff can skip prescribed medications for seriously injured residents without consequence or investigation, it raises questions about what other care gaps might go unnoticed.
The inspection concluded without any additional information from Highland Ridge about how they planned to prevent similar medication omissions. Resident #6's case demonstrated how administrative indifference can leave vulnerable residents without the pain management and muscle spasm relief they need during recovery from traumatic injuries.
For a cognitively intact resident dealing with multiple fractures and neurological conditions, missing prescribed medication represented more than a paperwork error. It meant enduring potentially preventable pain and muscle spasms while administrators made assumptions about unsigned medication records instead of ensuring proper care delivery.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Highland Ridge Rehab Center from 2025-09-05 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
HIGHLAND RIDGE REHAB CENTER in DUBLIN, VA was cited for violations during a health inspection on September 5, 2025.
The muscle relaxant had been ordered three times daily to treat muscle spasms in a resident dealing with an extensive list of injuries and medical conditions.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.