Federal inspectors found the violations at Highland Ridge Rehab Center on September 5, when they discovered Resident #16 had been under contact isolation orders since August 8 — but staff either didn't know or weren't following the protocols designed to prevent disease transmission.
Licensed practical nurse #5 told the surveyor she believed the resident was on "enhanced barrier precautions" because of a catheter. When the inspector and nurse reviewed the medical orders together, they revealed the resident was actually on contact isolation with tuberculosis precautions, known as TBP.
The nurse knew the protocol. An isolation cart should be placed outside the door, personal protective equipment should be available, and a sign should be placed on the door for residents on TBP.
None of that was happening.
At 2:18 PM, the inspector watched a male nursing staff member sitting at the resident's bedside without any protective gear. Licensed practical nurse #3 then entered the room without donning PPE.
When the surveyor informed nurse #3 that the resident was on contact precautions, she said she would "take care of this right away."
The facility's own policy required exactly what wasn't happening. Signs outside each room requiring transmission-based precautions. The signs identifying the type of PPE and special instructions. An adequate supply of protective equipment accessible outside each resident room for staff and visitors.
The policy stated the facility would "ensure systems and processes are in place for the prevention and spread of infectious diseases." Contact precautions were to be implemented for residents "known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment."
For nearly a month, those systems had failed.
When inspectors met with facility leadership at 2:54 PM — the interim administrator, interim director of nursing, regional director of clinical services, and licensed practical nurse #1 — the regional director claimed the issues were "corrected now" and that signs and PPE carts were available outside resident rooms.
The rapid response suggested the facility knew the requirements but hadn't been enforcing them. The timing raised questions about how long staff had been entering the isolated resident's room unprotected, and whether other residents on precautions faced similar lapses in infection control.
Contact isolation protocols exist because certain infections can spread through direct touch or contact with contaminated surfaces. When healthcare workers enter these rooms without gloves, gowns, and other protective equipment, they risk carrying pathogens to other residents, creating the potential for facility-wide outbreaks.
The violation occurred during a complaint inspection, suggesting someone had raised concerns about infection control practices at the facility. Federal inspectors classified the harm level as minimal, affecting few residents, but the breakdown in basic safety protocols revealed systemic problems with staff training and oversight.
Highland Ridge Rehab Center operates on Hanks Street in Dublin, a small town in southwestern Virginia's Pulaski County. The facility houses vulnerable elderly residents who depend on staff to follow infection control measures that protect the entire community.
The inspection report provided no information about how long the isolation protocols had been ignored, whether other residents were affected, or what specific infection the resident carried that required contact precautions with tuberculosis protocols.
The interim leadership titles suggest the facility was already experiencing management instability when the infection control violations occurred. An interim administrator and interim director of nursing indicate recent turnover in key positions responsible for ensuring compliance with federal safety standards.
The regional director's claim that problems were immediately corrected contrasted with the month-long gap between the isolation order and its proper implementation. The disconnect between written policies and actual practice suggested deeper issues with staff communication and training systems.
No additional information was provided to the survey team before they completed their inspection on September 5.
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.