The incident happened on April 22 as the driver returned Resident 3 from a doctor's appointment to Hurricane Health and Rehabilitation.
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The lab company placed the facility on a non-payment hold on April 23, 2025, over an unpaid balance of $9,536.92.
The resident, identified as R2, was observed on June 18 lying in bed with disheveled hair, dirty nails, and dried food on her face and clothing.
Her care plan specifically called for repositioning every two hours and daily skin inspections by nursing assistants.
Her physician had ordered the specialized diet texture in August 2023, more than a year before the choking incident.
The CNA also shouted at the resident and made other inappropriate comments during the incident, according to a January 31 federal inspection report.
Despite these documented risks, staff failed to prevent the April 9 attack on his roommate.
The violations put dozens of residents at risk across multiple areas of care.
The facility's training failures extended across multiple safety areas during an April inspection.
Resident 85 arrived at Highland House in 2023 following fractures to both arms and legs.
Resident 16 had been prescribed lorazepam 0.5 milligrams every 12 hours as needed for restlessness.
Licensed Vocational Nurse 3 was responsible for monitoring Resident 76 for signs of the streptococcus infection on July 23, 2024.