Highland Ridge Rehab Center

F 0558

was discussed with DON, ADON, regional director of clinical services, UM/LPN #1, UM/LPN #3, and UM/LPN #4 on 09/05/25 at 3:35 pm. No further information was provided prior to exit.

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/05/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Ridge Rehab Center

5872 Hanks Street Dublin, VA 24084

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

Based on staff interview and clinical record review, the facility staff failed to follow the medical provider orders for medication administration for 1 of 16 sampled residents (Resident #6). The findings included:For Resident #6, the facility staff failed to administer the oral medication, Cyclobenzaprine as ordered by the medical provider. Cyclobenzaprine is a muscle relaxant used to treat skeletal muscle conditions such as pain and injury. Resident #6's diagnosis list indicated diagnoses, which included, but not limited to Encephalopathy, Hemiplegia and Hemiparesis, Congestive Heart Failure, Epilepsy, Multiple Rib Fractures Left Side, Fracture of Nasal Bones, Fracture of Left Thumb, and Fracture of Shaft of Left Clavicle. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 1/23/25 assigned the resident

a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #6's clinical record included a medical provider order for Cyclobenzaprine HCL 10 mg by mouth three times a day for muscle spasms. A review of Resident #6's September 2024 Medication Administration Record (MAR) revealed an omission for the administration of Cyclobenzaprine

on 9/08/24 at 6:00 AM. On 9/05/25 at 12:25 PM, surveyor spoke with the Interim Administrator concerning

the Cyclobenzaprine omission. She stated the medication was not signed off and she would assume that meant it was not given. No further information regarding this concern was presented to the survey team prior to the exit conference on 9/05/25.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/05/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Ridge Rehab Center

5872 Hanks Street Dublin, VA 24084

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

On 9/5/25 at 2:15 PM, surveyor spoke with licensed practical nurse #5 (LPN#5) and inquired if Resident #16 was on precautions and she informed surveyor she believed the resident to be on EBP (enhanced barrier precautions) because the resident had a catheter. Surveyor and LPN#5 reviewed Resident #16's medical provider orders together and the orders disclosed Resident #16 was on contact isolation (TBP) with an order start date of 8/8/25. Surveyor asked LPN#5 the protocol for someone on TBP and she stated

an isolation cart should be placed outside of door, PPE should be available, and a sign should be placed on

the door for residents on TBP.

On 9/5/25 at 2:18 PM, surveyor observed a male nursing staff member sitting at Resident #16's bedside without PPE and surveyor observed licensed practical nurse #3 (LPN#3) enter Resident #16's room without donning PPE. Surveyor spoke with LPN#3 and informed her Resident #16 is on contact precautions, she stated she would take care of this right away.

This concern was discussed on 9/5/25 at 2:54 PM in a meeting with interim administrator, interim director of nursing, regional director of clinical services, and licensed practical nurse #1. Regional director of clinical services informed the survey team that the issues are corrected now and there are signs and PPE carts available outside the resident rooms.

Surveyor requested and received a facility policy titled, “Transmission-Based Precautions” which read in part, “…The facility will ensure systems and processes are in place for the prevention and spread of infectious diseases…Contact Precautions may be implemented for resident's 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…1. Signs will be placed outside to each resident's room requiring transmission-based precautions…the signs will identify the type of PPE and special instructions…2. An adequate supply of PPE will be accessible and maintained outside of each resident room for staff and visitor use…” No further information was provided to the survey team prior to exit on 9/5/25.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/05/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Ridge Rehab Center

5872 Hanks Street Dublin, VA 24084

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Designate a qualified infection preventionist to be responsible for the infection prevent and control program

in the nursing home.

Based on observations, staff interview, and facility document review, the facility staff failed to employ an infection preventionist with the required training prior to assumption of the role.The findings included:On 9/5/25, members of the survey team made multiple observations of residents requiring EBP (enhanced barrier precautions) and/or TBP (transmission-based precautions) without proper notification/signage and PPE available to staff, residents and/or visitors. On 9/5/25 at 2:54 PM-surveyors met with interim administrator (ADM), interim director of nursing (DON), regional director of clinical services and licensed practical nurse #1 (LPN#1). This surveyor inquired about the facility IP (infection preventionist) and the DON informed surveyor the previous IP left employment at the facility on 7/4/25 and she and the ADM are acting IPs and both agreed neither of them has an IP certification. LPN#1 has an IP certification from 2022 and

she agreed that she does not perform the IP role at the facility. Surveyor requested evidence of staff education on infection control procedures for EBP/TBP and was provided evidence of staff education.

Surveyor requested and received a facility job description for Infection Preventionist which read in part, .Infection Prevention Responsibilities.Education.Be able to obtain certification in Infection Control. No further information was provided to the survey team prior to exit on 9/5/25.

Event ID:

Facility ID:

If continuation sheet