Highfield Nursing and Rehabilitation

Inspectors wroteBased on observations and resident and staff interviews, the facility failed to maintain intact tiles and grout on a shower room floor and prevent black colored buildup on the shower floor, walls, and ceiling in 1 of 2 shower rooms reviewed for safe, clean, and homelike environment (100/200 shower room). Review of the quarterly MDS dated [DATE] for Resident #29 coded her as cognitively intact. On 3/23/26 at 2:39PM an interview was conducted with Resident #29 that revealed she received showers in the 100/200 shower room [ROOM NUMBER] times per week. Resident #29 went on to state that while receiving showers, she had observed what she described as black colored mold and filth on the walls and the ceiling. [...]

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to adhere to the required personal protective equipment (PPE) for Resident #29 who had a peg tube (a feeding tube inserted directly into the stomach through the abdominal wall) when nursing staff members were observed providing a bath to the resident without wearing a gown and gloves for 2 of 5 staff members observed for infection control practices (Nurse Aide #1 and NA #2). A facility policy provided by the Director of Nursing (DON) titled 'Enhanced Barrier Precautions' (EBP) revised 11/13/25 indicated the facility would implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. [...]

Inspectors wroteBased on observation, record review, and interviews with staff, Psychiatric Nurse Practitioner, Responsible Party (RP), and the Police Detective, the facility failed to protect the right of two cognitively impaired residents (Residents # 1 and # 7) to be free from abuse. On the evening of 2/6/25 Resident # 2 returned from an outing and was observed by staff to show signs of being inebriated. That evening he was also observed at the bedside of Resident # 1, who was cognitively impaired and who did not have the ability to invite him into her room. After his removal from Resident # 1's room by staff, Resident # 2 was observed in Resident # 1's room a second time with the curtain pulled so that he and Resident # 1 were out of view. [...]

Inspectors wroteBased on observation, and interviews with resident and staff, the facility failed to provide housekeeping services to ensure a clean bathroom for a bathroom which was jointly shared by multiple residents. This was for one (Resident # 5) of four sampled residents who were interviewed regarding services at the facility.

Inspectors wroteBased on observation, record review and interviews with resident and staff, the facility failed to ensure a system was in place to avoid placing an item on a resident's tray which she preferred not to have. This was for one (Resident # 4) of three sampled residents reviewed for food choices.

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to ensure a resident received a beverage on her tray per her preference. This was for one (Resident # 8) of three residents reviewed for dietary preferences.

Inspectors wroteBased on record review, and staff, family member, Physician Assistant, and Medical Director interviews the facility failed to notify the physician of a significant change in condition when staff were unable to obtain a urine sample on 3 instances (10/31/24 at approximately 5:00 AM and 9:00 PM and 11/1/24 at approximately 5:30 AM) for a resident identified with complaints of burning urination and decreased fluid intake. Resident #294 was first identified with decreased nutritional and fluid intake on 10/29/24 requiring staff to push fluids (deliberately drink beyond what thirst dictates to avoid dehydration) through 11/1/24. [...]

Inspectors wroteBased on record review, and staff, family member, Physician Assistant, and Medical Director interviews, the facility staff failed to recognize the seriousness of a significant change in condition, the importance of and identify the need for urgent medical attention to address an emergent situation. On 10/29/24 a sudden decrease in food and fluid intake was observed by staff. Resident #294 reported burning with urination to the night shift nurse (10/29/24 at 11:00 PM through 10/30/24 at 7:00 AM) and an order for a urinalysis (UA) and urine culture and sensitivity (C & S) was obtained from Physician Assistant #2 on 10/30/24. No attempts were made to collect the urine specimen for the UA until 10/31/24 at around 5:00 AM and the nurse was not successful. Another nurse attempted to obtain the urine specimen the evening of 10/31/24 and the morning of 11/1/24 but was not successful. [...]

Inspectors wroteBased on record review, and staff, family member, Physician Assistant (PA), and Medical Director interviews the facility failed to ensure staff recognized the seriousness of signs and symptoms of dehydration for a resident receiving a diuretic (Lasix 20 mg daily) and who had decreased fluid intake. Resident #294 was first identified with decreased nutritional and fluid intake on 10/29/24 requiring staff to push fluids (deliberately drink beyond what thirst dictates to avoid dehydration) through 11/1/24. Resident #294 exhibited signs and symptoms of dehydration on 10/31/24 at approximately 9:00 PM and 11/1/24 at approximately 5:30 AM as evidenced by the inability to collect urine via an in and out catheter (inserting a thin, hollow tube into the bladder) when the resident had no recent episodes of urination. [...]

Inspectors wroteBased on record review, observation, and staff interview, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of hypnotics medication for 1 of 30 sampled resident reviewed (Resident # 55).

Inspectors wroteBased on observation, record review, and Resident and staff interviews, the facility failed to ensure call bells were plugged into the wall panel for a dependent resident to allow them to call for assistance if needed. The deficient practice was for 1 of 30 residents reviewed for accommodation of needs (Resident #6).

Inspectors wroteBased on record review and staff interview the facility failed to protect the resident's right to be free from misappropriation of controlled medication for 1 (Resident #5) of 2 residents reviewed for misappropriation of controlled medication.

Inspectors wroteBased on record review, staff, and resident interviews, the facility failed to treat residents (Resident #1, and Resident #2) with dignity and respect when staff failed to provide the resident with a bed bath or shower. The residents expressed anger, frustration, and embarrassment. This was for 2 of 8 residents reviewed for dignity.

Inspectors wroteBased on record review, observation, and staff and resident interviews, the facility failed to provide a bed bath or shower for 3 of 7 dependent residents (Resident #1, Resident #2, and Resident #12) reviewed for activities of daily living (ADL) care.

Inspectors wroteBased on record reviews, resident and staff interviews, the facility failed to provide effective leadership and implement effective systems to ensure there was an adequate number of washcloths and towels for the provision of resident care. This failure had the potential to affect all the residents in the facility.

Inspectors wroteBased on observation and staff interviews, the facility failed to safeguard protected health information (PHI) for 1 of 100 residents residing in the facility by leaving confidential PHI unattended and exposed in an area accessible to the public (Resident #11).

Inspectors wroteBased on record review, resident and staff interviews, the facility failed to report an allegation of abuse to the Administrator immediately for 1 of 1 resident (Resident #4) reviewed for Abuse. The facility further failed to implement their policy and procedures in the area of resident protection.

Inspectors wroteBased on record review, resident interview, and staff interview the facility failed to create a baseline care plan with the resident or responsible party for one (Resident #7) of three residents reviewed for creation of a baseline care plan upon admission.

Inspectors wroteBased on record review, resident and staff interviews, the facility failed to update the care plan after the quarterly assessment for 1 of 4 residents reviewed for care plans (Residents #3).

Inspectors wroteBased on records reviews and staff interviews, the facility failed to have Advance Directives (AD) in the residents' records for 7 of 9 sampled residents. (Resident #16, Resident #76, Resident #132, Resident #33, Resident #44, Resident #47, and Resident #52).