Highland Care Center

Inspectors wroteBased on record review and interviews, the facility failed to ensure sufficient nursing staff were available to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility reported short staffing on weekends confirmed by a review of the Daily Staffing and the Payroll Based Journal Staffing Data Report Quarter 1 2026 (October 1-December 31).

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that necessary housekeeping and maintenance services were provided to maintain a safe, clean, comfortable and homelike environment for residents. This was evident for two (2) of eight (8) resident units (Unit 1 and Unit 2) observed for the Environment Task. Specifically, blood pressure stands were observed with the base layered with dirt dust and debris, wheelchairs, Geri chairs and wheelchair seat cushions were observed to be heavily soiled, layered with an accumulation of dirt, dust and debris, air conditioners were observed with black substances and an accumulation of dirt and debris within the grates, and an air conditioner did not have an outside cover.

Inspectors wroteBased on record review and interview conducted during the recertification survey from 1/29/2024 to 02/06/2024, the facility did not ensure the resident's representative was immediately notified of a need to alter the resident's treatment. This was evident for 1 (Resident #289) of 2 residents reviewed for Notification of Change out of 38 total sampled residents. Specifically, Resident #289 was ordered to start an antianxiety medication, Buspirone, and the designated representative was not immediately informed.

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 01/29/2024 to 2/06/2024, the facility did not ensure that a resident remained free of physical restraints. This was evidenced for 1 (Resident #36) resident reviewed for Physical Restraints out of 38 total sampled residents. Specifically, Resident #36 was seated in a wheelchair in the floor dining room in a boxed-in position preventing them from moving around.

Inspectors wroteBased on record review and interviews conducted during the Recertification survey from 01/29/2024 to 02/06/2024, the facility did not ensure adequate supervision and an environment free from accident hazards. This was evident for 1 (Resident #88) of 4 resident reviewed for accidents out of 38 total sampled residents. Specifically, Resident #88 was observed in possession of a sharp steak knife in their room.

Inspectors wroteBased on record review and interviews conducted during the Recertification survey from 1/29/2024 to 2/06/2024, the facility did not ensure the development and maintenance of policies and procedures for the monthly drug regimen review that include time frames for the different steps in the process. This was evident for 1 (Resident #78) of 5 residents reviewed for Unnecessary Medications out of 38 total sampled residents. Specifically, the facility policy for the drug monthly regimen review did not develop a timeline for the Medical Doctor to answer the pharmacist's recommendations for Resident #78.

Inspectors wroteBased on record review, and staff interviews during the Recertification survey, the facility did not ensure infection prevention control practices were followed to help prevent the spread, development, and transmission of communicable diseases and infections. Specifically, (1) the facility water management plan was not reviewed/revised within the last year, (2) the facility lacked a Legionella sampling plan based on the facility risk assessment, (3) oxygen tubing was observed with no label, and there was no documented evidence that the oxygen tubing was changed, and (4) a urinary catheter bag was observed touching the floor on multiple occasions. This was evident for the Water Management Plan reviewed for Infection Control and 1 of 2 residents sampled for Respiratory Care and 1 of 1 resident sampled for Urinary Catheter or UTI out of 38 residents sampled (Resident # 17 & 284).

Inspectors wroteBased on observation, record review and staff interviews conducted during the Recertification survey, the facility did not ensure that individual resident financial records were made available to resident and resident representatives through quarterly statements. Specifically, quarterly statements were not provided in writing to residents and/or resident representatives within 30 days after the end of the quarter. This was evident for 2 of 3 residents reviewed for Personal Funds out of a sample of 38 residents. (Residents #105 & #103)

Inspectors wroteBased on interviews and record review conducted during Recertification and Facility Complaint investigations (NY00278901, NY00269594 ), the facility did not ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the State Survey Agency. Specifically, the facility did not report incidents of abuse to the New York State Department of Health (NYSDOH) within 2 hours. This was evident for 2 of 6 residents reviewed for Abuse out of a sample of 38 residents. (Resident #70 and Resident #646).

Inspectors wroteBased on observations, record review and staff interviews during the Recertification survey, the facility did not ensure that a person-centered comprehensive care plan (CCP) was developed and implemented to address the resident's medical, physical, mental, and psychosocial needs. Specifically, 1). A care plan was not developed and implemented for a resident with contractures and splint device and 2). A care plan was not developed to address a resident's range of motion needs. This was evident for 2 of 2 residents reviewed for Limited ROM, and 1 of 2 residents reviewed for ADL Decline out of a sample of 38 residents. (Residents #10, #256 & #157)

Inspectors wroteBased on record review and interviews conducted during the Recertification survey, the facility did not ensure that each Resident or resident representative was offered the opportunity to participate in the revision and/or review of the comprehensive care plan. Specifically, cognitively intact residents were not invited to quarterly care plan meetings. This was evident for 2 of 38 sampled residents (Resident #94 and #229).

Inspectors wroteBased on record review, observations, and staff interviews during the Recertification survey, the facility did not ensure that needed services, care and equipment are provided to assure that resident with limited range of motion and mobility maintain or improve function based on the residents' clinical condition. Specifically, a resident was not provided with the splint device ordered to improve resident's contractures, this was evident for 1 out of 2 residents reviewed for Limited ROM out of a sample of 38 residents sampled. (Resident #10)

Inspectors wroteBased on observation, record review, and staff interviews conducted during the Recertification survey, the facility did not ensure that medication and biologicals were discarded by expiration date. Specifically, 4 medications were found to be expired in the medication cart. This was evident for 1 of 8 units observed for Medication Storage (5th floor)