Highland Health Care Center

Inspectors wroteBased on observation, interview and record review the facility failed to prevent physical abuse for 2 (R49, R32) of 3 residents in a sample of 44. The surveyor confirmed by observation, interview and record review that the deficiency practice occurred on 1/5/2026 and was corrected on 1/19/2026, prior to the start of this survey, and was therefore Past Noncompliance. Jnoknptnporemg]

Inspectors wroteBased on observation, interview and record review the facility failed to perform a thorough abuse investigation for 2 (R49, R32) of 3 residents reviewed for abuse in the sample of 44. The surveyor confirmed by observation, interview and record review that the deficiency practice occurred on 1/5/2026 and was corrected on 1/19/2026, prior to the start of this survey, and was therefore Past Noncompliance.

Inspectors wroteBased on observation, interview and record review the Facility failed to ensure R30's dialysis site was being monitored for potential complications for 1 of 3 residents (R30) reviewed for dialysis in the sample of 44.

Inspectors wroteBased on observation, interview and record review, the Facility failed to provide at least 80 square feet per resident bed in multiple resident bedrooms for 14 of 86 residents (R2, R21, R22, R27, R26, R30, R32, R36, R39, R41, R43, R51, R76, and R84) reviewed for room size in the sample of 44.

Inspectors wroteBased on observation, interview and record review the facility failed to provide incontinence care for 2 of 3 Residents (R8, R9) reviewed for neglect in the sample of 3. This resulted in R8 and R9 both left saturated in urine for hours and using a reasonable person approach resulted in psychosocial harm that a person would feel ashamed, humiliated, hopeless, and neglected being left in their own incontinence of bowel/bladder.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure 2 (R8, R9) of 3 residents received adequate and timely incontinence care for ADL dependent residents reviewed for incontinence in the sample of 3.

Inspectors wroteBased on interview and record review, the facility failed to implement a systematic approach to assess and evaluate a resident's unsafe wandering, record resident specific information, and monitor a resident with known exit seeking behaviors for 1 of 3 residents reviewed for elopement. This failure resulted in R2 eloping out of the facility on an unknown date and getting down a public street before staff were able to catch up with him and again on 8/25/2025 when R2 was seen exiting the facility unsupervised when police officers patrolling the area heard the alarm and found R2 exiting the fire door attempting to leave unsupervised and with no staff anywhere around. R3's room remains adjacent to the fire door exit. This failure has the potential to affect all 11 residents who are at risk for elopement and wandering. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent resident to resident sexual abuse for 1 of 1 (R2) resident reviewed for abuse in the sample of 4. This failure resulted in psychosocial harm in that, a reasonable person would react to such a situation with feelings of anxiety, distress, fearfulness and humiliation. This past compliance occurred from 4/14/2025 to 4/15/2025. Prior to the survey date, the facility took the following actions to correct the noncompliance: -R1 (alleged perpetrator) was immediately removed from the dementia unit on 4/14/2025 upon report of the incident and placed on 1:1 supervision by staff to prevent further resident contact and mitigate risk. - R2 (alleged victim) received immediate psychosocial support. Referred for ER evaluation for possible sexual assault. [...]

Inspectors wroteBased on interview and record review the facility failed to provide pain management for one of three residents (R3) reviewed for pain in the sample of 5. This failure resulted in R3 not receiving pain management for a fall with serious injury for 24 hours. This past non-compliance occurred from 11/16 until 11/18/24. Finding Include: R3's Minimum Data Set (MDS) dated [DATE] documents R3 is severely cognitively impaired, and R3 requires substantial to maximum assistance. R3's MDS dated [DATE] documents R3 is moderately cognitively impaired. R3 needs partial assistance from another person for any activities. R3's Electronic Health Record documents R3 has diagnoses of FX (Fracture) of Unspecified Part of Neck of Left Femur and Traumatic FX. [...]

Inspectors wroteBased on observation, interview, and record review, the Facility failed to properly store and label medications and dispose of expired medications for 4 of 4 residents (R25, R59, R63, R283) reviewed for medication storage and labeling in the sample of 46.

Inspectors wroteBased on interview and record review the facility failed to maintain a system of unnecessary or inappropriate antibiotic use for 4 out of 4 residents (R16, R28, R45, R48) investigated for antibiotic use in a sample of 36.

Inspectors wroteBased on observation, interview and record review, the Facility failed to provide at least 80 square feet per resident bed in multiple resident bedrooms for 13 of 80 residents (R9, R35, R41, R50, R51, R54, R63, R70, R77, R133, R134, and R183) .

Inspectors wroteBased on interview and record review, the facility failed to assist residents with activities of daily living for dependent residents including oral and hygiene care for 1 of 4 residents (R2) reviewed for Activities of Daily Living (ADLs) for dependent residents in the sample of 24. This failure resulted in psychosocial harm as a normal person would have been embarrassed if they could not maintain good hygiene and be clean and odor free when going out in public.

Inspectors wroteBased on interview and record review, the facility failed to provide timely care/treatment for 1 of 4 residents (R2) reviewed for quality of care in the sample of 24.

Inspectors wroteBased on interview and record review, the facility failed to provide gastrostomy tube care per standards of practice for 1 of 4 residents (R2) reviewed for tube feeding management in the sample of 24.

Inspectors wroteBased on observation, interview, and record review, the Facility failed to provide a clean, comfortable, homelike environment for 3 of 7 residents (R4, R5, R6) reviewed for physical environment in the sample of 7.

Inspectors wroteBased on observation, interview, and record review, the Facility failed to ensure progressive fall interventions were in place for 1 of 3 residents (R1) reviewed for accidents and hazards in the sample of 6.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse in 2 of 8 residents (R4, R6) reviewed for abuse in the sample of 9.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure fall prevention interventions were in place in 1 of 3 residents (R6), reviewed for falls in the sample of 9.

Inspectors wroteBased on observation, interview, and record review, the Facility failed to properly store, prepare, and distribute food in a manner that prevents potential contamination. This has the potential to affect all 83 residents living in the Facility.

Inspectors wroteBased on observation, interview, and record review, the Facility failed to provide palatable food for 4 of 4 residents (R7, R11, R43 and R61) reviewed for palatable food in the sample of 51.

Inspectors wroteBased on interview and record review, the Facility failed to establish an infection prevention and control program that reduces the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use in 4 of 4 residents (R15, R42, R20 and R55) reviewed for antibiotic stewardship in the sample of 51.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement pressure reducing measures to prevent pressure ulcers and failed to provide aseptic technique during pressure ulcer treatments for two of eight residents (R65, R67) reviewed for pressure ulcers in the sample of 51.

Inspectors wroteBased on interview and record review, the facility failed to maintain a clutter free environment to prevent falls for 1 of 6 residents (R8) reviewed for falls in the sample of 51.

Inspectors wroteBased on interview, record review, and observation the facility failed to perform complete catheter care for two of four residents (R42, R67) reviewed for catheter care in the sample 51. Findings Include: 1. R67's Care Plan Dated 7/20/23 documents R67 is high risk for urinary tract infection due to indwelling catheter. Provide catheter care per shift. R67's Treatment Administration Record dated October 1-12 documents (indwelling) catheter care every shift. (This facility works twelve hours). Catheter Care was not completed on October 1, 2, 7, and 8 on the day shift. Catheter Care was not completed on the night shift on October 1. R67's Treatment Administration Record for the month of September documents that catheter care was not completed on September 23 and 24th on the day shift. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow doctor orders for Gastrostomy tube flush for 1 of 2 residents (R67) reviewed for tube feedings in the sample of 51. Findings Include: R67's Enteral Feed Order, with start date of 8/1/23, documents every 8 hours Enteral - Flush Tubing with Min (minimum) of 60 ml (milliliters) water Q 8 hours. R67's Treatment Administration Record (TAR) dated 10/4/23 documents an order for Enteral Feed Order: flush tubing with 100 milliliters (ML) of water every hour. R67's TAR dated 10/4/23 documents Enteral Feed Order: Jevity 1.2 continuous at 55 ml per hour. R67's Care Plan dated 7/20/23 documents R67 requires tube feeding related to Dysphagia and Weight Loss. The Care Plan documents R67 will remain free of side effects or complications related to tube feedings. [...]

Inspectors wroteBased on observation, interview, and record review, the Facility failed to provide at least 80 square feet per resident bed in multiple resident bedrooms for 11 of 83 residents (R10, R15, R28, R36, R40, R44, R63, R65, R68, R73, and R78) reviewed for room size in the sample of 83.