Highland Home

Inspectors wroteBased on observation, interview, record reviews, and facility policy review, the facility failed to provide adequate supervision to prevent residents from leaving the facility unnoticed and unsupervised for 2 (two) of 7 (seven) residents who were at risk for elopement and wandering. Resident #1 and Resident #2. The facility failed to provide adequate supervision to prevent the elopement of Residents #1 and Resident #2, who had exhibited exit-seeking behaviors. This failure allowed Residents #1 and #2 to exit the facility unnoticed and unsupervised when a visitor was observed on video on 3/24/2026 at 6:20 PM holding the door open for the residents to exit. A nurse immediately responded to the door alarm sounding and went outside down the walkway but did not see the residents. [...]

Inspectors wroteBased on observation, staff and resident interview, record review, and facility policy review the facility failed to implement care plans for a resident's Activities of Daily Living (ADL) care and a resident's pain medication management for two (2) of 18 resident care plans reviewed.

Inspectors wroteBased on staff and resident interview, record review, and facility policy review, the facility failed to ensure a resident was free of pain for one (1) of three (3) residents reviewed for pain.

Inspectors wroteBased on staff interview, record review and facility policy review, the facility failed to transmit a discharge Minimum Data Set (MDS) Assessment for one (1) of three (3) residents reviewed for discharge MDS assessments.

Inspectors wroteBased on observations, staff and resident interviews, record review, and facility policy review, the facility failed to ensure a resident who required assistance with Activities of Daily Living (ADLs) was assisted with personal hygiene as evidenced by long, jagged nails with brown substance underneath nails and unshaven facial hair for one (1) of three (3) residents reviewed for ADLs.

Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review, the facility failed to label and store an aerosol nebulizer mask in a manner that prevented possible contamination of the device for one (1) of 27 nebulizers in the facility. Resident #98 Findings Include: Record review of the facility policy titled Infection Control Oxygen Equipment Cleaning with a revision date of 8/2021 revealed when not in use, store the mask/cannula in a plastic bag clearly labeled with the resident's name and date. An observation and interview with Resident #98 on 6/17/2024 at 12:39 PM, revealed a nebulizer machine was sitting on the bedside dresser, with an unbagged and undated nebulizer mask and tubing lying on top of the machine. The resident revealed she did use the mask, but she was unsure how often. [...]

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to store controlled substances in a permanently affixed locked compartment inside the refrigerator for one (1) of two (2) medication storage rooms observed. Findings Include: Review of the facility policy titled Controlled Drug Emergency Safe Protocol with a revision date of 6/17 revealed, Protocol: . Refrigerated controlled substances will be kept in a refrigerator lock box with the key stored in the Controlled Drug Emergency Safe. An observation of medication storage room [ROOM NUMBER], on 6/19/2024 at 8:16 AM, revealed a small black refrigerator that contained a large tan lock box with four (4) boxes of liquid lorazepam concentrate. The refrigerator also held a small clear box that contained three (3) injectable vials of lorazepam, which was secured with a yellow sealed tab. [...]

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to accurately document the administration of the prn (as needed) pain medication in the electronic medication system for one (1) of three (3) residents reviewed for pain.

Inspectors wroteBased on staff interview, record review and facility policy review the facility failed to complete the residents Minimum Data Set assessments timely according to the Resident Assessment Instrument (RAI) guidelines for six (6) of 16 residents reviewed for annual assessment. Resident's #15, #32, #79, #88, #92, and #104.

Inspectors wroteBased on staff interview, record review and facility policy review the facility failed to complete the residents Minimum Data Set (MDS) assessments timely according to the Resident Assessment Instrument (RAI) guidelines for nine (9) of 16 residents reviewed for quarterly assessment. Resident's #6, 20, 31, 36, 39, 49, 58, 60, and 93.

Inspectors wroteBased on staff interview, record review and facility policy review the facility failed to transmit the residents Minimum Data Set assessments timely according to the Resident Assessment Instrument (RAI) guidelines for 16 of 16 residents reviewed for assessment. Resident's 6, 15, 20, 24, 31, 32, 36, 39, 49, 58, 60, 79, 88, 92, 93, and 104.

Inspectors wroteBased on staff interview, record review , and facility policy review, the facility failed to send a written notice of resident transfer, including the reason for transfer, to the hospital, to the resident or resident representative (RR) for two (2) of five (5) residents reviewed for transfer. Resident #25 and #73.

Inspectors wroteBased on staff interview, record review , and facility policy review the facility failed to notify the resident or resident representative (RR) in writing of the bed hold for a resident transferred to an acute care facility for one (1) of five (5) residents reviewed for bed hold. Resident #73.

Inspectors wroteBased on resident and staff interview, record review and facility policy review the facility failed to develop a person centered comprehensive care plan for residents with a language deficit and respiratory care for three (3) of 34 resident care plans reviewed. Residents #7, #24, and #98.

Inspectors wroteBased on observation, resident and staff interview, record review and facility policy review the facility failed to properly store nebulizer mask and tubing in a storage bag for two (2) of nine (9) residents reviewed for respiratory care. Residents # 7 and #98.

Inspectors wroteBased on observations, staff interviews, record review and facility policy review the facility failed to provide documentation or a diagnosis supporting the use of an anti-psychotic medication for one (1) of three (3) residents reviewed for unnecessary psychotropic medications.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) for Hospice, for two (2) of 21 residents reviewed, Resident #30 and Resident #44.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to properly store the oxygen (O2) tubing for one (1) of 34 residents utilizing oxygen, Resident #186.