Highland Park Rehabilitation & Care Center

Inspectors wroteBased on record review and interviews, the facility failed to ensure supervision and monitor assistive devices to prevent accidents for one (#1) of three residents reviewed for accidents out of 20 sample residents. Resident #1 was admitted to the facility for skilled nursing care on 6/13/25 .The resident's care plan directed staff to utilize a mechanical lift for transfers. On 6/18/25, Resident #1 was noted to have pain to her left upper extremity and bilateral lower extremities after being lowered to the floor with the use of a mechanical lift by certified nurse aide (CNA) #1. After the resident's fall, CNA #1 and CNA #6 proceeded to assist Resident #1 into her wheelchair using the mechanical lift, prior to the resident being assessed by a registered nurse (RN) (see staff interviews below). [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure notification to the resident representative of a significant change in the resident's physical, mental or psychosocial status for one (#11) of three residents reviewed for change of condition out of 20 sample residents. Specifically, the facility failed to notify Resident #11's representative of the resident's deteriorating wounds in a timely manner.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#6) of seven residents reviewed for abuse out of 20 sample residents were free from abuse. Specifically, the facility failed to protect Resident #6 from abuse by Resident #9.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide each resident with a nourishing, palatable and well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences. Specifically, the facility failed to ensure weekly menus were balanced and included a variety of menu items.

Inspectors wroteBased on record review and interviews, the facility failed to thoroughly investigate allegations of abuse for two (#2 and #3) of eight residents out of 15 sample residents. Specifically, the facility failed to complete a thorough investigation after an allegation of physical abuse towards Resident #3 by Resident #2.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure three (#19, #54 and #25) of four residents who required respiratory care received care consistent with professional standards of practice out of 34 sample residents. Specifically, the facility failed to: -Follow physician's orders to maintain, clean, sanitize and store Resident #19's continuous positive airway pressure (CPAP) mask and machine and Resident #54's bilevel positive airway pressure (BiPAP) mask and machine; and, -Rinse and store cup and mouthpiece for Resident #25's nebulizer (a small machine that turns liquid medication into a mist that can be inhaled to treat lung conditions.)

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection on one of four units. Specifically, the facility failed to: -Ensure housekeepers followed appropriate infection control processes when cleaning resident rooms; and, -Ensure high touch areas in resident rooms were disinfected.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure staffing information was posted in a prominent place, readily accessible to residents and visitors. Specifically, the facility failed to post the total number of actual hours worked by the licensed and unlicensed staff directly responsible for resident care per shift.

Inspectors wroteBased on observations, interviews and record review, the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to ensure: -Hair restraints were worn by staff in the main kitchen while preparing, handling, cooking and serving food for the residents: and, -Ensure fluorescent ceiling lights above areas where food was prepared, cooked, and served were covered by light shades.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure an effective program of pest management. Specifically, the facility failed to ensure hallway ceiling light fixtures on hallways 200 and 500, and Resident #4's room were free from bugs.

Inspectors wroteBased on observations, resident and staff interviews the facility failed to provide a comfortable and homelike environment for the residents of the facility for three out of four units. Specifically the facility failed to ensure: -Residents were provided with washcloths and hand towels; and -Room walls, furniture were properly maintained.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide necessary services consistent with professional standards of practice in accordance with a resident's inability to carry out activities of daily living (ADLs) for three (#68, #47 and #20) out of seven residents reviewed for ADLs of 43 sample residents. Specifically, the facility failed to provide supervision, encouragement, cueing and assistance during meals to Resident #68, Resident #47 and Resident #20.

Inspectors wroteBased on interviews, observations and record review the facility failed to ensure that each resident received food that was palatable, attractive and an appetizing temperature. Specifically, the facility failed to: -Ensure food was palatable and attractive when delivered to residents; and, -Ensure food was served at a safe and appetizing temperature.

Inspectors wroteBased on observations, record review and interviews, the facility failed to implement their policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption. Specifically, the facility failed to have a thermometer and monitor temperatures for Resident #28, #15, #9, #38, #37 and #19's personal refrigerators.

Inspectors wroteBased upon an observation and interviews, the facility failed to provide a safe and sanitary environment consistent with professional standards of practice to help prevent the development and transmission of communicable disease and infections. Specifically, the facility failed to: -Ensure standard hand hygiene precautions and donning and doffing gloves were followed by staff involved in direct resident incontinent care and contact; -Clean high touch items, call button and door knobs, in resident rooms; and, -Follow the recommended surface disinfectant time for cleaning solution.

Inspectors wroteBased on observations, record review, and resident and staff interviews, the facility failed to provide one (#91) of two residents reviewed for dignity, out of 43 sample residents, care in a dignified, respectful and individualized manner. Specifically, on 7/11/23, Resident #91 said she did not receive her dinner meal, and the cook disagreed and refused to prepare a meal for her. Resident #91 said this made her feel unimportant and that she did not matter.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to implement an ongoing resident centered activities program to enhance the interest of, and support the physical, mental, and psychosocial well-being for one resident (#7) of 13 residents reviewed for activities out of 43 sample residents. Specifically, the facility failed to ensure Resident #7 was provided with meaningful, individualized activities and social engagement in accordance with the resident's functional and psychological strengths and abilities in fulfillment with the resident's plan of care.

Inspectors wroteBased on resident observations, record review and staff interviews, the facility failed to ensure residents received proper respiratory treatment and care for one (#61) out of one reviewed for the use of the trilogy bilevel positive airway pressure (BIPAP) machine out of 43 sample residents. Specifically, the facility failed to for Resident #61: -Ensure the physician orders included settings of the Trilogy BIPAP; -Ensure the licensed nurses and certified nurse aides were trained on the system; and, -Ensure the care plan was updated to include the settings of the Trilogy

Inspectors wroteBased on observations, record review and interviews, the facility failed to effectively address the care and service needs of two (#53 and #66) of three residents reviewed for dementia care out of 43 sample residents. Specifically, the facility failed to: -Provide personalized activities programming to Resident #53 and Resident #66, who had a diagnosis of dementia; -Consistently monitor behaviors of concern including aggression toward others for Resident #53; and, -Implement personalized interventions in response to Resident #53's behaviors towards other residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure consistent behavior monitoring was conducted for target behaviors related to the use of psychotropic medications for two (#258 and #89) of five residents reviewed for medications of 43 sample residents. Specifically, the facility failed to: -Ensure staff identified triggers for the residents use of the antipsychotic medication for Resident #258 and Resident #89; -Ensure provided non-pharmacological interventions for Resident #258 and Resident #89; and, -Ensure the facility developed specific target behaviors and ensure the behavior monitoring forms consistently matched the target behaviors were documented for Resident #258 and Resident #89.

Inspectors wroteBased on interview, record review, and observation the facility failed to provide routine dental services to one (#44) of three residents out of 43 sample residents. Specifically, the facility failed to provide dental services to Resident #44.

Inspectors wroteBased on observations, interviews, document review, and policy review, the facility failed to ensure one of one facility kitchen was maintained in accordance with professional food service/safety standards. This deficient practice had the potential to affect all 93 residents residing in the facility. Specifically, the facility failed to ensure dietary staff: - regularly cleaned soiled areas in the kitchen; - dated and discarded perishable food appropriately; - regularly measured and recorded food temperatures; and - maintained freezer temperatures at or below zero degrees Fahrenheit (F).