Highland Park Rehabilitation & Nursing Center

Inspectors wroteBased on observations, interviews and record review the facility failed to maintain acceptable parameters of nutritional status in such as usual body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicate otherwise for 1 of 8 (Resident #67) residents reviewed for weight loss. -The facility failed to ensure Resident #67 was monitored for weight loss resulting in a 14.5% or 24.8 pounds in a 3-month period. An Immediate Jeopardy (IJ) was identified on 6/6/25. The IJ template was provided to the facility on 6/6/25 at 3:16pm, While the IJ was removed on 6/8/25, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm the facility continued to monitor the implementation and effectiveness of their corrective systems. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care and services, including oxygen administration was provided such care, consistent with professional standards of practice for 1 of 3 residents (Resident #43) reviewed for respiratory therapy in that:The facility failed to ensure Resident #43 received continuous oxygen and nebulizer treatments to meet her respiratory needs, resulting in Resident #43 experiencing oxygen saturations of 90 on 6/3/25 and 80 on 6/5/25. Resident #43 was experiencing anxiety and a change to her daily routine as a result. The facility failed to ensure Resident #43 was administered oxygen per the physician's order resulting in the resident receiving oxygen at a rate higher than what was prescribed placing her at risk of medical complications. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 2 (Resident #1 and Resident #2) of 7 residents reviewed for resident right. - Resident #1 did not have a privacy covering on his catheter bag. -Resident #2 was not fully covered, and his body was partially exposed, while he was transported from his room to the shower room. These failures could place residents at risk of decreased self-esteem and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident who was incontinent of bowel/bladder and each resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections, for 1 (Resident #1) of 3 residents reviewed for incontinent care and for indwelling urinary catheters. -The facility failed to ensure Resident #1's catheter stabilizer was in place. -The facility failed to ensure Resident #1's catheter tubing was free of kinks. These failures could place residents with urinary catheters at risk for infections and injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the daily staffing was posted and readily accessible for review for 1 of 1 facility reviewed for required postings. -The facility failed to post the daily nursing staffing information on 9/10/2024. This failure could affect residents, facility visitors, vendors, and emergency personnel by placing them at risk of not having access to information regarding daily nursing staffing in a timely manner. Findings Include: Observation on 9/10/24 at 8:40 a.m., during entrance revealed the nursing staffing information was posted at the receptionist desk dated 9/8/2024. Observation on 9/10/24 at 12:10 p.m., during rounds revealed the nursing staffing information was posted at the receptionist desk dated 9/8/2024. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents received care, consistent with professional standards of care to prevent development of pressure ulcers for 1 of 6 (Resident #16) reviewed for pressure ulcers. -The facility failed to apply Resident #16's physician ordered pressure relieving heel protectors or to off-load his heels. This failure could place residents at risk for developing a pressure ulcer or worsening a pressure ulcer, which could cause pain and infection.

Inspectors wroteBased on interview and record review, the facility failed to refer all residents with newly evident or possible serious mental disorders, intellectual disabilities, or a related conditions for level II resident review upon a significant change in status assessment for 1 of 18 residents (Resident #28) reviewed for PASARR evaluations. -The facility failed to refer Resident #28 to the appropriate, State-designated authority when she was diagnosed with schizophreniform disorder. This failure could place residents at risk for not receiving necessary PASARR mental health services, causing a possible decline in mental health.

Inspectors wroteBased on interview and record review, the facility failed to create a comprehensive resident-centered care plan with measurable objectives for person-centered care for one of three closed records (CR #89) and 1 (Resident #52) of 6 residents reviewed for resident-centered care plans. - CR #89 did not have a documented comprehensive resident-centered care plan. - Resident #52 was a DNR but his care plan had both DNR and Full Code on it. These failures placed residents at risk of not receiving accurate care and services according to their individual needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 8% based on 3 errors out of 35 opportunities, which involved 1 of 5 residents (Resident #3) reviewed for medication errors. -MA B administered the incorrect dose of Famotidine (a medication used to reduce stomach acid and treat ulcers), Furosemide (a medication used to treat fluid retention and high blood pressure), and Polyethylene Glycol 3350 (also known as Clearlax which is used to treat occasional constipation) to Resident #3 according to physician's orders. These failures could place residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health.

Inspectors wroteBased on observation, interview, and record review, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible, and systematically organized for 1 (Resident #52) of 6 residents reviewed for accurate medical records. -The facility failed to correctly transcribe and clarify with the physician orders for Resident #52's PEG tube (tube into stomach for nutrition) feeding rate. -The facility failed to maintain Resident #52's April 2024 MAR for his PEG tube (tube into stomach for nutrition) feeding. This failure could place residents at risk receiving the wrong rate of feeding and water flush which can cause malnutrition and dehydration/fluid overload.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #16) of 6 residents viewed for infection control. -CNA R and CNA Z did not wear appropriate PPE when changing Resident #16 during incontinence care, when he was on Enhanced Barrier Precautions. This failure could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure a resident who was unable to carry out activities of daily living received necessary services to maintain good personal hygiene for 8 (Residents #9, #10, #19, #24, #33, #34, #35, and #37) out of 8 residents reviewed for ADL care. -The facility failed to provide scheduled showers three times a week to Residents #10, #19, #24, #33, and #37. -The facility failed to provide incontinence care to Residents #9, #33, #34, and #35 every 2 hrs and/or as needed. This failure could place residents who were unable to carry out ADLs independently, at risk of skin breakdown and infection.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring and administering of all drugs to meet the needs of the residents, for one Resident (Resident #9) of one resident reviewed for PRN medication use. -Resident #9 was not administered her prescribed hydrocortisone PRN for 3 months and 8 days. This failure could cause the Resident's condition to worsen.

Inspectors wroteBased on interview and record review the facility failed to ensure residents who were unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 10 residents (Resident #5, Resident #61, and Resident # 67) reviewed for ADLs. The facility failed to ensure Residents #61, #5 and #67 received their scheduled showers. This failure could place residents at risk for not receiving care and services to meet their needs and ADL decline.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 18 percent based on 6 errors out of 32 opportunities, which involved 5 of 8 residents (Resident #6, Resident #45, Resident #65, Resident #69 and Resident #273) reviewed for medication errors. - MA A failed to administer medication to Resident #6 as ordered by administering Lidocaine 4% instead of Lidocaine 5% as ordered by the MD. - RN A failed to administer medications to Resident #45 as ordered by administering Linzess ( medication to treat constipation) at 9 AM, regardless of food as ordered and 2 hours after the scheduled administration time. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to coordinate the Pre-admission Screening and Resident Review (PASARR ) program with the local Mental Health Authority if the resident requires level of services for intellectual disability for 2 (Resident #2 and #8) of 6 residents reviewed for PASARR. The facility failed to refer Resident #2 and Resident #8 for PASRR Level II assessments when the facility incorrectly coded their PASRR Level I assessment. This failure could place residents at risk of not having their special needs assessed and met by the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding, which included but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and nasal-pharyngeal ulcers for 1 of 1 resident (Resident #69) reviewed for gastrostomy tube management. LVN A failed to appropriately check the placement of Resident #67's G-tube (a tube inserted through the belly that brings nutrition directly to the stomach) by pushing by force 5 ml of water instead of air into the resident's G-tube and failing to check for residual. This failure could place residents at risk for adverse reactions, inadequate therapy, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 7 residents (Resident #69) reviewed for pharmacy services. The facility failed to administer the correct medication to Resident #69 by administering Pantoprazole instead of Lansoprazole as ordered by the MD for the treatment of the resident's GERD. This failure could place residents at risk of not receiving the therapeutic benefit of medications and/or adverse reactions to medications.