Highland Pines Rehabilitation Center

Inspectors wroteBased on interviews and record review, the facility failed to ensure physician orders were followed in a timely manner, related to wound care treatment for one resident (#19) out of three residents sampled. On 10/20/2025 Resident #10 sustained an injury to his right pinky finger. On 10/20/2025 orders were given by the provider for wound care treatment and medications to fight infection. The facility staff failed to enter the orders until 10/22/2025. Resident #10 continued to experience pain and go without medications for the infection for two days. Resident #10 was transferred to a higher level of care and had to have his right pinky finger amputated. Findings Included:During an interview on 02/25/2026 at 10:41 AM, Staff A Licensed Practical Nurse (LPN), stated she went to give Resident #10 medication on 10/20/2025 and noticed the resident had an injury to the right pinky finger. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure urinary catheter care and services were provided in accordance with professional standards of practice for two residents (#16, #7) out of three residents sampled for catheter care. Findings Include:1. On 03/04/2026 At 9:27 AM Resident #16's urinary catheter bag was observed detached from the bed and resting directly on the floor. Urine appeared slightly cloudy. On 03/04/2026 At 12:32 PM the urinary catheter bag was observed on the floor. On 03/04/2026 At 1:35 PM the urinary catheter bag was observed on the floor. Record review of the March 2026 (Treatment Administration Record) TAR indicated Resident #16 received urinary catheter care as ordered on the day shift of 03/04/2026. [...]

Inspectors wroteBased on interviews and record review the facility did not ensure pain management was provided as ordered for two residents (#11 and #13) out of two residents sampled.

Inspectors wroteBased on record review and interviews, the facility failed to protect the residents' right to be free from neglect for eleven residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11) out of eleven residents sampled related to seizure medication management and follow-up laboratory orders for seizure medication therapeutic levels. Serious harm occurred when Resident #1's seizure medication levels were not monitored, and neurology consultation was not obtained per the provider's request. Resident #1 experienced a seizure on 7/10/24, 9/28/24, 9/29/24, and 2/27/25. Resident #1 had to be transferred to a higher level of care as a result of the seizure suffered on 2/27/25. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to Resident #1 and resulted in the determination of Immediate Jeopardy on 4/16/2025. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to provide competent physician services for the treatment and monitoring of seizure diagnoses for eleven residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11) out of eleven sampled residents. Serious harm occurred when Resident #1's seizure medication levels were not monitored, and neurology consultation was not obtained per the provider's request. Resident #1 experienced a seizure on 7/10/24, 9/28/24, 9/29/24, and 2/27/25. Resident #1 had to be transferred to a higher level of care as a result of the seizure suffered on 2/27/25. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to residents and resulted in the determination of Immediate Jeopardy on 4/16/2025. [...]

Inspectors wroteBased on interviews and record review the facility failed to ensure nursing staff were competent in caring for residents with seizure diagnoses to include laboratory monitoring process, following through with orders, processing consultations, and communications with physicians for eleven residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11) out of eleven residents sampled. Serious harm occurred when Resident #1's seizure medication levels were not monitored, and neurology consultation was not obtained per the provider's request. Resident #1 experienced a seizure on 7/10/24, 9/28/24, 9/29/24, and 2/27/25. Resident #1 had to be transferred to a higher level of care as a result of the seizure suffered on 2/27/25. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure laboratory orders were entered in the electronic medical record and electronic laboratory (lab) portal, labs were completed as ordered, and abnormal results were reported to providers in a timely manner for eleven residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11) out of eleven residents sampled. Serious harm occurred when Resident #1's seizure medication levels were not monitored, and neurology consultation was not obtained per the provider's request. Resident #1 experienced a seizure on 7/10/24, 9/28/24, 9/29/24, and 2/27/25. Resident #1 had to be transferred to a higher level of care as a result of the seizure suffered on 2/27/25. [...]

Inspectors wroteBased on interviews and record review the facility failed to ensure they effectively monitored adverse events to systematically identify, report, track, and analyze the data to prevent potential or serious harm to residents for ineffective management of health care services, and treatment for seizure medication management for eleven residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11) out of eleven residents sampled. Serious harm occurred when Resident #1's seizure medication levels were not monitored, and neurology consultation was not obtained per the provider's request. Resident #1 experienced a seizure on 7/10/24, 9/28/24, 9/29/24, and 2/27/25. Resident #1 had to be transferred to a higher level of care as a result of the seizure suffered on 2/27/25. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure the Preadmission Screening and Resident Reviews (PASRRs) for residents with a mental disorder and individuals with intellectual disability with qualifying mental health diagnosis, were updated for five (#9, #22, #7, #39 and #23) of six residents sampled.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure resident rooms were maintained in a clean and sanitary manner in three (300, 200, 100) of three halls observed, during 4 of 4 days of survey.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5.00%. 32 medication administration opportunities were observed, and six errors were identified for two residents (#110 and #107) of six residents observed. These errors constituted a 18.75% medication error rate. Findings Included: On 8/28/24 at 10:08 a.m., a medication administration observation was conducted with Staff U, Registered Nurse (RN) for Resident #110. Staff U, RN administered insulin subcutaneously and Cyanocobalamin (Vitamin B 12) intramuscularly. Resident #110's electronic medication administration record (eMAR) was highlighted in red. Staff U, RN, confirmed the medications were late. Review of Resident #110's August 2024 MAR showed insulin administration was due at 0800 with meal and Cyanocobalamin was scheduled to be given at 9:00 a.m. [...]

Inspectors wroteBased on observations and interviews, the facility failed to maintain an effective infection prevention and control program by failing to ensure staff members donned appropriate personal protective equipment (PPE) before entering the rooms of residents with transmission based precaution signage on the door for four (#2, #86, #104, #38) of four residents and two (#102 and #217) of four rooms sampled in the secure unit.

Inspectors wroteBased on interview and record review, the facility failed to maintain an ongoing antibiotic stewardship program for two out of three months reviewed.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure the resident's living environment promoted, maintained and enhanced dignity and respect for three (#56, #265, #264) of four residents sampled.

Inspectors wroteBased on observations interviews, and record review, the facility failed to ensure call lights were within reach in eight resident rooms (207A/B, 206B, 210A/B, 214B, 305, 307, 312 and 314) in two (200 and 300) of four halls.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident had privacy in his room for one (#9) of two residents sampled.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accommodations were in place for two (#25 and #61) of two sampled residents with limited English proficiency. Findings Included: On 8/26/24 at 4:09 p.m. during observation and interview, Resident #61 used their personal cell phone to translate from English to Vietnamese to communicate with staff. Review of the admission record showed Resident #61 was admitted on [DATE] with diagnoses including paraplegia, depression, anxiety, and heart failure. Review of Resident #61's quarterly Minimum Data Set (MDS), dated [DATE], Section A, Identification Information showed the resident's preferred language is Vietnamese. Section C- Cognitive Pattern revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to address a change in condition for one (#46) of two residents reviewed.

Inspectors wroteBased on observations, interview and record review the facility failed to ensure that services were provided to address resident vision needs for one (#105) of 48 residents sampled.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor for medication related side effects and behaviors for two (#10 and #73) of five residents reviewed for unnecessary medications. Findings Included: 1. Review of Resident #10's admission record showed he was admitted on [DATE] with diagnoses including epilepsy, mood disturbance, dementia, cognitive communication deficit, schizoaffective disorder, seizures, and anxiety. Review of Resident #10's orders showed, Levetiracetam tablet 500 milligrams (mg) every 12 hours for seizures, Escitalopram Oxalate tablet 20 mg daily for depression, and Olanzapine tablet 20 mg at bedtime for schizoaffective disorder. Review of care plans showed Resident #10 has a behavior problem related to yelling out in the hallway, refuses to go to bed, places self on the floor, .combative with staff. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to appropriately store and secure medications related to medication at the bedside on one (100 hall) of four resident hallways for Resident #20 and in two (200 hall and Birch hall) of four medication rooms.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure residents received adequate dental care and services for two (#78, #84) of 48 sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to collaborate and coordinate care with hospice related to code status for one (#69) of two residents reviewed for hospice services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (Resident #5) of five sample residents had access to his wheelchair during one of one days of survey.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide a safe, clean, comfortable, and homelike environment in four (Unit 100, Unit 200, Birch Unit, and the Reflections Unit) of four units, as evidenced by lack of daily visual inspection and cleaning of surfaces, ensuring surfaces were cleanable without pits, cracks, corrosion, and organic matter was removed from surfaces prior to sanitizing. Additionally, the facility failed to ensure air quality was maintained at the highest possible standards and failed to ensure one of one sampled Packaged Terminal Air Conditioners (PTAC) units was maintained in a workable and safe condition. Findings Included: On 12/27/2023 at 9:24 a.m. during a tour of Unit 100, the following observations were made in resident room [ROOM NUMBER] bedroom and bathroom: [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure an intravenous (IV) access was properly maintained for one (Resident #5) of one resident sampled for IV access.

Inspectors wroteBased on observation, record review, interviews, policy review, and the Plan of Correction review, the facility failed to ensure that it had a functioning Quality Assurance and Performance Improvement Program (QAPI). The facility was actively involved in the creation, implementation and monitoring of the plan of correction for deficient practice identified during a complaint survey conducted 11/8/23 and was cited F684. On 12/27/23 a revisit survey was conducted, and the facility was recited F684. The facility had developed a Plan of Correction with a completion date of 12/8/23.

Inspectors wroteBased on observation of the dietary staff washing dishes, interview with dietary staff, and review of facility documents, the facility failed to ensure that the dish machine was maintaining wash and rinse water temperatures according to the manufacturer's guidelines, and failed to document temperatures during each meal period, which could potentially cause the use of unclean dishes in the meal service.

Inspectors wroteBased on observations, interviews and record review, the facility failed to store medications in accordance with State and Federal laws in three of four medication carts (100, 200 and 300 Halls), and for one (Resident #100) of one resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions, including adequate supervision, consistent with the resident's needs, goals, and care plan in order to eliminate or reduce the risk of accidents and injuries for one (Resident #44) of five residents sampled for accidents. Resident #44 was admitted to the facility in September of 2020 with a diagnosis of repeated falls. Resident #44 sustained five falls since admission between 10/8/20 and 2/27/21 with no documented evidence of analysis of hazards and risks to prevent further accidents. Resident #44 was placed on 15 minute checks on 1/20/21 with no documentation of safety checks maintained. On 3/10/2021 scans revealed Resident #44 had bilateral fractures in the hip area thought to be associated with the fall on 2/27/21. [...]

Inspectors wroteBased on a review of facility documents and the resident's medical and hospital records, interview with the facility staff, and observation of the resident's room, it was determined that the facility failed to ensure all injuries of unknown origin were investigated timely, for one resident (#144) of a total sample of 43 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess to accurately reflect the resident's status and document discoloration of skin for two (Residents #76 and #245) of three residents observed. Findings Included: 1. Observation of Resident #76 on 3/15/21 at 9:57 a.m. revealed the resident lying in bed with a purple colored rectangular area to the left center of forearm and right hand. Resident #76 stated she had no idea where she got the marks and called them bruises. She stated her memory was not great but was happy they did not hurt. Observation on 3/16/21 at 12:59 p.m. revealed a rectangular left forearm discoloration and a right hand purple discoloration. Resident #76 was unsure how she obtained the marks. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice as evidence by 1. Failure to ensure a wound vac (vacuum assisted closure) was on and in working order for one (Resident #66) of three residents with wound vacs and 2. Failure to follow up on the Registered Dietitian's (RD) recommendations for one (Resident #145) of one resident reviewed. 1 -An observation of Resident #66 was conducted on 3/15/21 at 11:11 a.m. She was lying in bed, dressed, and a wound vac was observed on the left side of resident's bed. Resident #66 stated, My wound vac has not been working all morning, and I have been calling for assistance and no one has responded to assist in reconnecting or fixing the wound vac. [...]

Inspectors wroteBased on observation of the resident, interview with the resident's nurse and Director of Nurses (DON), and review of the resident's medical record and facility documents, the facility failed to ensure one (Resident #54) of eight residents with indwelling urinary catheters, was provided care to aid in the prevention of an infection related to his urinary catheter bag observed out of the privacy bag, laying on the floor, under the front left wheel of his wheelchair.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure enteral feeding pumps and the pump settings were accurately calibrated to provide the rate and volume consistent with the care plan for two (Resident #68 and Resident #41) out of two sampled residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide sufficient qualified nursing staff at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being for one (Resident #44) of five sampled residents related to falls and one (Resident #66) of four residents related to a wound vac (vacuum assisted closure).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure effective infection prevention measures were in place to reduce the spread of COVID-19 and prevent the development of infections by failing to ensure staff donned Personal Protective Equipment during a COVID-19 nasal test for one (Resident #67) of one observed while the nurse performed a nasal swab, for failing to don Personal Protective Equipment (PPE) while obtaining vital signs in one of one rooms on contact precautions for clostridium difficile (C-diff), for failing to don gloves while holding and cleaning a recently used glucometer, and for failing to disinfect a face shield prior to replacing in a clear plastic bag for reuse. Findings Included: During an interview with the Director of Nursing (DON) on 3/17/21 at 10:00 a.m. [...]