Highland Rehabilitation and Nursing Center

Inspectors wroteBased on record review and interviews, the facility failed to ensure the right to receive written notice, including the reason for the change, before the resident's room in the facility is changed for one of one resident (Resident #98) reviewed for room change. Specifically, there was no documented evidence that Resident #98 and/or their Representative were provided written notification prior to Resident #98's room change from a private room on the third floor to a semi-private room on the second floor.

Inspectors wroteBased on record review and interview the facility failed to ensure each resident was free from verbal and/or physical abuse and/or that supervision was provided to prevent abuse for one of three residents (Resident #24) reviewed for abuse. Specifically, on 02/19/2026 Resident # 93 walked over and grabbed Resident # 24 by the arms and legs when Certified Nurse Aide # 32 left the two residents in the common area unsupervised to obtain coffee from the kitchen for Resident #24 and on 04/07/2026, Resident #24 was involved in a verbal altercation with Resident #92 which resulted in Resident #92 throwing a cup of liquid at Resident #24.

Inspectors wroteBased on record review and interview the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one of two residents (Resident #98) reviewed for insulin and one of three residents (Resident #92) reviewed for pain. Specifically, 1) the physician was not consistently notified when Resident #98's fingerstick blood glucose readings were greater than 401 as per physician order, and 2) Resident #92's Medication Administration Records for November 2025 and December 2025 revealed incomplete documentation for physician ordered intravenous cefazolin.

Inspectors wroteBased on record review and interviews conducted during a Survey (2566010), the facility did not ensure that the resident's family representative was notified of a change in condition for one (Resident #1) of three(3) residents reviewed for notification of changes in condition for end of life care. Specifically, from [DATE] through [DATE], Resident #1 was prescribed Tramadol 50 mg for pain management. On [DATE], Tramadol was discontinued, and Resident #1 was prescribed morphine 5 mg every 6 hours as needed for pain and end-of-life care. On [DATE], the resident's morphine dosage was increased to 10 mg every 3 hours as needed for pain. Review of the medical record revealed no documented evidence of communication with the resident's family representative from [DATE] through [DATE] regarding changes in the resident's treatment, medication regimen, and health status. [...]

Inspectors wroteBased on record review and interviews conducted during the Abbreviated Surveys (2566010 and 2658860), the facility did not ensure the accurate and timely completion of the admission Minimum Data Set assessment for one resident (Resident #4) of six residents reviewed. Specifically, Resident #4 was admitted to the facility on [DATE]. The federally required Comprehensive Minimum Data Set assessment, which must be completed within 14 days of admission, was not initiated as of record review conducted on 01/02/2026. The Assessment Reference Date of 12/23/2025 reflected that the Comprehensive Minimum Data Set assessment was overdue by 10 days at that time. Upon revisit on 01/27/2026, record review revealed that the Comprehensive Minimum Data Set assessment associated with the same Assessment Reference Date remained incomplete and was 35 days overdue.

Inspectors wroteBased on observation, record review, and interviews conducted during an Abbreviated Survey (2566010 and 2658860), the facility did not ensure a system was in place to easily identify residents to prevent accidents for two (Residents #2 and #5) of seven residents reviewed. Specifically, 1) on 10/27/2025, during the provision of routine podiatry services, the podiatrist identified Resident #2 by the incorrect name based on the identification band provided to the resident by the facility. Resident #2 was wearing another resident's identification wristband. 2) On 01/02/2026, Resident #5, who was newly admitted and was severely cognitively impaired, was observed without an identification wristband in place. Certified Nurse Aide #1 was asked by the surveyor to identify Resident #5(who was assigned to them) and was unable to identify Resident #5.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification and abbreviated (NY00354392) the facility did not ensure the resident's right to a safe, clean, comfortable environment and reasonable care for the protection of resident property from loss or theft. This was evident for 1 (Unit 2) of 2 resident units and 1 (Resident #5) of 3 residents investigated for abuse. Specifically, 1) Unit 2 was observed with peeling wallpaper, floors covered in dirt, debris, a floor mat emanating a strong odor of urine, a soiled wheelchair, and radiators throughout the unit with air vent grates and metal conductor fins heavily covered and soiled in dirt, debris, dust, and dried crusty food and liquids, and 2) Resident #5's personal food was taken and eaten by staff while being stored in the dining room refrigerator designated only for resident food.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 6/25/2025 to 7/3/2025, the facility did not ensure residents unable to carry out activities of daily living received necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This was evident for 3 ( Resident #54, #19, and #27) of 4 residents reviewed for activities of daily living. Specifically, 1) Resident #54 was observed with long, jagged, brown and yellow nails, 2) Resident #19 was observed in bed on multiple occasions and there was no evidence the resident was provided with the assistance to transfer out of bed to their wheelchair, and 3) Resident #27 was observed with long, jagged fingernails covered with brown crusty stains.

Inspectors wroteBased on observation, interview, and record review conducted during recertification survey from 6/25/2025 to 7/3/2025, the facility did not ensure each resident was provided with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs. This was evident for 1 (Unit 2) of 2 resident units during dining review. Specifically, Unit 2 residents eating in the floor dining room were not consistently served their entire meal in accordance with Physician Order and meal tickets.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 6/25/2025 to 7/3/2025, the facility did not ensure resident food was stored, prepared, distributed and served in accordance with professional standards for food service safety. This was evident for 1 (Unit 2) of 2 resident units during dining review. Specifically, 1) Unit 2 floor dining room refrigerator held undated, unlabeled food, and 2) potentially hazardous foods were not held within a safe temperature range during food service.

Inspectors wroteBased on interview and record review conducted during the recertification survey from 6/25/2025 to 7/03/2025, the facility did not ensure the facility-wide assessment was updated to determine what resources were necessary to ensure residents were able to maintain or attain their highest practicable physical, functional, mental, and psychosocial well-being and meet current professional standards of practice. Specifically, the Facility Assessment did not include the staff training/education and competencies required for all personnel listed, did not include specific staffing needs for each facility unit and did not develop and maintain a plan to maximize recruitment and retention of direct care staff.

Inspectors wroteBased on observation, record review and interview conducted during the recertification survey from 6/25/25 to 7/3/25, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases and infection for all residents. Specifically, the facility did not provide documentation of screening, administration or declination and education provided for 1 of 5 Residents (Resident#25) and 10 of 10 staff (Certified Nurse Aides #26, #27, Food Service Workers #25, #30, Activities Aide #24, Occupational Therapist #23, Dietary Technician #14 Licensed Practical Nurses #7, #4, Registered Nurses #28), reviewed for COVID-19 vaccinations.

Inspectors wroteBased on record review and interviews during recertification and abbreviated (NY00374708) surveys conducted from 6/25/2025-7/03/2025, the facility did not ensure residents had the right to receive visitors of their choosing at the time of their choosing for 1 of 2 residents (Resident #25) reviewed for choices. Specifically, the facility restricted Resident #25's friend's visitation based on the resident's family member and the Administrator's wishes.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification and abbreviated (NY00354392) surveys from 6/25/2025 to 7/3/2025, the facility did not ensure a resident's right to be free from misappropriation of property. This was evident for 1 (Resident #5) of 3 residents investigated for abuse. Specifically, Resident #5's personal food was not stored safely and was eaten by staff, and facility staff diverted Resident #5's income directly to the facility without the resident's consent or knowledge.

Inspectors wroteBased on observations, interviews, and record review conducted during the recertification and abbreviated (NY00356178) surveys conducted from 6/25/25 - 7/3/25, the facility did not ensure that Comprehensive Care Plans were reviewed and/or revised for 1 of 5 residents (Resident #345) reviewed for Accidents and 1 of 3 residents (Resident #363) reviewed for Abuse Specifically, 1. for Resident #345, there was no documented evidence the comprehensive care plan was reviewed and/or revised after a 6/22/25 fall and 2. there was no documented evidence comprehensive care plans were reviewed and/or revised to address Resident # 363's ongoing behaviors after 9/8/24, 9/12/24 and 9/22/24 episodes of physical and/or verbal aggression.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 6/25/2025 to 7/3/2025, the facility did not ensure resident/s received necessary treatment and services to prevent new pressure ulcers from developing and/or promote healing of a facility acquired pressure ulcer for 1 of 2 residents (Resident #19) reviewed for pressure ulcer. Specifically, for Resident #19 with a documented 2/20/2025 superficial (surface) sacral wound, Braden Assessment/s were incomplete and did not include a score to determine resident risk for pressure ulcer, labs were not obtained as per the 2/20/2025 medical doctor note, and use of an air mattress as per the 3/3/2025 wound doctor note was not implemented until 3/20/2025. Subsequently the sacral wound progressed to stage 4 (full thickness tissue loss with exposed bone and tendon).

Inspectors wroteBased on observation, record review and interviews conducted during the recertification and abbreviated surveys (NY00372410), the facility did not ensure each resident received adequate supervision consistent with resident's needs to prevent accidents. This was evident for 1 of 5 residents (Resident #67) reviewed for accidents. Specifically, Resident #67 was assessed to be at high risk for falls, had multiple unwitnessed falls and complete investigations were not done to determine the root cause and/or add interventions to protect the resident.

Inspectors wroteFACILITY Based on observations, record review, and interviews during the recertification survey from 6/25/25 to 07/03/25, the facility did not ensure a medication error rate of no more than 5%, during a medication administration observation, when 4 of 40 opportunities (10.0%) resulted in error for 1 of 4 residents (Resident #22) observed. Specifically, 1) Resident #22 was administered two inhalant medications (Incruse Ellipta and Fluticasone-Salmeterol) in succession without having the resident rinse their mouth in between and after inhalations or waiting one to three minutes in between inhaler administration. 2). Resident #22 was administered two different eye drops medications (artificial tears and cyclosporine emulsion) to the bilateral eyes without waiting three to five minutes in between administation to allow for absorption.

Inspectors wroteBased on observations and interviews, during the Recertification Survey from 6/25-7/3/25, the facility did not ensure that all drugs and biologicals accessible for use were not expired and that all drugs and biologicals were stored in locked compartments accessed only by authorized personnel. Specifically, 1) nine boxes of Sequirus Flucelvax influenza vaccine were observed in freezer section of the Third floor unit medication refrigerator, 2) expired biologicals and medications for five residents no longer in the facility or no longer receiving medications were found stored in the Third floor medication room and not returned to the pharmacy or disposed of and 3) expired and undated medications were observed in the Second and Third floor units medication carts.

Inspectors wroteBased on record review and interview during the recertification survey conducted 06/25/25 to 07/03/25, the facility did not ensure each resident was offered influenza and pneumococcal immunizations and received education regarding the benefits and potential side effects of the immunizations for 1 of 5 residents (Resident #25) reviewed. Specifically, there was no documented evidence Resident #25 had been offered, declined, or educated about the influenza and pneumococcal and immunization.

Inspectors wroteBased on observation and interview during the Recertification Survey from 8/21/23 to 8/25/23, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Specifically, 1. multiple kitchen employees did not use hygienic practices and were observed not wearing a hair restraint over their beard, and 2. a cook did not follow safe food handling practices when recording food temperatures and did not ensure that cold foods were held at 41 degrees Fahrenheit or lower.

Inspectors wroteBased on observation and interviews conducted during the Recertification Survey from 8/21/23 to 8/25/23, the facility did not ensure that all essential kitchen equipment was maintained in safe operating condition. The issues included use of a low temperature dishwasher (chemical sanitization) without properly monitoring the chemical sanitizer concentration of the final rinse. According to the U.S. Department of Health and Human Services, Public Health Services, Food and Drug Administration Food Code, the recommendations for Low Temperature Dishwasher (chemical sanitization) are: - Wash - 120 degrees F; and - Final Rinse - 50 ppm (parts per million) hypochlorite (chlorine) on dish surface in final rinse. [...]

Inspectors wroteBased on observation, record review and interview during the recertification survey, the facility did not ensure that the call bell system was accessible for 1 of 3 residents (Resident #5) reviewed for activities of daily living (ADL). Specifically, the call bell for Resident #5 was not within reach on multiple occasions.

Inspectors wroteBased on record review and interview during the Recertification Survey conducted from 8/21/23 to 8/25/23, the facility failed to provide the appropriate liability and appeal notices to Medicare beneficiaries for 1 of 3 residents (Resident #74) reviewed. Specifically, the facility was unable to provide documented evidence that Resident #74 or their Representative received the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 (Centers for Medicare and Medicaid Services) for Medicare Part A as required.

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey from 8/21/23-8/25/23, the facility did not ensure the residents or the residents' representatives were notified in writing of the reason for the transfer/discharge to the hospital in a language that they understood, and the facility did not notify the Ombudsman for 2 of 3 residents (#11 and #91) reviewed for hospitalizations. Specifically, Resident #11 and Resident #91 were transferred to the hospital and the facility could not provide evidence that a written notice of transfer/discharge was provided to the residents or the residents' representatives or that notification was sent to the Ombudsman.

Inspectors wroteBased on record review and interviews during the Recertification Survey from 8/21/23 to 8/25/23, the facility did not ensure that residents or resident's representatives were notified in writing of the facility Bed Hold Policy for 2 of 3 residents reviewed for hospitalization. Specifically, Residents #11 and #91 were transferred to the hospital and the facility was unable to provide evidence that written notice of the facility Bed Hold Policy was given to the residents or their representatives.

Inspectors wroteBased on record review and interview conducted during a recertification survey, the facility did not review and revise the resident's comprehensive care plan with appropriate interventions for 1 of 3 residents (#84) reviewed for urinary catheter. Specifically, Resident #84's Foley catheter was discontinued on 7/18/2023 and the care plan was not reviewed and revised to address urinary incontinence care.

Inspectors wroteBased on observations, interviews, and record review conducted during the recertification survey, the facility did not ensure that special eating equipment and utensils for residents who need them was provided for 1 of 2 residents (R) # 45 reviewed for adaptive equipment. Specifically, a divided scoop plate and built up bendable (bent to the L) utensil were not provided for Resident #45 as per physician order and therapy evaluation and recommendation.

Inspectors wroteBased on observations and interviews conducted during the recertification and abbreviated surveys (NY00312542, NY00296734) from 8/21/2023 to 8/25/2023, the facility did not provide a safe, functional, sanitary, and comfortable environment for all residents, staff, and the public. This was evident for two (Resident #42, #69) of 8 residents reviewed for Environment. Specifically, the care equipment for Residents #42 and #69 was not maintained in a sanitary condition.

Inspectors wroteBased on observation, interview, and record review conducted during a recertification survey, the facility did not ensure that dignity was maintained during a wound care procedure for one resident (Resident#196).

Inspectors wroteBased on observation, interview and record review conducted during the recertification survey, it was determined that the facility did not develop a person-centered care plan with measurable goals, time frames and appropriate interventions based on comprehensive assessments for 2 of 3 residents (#35 and #46 ) reviewed for positioning and mobility and for 1 of 5 residents (#89) reviewed for pressure ulcers. Specifically, 1. Resident #35 did not have a care plan with measurable goals and appropriate interventions to address right sided hemiplegia and the use of a physician prescribed right resting hand splint and right lower extremity ankle foot orthotic; 2. Resident #46 did not have a care plan with measurable goals and interventions to address contracture of the right hand; and 3. [...]

Inspectors wroteBased on observation, interview and record review conducted during the most recent re-certification survey and an abbreviated survey (#NY00248106), the facility did not ensure that the plan of care for each resident was evaluated when indicated to reflect each resident's current status and/or address the effectiveness of planned interventions. This was evident for 1 of 3 residents (Resident #27) reviewed for activities of daily living and 1 of 4 residents reviewed for nutrition (Resident #46).

Inspectors wroteBased on observation, interview and record review conducted during the most recent recertification survey and an abbreviated survey (#NY00248106), the facility did not ensure that 1 of 3 residents (Resident #27) reviewed for activities of daily living was provided appropriate care or services to prevent decline in ambulation. Specifically, after the resident completed rehabilitation services, the interdisciplinary team did not promptly 1) address with the resident the negative impact of not complying with planned interventions to promote ambulation. and 2) offer the resident other treatment options to maintain the resident's ambulation status.

Inspectors wroteBased on observations, interviews and record review conducted during the most recent recertification survey, it could not be ensured that the facility provided appropriate care to prevent the development of Pressure Ulcers (PUs) or Deep Tissue Injuries (DTIs) to 2 of 3 residents (Residents #89 and #196) reviewed for skin integrity. Specifically, 1) the facility did not ensure that ongoing interventions were established and implemented in accordance with Resident #89's clinical condition and risk factors to prevent the development of DTIs and 2) the facility did not ensure implementation of the use of heel booties at all times for Resident #196 to promote healing of DTIs and the prevention of wounds.

Inspectors wroteBased on observation, record review and interview conducted during the most recent recertification survey, the facility did not ensure that residents were provided the appropriate treatment and services to improve and/or prevent a further decline in range of motion (ROM). Specifically, 1) a resident did not have a right resting hand splint, and right lower extremity AFO applied as per the Physician's order; and 2) a resident with a right hand contracture was not provided a right resting hand splint as per occupational therapy recommendation. This was evident for 2 of 3 residents ( Residents #35 and #46) reviewed for positioning and limited mobility.

Inspectors wroteBased on interview and record review conducted during the most recent recertification survey and an abbreviated survey (#NY00248106), the facility did not ensure that 1 of 3 residents (Resident #27) reviewed for bowel and bladder incontinence was provided appropriate care or services to address a decline in bowel continence and to address occasional bladder incontinence.

Inspectors wroteBased on interview and record review conducted during the most recent recertification survey, the facility did not ensure that 1 resident (Resident #81) reviewed for respiratory care was provided appropriate care to maintain adequate respiratory functioning. Specifically, the physician did not specify parameters for the administration of oxygen with an order for it to be administered to up to 3 liters. Additional, the resident was routinely being administered oxygen with no routine monitoring of the resident's oxygen saturation levels.

Inspectors wroteBased on interview and record review conducted during the most recent recertification survey, the facility did not ensure that 1 resident reviewed for dialysis (#33) was provided the necessary care related to dialysis in accordance with professional standards of practice. Specifically, the resident's plan of care did not address the assessment of the resident before and after receiving dialysis and the nursing staff did not consistently conduct pre and post dialysis assessments of the resident.

Inspectors wroteBased on observation, interview and record review conducted during the most recent recertification survey, the facility did not ensure that the care provided for 2 of 3 residents (Residents #31 and #35) reviewed for position and mobility was accurately documented in the residents' medical record. Specifically, 1) the certified nursing assistant (CNA) inaccurately documented a resident that remained in bed (Resident #31) was transferred with extensive assist of 2 staff support; and 2) the nurse inaccurately documented a resident (Resident #35) who was not wearing physician prescribed positioning devices was wearing a right hand resting splint and an ankle foot orthotic (AFO).

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey, the facility did not ensure that nursing staff followed proper hand hygiene to prevent cross contamination and the spread of infection for 2 of 3 residents (Residents #194 and #196) reviewed for pressure ulcers (PU).

Inspectors wroteBased on interview and record review conducted during the most recent recertification survey, the facility did not ensure that written notice regarding the facility's bed-hold policy was provided to residents and their designated representatives. This was evident for 3 of 3 residents reviewed for hospitalization. (Resident #5, #81 and #195).