Highland Square Nursing and Rehabilitation

Inspectors wroteBased on medical record review, review of a facility Self-Reported Incident (SRI), review of a facility investigation, review of text messages, review of a police report, review of the facility abuse policy, and interview, the facility failed to protect Resident #50's right to be free from sexual abuse by Housekeeper (HK) #208. This resulted in Immediate Jeopardy and the potential for actual physical and psychosocial harm beginning on 08/15/25 when Housekeeper (HK) #208 sent his picture and inappropriate text messages to Resident #50's phone asking for sexual favors to Resident #50 and then subsequently had the resident perform oral sex on him on two occasions, with evidence the resident performed the act out of fear. The facility failed to recognize the staff to resident sexual contact as abuse and failed to properly follow up with police regarding the incident. [...]

Inspectors wroteBased on observations, interview, and review of the facility policy, the facility failed to provide a clean, sanitary and well maintained environment. This affected eight residents (Resident #7, #27, #36, #37, #39, #44, #46 and #63) but had the potential to affect all residents. The facility census was 64.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure residents attended physician ordered follow-up appointments status-post hospitalization and failed to ensure treatment orders were written for wound care. This affected one resident (Resident #65) of three residents reviewed for appointments and one resident (Resident #49) of four residents reviewed for wound care. The facility census was 64.

Inspectors wroteBased on closed record review and interview the facility failed to ensure adequate follow-up regarding optometry services. This affected one resident (#65) of three residents reviewed for ancillary services. The facility census was 64.

Inspectors wroteBased on record review, observation, staff interview and policy review the facility failed to ensure infection control guidelines were followed during incontinence care for Resident #7. This affected one resident (Resident #7) of three residents reviewed for activities of daily living. The facility census was 64.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed record review, review of the facility's investigation, review of facility timeline, review of emergency medical services (EMS) run report, staff interview, and policy review, the facility failed to provide basic life support (BLS), including Cardiopulmonary resuscitation (CPR) to Resident #61 per the resident's advance directive, when the resident was found unresponsive on the toilet. This resulted in Immediate Jeopardy and serious life-threatening harm and the subsequent of death of Resident #61 beginning on [DATE] when Certified Nursing Assistant (CNA) staff alerted Licensed Practical Nurse (LPN) #341 who assessed Resident #61 and found the resident to be unresponsive. [...]

Inspectors wroteBased on observation of camera footage, interview, record review, and policy review the facility failed to ensure staff members remained awake and alert while on duty to prevent the potential for resident neglect. This had the potential to affect 39 residents (#14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #45, #46, #57, #48, 49, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69) of 39 residents the facility identified as residing on the second and third floors. The facility census was 68.

Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure beard restraints covered the beard to prevent hair from contacting the food and failed to use sanitary methods when handling food items. This had the potential to affect 56 of 59 residents as three residents (Residents #51, #106, and #110) received no food by mouth (NPO). The facility census was 59.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Resident #43's received treatment and comprehensive care to ensure leg braces were in place. This affected one resident (Resident #43) of two residents reviewed for leg braces. The facility census was 59.

Inspectors wroteBased on review of the medical record and interview with the staff the facility failed to ensure Resident #5 received his medication as ordered by the physician. This affected one resident (Resident #5) of three reviewed for mediation administration. The facility census was 58.

Inspectors wroteBased on review of the medical record, review of therapy notes, and interview with staff the facility failed to provide therapy services to Resident #5 after he won his appeal. This affected one resident ( Resident #5) of three reviewed for therapy services. The facility census was 58. Findings Included: Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses included diabetes, pain in leg, psychoactive substance abuse, asthma, and muscle weakness. Review of the physician's orders revealed Resident #5 had orders for physical therapy (PT) to evaluate and treat four times a week for four weeks and occupational therapy (OT)would evaluate and treat four times a week for four weeks dated 07/08/24. [...]

Inspectors wroteBased on observation, staff interview and facility policy review the facility failed to maintain the kitchen in a clean and sanitary manner. This affected 57 of 57 residents who received meals from the kitchen. The facility identified one resident (#36) who received nothing by mouth. The facility census was 58.

Inspectors wroteBased on observation, interview with staff and review of the facility policy, the facility failed to implement the smoking policy to maintain a safe and clean environment free from discarded cigarette butts at the facility's side entrance door and the resident smoking area. This had the potential to affect all the residents in the facility. The facility census was 58.

Inspectors wroteBased on record review and interview the facility failed to ensure a palliative care consult was arranged for Resident #24 to address the resident's chronic pain. This affected one resident (#24) of three residents reviewed for pain management. The facility census was 58.

Inspectors wroteBased on record review and interviews, the facility failed to ensure pain medications were available and administered as ordered by the physician. This affected one (Resident #5) of three residents reviewed for pain management. The facility census was 57.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of the facility assessment, visitation policy, substance use disorder program contract and interview, the facility failed to properly identify potential risks/hazards for residents with a substance use disorder and provide adequate supervision and/or supervised visitation to prevent intentional/unintentional drug overdoses for residents in the facility. This resulted in Immediate Jeopardy and actual harm on [DATE] when Resident #44 who had known substance abuse history was found unresponsive and required cardiopulmonary resuscitation (CPR) and hospitalization after a Fentanyl and Methadone overdose. [...]

Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to provide a phone in a private area where calls could be made without being overheard. This affected 47 residents (Residents #25, #11, #23, #40, #49, #45, #69, #53, #8, #3, #72, #52, #47, #2, #44, #63, #54, #57, #22, #55, #58, #19, #28, #33, #6, #66, #64, #27, #48, #31, #26, #32, #51, #16, #30, #35, #56, #69, #36, #61, #15, #29, #24, #14, #7, #62 and #10) who resided on the second and third floor units. The census was 74.

Inspectors wroteBased on medical record review, Self-Reported Incident (SRI) review, employee warning notice review, policy review and interview, the facility failed to ensure Resident #38 was free from staff-to-resident abuse. This affected one (Resident #38) of three residents reviewed for abuse. The census was 74.

Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to provide care and services to ensure the safety of Resident #33 who had a diagnosis of dementia. This affected one (Resident #33) of three residents reviewed for dementia. The census was 74.

Inspectors wroteBased on observation, medical record review, review of a local police and missing persons' report, resident, family and legal guardian interview, staff interviews, local police detective interview, review of the National Weather Forecast, and review of the facility Elopement Policy and Procedure, the facility failed to provide adequate supervision to prevent Resident #71, who had a diagnosis of vascular dementia with moderate cognitive impairment from leaving the facility without staff knowledge. This resulted in Immediate Jeopardy and the potential for serious harm, injury, death on [DATE] at 7:35 P.M. when Resident #71 exited the facility through a supervised smoking area door without staff knowledge. At 9:30 P.M. Licensed Practical Nurse (LPN) #309 noted Resident #71 was not in his room during medication pass. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure all residents and their guardians were provided the opportunity to choose a physician prior to their attending physician leaving the facility. This affected two residents (#8 and #24) of 14 residents reviewed for choice of physician. The facility census was 72.

Inspectors wroteBased on record review, and resident and staff interview, the facility failed to ensure a resident was afforded the right manage their financial affairs as requested. This affected one resident (Resident #29) of two residents reviewed for finances. The facility census was 72. Findings Include: Review of the medical record for Resident #29 revealed an admission date of 8/18/23. Diagnoses included osteoarthritis of the left knee, alcohol abuse, anxiety, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] under section C revealed Resident #29 had a brief interview for mental status score of 15 indicating no cognitive impairment. Review of the face sheet for Resident #29 was his own responsible party and managed his own medical and financial affairs. [...]

Inspectors wroteBased on interview, record review, and facility Self-Reported Incident (SRI) review, the facility failed to ensure all allegations of sexual abuse and potential neglect were reported to the proper officials. This affected two residents (Resident #37 and #71) of three residents reviewed for abuse, neglect, exploitation, or mistreatment.

Inspectors wroteBased on interview, record review, and facility Self-Reported Incident (SRI) Review, the facility failed to thoroughly investigate an allegation of staff to resident sexual abuse towards Resident #37. This affected one resident (#37) of three residents reviewed for abuse, neglect, exploitation, or mistreatment.

Inspectors wroteBased on interview and record review the facility failed to ensure staff provided care and services that met professional standards. This affected one resident (#37) of three residents reviewed for abuse, neglect, exploitation, and mistreatment.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed record review, review of a facility Self-Reported Incident (SRI), review of a Police Report, review of the facility Elopement Policy and Procedure, and interviews, the facility failed to provide adequate supervision and failed to respond and act appropriately when Resident #70, who was cognitively impaired, demonstrated exit seeking behaviors, and was ordered to wear a wander guard (a bracelet integrated with a security system to alert caregivers when residents have wandered from a protected zone), eloped from the facility. This resulted in Immediate Jeopardy and the potential for actual harm, injury, or death on [DATE] at approximately 7:28 A.M. when Resident #70 left the facility via an exit door without the knowledge of staff. [...]

Inspectors wroteBased on record review, review of the facility Self-Reported Incident (SRI), review of the facility investigation, and interview the facility failed to ensure Resident #70's medical record was accurate and completed to reflect incidents. This affected one resident (#70) of three residents reviewed for medical record accuracy. The facility census was 65.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure residents rooms and restrooms were maintained in a clean, comfortable, and homelike environment. This affected one resident (#39) of three residents reviewed for homelike environment. The facility census was 65.

Inspectors wroteBased on observation, medical record review, review of facility policy, and interview, the facility failed to implement physician orders, care-planned interventions and professional standards of practice to promote healing of a Stage 3 pressure ulcer to Resident #52's heel. This affected one (Resident #52) of three residents reviewed for pressure ulcers. The census was 74.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of facility self-reported incident (SRI), facility investigation, facility policy review, and interview, the facility failed to ensure a resident was free from misappropriation of medications. This affected one resident (#74) of three residents reviewed for misappropriation.

Inspectors wroteBased on record review and interview, the facility failed to safeguard Resident #69's personal funds to ensure funds were only dispersed for Resident #69. This finding affected one (Resident #69) of three residents reviewed for personal funds.

Inspectors wroteBased on record review and interview, the facility failed to ensure only non-covered items and services from Resident #69 were paid from the resident's personal funds account. This finding affected one (Resident #69) of three residents reviewed for personal funds accounts.

Inspectors wroteBased on record review and interview, the facility failed to ensure Residents #27 and Resident #70 were free from sexual abuse. This finding affected two (Residents #27 and #70) of three residents investigated for abuse.

Inspectors wroteBased on record review and interview, the facility failed to ensure all staff reported an allegation of sexual abuse immediately and then reported the allegation to the State agency timely. This finding affected one (Resident #27) of three residents investigated for abuse.

Inspectors wroteBased on observation, interview, and facility policy review the facility failed to ensure kitchen staff wore hair restraints, food items were properly stored and labeled, refrigerator temperatures were monitored, the kitchen was maintained in a clean and sanitary manner to prevent contamination and/or food borne illness. This had the potential to affect 66 of 66 residents who received meals from the kitchen. The facility identified two residents (#5 and #54) who received nothing by mouth. The facility census was 68.

Inspectors wroteBased on observation, interview, record review, facility policy review, review of guidelines from the Centers for Disease Control and Prevention the facility failed to maintain clean fans in the clean linen areas of the laundry rooms, failed to ensure proper use of Personal Protective Equipment (PPE) by staff in a transmission based precaution room for Resident #23 and throughout the facility and failed to ensure staff practiced proper hand hygiene during medication administration and food service for Residents #7, #29, #46, #50 and #220. This affected six residents (#7, #23, #29, #46, #50 and #220) and had the potential to affect all 68 residents residing currently residing in the facility.

Inspectors wroteBased on medical record review, interview, and review of facility policy, the facility failed to notify the State Long Term Care Ombudsman of the transfer and discharge for Resident #68 and failed to provide written notification of transfer and discharge and bed-hold policy to Resident #68's representative. This affected one of one residents reviewed for hospitalization. The facility census was 68.

Inspectors wroteBased on record review, interview and facility policy review the facility failed to submit Minimum Data Set 3.0 assessments timely. This affected two residents (Resident #1 and #2) of three reviewed (Resident #1, #2, and #3). The facility census was 68.

Inspectors wroteBased on medical record review, interview and review of facility policy the facility failed to develop a comprehensive person-centered care plan timely after admission. This affected one resident (Resident #316) of seven residents (Residents #1, #18, #26, #49, #51, #67 and #316) reviewed. The facility census was 68.

Inspectors wroteBased on record review and staff interview the facility failed to timely revise care plans following a change in resident status and failed to provide care conferences as required. This affected three (Residents #24, Resident #26 and #49) of eight residents (Residents #1, #18, #24, #26, #49, #51, #67, and #316) reviewed for care plans. The facility census was 68.

Inspectors wroteBased on observation, record review, interview the facility failed to ensure Resident #59 kept all smoking materials at the nurses' station as assessed and care planned. This affected one (Resident #59) of four residents (Resident #39, Resident #44, Resident #55 and Resident #59) reviewed for smoking.

Inspectors wroteBased on record review, interview, and policy review the facility failed to ensure residents' monthly weights were consistently obtained for adequate monitoring of resident nutritional status. This affected three (Residents #26, #49 and #51) of seven residents (Resident #1, #18, #26, #49, #51, #67, and #316) reviewed for nutrition. 1. Resident #26's medical record revealed an admission date of 04/06/20 and diagnoses of chronic obstructive pulmonary disease, vascular dementia with behavioral disturbance, epilepsy, and stage III kidney disease. Review of Resident #26's physician orders dated 04/20/22 revealed to obtain weights monthly. Review of Resident #26's weights revealed a weight of 202.5 pounds (#) on 11/05/21, 204# on 12/27/21, 204.4# on 01/03/22, 197.6# on 02/02/22, and 188.5# on 04/12/22. There was no weight recorded for March or May of 2022. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the dietary department had adequate staffing to carry out dietary services. This had the potential to affect all 91 residents residing in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure food was stored and prepared under sanitary conditions. This had the potential to affect all 91 residents who were served meals prepared in the facility kitchen.

Inspectors wroteBased on observation and interview, the facility failed to ensure the food delivery system was working properly in order to assure hot food temperatures were maintained during meal service. This had the potential to affect all 91 residents receiving meals served from the facility kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement care plans for Resident #63 for a palm enabler, Resident #53 for anticoagulant use, and for Resident #57 for sleep apnea. This affected three of 19 residents reviewed for the development and implementation of care plans. The facility census was 91.

Inspectors wroteBased on record review and interview the facility failed to revise the plan of care for Resident #8 for activities of daily living (ADL) and for Resident #38 for dialysis and nutritional needs, and failed to include Resident #79's son during the plan of care meetings. This affected two (Residents #8 and #38) of 29 resident (#5, #7, #8, #22, #28, #29, #30, #34, #38, #47, #49, #51, #52, #53, #54, #57, #59, #62, #63, #67, #69, #71, #75, #79, #87, #88, #89, #91, and #290 ) were reviewed for care plans, and one (Resident #79) of three residents (#18, #71, #79) reviewed for participation in care plan meetings.

Inspectors wroteBased on observation and interview, the facility failed to ensure there was adequate staffing to provide for the direct care needs of the residents. This affected 26 (Residents #4, #5, #12, #18, #22, #28, #30, #31, #34, #37, #38, #47, #49, #53, #54, #56, #57, #63, #69, #71, #72, #73, #75, #83, #95, and #29) residents, and had the potential to affect the remaining 65 residents. The facility census was 91 residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure medications stored in the medication room and the first floor medication cart were not expired. This affected three (Residents #37, #43, and #72), and had the potential to affect all 91 facility residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure privacy during incontinence care for Resident #59. This affected one resident of 19 sampled residents. The facility census was 91.

Inspectors wroteBased on observation and interview, the facility failed to maintain resident rooms in good repair for Residents #28, #38, and #75. This affected three of 19 sampled residents whose rooms were observed. The facility census was 91.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure an accurate comprehensive was completed for Resident #7. This affected one of 29 (#5, #7, #8, #22, #28, #29, #30, #34, #38, #47, #49, #51, #52, #53, #54, #57, #59, #62, #63, #67, #69, #71, #75, #79, #87, #88, #89, #91, #290 ) residents who were reviewed for comprehensive assessments.

Inspectors wroteBased on record review and interview the facility failed to provide interventions for decline in eating ability for Resident #8. This affected one (Resident #8) of five residents reviewed for activities of daily living. The facility census was 91.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure adequate supervision for Resident #59 to prevent falls. This affected one of two residents reviewed for accidents.

Inspectors wroteBased on observation, interview, and review of the facility policy and procedure, the facility failed to ensure infection control standards were followed during incontinence care and wound care. This affected one (Residents #22) of two residents reviewed for wound care and one (Resident #59) resident observed for incontinence care. The facility census was 91 residents.