Highlands Nursing and Rehabilitation

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure that three of three residents reviewed for medications (Residents (R) 5, R126, and R135) were free from significant medication errors. Facility staff failed to follow physician orders and administered blood pressure medications outside of ordered parameters. These errors are considered significant because these medications are critical in preventing life=threatening complications by managing blood pressure.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to provide a safe, clean, comfortable, and homelike environment. Necessary Maintenance and Housekeeping was not provided in order to maintain a sanitary, orderly, and comfortable interior. Observation during tour of the building on 02/24/2025 revealed the following: There was a foul odor that smelled of stale urine noted throughout the 1C Unit hallway. The bathroom for room [ROOM NUMBER] had the appearance of dried urine on the floor and the room smelled liked strong stale urine. Additionally, the baseboard surrounding the sink in room [ROOM NUMBER] was pulled away from the sink and pulled away from the section of wall adjacent to the sink. The bathroom for room [ROOM NUMBER] had paint peeling off the wall around the plumbing, ceiling tile was sagging and there was a large water stain on the ceiling tile. [...]

Inspectors wroteBased on personnel files, facility policies, Kentucky regulation KRS 216.789 (1), and KRS 216.718 (4), the facility failed to ensure it did not employ or otherwise engage individuals with a disqualifying criminal conviction or finding in the State Nurse Aide Abuse Registry for three of 10 employee files reviewed. Review of the Cook's background check, Statewide Criminal Repository, revealed a Felony Burglary, 3rd degree with a Guilty disposition on 06/02/2016. Additionally, there was no documented evidence Nurse Aide (NA) Abuse Registry checks were completed for the Cook, Business Office Manager, or Administrative Assistant, prior to employment.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to send a copy of the notice of transfer to a representative of the Office of the State Long-Term Care Ombudsman for 3 of 3 sampled residents investigated for hospitalizations out of a total sample of 29 residents, Resident (R)23, R95, and R107.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to implement the Comprehensive Care Plan (CCP) for 1 of 29 residents reviewed for care planning, Resident (R)141. On 01/15/2025, a care plan intervention for a perimeter mattress was added to R141's CCP due to the resident sustaining a fall from bed on the same date. Although the resident sustained another fall from bed on 01/19/2025, the intervention for the perimeter mattress was not implemented until 02/28/2025, during survey.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 7 sampled residents reviewed for falls, out of a total sample of 29 residents, Resident (R)141. R141 sustained a fall on 01/15/2025 and was found lying on the floor by her bed. The Interdisciplinary Team (IDT) decided a perimeter mattress should be placed on the bed to prevent further falls, on 01/16/2025. However, the perimeter mattress was not placed on the bed, and the resident sustained another fall on 01/19/2025, when she was again found on the floor lying beside her bed. The perimeter mattress was not placed on the bed until 02/28/2025, during the Survey.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to assist residents in obtaining routine dental care for 2 of 7 sampled residents reviewed for dental care out of a total sample of 29 residents, Residents (R) 87 and R95.

Inspectors wroteBased on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, and review of the facility's policies, the facility failed to establish and 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 of 3 sampled residents reviewed with urinary catheters on Enhanced Barrier Precautions (EBP) out of a total sample of 29 residents, Resident (R) 75. Observation on 02/26/2025 at 2:59PM, revealed Licensed Practical Nurse (LPN)1 touched R75's privacy curtain and sink faucet handles while wearing gloves. She then failed to perform hand hygiene and don new gloves prior to performing suprapubic catheter care.

Inspectors wroteBased on interview, record review and review of the facility's policy, the facility failed to develop a baseline care plan for one (1) of three (3) residents sampled related to elopement (Resident #642). Upon admission, the facility assessed Resident #642 as a high risk for wandering/elopement. However, the facility failed to care plan the resident for his/her high risk for wandering/elopement. Resident #642 exited through the front door and left the faciity on [DATE]. Resident #642 returned to his/her home located eighty-five (85) miles away. Resident #642 did not return to the facility. Immediate Jeopardy (IJ) was identified on 03/12/2024 and was determined to exist on 01/07/2023 in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F 655; and 42 CFR 483.25 Quality of Care, F689 at a Scope and Severity (S/S) of an J. [...]

Inspectors wroteBased on observation, interview, record review, review of facility policy, and Internet Google Maps, the facility failed to ensure all residents were in a safe and supervised environment to prevent elopement for one (1) of three (3) residents sampled for elopement (Resident #642). The facility admitted Resident #642 on 01/05/2023 and he/she eloped from the facility on 01/07/2023 and did not return. The resident exited out the facility's front door when the receptionist, not knowing he/she was a resident, opened the door to let him/her out. Resident #642 was located 85 miles away from the facility. The facility failed to increase the resident's supervision to promote his/her safety, after learning the resident was at high risk for elopement. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility policies, the facility failed to ensure residents were: informed of their rights to conduct resident council meetings without staff present; and that visitors and/or other guests might attend resident council meetings only at the respective group's invitation. The facility failed to address and follow-up with Resident Council grievances, and further communicate the results to residents for seven (7) out of eight (8) sampled residents attending Resident Council meetings (Residents #5, #49, #55, #71, #101, #119, and #128).

Inspectors wroteBased on observation, interview, review of the facility's policy, and review of the manufacturer's drug package insert, the facility failed to ensure all drugs and biological agents were properly labeled and stored in accordance with current accepted professional principles. Observation of the Unit 1B storage room revealed one (1) vial of Tuberculin (TB) Purified Protein Derivative five (5) milliliters (ml) with an open date of 02/12/2024 that had not been discarded after thirty (30) days per facility policy. Additionally, a pink jacket and pink polka dotted bag were observed on the counter on top of the pharmacy medication return tote.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to ensure the call system was accessible to residents while in their bed, chair or other sleeping accommodations for two (2) of seventy-five (75) sampled residents (Resident #22 and Resident #76). Observation on 03/21/2024 revealed Resident #22's and Resident #76's call lights were attached to the wall behind the head of their beds, out of their reach.