Highlands, the

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide food and drink at a safe and appetizing temperature for residents on Three (Unit Two, Unit Three and Unit Five) of Four units observed and for one Resident (#11) out of a total sample of 31 residents. Specifically, the facility failed to: 1. Ensure that residents on Unit Two, Unit Three and Unit Five received food that was served at safe and appetizing temperatures.2. Ensure that Resident #11's meal preferences were honored when the meals tickets identified the Residents' choices of meal.

Inspectors wroteBased on observations, record review, and interview, the facility failed to adhere to infection control practices and standards for two (Unit Two and Unit Five) out of four resident units and for one Resident (#69) out of a total sample of 31 residents, increasing the risk of contamination and spread of infection for residents in the facility. Specifically, the facility failed to:1. conduct testing of residents and staff for COVID-19 infections, every forty-eight hours as required, when Unit Two and Unit Five were experiencing an outbreak of COVID-19 infections.2. for Resident #69, ensure that staff wore the required Personal Protective Equipment (PPE: [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement a person-centered care plan relative to meal assistance for one Resident (#125) out of a total sample of 31 residents. Specifically, for Resident #125, the facility failed to implement care plan interventions of cutting up larger meal items to bite sized pieces, getting the Resident out of bed and in the dining room for meals, and staff supervision to eat as identified on Resident #125's person-centered care plan to address nutritional interventions for significant weight loss over a one-month period of time.

Inspectors wroteBased on observations, interviews and records review, the facility failed to provide necessary care and services to ensure that abilities in activities of daily living (ADL's) did not diminish for two Residents (#12 and #16), out of a total sample of 31 residents. Specifically,For Resident #12, the facility staff failed to assist Resident #12 with applying his/her hearing aid during ADL care when the Resident had documented hearing deficits and required assistance with personal care, resulting in Resident #12 being unable to hear and communicate with others as required. For Resident #16, the facility failed to initiate the Restorative Nursing Program timely for upper extremity strengthening to maintain and increase bilateral upper extremity strength and independence with Activities of Daily Living (ADL's) for the Resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate indwelling urinary catheter (also referred to as Foley catheter) care and services for one Resident (#10) of four applicable residents, out of a total sample of 31 residents. Specifically, for Resident #10, the facility failed to obtain Physician orders for the placement and size of an indwelling urinary catheter when the Resident had a functioning urinary catheter in place.

Inspectors wroteBased on record review, and interviews, the facility failed to ensure that laboratory services were completed as ordered for one Resident (#88) out of a total sample size of 31 residents. Specifically, for Resident #88, the facility failed to obtain laboratory testing as ordered by the Provider on 10/29/25, placing the Resident at risk for delayed assessment, management, and diagnosis of his/her medical symptoms based on the laboratory testing results. Findings Include:Review of the facility policy titled Laboratory Services dated 9/23/25 included but was not limited to the following: [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that medical records were complete and accurate for two Residents (#7 and #61), out of a total sample of 31 residents. Specifically,For Resident #7, the facility failed to ensure the Physician orders obtained on 11/18/25 for wound care treatment to the Resident's right lower extremity were transcribed into the Resident's medical record, resulting in the potential risk for the Resident's right lower extremity wounds to worsen or become infected without timely and appropriate treatment and monitoring. 2. For Resident #61, the facility failed to ensure that the use of a physical restraint device (Enclosed Walker) was documented as required to determine the Resident's response and provide ongoing evaluation of the use of the physical restraint.

Inspectors wroteBased on interview, policy and record review, the facility failed to provide services according to professional standards of practice relative to medication administration for two Residents (#51 and #13) out of a total sample of 31 residents. Specifically, the facility staff failed to: 1. Administer Pantoprazole Sodium (prescription medication used to treat heartburn [burning, stabbing, or squeezing sensation in the chest, nausea] and conditions caused by too much acid in the stomach) to Resident #51 when the Pantoprazole Sodium was ordered by the Physician, was available to be administered, and the Physician was not notified of the missed doses of Pantoprazole Sodium, which increased the Resident's risk for discomfort. 2. [...]

Inspectors wroteBased on interview, record and policy review, the facility failed to develop and implement a comprehensive person-centered care plan for one Resident (#29) out of a total sample size of 31 residents. Specifically, the facility staff failed to develop and implement timely a comprehensive person-centered care plan specific to required care and services for Resident #29 when the Resident was discharged from and then re-admitted to the facility.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide care and services according to professional standards for one Resident (#143) out of a total sample of 31 Residents, who had an indwelling urinary catheter (Foley Catheter/Foley - a tube placed through the urethra into the bladder to drain urine) and had been identified as being at risk for developing a urinary tract infection (UTI- an infection of the urinary system caused by bacteria entering the body through the urethra). Specifically, 1) The facility staff failed to change the indwelling urinary catheter according to professional standards of practice thereby increasing the risk of urinary infections for the Resident. 2) The facility staff failed to administer an antibiotic (medication that fights infection) to Resident #143 prior to changing an indwelling urinary catheter as ordered. Findings Include: [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain safe and sanitary conditions for two nourishment kitchens (Fifth Floor and Third Floor [Garden Terrace]) out of four applicable nourishment kitchens to prevent contamination and the spread of food borne infections. Specifically, 1. The facility failed to maintain the toaster in the Fifth Floor nourishment kitchen in a safe and sanitary manner. 2. The facility failed to maintain clean and sanitary conditions for the ice machine in the Third Floor nourishment kitchen.

Inspectors wroteBased on interview, record and policy review, the facility failed to offer Pneumococcal Vaccinations for one Resident (#51), out of five applicable Residents, out of a total sample of 31 residents, putting the Resident at risk for developing facility acquired Pneumonia. Specifically, the facility failed to ensure that Pneumococcal Vaccination was provided to Resident #51 after obtaining consent from the Resident's Representative.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect the Resident's status for one Resident (#162) out of three applicable residents. Specifically, the MDS failed to accurately reflect that Resident #162 was discharged home.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure that its staff notified the Physician regarding a change in the treatment plan for one Resident (#70), out of a total sample of 28 residents. Specifically, the facility staff failed to notify Resident #70's Physician when dialysis treatment was not administered as ordered.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure that its staff provided care and services consistent with professional standards for one Resident (#70), who required renal dialysis (a procedure to remove waste products and excess fluid from the body when the kidneys stop working properly) out of one applicable resident, in a total sample of 28 residents. Specifically, the facility staff failed to: 1) evaluate the resident pre and post dialysis treatment, 2) communicate and maintain ongoing documentation with the dialysis center, 3) ensure that the dialysis center received the most current information regarding Physician's orders for the Resident, and 4) maintain documentation regarding the Resident's weight per the plan of care.

Inspectors wroteBased on observation, policy review, record review and interview, the facility failed to ensure its staff assessed two Residents (#43 and #35) for the risk of entrapment related to bed rail use. Specifically, 1) for Resident #43 the facility failed to ensure its staff assessed the Resident for risk of entrapment related to bed rail use prior to the installation of bed rails and quarterly thereafter, and 2) for Resident #35 the facility failed to ensure its staff assessed the Resident for risk of entrapment related to bed rail use after a significant change in weight.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure its staff adhered to safe food practices relative to labeling/dating, and storage guidelines in order to reduce the risk of cross contamination/spoilage of food items for resident consumption in the main facility kitchen.