Highline Post Acute

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents were free from any significant medication errors, affecting one (#1) of three residents out of 10 sample residents. Specifically, the facility failed to provide Resident #1 with the physician-prescribed medication for human immune deficiency virus (HIV) disease. Resident #1 was admitted to the facility on [DATE] with a physician's order to receive the HIV medication Biktarvy. Biktarvy consists of three components, bictegravir, emtricitabine & tenofovir alafenamide (tenofovir). On [DATE], the nurse who admitted Resident #1 transcribed the Biktarvy order as tenofovir alafenamide only. The nurse did not recall why the order was changed, and there was no evidence that the pharmacist or the medical director reviewed the order before it was changed. [...]

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure an environment free of accident hazards for two (#1 and #19) of nine residents reviewed for accident hazards out of 21 sample residents. On 5/18/25 Resident #1 requested certified nurse aide (CNA) #1 to heat up an egg roll from his personal refrigerator in a microwave that was at the nurses' station. After heating up the egg roll, CNA #1 gave the egg roll to Resident #1, without using a thermometer to check the temperature of the egg roll, and told the resident not to touch the egg roll because it was very hot. However, Resident #1 immediately picked up the egg roll after CNA #1 gave it to him. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#10) of three residents reviewed for falls out of 10 sample residents received adequate supervision and services to prevent an accident. Specifically, the facility failed to: -Ensure a root cause was identified for Resident #10's fall on 3/16/25; and, -Ensure Resident #10's care plan was reviewed for appropriate fall interventions after a fall.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that one (#1) of eight residents out of 16 sample residents remained as free from accidents as possible. Resident #1, severely cognitively impaired and with a history of elopement on 6/8/24 and frequent exit-seeking behaviors in January 2025 and February 2025, left the facility without staff knowledge on 2/5/25 between 9:30 p.m. and 10:30 p.m. He was not located until approximately 8:00 a.m. the next day. The facility's failures in responding to his elopements created a reasonable expectation, absent immediate correction, that an adverse outcome resulting in serious harm, impairment, or death would occur. Record review revealed that on 6/8/24, Resident #1 eloped from the facility and was found across the street later that day. On 6/11/24, the resident was evaluated as being at risk for future elopement. [...]

Inspectors wroteBased on record review and interviews, the facility failed to have a written transfer agreement with one or more hospitals approved for participation under Medicare and Medicaid programs to reasonably ensure residents would be transferred from the facility to a hospital, and assured of timely admission to the hospital when transfer was medically appropriate. Specifically, the facility failed to ensure a written agreement was in effect with one local area hospital.

Inspectors wroteBased on record review and interviews, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented in order to facilitate improvement in the lives of nursing home residents through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance and performance improvement (QAPI) program committee failed to identify and address concerns related to accidents and safety of residents, which rose to the level of immediate jeopardy and created a situation that a serious adverse outcome was likely.

Inspectors wroteBased on interviews and record review, the facility failed to ensure they had activities to meet the needs and preferences of the residents for three (#6, #4 and #2) of five residents reviewed for activities out of 16 sample residents. Specifically, the facility failed to meet the socialization and activity needs for Residents #6, #4 and #2.

Inspectors wroteBased on interviews and record review, the facility failed to protect and keep residents safe from physical abuse by a facility employee for one (#1) of three residents reviewed for alleged physical abuse by a facility employee of eight sample residents. On 8/18/24 Resident #1 was physically assaulted by a nonclinical employee of the facility. The facility failed to protect Resident #1 from being physically abused by a facility employee. The incident occurred in an outside smoking patio and was caught on the facility's video surveillance. The assault began following the initiation of an argument where the staff was asking the resident to pay him back and the resident and staff began to argue. As the argument continued the facility employee punched the resident in the head and face with so much force that the resident fell out of his manual wheelchair. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure a phone was consistently available and functional for resident use on two of two units. Specifically, the facility failed to consistently provide operational phones for residents to use from their rooms or other private areas and relay messages left for residents.

Inspectors wroteBased on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for five of five certified nurse aides (CNA). Specifically, the facility failed to complete annual performance reviews for CNA #1, CNA #2, CNA #5, CNA #6 and CNA #7 in order to determine potential training needs.

Inspectors wroteBased on observations and interviews, the facility failed to provide food and drinks that accommodate resident allergies, intolerances and preferences for residents in one of two dining rooms and for one (#63) of four residents reviewed for preferences out of 46 sample residents. Specifically, the facility failed to: -Ensure residents in the secured unit were offered drinks of choice at meal time; and, -Ensure Resident #63 received the meal items that he ordered.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the kitchen. Specifically, the facility failed to: -Ensure ready-to-eat foods were handled in a sanitary manner to prevent cross contamination; -Ensure safe and appropriate storage of food items in the refrigerators and pantry; and, -Ensure safe holding temperatures for food items were maintained.

Inspectors wroteBased on record review and interviews, the facility failed to ensure five (#1, #2, #5, #6 and #7) of five certified nurse aides (CNA) received the required 12 hours of annual in-service training for continued competence. Specifically, the facility failed to ensure five CNAs (#1, #2, #5, #6 and #7) received 12 hours of annual training.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#2) of three residents out of 46 sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to ensure Resident #2's insulin (medication used for blood glucose) was consistently administered in a timely manner per the physician's orders.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services for two (#23 and #46) of four residents reviewed for ADLs out of 46 sample residents. Specifically, the facility failed to: -Ensure Resident #23 and Resident #46 received timely repositioning and toileting/incontinence care; and, -Ensure Resident #23 received proper assistance with meals, snacks and hydration.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure one (#24) of two residents with limited mobility reviewed for range of motion (ROM) out of 46 sample residents received appropriate treatment and services to increase range of motion and.or to prevent further decrease in range of motion. Specifically, the facility failed to ensure Resident #24 was provided with a restorative nursing program as was recommended by the director of rehabilitation (DOR).

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide necessary respiratory care and services consistent with professional standards of practice and the comprehensive person-centered care plan for two (#19 and #24) of three residents reviewed for respiratory care out of 46 sample residents. Specifically, the facility failed to ensure Resident #19 and #24 received oxygen therapy in accordance with their physician's orders.

Inspectors wroteBased on observations and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly according to professional standards in two of three medication carts and one of two medication storage rooms. Specifically the facility failed to: -Ensure medications were properly labeled with resident names; -Ensure medications were stored according to route of administration; -Ensure food was not stored with medications; and, -Ensure medications were not stored in a dormitory style.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents received food and fluids prepared in a form designed to meet his or her needs. Specifically, the facility failed to ensure residents who were prescribed mechanically altered diets had food prepared according to their diet orders of puree, level five minced and moist and level six soft and bite sized as indicated on their meal tray cards.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to ensure staff followed proper infection control procedures for a resident on enhanced barrier precautions (EBP).

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain the emergency response carts and equipment in safe operating condition for five of five emergency response (crash) carts. Specifically, the facility failed to: -Ensure equipment was checked on a regular basis to ensure it was in proper working condition; -Ensure crash carts contained backboards and they were properly maintained and ready for use; and, -Ensure each crash cart contained a blood pressure cuff and stethoscope that was properly maintained and ready for use.

Inspectors wroteBased on observation, record review and interviews, the facility failed to provide services in accordance with currently accepted professional principles for two (#11 and #3) of five residents reviewed for wound care management out of 13 sample residents. Resident #11 was admitted to the facility on [DATE] for long term care. She did not have any skin injuries prior to December 2023. Between 12/20/23 and 12/27/23, Resident #11 developed several traumatic injuries, including a blister on her left calf. The origin of the blister was not communicated to the management team and not investigated. Resident #11 was being followed by a wound care physician with routine treatments for wounds on her hands. On 12/29/23 the deterioration of the left calf wound (blister) was mentioned in the progress notes without any evidence of communication to the wound care physician. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure snacks were offered and were easily available for residents on two of four units in the facility. Specifically, snacks were not available on the Cherry Creek and Union units. I. Resident interviews Resident #4 was interviewed on 1/8/24 at 11:30 a.m. She said snacks were never offered by staff and she relied on her family and friends to bring snacks. Resident #6 was interviewed on 1/8/24 at 12:01 p.m. She said staff did not offer the snacks and she did not see snacks available at the nurses station. Resident #7 was interviewed on 1/8/24 at 12:15 p.m. She said staff did not offer snacks and she relied on her own snacks that she kept in her room. Resident #3 was interviewed on 1/9/23 at 1:34 p.m. She said snacks were not always available. [...]

Inspectors wroteBased on record review and interviews, the facility failed to allow residents the right to make choices about aspects of his or her life in the facility that were significant to the resident for three (#1, #10 and #4) of five residents reviewed for preferences out of 13 sample residents. Specifically, the facility failed to: -Accommodate shower preferences for Residents #4 and #10; -Consistently provide oral care according to her preference to Resident #10; and, -Assist Resident #1 to the recliner daily and trim his nails according to his preferences.

Inspectors wroteBased on record review and interviews, the facility failed to assist residents in making transportation arrangements to and from the source of service for one (#10) of five residents reviewed for transportation out of 13 sample residents. Specifically, the facility failed to assist Resident #10 with scheduling transportation for a urology follow up appointment

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection for one (#3) of three residents out of 13 sample residents. Specifically, the facility failed to ensure: -Licensed practical nurse (LPN) #1 followed enhanced barrier precautions during wound care for Resident #3; and, -Certified nurse aide (CNA) #5 donned appropriate personal protective equipment (PPE) when providing direct care to Resident #3.

Inspectors wroteBased on observations and interviews, the facility failed to provide a safe, functional and comfortable environment for residents, staff and the public on one of four units. Specifically, the facility failed to ensure mechanical transfer lifts were not stored in the hallways.

Inspectors wroteBased on observation and interview, the facility failed to dispose of garbage and refuse properly for 4 of 4 dumpsters. Observations of the dumpsters revealed the lids were not secured leaving them uncovered.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure activities of daily living (ADL) care was provided to maintain good grooming for 1 (Resident #94) of 4 residents who were reviewed for ADL care.

Inspectors wroteBased on observations, interviews, record review, and review of facility procedure, the facility failed to provide care and treatment to prevent skin integrity problems for 1 (Resident #53) of 3 residents reviewed for incontinence care. Observations revealed staff failed to adequately clean Resident #53 after the resident was incontinent of bowel.

Inspectors wroteBased on observations and staff interview, the facility failed to employ sufficient dietary support to carry out the functions of the food and nutrition services department in one of one facility production kitchen. Specifically, insufficient numbers of adequately trained food and nutrition staff contributed to prolonged wait times for meals and overall decreased resident satisfaction with dining services.

Inspectors wroteBased on observation and staff interview, and record review, the facility failed to ensure a safe, clean, and sanitary kitchen. Specifically, the facility failed to ensure sanitary conditions were maintained in the kitchen.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that services were provided by individuals who had the skills, experience, and knowledge to do a particular task or activity for one (#78) of one of the 37 total sampled residents. Specifically, the facility failed to have a qualified staff provide colostomy care for Resident #78

Inspectors wroteBased on observation, record review and interviews the facility failed to ensure that three ( #27, and #36 ) out of three residents reviewed for assistance with activities of daily living (ADL) received appropriate treatment and service to maintain or improve his or her abilities. Specifically: --The facility failed to ensure cueing and encouragement during meals.

Inspectors wroteBased on observation and interviews, the facility failed to provide a safe environment and as free from accident hazards as possible for 18 out of 79 occupied residents rooms. Specifically, the facility failed to ensure medical devices were not plugged into non-medical grade power strips.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure menus met the needs of residents and were followed during meal service. Specifically, the facility failed to ensure menus were followed, menu items were not omitted without substitutions being made.