The Highlands Guest Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen must be free from unnecessary drugs used without adequate indications for its use for 1 of 3 Residents (Resident #1) whose records were reviewed for unnecessary drugs Nursing staff failed to obtain a consent from Resident #1's RP for the use of divalproex (psychotropic medication used for anxiety). This failure could place residents at risk of the use of unnecessary medications. Findings inlcuded: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food prepared that conserved nutritive value, flavor, and appearance for one of one kitchen, reviewed for nutritive value, in that:Cook A did not follow the recipe for the pureed (cooked food, usually vegetables, fruits, or legumes, that has been ground, pressed, blended, or sieved to the consistency of a creamy paste or liquid) BBQ Brisket served for lunch service on 07/14/26. This failure could place residents at risk of weight loss, altered nutritional status, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 5 residents (Resident #1) reviewed for care plan development. The facility failed to ensure Resident #1's comprehensive care plan included a plan of care for ADLs. This failure could place residents at risk of not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents' right to be treated with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 6 residents (Resident #38) reviewed for respect and dignity in that: The facility failed to ensure RN A provided privacy by leaving the door open and not pulling privacy curtain, exposing Resident #38's abdomen while administering the medications through gastroenterology tube (feeding tube). This failure could place residents at risk of emotional distress and low self-esteem.

Inspectors wroteBased on observation, interview, and record review the facility failed to post the daily nurse staffing information with the current date, resident census, and numbers of staff actual hours worked at the beginning of each shift for 1 of 1 facility reviewed for nurse staffing. The facility failed to update and post the daily nurse staffing information from 12/27/2025-12/28/2025. This failure could affect residents, their families, and facility visitors by placing them at risk of not having access to information regarding the numbers of staff caring for the residents each shift and the facility census.

Inspectors wroteBased on interviews,observation and record reviews, the facility failed to ensure resident has the right to be free from neglect for one (Resident #1) of eight residents reviewed for abuse neglect. On 2/21/2025, CNA A transferred Resident #1 without a gait belt from the shower chair to the bed. As a result, Resident #1 suffered a fracture to the left distal diaphysis of the tibia (lower area of the shin bone). Oversight and monitoring of direct care staff (nurse aides), was not addressed. CNA A transferred Resident #1 inappropriately on 2/21/25 causing a left lower extremity fracture, was not retrained and or monitored, and then CNA A transferred Resident #1 inappropriately on 04/07/25 causing a right lower extremity fracture. CNA A was aware Resident #1 required two staff to transfer but transfered the resident alone. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of nine residents reviewed for accidents and supervision. On 2/21/2025, CNA A transferred Resident #1 without a gait belt from the shower chair to the bed. As a result, Resident #1 suffered a fracture to the left distal diaphysis of the tibia (lower area of the shin bone). Oversight and monitoring of direct care staff (nurse aides), was not addressed. CNA A transferred Resident #1 inappropriately on 2/21/25 causing a left lower extremity fracture, was not retrained and or monitored, and then CNA A transferred Resident #1 inappropriately on 04/07/25 causing a right lower extremity fracture. This failure resulted in an Immediate Jeopardy situation on 4/10/2025. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to provide pain management consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of eight residents reviewed for abuse and neglect. 1. The facility failed to ensure Resident #1 did not experience additional pain after sustaining a fracture on 2/21/2025 to the left distal diaphysis of the tibia (lower area of the shin bone) and was not transferred to the hospital until 2/26/2025 (five days later). 2. The facility failed to ensure Resident #1's pain was accurately assessed and documented. This failure resulted in an Immediate Jeopardy situation on 04/10/2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to promptly notify the ordering physician of results which fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders for one (Resident #1) of eight residents reviewed for notification of changes. 1. The facility failed to notify and consult with Resident #1's physician on 2/21/2025 when x-ray results were received revealing Resident #1 had a fracture to the left distal diaphysis of the tibia (lower area of the shin bone). Resident #1 was not sent to the hospital until five days later, on 2/26/2025. 2. [...]

Inspectors wroteBased on observation and interview the facility failed to ensure all patient care equipment was in safe operating condition for three (Resident #1, Resident #2, and Resident #3) of eight residents reviewed for safe operating patient care equipment. 1. The facility failed to ensure Resident #3 had brakes on the foot of his bed. 2. The facility failed to ensure one brake on Resident #1's bed was able to lock. 3. The facility failed to ensure Resident #2's bed had a working remote control. These failures could place residents at risk of living in an unsafe and un-homelike environment.

Inspectors wroteBased on interview, observation, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 4 residents, (Resident #1) reviewed for care plans. 1. The facility failed to follow the care plan dated 07/05/24 when staff failed to ensure a pillow was always under Resident #1's feet who had a DTI to the heel, while she was in the bed on 02/19/25. This failure could place residents at risk of not receiving the necessary care and services.

Inspectors wroteBased on observation, record review and interview, the facility failed ensure a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers from developing 1 (Resident #1) of 6 residents reviewed for pressure ulcers. The facility failed on 02/19/25 to use a pillow under Resident #1's heels, at all times, to offload Resident #1's heels to prevent pressure ulcers or skin breakdown. This failure could affect residents at risk for pressure ulcers of developing new or worsening existing pressure ulcers.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for five (Resident #13, Resident #39, Resident #49, Resident #70, and Resident #71) of twenty-seven residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light was in reach and accessible for Resident #13, Resident #39, Resident #49, Resident #70, and Resident #71. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased observations, interviews, and record review, the facility failed to 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 eight (Resident #10, Resident #13, Resident #44, Resident #49, Resident #56, Resident #61, Resident #80, and Resident #84) of eighteen residents observed for Infection Control. 1. The facility failed to ensure that CNA D changed her gloves and performed hand hygiene while providing incontinent care to Resident #49. 2. The facility failed to ensure that CNA E changed her gloves and performed hand hygiene while providing incontinent care to Resident #80. 3. The facility failed to ensure that LVN B sanitized the blood pressure cuff in between Resident #44, Resident #56, Resident #61, and Resident #84. 4. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide the right to personal privacy which includes accommodations during personal care for one (Resident #13) of thirteen residents reviewed for Privacy. The facility failed to ensure LVN D closed Resident #13's door while performing wound care. This failure could place the residents at risk of not having their personal privacy maintained during medical treatment.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #13) of eight residents reviewed for Respiratory Care. The facility failed to ensure that Resident #13's BiPAP (Bilevel Positive Airway Pressure: machine used to deliver pressurized air through a mask to keep airways open) mask was stored properly. This failure could place the resident at risk for respiratory infection and not having her respiratory needs met.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 3 of 5 resident rooms (Resident #13, 29, and 84) observed for a clean environment. The facility failed to ensure that resident rooms were cleaned daily, and in accordance with the facility's Housekeeping Workers' Checklist. This deficient practice could negatively impact the facility's ability in preventing the spread of disease-causing organisms in residents' living areas.

Inspectors wroteBased on observation, interviews and record reviews the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. The facility failed to ensure foods in the facility's dry storage area, refrigerator, and freezer were stored and dated according to guidelines. The facility failed to ensure the Ice machine, Ice Scooper, and Ice Scooper Holder, located in the facility's only kitchen, was clean and sanitary. These failures could place residents at risk for cross contamination and other air-borne illnesses.

Inspectors wroteBased observation, interview, and record review, the facility failed to 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 4 (Residents #60, #63, #16, and #30) of residents observed for infection control. The facility failed to ensure CMA C sanitized the blood pressure cuff between Resident #60, Resident #63, Resident #16, and Resident #30. These failures could place the residents at risk of cross-contamination and development of infections.

Inspectors wroteBased observation, interview, and record review, the facility failed to secure the catheter to facilitate flow of urine, prevent kinking of the tubing and position below the level of the bladder for 1 (Resident #57) of 1 resident observed for urinary catheter care. The facility failed to ensure CNA E kept the urine collection bag of Resident #57 below the level of the bladder. These failure could place the resident at risk for infection development.

Inspectors wroteBased observation, interview, and record review, the facility failed to ensure that 2 of 2 residents (Resident #16 and Resident #30) were provided medications and/or biologicals and pharmaceutical services to meet the needs of the residents. The facility failed to ensure CMA C re-ordered medications on a timely manner for Resident #16 (Duloxetine 60 mg) and Resident #30 (Pravastatin 40 mg). This failure placed the residents at risk of not receiving medications as ordered by the physician.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to provide specialized rehabilitative services such as but not limited to physical therapy, speech-language pathology, occupational therapy, respiratory therapy, and rehabilitative services for mental illness and intellectual disability, or services of a lesser intensity as set forth at §483.120(c) for 2 of 5 residents (Resident #68 and #82) for residents observed for specialized rehabilitative services. The facility failed to ensure Resident #68, and Resident #82 received their physical therapy evaluation and physical therapy. This failure placed residents at risk of having a decline in their activities for daily living.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 1 of 5 resident rooms (Resident # 12) observed for a safe environment. The facility failed to ensure that Resident #12's room was free from any safety hazards by allowing the resident to have had a plugged-in surge protector located on the top of his bed. This failure placed residents at risk of a safety hazard, specifically an electrical fire, occurring within the facility and causing potential harm to the residents.