Heights Care & Rehabilitation LLC

In the surveyor’s words

From the most serious findings on record at Heights Care & Rehabilitation LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF740Jan 11, 2024

  Based on record review and interviews, the facility failed to provide the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being for two (#80 and #281) of two residents reviewed for psychosocial well-being out of 44 sample residents. Both residents had expressed suicidal ideations. The facility's failures in response created a situation of immediate jeopardy for serious harm. -The facility failed to ensure Resident #80 received the appropriate level of support and supervision to ensure she did not engage in self-harm after making a suicidal ideation with a plan to self-harm. Resident #80 was admitted with diagnoses of bipolar disorder and major depressive disorder and had a history of suicide attempts. […]

• Actual harm, isolatedF686May 15, 2024

  Based on observations, record review and interviews, the facility failed to provide the necessary treatment and services to prevent pressure injuries from occurring and worsening for one (#9) of three residents out of 14 sample residents. Resident #9 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease and type II diabetes mellitus with diabetic chronic kidney disease. On 2/29/24, Resident #9 was identified to have developed a stage 3 pressure ulcer to his left heel. Record review and interviews revealed the facility failed to identify the skin breakdown on the comprehensive care plan and identify and implement person-centered interventions to prevent the worsening of the pressure injury to the left heel. […]

• Actual harm, isolatedF867Jan 11, 2024

  Based on record review and interviews, the facility failed to have an effective system to identify deviations in performance and adverse events, and to develop and implement appropriate quality assurance and performance improvement (QA/QAPI) plans of action to correct quality deficiencies. Specifically, the QAPI program committee failed to identify and address concerns related to suicidal ideations and the prevention of incidents of self-harm that rose to the level of immediate jeopardy. Cross-reference F740. Findings include: I. Facility policy and procedure The Quality Assessment and Assurance Committee policy and procedure, revised January 2018, was provided by the nursing home administrator (NHA) on 1/8/24 at 2:00 p.m. […]

• Actual harm, isolatedF684Aug 16, 2023

  Based on interviews and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one (#2) of three residents reviewed out of 13 sample residents. Resident #2 was admitted to the hospital from his mother's home on 5/8/23 due to alcohol intoxication with vomiting and inability to control his secretions. The resident's blood alcohol level was 257 (0.257), almost four times the legal limit. Resident #2 had a history of alcohol abuse and seizures with alcohol withdrawal. The facility admitted the resident on 5/9/23, less than 24 hours after he was admitted to the hospital highly intoxicated. […]

• Actual harm, isolatedF690Aug 16, 2023

  Based on record review and interviews, the facility failed to ensure residents with indwelling catheters received the appropriate care and services according to professional standards for one (#4) of three residents reviewed for catheters of 13 sample residents. Specifically, the facility failed to obtain physician orders, a diagnosis, urology follow up or document catheter care for Resident #4. The resident had a history of liver transplant and was taking immunocompromising (lowered immune system response to fight infections) medications. Observations revealed the resident's catheter bag was lying on the floor in the hallway under his chair. He suffered repeated urinary tract infections with fever and falls. […]