Highland Care Center

In the surveyor’s words

From the most serious findings on record at Highland Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jan 2, 2024

  Based on observation and interview it was determined the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the facility did not have detergent for the dish machine, there was cardboard duct taped to the hood vent, refrigerators at the nurses stations were soiled and there were soiled areas in the kitchen. Findings include: 1. On 1/2/24 at 9:49 AM, a dirty meal tray was observed at the bottom of the ice and water cart in the hallway outside room [ROOM NUMBER]. 2. On 1/2/24 at 10:00 AM, an observation was made of the facility dish machine. There were 3 tubes coming from the dish machine. One tube was in a bucket labeled Ultra San, another labeled Rinse Aide and a third labeled Dish Machine Detergent. […]

• No harm, potential for more than minimal, widespreadF880Mar 16, 2022

  Based on observation and interview it was determined the facility did not 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. Specifically, staff were observed to enter transmission based precaution (TBP) rooms without the proper personal protective equipment (PPE) in place, staff were observed to enter the facility through a back entrance and walk down a hallway past residents prior to performing the COVID-19 screening process, staff were observed to have placed a spoon on the top of the medicine cart, then used the spoon to obtain applesauce from a communal container of applesauce, mix the applesauce with the… […]

• No harm, potential for more than minimal, patternF812Jul 22, 2026

  Based on observation and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, food items in the refrigerator and freezer were undated and opened to air. Findings included:On 7/22/26 at 10:31 AM, a follow-up tour of the kitchen was conducted. The following was observed:a. The walk-in refrigerator had two packages of strawberries that were opened and undated. b. The walk-in refrigerator had an opened plastic package of shredded cheese that was opened and undated.c. The walk-in refrigerator had an opened plastic package of hotdogs that was undated.d. The dessert freezer had a package of donut holes that was opened and undated.e. […]

• No harm, potential for more than minimal, patternF692Jan 2, 2024

  Based on observation, interview, and record review, it was determined for 1 of 7 sample residents, that the facility did not ensure a therapeutic diet was offered when there was a nutritional problem and the health care provider ordered a therapeutic diet. Specifically, a resident was not provided a fortified/enhanced diet. Resident identifiers: 4. Findings included: Resident 4 was admitted to the facility on [DATE] with diagnoses which included mycobacterial infections, human immunodeficiency disease (HIV), localized edema, anemia, immune reconstitution syndrome, severe protein calorie malnutrition, hypotension, ascites, splenomegaly and pleural effusion. Resident 4's medical record was reviewed on 1/2/24. […]

• No harm, potential for more than minimal, patternF561Mar 16, 2022

  Based on interview and record review it was determined for 3 of 35 sample residents, that the residents were not able to make choices about aspects of their life in the facility, that were significant to the resident. Specifically, residents were not regularly showered three times a week, as was their preference. Resident identifiers: 6, 22, 48. Findings include: 1. Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/14/22, resident 6 was interviewed and stated she was lucky to shower two times a week but only got 1 shower last week. They used to have a shower aide to do the showers now it was just the certified nursing assistants (CNA's). […]