Highland Health Care Center

In the surveyor’s words

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

• Immediate jeopardy, widespreadF689Sep 4, 2025

  Based on interview and record review, the facility failed to implement a systematic approach to assess and evaluate a resident's unsafe wandering, record resident specific information, and monitor a resident with known exit seeking behaviors for 1 of 3 residents reviewed for elopement. This failure resulted in R2 eloping out of the facility on an unknown date and getting down a public street before staff were able to catch up with him and again on 8/25/2025 when R2 was seen exiting the facility unsupervised when police officers patrolling the area heard the alarm and found R2 exiting the fire door attempting to leave unsupervised and with no staff anywhere around. R3's room remains adjacent to the fire door exit. […]

• Actual harm, isolatedF600Dec 5, 2025

  Based on observation, interview and record review the facility failed to provide incontinence care for 2 of 3 Residents (R8, R9) reviewed for neglect in the sample of 3. This resulted in R8 and R9 both left saturated in urine for hours and using a reasonable person approach resulted in psychosocial harm that a person would feel ashamed, humiliated, hopeless, and neglected being left in their own incontinence of bowel/bladder. Findings include: 1. R9 R9's undated face sheet documents that he was initially admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia and anxiety. R9's admission Bowel and Bladder Assessment, dated 11/17/2025, documents that he has occasional incontinence episodes and requires one-person assistance with toileting. […]

• Actual harm, isolatedF600Apr 17, 2025

  Based on observation, interview and record review, the facility failed to prevent resident to resident sexual abuse for 1 of 1 (R2) residents reviewed for abuse in the sample of 4. This failure resulted in psychosocial harm in that, a reasonable person would react to such a situation with feelings of anxiety, distress, fearfulness and humiliation. This past compliance occurred from 4/14/2025 to 4/15/2025. Findings include: 1.R2's Undated Face Sheet documents he was initially admitted to the facility on [DATE] with diagnoses including dementia, psychotic disorder with hallucinations and post traumatic stress disorder (PTSD.) R2's MDS, dated [DATE] documents he is cognitively impaired. […]

• Actual harm, isolatedF677Jun 27, 2024

  Based on interview and record review, the facility failed to assist residents with activities of daily living for dependent residents including oral and hygiene care for 1 of 4 residents (R2) reviewed for Activities of Daily Living (ADLs) for dependent residents in the sample of 24. This failure resulted in psychosocial harm as a normal person would have been embarrassed if they could not maintain good hygiene and be clean and odor free when going out in public. Findings include: R2's Face Sheet, undated, documents R2 has the following diagnoses: Osteomyelitis, Protein Calorie Malnutrition, Non-Traumatic Extradural Hemorrhage, Aphasia, Parkinson's Disease, Stage 3 Pressure Ulcer to the Sacral Area, PVD (Peripheral Vascular Disease), Dysphagia, Seizures, Neurocognitive Disorder with Lewy… […]

• Actual harm, isolatedF690Mar 2, 2023

  Based on observation, interview, and record review, the Facility failed to provide complete and thorough catheter care to prevent infections for 3 of 7 residents (R1, R2, and R4) reviewed for Urinary Tract Infections, (UTIs), in the sample of 10. This failure resulted in R2 being hospitalized for sepsis with the source of Catheter Associated Urinary Tract Infection, (CAUTI). Findings include: 1-R2's Face Sheet documents R2 has diagnoses including obstructive uropathy, urinary tract infection, Alzheimer's disease, coronary artery disease, congestive heart failure, hypertension, arthritis, and depression. R2's Minimum Data Set (MDS) dated [DATE] documented R2 was moderately cognitively impaired, required extensive assistance with bed mobility and toileting, and was dependent for transfers. […]