Highland Home

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Mar 30, 2026

  Based on observation, interview, record reviews, and facility policy review, the facility failed to provide adequate supervision to prevent residents from leaving the facility unnoticed and unsupervised for 2 (two) of 7 (seven) residents who were at risk for elopement and wandering. Resident #1 and Resident #2.The facility failed to provide adequate supervision to prevent the elopement of Residents #1 and Resident #2, who had exhibited exit-seeking behaviors. This failure allowed Residents #1 and #2 to exit the facility unnoticed and unsupervised when a visitor was observed on video on 3/24/2026 at 6:20 PM holding the door open for the residents to exit. A nurse immediately responded to the door alarm sounding and went outside down the walkway but did not see the residents. […]

• Actual harm, isolatedF656Jun 20, 2024

  Based on observation, staff and resident interview, record review, and facility policy review the facility failed to implement care plans for a resident's Activities of Daily Living (ADL) care and a resident's pain medication management for two (2) of 18 resident care plans reviewed. Resident #14 and Resident #53 Findings include: Record review of facility policy titled, Care Plan Process, dated 8/17, revealed, Regulations require facilities to complete, at a minimum and at regular intervals, a comprehensive, standardized assessment of each resident's functional capacity and needs, in relation to a number of specified areas. […]

• Actual harm, isolatedF697Jun 20, 2024

  Based on staff and resident interview, record review, and facility policy review, the facility failed to ensure a resident was free of pain for one (1) of three (3) residents reviewed for pain. Resident #53 Findings include: Record review of facility policy titled, Pain Screen and Management, dated 12/23 revealed, All residents have the right to treatment for pain. Resident preferences are respected when deciding on methods to be used for pain management. Family members are involved when appropriate. The resident's statements are the most valid measurement of pain. Record review of facility policy titled, Medication Ordering, Reordering and Receiving Procedures, dated 12/19, revealed, Reordering Medications . […]

• No harm, potential for more than minimal, patternF636Mar 9, 2023

  Based on staff interview, record review and facility policy review the facility failed to complete the residents Minimum Data Set assessments timely according to the Resident Assessment Instrument (RAI) guidelines for six (6) of 16 residents reviewed for annual assessment. Resident's #15, #32, #79, #88, #92, and #104. Findings include: A record review of the facility's policy titled Resident Assessment, revealed, An assessment will be completed on each resident utilizing the MDS .The reason for the assessment, schedule and timeframe's will be according to the guidance of the Resident Instrument RAI Manual RESIDENT # 15 Record review of Resident #15's Annual Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 01/27/23 revealed the assessment closure was 03/07/23,… […]

• No harm, potential for more than minimal, patternF638Mar 9, 2023

  Based on staff interview, record review and facility policy review the facility failed to complete the residents Minimum Data Set (MDS) assessments timely according to the Resident Assessment Instrument (RAI) guidelines for nine (9) of 16 residents reviewed for quarterly assessment. Resident's #6, 20, 31, 36, 39, 49, 58, 60, and 93. Findings include: A record review of the facility's policy titled Resident Assessment revealed an assessment will be completed on each resident utilizing the MDS .The reason for the assessment, schedule and timeframe's will be according to the guidance of the Resident Instrument RAI Manual. […]