Highland House Nursing & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Highland House Nursing & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF600Jul 16, 2024

  Based on interview and record review it was determined a facility employee sexually abused 6 of 10 sampled residents (#s 6, 7, 8, 9, 10 and 11) who were reviewed for sexual abuse. As a result of the pattern of sexual abuse, it was determined to be an immediate jeopardy situation and residents experienced psychosocial harm. Findings include: 1. Resident 6 was admitted to the facility in April 2024, with diagnoses including a stroke. Review of a progress note dated 6/16/24 at 9:45 AM revealed Resident 6 reported to staff that a night shift male CNA came into her/his room every hour to provide incontinence care and played with her/his clit. […]

• Immediate jeopardy, isolatedF689May 20, 2021

  Based on observation, interview, and record review it was determined the facility failed to appropriately assess and evaluate smokers who required supervision for 2 of 10 sampled residents (#s 17 and 24) and 7 out of 10 sampled residents (#s 2, 18, 19, 20, 21, 22 and 23) not appropriately assessed or reassessed timely for smoking. Resident 17 and Resident 24 were observed independently in possession of smoking materials and were not assessed or reassessed for smoking safety. Resident 17 was care planned to require assistance with smoking. Resident 24 was found by the facility smoking independently in her/his room. An immediate jeopardy was called. Findings include: 1. […]

• Actual harm, isolatedF692May 20, 2021

  Based on observation, interview and record review it was determined the facility failed to maintain acceptable parameters of nutritional status for 1 of 3 sampled residents (#6) reviewed for nutrition. Resident 6 had severe weight loss of 14 pounds (greater than 10% of her/his body weight) in a three-month period. Findings include: Resident 6 was admitted to the facility in 10/2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 6's weights revealed the following: -3/22/20: 129.4 pounds. -No weights were obtained during the month of 4/2020. -5/22/20: 117 pounds -6/28/20: 115.2 pounds A total weight loss of 14.2 pounds. […]

• No harm, potential for more than minimal, widespreadF812Feb 1, 2022

  Based on observation and interview it was determined the facility failed to ensure 1 of 1 ice machine was plumbed correctly to prevent the backflow of contaminated matter into the ice machine. This placed residents at risk for foodborne illness. Findings include: According to the 2013 FDA Food Code 5-402.11: . a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed. During an initial tour of the kitchen on 1/24/22 at 11:43 AM, the facility ice machine was observed to have a drain pipe coming from the back panel that extended along the floor approximately six feet where it entered the wall. […]

• No harm, potential for more than minimal, widespreadF882Nov 24, 2021

  Based on interview and record review it was determined the facility failed to ensure the Infection Preventionist (IP) participated in the quality assessment and assurance committee and reported to the committee on the Infection Prevention Control Plan on a regular basis. This placed all residents at risk for infections. Findings include: On 11/5/21 at 3:24 PM Witness 26 (former Infection Preventionist) stated she was certified as the IP in 2/2021, she was not involved in the infection control planning process particularly as it related to the coronavirus disease of 2019 (COVID-19) and did not attend quality assessment and assurance committee meetings. […]