Highland House Rehabilitation and Healthcare

In the surveyor’s words

From the most serious findings on record at Highland House Rehabilitation and Healthcare, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jun 24, 2022

  Based on staff interviews, record reviews and Physician interview the facility failed to protect a resident's right to be free from physical and emotional injuries for 1 of 2 sampled residents (Resident #222). Resident # 222 sustained a bruising on bilateral upper extremities with open skin tears on anterior right arm, posterior wrist to left arm, bruising on the left upper lip and the resident's emotional response & behaviors were crying, fretful, and agitated. The findings included: Resident #222 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS) dated [DATE] specified the resident had clear speech and was usually able to make herself understood and usually able to understand others. […]

• Immediate jeopardy, isolatedF607Jun 24, 2022

  Based on record reviews and staff interviews, the facility failed to follow their abuse policies and procedures in the areas of immediately reporting to administration, and protection of residents by allowing the alleged perpetrator to continue to work and be assigned to take care of residents, and notification of law enforcement for two days for 1 of 2 sampled residents (Resident # 222). The findings included: The policy and procedure for Resident Abuse undated stated the following procedure: If abuse or suspicion of abuse is identified, the employee must immediately report the findings to the supervisor. […]

• Actual harm, isolatedF550Jan 5, 2022

  Based on observation, record review, resident and staff interviews, the facility failed to treat resident in a dignified manner by asking him to have a bowel movement in his incontinence brief when he asked to be transferred to the bedside commode for 1 of 1 sampled resident reviewed for respect and dignity (Resident #1). The resident voiced he felt humiliated and disrespected. The findings included: Resident #1 was admitted to the facility on [DATE]. The resident diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) dated [DATE] indicated Resident #1 was moderately intact and required extensive assistance with bed mobility, transfers, toileting, and personal hygiene. He was occasionally incontinent of urine and continent of bowel. […]

• No harm, potential for more than minimal, patternF690Aug 24, 2023

  Based on record review and resident, staff, and Nurse Practitioner and Physician interviews the facility failed to provide services for two of three sampled residents (Resident #3 and Resident #5) with a urinary catheter or symptoms of urinary tract infection. For Resident #3 the facility failed to 1) assure an accurate monitoring of his output after a newly placed catheter per the plan of care 2) assure that nursing staff communicated about problems the resident was having with the catheter and 3) clarify with the physician and urologist what measures should be taken if the catheter became occluded or leaking when they became aware Resident #3 had the catheter and was experiencing these problems. […]

• No harm, potential for more than minimal, patternF880Apr 26, 2023

  Based on observation and staff interview the facility 1) failed to implement their policy for transmission-based precautions when Resident #8 presented with fever and cough and 2) perform hand hygiene during meal delivery and set up which required a Nurse Aide to position residents or their personal belongings on 1 of 2 units. The findings included: Review of the facility's policy, entitled 2022 COVID-19 Response Program revealed the policy originated on 10/2022 and was last reviewed in 4/2023. The policy noted it referenced the CDC's (Centers for Disease Control) recommendations in their policy. The policy directed that health care personnel should initiate transmission- based precautions when there is suspected or confirmed COVID 19 (Coronavirus Disease). 1. […]