Highland Manor Rehabilitation and Nursing Center

In the surveyor’s words

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

• Actual harm, isolatedF689Jan 10, 2024

  Based on an observation, review of clinical records, select facility policy and fall incident reports, and staff interviews, it was determined that the facility failed to consistently implement, and evaluate the effectiveness, of planned individualized fall prevention measures and provide sufficient staff supervision at the level and frequency required, of residents identified as at high risk for falls and known unsafe behaviors to prevent falls resulting in serious injuries, a fractured femur, for one resident (Resident 98) and a fractured neck for one resident (Resident 56), and failed to provide necessary assistance devices and assure that the resident's environment was free of potential accident hazards to prevent a fall and injuries, abrasions and bruises, to one resident (Resident… […]

• Actual harm, isolatedF689Nov 15, 2022

  Based on a review of clinical records and select facility fall investigation reports and staff interviews, it was determined that the facility failed to provide necessary assistance devices as planned to safely transfer a resident identified at high risk for falls to prevent a fall resulting in a serious injury, a fractured tibia/fibula, sustained by one resident out of five residents reviewed for accidents/falls (Resident 42). Findings included: Review of Resident 42's clinical record revealed admission to the facility on [DATE], with diagnoses that included a history of falling and abnormal gait. Resident 42 was identified at high risk for falls based on the resident's history of falls and abnormal gait. […]

• Actual harm, isolatedF689Apr 16, 2021

  Based on a review of clinical records, select facility policy and investigation reports and staff interviews, it was determined that the facility failed to provide adequate supervision of residents with known unsafe/restless behaviors and history of falls, to prevent falls with serious injuries, multiple rib fractures with pneumothorax (collapsed lung) and [CONDITION(S)] for two residents out of six residents reviewed with falls (Resident 79 and Resident 68). Findings include: Review of the facility's policy and procedures titled, Safety Observations, with a facility review date of January 2021, revealed that a process will be implemented to identify high risk behaviors and monitor residents who demonstrate those behaviors in an effort to maintain the resident's safety and the safety of… […]

• No harm, potential for more than minimal, widespreadF880Jan 10, 2024

  Based on observation, and staff interviews it was determined that the facility failed to maintain infection control practices during medication administration on one out of two medication carts (Station A, Back Hall), failed to maintain ice machines and ice distribution areas in a sanitary manner on two of two resident units and failed to maintain the facility's laundry area in a clean and sanitary manner. Findings include: Observation of medication administration pass, on January 7, 2024, at approximately 10:05 AM, revealed Employee 1, Registered Nurse (RN), on the Station A, Back Hall, medication cart. During the medication pass observation, the surveyor observed an open, purple can Monster energy drink, on the top left side of the medication cart. […]

• No harm, potential for more than minimal, widespreadF812Apr 16, 2021

  Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. […]