Highland Nursing Center

In the surveyor’s words

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

• Immediate jeopardy, patternF689Oct 11, 2023

  Based on observations, interviews, and record reviews the facility failed to ensure the resident environment remains as free of accident hazards as is possible; and Each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 4 (Res #1) reviewed for elopements in that: Resident #1 had eloped from facility 3 times (7/26/2023, 8/8/2023, 8/26/2023) with a wander guard on. a. staff were not in-serviced following each elopement. b. no elopement assessment was completed for Resident #1 prior to or immediately following the elopements. c.no measurable (dated) care plan for elopement risk. d. an alarm was not in place on Resident #1's window as indicated on care plan. An IJ was identified on 10/07/2023. […]

• No harm, potential for more than minimal, widespreadF880Mar 27, 2026

  Based on interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections for 1 of 1 facility reviewed for infection prevention. The facility failed to develop and implement a system of infection surveillance program for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents and staff. These failures could result in the spread of illness or infection. […]

• No harm, potential for more than minimal, widespreadF887Mar 27, 2026

  Based on interview and record review, the facility failed to implement policies and procedures to ensure each staff member is offered the COVID-19 vaccine for 1 of 1 facility reviewed for infection prevention. The facility failed to offer staff members the 2025-2026 COVID-19 vaccination.This failure could result in illness and the spread of infection.Findings included: Records were requested in e-mails dated 3/25/2026 at 10:45 AM and 3/27/2026 at 8:34 AM to the Admin. for evidence of staff acceptance or declination of the COVID-19 vaccination for 2025-2026. These records were not provided by the facility prior to survey exit. In an interview with CRN on 3/27/2026 at 9:26 AM, she said the facility does not offer COVID-19 vaccinations to the staff. […]

• No harm, potential for more than minimal, widespreadF944Nov 30, 2023

  Based on record review and interview, the facility failed to include as part of its QAPI program, mandatory training that outlined and informed staff of the elements and goals of the facility's QAPI program, for 9 of the 16 staff members (the AADM, the DON, LVN C, LVN D, CNA E, CNA F, CNA G, CNA H, CNA I) reviewed for mandatory training, in that: Nine staff members (the AADM, the DON, LVN C, LVN D, CNA E, CNA F, CNA G, CNA H, CNA I) reviewed for mandatory training had not received training regarding the facility's QAA-QAPI program. This failure could place residents at risk of receiving inadequate care from staff who are unfamiliar with the facility's QAPI program. […]

• No harm, potential for more than minimal, patternF627Mar 27, 2026

  Based on interview and record review, the facility failed to ensure the development and implementation of an effective discharge planning process that focuses on the resident's discharge goals for 4 of 4 residents (Residents #3, #16, #2, #1) reviewed for discharge planning.The facility failed to ensure Resident #3's discharge goals were reviewed and implemented during an attempted facility transfer in December 2025. The facility failed to ensure Resident #16's care plan included discharge plans. […]