Highland Oaks

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF880Dec 11, 2025

  Based on observation, interview and record review the facility failed to develop and implement a comprehensive water management program plan to detect and control legionella and water borne pathogens in the facility's water system. This failure had the potential to affect all 20 residents in the certified section. The findings include: The resident roster provided by the facility on December 8, 2025, during the survey entrance conference shows 20 residents in the certified section. 1.On December 9, 2025, at 3:10 PM, V2 (Director of Nursing) and V10 (Maintenance Director presented the facility's Water Management Program, a 3 page document. […]

• No harm, potential for more than minimal, widespreadF812Aug 29, 2024

  Based on observation, interview, and record review the facility failed to properly label and store food in the refrigerator; ensure thermometers were inside the refrigerator; and ensure leftovers were properly cooled. This affects all residents residing in the facility. The findings include: The CMS 671 dated 8/29/24 showed there were 22 residents. On 8/27/24 at 8:59 AM, during a kitchen tour with V6 (Dietary Manager) there was a small refrigerator, under the steamer. The digital thermometer on the exterior of the refrigerator showed 37 degrees. There was no thermometer inside the refrigerator. V6 said the dietary staff use the digital reading from the exterior for the temperature logs. He said temperatures were monitored to ensure the quality of the food and prevent foodborne illness. […]

• No harm, potential for more than minimal, patternF880May 6, 2021

  Based on observation, interview, and record review, the facility failed to follow standards of infection control practices with regards to donning of personal protective equipment (PPE), placement of door signage/isolation bin and hand hygiene during provision of care. This applies to 4 of 4 residents (R5, R24, R26 and R28) reviewed for infection control practices in a sample of 12. The findings include: 1. On 5/4/21 at 08:30 AM, V7 CNA (Certified Nursing Assistant) walked in to R5's room without isolation gown or gloves. The signage at R5's door showed: Stop: Contact precautions (in addition to standard precautions). Everyone must: clean hands when entering and leaving room. And, Gown and Glove at the door. […]

• No harm, potential for more than minimal, isolatedF684Dec 11, 2025

  Based on observation, interview and record review the facility failed to properly evaluate and treat a resident who sustained a burn injury from coffee spill.This applies to 1 of 1 resident (R20) reviewed for quality of care in the sample of 12.The findings include:R20's Nursing Progress Note documented by V13 (Nurse) on December 6, 2025, at 10:30 PM, showed a notification time to the physician of 8:30 PM. The note showed that R20 sustained a burn on his thigh while drinking coffee at dinner due to R20's tremors. […]

• No harm, potential for more than minimal, isolatedF686Dec 11, 2025

  Based on observation, interview and record review, the facility failed to notify the physician and failed to implement pressure ulcer interventions to prevent the development of facility acquired pressure ulcers for a resident at high risk for developing a pressure ulcer.This applies to 1 of 3 resident (R20) reviewed for pressure ulcers in the sample of 12.The findings include:R20's face sheet showed that R20 was admitted to the facility on [DATE]. R20 had multiple diagnoses, including Parkinson's Disease with dyskinesia and dementia. R20's Quarterly (MDS) Minimum Data Set, dated [DATE], showed R20 had severe cognitive impairment. […]