Highland Oaks Health Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Jan 27, 2025

  Based on observation, record review, review of the facility Abuse and Neglect policy and procedure, and interviews, the facility failed to provide adequate and necessary supervision and intervention to protect Resident #27's right to be free from sexual abuse by Resident #21. This resulted in Immediate Jeopardy and the potential for actual harm beginning on 11/16/24 when Certified Nursing Assistant (CNA) #300 observed Resident #21, who was positive for Hepatitis C engaging in non-consensual sexual intercourse with Resident #27, a cognitively impaired and non-interviewable male resident who lacked the cognition to consent to the interaction. […]

• Immediate jeopardy, isolatedF689Sep 21, 2021

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, record review, review of a self-reporting incident (SRI), review of the facility's investigation, observation, staff interview, and policy review, the facility failed to provide adequate supervision to prevent Resident #7, whose cognition was severely impaired, was known to be at high risk for elopement and had verbalized a desire/ intent to leave the facility, from eloping from the facility. This resulted in Immediate Jeopardy on 08/28/21 at 9:15 P.M. when Resident #7 exited the building through the facility's main entrance without the staff's knowledge. […]

• Actual harm, isolatedF684Jan 27, 2025

  Based on observations, record reviews, and interviews, the facility failed to monitor and administer Resident #31's vancomycin per standards of care, failed to address edema and obtain Doppler testing timely for Residents #59, #85, and #191, failed to communicate orders and care plan with hospice for continuity of care for Resident #54, and failed to address a change in condition for Resident #41 following a fall. This affected six sampled residents (#31, #41, #54, #59, #85, #191) of 20 residents reviewed for quality of care. […]

• Actual harm, isolatedF686Jan 27, 2025

  Based on observations, record reviews, and interviews, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to ensure skin assessments/skin checks were completed and to ensure skin integrity issues were reported to the medical provider. In addition, the facility failed to provide treatment to newly developed pressure ulcers for Resident #41 and failed to implement skin interventions for Resident #1 per the resident's plan of care. This affected two residents (#1 and #41) of two residents reviewed for pressure ulcers. The facility census was 85. […]

• Actual harm, isolatedF689Jan 27, 2025

  Based on observation, record review and interview, the facility failed to develop and implement comprehensive, individualized and effective interventions to prevent a fall and wandering behavior resulting in Resident #71 exiting the facility. Actual harm occurred on 07/31/24 when the facility failed to prevent Resident #71 from exiting the building to the patio after the resident reported he was aware he could exit after pushing on the door for 15 seconds to get out. Following this incident on this date, the facility failed to implement additional/new interventions for Resident #71's safety and five hours later, Resident #71 exited the building again, and sustained a fall. […]