Highland Palms Healthcare Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Apr 30, 2026

  Based on observation, interview, and record review, the facility failed to maintain a sanitary kitchen when the walk-in refrigerator had a wet box containing cold cut meat sitting on top of a thawing roast beef inside the container.This failure had the potential to cause food borne illness (illnesses contracted from eating contaminated food or beverages) to 91 of 91 medically compromised residents who received food from the kitchen.During a concurrent observation and interview on April 27, 2026, at 9:08 AM, with the Dietary Supervisor (DS), in the kitchen, the walk-in refrigerator was inspected. There was a wet box thawing inside a plastic container. When DS lifted the wet box, a thawed roast beef under was observed. […]

• No harm, potential for more than minimal, widespreadF880Apr 30, 2026

  Based on observation, interview, and record review, the facility failed to maintain infection control and prevention practices for two of four sampled residents (Resident 36 and 122) when:1.Resident 122's foley catheter bag (a drainage unit attached to an indwelling catheter to collect urine) was on the floor, while Resident 122 was in the dining room. 2.One Registered Nurse 1 (RN 1) carried pre-prepared Intravenous medication (IV- into the vein) in his scrub pocket before administering it through a peripherally inserted central catheter (PICC line - a very long thin flexible tube inserted into the large vein in the upper arm and threaded to a vessel just above the heart) to one vulnerable resident (Resident 36). […]

• No harm, potential for more than minimal, widespreadF812Oct 28, 2022

  Based on observation, interview, and record review, the facility failed to maintain a sanitary kitchen in accordance with professional standards for food service safety when: 1. Plastic food storage containers were stacked and stored wet, which prevented them from drying and had the potential to allow an environment where microorganisms can begin to grow. 2. The floor, under the stainless-steel counter, had food crumbs and loose trash, which had the potential for microorganism growth that could unintentionally be transferred to the food. 3. There were food crumbs found on the bottom shelf of reach-in freezer near the three-compartment sink, which had the potential for microorganism growth that could be transferred to the food. 4. […]

• No harm, potential for more than minimal, patternF684Apr 30, 2026

  Based on observation, interview, and record review, the facility failed to maintain a complete and accurate clinical records (documentation used to show that ordered treatments and care were provided) for one of eight sampled residents (Resident 10) reviewed for treatment orders when monitoring and care for indwelling urinary catheter (a tube inserted into the bladder to drain urine that requires routine care and monitoring) and APP mattress (a special air mattress used to prevent skin breakdown that requires routine monitoring to ensure proper function) were not documented for multiple days from March 2026 through April, 2026.This failures had the potential to result in unverified treatment orders, lack of continuity for care, and increase for adverse outcomes, including infection, skin… […]

• No harm, potential for more than minimal, patternF842Oct 28, 2022

  Based on interview, and record review, the facility failed to ensure the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure had the potential to result in a delay of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: 1. A review of Resident 22's Admission Record (contains demographic information) indicated Resident 22 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent interview and record review, with the Director of Nursing (DON), on October 28, 2022, at 2:00 PM, the DON reviewed Resident 22's POLST, dated February 1, 2021, which indicated Section D - Information and Signatures, was unanswered. The DON stated Section D was blank and should have been completed. 2. […]