Highland Park Skilled Nursing and Wellness Center

In the surveyor’s words

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

• Immediate jeopardy, patternF755Jul 19, 2021

  Based on interview, observation and record review the facility failed to provide pharmacy services, have safeguards and systems in place for the control, accountability, and reconciliation of controlled medications by failing to: 1. Reconcile and account for the use of [MEDICATION(S)] (a Schedule II controlled substance [medications with a high potential for abuse]) among licensed nurses prior to the start/end of their working shift to conduct the narcotic counts (a physical inventory of all controlled medications, including the emergency supply, is conducted by two licensed nurses) and document on the facility's controlled medication accountability record for one resident (Residents 25) in 22 sampled residents on controlled drugs to prevent diversion [stealing prescription medicines or… […]

• No harm, potential for more than minimal, patternF755Mar 12, 2026

  Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures to ensure the accurate acquiring, administering of drugs and biologicals to meet the needs for two (2) of four (4) sampled residents (Resident 4 and 8) reviewed and observed for medication administration, in accordance with the facility's policy and procedure (P&P) by failing to ensure:Resident 4's Amiodarone Hydrocholoride (HCL) (used to treat and prevent serious, life-threatening heart rhythm problems) was administered and failing to follow gastrostomy tube (g-tube, surgical procedure wherein a tube is inserted through the abdomen wall and into the stomach used for nutrition and medication administration) flush as indicated on the physician's orderResident 8's… […]

• No harm, potential for more than minimal, patternF759Mar 12, 2026

  Based on observation, interview, and record review the facility failed to ensure its medication error rate was less than five (5) percent (%). Three medication errors (the observed or identified preparation or administration of medication or biologicals which is not in accordance with the prescriber's order/manufacturer's specifications/accepted professional standards and principles) out of 25 opportunities (observed administered medications) for error which yielded a facility medication error rate of 50% for two (2) of four (4) sampled residents (Residents 4 and 8) observed for medication administration (med pass).Resident 4's Amiodarone Hydrocholoride (HCL) (used to treat and prevent serious, life-threatening heart rhythm problems) was administered and failing to follow gastrostomy tube… […]

• No harm, potential for more than minimal, patternF812Mar 12, 2026

  Based on observation, interview, and record review, the facility failed to follow proper food storage handling practices and infection prevention in accordance with its policy and procedure (P&P) by failing to ensure:1. Dietary Aide 1 (DA 1) was wearing a hair cover (hair net- a protective, typically disposable, mesh or non-woven covering worn over the hair by food service workers to prevent contamination from loose hair and dandruff) while in the kitchen. 2. Two (2) dry food items (a bag of pasta and a bag of sugar) were sealed tightly after being opened.3. One (1) expired dry food items (a bag of grits) were discarded.4. Pots and pans were stored away from the trash can, in a clean and sanitary manner. […]

• No harm, potential for more than minimal, patternF813Mar 12, 2026

  Based on observation, interview and record review, the facility failed to ensure all the food items brought into the facility by visitors for residents were labeled and dated with the resident's name as indicated in the facility's policy titled Food Brought in by Visitors,. This failure had potential for residents to receive and consume the food of another resident and/or not receive their food brought into the facility. Findings:During an observation on 3/9/2026 at 9:51 AM with Dietary Supervisor (DS) in the facility Activity Room, three (3) food containers not labeled with the resident's name were observed in the resident's refrigerator (refrigerator used only for personal food items [NAME] to the facility by family and/or friends). […]