Highland Pines Nursing Home

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Aug 1, 2024

  Based on observations, interviews, and record review the facility failed to ensure a resident received adequate supervision to prevent accidents for 1 of 7 residents reviewed for accidents (Resident #1). The facility failed to ensure Resident #1 who was identified as confused and a wanderer and had increased confusion was monitored more closely. Resident#1 was found on a high traffic street in a wheelchair in the street, with no sidewalk and a few inches for a holder on 7/27/24. The facility staff did not know the resident had eloped, or exactly how he left the facility. An Immediate Jeopardy (IJ) was identified on 07/31/24. […]

• Immediate jeopardy, isolatedF684Apr 19, 2022

  Based on interview and record review the facility failed to provide care in accordance with resident's comprehensive assessment and failed to ensure resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice for 1 of 8 residents reviewed for quality of care. (Resident #1) The facility did not monitor the condition of Resident #1's feet. Resident #1 developed gangrene (Gangrene is death of body tissue due to a lack of blood flow or a serious bacterial infection.) in his right great toe. Seven days later he was admitted to the hospital and had surgery to amputate all five toes on his right foot. An Immediate Jeopardy (IJ) was identified on at 2:40 p.m. on 04/14/2022. […]

• No harm, potential for more than minimal, patternF600Oct 17, 2024

  Based on interviews and record review, the facility failed to ensure residents were free from abuse for 3 of 6 residents (Resident #21, Resident #50, and Resident #74) reviewed for abuse. The facility failed to ensure Resident #21 did not feel abused during bathing by CNA P in September and October 2024. The facility failed to ensure Resident #50 did not experience abuse by Resident #70 on 10/06/24. The facility failed to ensure Resident # 74 (victim) was free from undesired touching by Resident #77 (alleged perpetrator) on 10/5/2024. These failures could place resident at risk for emotional distress and further abuse. Findings included: 1. […]

• No harm, potential for more than minimal, patternF686Oct 17, 2024

  Based on observations, interviews, and record review the facility failed to ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers based on the comprehensive assessment for 3 of 6 Residents (Resident #21, Resident #51, and Resident #79) whose records were reviewed for skin integrity. The facility failed to ensure Resident #21, Resident #51, and Resident #79's pressure-relieving mattresses (is designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) were on the correct settings. The facility failed to ensure Resident #79 received and/or documented wound care on 10/05/24, 10/06/24, 10/07/24, 10/10/24, 10/11/24, and 10/13/24. […]

• No harm, potential for more than minimal, patternF690Oct 17, 2024

  Based on observation, interview, and record review, the facility failed to ensure that each resident who was incontinent of bowel/bladder and each resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections, for 3 of 7 residents (Resident #52, Resident #79, and Resident #88) reviewed for indwelling urinary catheters. The facility failed to ensure Resident #52, Resident #79, and Resident #88's indwelling catheter (drains urine from your bladder into a bag outside your body) had a catheter securement device to anchor catheter to their legs on 10/14/24, 10/15/24, and 10/16/24. The facility failed to ensure Treatment Nurse M did not place Resident #79's catheter bag on the bed during wound care on 10/15/24. […]