Highland Place Rehab and Nursing Center

In the surveyor’s words

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

• Immediate jeopardy, patternF600Feb 4, 2025

  Based on interviews and record reviews the facility failed to protect the residents' right to be free from sexual abuse and psychosocial harm from another resident for 3 (Resident #1, #6, #7) of 7 (Resident #1, #2, #3, #4, #5, #6, and #7) sampled residents. The deficient practice resulted in an Immediate Jeopardy on 12/27/2024 at approximately 2:38 a.m., when Resident #1 was approached at his bedside by Resident #2 with Resident #2's penis exposed playing with himself. Residents #6 and #7 resided in the shared resident room at the time of the event. Resident #1 was verbal and his cognition was intact. Resident #1 reported Resident #2 grabbed him by his upper arms and shoulders and he had to wrestle with Resident #2 to get away. […]

• Immediate jeopardy, patternF835Feb 4, 2025

  Based on interviews and record reviews, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 (Resident #1) of 7 (#1, #2, #3, #4, #4, #5, #6, and #7) residents. The deficient practice resulted in an Immediate Jeopardy on 12/27/2024 at approximately 2:38 a.m., when Resident #1 was approached at his bedside by Resident #2 with Resident #2's penis exposed playing with himself. Residents #6 and #7 resided in the shared resident room at the time of the event. Resident #1 was verbal and his cognition was intact. Resident #1 reported Resident #2 grabbed him by his upper arms and shoulders and he had to wrestle with Resident #2 to get away. […]

• Immediate jeopardy, isolatedF689Jun 8, 2023

  Based on record reviews and interviews, the provider failed to ensure residents received adequate supervision and to prevent elopement for 1 (#140) out of 1 (#140) residents reviewed for wandering. This failed practice led to an immediate jeopardy situation for Resident #140, which began on 05/06/2023 at 3:25 p.m. when he exited the facility, attempted to walk home and received a ride from a person unknown to him. S20 Agency LPN (licensed practical nurse) failed to notify the appropriate staff after he had not observed Resident #140 after administering four o'clock medications on the evening shift of 05/06/2023. S21 LPN failed to notify the appropriate staff when S20 Agency LPN reported Resident #140 had not been seen after four o'clock. […]

• Immediate jeopardy, isolatedF835Jun 8, 2023

  Based on record reviews and interviews the facility failed to be administered to in a manner that used its resources efficiently to ensure staff supervised residents to prevent elopement for 1 (#140) of 1 (#140) residents reviewed for wandering. This failed practice led to an immediate jeopardy situation for Resident #140, which began on 05/06/2023 at 3:25 p.m. when he exited the facility, attempted to walk home and received a ride from a person unknown to him. S20 Agency LPN (licensed practical nurse) failed to notify the appropriate staff after he had not observed Resident #140 after administering four o'clock medications on the evening shift of 05/06/2023. S21 LPN failed to notify the appropriate staff when S20 Agency LPN reported Resident #140 had not been seen after four o'clock. […]

• Actual harm, isolatedF689Aug 13, 2026

  Based on record reviews and interviews, the facility failed to ensure a resident received adequate assistance to prevent an avoidable accident for 1 (#7) of 1 resident reviewed for accidents by failing to implement two person assist intervention during ADL care.The deficient practice resulted in actual harm for Resident #7 on 08/10/2026 at approximately 4:45 p.m. when Resident #7 fell out of bed while receiving ADL care by one staff member. Resident #7's MDS assessment and comprehensive care plan indicated Resident #7 was dependent with ADLs and mobility and required two person assist. S15CNA reported Resident #7 was receiving pericare related to Resident #7's large bowel movement. […]