Highland Rehabilitation & Health Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Mar 27, 2025

  Based on interview and record review, the facility failed to provide adequate supervision of residents to prevent accidents. Facility staff failed to develop and implement interventions for one resident (Resident #8) who was at risk of elopement and who made statements regarding his/her intent to leave. The facility failed to ensure adequate supervision of residents during the smoke break, resulting in the resident not returning into the building at the end of the break. The resident climbed a fence and pushed him/herself off the ledge from the second floor smoke deck and broke his/her left tibia with a compound fracture which required immediate surgery and will require a second surgery. The facility census was 136. […]

• Actual harm, isolatedF600Mar 18, 2026

  Based on interview and record review, the facility failed to ensure one sampled resident (Resident #4) was free from abuse when Resident #3 punched him/her multiple times resulting in Resident #3 fracturing his/her hand and Resident #4 scared and praying for a reason to live out of 19 residents sampled. The facility census was 127 residents.The facility staff was notified on 3/18/26 of Past Non-Compliance which occurred on 3/10/26. Facility investigation, safety measures to mitigate further occurrence, staff in-services and education was completed. The deficiencies was corrected 3/18/26. […]

• Actual harm, isolatedF600Dec 2, 2025

  Based on observation, record review and interview, the facility failed to ensure one sampled resident (Resident #6) out of seven sampled residents, was free from physical abuse. On 11/21/25, Resident #5 kicked and punched Resident #6 in the left jaw resulting in a fracture of the jaw. The facility census was 125 residents. Review of the facility Abuse, Prevention and Prohibition Policy dated 11/2025 showed: -Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. -Residents must not be subjected to abuse by anyone, including, but not limited to other residents. -The facility prohibited abuse of residents. -The resident must not be subjected to abuse by anyone. […]

• Actual harm, isolatedF689Dec 2, 2025

  Based on observation, record review and interview, the facility failed to provide adequate care and supervision to prevent accidents for one sampled resident (Resident #2) out of seven sampled residents, when on 11/12/25 CNA A failed to position the resident properly in the bed and then turned away from the resident which resulted in a fall from the bed onto the floor with bruising and abrasions. The facility had further failed to transfer the resident with a Hoyer lift (mechanical transfer) and two staff per policy. The facility census was 125 residents. […]

• Actual harm, isolatedF689Aug 4, 2022

  Based on observation, interview, and record review, the facility failed to ensure that one sampled resident (Resident# 1) remained accident free when the resident reported pain and sustained bruising on both of his/her upper arms and forearms due to staff not following the resident care plan instruction to transfer with a Hoyer lift (mechanical lift) out of seven sampled residents. The facility census was 125 residents. Record review of the facility's undated skills checklists, which were provided as the facility's transfer policy, showed: -There were skills checklists for sit-to-stand lift; one person transfer; two person transfer to bed; two person transfer to chair; and Hoyer lift. […]