Highland Square Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Highland Square Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Sep 18, 2025

  Based on medical record review, review of a facility Self-Reported Incident (SRI), review of a facility investigation, review of text messages, review of a police report, review of the facility abuse policy, and interview, the facility failed to protect Resident #50's right to be free from sexual abuse by Housekeeper (HK) #208. This resulted in Immediate Jeopardy and the potential for actual physical and psychosocial harm beginning on 08/15/25 when Housekeeper (HK) #208 sent his picture and inappropriate text messages to Resident #50's phone asking for sexual favors to Resident #50 and then subsequently had the resident perform oral sex on him on two occasions, with evidence the resident performed the act out of fear. […]

• Immediate jeopardy, isolatedF678May 21, 2025

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed record review, review of the facility's investigation, review of facility timeline, review of emergency medical services (EMS) run report, staff interview, and policy review, the facility failed to provide basic life support (BLS), including Cardiopulmonary resuscitation (CPR) to Resident #61 per the resident's advance directive, when the resident was found unresponsive on the toilet. […]

• Immediate jeopardy, isolatedF689May 24, 2024

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of the facility assessment, visitation policy, substance use disorder program contract and interview, the facility failed to properly identify potential risks/hazards for residents with a substance use disorder and provide adequate supervision and/or supervised visitation to prevent intentional/unintentional drug overdoses for residents in the facility. This resulted in Immediate Jeopardy and actual harm on [DATE] when Resident #44 who had known substance abuse history was found unresponsive and required cardiopulmonary resuscitation (CPR) and hospitalization after a Fentanyl and Methadone overdose. […]

• Immediate jeopardy, isolatedF689Feb 21, 2024

  Based on observation, medical record review, review of a local police and missing persons' report, resident, family and legal guardian interview, staff interviews, local police detective interview, review of the National Weather Forecast, and review of the facility Elopement Policy and Procedure, the facility failed to provide adequate supervision to prevent Resident #71, who had a diagnosis of vascular dementia with moderate cognitive impairment from leaving the facility without staff knowledge. This resulted in Immediate Jeopardy and the potential for serious harm, injury, death on [DATE] at 7:35 P.M. when Resident #71 exited the facility through a supervised smoking area door without staff knowledge. At 9:30 P.M. […]

• Immediate jeopardy, isolatedF689Jan 18, 2024

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed record review, review of a facility Self-Reported Incident (SRI), review of a Police Report, review of the facility Elopement Policy and Procedure, and interviews, the facility failed to provide adequate supervision and failed to respond and act appropriately when Resident #70, who was cognitively impaired, demonstrated exit seeking behaviors, and was ordered to wear a wander guard (a bracelet integrated with a security system to alert caregivers when residents have wandered from a protected zone), eloped from the facility. This resulted in Immediate Jeopardy and the potential for actual harm, injury, or death on [DATE] at approximately 7:28 A.M. […]