Highland View Rehabilitation & Healthcare Center

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF584Feb 13, 2026

  Based on observations, review of facility policies and documents, and staff interview, it was determined that the facility failed to provide housekeeping services necessary to maintain a clean environment for five of 27 resident rooms (Resident rooms 2, 3, 5, 8, and 12). Findings include: A facility policy entitled Daily Resident/Patient Room Cleaning dated 1/02/26, indicated that staff is expected to dust mop the floor and sweep all trash and debris to the door and pick it up with the dustpan, empty and clean the trashcans, and wet mop the room. A facility policy entitled Restroom Cleaning dated 1/02/26, indicated that staff disinfect and clean all parts of the toilet, and damp mop the room. […]

• No harm, potential for more than minimal, isolatedF605Feb 13, 2026

  Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide a clinical rationale for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14-days and failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of a PRN psychotropic (mind altering) medication, and failed to provide evidence of attempted gradual dose reductions (GDR) and/or evidence that a GDR was clinically contraindicated for two of six residents reviewed (Residents R35 and R13). Findings include: A facility policy entitled Psychotropic Medication Use dated 1/2/26, indicated. […]

• No harm, potential for more than minimal, isolatedF628Feb 13, 2026

  Based on review of facility policies, clinical records, and staff interviews it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day), and failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital for two of four residents reviewed (Residents R1 and R44).Findings include: Review of facility policy entitled Transfer or Discharge, Facility-Initiated dated 1/2/26, indicated Notice of facility bed-hold and return policies are provided to the resident and representative within 24 hours of emergency transfer. […]

• No harm, potential for more than minimal, isolatedF641Feb 13, 2026

  Based on review of clinical records and Minimum Data Set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care), and staff interview, it was determined that the facility failed to ensure that MDS assessments accurately reflected the status of two of 14 residents reviewed (Residents R27 and R40). Findings include: MDS instructions for section N Medications, subsection N0350A Insulin Injections Record the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry if less than 7 days. […]

• No harm, potential for more than minimal, isolatedF657Feb 13, 2026

  Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to review and revise comprehensive care plans to reflect the current care and services for one of 14 residents reviewed (Resident R2). Findings include: Facility policy dated 1/2/26, entitled Care Plans, Comprehensive Person-Centered revealed a comprehensive, person-centered care plan that includes measurable objectives, and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implement for each resident. The policy further stated that assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. […]