Highlands Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Highlands Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Feb 10, 2026

  Based on policy review, Administrator job description review, Director of Nursing (DON) job description review, National Weather Service website review, medical record review, facility video footage review, facility investigation review, hospital record review, and interview, the facility failed to ensure a safe environment and provide adequate supervision to prevent an incident of elopement for 1 of 3 (Resident #1) sampled residents assessed to be at risk for wandering and exit seeking behaviors. Immediate Jeopardy was identified when Resident #1 a vulnerable and cognitively impaired resident with a history of wandering behaviors, exited the building without staff knowledge or assistance on 1/31/2026. […]

• Immediate jeopardy, isolatedF684May 5, 2023

  Based on Centers for Disease Control (CDC) Guidance, policy review, medical record review, observation, camera footage, and interview, the facility failed to implement appropriate safety measures to ensure the highest practicable well-being for 1 resident (Resident #13) of 3 residents reviewed for elopement. Resident #13 eloped the facility without staff knowledge and supervision on 5/5/2023. Resident #13 was known for drug seeking and left the facility with a Peripherally inserted central catheter (PICC - a tube inserted in a large vein above the right side of the heart, used to administer medication by licensed professionals). […]

• Immediate jeopardy, isolatedF689May 5, 2023

  Based on policy review, medical record review, observation, video footage review and interview, the facility failed to ensure a safe environment and provide supervision and oversight to prevent the potential for serious injury for 2 residents (Resident #2 and Resident #12) of 6 residents reviewed with a known history of substance abuse, who overdosed in the facility and failed to implement an effective fall prevention program for 3 residents (Resident #8, #9, and #15) reviewed for falls. On [DATE], Resident #8, a resident with a history of seizures, was left alone during a seizure with his bed in a high position. The resident fell from the bed and sustained a fractured neck, which resulted in the resident's death on [DATE]. […]

• Immediate jeopardy, isolatedF600Feb 18, 2022

  Based on the facility's timeline review, policy review, medical record review, and interview, the facility failed to provide a safe environment and ensure supervision to prevent neglect for 1 of 4 residents (Resident #1) reviewed for elopement risk. The facility's failure to provide care and services necessary to prevent neglect resulted in Immediate Jeopardy when Resident #1, a moderately impaired vulnerable resident wearing an ankle wander guard monitor (a monitoring device to alert staff when a resident attempts to exit a door in the facility) was left unsupervised at a medical appointment and the resident left the appointment without authorization or necessary supervision. The facility was unaware of the resident's location for 8 hours and 39 minutes. […]

• Immediate jeopardy, isolatedF689Feb 18, 2022

  Based on the policy review, facility's timeline review, medical record review, observation, and interview, the facility failed to ensure a safe, secure environment for a vulnerable, moderately impaired resident wearing a wander guard bracelet (a monitoring device to alert staff when the resident attempts to exit a door in the facility) for 1 of 4 sampled residents (Resident #1) reviewed for elopement. The facility's failure to ensure a safe, secure environment resulted in Immediate Jeopardy (IJ) when Resident #1 was transported to a medical office and left at the medical office without supervision. […]