Highline Post Acute

In the surveyor’s words

From the most serious findings on record at Highline Post Acute, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Dec 11, 2025

  Based on interviews and record review, the facility failed to ensure residents were free from any significant medication errors, affecting one (#1) of three residents out of 10 sample residents.Specifically, the facility failed to provide Resident #1 with the physician-prescribed medication for human immune deficiency virus (HIV) disease.Resident #1 was admitted to the facility on [DATE] with a physician's order to receive the HIV medication Biktarvy. Biktarvy consists of three components, bictegravir, emtricitabine & tenofovir alafenamide (tenofovir). On [DATE], the nurse who admitted Resident #1 transcribed the Biktarvy order as tenofovir alafenamide only. […]

• Immediate jeopardy, isolatedF689Feb 27, 2025

  Based on interviews and record review, the facility failed to ensure that one (#1) of eight residents out of 16 sample residents remained as free from accidents as possible. Resident #1, severely cognitively impaired and with a history of elopement on 6/8/24 and frequent exit-seeking behaviors in January 2025 and February 2025, left the facility without staff knowledge on 2/5/25 between 9:30 p.m. and 10:30 p.m. He was not located until approximately 8:00 a.m. the next day. The facility's failures in responding to his elopements created a reasonable expectation, absent immediate correction, that an adverse outcome resulting in serious harm, impairment, or death would occur. […]

• Actual harm, isolatedF689Jul 14, 2025

  Based on observations, record review and interviews the facility failed to ensure an environment free of accident hazards for two (#1 and #19) of nine residents reviewed for accident hazards out of 21 sample residents.On 5/18/25 Resident #1 requested certified nurse aide (CNA) #1 to heat up an egg roll from his personal refrigerator in a microwave that was at the nurses' station. After heating up the egg roll, CNA #1 gave the egg roll to Resident #1, without using a thermometer to check the temperature of the egg roll, and told the resident not to touch the egg roll because it was very hot. However, Resident #1 immediately picked up the egg roll after CNA #1 gave it to him. […]

• Actual harm, isolatedF600Sep 3, 2024

  Based on interviews and record review, the facility failed to protect and keep residents safe from physical abuse by a facility employee for one (#1) of three residents reviewed for alleged physical abuse by a facility employee of eight sample residents. On 8/18/24 Resident #1 was physically assaulted by a nonclinical employee of the facility. The facility failed to protect Resident #1 from being physically abused by a facility employee. The incident occurred in an outside smoking patio and was caught on the facility's video surveillance. The assault began following the initiation of an argument where the staff was asking the resident to pay him back and the resident and staff began to argue. […]

• Actual harm, isolatedF684Jan 11, 2024

  Based on observation, record review and interviews, the facility failed to provide services in accordance with currently accepted professional principles for two (#11 and #3) of five residents reviewed for wound care management out of 13 sample residents. Resident #11 was admitted to the facility on [DATE] for long term care. She did not have any skin injuries prior to December 2023. Between 12/20/23 and 12/27/23, Resident #11 developed several traumatic injuries, including a blister on her left calf. The origin of the blister was not communicated to the management team and not investigated. Resident #11 was being followed by a wound care physician with routine treatments for wounds on her hands. […]