The Highlands

In the surveyor’s words

From the most serious findings on record at The Highlands, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Dec 9, 2024

  Based on record review, staff and medical professional interviews the facility failed to promptly identify and intervene for an acute change in a resident's condition related to dehydration for 1 of 3 residents reviewed (Resident#2), resulting in Resident #2 being transported and admitted to the hospital via ambulance [DATE] with severe dehydration and sepsis. Resident #2 died on [DATE]. Resident #2's Electronic Health Record (EHR) documented he had acute changes in condition noted as follows with lack of follow up assessments and notification to the physician with the condition changes: [DATE] increased blood pressure [DATE] No assessment completed [DATE] slightly elevated pulse [DATE] increase in pulse, blood pressure and mental status change. […]

• Immediate jeopardy, isolatedF684Jul 11, 2023

  Based on observations, clinical record review, staff interview, family interview, physician interview, the director of the emergency room interview, and facility policy review, the facility failed to assure that staff provided appropriate assessments and interventions for one (1) resident who presented with a high blood sugar (Resident #1). This failure resulted in the resident having a significant change of condition, a trip to the emergency room (ED) for treatment, and an attempted stabilization of condition. The ambulance crew then attempted to transfer the resident to a larger hospital when he suffered a cardiac arrest (heart beat stopped) in the ambulance and passed away, therefore causing an Immediate Jeopardy to the health, safety, and security of the resident. […]

• Actual harm, isolatedF689Jul 25, 2024

  Based on clinical record review, facility documents, and staff interviews the facility failed to prevent accidents and hazards for 1 of 3 residents reviewed (Resident #41). The facility reported a census of 62 residents. Findings include: Review of the MDS (minimum data set) dated 5/2/24 revealed Resident #41, was non-verbal, had a BIMS (Brief Interview for Mental Status) score of 0, indicating the resident is rarely understood, and a cognitive pattern of 2, indicating moderately impaired (decisions poor; cues/supervision required). Resident #41 had diagnoses of Dementia with other behavioral disturbance, mood disturbance, and anxiety disturbance. […]

• Actual harm, isolatedF689Feb 7, 2024

  Based on clinical record review, hospital record review, policy review, and former and current staff interviews the facility failed to use safe transfer techniques for 1 of 4 (Resident #3) residents reviewed for gait belt transfers, resulting in a hip fracture. The facility failed to provide adequate supervision for a resident with dementia (Resident #1) who accessed a potentially hazardous area through a locked door. The facility reported a census of 64 residents. Findings include: The Face Sheet for Resident #3 documented an admitted [DATE]. The Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 15, indicating no cognitive impairment. […]

• Actual harm, isolatedF689Mar 3, 2022

  58.28(135C) Safety. The licensee of a nursing facility shall be responsible for the provision and maintenance of a safe environment for residents and personnel. (3) Resident safety. e. Each resident shall receive adequate supervision to protect against hazards from self, others, or elements in the environment. (I, II, III) DESCRIPTION Based on clinical record review, observations, and staff interviews, the facility failed to provide supervision and/or assistance needed by residents to prevent accident (injury) for 3 of 17 residents reviewed (Residents #7, #46, and #113). The facility reported a census of 60 residents. Findings include: 1. […]