The Highlands Guest Care Center

In the surveyor’s words

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

• Immediate jeopardy, patternF600Apr 14, 2025

  Based on interviews,observation and record reviews, the facility failed to ensure resident has the right to be free from neglect for one (Resident #1) of eight residents reviewed for abuse neglect. On 2/21/2025, CNA A transferred Resident #1 without a gait belt from the shower chair to the bed. As a result, Resident #1 suffered a fracture to the left distal diaphysis of the tibia (lower area of the shin bone). Oversight and monitoring of direct care staff (nurse aides), was not addressed. CNA A transferred Resident #1 inappropriately on 2/21/25 causing a left lower extremity fracture, was not retrained and or monitored, and then CNA A transferred Resident #1 inappropriately on 04/07/25 causing a right lower extremity fracture. […]

• Immediate jeopardy, patternF689Apr 14, 2025

  Based on observations, interviews, and record reviews the facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of nine residents reviewed for accidents and supervision. On 2/21/2025, CNA A transferred Resident #1 without a gait belt from the shower chair to the bed. As a result, Resident #1 suffered a fracture to the left distal diaphysis of the tibia (lower area of the shin bone). Oversight and monitoring of direct care staff (nurse aides), was not addressed. CNA A transferred Resident #1 inappropriately on 2/21/25 causing a left lower extremity fracture, was not retrained and or monitored, and then CNA A transferred Resident #1 inappropriately on 04/07/25 causing a right lower extremity fracture. […]

• Immediate jeopardy, patternF697Apr 14, 2025

  Based on observation, interviews and record reviews, the facility failed to provide pain management consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of eight residents reviewed for abuse and neglect. 1. The facility failed to ensure Resident #1 did not experience additional pain after sustaining a fracture on 2/21/2025 to the left distal diaphysis of the tibia (lower area of the shin bone) and was not transferred to the hospital until 2/26/2025 (five days later). 2. The facility failed to ensure Resident #1's pain was accurately assessed and documented. This failure resulted in an Immediate Jeopardy situation on 04/10/2025. […]

• Immediate jeopardy, patternF777Apr 14, 2025

  Based on interview and record review, the facility failed to promptly notify the ordering physician of results which fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders for one (Resident #1) of eight residents reviewed for notification of changes. 1. The facility failed to notify and consult with Resident #1's physician on 2/21/2025 when x-ray results were received revealing Resident #1 had a fracture to the left distal diaphysis of the tibia (lower area of the shin bone). Resident #1 was not sent to the hospital until five days later, on 2/26/2025. 2. […]

• No harm, potential for more than minimal, widespreadF812Apr 15, 2021

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure food items in the dry storage were dated, sealed, labeled and kept cleaned and not spoiled. 2. The facility failed to ensure food items in the freezers were dated, labeled, and sealed. 3. The facility failed to ensure clean dishes were free from food debris. These failures affected residents by placing them at risk for food-borne illness. Findings included: 1. […]