Deficiency Records for Highlands Nursing and Rehabilitation
Updated as of April 01, 2024
A list of the most recent deficiencies for Highlands Nursing and Rehabilitation. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-04-15 | 2021-04-20 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-04-15 | 2021-04-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-04-15 | 2021-04-20 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-04-15 | 2021-04-20 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-15 | 2021-04-20 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-04-15 | 2021-04-20 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-04-15 | 2021-04-20 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-04-15 | 2021-04-20 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-01-11 | 2020-03-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-11 | 2020-03-17 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2020-01-07 | 2020-03-12 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-01-07 | 2020-03-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-01-07 | 2020-03-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-01-07 | 2020-03-12 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2020-01-07 | 2020-03-12 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-01-07 | 2020-03-12 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2020-01-07 | 2020-03-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-01-07 | 2020-03-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-01-07 | 2020-03-12 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-01-11 | 2020-03-09 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2020-01-11 | 2020-03-09 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-01-11 | 2020-03-09 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-01-11 | 2020-03-09 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2020-01-11 | 2020-03-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-11 | 2020-03-09 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-01-11 | 2020-03-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-01-11 | 2020-03-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-11 | 2020-03-09 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-01-11 | 2020-03-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-01-11 | 2020-03-09 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2020-01-11 | 2020-03-09 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2020-01-11 | 2020-03-09 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2020-01-11 | 2020-03-09 | N |
| Ensure that residents are free from significant medication errors. | Health | 2020-01-11 | 2020-03-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-11 | 2020-03-09 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-10-18 | 2018-11-28 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-10-18 | 2018-11-28 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2018-10-18 | 2018-11-28 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2018-10-18 | 2018-11-28 | N |
| Respond appropriately to all alleged violations. | Health | 2018-10-18 | 2018-11-28 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-10-18 | 2018-11-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-18 | 2018-11-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-10-18 | 2018-11-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-10-18 | 2018-11-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-10-18 | 2018-11-28 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-10-18 | 2018-11-28 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2018-10-18 | 2018-11-28 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-10-18 | 2018-11-28 | N |
| Keep all essential equipment working safely. | Health | 2018-10-18 | 2018-11-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-10-17 | 2018-11-28 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-10-17 | 2018-11-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-10-17 | 2018-11-28 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-09-08 | 2017-10-18 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-09-08 | 2017-10-18 | N |
| Provide housekeeping and maintenance services. | Health | 2017-09-08 | 2017-10-18 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-09-08 | 2017-10-18 | N |
| Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Health | 2017-09-08 | 2017-10-18 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-09-08 | 2017-10-18 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-09-08 | 2017-10-18 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-09-08 | 2017-10-18 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2017-09-07 | 2017-10-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2017-09-07 | 2017-10-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-09-07 | 2017-10-18 | N |
