Deficiency Records for Highland Square Nursing and Rehabilitation
Updated as of April 01, 2024
A list of the most recent deficiencies for Highland Square 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? |
|---|---|---|---|---|
| Honor the resident's right to choose his or her attending physician. | Health | 2024-02-21 | 2024-03-18 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2024-02-21 | 2024-03-18 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-02-21 | 2024-03-18 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-02-21 | 2024-03-18 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-02-21 | 2024-03-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-21 | 2024-03-18 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2024-02-27 | 2024-03-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-02-27 | 2024-03-15 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2024-02-27 | 2024-03-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-18 | 2024-02-08 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-01-18 | 2024-02-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-18 | 2024-01-09 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-12-18 | 2023-12-28 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2023-09-01 | 2023-09-19 | Y |
| Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid. | Health | 2023-09-01 | 2023-09-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-01 | 2023-09-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-01 | 2023-09-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-19 | 2023-09-19 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-07-19 | 2023-09-19 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-10-24 | 2023-09-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-21 | 2023-03-27 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-27 | 2023-03-27 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-02-27 | 2023-03-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-01 | 2023-03-27 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-02-01 | 2023-03-27 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-02-01 | 2023-03-27 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-12-20 | 2023-01-06 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-12-20 | 2023-01-06 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-12-20 | 2023-01-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-29 | 2023-01-06 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-11-29 | 2023-01-06 | 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 | 2022-10-31 | 2022-11-11 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-10-31 | 2022-11-11 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-09-06 | 2022-09-23 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-05-20 | 2022-06-16 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-05-20 | 2022-06-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-20 | 2022-06-16 | 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 | 2022-05-20 | 2022-06-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-20 | 2022-06-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-05-20 | 2022-06-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-20 | 2022-06-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-20 | 2022-06-16 | 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 | 2022-05-17 | 2022-06-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-17 | 2022-06-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-17 | 2022-06-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-05-17 | 2022-06-16 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-05-17 | 2022-06-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-05-17 | 2022-06-16 | 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 | 2022-04-28 | 2022-05-05 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2021-12-28 | 2022-01-07 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-28 | 2022-01-07 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-12-28 | 2022-01-07 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-28 | 2022-01-07 | 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 | 2021-08-06 | 2021-08-20 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-07-23 | 2021-08-20 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-07-23 | 2021-08-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-23 | 2021-08-20 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-07-23 | 2021-08-20 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-07-23 | 2021-08-20 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-07-23 | 2021-08-20 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-23 | 2021-08-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-07-23 | 2021-08-20 | Y |
| Provide activities to meet all resident's needs. | Health | 2021-05-10 | 2021-05-24 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2019-06-06 | 2019-07-09 | 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 | 2019-06-06 | 2019-07-09 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-06-06 | 2019-07-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-06 | 2019-07-09 | 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 | 2019-06-06 | 2019-07-09 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-06-06 | 2019-07-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-06 | 2019-07-09 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2019-06-06 | 2019-07-09 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-06-06 | 2019-07-09 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-06-06 | 2019-07-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-06 | 2019-07-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-06 | 2019-07-09 | N |
| Keep all essential equipment working safely. | Health | 2019-06-06 | 2019-07-09 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-06-03 | 2019-07-09 | 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 | 2019-06-03 | 2019-07-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-03 | 2019-07-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-06-03 | 2019-07-09 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-06-03 | 2019-07-09 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-06-03 | 2019-07-09 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-06-03 | 2019-07-09 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2019-06-03 | 2019-07-09 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-06-03 | 2019-07-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-06-03 | 2019-07-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-06-03 | 2019-07-09 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-04-19 | 2018-07-02 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-04-19 | 2018-07-02 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-04-19 | 2018-07-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-04-19 | 2018-07-02 | N |
| Meet other general requirements. | Fire Safety | 2018-04-18 | 2018-07-02 | N |
| Use approved construction type or materials. | Fire Safety | 2018-04-18 | 2018-07-02 | 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 | 2018-04-18 | 2018-07-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-04-18 | 2018-07-02 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-04-18 | 2018-07-02 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2018-04-18 | 2018-07-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-04-18 | 2018-07-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-04-18 | 2018-07-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-04-18 | 2018-07-02 | N |
