Deficiency Records for Highland House Nursing and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Highland House Nursing and Rehabilitation Center. 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? |
|---|---|---|---|---|
| Ensure each resident receives an accurate assessment. | Health | 2023-03-10 | 2023-04-29 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-03-10 | 2023-04-29 | Y |
| 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 | 2023-03-10 | 2023-04-29 | Y |
| 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 | 2023-03-10 | 2023-04-29 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-10 | 2023-04-29 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-03-10 | 2023-04-29 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-10 | 2023-04-29 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-10 | 2023-04-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-10 | 2023-04-29 | Y |
| Provide appropriate foot care. | Health | 2023-03-10 | 2023-04-29 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-10 | 2023-04-29 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-03-10 | 2023-04-29 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-03-10 | 2023-04-29 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-03-10 | 2023-04-29 | Y |
| Post nurse staffing information every day. | Health | 2023-03-10 | 2023-04-29 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-03-10 | 2023-04-29 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-03-10 | 2023-04-29 | 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 | 2023-03-10 | 2023-04-29 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-10 | 2023-04-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-10 | 2023-04-29 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-08 | 2023-04-29 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-03-08 | 2023-04-29 | N |
| Ensure that suites are correctly sub-divided by noncombustible or limited-combustible construction. | Fire Safety | 2023-03-08 | 2023-04-29 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-03-08 | 2023-04-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-03-08 | 2023-04-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-08 | 2023-04-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-01 | 2022-05-24 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-02-01 | 2022-03-23 | 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 | 2022-02-01 | 2022-03-23 | N |
| Provide activities to meet all resident's needs. | Health | 2022-02-01 | 2022-03-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-02-01 | 2022-03-23 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-02-01 | 2022-03-23 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-02-01 | 2022-03-23 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-02-01 | 2022-03-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-01 | 2022-03-23 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-01 | 2022-03-23 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2022-01-18 | 2022-03-23 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-01-18 | 2022-03-23 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-01-18 | 2022-03-23 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-01-18 | 2022-03-23 | N |
| Ensure that suites are correctly sub-divided by noncombustible or limited-combustible construction. | Fire Safety | 2022-01-18 | 2022-03-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-18 | 2022-03-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-01-18 | 2022-03-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-01-18 | 2022-03-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-01-18 | 2022-03-23 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-11-24 | 2022-01-11 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-11-24 | 2022-01-11 | Y |
| Report COVID19 data to residents and families. | Health | 2021-07-02 | 2021-08-03 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-05-20 | 2021-07-23 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-05-20 | 2021-07-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-20 | 2021-07-23 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-05-20 | 2021-07-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-20 | 2021-07-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-20 | 2021-07-23 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-05-20 | 2021-07-23 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-05-20 | 2021-07-23 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-05-20 | 2021-07-23 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-05-20 | 2021-07-23 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-05-20 | 2021-07-23 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-05-20 | 2021-07-23 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-05-20 | 2021-07-23 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-05-20 | 2021-07-23 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2021-05-20 | 2021-07-23 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-05-20 | 2021-07-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-05-20 | 2021-07-23 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2021-05-20 | 2021-07-23 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-03-15 | 2021-04-14 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-03-15 | 2021-04-14 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-03-15 | 2021-04-14 | Y |
| Post nurse staffing information every day. | Health | 2021-03-15 | 2021-04-14 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-10-12 | 2018-11-20 | N |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2018-10-12 | 2018-11-20 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-10-12 | 2018-11-20 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-10-12 | 2018-11-20 | N |
| 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 | 2018-10-12 | 2018-11-20 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-10-12 | 2018-11-20 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2018-10-12 | 2018-11-20 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-10-12 | 2018-11-20 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-10-12 | 2018-11-20 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2018-10-11 | 2018-11-20 | N |
