Deficiency Records for Highland Manor Rehabilitation and Nursing Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Highland Manor Rehabilitation and Nursing 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? |
|---|---|---|---|---|
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-02-01 | 2024-03-05 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2024-02-01 | 2024-03-05 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-02-01 | 2024-03-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-02-01 | 2024-03-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-02-01 | 2024-03-05 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-01-10 | 2024-02-08 | 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 | 2024-01-10 | 2024-02-08 | N |
| Assess the resident when there is a significant change in condition | Health | 2024-01-10 | 2024-02-08 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2024-01-10 | 2024-02-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-01-10 | 2024-02-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-10 | 2024-02-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-10 | 2024-02-08 | N |
| 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 | 2024-01-10 | 2024-02-08 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-01-10 | 2024-02-08 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-01-10 | 2024-02-08 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2024-01-10 | 2024-02-08 | 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 | 2024-01-10 | 2024-02-08 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2024-01-10 | 2024-02-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-10 | 2024-02-08 | N |
| 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 | 2023-03-17 | 2023-04-11 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-03-17 | 2023-04-11 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-17 | 2023-04-11 | Y |
| 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 | 2023-03-17 | 2023-04-11 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-02-24 | 2023-04-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-02-24 | 2023-04-11 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-02-24 | 2023-04-11 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-02-24 | 2023-04-11 | 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 | 2023-02-24 | 2023-04-11 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-02-08 | 2023-03-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-02-08 | 2023-03-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-02-08 | 2023-03-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-02-08 | 2023-03-31 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-02-08 | 2023-03-31 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-02-08 | 2023-03-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-15 | 2022-12-20 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-15 | 2022-12-20 | 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 | 2022-11-15 | 2022-12-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-15 | 2022-11-15 | 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 | 2022-03-18 | 2022-04-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-18 | 2022-04-26 | N |
| 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 | 2022-03-18 | 2022-04-26 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-03-18 | 2022-04-26 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-03-18 | 2022-04-26 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-03-18 | 2022-04-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-08-30 | 2021-10-19 | 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 | 2021-08-30 | 2021-10-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-30 | 2021-10-19 | 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 | 2023-11-14 | Not Fixed | Y |
