Highland Palms Healthcare Center

Based on observation, interview, and record review, the facility failed to follow physician orders in accordance with the facility's policy and procedure for one of six sampled residents (Resident 44) when Resident 44's enteral feeding (nutrition feeding through a tube into the stomach) was found running at 65 mL/hr (ml-milliliters - a unit of measurement, hr-hour, amount given in an hour) instead of 60 mL/hr, on October 31, 2024 as specified by physician order. This failure had the potential to result in Resident 44 receiving extra calories than ordered by the physician and excessive weight gain. Findings: During an observation on October 28, 2024, at 10:16 AM, in Resident 44's room, Resident 44 was observed to be lying in bed, with the head of the bed elevated, facing the television. Resident 44 was unable to make needs known. During an observation on October 29, 2024, at 4:21 PM, in Resident 44's room, Resident 44's enteral feeding was running at 60ml/hr . During an interview on October 30, 2024, at 2:04 PM, with Licensed Vocational Nurse (LVN 1), LVN 1 stated Resident 44's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one resident (Resident 73) investigated for respiratory care, received services as specified by the physician's orders when Resident 73's tracheostomy (a surgically created hole in the windpipe [trachea] that provides an alternative airway for breathing) was not monitored for redness, discharge, and discoloration every shift. This failure had the potential for Resident 73 to experience a delay in the staff identification and subsequent treatment of possible complications with his tracheostomy (such as infection) which would affect the resident's overall health and safety. Findings: During a review of Resident 73's admission Record (contains medical and demographic information), the admission record indicated Resident 73 was admitted on [DATE], with diagnoses which included muscle wasting and atrophy (loss of muscle mass), Asthma (a chronic lung disease that causes inflammation and tightening of the muscles around the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the facility's policies and procedures for destruction, final disposition, and disposal for medications were followed when six medication tablets were found on top of the medication waste receptacle, available for use on [DATE]. This failure had the potential for the misuse of expired and discarded medications that could harm residents when administered. Findings: During a concurrent observation and interview on [DATE], at 6:50 AM, with Licensed Vocational Nurse 2 (LVN 2) in the facility's medication supply room, six medication tablets were observed on top of the medication waste receptacle, readily available for use. LVN 2 stated the six medication tablets were not narcotics. The LVN 2 further stated the medication tablets were not properly disposed of inside the medication waste receptable and they (the tablets) were not supposed to be on top of the lid. During a concurrent observation and interview on [DATE], at 6:52 AM, with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure expired medications were removed from one of the two facility's medication supply rooms when one expired intravenous (IV-a method of delivering fluids, nutrients, medications, or blood directly into a vein using a needle or tube) antibiotic (medicine that treats bacterial infections by killing bacteria or preventing them from growing and multiplying) was found in the medication fridge, readily available for use on October 30, 2024. This failure had the potential for the IV antibiotic to have decreased efficacy (ability to produce a desired result) and sub-therapeutic (less than optimal) effects when administered. Findings: During a concurrent observation and interview on October 30, 2024, at 6:57 AM, in the facility's medication supply room, with the Registered Nurse 1 (RN 1), one IV antibiotic medication of Daptomycin (antibiotic to treat a bone infection) was observed to be inside the medication refrigerator where IV medications are stored, readily available for use. The medication had an expiration…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain infection control practices when Certified Nursing Assistant 1 did not don (put on) a gown upon entering the room of a resident (Resident 391) who was on contact precautions (a set of measures to prevent the spread of infectious agents through direct or indirect contact with a patient or their environment) on October 29, 2024. This failure had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi, or parasite) to 91 medically compromised residents and staff in the facility. Findings: During a review of Resident 391's admission Record (contains medical and demographic information), the admission record indicated Resident 391 was admitted [DATE], with diagnoses which included sepsis (is an illness in which the body has a severe, inflammatory response to bacteria or other germs), local infection of the skin and subcutaneous tissue (the deepest layer of the skin), and methicillin resistant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications were properly stored in accordance with facility ' s policies and procedures and standards of practice when one of three residents, Resident 3 was observed to have these medications stored at his bedside unlocked: 1. One opened bottle of Genvoya (used to treat infections). 2. An injection pen of Ozempic (used to treat diabetes). This failure had the potential to place Resident 3 ' s health at risk for drug abuse and ingestion of unsanitary drugs. Findings: During a review of Resident 3 ' s admission Records, the record (contains demographic and medical information), indicated Resident 3 was admitted on [DATE]. With diagnoses that included type 2 diabetes mellitus (a disease of not able to control the blood sugar levels), cirrhosis of liver (a condition of damaged liver) and chronic kidney disease (a condition when the kidneys gradually stop working). During a review of Resident 3 ' s clinical record, History and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one of four sampled residents (Resident 1) received treatment and care in accordance with professional standards of practice. This failure had the potential to delay and promote wound healing for Resident 1 when one staff did not cover the surgical site (a cut in the skin made by a doctor) during surgery) with dry dressing per physician ' s order. Findings: During a review of Resident 1 ' s admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included orthopedic aftercare (the care and treatment one receives after an injury of the muscles, bones and joints), alcoholic cirrhosis of liver (a condition that causes the liver to become swollen and stiff), left artificial hip joint (left hip replacement surgery) and osteoarthritis (a condition in which the tissues in the joint break down over time). A review of Order Summary Report (physician ' s orders),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a comprehensive person-centered care plan for one of four sample residents (Resident 1) who had used and tested positive for an illicit drug (a drug that is not allowed by the law). This failure had the potential to place Resident 1's overall health and safety at risk. Findings: During a review of Resident 1's admission Record (general demographics), the document indicated Resident 1 was last admitted to the facility on [DATE], with diagnoses that included, shortness of breath, opioid use (a chronic condition that causes a person to have an uncontrollable urge to use unlawful drug), other acute and chronic respiratory failure (a condition that makes it difficult to breath on your own) and major depressive disorder a condition that affect how a person feels). A review of Resident 1's hospital records, titled, Discharge Summary page 4 of 36 indicated, Ms. [Name of Resident 1] is a 61 year with a history of stroke . and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review for one of three sampled residents (Resident 1), the facility failed to follow their policy and procedure for: a. Change of Condition for weight loss. b. To notify responsible party (RP) of left foot discoloration. This failure resulted in Resident 1 having unplanned weight loss and (RP) uniformed and unaware in foot discoloration changes. Findings: During review of Residents 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on originally on October 30, 2021 and readmit August 20, 2023, with diagnoses to include: metabolic encephalopathy (chemical imbalance in the blood/brain), hemiplegia and hemiparesis following cerebral infarction (muscle weakness or paralysis on one part of body due to stroke), pyelonephritis (kidney infection), vitamin B12 deficiency (can lead to reduction on red blood cells). During a concurrent interview and record review of Resident 1's Medical Record with the Director of Nursing (DON), reviewed are as follows: 1. Cognitive patterns Section C, Brief Interview for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report for one of three sampled residents (Resident 1) per there policy and procedure to the state agency and the local ombudsman for an alleged physical abuse by staff member towards (Resident 1). This failure has the potential to put (Resident 1) health, safety, and well-being at risk. Findings: During review of Residents 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: kidney transplant, drug, or chemical induced diabetes mellitus (condition affecting how body processes sugar), hypertension (high blood pressure), osteoporosis (bones are brittle and fragile). During an interview with the License Vocational Nurse (LVN1) on November 30, 2023, at 12:06 PM, the (LVN1) stated, Around noon time on Sunday November 26, 2023, Resident 1, said I want to call 911, there was a woman who walked in, and she held me upside down. Which I thought that was odd, he was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to maintain a sanitary kitchen in accordance with professional standards for food service safety when: 1. Plastic food storage containers were stacked and stored wet, which prevented them from drying and had the potential to allow an environment where microorganisms can begin to grow. 2. The floor, under the stainless-steel counter, had food crumbs and loose trash, which had the potential for microorganism growth that could unintentionally be transferred to the food. 3. There were food crumbs found on the bottom shelf of reach-in freezer near the three-compartment sink, which had the potential for microorganism growth that could be transferred to the food. 4. There was food, black grime, and trash build-up found behind, and underneath the stove. This had the potential for microorganism growth that could inadvertently be transferred to food. 5. Ice machine had brown substance on the ice chute, which had the potential for microorganism growth that could contaminate the ice. These failures had the potential to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the Physician Orders for Life-Sustaining Treatment (POLST- written medical orders that addresses a limited number of critical medical decisions) were filled out completely for six of nine residents (Residents 22, 34, 56, 58, 71, 77, and 85) reviewed for advance directives (legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions). This failure had the potential to result in a delay of treatment for Residents 22, 34, 56, 58, 71, 77, and 85 as related to advance directives, or for life sustaining measures to be rendered against what the resident wanted. Findings: 1. A review of Resident 22's admission Record (contains demographic information) indicated Resident 22 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), acute respiratory failure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident's right to dignified existence, self-determination and communication was exercised for two of 34 sampled residents (Residents 75 and 42) when: 1. For Resident 75, the facility failed to provide the means for Resident 75 to be able to communicate her individualized care needs and preferences accurately and thoroughly with the facility. 2. For Resident 42, the facility failed to ensure Resident 42 was fed in a dignified manner when a Certified Nursing Assistant (CNA 5) stood over while feeding her. These failures resulted in Residents 75, and 42's rights to be violated, which had the potential to cause psychosocial harm leading to low self-esteem, feeling irritated, sad, and anxious. Findings: 1. During a review of Resident 75's clinical record, the admission Record (contains demographic and medical information) indicated Resident 75 was admitted to the facility on [DATE], with diagnoses that included muscle wasting and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS- a facility assessment tool) assessment was completed in accordance with the Centers of Medicare and Medicaid Services (CMS) federal completion timeframes, for two residents reviewed for resident assessment (Residents 2 and 90). These failures had the potential to result in inadequate monitoring of Residents 2 and 90's progress and decline, and the lack of resident specific information to CMS for payment and quality measure monitoring. Findings: 1. A review of Resident 90's clinical record, the admission Record (contains demographic and medical information) indicated Resident 90 was admitted to the facility on [DATE], with diagnoses that included malignant neoplasm of larynx (cancer of the throat), adult failure to thrive (general state of decline that is characterized by profound weight loss, diminished appetite, poor nutrition, and lack of physical activity), and cerebral infarction (damage to the brain from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR- a federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) was re-evaluated after a Significant Change in Status Assessment (SCSA- a comprehensive Minimum Data Set [MDS] - a facility assessment tool) assessment done for a resident that must be completed when a resident meets the significant change guidelines for either improvement or decline), for three residents reviewed for PASRR (Residents 6, 32 and 90). These failures had the potential for Residents 6, 32, and 90 not to receive the care and services most appropriate for their needs. Findings: 1. During a review of Resident 90's clinical record, the admission Record (contains demographic and medical information) indicated Resident 90 was admitted to the facility on [DATE], with diagnoses that included malignant neoplasm of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an individualized comprehensive care plan (specific interventions to provide effective and person-centered care to meet the resident's needs) was initiated for one of three residents (Resident 10) reviewed for pain management. This failure had the potential for Resident 10 to have unidentified care concerns related to pain management, placing his health and safety at risk. Findings: During a concurrent observation and interview, on October 25, 2022, at 10:34 AM, with Resident 10, Resident 10 was lying in her bed watching television. Resident 10 was alert, oriented and able to make needs known. She also stated she has rheumatoid arthritis (disorder affecting many joints causing painful swelling) and was receiving pain medications to manage her pain level. During a review of Resident 10's clinical record, the admission Record (contains demographic and medical information) indicated Resident 10 was admitted to the facility on [DATE],…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a safe environment for two of four residents reviewed for accidents (Residents 56 and 77) when Residents 56 and 77's smoking care plan were not implemented by the staff. These failures had the potential for Residents 56 and 77's safety needs to be unmet, which could place them at risk for accidents and life-threatening injuries. Findings: 1. During a review of Resident 56's admission Record (demographic information), it indicated Resident 56 was admitted to the facility on [DATE] with diagnoses that included hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time), atrophy of the kidney (condition in which one or both kidneys shrink to a smaller size, thus hindering normal function), and dementia (mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems). During review of Resident 56's Comprehensive Care Plan,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the provision of pain management before, during, and after wound care treatment was implemented for one of four residents (Resident 63) reviewed for wound care. This failure had the potential for Resident 63 to experience excessive unrelieved and/or uncontrolled pain associated with the wound care treatment, due to absence of pain management intervention by facility staff providing the wound care treatment. Findings: During a review of Resident 63's clinical record, the document titled admission Record, (contains demographic and medical information) indicated Resident 63 was admitted to the facility on [DATE], with diagnoses that included hemiplegia/hemiparesis (caused by a brain injury resulting in varying degree of weakness on one side of the body), and pressure ulcer (a wound caused by unrelieved pressure and restricted blood flow) of sacral (a spine located at the back within the hip) region. During a review of Resident 63's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection control and prevention measures to help prevent and manage transmission of diseases and infections when: 1. Resident 25's used nebulizer (a device producing a fine spray of liquid) masks and tubing were not properly stored per facility's policy. 2. Resident 10's used nebulizer masks and tubing were not properly stored per facility's policy. 3. A Licensed Vocational Nurse (LVN 6) failed to perform handwashing or hand hygiene during medication administration for Residents 42 and 85. These failures had the potential for cross contamination (physical movement or transfer of harmful bacteria from one person, object or place to another) and spread of infection which can adversely affect the health and wellbeing of 91 medically compromised residents. Findings: 1. During a review of Resident 25's clinical record, the admission Record (contains demographic and medical information) indicated Resident 25 was re-admitted on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.