Highlands Nursing and Rehabilitation

Based on interview, record review, and facility policy review, the facility failed to ensure that three of three residents reviewed for medications (Residents (R) 5, R126, and R135) were free from significant medication errors. Facility staff failed to follow physician orders and administered blood pressure medications outside of ordered parameters. These errors are considered significant because these medications are critical in preventing life=threatening complications by managing blood pressure. The findings include:Review of the facility's policy, titled, Administering Medications, revised 04/2019, revealed Policy Statement, Medications are administered in a safe and timely manner, and as prescribed. The policy noted, Medications are administered in accordance with prescriber orders. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.1. Review of R126's electronic medical record's (EMR) Face Sheet revealed 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 facility policy review, the facility failed to provide a safe, clean, comfortable, and homelike environment. Necessary Maintenance and Housekeeping was not provided in order to maintain a sanitary, orderly, and comfortable interior. Observation during tour of the building on 02/24/2025 revealed the following: There was a foul odor that smelled of stale urine noted throughout the 1C Unit hallway. The bathroom for room [ROOM NUMBER] had the appearance of dried urine on the floor and the room smelled liked strong stale urine. Additionally, the baseboard surrounding the sink in room [ROOM NUMBER] was pulled away from the sink and pulled away from the section of wall adjacent to the sink. The bathroom for room [ROOM NUMBER] had paint peeling off the wall around the plumbing, ceiling tile was sagging and there was a large water stain on the ceiling tile. The bathroom for room [ROOM NUMBER] smelled like old stale urine, the toilet was missing a seat, and the ceiling tile above 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.

Based on personnel files, facility policies, Kentucky regulation KRS 216.789 (1), and KRS 216.718 (4), the facility failed to ensure it did not employ or otherwise engage individuals with a disqualifying criminal conviction or finding in the State Nurse Aide Abuse Registry for three of 10 employee files reviewed. Review of the Cook's background check, Statewide Criminal Repository, revealed a Felony Burglary, 3rd degree with a Guilty disposition on 06/02/2016. Additionally, there was no documented evidence Nurse Aide (NA) Abuse Registry checks were completed for the Cook, Business Office Manager, or Administrative Assistant, prior to employment. The findings include: 1. Review of the facility policy titled, Abuse Prevention Program, revised 03/2021, revealed the facility conducted employee background checks per state and federal regulations, and will not knowingly employ or otherwise engage any individual who has been convicted of abuse, neglect, or misappropriation. The facility abuse prevention program provides policies and procedures that govern conducting background checks 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.

Based on interview, record review, and review of facility policy, the facility failed to send a copy of the notice of transfer to a representative of the Office of the State Long-Term Care Ombudsman for 3 of 3 sampled residents investigated for hospitalizations out of a total sample of 29 residents, Resident (R)23, R95, and R107. The findings include: Review of the facility policy titled, Transfer and Discharge, dated 12/12/2023, revealed the facility was to notify the long-term care ombudsman of transfers and maintain evidence the notice was sent to the Ombudsman. 1. Review of R95's admission Record revealed the facility admitted the resident on 07/14/2021 with diagnoses at time of survey including Alzheimer's disease, bariatric surgery status, and alcohol dependence in remission. Review of the facility Notice of Transfer or Discharge, dated 09/03/2024, revealed the resident was sent to the hospital after sustaining a fall at the facility. Further review revealed there was no documented evidence the form was sent to the Ombudsman. 2. Review of R107's admission Record revealed 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.

Based on observation, interview, record review, and review of facility policy, the facility failed to implement the Comprehensive Care Plan (CCP) for 1 of 29 residents reviewed for care planning, Resident (R)141. On 01/15/2025, a care plan intervention for a perimeter mattress was added to R141's CCP due to the resident sustaining a fall from bed on the same date. Although the resident sustained another fall from bed on 01/19/2025, the intervention for the perimeter mattress was not implemented until 02/28/2025, during survey. The findings include: Review of the facility policy, titled, Comprehensive Care Plans, dated 11/01/2024, revealed the facility was to develop and implement a comprehensive person-centered care plan for each resident that included an assessment of the resident's needs. Further review revealed qualified care team members responsible for carrying out interventions would be notified of their responsibilities for the initial care plan, as well as when changes were made. Review of R141's admission Record revealed the facility admitted the resident on 01/15/2025 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, record review, and review of facility policy, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 7 sampled residents reviewed for falls, out of a total sample of 29 residents, Resident (R)141. R141 sustained a fall on 01/15/2025 and was found lying on the floor by her bed. The Interdisciplinary Team (IDT) decided a perimeter mattress should be placed on the bed to prevent further falls, on 01/16/2025. However, the perimeter mattress was not placed on the bed, and the resident sustained another fall on 01/19/2025, when she was again found on the floor lying beside her bed. The perimeter mattress was not placed on the bed until 02/28/2025, during the Survey. The findings include: Review of the facility policy, titled, Incidents, Accidents, and Supervision, dated 12/12/2023, revealed the facility was to conduct investigations into incidents, including falls, to identify a root cause and implement corrective actions and interventions. Review of R141's admission Record revealed…

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, record review, and review of facility policy, the facility failed to assist residents in obtaining routine dental care for 2 of 7 sampled residents reviewed for dental care out of a total sample of 29 residents, Residents (R) 87 and R95. The findings include: Review of the facility policy titled, Dental Services, dated 12/12/2023, revealed the facility was expected to assist residents in obtaining routine dental services. Further review revealed the policy defined routine services as an annual inspection for signs of dental disease, dental cleaning, and dental x-rays. 1. Review of R87's admission Record revealed the facility admitted the resident on 02/02/2021 with diagnoses including early onset Alzheimer's disease, type 2 diabetes, and low body mass index. Review of R87's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/23/2025, revealed the facility assessed the resident as having both short and long term memory problems, as severely cognitively impaired, and as unable to make herself understood. Continued review 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.

Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 sampled residents reviewed with urinary catheters on Enhanced Barrier Precautions (EBP) out of a total sample of 29 residents, Resident (R) 75. Observation on 02/26/2025 at 2:59PM, revealed Licensed Practical Nurse (LPN)1 touched R75's privacy curtain and sink faucet handles while wearing gloves. She then failed to perform hand hygiene and don new gloves prior to performing suprapubic catheter care. The findings include: Review of the facility's policy titled, Infection Prevention and Control Program, dated 01/02/2024, revealed, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable…

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, record review, and review of facility policies, the facility failed to ensure residents were: informed of their rights to conduct resident council meetings without staff present; and that visitors and/or other guests might attend resident council meetings only at the respective group's invitation. The facility failed to address and follow-up with Resident Council grievances, and further communicate the results to residents for seven (7) out of eight (8) sampled residents attending Resident Council meetings (Residents #5, #49, #55, #71, #101, #119, and #128). The findings include: Review of the facility's policy titled, Resident Council Meetings, undated, revealed the facility supported the rights of residents to organize and participate in resident groups. Per policy review, the meeting minutes were to include issues discussed and recommendations from the group. Further review revealed the facility was to act upon concerns and recommendations of the Resident Council by making…

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, review of the facility's policy, and review of the manufacturer's drug package insert, the facility failed to ensure all drugs and biological agents were properly labeled and stored in accordance with current accepted professional principles. Observation of the Unit 1B storage room revealed one (1) vial of Tuberculin (TB) Purified Protein Derivative five (5) milliliters (ml) with an open date of 02/12/2024 that had not been discarded after thirty (30) days per facility policy. Additionally, a pink jacket and pink polka dotted bag were observed on the counter on top of the pharmacy medication return tote. The findings include: Review of the facility's policy titled Storage of Medications, revised 08/2020 revealed medications and biologicals were stored safely, securely, and properly, following the manufacturer's recommendations or those of the supplier. Review of the policy under the Procedures/General Guidance section, item eight (8) revealed outdated medications were immediately removed from inventory, disposed of according to procedures 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 observation, interview, record review, and review of the facility's policy, the facility failed to ensure the call system was accessible to residents while in their bed, chair or other sleeping accommodations for two (2) of seventy-five (75) sampled residents (Resident #22 and Resident #76). Observation on 03/21/2024 revealed Resident #22's and Resident #76's call lights were attached to the wall behind the head of their beds, out of their reach. The findings include: Review of the facility's policy titled, Call Lights: Accessibility and Timely Response, undated, revealed the purpose of the policy was to assure the facility was adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights would directly relay to a staff member or centralized location to ensure appropriate response. Review of the Policy Explanation and Compliance Guidelines, revealed staff would ensure the call light was within reach of the resident…

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.