Highland Farms

Based on observations and staff interviews the facility failed to label and date leftover food stored for use in 1 of 1 walk in cooler and 1 of 1 walk-in freezer and failed to discard expired food items in 1 of 1 dry goods storage room. These practices had the potential to affect food served to residents. The findings included:a. During an initial observation of the facility's kitchen with the Dietary Manager (DM) on 08/11/2025 at 10:37AM the walk-in cooler was noted to have the following concerns:- An open to air and unlabeled ripped plastic bag of cooked chicken fillets on a shelf available for use.- An opened and unlabeled plastic wrapped bag of thin sliced potatoes on a shelf available for use. b. During an initial observation of the facility's kitchen with the Dietary Manager (DM) on 08/11/2025 at 10:43AM the walk-in freezer was noted to have frozen angel food cake on a tray wrapped in plastic, labeled 7/1 use by 7/21 on a shelf, available for use. c. The dry goods storage room was observed in the presence of the Dietary Manager on 08/11/2025 at 11:03AM with the following…

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 record review, and responsible party (RP) and staff interviews, the facility failed to notify the Responsible Party in advance of a room change for 1 of 1 resident reviewed for transfer to a new room in the facility (Resident #4).The findings included:Resident #4 was admitted to the facility on [DATE].The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #4 was moderately cognitively impaired. Review of a note written by the Social Service Director dated 5/20/2025 revealed the Social Service Director called and left the Responsible Party (RP) a voice mail informing them of the room change for Resident #4 and an email was sent. There was no documentation in the social service notes that indicated notification to the residents or RP of reason for the room change.A review of an email sent on 5/20/2025 at 10:23 AM by the Social Service Director to the Responsible Party revealed the email was delivered on 5/20/2025 and indicated that a voice mail was left for the RP that Resident #4…

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 observations, record review, Security Officer interview, Independent Living (IL) Resident interview, and staff interviews, the facility failed to supervise a severely cognitively impaired resident who was known to wander and used a wander guard so staff could monitor whereabouts. On 5/25/2025, Nurse #3 disarmed the service hallway exit doors and overrode the wander guard system. Resident #3 exited the healthcare center and entered a service hallway to the old assembly room area in the independent living area of the continuing care retirement community without staff supervision. Resident #3 was returned to the healthcare center by an IL Resident and the Lead [NAME] without injury. This deficient practice affected 1 of 5 residents reviewed for accidents (Resident #3).The findings included:Resident #3 was admitted to the facility on [DATE] with a diagnosis of senile degeneration of the brain, dementia, and history of falling.Resident #3's care plan dated 2/08/2025 revealed a care plan for wander guard…

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 observations, record review, and staff interviews the facility failed to provide competent nursing staff when 2 of 4 nursing staff (Nurse #1 and Medication Aide #1) were not educated on the facility's glucometer disinfection policy and procedures. Findings included: a. An observation was conducted on 8/21/24 at 4:30 PM of Nurse #1 performing a blood glucose check. After performing the blood glucose check Nurse #1 returned the glucometer to the top drawer of the medication cart without disinfecting the glucometer. An interview with was conducted on 8/21/24 at 4:40 PM with Nurse #1. She said she had not cleaned the glucometer after performing the blood glucose check because she had not been aware that she needed to do so. Nurse #1 said she had worked at the facility for about 3 months and that she had not received education or training on glucometer disinfection. Nurse #1's employee file revealed there was no record of education on glucometer disinfection. b. An interview was conducted with Medication…

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 observations, record review, and staff interviews the facility failed to implement their policy and procedures for glucometer disinfection when Nurse #1 failed to disinfect a resident (Resident #201) glucometer after performing a capillary blood glucose test. This deficient practice occurred for 1 of 1 resident (Resident #201) reviewed for infection prevention and control. The findings included: The facility policy dated 5/29/24 and entitled Glucometer Disinfection read in part: The purpose of this procedure is to provide guidelines for the disinfection of capillary-blood glucose sampling devices to prevent transmission of blood borne disease to resident and employees. The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions. The glucometers will be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant that is effective against Human Immunodeficiency Virus (HIV) (blood borne virus), Hepatitis C (blood borne virus), and Hepatitis B (blood borne virus). Glucometers…

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 record review, resident and staff interviews the facility failed to administer a pneumococcal vaccine to a resident who had consented for the vaccine to be administered. This deficient practice occurred for 1 of 5 residents reviewed for Pneumococcal Immunizations (Resident #18). The findings included: Resident #18 was admitted to the facility on [DATE]. The quarterly Minimum Data Assessment (MDS) dated [DATE] revealed Resident #18 was cognitively intact. It was not documented on the MDS that she had received the pneumonia vaccine. Review of Resident #18's medical record revealed a form titled Resident Vaccine Consent Form. The pneumococcal vaccine was marked under the section entitled check vaccines consented to be given. The vaccine consent signature section indicated verbal consent was provided by Resident #18's family during a video conference and was dated 7/18/24. Review of Resident #18's medical record revealed there was no documentation that a pneumococcal vaccine had been administered. There 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interviews the facility failed to offer and provide a COVID-19 vaccine to 1 of 5 residents reviewed for COVID-19 immunizations (Resident #42). The findings included: Resident #42 was admitted to the facility on [DATE]. The admission Minimum Data Set Assessment (MDS) dated [DATE] revealed Resident #42 had moderate cognitive impairment. Review of Resident #42's medical record revealed he had last received a COVID-19 vaccine prior to admission on [DATE]. There was no documentation in the medical record that indicated the COVID-19 vaccine had been offered to Resident #42. An interview was conducted on 8/21/24 at 3:40 PM with Resident #42. He stated that the facility had not discussed or offered the COVID-19 vaccine with him since his admission to the facility. Resident #42 said that it had been more than a year since he had last received a COVID-19 vaccine. He said he had not received the newest recommended COVID-19 vaccine. Resident #42 said that if he was able to get 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 record review and interviews with the Medical Director, Responsible Party, and staff the facility failed to allow a resident who experienced delusions and exit seeking behaviors to return to the facility following a hospital admission using the resident's behaviors prior to transfer as a basis for their decision for 1 of 1 resident reviewed for hospitalization (Resident #252). Resident #252 remained in the hospital from [DATE] through 11/09/22 waiting for placement to another facility. The findings included: Resident # 252 was admitted to the facility 08/02/22 with diagnoses including Parkinson's disease and dementia. Review of the care plan started on 08/05/22 identified Resident #252 as having impaired decision making related to his dementia that included behaviors and being at risk for elopement. Interventions included: to provide a consistent physical environment and daily routine; determine where the resident was going and validate his need to find someone or something; provide close monitoring…

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 observations and staff interviews the facility failed to remove expired food from 1 of 1 dry food storage rooms and from 1 of 4 kitchen refrigerators (lift top refrigerator). This practice had the potential to affect food served to residents. Findings included. A. On 4/24/23 at 8:49 AM an observation of the dry goods storage room in the kitchen with the Dietary Manager (DM) revealed one opened package of pancake mix with the date 3/12 use by 4/12 written on it. The DM immediately removed the package of pancake mix and stated that a kitchen staff was assigned to check the dry storage food area for expired food 5 days every week in the evenings. The DM said pancake mix was overlooked when the dry goods storage room was checked the previous Friday. B. On 4/24/23 at 9:17 AM an observation of a reach-in flip top refrigerator found an opened 1-gallon milk container, with an expiration date of 4/17/23 printed on the container. The DM immediately removed the milk container. He stated all refrigerators in the kitchen are checked nightly for any expired food items and disposed 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 record review and staff interviews, the facility failed to complete care area assessments to address underlying causes and contributing factors for the triggered areas for 1 of 5 residents reviewed for unnecessary medication. (Residents #33). The findings included: Resident #33 was admitted to the facility on [DATE]. Review of Section V (Care Area Assessment Summary) for the significant change in status Minimum Data Set (MDS) dated [DATE] revealed 8 care areas had been triggered. Five of the care area assessments (CAAs) triggered did not contain any analysis addressing the nature of Resident #33's condition, the presence of causes and contributing factors, risk factors related to the care area, and the reasons for a decision to proceed with care planning. The incomplete CAAs consisted of psychotropic drug use, activities of daily livings functional and rehabilitation potential, urinary incontinence and indwelling catheter, falls, and pressure ulcer/injury. The most recent quarterly MDS dated [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 record review and interviews with the resident, staff, Consultant Pharmacist, Nurse Practitioner (NP), and Medical Director (MD), the Consultant Pharmacist failed to identify drug irregularities and provide recommendations for 1 of 5 residents reviewed for unnecessary medications (Residents #7). The findings included: Resident #7 was admitted to the facility on [DATE] with diagnoses included hyperlipidemia. Review of physician's orders dated 03/07/20 revealed Resident #7 had an order to receive 1 tablet of atorvastatin 20 milligrams (mg) once daily for hyperlipidemia since its initiation. Review of Resident #7's medical records revealed her last lipid panel was completed on 09/08/20. No subsequent lipid panel had been documented since then. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #7 with moderate impaired cognition. A review of medication administration records (MARs) on 04/24/23 indicated Resident #7 had received atorvastatin 20 mg once daily at bedtime as ordered since its…

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 record review and interviews with the resident, staff, Consultant Pharmacist, Nurse Practitioner (NP), and Medical Director (MD), the facility failed to monitor the cholesterol level for 1 of 5 residents reviewed for unnecessary medications (Residents #7). The findings included: Resident #7 was admitted to the facility on [DATE] with diagnoses included hyperlipidemia. Review of physician's orders dated 03/07/20 revealed Resident #7 had an order to receive 1 tablet of atorvastatin 20 milligrams (mg) once daily for hyperlipidemia since its initiation on 03/07/20. Review of Resident #7's medical records revealed her last lipid panel was completed on 09/08/20. No subsequent lipid panel had been documented since then. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #7 with moderately impaired cognition. A review of medication administration records (MARs) on 04/24/23 indicated Resident #7 had received atorvastatin 20 mg once daily at bedtime as ordered since its initiation. During an…

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 record review and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions previously put in place following the annual recertification survey conducted on 07/28/21. This was for one deficiency originally cited in July 2021 in the area of Drug Regimen is Free from Unnecessary Drugs and was subsequently recited on the current annual recertification survey of 04/27/23. The duplicate citation during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag was cross referenced to: During the annual recertification survey conducted on 04/27/23, the facility failed to monitor the cholesterol level for 1 of 5 residents reviewed for unnecessary medications (Residents #7). F757: During the annual recertification survey conducted on 07/28/21, the facility failed to follow the parameter set by the physician to hold the diuretic as ordered for 1 of 5 sampled residents reviewed for unnecessary medications. An…

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.