Highland Care Center

Based on record review and interviews, the facility failed to ensure sufficient nursing staff were available to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility reported short staffing on weekends confirmed by a review of the Daily Staffing and the Payroll Based Journal Staffing Data Report Quarter 1 2026 (October 1-December 31). The findings include: The facility policy titled Staffing reviewed 11/2025 stated that the facility will provide adequate staffing to meet needed care and services of our resident/patient population, promote resident quality care and safety by ensuring adequate and competent staffing levels are based on the Facility Assessment. The policy also stated that on a regular basis, a minimum of annually and upon changes in the facility population and care needs, the facility will evaluate the overall number of staff needed to ensure sufficient qualified staff are available to meet each resident needs. On 04/22/2026…

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, record review, and interviews, the facility failed to ensure that necessary housekeeping and maintenance services were provided to maintain a safe, clean, comfortable and homelike environment for residents. This was evident for two (2) of eight (8) resident units (Unit 1 and Unit 2) observed for the Environment Task. Specifically, blood pressure stands were observed with the base layered with dirt dust and debris, wheelchairs, Geri chairs and wheelchair seat cushions were observed to be heavily soiled, layered with an accumulation of dirt, dust and debris, air conditioners were observed with black substances and an accumulation of dirt and debris within the grates, and an air conditioner did not have an outside cover. The findings include:The facility policy titled Cleaning and Disinfection of Equipment stated all wheelchairs and mobility devices are maintained in a clean sanitary and safe condition. The policy also stated proper cleaning and disinfection reduce the risk of cross contamination, infection transmission, and environmental hazards while promoting…

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 interview conducted during the recertification survey from 1/29/2024 to 02/06/2024, the facility did not ensure the resident's representative was immediately notified of a need to alter the resident's treatment. This was evident for 1 (Resident #289) of 2 residents reviewed for Notification of Change out of 38 total sampled residents. Specifically, Resident #289 was ordered to start an antianxiety medication, Buspirone, and the designated representative was not immediately informed. The findings are: The facility policy titled Change in Resident's Condition or Status dated 11/2023 documented the facility will promptly notify the resident, their attending physician and representative of changes in their medical condition and/or status. Notification will be made within twenty-four hours of a change occurring. Resident #289 had diagnoses of dementia and recurrent falls. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #289 had severely impaired cognition. On 01/30/2024…

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, interviews, and record review conducted during the Recertification Survey from 01/29/2024 to 2/06/2024, the facility did not ensure that a resident remained free of physical restraints. This was evidenced for 1 (Resident #36) resident reviewed for Physical Restraints out of 38 total sampled residents. Specifically, Resident #36 was seated in a wheelchair in the floor dining room in a boxed-in position preventing them from moving around. The findings are: The facility policy titled Restraint Usage dated 06/22 documented restraints shall only be used to treat the resident's medical symptoms and never for discipline or staff convenience. The dignity, rights and wellbeing of the resident will be maintained. Resident #36 had diagnoses of Autistic disorder, anxiety disorder, and Schizophrenia. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #36 was severely cognitively impaired and exhibited behavioral symptoms not directed towards others daily. On 01/29/2024 at 12:17 PM 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 record review and interviews conducted during the Recertification survey from 01/29/2024 to 02/06/2024, the facility did not ensure adequate supervision and an environment free from accident hazards. This was evident for 1 (Resident #88) of 4 resident reviewed for accidents out of 38 total sampled residents. Specifically, Resident #88 was observed in possession of a sharp steak knife in their room. The findings are: Resident #88 had diagnoses of congestive heart failure and diabetes. The facility policy titled Accidents/incident/Occurrence dated 4/2023 documented the Comprehensive Care Plan will be reviewed and revised as needed to reflect occurrence and prevention measures. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #88 was cognitively intact. On 01/29/2024 at 10:53 AM, Resident #88 was observed in their room in bed and a sharp metal steak knife was observed standing up in a coffee mug on their bedside table. Resident #88 was interviewed and stated they had the knife since…

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 conducted during the Recertification survey from 1/29/2024 to 2/06/2024, the facility did not ensure the development and maintenance of policies and procedures for the monthly drug regimen review that include time frames for the different steps in the process. This was evident for 1 (Resident #78) of 5 residents reviewed for Unnecessary Medications out of 38 total sampled residents. Specifically, the facility policy for the drug monthly regimen review did not develop a timeline for the Medical Doctor to answer the pharmacist's recommendations for Resident #78. The findings are: The facility policy titled Drug Regimen Review dated 9/2021 documented the pharmacist will report any irregularities to the Medical Doctor, Director of Nursing and Medical Director. Medical Doctors will receive and respond appropriately to drug regimen reviews. Resident #78 had diagnoses of hypertension and left eye blindness. The Minimum Data Set 3.0 assessment dated [DATE] documented that 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff interviews during the Recertification survey, the facility did not ensure infection prevention control practices were followed to help prevent the spread, development, and transmission of communicable diseases and infections. Specifically, (1) the facility water management plan was not reviewed/revised within the last year, (2) the facility lacked a Legionella sampling plan based on the facility risk assessment, (3) oxygen tubing was observed with no label, and there was no documented evidence that the oxygen tubing was changed, and (4) a urinary catheter bag was observed touching the floor on multiple occasions. This was evident for the Water Management Plan reviewed for Infection Control and 1 of 2 residents sampled for Respiratory Care and 1 of 1 resident sampled for Urinary Catheter or UTI out of 38 residents sampled (Resident # 17 & 284). The findings are: (1) Record review of plan titled, Protection Against Legionella-Water Management Program, effective December 2016,…

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, record review and staff interviews conducted during the Recertification survey, the facility did not ensure that individual resident financial records were made available to resident and resident representatives through quarterly statements. Specifically, quarterly statements were not provided in writing to residents and/or resident representatives within 30 days after the end of the quarter. This was evident for 2 of 3 residents reviewed for Personal Funds out of a sample of 38 residents. (Residents #105 & #103) The findings are: The facility policy titled Resident's Banking/Personal Needs Accounts dated 01/2005, last revised 06/2019 documented that quarterly statements are provided to residents regarding the status of their accounts. (1). Resident #105 was re-admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) dated [DATE] documented that the resident had intact cognitive status. On 12/13/21 at 10:26 AM, during the initial pool interview, Resident #105 stated they had…

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 interviews and record review conducted during Recertification and Facility Complaint investigations (NY00278901, NY00269594 ), the facility did not ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the State Survey Agency. Specifically, the facility did not report incidents of abuse to the New York State Department of Health (NYSDOH) within 2 hours. This was evident for 2 of 6 residents reviewed for Abuse out of a sample of 38 residents. (Resident #70 and Resident #646). The findings are: The facility policy and Procedure titled Abuse Prevention Protocol dated 01/2019 states that the acts of physical, verbal, psychological, and financial Abuse directed against residents are prohibited. Each resident has the right 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 observations, record review and staff interviews during the Recertification survey, the facility did not ensure that a person-centered comprehensive care plan (CCP) was developed and implemented to address the resident's medical, physical, mental, and psychosocial needs. Specifically, 1). A care plan was not developed and implemented for a resident with contractures and splint device and 2). A care plan was not developed to address a resident's range of motion needs. This was evident for 2 of 2 residents reviewed for Limited ROM, and 1 of 2 residents reviewed for ADL Decline out of a sample of 38 residents. (Residents #10, #256 & #157) The findings are: The facility's Policy titled Care Planning-Interdisciplinary Team dated 04/2016 documented that the Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. The care plans shall be used in developing the resident's daily care and will be available to the staff personnel who have…

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 conducted during the Recertification survey, the facility did not ensure that each Resident or resident representative was offered the opportunity to participate in the revision and/or review of the comprehensive care plan. Specifically, cognitively intact residents were not invited to quarterly care plan meetings. This was evident for 2 of 38 sampled residents (Resident #94 and #229). The findings are: The facility's policy and procedure titled Care Planning-Interdisciplinary Team dated 04/2016 states that the Resident, the Resident family, and/or the Resident legal representative/guardian/surrogate are encouraged to participate in the development and revision of the Resident care plan. 1) Resident # 94 was admitted to the facility on [DATE] with diagnoses which include Post Traumatic Stress Disorder, Heart Failure, and Adult Failure to Thrive. The Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 94 cognition as intact with a brief Interview for Mental…

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, observations, and staff interviews during the Recertification survey, the facility did not ensure that needed services, care and equipment are provided to assure that resident with limited range of motion and mobility maintain or improve function based on the residents' clinical condition. Specifically, a resident was not provided with the splint device ordered to improve resident's contractures, this was evident for 1 out of 2 residents reviewed for Limited ROM out of a sample of 38 residents sampled. (Resident #10) The findings are: The facility's policy titled Rehab Services dated 12/31/2013 documented that indication of splint device is for prevention of permanent deformity caused by abnormal tone. Establish a wearing schedule: A patient adjusts to a new splint over time by following a wearing schedule that designates the amount of the time the splint is to be worn and the amount of time the splint should remain of each day Resident #10 was initially admitted to the facility 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.

Based on observation, record review, and staff interviews conducted during the Recertification survey, the facility did not ensure that medication and biologicals were discarded by expiration date. Specifically, 4 medications were found to be expired in the medication cart. This was evident for 1 of 8 units observed for Medication Storage (5th floor) The findings are: The facility policy and procedure titled Medication Storage and Handling, reviewed on 02/12, documented that storage of medication and other pharmaceuticals will be stored in the following methods: medications and other solutions past their noted expiration date will be removed from usage and returned to the pharmacy. On 12/15/21 09:49 AM, an observation was conducted of the medication cart on the 5th floor. The following medications were in the cart: One Incruse Ellipta Aerosol Powder Breath 62.5 mcg (micrograms) inhalation was observed in the medication cart. The directions documented to store in unopened foil tray, discard 6 weeks after foil tray opened or when counter reads 0, whichever one comes first. An open…

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.