Inspection Reports for
Highland Palms Healthcare Center

The facility was found deficient in multiple areas including failure to document changes in resident conditions, incomplete care plans, failure to follow physician orders, improper medication disposal, expired medication storage, inadequate infection control practices, and failure to monitor residents as ordered.

The facility was found deficient in multiple areas including failure to document changes in resident condition, lack of comprehensive care plans, failure to follow physician orders for feeding tubes, inadequate respiratory care monitoring, improper medication disposal and storage, and failure to maintain infection control practices related to contact precautions.

The facility failed to ensure medications were properly stored as one resident was observed to have medications stored unlocked at his bedside, which posed a potential risk for drug abuse and ingestion of unsanitary drugs. The Director of Nursing acknowledged the facility did not follow its policy requiring medications to be stored in locked compartments under proper temperature.

The investigation was complaint-related, focusing on medication storage practices for Resident 3. The complaint was substantiated as the facility did not follow its policy requiring locked storage of medications.

The facility failed to ensure medications were properly stored according to policies and standards when Resident 3 was observed to have medications stored unlocked at his bedside. This posed a potential risk for drug abuse and ingestion of unsanitary drugs.

The facility failed to ensure one of four sampled residents received treatment and care according to physician's orders, specifically failing to cover a surgical site with a dry dressing as ordered, which had the potential to delay wound healing.

The facility failed to ensure one of four sampled residents received treatment and care according to physician orders, specifically failing to cover a surgical site with a dry dressing as ordered, potentially delaying wound healing.

The facility failed to provide a comprehensive person-centered care plan for one resident with a history of illicit drug use, which had the potential to place the resident's health and safety at risk. Interviews and record reviews confirmed the absence of a care plan to monitor and treat the resident's condition, despite facility policies requiring such plans.

The complaint investigation focused on Resident 1, who had a history of stroke and methamphetamine abuse and tested positive for illicit drug use while hospitalized. The facility was not informed formally and lacked a care plan to monitor or treat the resident's condition.

The facility failed to develop and implement a complete care plan for Resident 1, who tested positive for methamphetamine, placing the resident's health and safety at risk. The interdisciplinary team did not have a care plan in place for assessment, intervention, and monitoring of the resident's behavioral health needs.

The facility failed to follow its policy and procedure for change of condition reporting related to weight loss and failed to notify the responsible party about left foot discoloration for Resident 1. This resulted in unplanned weight loss and the family being uninformed about the foot discoloration.

The facility failed to follow its policy and procedure for change of condition reporting related to unplanned weight loss and did not notify the responsible party about the resident's left foot discoloration. This resulted in minimal harm or potential for actual harm to the resident.

The complaint investigation was substantiated by interviews and record review showing failure to report an alleged physical abuse incident involving Resident 1 by a staff member on November 26, 2023. The police investigated the allegation, but the facility did not follow proper reporting protocols to the state agency.

The facility failed to timely report the suspected abuse of Resident 1 to the state agency and local ombudsman as required by policy. Interviews revealed that the Director of Nursing and staff did not document or report the incident properly, despite police involvement and an ongoing investigation. The facility's policy requires immediate reporting of abuse allegations, which was not followed.

The complaint involved an allegation of physical abuse by a staff member towards Resident 1. The allegation was substantiated as the facility failed to report the incident timely and properly according to their policies. Police investigated the allegation and a case number was obtained. The facility started investigation after police involvement but did not document or report as required.

The facility failed to report suspected abuse of Resident 1 in a timely manner according to their policy and procedures. Interviews revealed inconsistent documentation and delayed reporting despite police involvement and an ongoing investigation.

The visit was complaint-related, investigating a complaint about Admission, Transfer & Discharge Rights. The complaint was substantiated as the facility failed to notify the Ombudsman and did not document an Integrated Discharge Team meeting for the transfer.

The facility failed to notify the resident, resident representative, and Ombudsman of a facility-initiated transfer for one sampled resident, resulting in the resident being transferred without capacity to understand and make decisions and without being informed of rights regarding transfer/discharge.

The survey was complaint-related, investigating a complaint about Admission, Transfer & Discharge Rights. The complaint was substantiated as the facility failed to notify required parties and document the transfer process properly.

The facility failed to notify the resident, resident representative, and Ombudsman of a facility-initiated transfer for one of three sampled residents. Resident 1 was transferred without capacity to understand and make decisions and was not informed of transfer/discharge rights or Ombudsman protections.

The facility was found deficient in multiple areas including failure to ensure residents' rights to dignified care and communication, timely completion of Minimum Data Set assessments, re-evaluation of PASRR after significant status changes, development of individualized care plans, implementation of smoking care plans, provision of pain management during wound care, maintenance of sanitary kitchen conditions, completion of POLST forms, and adherence to infection control protocols including proper nebulizer equipment storage and hand hygiene.

The facility was found deficient in multiple areas including resident rights and dignity, timely completion of Minimum Data Set assessments, care planning, accident prevention, pain management, food service sanitation, advance directives documentation, infection control, and medication administration practices.

The visit was complaint-related, triggered by allegations of failure to inventory personal belongings, misappropriation of property, inadequate care planning, medication issues, inaccurate documentation, and infection control breaches. The investigation found multiple deficiencies as detailed in the findings.

The facility failed to ensure proper inventory and documentation of residents' personal belongings, timely investigation and reporting of alleged misappropriation, initiation of individualized care plans, assistance with activities of daily living, accurate resident assessments, availability and proper storage of medications, accurate documentation of meal intake and resident sign-in/out, and adherence to infection prevention protocols. These failures posed risks of loss of personal property, inadequate care, potential medication errors, and infection spread.

The facility was found deficient in multiple areas including failure to inventory and document resident personal belongings, failure to investigate and report alleged misappropriation of resident property, incomplete care plans, inadequate assistance with activities of daily living, inaccurate resident smoking assessments, medication availability issues, improper storage of controlled substances, inaccurate documentation of meal intake, inconsistent POLST documentation, incomplete resident sign-out/in records, and infection control lapses related to unlabeled and uncovered urinals.