Inspection Reports for
Highlands Living Center
500 Hahnemann Trail, Pittsford, NY, 14534
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
12 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
135% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Feb 19, 2025
Visit Reason
The survey was a Recertification Survey conducted from 02/11/2025 to 02/19/2025 to assess compliance with regulatory requirements for Highlands Living Center.
Findings
The facility was found deficient in multiple areas including incomplete investigations of alleged abuse and neglect, inadequate development and implementation of comprehensive care plans, medication errors including crushing medications labeled 'Do Not Crush' and failure to check vital signs prior to administration, failure to provide necessary assistance with activities of daily living, inadequate infection control practices, malfunctioning resident call systems, and unsanitary conditions with non-functional handwash sinks and dirty resident lift equipment.
Deficiencies (8)
F 0610: The facility failed to thoroughly investigate alleged abuse, neglect, or mistreatment for 7 residents, including injuries of unknown origin and allegations of staff abuse.
F 0656: The facility did not develop and implement comprehensive care plans with measurable interventions for 3 residents, omitting key elements such as oxygen use and splint application.
F 0677: Resident #81 did not receive necessary assistance with nail care over an extended period, despite care plan requirements.
F 0759: The facility had a medication error rate of 12.5%, including crushing enteric-coated and extended-release medications and failure to check vital signs prior to administration.
F 0760: Resident #110 experienced significant medication errors including crushing medications labeled 'Do Not Crush' and administration without documented vital sign checks.
F 0880: The facility failed to ensure staff wore appropriate Personal Protective Equipment during wound care for a resident on Enhanced Barrier Precautions.
F 0919: The resident call system was not properly maintained on two floors, with call lights failing to alert staff and some call cords disconnected.
F 0921: The facility did not provide a safe, clean, and functional environment; handwash sinks dispensed only cold water or were non-functional, and resident lift footrests were dirty.
Report Facts
Medication errors: 4
Residents reviewed for care plans: 25
Residents reviewed for abuse investigations: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Manager #3 | Named in relation to incomplete investigations and medication error discussions. | |
| Director of Nursing | Named in relation to oversight of investigations, care plans, and medication errors. | |
| Licensed Practical Nurse Clinical Coordinator #1 | Named in relation to medication administration errors. | |
| Certified Nursing Assistant #3 | Named in relation to abuse allegation and call system issues. | |
| Registered Nurse #2 | Named in relation to call system observations and interviews. | |
| Physician Assistant #1 | Named in relation to medication error and clinical guidance. | |
| Occupational Therapist #1 | Named in relation to care plan and splint use. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 11
Date: Feb 19, 2025
Visit Reason
Inspection identified 8 health and 3 life safety deficiencies mostly level 2 severity, all corrected by April 15, 2025.
Findings
Inspection identified 8 health and 3 life safety deficiencies mostly level 2 severity, all corrected by April 15, 2025.
Deficiencies (11)
ADL care provided for dependent residents
Develop/implement comprehensive care plan
Free of medication error rts 5 prcnt or more
Infection prevention & control
Investigate/prevent/correct alleged violation
Resident call system
Residents are free of significant med errors
Safe/functional/sanitary/comfortable environ
Development of communication plan
Gas equipment - cylinder and container storag
Vertical openings - enclosure
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jun 9, 2023
Visit Reason
The inspection was a Recertification Survey conducted from June 2 to June 9, 2023, to assess compliance with regulatory requirements for Highlands Living Center.
Findings
The survey identified multiple deficiencies including failure to provide appropriate respiratory care, lack of routine dental services, improper food service sanitation practices, noncompliance with carbon monoxide detector testing requirements, and inadequate access to the facility's Electronic Health Records (EHR) for the survey team.
Deficiencies (5)
F 0695: The facility failed to provide specialized respiratory care for Resident #3, including not changing oxygen tubing and humidification bottles as required by policy, resulting in nasal irritation and ulceration.
F 0791: The facility did not provide or obtain routine dental services for Resident #33, who had not received dental care since admission approximately 11 months prior.
F 0812: The facility's main kitchen did not maintain acceptable sanitizer concentrations in two mechanical dish machines, had a malfunctioning temperature gauge, and observed improper dish washing and drying procedures.
F 0836: The facility was not in compliance with fire code requirements for carbon monoxide detection, including lack of monthly testing of detectors as required by NFPA 720.
F 0842: The facility did not ensure timely and adequate access to the Electronic Health Records for the survey team, causing delays and incomplete review of resident medical records.
Report Facts
Survey dates: 8
Chlorine concentration: 0
Sanitization log chlorine concentration: 160
Oxygen tubing change interval: 7
Dental service timeframe: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Assistant Nurse Manager | Documented oxygen care issues and inability to find dental service documentation |
| Director of Nursing | Provided expectations on oxygen tubing changes and dental service timelines | |
| Director of Social Work | Reported no dental service records for Resident #33 and contacted dental provider | |
| Fine Dining Director | Reported dish machine sanitizer testing and maintenance issues | |
| Maintenance Technician | Described carbon monoxide detector battery replacement practices | |
| Health Information Manager | Reported and assisted with EHR access issues during survey | |
| Administrator | Acknowledged EHR access issues and escalated concerns | |
| Certified Nursing Assistant #1 | Observed Resident #33 spitting out food due to chewing difficulty | |
| Certified Nursing Assistant #2 | Reported nurses responsible for oxygen management for Resident #3 |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Jun 9, 2023
Visit Reason
The inspection was a Recertification Survey conducted to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including failure to provide adequate nutritional assistance and meal monitoring for a resident with significant weight loss, inadequate respiratory care related to oxygen therapy equipment maintenance, lack of routine dental services for a resident, improper food service sanitation practices, noncompliance with carbon monoxide detector testing requirements, and issues with timely and adequate access to the Electronic Health Records (EHR) for the survey team.
Deficiencies (6)
F 0692: The facility did not ensure Resident #51 was consistently offered assistance during meals and failed to document meal intake despite significant weight loss of approximately 25% over six months.
F 0695: Resident #3's oxygen therapy was not properly managed; humidification bottles were empty and tubing was not changed or documented per facility policy, resulting in nasal irritation and ulceration.
F 0791: Resident #33 did not receive routine dental services since admission approximately 11 months prior, and no dental evaluations or consents were documented.
F 0812: Two mechanical dish machines failed to maintain acceptable sanitizer concentration and temperature; improper dish washing and drying procedures were observed, including stacking wet dishes preventing air drying.
F 0836: The facility was not in compliance with fire code requiring monthly testing of carbon monoxide detectors; no documentation of monthly testing was provided.
F 0842: The facility did not ensure timely and adequate access to the Electronic Health Records for the survey team, causing delays and incomplete access to resident medical information.
Report Facts
Weight loss: 47
Meals without intake documentation: 85
Sanitizer concentration: 0
Dish machine temperature: 120
Sanitizer concentration recorded: 160
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse/Assistant Nurse Manager #1 | LPN/Assistant Nurse Manager | Interviewed regarding failure to assist Resident #51 with meals and feeding. |
| Certified Nursing Assistant #3 | CNA | Interviewed about meal tray handling and documentation for Resident #51. |
| Registered Dietitian | RD | Provided recommendations and education regarding Resident #51's nutritional intake. |
| Director of Nursing | DON | Interviewed about expectations for meal intake documentation and oxygen therapy procedures. |
| Certified Nursing Assistant #2 | CNA | Interviewed about oxygen therapy management for Resident #3. |
| Director of Social Work | DSW | Interviewed regarding lack of dental services for Resident #33. |
| Licensed Practical Nurse #1/Assistant Nurse Manager | LPN/Assistant Nurse Manager | Interviewed about dental service documentation for Resident #33. |
| Fine Dining Director | Food Service Director | Interviewed about dish machine sanitizer testing and maintenance. |
| Pot Washer | Food Service Staff | Interviewed about sanitizer testing of dish machines. |
| Director of Facilities | Facilities Director | Interviewed about carbon monoxide detector maintenance. |
| Maintenance Technician | Maintenance Staff | Interviewed about carbon monoxide detector battery replacement and testing. |
| Health Information Manager | HIM | Interviewed about EHR access issues during survey. |
| Administrator | Facility Administrator | Interviewed about EHR access issues and survey delays. |
| Staff Educator | Staff Educator | Assisted survey team with EHR access and reported access limitations. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 14
Date: Jun 9, 2023
Visit Reason
Inspection found 8 health and 6 life safety deficiencies, mostly level 2 severity, all corrected by late July or August 2023.
Findings
Inspection found 8 health and 6 life safety deficiencies, mostly level 2 severity, all corrected by late July or August 2023.
Deficiencies (14)
Food procurement,store/prepare/serve-sanitary
Infection control
License/comply w/ fed/state/locl law/prof std
Nutrition/hydration status maintenance
Resident records - identifiable information
Respiratory/tracheostomy care and suctioning
Routine/emergency dental srvcs in nfs
Standards of construction for new nh
Cooking facilities
Electrical equipment - testing and maintenanc
Electrical systems - essential electric syste
Elevators
Ep training program
Sprinkler system - installation
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Aug 22, 2022
Visit Reason
Covid-19 Survey identified one level 2 health citation related to reporting to national health safety network, not corrected at time of report.
Findings
Covid-19 Survey identified one level 2 health citation related to reporting to national health safety network, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Sep 2, 2021
Visit Reason
The inspection was conducted as a Recertification Survey to assess compliance with regulatory requirements for nursing home operations.
Findings
The facility was found deficient in posting daily nurse staffing information, maintaining an effective infection prevention and control program including proper PPE use, and timely reporting of COVID-19 cases and deaths to residents and their representatives.
Deficiencies (3)
F 0732: The facility failed to post daily nurse staffing information for an extended period, with 57 of 92 days lacking completed staffing sheets.
F 0880: The facility failed to maintain an infection prevention and control program; a phlebotomy technician did not wear required PPE and did not change gowns between residents on transmission-based precautions.
F 0885: The facility failed to notify three residents or their representatives of new COVID-19 cases and related deaths within the required timeframe.
Report Facts
Days without staffing information posted: 57
Residents not notified of COVID-19 cases: 3
COVID-19 positive residents: 4
COVID-19 positive staff: 3
COVID-19 related deaths: 1
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