Inspection Reports for
Highline Post Acute

The facility failed to ensure Resident #1 received the prescribed HIV medication Biktarvy, instead administering only one component, tenofovir, or no medication for an extended period. This error led to a high viral load and risk of serious harm, including potential drug resistance and disease progression.

The complaint investigation found that Resident #1 did not receive the full prescribed HIV medication regimen from February 2025 until approximately ten months later, resulting in a viral load of 65,900. The medication error was substantiated and created immediate jeopardy to resident health and safety.

The facility failed to provide Resident #1 with the prescribed HIV medication Biktarvy, instead administering only one component, tenofovir alafenamide, from admission in February 2025 until the medication was discontinued. This error led to immediate jeopardy to resident health, with Resident #1's viral load rising significantly due to lack of proper treatment. The facility implemented a plan of correction including staff education and medication order review to prevent recurrence.

The complaint investigation substantiated that the facility failed to prevent accident hazards leading to injuries for two residents. Resident #1 was burned by overheated food served without temperature checks, and Resident #19 fell from his wheelchair in the facility van due to improper seatbelt securing. Corrective actions were implemented for Resident #19's incident but were not fully in place for Resident #1 at the time of the survey.

The facility failed to ensure a safe environment free from accident hazards, resulting in Resident #1 sustaining a second degree burn from improperly heated food and Resident #19 sustaining a skin tear and abrasions after falling out of an improperly secured wheelchair in the facility van. Corrective actions were implemented for Resident #19's incident but not fully for Resident #1's incident at the time of survey.

The complaint investigation found substantiated deficiencies related to accident hazards causing injury to two residents. Resident #1 was burned by overheated food served without temperature checks, and Resident #19 fell out of a wheelchair due to improper seatbelt securing in the facility van.

The facility failed to ensure a safe environment free from accident hazards, resulting in Resident #1 sustaining a second degree burn from improperly heated food and Resident #19 sustaining a skin tear and abrasions after falling out of a wheelchair in an improperly secured van seatbelt. Corrective actions were partially implemented but not fully effective at the time of survey.

The complaint investigation found that Resident #10 had an unwitnessed fall on 3/16/25 with no injuries noted. The fall was not documented in the facility's risk management system, and no interdisciplinary team (IDT) meeting was held to determine the root cause. The care plan was not reviewed or updated following the fall. The Director of Nursing and Regional Clinical Resource were unaware of the fall until the investigation. The DON planned to educate staff and agency nurses on proper fall reporting and follow-up procedures.

The facility failed to ensure adequate supervision and services to prevent a fall for Resident #10. The root cause of the fall on 3/16/25 was not identified, and the resident's care plan was not reviewed or updated for fall interventions after the incident.

The complaint investigation focused on Resident #10's fall on 3/16/25. The fall was unwitnessed, and the facility failed to document the incident in the risk management system, resulting in no interdisciplinary team meeting to determine the root cause or update the care plan. The Director of Nursing and Regional Clinical Resource were unaware of the fall until the investigation.

The facility failed to ensure adequate supervision and services to prevent Resident #10's fall and did not identify a root cause for the fall or review the resident's care plan for appropriate fall interventions after the incident. Staff interviews revealed the fall was not documented in the risk management system, and no interdisciplinary team meeting was held to address the fall.

The complaint investigation focused on the facility's failure to provide adequate activities for residents and failure to prevent elopement of Resident #1, who eloped twice, including one incident resulting in immediate jeopardy. The facility's response and investigation were inadequate, with delays in notification and insufficient care plan updates.

The facility failed to provide sufficient activities tailored to residents' preferences and failed to prevent elopements of a cognitively impaired resident, resulting in an immediate jeopardy situation. The facility also lacked a written hospital transfer agreement and an effective quality assurance program to address these issues.

The complaint investigation was triggered by concerns about inadequate activities for residents and a serious safety incident involving Resident #1 eloping twice, with the second elopement resulting in an Immediate Jeopardy due to failures in supervision, risk assessment, and response.

The facility failed to provide adequate activities to meet the socialization and activity needs of residents #6, #4, and #2. Additionally, the facility failed to prevent elopement of Resident #1, who eloped twice, resulting in an Immediate Jeopardy situation due to inadequate supervision, inaccurate risk assessments, and delayed response. The facility also lacked a written hospital transfer agreement and had deficiencies in its quality assurance program.

The complaint investigation substantiated that Resident #1 was physically assaulted by a housekeeper (HSK #1) on 8/18/24. The assault was witnessed by Resident #7 and confirmed by video surveillance. The resident sustained serious injuries and was hospitalized. The staff assailant was suspended and terminated. The police and state oversight agencies were notified.

The facility failed to protect Resident #1 from physical abuse by a nonclinical employee, resulting in serious injuries including brain bleeds and fractures. The abuse was substantiated by video surveillance and witness statements, and the facility took corrective actions including staff suspension, training, and ongoing monitoring.

The complaint investigation was substantiated based on video surveillance and witness testimony. Resident #1 was physically assaulted by a housekeeper (HSK #1) on 8/18/24, causing serious injuries. The facility reported the incident to police and state oversight agencies and took corrective actions.

The facility failed to protect Resident #1 from physical abuse by a nonclinical employee, resulting in significant bodily injury including brain bleeds and fractures. The abuse was substantiated by video surveillance and witness statements. The facility took immediate corrective actions including suspension and termination of the employee, staff education, and ongoing monitoring.

The facility had multiple deficiencies including failure to ensure residents had reasonable access to communication phones, timely medication administration, adequate assistance with activities of daily living, proper restorative nursing programs, accurate oxygen therapy administration, proper medication storage and labeling, provision of mechanically altered diets according to orders, offering residents drink choices, safe food handling and storage, infection control practices, and completion of annual nurse aide training.

The facility was found deficient in multiple areas including failure to provide residents reasonable access to communication phones, inadequate assistance with activities of daily living for some residents, improper oxygen therapy administration, lack of annual performance reviews and training for nurse aides, improper medication storage and labeling, failure to provide mechanically altered diets according to orders, failure to accommodate resident food preferences, unsafe food handling and storage practices, and failure to maintain an effective infection prevention and control program.

The facility was found deficient in multiple areas including failure to ensure residents had reasonable access to communication devices, timely medication administration, adequate assistance with activities of daily living, implementation of restorative nursing programs, proper oxygen therapy administration, medication storage and labeling, provision of mechanically altered diets according to orders, accommodating resident food preferences, safe food handling and storage, infection control practices for residents on enhanced barrier precautions, and completion of annual nurse aide training and performance reviews.

The facility had multiple deficiencies including failure to ensure residents had reasonable access to communication devices, inadequate assistance with activities of daily living for some residents, improper oxygen therapy administration, incomplete annual nurse aide performance reviews and training, medication storage and labeling issues, failure to provide mechanically altered diets according to orders, failure to accommodate resident food preferences, unsafe food handling and storage practices, and failure to maintain infection control precautions for residents on enhanced barrier precautions.

The facility failed to ensure that emergency crash carts were regularly checked and properly maintained, including missing backboards, incomplete safety check logs, and absence of essential equipment such as blood pressure cuffs and stethoscopes on some carts.

The facility failed to ensure that emergency crash carts were regularly checked and properly maintained. Several crash carts lacked backboards, blood pressure cuffs, stethoscopes, and had incomplete or missing safety check logs.

The facility failed to fully honor resident preferences for showers and oral care, failed to provide timely wound care and documentation leading to actual harm for some residents, failed to assist with transportation scheduling, failed to ensure snacks were available on some units, failed to maintain proper infection control precautions, and failed to keep hallways clear of mechanical lifts.

The facility failed to fully honor resident self-determination regarding shower and oral care preferences for multiple residents, failed to provide appropriate wound care and documentation leading to hospitalization for cellulitis, failed to assist a resident with transportation scheduling, failed to ensure snacks were available on certain units, failed to maintain proper infection control precautions for a resident on isolation, and failed to maintain a safe environment by storing mechanical lifts in hallways blocking handrails.

The facility was found deficient in providing adequate ADL care for one resident, failing to prevent skin integrity problems due to incomplete cleaning after incontinence for another resident, and improperly disposing of garbage with uncovered dumpsters. Deficiencies were noted with minimal harm potential affecting few to many residents.

The facility failed to provide adequate personal care such as nail trimming and shaving for Resident #94, failed to properly clean Resident #53 after bowel incontinence which could lead to skin breakdown, and failed to properly secure dumpster lids posing sanitation concerns.

The facility was found deficient in multiple areas including failure to ensure qualified staff provided colostomy care, inadequate assistance with activities of daily living, unsafe use of non-medical grade power strips for medical equipment, insufficient dietary staffing leading to delayed meal service and resident dissatisfaction, failure to follow menus and provide nutritional needs, and unsanitary kitchen conditions including improper handwashing and dishwashing practices.

The facility failed to ensure qualified staff provided colostomy care, adequate assistance with activities of daily living, safe environment regarding medical device power strips, sufficient dietary support, adherence to menus, and sanitary kitchen conditions. Multiple minimal harm deficiencies were identified related to care, nutrition, safety, and sanitation.