Heights Care & Rehabilitation LLC

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

A survey for Incident #39734 and Incident #39895 was conducted 5/7/25 to 5/8/25. One deficiency was cited. Based on record review and interviews, the facility failed to ensure four (#1, #2, #3 and #4) of four residents reviewed for abuse out of four sample residents were free from abuse.Specifically the facility failed to:-Prevent verbal and physical abuse between Resident #2 and Resident #4.-Protect Resident #1 from physical abuse by Resident #2; and,-Protect Resident #3 from physical abuse by Resident #4.Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy and procedure, revised 2025, was provided by the nursing home administrator (NHA) on 5/8/25 at 11:33 a.m. It read in pertinent part,"Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation."The Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigation policy and procedure, revised September 2022, was provided by the NHA on 5/8/25 at 11:33 a.m. It read in pertinent part,"Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents."II. Incident of verbal and physical abuse between Resident #2 and Resident #4 on 1/31/25A. Facility investigationThe 1/31/25 physical abuse investigation documented a witnessed resident-to-resident verbal and physical altercation between Resident #2 and Resident #4. Resident #2 and Resident #4 were in the smoking area during a supervised smoking session. Resident #2 walked up to Resident #4, who was standing with his back against the wall, and yelled at him. Resident #4 then called Resident #2 an expletive. Resident #2 attempted to push Resident #4, which caused Resident #2 to fall to the ground. Resident #2 then stood up and attempted to slap Resident #4.The staff separated the two residents. The two residents were assessed and no injuries were identified.The investigation indicated both residents were started on psychosocia..

A complaint survey, prompted by #CO36556, Incident #36259 and Incident #36558 was conducted on 7/9/24. One deficiency was cited. Based on record review and staff interviews, the facility failed to ensure one (#1) of three residents reviewed for abuse were kept free from abuse out of five sample residents. Specifically, the facility failed to protect Resident #1 from physical abuse by Resident #2.Findings include:I. Facility policy and procedureThe Abuse, Neglect, and Exploitation policy and procedure, revised April 2024, was provided by the director of nursing (DON) on 7/11/24 at 12:39 p.m. The policy read in pertinent part, "The nursing home administrator (NHA) is responsible for the overall coordination and implementation of the facility' s policies and procedures against abuse, neglect, exploitation and misappropriation of resident' s property. "Policies are in place that prohibit and prevent resident abuse, neglect, exploitation and misappropriation of resident' s property, establish processes to investigate such allegations, implement staff training and coordinate with the quality assurance and performance improvement (QAPI) committee."Policies address the following as part of abuse, neglect, exploitation and misappropriation prevention: Employee screening, staff training, prevention, identification of violations, investigative processes, protection of residents during investigations and reporting of and response to investigations."II. Facility investigation of the 2/4/24 incident between Resident #2 and Resident #1The 2/4/24 altercation investigation revealed Resident #2 began getting upset when Resident #1 was looking at him while they were smoking. Resident #2 ran up to Resident #1 and hit him multiple times in the head.Resident #2 was immediately placed on one to one supervision with a staff member. Resident #2 said Resident #1 was "talking crap so I hit him and he tried to fight me back." Resident #1 stated Resident #2 had just hit him and he yelled at him to stop. He said he hit his head. III. Resident #2 (assailant)A. Resident statusResident #2, age greater than 65, was admitted on 12/7/23 and discharged on 3/7/24. According to the March ..