Highland Park Rehabilitation & Care Center

Quality of Life and Care Deficiencies

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

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

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.

Nutrition and Dietary Deficiencies

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Smoke Deficiencies

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

Nutrition and Dietary Deficiencies

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

Nutrition and Dietary Deficiencies

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

Environmental Deficiencies

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Environmental Deficiencies

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Smoke Deficiencies

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

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.

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Nutrition and Dietary Deficiencies

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Smoke Deficiencies

Provide properly protected cooking facilities.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Quality of Life and Care Deficiencies

Provide or obtain dental services for each resident.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Nutrition and Dietary Deficiencies

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

A complaint survey, prompted by #CO1932100, #CO1932102, #CO1932104, #CO1932107, #CO2565214, #CO2565245, #CO2565254, Incident #1932105 and Incident #1932106 was conducted on 6/30/25 to 7/28/25. Three deficiencies were cited. Based on record review and interviews, the facility failed to ensure notification to the resident representative of a significant change in the resident’s physical, mental or psychosocial status for one (#11) of three residents reviewed for change of condition out of 20 sample residents.Specifically, the facility failed to notify Resident #11’s representative of the resident’s deteriorating wounds in a timely manner.Findings include:I. Facility policy and procedureThe Notification of Change policy, revised January 2025, was provided by the nursing home administrator (NHA) on 7/28/25 at 12:11 p.m. The policy read in pertinent part, “The facility must inform the resident, consult with the resident’s physician and/or notify the resident’s family members or legal representative when there is a change requiring such notification. Circumstances requiring notification include significant change in the resident’s physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include life .. Based on record review and interviews, the facility failed to ensure one (#6) of seven residents reviewed for abuse out of 20 sample residents were free from abuse.Specifically, the facility failed to protect Resident #6 from abuse by Resident #9.Findings include:I. Facility policy and procedureThe Abuse, Neglect and Exploitation policy, reviewed January 2025, was provided by the nursing home administrator (NHA) on 6/30/25 at 12:00 p.m. It read in pertinent part, “It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.“The facility will have written procedures to assist staff in identifying the different types of abuse: mental/verbal abuse, sexual abuse, physical abuse and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident-to resident altercations. Possible indica.. Based on record review and interviews, the facility failed to ensure supervision and monitor assistive devices to prevent accidents for one (#1) of three residents reviewed for accidents out of 20 sample residents. Resident #1 was admitted to the facility for skilled nursing care on 6/13/25 .The resident’s care plan directed staff to utilize a mechanical lift for transfers. On 6/18/25, Resident #1 was noted to have pain to her left upper extremity and bilateral lower extremities after being lowered to the floor with the use of a mechanical lift by certified nurse aide (CNA) #1. After the resident’s fall, CNA #1 and CNA #6 proceeded to assist Resident #1 into her wheelchair using the mechanical lift, prior to the resident being assessed by a registered nurse (RN) (see staff interviews below). Resident #1 was transported to the hospital on 6/18/25 where it was revealed that the resident had sustained fractures to her upper left arm (humerus) and both legs (tibia). The facility investigation after the incident revealed CNA #1 attempted to t..

A complaint survey. prompted by #CO38919, #CO39860 and #CO39903 was conducted on 5/21/25 to 5/22/25. Two deficiencies were cited. Based on record review and interviews, the facility failed to thoroughly investigate allegations of abuse for two (#2 and #3) of eight residents out of 15 sample residents. Specifically, the facility failed to complete a thorough investigation after an allegation of physical abuse towards Resident #3 by Resident #2.Findings include:I. Facility policy and procedureThe Abuse, Neglect and Exploitation policy, revised January 2025, was provided by the nursing home administrator (NHA) on 5/21/25 at 11:30 a.m. The policy read in pertinent part, "It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect and exploitation and misappropriation of property or resident property. "An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include identifying staff responsible for the investigation, exercising caution in handling evidence that could be used in a criminal investigation, investigating different types of alleged violations, identifying and interviewing all involved persons including that alleged victim, alleged perpetrator, witnesses and others who might have knowledge of the allegations, focusing the investigation on determining if abuse, neglect, exploitation and/or mistreatment has occurred, the extent and the cause, and providing complete and thorough documentation of the investigation."II. Incident of physical abuse of Resident #3 by Resident #2A. Facility investigationThe 3/10/25 facility investigation was provided by the director of nursing (DON) on 5/22/25 at 12:00 p.m. The incident report revealed Resident #2 had combative behaviors during care toward staff on 4/6/25. When Resident #2 was in the dining room, he was offered snacks by activities assistant (AA) #1 at approximately 10:30 a.m. Resident #2 started to throw items off the table and splashe..

Based on a record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72. This was evidenced by the following:1. A current 2-year smoke detector sensitivity report was not provided.NFPA 101 19.3.4.1 to comply with section 9.6. Section 9.6.1.3, fire alarm system testing and maintenance to comply with NFPA 72. NFPA 72 14.4.5.3.4; to ensure that each smoke detector or smoke alarm is within its listed and marked sensitivity range, it shall be tested using any of the following methods:(1) Calibrated test method(2) Manufacturer' s calibrated sensitivity test instrument(3) Listed control equipment arranged for the purpose(4) Smoke detector/fire alarm control unit arrangement whereby the det.. Based on observation and staff interviews, it was determined that the facility failed to maintain fire barriers and fire doors in accordance with NFPA 101 Chapter 19,8 and 7 and NFPA 80. This was evidenced by the following:1. Inspection reports were not provided for drop-down fire doors in the kitchen (x2).NFPA 80, 5.2.14.3 All horizontal or vertical sliding and rolling fire doors shall be inspected and tested annually to check for proper operation and full closure.5.2.14.3.2 A written record shall be maintained and shall be made available to the AHJ.5.2.14.3.3 When the annual test for proper operation and full closure is conducted, rolling steel fire doors shall be drop-tested twice.5.2.14.3.4 The first test shall be to check for proper operation and full closure.5.2.14.3.5 A second test shall b.. Based on record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.6. This was evidenced by the following:1. Fire drills were not conducted for the first shift during the first quarter and for the second shift in the third quarter.NFPA 101, 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance Director at the exit conference. INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics.This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.90(a).This survey was conducted on January 2, 2025 for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies."This structure is a one (1) story, Type V (111) (VA) construction. This original facility was constructed in 1972. There is no basement. The facility is licensed for 110 beds. The facility is fully protected throughout by a National Fire Protection Association (NFPA) 13 Fire Sprinkler Systems. The wet-pipe system protects the main level and attic space. There is an anti-freeze loop that protects the .. Through observation during the documentation review, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 25, and 13. This was evidenced by the following:1. A current Semi-annual fire sprinkler inspection report was not provided.NFPA 101 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part ..