Highline Post Acute

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Quality of Life and Care Deficiencies

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

Quality of Life and Care Deficiencies

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

Quality of Life and Care Deficiencies

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

Administration Deficiencies

Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

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.

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

Resident Rights Deficiencies

Ensure residents have reasonable access to and privacy in their use of communication methods.

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Nutrition and Dietary Deficiencies

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

Nursing and Physician Services Deficiencies

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

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

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

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.

A complaint survey, prompted by #CO1936080, #CO1936085, #CO1936087, #CO1936088, #CO1936090, #CO1936091, #CO1936092, #CO1936093 and Incident #1936089 was conducted on 6/30/25 to 7/14/25. One deficiency was cited. Based on observations, record review and interviews the facility failed to ensure an environment free of accident hazards for two (#1 and #19) of nine residents reviewed for accident hazards out of 21 sample residents.On 5/18/25 Resident #1 requested certified nurse aide (CNA) #1 to heat up an egg roll from his personal refrigerator in a microwave that was at the nurses’ station. After heating up the egg roll, CNA #1 gave the egg roll to Resident #1, without using a thermometer to check the temperature of the egg roll, and told the resident not to touch the egg roll because it was very hot. However, Resident #1 immediately picked up the egg roll after CNA #1 gave it to him. Hot liquid came out of the egg roll and dropped on the resident’s leg causing a second degree burn to Resident #1’s left thigh..On 5/19/25 the facility implemented a plan of correction in response to the incident which caused Resident #1’s left thigh burn. The corrective actions included placing thermometers and temperature logs at each nurses’ station for staff to take the temperatures of heated up food for residents and logging the temperatures prior to giving the food to the residents. However, on 6/30/25, during the survey, observations revealed the corrective actions implemented by the facility on 5/19/25 were not in place and none of the facility’s three microwaves at the nurses’ stations had a thermometer or a temperature log for staff to utilize.Additionally, on 6/19/25 Resident #19 was in the facility van, in his wheelchair, for an activity outing. Resident #19 was supposed to be secured in the van with a shoulder harness seatbelt placed across his chest, which also included a seatbelt extender attached to the seatbelt. The seatbelt extender was to be secured into a hook on the van floor. However, the seat belt was not secured properly on Resident #19. During the outing, another driver in front of the van made an abrupt turn which caused the transportation driver to quickly utilize the brakes. When the transportation driver suddenly stepped on the brakes, R..

A complaint survey, prompted by #CO39689, Incident #39505 and Incident #39631 was completed on 4/3/25 to 4/7/25. One deficiency was cited. Based on observations, record review and interviews, the facility failed to ensure one (#10) of three residents reviewed for falls out of 10 sample residents received adequate supervision and services to prevent an accident. Specifically, the facility failed to:-Ensure a root cause was identified for Resident #10' s fall on 3/16/25; and, -Ensure Resident #10' s care plan was reviewed for appropriate fall interventions after a fall. Findings include:I. Facility policy and procedureThe Safety and Supervision of Residents policy and procedure, reviewed 4/4/25, was provided by the nursing home administrator (NHA) on 4/8/25 at 12:02 p.m. It read in pertinent part, "Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities."Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. The interdisciplinary care team (IDT) shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents.The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices."Implementing interventions to reduce accident risks and hazards shall include the following: communicating specific interventions to all relevant staff, assigning responsibility for carrying out interventions, providing training, as necessary, ensuring that interventions are implemented and documenting interventions."Monitoring the effectiveness of interventions shall include the following: ensuring that interventions are implemented correctly and consistently, evaluating the effectiveness of interventions, modifying or replacing interventions as needed and evaluating the effectiveness of new or revised interventions.II. Resident #10A. Resident statusResident #10, age greater than 65, was admitted on 3/9/18. According to the April 2025 computerized physicia..