Resident 339 was admitted on June 13, 2024, at 11:45 AM with a left femur fracture. She told inspectors she requested pain medication that afternoon and again during the night but received nothing until 8:30 AM the following morning — nearly 21 hours after admission.
Her family member confirmed the resident called during the night to report the lack of pain medication. The night shift nursing assistant acknowledged the resident requested pain medication and said she informed the nurse.
The facility's Director of Nursing Services admitted the emergency medication kit contained the resident's prescribed pain medications and that every nurse had access. "Resident 339 should have received her pain medications when she requested it," the DNS told inspectors.
This was not an isolated incident. Another resident, 85, experienced similar problems in November 2023 while recovering from arm and leg fractures. Despite being prescribed oxycodone every four hours while awake, the resident missed six doses between November 24 and November 27. When staff tried to switch to Percocet, notes indicated the medication was "not available."
No additional pain medications were added to help the resident. Her pain levels during this period ranged from four to nine on a 10-point scale, with levels of four to six indicating moderate pain and seven or higher representing severe pain.
During a physical therapy session on November 27, Resident 85 reported pain levels of six in her leg and eight in her wrist. The therapist noted she was "frustrated with not having proper pain medications."
The facility's medication problems extended beyond pain management. Resident 133, admitted in 2023 with an infection, missed prescribed antibiotics on multiple occasions. In November 2023, staff failed to administer antibiotics five times when they were ordered every four hours. The following month, the resident missed three more doses.
When inspectors asked about the missed medications, an LPN explained that staff were supposed to enter "yes" in the electronic record after giving medication, or mark "refused," "resident not available," or "see nurse's note" if the medication wasn't given. The medication record "should not be blank for scheduled medications," the nurse said.
Safety equipment failures put residents at additional risk. Resident 51, admitted in 2023 with cancer, fell out of bed in March 2024 when her mattress slipped. The fall investigation determined staff should readjust the mattress and apply nonslip material underneath to prevent future incidents.
Three months later, the resident told inspectors her mattress still didn't fit the bed frame and had caused her to fall. "Staff did not provide her with a new mattress," she said.
When a nursing assistant checked under the bed with the resident's permission, no nonslip material was visible. The mattress was positioned on top of the bed brackets rather than within them, as intended. The administrator acknowledged the mattress was too large and said it would be addressed.
Resident 57 faced even more serious safety lapses. Admitted in 2023 following a stroke, she had a history of falls and impulsive behavior, often getting up without using her call light. Her care plan specified multiple fall prevention measures: ambulation during day and evening shifts, a bedside commode next to the bed, commonly used items within reach, and a sign reminding her to call for assistance.
On June 6, 2024, a housekeeper witnessed Resident 57 attempting to transfer to the bathroom without assistance. The resident lost her balance and fell backward against the bed, sustaining bruising on her mid back. The fall investigation noted she was wearing regular socks instead of nonslip socks and attributed the incident to "poor safety awareness and cognitive impairment exacerbated by the use of regular socks."
Despite the care plan requirements, inspectors found the bedside commode positioned against the wall near the door, away from the bed, on multiple occasions. The bedside table was often out of reach. During one observation, inspectors watched Resident 57 transfer from her wheelchair to bed without assistance.
When the housekeeper who witnessed the June 6 fall was interviewed, she said another nurse questioned a nursing assistant about "the absence of the bedside commode and fall mat near Resident 57's bed."
A third resident, 63, fell three times in May 2024 while attempting to use the bathroom. Her care plan specified she needed a bedside commode for toileting, but inspectors found no commode in her room. A nursing assistant confirmed "a bedside commode would be helpful to prevent falls." The Resident Care Manager acknowledged "the care plan was not followed."
The facility also failed to provide basic vision care. Resident 20, admitted in 2021 with dementia, had been without functional glasses since at least December 2023. Her spouse said she liked to read and wore glasses, but they were broken. A nursing assistant confirmed the lens had been missing since December 2023.
The Social Service Director told inspectors she found an unsigned note on her desk on June 11, 2024, reporting one of the resident's lenses was broken. She was unaware of the issue and the resident had no scheduled vision appointments. The resident's quarterly assessment from March 2023 indicated she had adequate vision with corrective lenses.
Medical care coordination also suffered. Resident 134, admitted in 2023 with kidney disease, was supposed to receive dialysis three times weekly on Mondays, Wednesdays, and Fridays. On December 11, 2023, the facility failed to provide transportation, causing the resident to miss a treatment.
A former RN reported to the State Survey Agency that "the facility did not follow up with transportation for Resident 134." The dialysis center RN confirmed the resident missed treatment due to lack of transportation and noted that nursing facilities are responsible for assisting residents to and from dialysis.
Pharmacy recommendations went unaddressed for months. Resident 33 was prescribed temazepam for insomnia, but the pharmacist recommended discontinuation or reduced frequency in April and May 2024. The recommendation wasn't signed until June 11, and staff acknowledged they "did not follow up on pharmacy recommendations promptly."
The consultant pharmacist said the standard response time was 30 days, "but often took 60 days or longer to receive a response from the physician." The DNS said he expected staff to follow up weekly "to prevent oversights or delays."
Staff training deficiencies compounded these problems. Three of five randomly selected nursing assistants had not completed the required 12 hours of annual training. One completed only six hours, while two others completed 10 hours each.
The facility also struggled with basic infection control. A nursing assistant was observed carrying dirty linens down the hallway without placing them in a bag first. She acknowledged not having bags and knowing that linens should be bagged before transport.
Administrative oversight proved inadequate as well. The facility failed to post complete daily staffing information on multiple occasions. Required census numbers were missing from evening and night shifts on several dates, and the night shift information was completely blank on some daily reports.
Highland House's problems reflect systemic failures in medication management, safety protocols, and basic care coordination that left vulnerable residents without essential services and protections.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Highland House Nursing & Rehabilitation Center from 2024-06-14 including all violations, facility responses, and corrective action plans.
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