Highlands Living Center: Hip Fracture Left Uninvestigated - NY
The hip fracture required surgery. The facility's response was to assume they already knew the answer and move on. They were wrong to assume, and they knew it.
Resident #2, whose name was withheld in the inspection report, had dementia, pulmonary fibrosis, and anxiety. On September 18, 2025, she was walking in a hallway when another resident pushed her to the floor. The fall broke her right arm. She was transferred to a hospital, treated, and returned to the facility.
Five days later, on September 23, a therapy progress note recorded something that should have raised an immediate alarm. During therapy, Resident #2 resisted range of motion to her right lower extremity and grimaced when staff tried to flex her right hip. She was in pain. Nobody filed a report. Nobody opened an investigation.
The next day, September 24, a physician assistant examined her and documented worsening right hip pain. An x-ray confirmed what the grimacing had already suggested: an acute right femoral neck fracture, a break at the top of the thigh bone where it meets the hip socket. She was transferred to the hospital again. On September 25, surgeons performed a right hip hemiarthroplasty, replacing part of her hip joint.
Still, no incident report was filed. No investigation was opened.
The inspection report, completed following a complaint investigation on May 28, 2026, documented what facility leadership acknowledged directly and without much resistance: they had simply assumed the hip fracture was connected to the September 18 altercation and decided that was enough. Registered Nurse Manager #1 told inspectors exactly that during an interview on May 27. The facility assumed the fracture was related to the altercation. There was no incident report. There was no investigation.
The Director of Nursing, sitting in the same interview, said there should have been both.
What the facility never determined, because it never tried, was whether the fracture actually happened during the altercation on September 18, or whether it happened sometime in the six days between the push and the x-ray. It never determined whether staff missed signs of injury during that window. It never determined whether the care Resident #2 received in the days after the altercation was adequate, or whether something was overlooked that a proper assessment would have caught. It never determined what corrective actions, if any, were needed to prevent the same thing from happening to someone else.
The facility's own abuse and neglect policy, last reviewed in April 2025, required exactly this kind of investigation. Injuries of unknown origin were to be thoroughly investigated with a written report. The investigation was supposed to include interviews with everyone involved, witness statements, staff statements, a review of relevant records, documented findings, and corrective actions. None of that happened.
The gap between September 18 and September 24 is six days. During that time, the therapy note from September 23 shows Resident #2 was in enough pain that she resisted movement and grimaced during hip flexion. That note existed in the facility's records. It was not acted on as a potential sign of injury.
Physician Assistant #1, interviewed by inspectors on May 28, 2026, said that when Resident #2 was assessed after the September 18 altercation, she complained only of right arm pain. Registered Nurse Manager #1, also interviewed that morning, said Resident #2 had completed range of motion without complaints of hip pain after the incident and was able to stand without difficulty.
Those accounts are not necessarily wrong. They may accurately reflect what staff observed on September 18. But they also illustrate exactly why an investigation was required rather than an assumption. A femoral neck fracture does not always announce itself immediately. A resident with moderate cognitive impairment and dementia may not be able to reliably communicate pain, locate it precisely, or describe it consistently to caregivers. The grimacing during therapy five days later was a documented sign. It was in the record. It did not prompt a report.
The administrator, interviewed on May 27, 2026, told inspectors the facility had work to do regarding investigations. That was the extent of it.
The inspection report classified the violation at a level of minimal harm or potential for actual harm, a designation that reflects the regulatory framework's assessment of the deficiency's severity tier. It affected one of seven residents reviewed. Those classifications exist within a formal scoring system and do not change what happened to Resident #2: she was pushed, she broke her arm, she came back, she broke her hip, she had surgery, and the facility responsible for her safety never formally asked why or how.
A resident-to-resident altercation serious enough to send a woman with dementia and pulmonary fibrosis to the hospital with a broken arm is, by definition, a serious event. It requires documentation, investigation, and a determination of what went wrong and what needs to change. The September 18 incident report was filed. That part happened. But when Resident #2 returned and then deteriorated, when the therapy note documented pain and resistance, when the physician assistant ordered an x-ray that confirmed a second fracture, the facility's investigative process stopped entirely.
The Director of Nursing said there should have been an incident report and a thorough investigation, including statements from caregivers. The administrator said the facility had work to do. Registered Nurse Manager #1 confirmed no report was filed and no investigation was completed. None of them disputed the findings.
What remains unknown, because the investigation was never done, is whether the hip fracture was present on September 18 and missed, or whether it developed or worsened in the days that followed. Whether Resident #2 experienced pain during those six days that staff did not recognize or document as significant. Whether a resident with moderate cognitive impairment and dementia was able to communicate what she was feeling and whether the people around her understood what she was telling them.
Those questions do not have answers in the record. The facility chose not to look for them.
Resident #2 underwent hip replacement surgery on September 25, 2025. She was discharged from the hospital and returned to Highlands Living Center. The inspection that documented the facility's failure to investigate was conducted eight months later, in May 2026, following a complaint.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Highlands Living Center from 2026-05-28 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 21, 2026 · Our methodology
Highlands Living Center in Pittsford, NY was cited for violations during a health inspection on May 28, 2026.
The hip fracture required surgery.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.