Highlands Living Center
Highlands Living Center in Pittsford, NY — inspection on May 28, 2026.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of Resident #2's Comprehensive Care Plan and Kardex (care plan used by certified nursing assistants to direct care), last revised 07/28/2025, revealed Resident #2 was independent with a four (4) wheeled walker for ambulation (walking).Review of a facility Incident Report dated 09/18/2025 revealed Resident #2 was pushed to the floor by another resident while walking in the hallway. Resident #2 landed on the right side and complained of pain to the right shoulder and elbow.
The resident was found to have a right humeral fracture (arm fracture) and was transferred to the hospital.
The report did not identify a right hip injury.Review of a New York State Department of Health Incident Intake dated 09/18/2025 revealed the facility reported a resident-to-resident altercation and a right humeral fracture requiring hospital evaluation.Review of a Hospital Discharge summary dated [DATE] revealed Resident #2 was treated for a right humeral fracture and discharged back to the facility.Review of a therapy progress note dated 09/23/2025 revealed Resident #2 resisted range of motion to the right lower extremity and grimaced with right hip flexion (bringing the thigh closer to torso/abdomen).Review of a provider visit note dated 09/24/2025 and documented by Physician Assistant #1 revealed worsening right hip pain.
An x-ray identified an acute right femoral neck fracture (hip fracture). Resident #2 was transferred to the hospital for further evaluation and treatment.Review of a hospital Orthopedic (medical specialty focused on the conditions of the musculoskeletal system, such as bones) Surgery Consult dated 09/24/2025 revealed Resident #2 presented with right hip pain after being pushed by another resident on 09/18/2025.
The consult documented difficulty bearing weight (the amount of body weight you a person can safely put on an injured limb) since the incident and identified a right femoral neck fracture.Review of a Hospitalization Summary dated 10/01/2025 revealed Resident #2 underwent a right hip hemiarthroplasty (partial hip replacement) on 09/25/2025 following identification of the right femoral neck fracture.Review of an Investigative Report submitted to the New York State Department of Health on 09/23/2025 and revised on 09/24/2025 revealed the report included the resident-to-resident altercation and right humeral fracture.
The report did not include the right femoral neck fracture, hospitalization, or surgical intervention.
During an interview on 05/27/2026 at 11:06 AM with Registered Nurse Manager #1 and Director of Nursing #1, Registered Nurse Manager #1 stated the facility assumed the hip fracture was related to the 09/18/2025 altercation.
Registered Nurse Manager #1 stated no additional incident report was completed after the fracture was identified.
Director of Nursing #1 stated the right hip fracture should have been reported to the State Survey Agency.Title 10 New York Codes, Rules and Regulations 415.4(b)(4) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
335786 05/28/2026
Highlands Living Center 500 Hahnemann Trail Pittsford, NY 14534
Review of a facility Incident Report dated 09/18/2025 revealed Resident #2 was pushed to the floor by another resident while walking in the hallway. Resident #2 sustained a right humeral fracture (arm fracture) and was transferred to the hospital.Review of a Hospital Discharge summary dated [DATE] revealed Resident #2 returned to the facility following treatment of the right humeral fracture.Review of a therapy progress note dated 09/23/2025 revealed Resident #2 resisted range of motion to the right lower extremity and grimaced with right hip flexion (bringing the thigh closer to torso/abdomen).Review of a provider visit note dated 09/24/2025 and documented by Physician Assistant #1 revealed worsening right hip pain. An x-ray identified an acute right femoral neck fracture. Resident #2 was transferred to the hospital for further evaluation and treatment.Review of a Hospitalization Summary dated 10/01/2025 revealed Resident #2 underwent a right hip hemiarthroplasty on 09/25/2025 following identification of the right femoral neck fracture.Review of facility records revealed no incident report was completed after the right femoral neck fracture was identified on 09/24/2025.Review of facility records revealed no documented investigation was completed to determine the cause of the fracture, whether the fracture was related to the 09/18/2025 resident-to-resident altercation, whether signs or symptoms of injury were missed following the incident, or whether additional corrective actions were needed.
During an interview on 05/27/2026 at 11:06 AM with Registered Nurse Manager #1 and Director of Nursing #1, Registered Nurse Manager #1 stated the facility assumed the fracture was related to the 09/18/2025 altercation and there was no incident report or investigation completed after the fracture was identified.
Director of Nursing #1 stated there should have been an incident report and a thorough investigation completed regarding the right hip fracture, including statements from caregivers.
During an interview on 05/27/2026 at 1:30 PM, the Administrator stated the facility had work to do regarding investigations.
During an interview on 05/28/2026 at 9:41 AM, Physician Assistant #1 stated Resident #2 was assessed following the 09/18/2025 altercation and complained only of right arm pain.During an interview on 05/28/2026 at 9:41 AM, Registered Nurse Manager #1 stated Resident #2 was assessed following the altercation, completed range of motion without complaints of hip pain, and was able to stand without difficulty.Title 10 New York Codes, Rules and Regulations 415.4(b)(2)
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.