Inspection visit
Inspection
Citations
44 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0347GeneralS&S Epotential for harm
Properly provide smoke detection systems in areas open to corridors.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
F926 - Establish policies, in accordance with applicable Federal, State, and
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
F584 - Safe Environment
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.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F625 - Transfer and discharge-
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
F645 - Preadmission Screening for individuals with a mental disorder and individuals
PASARR screening for Mental disorders or Intellectual Disabilities
F732 - Nurse Staffing Information
Post nurse staffing information every day.
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F813 - Food Safety Requirements
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
F814 - Food Safety Requirements
Dispose of garbage and refuse properly.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- 0036GeneralS&S Fpotential for harm
Establish emergency prep training and testing.
- 0037GeneralS&S Fpotential for harm
Establish staff and initial training requirements.
- 0100GeneralS&S Epotential for harm
Meet other general requirements.
- 0211GeneralS&S Dpotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0222GeneralS&S Dpotential for harm
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- 0281GeneralS&S Fpotential for harm
Install proper backup exit lighting.
- 0293GeneralS&S Epotential for harm
Have properly located and lighted "Exit" signs.
- 0311GeneralS&S Epotential for harm
Have an enclosure around a vertical opening shaft.
- 0321GeneralS&S Epotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0324GeneralS&S Fpotential for harm
Provide properly protected cooking facilities.
- 0331GeneralS&S Epotential for harm
Construct fire resistant interior walls.
- 0341GeneralS&S Epotential for harm
Install a fire alarm system that can be heard throughout the facility.
- 0343GeneralS&S Epotential for harm
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0355GeneralS&S Epotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0362GeneralS&S Epotential for harm
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
- 0372GeneralS&S Epotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0531GeneralS&S Fpotential for harm
Have elevators that firefighters can control in the event of a fire.
- 0541GeneralS&S Epotential for harm
Install properly constructed and protected linen or trash chutes.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F741 - The facility must have sufficient staff who provide direct services to
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
F761 - Labeling of Drugs and Biologicals
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
F771 - The facility must provide or obtain laboratory services to meet the
Ensure that smoke control systems are tested and documented in accordance with established engineering principles.
- 0781GeneralS&S Epotential for harm
Have restrictions on the use of portable space heaters.
F914 - Be designed or equipped to assure full visual privacy for each
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F919 - Resident Call System
Meet requirements for the use of electrical equipment.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.
FAQ · About this visit
Common questions about this visit
What happened during the November 23, 2021 survey of HIGHLAND REHABILITATION & HEALTH CARE CENTER?
This was a inspection survey of HIGHLAND REHABILITATION & HEALTH CARE CENTER on November 23, 2021. The surveyor cited 44 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at HIGHLAND REHABILITATION & HEALTH CARE CENTER on November 23, 2021?
Yes, 44 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Properly provide smoke detection systems in areas open to corridors."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.