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Health Inspection Summary

Highland House Rehabilitation and Healthcare

1700 Pamalee Drive

Fayetteville, NC 28301

(910) 488-2295

Deficiency Category	Inspection Date: 12/19/24 Complaint Reporting Period: 4/1/24 - 3/31/25	Inspection Date: 10/25/23 Complaint Reporting Period: 4/1/23 - 3/31/24	Inspection Date: 6/24/22 Complaint Reporting Period: 4/1/22 - 3/31/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies	0	0	2
Quality of Life and Care Deficiencies	1	1	4
Infection Control Deficiencies	0	2	2
Resident Assessment and Care Planning Deficiencies	2	1	4
Nursing and Physician Services Deficiencies	0	0	1
Resident Rights Deficiencies	3	0	0
Nutrition and Dietary Deficiencies	0	1	0
Pharmacy Service Deficiencies	0	0	1
Environmental Deficiencies	0	0	0
Administration Deficiencies	0	0	0

Detailed result for inspection on 12/19/24

Date of last standard health inspection:	12/19/24Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25	12/19/24Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/24 - 3/31/25	No infection control inspections
Total number of Health Deficiencies for this nursing home:	6
Average number of Health Deficiencies in North Carolina:	7
Average number of Health Deficiencies in the United States:	9.6

Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide care and assistance to perform activities of daily living for any resident who is unable.	12/19/24	1/21/25	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure each resident receives an accurate assessment.	12/19/24	1/21/25	2 - Minimal harm or potential for actual harm	Few
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.	12/19/24	1/21/25	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.	12/19/24	1/21/25	2 - Minimal harm or potential for actual harm	Few
Honor the resident's right to manage his or her financial affairs.	12/19/24	1/22/25	1 - Potential for minimal harm	Some
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.	12/19/24	1/21/25	2 - Minimal harm or potential for actual harm	Few

Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.

Pharmacy Service Deficiencies
No Pharmacy Service Deficiencies were found during this inspection period.

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 10/25/23

Date of last standard health inspection:	10/25/23Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24	8/24/23Read the full report (PDF) 6/14/23Read the full report (PDF) 4/26/23Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/23 - 3/31/24	4/26/23Read the full report (PDF)
Total number of Health Deficiencies for this nursing home:	5
Average number of Health Deficiencies in North Carolina:	7
Average number of Health Deficiencies in the United States:	9.4

Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	8/24/23	9/19/23	2 - Minimal harm or potential for actual harm	Some

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	4/26/23	6/14/23	2 - Minimal harm or potential for actual harm	Some
Perform COVID19 testing on residents and staff.	4/26/23	6/14/23	2 - Minimal harm or potential for actual harm	Some

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Plan the resident's discharge to meet the resident's goals and needs.	8/24/23	9/19/23	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
No Resident Rights Deficiencies were found during this inspection period.

Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.	6/14/23	6/30/23	2 - Minimal harm or potential for actual harm	Few

Pharmacy Service Deficiencies
No Pharmacy Service Deficiencies were found during this inspection period.

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 6/24/22

Date of last standard health inspection:	6/24/22Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23	3/8/23Read the full report (PDF) 6/24/22Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23	No infection control inspections
Total number of Health Deficiencies for this nursing home:	14
Average number of Health Deficiencies in North Carolina:	7.1
Average number of Health Deficiencies in the United States:	8.7

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	6/24/22	6/24/22	4 - Immediate jeopardy to resident health or safety	Few
Develop and implement policies and procedures to prevent abuse, neglect, and theft.	6/24/22	6/24/22	4 - Immediate jeopardy to resident health or safety	Few

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide appropriate pressure ulcer care and prevent new ulcers from developing.	3/8/23	4/26/23	2 - Minimal harm or potential for actual harm	Few
Provide appropriate foot care.	6/24/22	7/22/22	2 - Minimal harm or potential for actual harm	Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	6/24/22	7/22/22	2 - Minimal harm or potential for actual harm	Few
Provide safe and appropriate respiratory care for a resident when needed.	6/24/22	7/22/22	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.	3/8/23	4/26/23	2 - Minimal harm or potential for actual harm	Few
Provide and implement an infection prevention and control program.	6/24/22	7/22/22	2 - Minimal harm or potential for actual harm	Few

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Assess the resident when there is a significant change in condition	3/8/23	4/26/23	2 - Minimal harm or potential for actual harm	Few
Assure that each resident’s assessment is updated at least once every 3 months.	3/8/23	4/26/23	2 - Minimal harm or potential for actual harm	Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	3/8/23	4/26/23	2 - Minimal harm or potential for actual harm	Some
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	6/24/22	7/22/22	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.	6/24/22	7/22/22	2 - Minimal harm or potential for actual harm	Some

Resident Rights Deficiencies
No Resident Rights Deficiencies were found during this inspection period.

Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure that residents are free from significant medication errors.	3/8/23	6/14/23	2 - Minimal harm or potential for actual harm	Few

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Complaints and facility-reported incidents in the past 3 years
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide care and assistance to perform activities of daily living for any resident who is unable.	12/19/24	1/21/25	2 - Minimal harm or potential for actual harm	Few
Ensure each resident receives an accurate assessment.	12/19/24	1/21/25	2 - Minimal harm or potential for actual harm	Few
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.	12/19/24	1/21/25	2 - Minimal harm or potential for actual harm	Few
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.	12/19/24	1/21/25	2 - Minimal harm or potential for actual harm	Few
Honor the resident's right to manage his or her financial affairs.	12/19/24	1/22/25	1 - Potential for minimal harm	Some
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.	12/19/24	1/21/25	2 - Minimal harm or potential for actual harm	Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	8/24/23	9/19/23	2 - Minimal harm or potential for actual harm	Some
Provide and implement an infection prevention and control program.	4/26/23	6/14/23	2 - Minimal harm or potential for actual harm	Some
Perform COVID19 testing on residents and staff.	4/26/23	6/14/23	2 - Minimal harm or potential for actual harm	Some
Plan the resident's discharge to meet the resident's goals and needs.	8/24/23	9/19/23	2 - Minimal harm or potential for actual harm	Few
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.	6/14/23	6/30/23	2 - Minimal harm or potential for actual harm	Few
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	6/24/22	6/24/22	4 - Immediate jeopardy to resident health or safety	Few
Provide appropriate pressure ulcer care and prevent new ulcers from developing.	3/8/23	4/26/23	2 - Minimal harm or potential for actual harm	Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	6/24/22	7/22/22	2 - Minimal harm or potential for actual harm	Few
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.	3/8/23	4/26/23	2 - Minimal harm or potential for actual harm	Few
Assess the resident when there is a significant change in condition	3/8/23	4/26/23	2 - Minimal harm or potential for actual harm	Few
Assure that each resident’s assessment is updated at least once every 3 months.	3/8/23	4/26/23	2 - Minimal harm or potential for actual harm	Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	3/8/23	4/26/23	2 - Minimal harm or potential for actual harm	Some
Ensure that residents are free from significant medication errors.	3/8/23	6/14/23	2 - Minimal harm or potential for actual harm	Few

Infection control inspection deficiencies in the past 3 years
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	4/26/23	6/14/23	2 - Minimal harm or potential for actual harm	Some
Perform COVID19 testing on residents and staff.	4/26/23	6/14/23	2 - Minimal harm or potential for actual harm	Some

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