Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Highland Court, A Rehabilitation And Resident Care during CMS and state inspections, most recent first.
A resident with a history of multiple UTIs and MRSA in the urine did not receive proper perineal care, as a CNA was observed wiping the rectal area and then the perineal area without changing gloves or performing hand hygiene, and did not consistently clean from front to back. This failure to follow infection control protocols and facility policy occurred despite the resident's dependence on staff for toileting and ongoing contact isolation precautions.
The facility failed to treat residents with respect and dignity by labeling a dining table as the 'feeder table' for those needing assistance with meals. This practice affected two residents, including one with severe cognitive impairment and a history of Alzheimer's Disease, and was acknowledged by staff as detrimental to the residents' quality of life.
The facility failed to ensure that residents' call devices were within reach for two residents with severe cognitive impairment, potentially affecting 23 residents on the 300 hall. Observations and staff interviews revealed that call lights were not consistently accessible, and the facility lacks a call light policy.
The facility failed to review and revise the care plans for two residents, one with Alzheimer's and abnormal weight loss and another with dementia and Alzheimer's, leading to inconsistencies in medication administration and elopement risk management. Staff interviews revealed a lack of adherence to care plan revision protocols.
A resident with COPD was observed receiving oxygen at 4 liters per minute instead of the prescribed 2-3 liters per minute. The resident could not adjust the oxygen settings, and both an LPN and the DON confirmed that it was the nurses' responsibility to ensure the correct flow rate.
The facility failed to remove expired medications from the medication storage room, including 17 bottles of nutritional drink, a bottle of hydrogen peroxide, and a bottle of wound and skin cleanser. The medication room is checked monthly, but expired items were still present, potentially affecting 56 residents.
The facility failed to honor the dining preferences of two residents, impacting their nutritional intake. Staff did not consistently follow meal tickets, and there was no policy in place to ensure residents' preferences were met.
The facility failed to maintain sanitary conditions in food storage and preparation. Observations included staff not wearing hair nets, improper hand sanitation, undated and moldy food items, and staff storing personal items in residents' refrigerators. Multiple staff members confirmed these practices were against facility guidelines.
The facility failed to ensure staff performed proper hand hygiene and used appropriate infection control practices while serving residents in the main dining room. Staff members were observed not sanitizing hands before or during beverage service, and one CNA touched the inside of a milk carton before serving it to a resident. These actions were observed during the service of meals to residents with severe cognitive impairments and various medical conditions, making them particularly vulnerable to infections.
A resident with dementia and major depressive disorder did not receive the prescribed therapeutic diet, including specific food textures and added ice cream, due to staff inconsistencies in following standing orders and updating meal tickets. The resident was served meals and drinks that did not align with the physician's orders, impacting their nutritional intake.
The facility failed to ensure that a Minimum Data Set (MDS) was accurately coded for tracheostomy status for a resident. Despite having diagnoses including tracheostomy status, the quarterly MDS indicated otherwise. Both the DON and MDS Coordinator confirmed the error.
Failure to Provide Proper Perineal Care Resulting in Increased Risk of UTIs
Penalty
Summary
A deficiency was identified when staff failed to provide appropriate perineal care to a resident with a history of multiple urinary tract infections (UTIs) and MRSA in the urine. During an observation, a CNA was seen assisting a resident with perineal care after toileting. The CNA wiped the resident's rectal area and then, without changing gloves or performing hand hygiene, proceeded to clean the perineal area using a circular motion, alternating directions, and did not consistently wipe from front to back. This practice was contrary to the facility's policy and standard infection control procedures, which require cleaning the perineal area before the rectal area and changing gloves between tasks to prevent contamination. The resident involved had a history of frequent UTIs, was frequently incontinent of urine, and was dependent on staff for toileting hygiene due to severely impaired cognition. The resident had been admitted with a UTI diagnosis and had multiple documented episodes of UTIs, including MRSA in the urine, requiring contact isolation precautions. Medical records and interviews confirmed the resident's ongoing issues with UTIs and the need for strict adherence to infection prevention protocols during perineal care. Interviews with facility staff, including the CNA involved, the RN Nurse Consultant, the Administrator, and the DON, confirmed that the observed perineal care did not follow facility policy or accepted standards. Staff acknowledged the importance of proper technique, including cleaning from front to back and changing gloves between clean and dirty tasks, to prevent the introduction of bacteria to the perineal area. The facility's policy referenced the Lippincott Nursing Manual for guidance, but the provided documentation did not include specific instructions for incontinent care.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to treat each resident with respect and dignity, specifically for two residents who were seated at the dining assistive table in the main dining room. Resident #9, who had severe cognitive impairment and required substantial assistance with activities of daily living, was placed at a table referred to by staff as the 'feeder table.' This term was used by multiple CNAs to describe the table where residents needing assistance with meals were seated. The use of this term was confirmed through interviews with various staff members, including CNAs and the Director of Nursing (DON), who acknowledged that labeling residents in this manner does not promote or enhance their quality of life and is a dignity issue. Resident #9 had a history of Alzheimer's Disease and abnormal weight loss, requiring significant assistance with meals as indicated in their care plan. The staff's practice of referring to the table as the 'feeder table' and labeling residents based on their need for assistance was identified as a failure to treat residents with the respect and dignity they deserve. Interviews with staff members, including CNAs and an LPN, highlighted that such labeling could negatively impact the residents' sense of dignity and self-worth, which is contrary to the residents' rights to a dignified existence and quality of life.
Failure to Ensure Call Devices Were Within Reach
Penalty
Summary
The facility failed to ensure that residents' call devices were within reach for two residents, which had the potential to affect 23 residents residing on the 300 hall. Resident #14, who has severe cognitive impairment and requires assistance with various activities, was observed with the call light clipped on the air mattress controller attached to the headboard, out of reach while the resident was in a wheelchair at the foot of the bed. Similarly, Resident #32, also with severe cognitive impairment, was found with the call light on the floor, out of reach, on multiple occasions. Both residents expressed uncertainty about how to call for assistance when the call light was not accessible. Interviews with staff, including a CNA and an LPN, revealed that rounds are conducted every two hours, and call lights should always be within residents' reach. However, the staff acknowledged that the call lights for Residents #14 and #32 were not within reach during the observations. The facility does not have a call light policy, which may have contributed to the inconsistency in ensuring call lights are accessible to residents. The deficiency was identified through observations, interviews, and record reviews, highlighting a failure to reasonably accommodate the needs and preferences of the residents.
Failure to Review and Revise Care Plans
Penalty
Summary
The facility failed to review and revise the care plans for two residents, which had the potential to affect 57 residents currently residing in the facility. Resident #9, who was admitted with Alzheimer's Disease and abnormal weight loss, had a care plan that documented a UTI with a revision date of 03/11/2024. However, the resident's Medication Administration Record showed that they were receiving different medications for a UTI at different times, indicating a lack of timely updates to the care plan. Additionally, Resident #25, diagnosed with dementia with severe psychotic disturbance and Alzheimer's Disease, had a care plan indicating a risk for elopement and the need for an elopement monitoring bracelet. Despite this, the resident was observed without the bracelet, and staff confirmed its absence, showing a failure to update and follow the care plan appropriately. Interviews with staff, including a Nursing Assistant and the MDS Coordinator, revealed a lack of adherence to care plan revision protocols. The MDS Coordinator acknowledged that care plans should be revised whenever there are changes in the resident's condition, medications, or treatments. However, the facility did not have a specific policy for care plan revisions, relying instead on the RAI Manual and guidelines. This lack of a structured approach contributed to the deficiencies observed in the care plans for Residents #9 and #25.
Failure to Administer Oxygen at Prescribed Flow Rate
Penalty
Summary
The facility failed to ensure that oxygen was consistently administered at the flow rate ordered by the physician for a resident with chronic obstructive pulmonary disease (COPD). The physician's order specified that the resident should receive oxygen at 2-3 liters per minute via nasal cannula. However, observations on multiple occasions revealed that the resident's oxygen was set at 4 liters per minute. The resident, who was cognitively intact and unable to adjust the oxygen settings, confirmed that they could not reach the oxygen concentrator to make adjustments themselves. Licensed Practical Nurse (LPN) #1 confirmed that the oxygen should be set at 2-3 liters per minute and acknowledged that it was the nurses' responsibility to ensure the correct oxygen flow rate. The Director of Nursing (DON) also stated that it was the nurses' responsibility to follow the physician's orders regarding oxygen administration. The deficiency was identified through record review, observation, and interviews with the resident, LPN #1, and the DON. The facility's procedure manual specified the correct administration of oxygen, including verifying the patient and setting the flow rate at the prescribed liters per minute. Despite these guidelines, the resident's oxygen was consistently observed to be set higher than the prescribed rate, potentially leading to respiratory complications. The failure to adhere to the physician's order for oxygen administration was attributed to the nursing staff's oversight.
Expired Medications Not Removed from Storage
Penalty
Summary
The facility failed to ensure medications that were beyond their expiration date were removed or discarded. This deficiency was identified during an observation of the medication storage room, where 17 bottles of nutritional drink expired on 12/23, a bottle of hydrogen peroxide expired on 10/23, and a bottle of wound and skin cleanser expired on 4/21 were found. The review was conducted with a registered nurse who stated that the medication room is checked for expired medications once a month. However, the medication carts for the 300 Hall and 100 Hall were found to have no issues, and the nurses responsible for these carts indicated that they check them daily. The facility's policy on pharmaceutical services requires checking the emergency medication supply and medication storage facilities at least monthly to ensure proper storage, cleanliness, and removal of expired medications. Despite this policy, the expired items were not removed from the medication storage room, indicating a lapse in adherence to the facility's procedures. This failure has the potential to affect 56 residents who receive medication from the affected medication room.
Failure to Honor Resident Preferences During Dining Services
Penalty
Summary
The facility failed to ensure that residents' preferences were honored during dining services, which impacted the nutritional intake of two residents. Resident #24, who has diagnoses including cerebral infarction, type 2 diabetes mellitus, and abnormal weight loss, experienced a 6.73 percent weight loss over six months. Despite having specific drink preferences listed on their meal ticket, the resident did not receive the correct beverages during a dining service observation. Similarly, Resident #30, who has type 2 diabetes and dementia, did not receive the correct beverages as per their standing orders during a meal. The staff admitted to not checking the meal tickets and relying on memory or practice to serve drinks, leading to inconsistencies in following the residents' preferences. Interviews with the staff, including CNAs and the Dietary Manager, revealed that the standing orders were not consistently followed, and there was no policy in place for ensuring that residents' preferences were met. The CNAs acknowledged that they did not always check the meal tickets before serving drinks and admitted that the residents' preferences were not always honored. The Dietary Manager confirmed the importance of following standing orders, especially for residents experiencing weight loss. The Administrator also confirmed the absence of a policy for standing orders or preferences.
Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to store and prepare foods under sanitary conditions, as observed by surveyors. The Dietary Manager (DM) was seen without a hair net upon entering the kitchen and only put it on after a few minutes. Additionally, a Dietary Employee (DE) was observed not changing gloves or washing hands after touching contaminated fixtures while preparing food. The facility also lacked a policy for food storage, as confirmed by the Administrator. Furthermore, a Certified Nursing Assistant (CNA) was found storing a personal cup in the residents' refrigerator, which is against the facility's guidelines. The CNA admitted to doing so to prevent a resident from taking it, but acknowledged that staff's food and drinks should not be in the residents' refrigerator. The surveyor also noted several issues in the main nourishment room, including undated lunch meat and bread, moldy bread, and a container of barbeque sauce that was dented and less than half full with an open date of over a year ago. Multiple staff members, including CNAs, the DM, and the Director of Nursing (DON), confirmed that food items should be dated and that moldy or expired food should not be present. The DON also confirmed that staff's food and drinks should not be stored in the residents' refrigerator, as it is designated for residents' use only.
Failure to Perform Proper Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to ensure staff performed proper hand hygiene and used appropriate infection control practices while serving residents in the main dining room. Specifically, staff members were observed not performing hand hygiene before or during beverage service. One CNA was seen touching the inside of a milk carton and then serving the milk to a resident without sanitizing hands. Another CNA was observed touching their face and then assisting a resident without performing hand hygiene. These actions were observed during the service of meals to residents with severe cognitive impairments and various medical conditions, including Alzheimer's disease, dementia, and diabetes, which required assistance with activities of daily living and meal consumption. Resident #9, who had severe cognitive impairment and required substantial assistance with activities of daily living, was served a beverage by CNA #1 without proper hand hygiene. Similarly, Resident #16, who also had severe cognitive impairment, was served food by CNA #1, who did not sanitize hands between tasks. Resident #24 and Resident #30, both with severe cognitive impairments and requiring assistance with meals, were also served by staff who did not follow proper hand hygiene protocols. These residents had multiple medical conditions, including dementia, diabetes, and nutritional deficits, making them particularly vulnerable to infections. Interviews with the CNAs and the Infection Preventionist confirmed that hand hygiene should be performed before and after meals, between tasks, and between residents to prevent the spread of bacteria and infection. However, the observed practices did not align with these guidelines, leading to potential risks for the residents. The facility's inservice books indicated that staff had received education on infection control and handwashing, but the observed actions demonstrated a failure to implement these practices effectively during meal service in the dining room.
Failure to Follow Physician's Order for Therapeutic Diet
Penalty
Summary
The facility failed to ensure a physician's order for a therapeutic diet was followed for a resident diagnosed with dementia and major depressive disorder. The physician's order specified an increased calorie diet with mechanical soft texture, thin consistency, and the addition of ice cream to lunch and dinner meals. However, during dining service, the resident was observed eating lunch with supervision help from staff, but the meal did not include the prescribed ice cream, and the food was served in red bowls instead of the clear bowls specified in the meal ticket. Additionally, the resident was served drinks that did not align with the standing orders, including water, fruit punch, and cola instead of the prescribed sweet tea and vanilla ice cream. Interviews with CNAs and the Dietary Manager revealed inconsistencies in following the standing orders and updating meal tickets to reflect resident preferences. CNAs relied on memory and practice to determine what drinks to pass, and there was a lack of clarity on the process for updating resident preferences. The Dietary Manager acknowledged that the notes needed to be updated and that the standing orders should be followed. The failure to adhere to the physician's dietary orders and properly update meal tickets resulted in the resident not receiving the prescribed therapeutic diet, which is essential for their nutritional intake and overall health.
Failure to Accurately Code MDS for Tracheostomy Status
Penalty
Summary
The facility failed to ensure that a Minimum Data Set (MDS) was accurately coded for tracheostomy status for one resident. A review of the Order Summary revealed that the resident had diagnoses including acquired absence of larynx, tracheostomy status, presence of artificial larynx, and malignant neoplasm of larynx. Despite this, the quarterly MDS indicated that the resident did not have a tracheostomy. The Director of Nursing confirmed that the resident had a tracheostomy prior to admission and acknowledged that the MDS should reflect this to ensure accurate care. The MDS Coordinator also confirmed that the MDS was not coded correctly for the resident's tracheostomy status.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Marshall
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Creekside At The Springs | 21.8 mi | ★★★★★ | 0 | 0 |
| Ozark Health Nursing And Rehab Center | 24 mi | ★★★★★ | 0 | 0 |
| Twin Lakes Therapy And Living | 26.1 mi | ★★★★★ | 0 | 0 |
| Gassville Therapy And Living | 27.3 mi | ★★★★★ | 4 | 0 |
| The Springs Of Fairfield Bay | 30 mi | ★★★★★ | 4 | 0 |
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