Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 The Highlands during CMS and state inspections, most recent first.
Multiple residents were found in bed with their pants or jeans pulled down to their ankles or knees, exposing their briefs, as confirmed by staff and family interviews. Staff reported this was done to make checking and changing briefs easier, but other CNAs acknowledged the practice was not acceptable.
Staff failed to promptly report and address a non-operational air conditioning unit in the CCDI unit, resulting in excessive heat and humidity, condensation, and wet floors. Multiple staff observed and attempted to manage the situation without notifying management or maintenance, leading to unsafe conditions for residents until the issue was escalated and addressed.
Two residents were not given the required 48-hour advance notice of Medicare non-coverage and potential financial liability before their Skilled Nursing Care ended and they transitioned to private pay. Documentation showed that the necessary NOMNC and SNFABN forms were not reviewed or signed in a timely manner, and staff interviews confirmed lapses in following the established process for providing these notices.
The facility did not ensure that required dependent adult abuse training was completed within six months of hire for an LPN, a Food Service Supervisor, a CNA, and a Cook. Personnel files lacked timely documentation of this training, and the facility had no system in place to track completion, despite policy and assessment requirements.
A resident was discharged to a hospital and later readmitted, but the facility did not complete the required Discharge and Reentry MDS assessments as mandated. Staff interviews and record reviews confirmed the assessments were not initiated or completed until after the deficiency was identified.
A resident with moderate cognitive impairment and supervision needs for eating experienced acute changes in condition, including increased blood pressure, elevated pulse, and mental status changes. Despite these signs, the facility failed to conduct follow-up assessments or notify the physician, leading to severe dehydration and sepsis. The resident was eventually transported to the hospital, where he was diagnosed with sepsis and dehydration, and later passed away.
A facility failed to notify a resident's family and PCP of bruising on the resident's forearm in a timely manner. The bruising was documented, but there was no notification until several days later, contrary to the facility's policy requiring notification by the next morning for non-emergent issues. Staff confirmed the expectation to follow the skin protocol and notify promptly.
A facility failed to assess and document a bruise on a resident's forearm, lacking measurements and photographs. Staff interviews revealed confusion about documentation procedures in the electronic health record system, with no formal policy for skin alterations. An RN provided informal training, but it was not part of the onboarding process.
A resident with cognitive impairment fell from a mechanical lift during a transfer due to an unsecured strap, resulting in a head injury and shoulder pain. Despite training protocols requiring two staff to ensure secure transfers, the incident occurred, and the resident was later sent to the ER for evaluation.
The facility failed to provide 10 residents on pureed diets with adequate portions, as observed during a chicken sandwich puree process. Staff initially did not include enough buns to match the number of chicken patties, risking insufficient caloric intake compared to regular diets. The surveyor intervened to correct the portioning, highlighting a lack of clear instructions in the facility's Therapeutic Diets policy.
The facility did not ensure that dietary staff were qualified and educated, as required by their job descriptions, to provide food service to residents. Meal service was observed to start later than scheduled on two occasions. Despite a cook's claim of training in diet preparation, the RN Supervisor confirmed that no dietary staff had completed the necessary training in safety, sanitization, or modified diets.
The facility failed to ensure proper sanitary conditions during meal service. A staff member, while wearing gloves, touched various surfaces and then handled sandwich buns with the same gloves, leading to contamination of food served to multiple residents. The facility's policy lacked specific instructions on glove use, and an RN Supervisor had instructed staff to remove gloves and wash hands when in doubt, but these instructions were not followed.
The facility failed to submit new PASRRs for two residents with severe cognitive impairments. One resident's PASRR omitted a bipolar disorder diagnosis, and another's omitted post-traumatic stress disorder, both requiring Level II evaluations. Staff interviews revealed a breakdown in the process for advising when PASRR Level II determinations are needed.
A resident with moderate cognitive impairment was found with unsecured medications in their room without physician orders or assessments for self-administration. The facility staff were unaware of any residents authorized to self-medicate, and the DON was unfamiliar with the policy for self-administration. The facility's policy requires a physician order, assessment, and secure storage, which were not followed.
The facility did not have a qualified Dietary Manager, as the current manager had not completed a state-approved food service supervisor's course, despite being employed since early 2024. This was confirmed through a review of the employee file and an interview with an RN Supervisor.
Residents Left in Bed with Pants Pulled Down for Staff Convenience
Penalty
Summary
Surveyors observed that multiple residents were positioned in bed with their pants or jeans pulled down to their ankles or knees, exposing their briefs. This was confirmed for five residents during random observations, with staff present at the time. One resident, diagnosed with Alzheimer's Disease, was found in bed with sweatpants around his ankles. Staff confirmed this positioning and removed the pants upon observation. The resident's wife also reported seeing her husband's pants around his ankles on several occasions and expressed her dissatisfaction with this practice, noting it was not how he was dressed at home. Staff interviews revealed that some CNAs positioned residents in bed with their pants around their ankles or knees to facilitate easier checking and changing of briefs. However, other staff members acknowledged that this practice was not acceptable and had observed it occurring at various times. The report documents that this practice was carried out for at least five residents, and staff were aware of the inappropriate positioning of resident clothing while in bed.
Failure to Address Air Conditioning Malfunction and Resulting Unsafe Conditions
Penalty
Summary
The facility failed to properly monitor and intervene when the air conditioning unit in the Chronic Confusion or Dementing Illness (CCDI) unit became non-operational, resulting in excessively warm and humid conditions. Multiple staff members, including RNs, LPNs, and CNAs, observed that the unit became hot, with significant humidity causing condensation and wet, slippery floors. Staff attempted to manage the moisture by dry mopping the floors, but did not notify management or the maintenance department about the high temperatures and humidity during the evening and night shifts. The lack of timely communication delayed appropriate intervention. Staff interviews confirmed that the issue persisted across several shifts, with reports of extremely hot conditions, condensation on floors in hallways and dining areas, and water observed in resident rooms. The Director of Human Resources/Interim Administrator was eventually notified by housekeeping staff, who reported the ongoing problem. Maintenance was contacted the following morning, at which point fans and dehumidifiers were brought in, and additional equipment was purchased to address the malfunction. The deficiency was further substantiated by climatological data indicating high outdoor temperatures during the incident.
Failure to Provide Timely Medicare Non-Coverage Notices Before End of Skilled Nursing Care
Penalty
Summary
The facility failed to provide the required 48-hour advance notice of Medicare non-coverage and potential financial liability to two residents prior to the end of their Skilled Nursing Care stays. For one resident, documentation showed that Skilled Nursing Care began on 2/28/25 and transitioned to private pay on 3/20/25, but there was no evidence in the electronic health record or progress notes that the Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) forms were reviewed with the resident or their Power of Attorney at least 48 hours before the transition. The forms were not signed until 10 days after the transition. For the second resident, Skilled Nursing Care started on 12/1/24 and transitioned to private pay on 1/14/25, but again, there was no documentation that the required notices were provided 48 hours in advance, and the forms were not signed until the day after the transition. Staff interviews confirmed that the process for providing these notices was not consistently followed. The Medical Records staff member stated that she spoke with the Power of Attorney before the resident was discharged from Skilled Nursing Care but admitted she may have forgotten to document it. The Nurse Manager indicated that a process exists to ensure the timely completion of Skilled Nursing Care notice forms, but the records reviewed did not reflect compliance with this process for the two residents in question.
Failure to Provide Timely Dependent Adult Abuse Training to Staff
Penalty
Summary
The facility failed to provide required dependent adult abuse training to staff within six months of hire, as evidenced by personnel file reviews for four out of five employees. Specifically, the files for an LPN, a Food Service Supervisor, a CNA, and a Cook all lacked documentation of the mandatory reporter training within the required timeframe. Although certificates for the training were eventually provided, they were dated after the six-month window had passed. The facility assessment indicated that such training was required for all positions, and the facility's abuse prevention policy mandated staff training on abuse prevention, identification, and reporting, but did not specify the required timeframe for completion. During staff interviews, it was revealed that there was no system in place to track the completion of dependent adult abuse training, and the Personnel Director/Provisional Administrator acknowledged that the required training had not been completed on time for the majority of employees reviewed. The facility had a census of 64 residents at the time of the review.
Failure to Complete Required Discharge and Reentry MDS Assessments
Penalty
Summary
The facility failed to complete a Discharge Minimum Data Set (MDS) and a Reentry MDS for a resident who was hospitalized and subsequently returned to the facility. Record review showed that the resident was discharged to the hospital and then readmitted, but the required Discharge and Reentry MDS assessments were not opened, started, or completed as mandated. Staff interviews confirmed that the assessments were not initially flagged for the MDS Coordinator, and the coordinator was not onsite at the time. The deficiency was identified through review of the resident's electronic health record and staff interviews, which revealed the assessments were only in progress after the issue was discovered.
Failure to Identify and Intervene in Resident's Acute Condition
Penalty
Summary
The facility failed to promptly identify and intervene for an acute change in a resident's condition, leading to severe dehydration and sepsis. The resident, who had moderate impaired cognition and required supervision with eating, exhibited several acute changes in condition, including increased blood pressure, elevated pulse, and mental status changes. Despite these signs, there was a lack of follow-up assessments and notification to the physician, which contributed to the resident being transported to the hospital with severe dehydration and sepsis. The resident's electronic health record documented multiple instances where assessments were either incomplete or not conducted at all. On several occasions, the resident showed signs of deterioration, such as increased blood pressure and pulse, mental status changes, and lethargy, but these were not followed up with appropriate medical intervention or physician notification. The resident's condition continued to decline, culminating in a transfer to the emergency department where he was diagnosed with sepsis and dehydration. Interviews with facility staff revealed that there was a failure to notify the physician or nurse practitioner about the resident's condition changes. The psychiatric-mental health nurse practitioner noted a significant change in the resident's mental status during a telehealth appointment and instructed the nursing staff to notify the primary care physician immediately. However, the resident's advanced registered nurse practitioner reported not being aware of any condition changes until the day the resident was sent to the emergency department. This lack of communication and timely intervention contributed to the resident's severe condition and subsequent death.
Removal Plan
- Immediate in-service for nurses on identifying acute changes in resident conditions, conducting complete assessments, and notification of providers of changes in condition.
- Attestation of these procedures for all shifts prior to caring for the residents.
- Review of all resident documentation to ensure there were no current changes of condition that may require follow-up, further assessment, or provider notification.
- Any identified concerns will be assessed and the proper notifications made prior to clinical leadership leaving.
- Started auditing of all resident records to ensure that there are no current changes of condition that may require follow-up, further assessment, or provider notification.
Failure to Notify Family and PCP of Resident's Bruising
Penalty
Summary
The facility failed to notify the family and primary care provider (PCP) of bruising observed on a resident's right forearm. A progress note dated 9/21/24 documented a larger red/purple area and multiple smaller bruises at various stages of healing on the resident's forearm, but there was no documentation of family or PCP notification. The clinical record also lacked any documentation on 9/22/24 and 9/23/24. It was not until 9/24/24 that a progress note indicated the PCP was notified, and the family was informed during their visit on the same day. The facility's policy, dated 6/29/23, required staff to notify the family and attending or on-call physician for any abnormal skin issues, including bruising, by the next morning for non-emergent issues. Staff D confirmed during an interview that she expected staff to follow the skin protocol and notify the family and PCP no later than the next morning.
Failure to Document and Assess Resident's Bruise
Penalty
Summary
The facility failed to properly assess and document a bruise on a resident's right forearm. A progress note dated 9/21/24 indicated the presence of a larger red/purple area and multiple smaller bruises at various stages of healing on the resident's forearm. However, the documentation lacked measurements or a picture of the bruising. During an observation on 9/24/23, the bruises were noted again, but there was still no documentation of measurements or photographs. Staff interviews revealed that the facility's electronic health record system, Point Click Care (PCC), was used for documenting skin concerns, but there was confusion among staff about how to document non-skin tear issues. Staff interviews further highlighted a lack of standardized procedures for documenting skin concerns. Staff C, an LPN, admitted to identifying the bruise but not taking measurements or a picture, citing uncertainty about documentation procedures for non-skin tears. Staff D, an RN, explained that she provides one-on-one education to nurses on taking pictures and measurements, but this training is not part of the formal onboarding process. Additionally, the RN Supervisor confirmed that the facility did not have a published policy for staff regarding skin alterations, contributing to the inconsistency in documentation and assessment of the resident's bruise.
Failure to Secure Mechanical Lift Leads to Resident Fall
Penalty
Summary
The facility failed to prevent an accident involving a resident who was non-verbal and had a cognitive impairment. The resident, who required assistance from two staff members for transfers and used a mechanical lift, fell from the lift during a transfer. The incident occurred when the left shoulder strap of the sling was not properly secured, causing the resident to fall backward and hit his head on the floor. This resulted in a skin tear on the resident's left elbow and subsequent pain and discomfort in the left shoulder and head. The resident's care plan indicated limited physical mobility and required the use of a mechanical lift at the nurse's discretion. During the transfer, two staff members were present, but the strap was not hooked into the mechanism completely, leading to the fall. The resident exhibited signs of pain and a change in consciousness following the incident, prompting a recommendation for evaluation at the emergency room. However, the resident's family initially declined the ER visit due to financial concerns. The facility's training and competency testing for mechanical lift transfers required two staff members to ensure the straps were secured before moving the resident. Despite this, the incident occurred, highlighting a lapse in following the established procedures. The resident was eventually sent to the ER after further deterioration in his condition, where he was diagnosed with an AC joint separation.
Failure to Provide Adequate Pureed Diet Portions
Penalty
Summary
The facility failed to ensure that 10 out of 10 residents on a pureed diet received a well-balanced diet that met their nutritional needs. During an observation of the puree process for chicken sandwiches, it was noted that Staff F, a cook, initially did not include the correct number of buns in the pureed mixture to match the number of chicken patties, which would have resulted in residents receiving fewer calories than those on a non-pureed diet. The surveyor had to intervene twice to ensure that the correct number of buns was added to the mixture to provide the same caloric intake as a regular diet. Additionally, Staff F was unsure of the process for measuring and ensuring correct portion sizes for the pureed food, which led to the surveyor intervening again to ensure accurate portions were served. The facility's policy on Therapeutic Diets lacked specific instructions on how to complete the puree process and ensure that residents on pureed diets received the same portions as those on regular diets. This oversight in policy and staff training contributed to the deficiency in providing a well-balanced diet to residents on pureed diets.
Deficiency in Dietary Staff Qualifications and Meal Service Timing
Penalty
Summary
The facility failed to provide a qualified and educated dietary staff to deliver food service to its residents, with a reported census of 62 residents. Observations revealed that the noon meal service in the dining room started later than the scheduled time on two separate occasions, indicating a delay in meal service. The facility's job descriptions for dietary staff, updated on 7/24/24, required completion of state-approved safety and sanitation, and modified diet courses. However, during an interview, a cook stated he had been trained on different types of diets and their preparation, but the RN Supervisor confirmed that no dietary staff had completed the necessary food service training for safety, sanitization, or modified diets.
Improper Glove Use During Meal Service
Penalty
Summary
The facility failed to maintain proper sanitary conditions during meal service, as observed on 7/24/24. Staff F, while wearing gloves, touched various surfaces such as handles, trays, countertops, his clothing, his arm, serving utensils, and the exterior of bread bags. He then proceeded to handle sandwich buns with the same contaminated gloves, which were used to prepare chicken sandwiches for multiple residents. The facility's policy on Dietary Sanitary Conditions was undated and lacked specific instructions on when gloves should be worn, although it did instruct staff to perform good hand washing before preparing, serving, and distributing food. During an interview on 7/25/24, Staff J, an RN Supervisor, stated that he had instructed staff to remove gloves and wash their hands when in doubt. However, the observations indicated that these instructions were not followed, leading to the contamination of ready-to-eat food.
Failure to Submit PASRR for Two Residents
Penalty
Summary
The facility staff failed to submit a new Preadmission Screening and Resident Review (PASRR) for two residents, leading to a deficiency. Resident #29, with a Minimum Data Set (MDS) assessment indicating severe cognitive impairment, had a PASRR Level 1 Screening Outcome that did not list a diagnosis of bipolar disorder, which was present in other medical documentation. Interviews with facility staff revealed that the clinical team and MDS nurse are responsible for advising when a PASRR Level II determination is required, but this process was not followed correctly for Resident #29. Similarly, Resident #56, also with severe cognitive impairment, had a PASRR Level 1 Screening Outcome that omitted a diagnosis of post-traumatic stress disorder, which should have triggered a Level II PASRR submission. The diagnosis was documented in the medical records but not reflected in the PASRR screening. The oversight in both cases indicates a failure in the facility's process for coordinating assessments and ensuring accurate PASRR submissions.
Failure to Secure Medication and Assess Resident Safety
Penalty
Summary
The facility failed to properly secure medication and assess resident safety for medication administration for a resident with moderate cognitive loss. The resident, who had a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment, was observed with a half-full bottle of Pepto Bismol and a bottle of vitamin D in his room without physician orders to self-administer these medications. The resident reported using Pepto Bismol frequently for an upset stomach, but there was no documentation in the electronic health record of an assessment to self-administer medications. Observations revealed that the resident's room door was often left open, and the medications were stored in a cabinet with the sliding glass door open, making them accessible to others. Staff interviews indicated a lack of awareness and proper procedure regarding self-administration of medications. The Licensed Practical Nurse (LPN) and Certified Medication Aide (CMA) were unaware of any residents authorized to self-medicate, and the Registered Nurse (RN) was unsure of the location of the self-administration assessment form. The Director of Nursing (DON) acknowledged that the facility had not encountered a situation where a resident wanted to self-administer medications and was unfamiliar with the facility's policy on the matter. The facility's policy required a physician order, an assessment of the resident's ability to self-administer, and secure storage of medications, none of which were followed in this case. The DON expressed doubt about the resident's ability to safely self-administer medication, highlighting a gap in staff training and awareness regarding medication management in resident rooms.
Deficiency in Dietary Manager Qualifications
Penalty
Summary
The facility failed to employ a qualified professional as the Dietary Manager, as required by regulations. A review of the Dietary Manager's employee file revealed a lack of documentation indicating completion of a state-approved food service supervisor's course. This deficiency was confirmed during an interview with a Registered Nurse Supervisor, who stated that the Dietary Manager had been employed since approximately February 2024 without completing the necessary course. Additionally, the facility's job description for Dietary Managers, updated in July 2024, explicitly required completion of a state-approved food service supervisor's course, which the current Dietary Manager had not fulfilled.
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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 Decorah
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wellington Place | 2.9 mi | ★★★★★ | 0 | 0 |
| Ossian Care Center | 12.3 mi | ★★★★★ | 15 | 0 |
| Green Lea Senior Living | 13.3 mi | ★★★★★ | 12 | 2 |
| Northgate Care Center | 15.8 mi | ★★★★★ | 18 | 1 |
| Good Samaritan - Waukon | 16.3 mi | ★★★★★ | 9 | 1 |
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