Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Health Care Center during CMS and state inspections, most recent first.
Two residents with cognitive and mental health conditions were left in urine-soaked bedding for hours due to staff failure to provide timely incontinence care and inadequate documentation of care refusals. Both experienced significant emotional distress, including feelings of humiliation and shame, as a result of being neglected.
Two residents dependent on staff for ADLs did not receive timely incontinence care, resulting in prolonged periods in soiled briefs and bedding. In both cases, CNAs failed to provide care, did not document refusals or interventions, and did not communicate residents' needs during shift changes. Facility policies requiring regular incontinence care and documentation were not followed.
A resident with severe cognitive impairment and a history of exit-seeking behaviors was not consistently identified as at risk for elopement, resulting in multiple unsupervised exits from the facility. Staff lacked a formal system to track or communicate which residents were at risk, and there was confusion and insufficient documentation regarding elopement incidents. This failure to systematically assess, document, and monitor residents with wandering tendencies led to the resident leaving the facility without supervision on more than one occasion.
A resident with dementia and PTSD, identified as at risk for abuse, was groped on the buttocks by another resident in a common area, causing distress and embarrassment. The incident was reported by the resident and family to staff, confirmed through interviews, and led to a medical evaluation. The facility's failure to prevent this incident resulted in psychosocial harm.
A resident with cognitive impairment and a history of fractures did not receive adequate pain management following a fall that resulted in a serious injury. Despite high pain levels recorded in the MAR, pain assessments were not completed, and pain medications were not administered for several days. The facility's failure to adhere to its pain management policy was confirmed by interviews with the DON and the physician.
The facility failed to properly store, label, and dispose of medications for several residents, as observed during an inspection of medication carts. Issues included unlabeled insulin pens, expired medications, and improper storage of refrigerated items. The DON confirmed that these practices did not align with the facility's Medication Storage Policy.
The facility failed to prevent inappropriate antibiotic use for four residents, prescribing antibiotics without necessary susceptibility reports. Residents with chronic kidney disease were given Ciprofloxacin and Bactrim, despite resistance or lack of evidence for effectiveness. The DON noted challenges in delaying prescriptions until culture results were available, contrary to the facility's Antibiotic Stewardship Policy.
The facility did not meet the required minimum square footage per resident bed for 13 residents. Seven rooms provided only 77.1 square feet per bed, while three others provided 74 square feet per bed. The DON stated that room and bed sizes are considered during room assignments to ensure safety and a clutter-free environment. No resident complaints or infection control issues were reported.
A resident with severe cognitive impairment and multiple medical conditions was not assisted with activities of daily living, including oral and hygiene care, leading to poor dental hygiene, dry mouth, cracked lips, and excoriated skin. The resident, dependent on a G-tube for nutrition, was transferred to the ICU with sepsis after the facility failed to address a clogged G-tube in a timely manner. Family and staff expressed concerns about the care provided.
A resident with severe cognitive impairment and G-tube dependence experienced a delay in care when their G-tube became clogged, preventing nutrition and hydration. Despite attempts to unclog the tube, the resident was not transferred to the ED until nearly four hours after the recommendation, arriving in critical condition with severe dehydration and hypernatremia. The facility's policy for acute changes in condition was not followed, contributing to the delay in treatment.
A resident with severe cognitive impairment and multiple medical conditions experienced a failure in gastrostomy tube care at a facility. The resident's G-tube became clogged, preventing nutrition and hydration, and despite attempts to unclog it, the resident was transferred to the hospital in a severely dehydrated state. The facility failed to follow up on a gastroenterology referral for G-tube replacement, leading to the use of a urinary catheter as a temporary solution, which was not properly managed.
The facility failed to maintain a clean and homelike environment, as residents reported infrequent linen changes and persistent unpleasant odors. Observations confirmed strong urine and bowel movement odors in bathrooms, and cluttered hallways with various equipment. The facility lacked a specific policy for changing bed sheets, relying on standard practices that were not effectively implemented.
Failure to Provide Timely Incontinence Care Results in Resident Neglect
Penalty
Summary
The facility failed to provide timely and adequate incontinence care for two residents, resulting in both being left saturated in urine for extended periods. One resident with paranoid schizophrenia and anxiety, who required one-person assistance with toileting, reported being left in urine all day without staff assistance, leading to feelings of humiliation and distress. Staff interviews revealed inconsistent documentation and communication regarding the resident's care needs and refusals, with one CNA admitting she did not know the resident was incontinent and failed to report alleged refusals of care. The resident was ultimately found by night shift staff to be soaked in urine, with saturated bedding and visible emotional distress. Another resident with dementia and anxiety, who was care planned for bladder incontinence and required regular checks and assistance, was also found lying in bed without clothing or a brief, saturated in urine. The resident expressed feelings of disgust and humiliation due to being left in soiled conditions for hours. Staff interviews indicated that the resident was known to be resistant to care and sometimes removed soiled items herself, but there was no documentation of care refusals or interventions attempted during the relevant shift. Day shift staff did not provide incontinence care, citing the resident's combative behavior and a lack of report on her status. Facility leadership confirmed that staff are expected to check and change incontinent residents every two hours and document any refusals of care, with further interventions required for continued refusals. However, in both cases, there was a lack of documentation, communication, and timely intervention, resulting in neglect as defined by regulatory standards. Both residents experienced psychosocial harm, including feelings of shame, humiliation, and emotional distress, as a direct result of being left in their own incontinence for prolonged periods.
Failure to Provide Timely Incontinence Care and Document Refusals
Penalty
Summary
The facility failed to provide adequate and timely incontinence care for two residents who were dependent on staff for activities of daily living. One resident with diagnoses including paranoid schizophrenia and anxiety reported being left in a saturated brief for an entire day shift, with no incontinence care provided by the assigned CNA. The resident stated he did not refuse care, and this was corroborated by the night shift CNA, who found the resident and his bedding soaked with urine and provided immediate care. The day shift CNA admitted she did not know the resident was incontinent and did not receive a report about his needs, leading to a lack of care throughout her shift. She later reported to the ADON that the resident refused care, but this was not documented during the shift, and no interventions or escalation were attempted at the time. Another resident with dementia and anxiety, who was known to be resistant to care, was found in bed without clothes or an incontinence brief, lying on saturated sheets and pads. The resident stated she removed her soiled clothing and brief due to being wet with urine. The night shift CNA reported that the resident refused care and threw soiled items at her, but there was no documentation of the refusal or of any interventions attempted to provide incontinence care overnight. The day shift CNA did not provide care in the morning, stating she did not want to wake the resident and was unaware of the resident's condition or lack of clothing. When care was finally provided, the resident was cooperative and received incontinence care and clean linens. Facility policies required CNAs to provide incontinence care every two hours and as needed, and to document refusals of care, including interventions attempted and notification of the charge nurse and provider. In both cases, staff failed to follow these policies, resulting in residents remaining in soiled conditions for extended periods without appropriate documentation or escalation. There was also a lack of communication during shift changes, leading to gaps in care and failure to meet residents' needs.
Failure to Systematically Assess and Monitor Resident with Exit-Seeking Behaviors Leads to Elopement
Penalty
Summary
The facility failed to implement a systematic approach to assess and monitor a resident with known unsafe wandering and exit-seeking behaviors, resulting in multiple elopement incidents. One resident with diagnoses of dementia, anxiety disorder, and depression, who was severely cognitively impaired and required substantial assistance, was not consistently identified as at risk for elopement in assessments, despite documented exit-seeking behaviors and previous elopement attempts. The care plan noted interventions such as redirection and 15-minute checks, but there was a lack of consistent documentation and follow-through, and the resident was able to leave the facility unsupervised on more than one occasion. Staff interviews revealed that there was no centralized or accessible list or binder of residents at risk for elopement, and many staff members were unaware of which residents were at risk or what interventions were in place. Several staff, including CNAs, LPNs, and RNs, stated that they relied on shift reports or visible Wander Guard devices to identify at-risk residents, but there was no formal system for tracking or communicating this information. Additionally, staff were not always aware of the resident's medical history or cognitive status, and there was confusion and lack of documentation regarding elopement incidents, with some staff and administrators denying that elopements had occurred or failing to complete incident reports as required by facility policy. Observations and interviews with staff, residents, and local police confirmed that the resident was able to exit the facility through both the front and fire exit doors without staff supervision, and in one instance, was found by police outside the facility. The lack of a systematic approach to assessment, documentation, and monitoring of residents with exit-seeking behaviors, as well as the absence of clear communication and staff awareness, directly contributed to the resident's ability to elope and the facility's failure to prevent these incidents.
Removal Plan
- Care plan reviewed to ensure appropriate interventions addressing exit-seeking behaviors.
- Elopement risk assessment reviewed for accuracy and completeness.
- Elopement assessments for all residents were reviewed and updated for accuracy as needed.
- Care plans for residents identified as at risk for elopement were reviewed and revised with appropriate interventions.
- Behavior tracking was initiated for all residents identified as at risk for elopement or exit-seeking behaviors.
- Staff education on elopement policy and procedures, recognition of exit-seeking behaviors, accurate and timely documentation requirements, and location/use of the facility's Elopement Binder.
- Licensed nursing staff received additional targeted training on documenting elopement attempts and exit-seeking behaviors.
- Facility will ensure staff members are educated prior to working their next shift if unable to be reached initially.
- Elopement Policy and Documentation Policy regarding exit-seeking behaviors were reviewed and approved by Chief Nursing Officer and Chief Operating Officer.
- DON or designee will review the 24-hour report and behavior tracking logs to identify and address exit-seeking behaviors.
- DON or designee will review all new admissions and readmissions to ensure elopement assessments are accurate and care plans reflect appropriate interventions.
- Administrator or designee will provide in-services on elopement policy, identification of exit-seeking behaviors, and implementation of appropriate interventions.
- Administrator or designee will conduct monitoring of three residents identified as at risk for elopement to ensure elopement assessments are completed, wandering/exit-seeking behaviors are documented and addressed with interventions, and care plans are updated as needed.
- Results of all monitoring activities will be reviewed during QAPI meetings led by the Administrator.
- Additional education and corrective measures will be implemented as necessary until sustained compliance is achieved.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident sexual abuse involving a cognitively impaired resident with a history of trauma, including PTSD and dementia. The resident's care plan identified a potential for abuse and noted that being grabbed or observing others being grabbed were known trauma triggers. Despite these documented risks, another resident approached from behind and grabbed the resident's buttocks with both hands while both were clothed. The incident occurred in a common area and was witnessed by the resident's family, who reported it to staff. The resident expressed distress, embarrassment, and pain as a result of the incident, which occurred in front of others and triggered his trauma. Multiple staff interviews and witness statements confirmed that the incident was reported to nursing staff and administration. The resident described the event as being groped and squeezed on the buttocks, and he reported feeling terrible and embarrassed. The resident's family corroborated his account and expressed concern about the documentation of the incident by outside medical providers. The resident was sent for medical evaluation, where no physical injuries were found, and the police were contacted. There was no evidence of prior inappropriate sexual contact between the involved residents, but one resident had a history of grabbing others, though not previously in a sexual manner. The facility's abuse policy prohibits all forms of abuse and requires measures to prevent such occurrences. However, the incident demonstrated a failure to protect a vulnerable resident from sexual abuse by another resident, resulting in psychosocial harm. The event was not immediately witnessed by staff, but was promptly reported by the resident and his family, and subsequently investigated by facility administration and outside agencies.
Failure to Provide Adequate Pain Management After Resident Fall
Penalty
Summary
The facility failed to provide adequate pain management for a resident who experienced a fall resulting in a serious injury. The resident, who was cognitively impaired and required assistance for activities, had a documented history of fractures and potential for pain due to conditions like unstable angina and COPD. Despite these conditions, the resident did not receive pain management for 24 hours following a fall on November 16, 2024. The fall investigation noted no immediate signs of trauma, but an X-ray later revealed an impacted subcapital fracture of the femoral neck. The resident's pain was recorded as high as 10 on the day of the fall, yet no pain medications were administered on November 16, 17, or 18, despite the availability of physician orders for pain relief medications like Norco and Tramadol. The resident's Medication Administration Record (MAR) indicated that pain assessments were not completed from November 16 to 21, and pain medications were not administered even when the resident's pain levels were documented. The resident was eventually given Tylenol on November 22 for a lower pain level, which was effective. Interviews with the Director of Nursing and the physician confirmed the expectation for pain management, highlighting the facility's failure to adhere to its pain management policy, which emphasizes prompt and accurate pain assessment and encourages self-reporting of pain by residents.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly store, label, and dispose of medications for four residents, as observed during an inspection of medication carts on two different halls. On the B Hall, a registered nurse identified several issues, including an insulin pen labeled with a date but not discarded after 30 days, an unopened vial of Epogen that required refrigeration, an unlabeled half tablet of magnesium, and an opened carton of thickened lemon water that was past its labeled date. On the F Hall, another registered nurse found a sealed, unopened eye drop solution that required refrigeration, an insulin pen not labeled with a resident's name, and another insulin pen that was opened and not labeled with any resident's name. Additionally, there were bottles of Pro-Heal and multivitamins that were either not dated upon opening or past their best-by dates. The Director of Nursing confirmed that insulin pens should be labeled with resident names, dated upon opening, and discarded within 30 days. Expired items should be thrown away, and manufacturer's instructions for medication storage should be followed. The facility's Medication Storage Policy mandates that all drugs and biologicals be stored in a safe, secure, and orderly manner, with proper labeling and disposal of discontinued, outdated, or deteriorated drugs. The policy also requires that medications be administered before their expiration date and that those requiring refrigeration be stored appropriately.
Inappropriate Antibiotic Use in LTC Facility
Penalty
Summary
The facility failed to maintain a system to prevent unnecessary or inappropriate antibiotic use for four residents. Resident 16 was prescribed Ciprofloxacin for a urinary tract infection (UTI) without a susceptibility report to confirm the bacteria's resistance or susceptibility to the antibiotic. Similarly, Resident 25 was also given Ciprofloxacin for a UTI, again without a susceptibility report to guide the antibiotic choice. Both residents had chronic kidney disease, which could complicate their treatment. Resident 45 was prescribed Cephalexin for a UTI, but the urine culture did not document a bacteria specimen or susceptibility report, indicating a lack of evidence to support the antibiotic choice. Resident 48 was given Bactrim for a bladder infection, despite the susceptibility report showing that the bacteria, Escherichia coli, was resistant to Bactrim. This indicates a failure to adjust the treatment based on the culture results. The Director of Nursing (DON) acknowledged difficulty in getting doctors to wait for culture results before prescribing antibiotics. The facility's Antibiotic Stewardship Policy aims to promote appropriate antibiotic use, but the events described show a failure to adhere to this policy, as antibiotics were prescribed without proper evidence of their necessity or effectiveness.
Facility Fails to Meet Minimum Room Size Requirements
Penalty
Summary
The facility failed to provide the required minimum square footage per resident bed in multiple resident bedrooms for 13 out of 80 residents. Specifically, seven resident bedrooms were found to provide only 77.1 square feet per resident bed, with each room measuring 15 feet 2 inches by 10 feet 2 inches. These rooms, numbered 105, 106, 107, 117, 118, and 119, are two-bed rooms certified for Medicaid/Medicare. Additionally, three other resident bedrooms provided only 74 square feet per resident bed, with room dimensions of 15 feet 3 inches by 21 feet, and included wardrobes measuring 23 inches by 63 inches and 24 inches by 94 inches. These rooms, numbered 225, 227, and 228, are also certified for Medicaid/Medicare. The Director of Nursing (DON) stated that the facility considers room size and bed size when assigning rooms to residents upon admission, ensuring a safe and clutter-free environment. Despite the undersized rooms, there were no complaints from residents regarding room size, nor were there any infection control concerns related to the room size.
Failure to Assist Resident with ADLs and Hygiene
Penalty
Summary
The facility failed to assist a resident, identified as R2, with activities of daily living, specifically oral and hygiene care. R2, who has severe cognitive impairment and is dependent on others for daily care, was found to have poor dental hygiene, dry mouth, cracked lips, and caked dried vaginal secretions with a foul smell and excoriated skin. These conditions were observed when R2 was transferred to the emergency department due to a clogged gastrostomy tube, which prevented her from receiving nutrition and fluids. R2's medical history includes osteomyelitis, protein calorie malnutrition, non-traumatic extradural hemorrhage, aphasia, Parkinson's disease, a stage 3 pressure ulcer, peripheral vascular disease, dysphagia, seizures, neurocognitive disorder with Lewy bodies, dystonia, hypernatremia, major depressive disorder, and hypertension. The resident was non-verbal, bed-bound, and dependent on a G-tube for nutrition. The facility's failure to maintain R2's hygiene and address the G-tube blockage in a timely manner resulted in her being transferred to the ICU with a diagnosis of sepsis. Interviews with facility staff and R2's family revealed concerns about the care provided. The facility's administrator and director of nursing acknowledged the family's dissatisfaction with R2's condition and care. The emergency department nurse noted R2's poor condition upon arrival, including severe dehydration and a strong odor in her mouth and perineal area. R2's son expressed that R2, a former nurse, would have been embarrassed by her lack of cleanliness and the odors present when she was sent to the hospital.
Failure to Provide Timely Care for G-Tube Dependent Resident
Penalty
Summary
The facility failed to provide timely care and treatment for a resident, identified as R2, who was dependent on a gastrostomy tube (G-tube) for nutrition and hydration. R2 had a complex medical history, including severe cognitive impairment, dysphagia, and a stage 3 pressure ulcer, among other conditions. On the day of the incident, the G-tube was found to be clogged, preventing the administration of necessary nutrition and fluids. Despite attempts by the nursing staff to unclog the tube using various methods, they were unsuccessful, and the resident was unable to eat or drink by mouth. The primary clinician recommended transferring R2 to the emergency department (ED) at 11:20 AM due to the inability to provide nutrition and fluids through the G-tube. However, there was a significant delay, as R2 did not arrive at the ED until 3:13 PM, nearly four hours later. Upon arrival at the ED, R2 was found to be severely dehydrated, tachycardic, and hypotensive, with a high lactic acid level and severe hypernatremia, indicating a critical condition. The ED notes also revealed that a urinary catheter had been used in place of the G-tube for some time, which frequently clogged, and there was no follow-up with the gastroenterologist to replace it with an actual G-tube. Interviews with the facility's nursing staff indicated that R2 had not received any nutrition since the night before the incident, and there was a lack of immediate action to address the clogged tube. The facility's Acute Change of Condition Policy requires prompt identification and treatment of residents with acute changes, but this was not adhered to in R2's case, leading to a delay in necessary medical intervention.
Failure in Gastrostomy Tube Care Leads to Resident Hospitalization
Penalty
Summary
The facility failed to provide appropriate gastrostomy tube care for a resident, identified as R2, who was dependent on tube feeding due to severe dysphagia and other complex medical conditions. R2's medical history included osteomyelitis, protein-calorie malnutrition, Parkinson's disease, and severe cognitive impairment, among others. The resident's care plan indicated a need for tube feeding due to dysphagia, and a physician's order was placed for a gastroenterology referral for G-tube replacement. However, there was no documentation that the referral or appointment was made, leading to a significant delay in addressing the resident's needs. On a particular day, R2's G-tube became clogged, preventing the administration of nutrition and fluids. Despite attempts by nursing staff to unclog the tube using various methods, they were unsuccessful. The resident was unable to eat or drink by mouth and was eventually transferred to the emergency department. Upon arrival at the hospital, R2 was found to be severely dehydrated, tachycardic, and hypotensive, with a high lactic acid level indicating septic shock. The hospital records revealed that R2 had previously been seen for a dislodged G-tube, and a urinary catheter had been used temporarily in place of the G-tube, but proper follow-up with the gastroenterologist was never completed. Interviews with facility staff and the resident's family highlighted a lack of communication and follow-up regarding the G-tube replacement. The facility's Director of Nursing and other staff members were unaware of any scheduled follow-up appointments with the gastroenterologist. The resident's son was not informed about the temporary use of a urinary catheter as a G-tube. The facility's failure to ensure timely and appropriate medical care for R2's G-tube issues resulted in the resident's severe dehydration and subsequent hospitalization.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for several residents, as evidenced by observations and resident interviews. One resident reported having to request sheet changes weekly and described the hallways as cluttered, resembling an obstacle course. Another resident complained about persistent unpleasant odors, likening the smell to a bathroom, and noted that bed sheets were changed only once a month. Observations confirmed strong urine odors in the shower area and bowel movement odors in another bathroom, where a smear of stool was found on the floor. Additionally, various equipment and carts cluttered multiple hallways, contributing to the unkempt environment. A resident's grievance documented concerns about bathroom cleanliness, and resident council meeting minutes highlighted issues with the frequency of linen changes. The facility administrator acknowledged the absence of a specific policy for changing bed sheets, stating that the standard practice was to change them on shower days and as needed. Despite the administrator's expectations for a clean and odor-free facility, the daily cleaning procedures policy was not effectively implemented, as evidenced by the persistent odors and clutter observed during the survey.
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Illustrative
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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 Highland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aviston Countryside Manor | 9.1 mi | ★★★★★ | 9 | 0 |
| Evercare Of Lebanon | 10.8 mi | ★★★★★ | 6 | 2 |
| Cedar Ridge Health & Rehab Ctr | 11.2 mi | ★★★★★ | 8 | 0 |
| Hitz Memorial Home | 11.6 mi | ★★★★★ | 5 | 1 |
| Evercare Of Breese | 11.6 mi | ★★★★★ | 3 | 0 |
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