Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Place Rehab And Nursing Center during CMS and state inspections, most recent first.
A facility failed to protect two residents with wounds by not maintaining EBP signage and by allowing a resident with a stage 3 ankle pressure injury to be showered with open wounds. The wound care nurse later noted the ankle wound had deteriorated and appeared frail and mushy, and a RN said the resident’s wounds were not dressed, only covered with a plastic bag that collected water. Staff also confirmed that EBP signage was missing from both residents’ rooms.
A resident with chronic pain did not receive scheduled Morphine due to failures in medication refill and communication processes. Nursing staff did not follow up with the pharmacy or escalate the issue when the medication ran out, resulting in the resident missing three consecutive doses, experiencing severe pain, and requiring transfer to the ER after alternative pain medications proved ineffective.
Two residents with PICC lines did not have care plans addressing their IV antibiotic administration, and one resident did not receive IV antibiotics as ordered, with missed doses confirmed by the DON. Another resident did not receive restorative nursing services as ordered, as staff failed to place the resident on the restorative schedule.
A resident with a PEG tube was observed receiving continuous enteral feeding while lying flat, despite physician orders and facility policy requiring the head of bed to be elevated 30-45 degrees during feeding. Facility leadership confirmed the resident was not positioned correctly at the time of observation.
A resident with bipolar disorder, MDD, severe depression with psychotic features, and moderate cognitive impairment received multiple psychotropic meds, including trazodone, Cymbalta, buspirone, mirtazapine, and PRN hydroxyzine. The EHR did not show informed consent was obtained before administration, and the Administrator confirmed the facility had not obtained consent for psychotropic meds as required by policy.
Resident council concerns about missing clothing and personal items were not promptly resolved. Several residents reported repeated loss of underwear, shirts, pants, hair grease, and other items, with complaints made to CNAs, nursing staff, Social Services, and the Laundry Supervisor but no resolution or replacement. Staff described a disorganized laundry process, with unorganized racks, a piled-up laundry barrel, and mixed missing-clothes and donated-clothes piles, and Social Services was unaware of the specific missing-item complaints.
A resident with hyperkalemia, dementia, CKD, HTN, and OA was transferred to the hospital twice for treatment, but the facility did not provide the resident or the resident's representative with the bed hold policy at either transfer. The Administrator confirmed the policy had not been given.
The facility failed to ensure a resident's MDS discharge assessment was encoded, transmitted, and completed. The resident had diagnoses including HF and type 2 DM, and review of the MDS record did not show a discharge assessment. During interview, the MDS nurse acknowledged the discharge MDS assessment had not been completed until that day.
Wheelchair Not Maintained in Safe Operating Condition: A resident who used a manual wheelchair was observed with a wheelchair that had non-locking brakes, a loose and unstable wheel, and no footrests. The resident had diagnoses including morbid obesity, right knee effusion, and muscle weakness. The DON said equipment repairs require a work order, but the Maintenance Director found no work order in the TELS system for the resident’s wheelchair.
Failure to consult RD for a resident with a stage 4 sacral PU. A resident admitted with ulcerative colitis, complete paraplegia, peripheral autonomic neuropathy, and a stage 4 sacral PU had no documented RD consult and no wound-healing supplements. The resident also lost 5.52% of body weight in one month, and the RD, WCN/LPN, and CNO all confirmed the consult had not been completed.
Respiratory equipment was not properly maintained for multiple residents with diagnoses including chronic respiratory failure, COPD, and hypoxia. Surveyors observed undated oxygen tubing and humidifier bottles, an empty humidifier bottle, and hand held nebulizer tubing and mouth pieces left on bedside tables instead of being stored in a covered bag. An LPN confirmed the equipment should have been dated, changed, and properly stored.
Failure to Provide Ordered Restorative Services: A resident reported receiving only a few therapy sessions and then no further therapy, despite being told restorative services would follow. The restorative referral showed services were ordered, but a Restorative CNA stated the resident was never placed on the schedule and no restorative services were provided. The resident had morbid obesity, R knee effusion, muscle weakness, and required substantial to maximal assist with bed mobility and dependent assist with transfers.
Inaccurate PBJ Staffing Submission: The facility failed to electronically submit accurate direct care staffing data to CMS based on payroll and other verifiable records. Review of the PBJ report showed triggers for a One Star Staffing Rating and Excessively Low Weekend Staffing, while staffing pattern forms for weekend shifts showed more hours than required and no days with insufficient hours. The Administrator said corporate submitted the PBJ information and it was not correct, and the CNO said she did not know why the submitted data was inaccurate.
Infection control deficiencies were identified when the DON’s surveillance binder showed no monthly infection tracking or trending, including antibiotic therapy and treatment review. A resident’s bath basins and bedpan were left on the shower floor without bags or labels, and dirty linen and briefs were observed on the floor in a shared room before a CNA returned with a trash bag. Laundry observations also found worn, discolored sheets, pillowcases, and blankets in poor condition.
Failure to Document and Offer Immunizations: The facility failed to follow its immunization policies for 4 of 5 sampled residents. The Nursing Policy Manual required education, offering, and the opportunity to refuse pneumococcal, influenza, and COVID-19 vaccines, but admission record review for four residents showed no documentation that they or their representatives were educated about or offered these immunizations. The Administrator stated immunizations are offered during admission and should be documented in the admission record.
A facility failed to maintain a safe, clean, comfortable, and homelike environment for several residents. One resident had clothing stored on the floor, another had a sticky room floor and a closet without a door, and two cognitively intact residents had no chairs in their shared rooms for themselves or visitors. Surveyors also observed worn, discolored sheets, pillowcases, and blankets in poor condition.
Failure to complete baseline care plans for two residents was identified. One resident had dementia, CKD, HTN, anxiety, and osteoarthritis, and another had lung cancer, acute/chronic resp failure with hypoxia, COPD, and pleural effusion. Record review showed no baseline plan of care was completed upon admission or re-admission, and the MDS Nurse confirmed the omission.
Failure to Obtain Ordered Biannual Labs: A resident with schizoaffective disorder, bipolar type, dementia, insomnia, and anxiety had biannual lab orders for CBC, CMP, A1C, TSH, lipid, B12, folate, Vitamin D, Mg, thiamine, and iron studies with ferritin. The EHR did not show that several ordered labs were obtained, despite the resident also receiving antipsychotic, antidepressant, antiplatelet, hypoglycemic, and anticonvulsant medications.
Failure to Provide ADL Hygiene Care: Multiple residents with significant care needs did not receive or have documented bathing, oral care, nail care, or peri-care. Observations found disheveled hair, long curled toenails, heavy debris on teeth, dirty nail beds, and caked-on barrier cream on a resident with MASD. Staff and the DON/Administrator confirmed missing task documentation and acknowledged the residents needed the ADL care.
The facility failed to provide ordered care for two residents. One resident with cerebral palsy and contractures did not receive a left hand splint through restorative nursing even though OT had discharged the resident with the splint and the splint was found on the bedside table instead of in the resident’s hand. Another resident with hyperkalemia, CKD, and dementia did not have the diagnosis reflected in the care plan, and ordered admission labs were incomplete and delayed, with several tests missing and others not completed until weeks after the order.
The facility failed to keep the most recent annual survey results available in the survey binder near the front door for residents, family members, or visitors to review. During observation, the 2024 annual survey was not found in the binder, and the Administrator acknowledged it should have been there.
A resident in a shared room did not have a privacy curtain around bed A. The resident and a visitor reported the curtain was missing, and a CNA later confirmed there was no privacy curtain present. The resident had diagnoses of bipolar disorder, current episode depressed, and altered mental status, and the MDS showed a BIMS score of 10, indicating moderately impaired cognition.
Missing Dementia Care Plan Focus: A resident with dementia had physician orders for Memantine for dementia and anxiety, but the care plan did not include a dementia focus with measurable goals or appropriate interventions. The MDS nurse confirmed the care plan lacked this individualized, person-centered content.
A resident with chronic respiratory failure with hypoxia and COPD had a bed remote with exposed wires. The resident’s cognition was intact per BIMS, and both Maintenance and the DON confirmed the bed control had exposed wires and should not have.
A resident with a documented preference for white meat chicken was served dark meat during a meal, despite staff being aware of this preference and it being clearly listed on the meal card. Staff and dietary management acknowledged the error and confirmed the resident's preference was not honored.
A resident with Type 2 diabetes did not receive care according to physician orders, including missed blood glucose rechecks after high readings, failure to perform required glucose checks before insulin administration, lack of physician notification for elevated glucose levels, and missed doses of prescribed Lantus insulin. These deficiencies were confirmed through record review and by the DON.
A resident with a gluteal cleft pressure injury did not receive wound care as recommended by a wound NP, as the new treatment orders were not started until more than two weeks after being documented. The delay was due to a misunderstanding by the treatment nurse, who did not initiate the updated care regimen as ordered.
A resident's grievance about delayed call light response was not resolved by the facility. The resident, with intact cognition but physical limitations, experienced long waits for assistance after being incontinent. Despite filing a grievance, neither the resident nor their responsible party received a review of the grievance. Observations confirmed the call light was ignored, and staff interviews revealed the grievance was not communicated back, indicating a failure in the grievance resolution process.
A resident with PTSD was subjected to sexual abuse by another resident who exposed himself and made unwanted advances. The facility failed to separate the perpetrator from the victim and other residents, and staff did not provide immediate protection or support. The incident was not reported to the administration until hours later, indicating a failure in communication and adherence to abuse prevention policies.
A resident was subjected to inappropriate behavior by another resident, including exposure and physical contact, without immediate intervention from facility staff. The administration was not informed until hours later, and the aggressor remained in the shared room without supervision. Interviews revealed a lack of documentation and adherence to the abuse/neglect policy, highlighting a significant lapse in procedures.
A resident with a post-surgical wound experienced unmanaged pain due to the facility's failure to provide appropriate pain management. Despite requesting Tylenol, the LPN on duty informed the resident that no pain medication could be administered due to prescription issues. The resident, experiencing significant pain, called 911 and was admitted to the hospital ER, where she received Dilaudid for acute pain. The facility's pain management policy did not adequately address the administration of pain medication, leading to this deficiency.
A resident with paraplegia and PTSD reported an incident of sexual abuse by another resident, which was captured on video. The facility's ADON was informed but failed to report the incident to the Administrator or state agency within the required timeframe, violating the facility's abuse prevention policy.
A facility failed to thoroughly investigate a sexual abuse allegation involving two residents. A resident reported inappropriate behavior by another resident, supported by video evidence. The investigation was insufficient as the administrator only interviewed staff not present during the incident, contrary to the facility's policy.
A facility failed to document a physician's discharge order for a resident with severe cognitive impairment and multiple diagnoses, including chronic viral hepatitis C. The ADON admitted to misplacing the verbal order and acknowledged the lack of a system for handling verbal orders.
A facility failed to provide transportation for a resident with metastatic cancer to attend scheduled medical appointments, including a lab, oncology visit, and chemotherapy infusion. Despite the facility's policy requiring transportation arrangements, there was no documentation of the resident being transported or attending the appointments, nor any record of refusal. Interviews with staff confirmed the absence of documentation and transportation.
A resident admitted with multiple fractures and hemorrhages had a care plan that was not updated to reflect their improved condition. Despite a July MDS assessment showing cognitive intactness and reduced need for assistance, the care plan still included outdated interventions. Interviews in October revealed the resident was independently performing tasks and had stopped using prescribed devices. The MDS Director acknowledged the care plan should have been revised.
A facility failed to provide necessary treatment and services to a resident at risk for pressure ulcers. Despite being care planned for potential skin integrity issues, the facility did not perform an accurate assessment or notify the MD/NP of the resident's skin condition. Inconsistent assessments by staff led to a lack of attention to the resident's sacral area, potentially worsening the condition.
The facility failed to implement a comprehensive care plan for two residents. One resident did not receive prescribed doses of Keflex due to a lack of communication with the pharmacy, while another resident's care plan was not updated after multiple falls, despite requiring extensive assistance. The DON acknowledged these oversights.
A facility failed to notify a resident's responsible party about a change in medical condition, specifically the initiation of antibiotics for a urinary tract infection. The facility's policy mandates prompt notification of changes, but records lacked documentation of such communication. Interviews with staff, including an LPN and the DON, confirmed the oversight.
A resident with multiple health conditions, including quadriplegia and acute kidney failure, was observed with a urinary catheter drainage bag improperly positioned, with the drain port tubing touching the floor. This was against the facility's CAUTI prevention guidelines, which require the drainage bag to be kept below the bladder level and off the floor. An LPN confirmed the improper positioning, highlighting a failure in adhering to catheter care protocols.
A facility failed to obtain informed consent and a physician's order for bed rail use for a resident with severe cognitive impairment and multiple diagnoses. Despite the facility's policy requiring these steps, the resident's medical records lacked the necessary documentation. Interviews with staff confirmed the presence of bed rails without the required consent and order, highlighting a breach in protocol.
The facility did not ensure that a CNA completed the required annual training on abuse and dementia care. The CNA's personnel record showed the last training was completed over a year ago, contrary to the facility's policy requiring annual training. This was confirmed during an interview with the Staff Development Coordinator, who acknowledged the lack of documentation for the required training.
The facility failed to ensure call lights were within reach for two residents, compromising their ability to request assistance. One resident's call light was found on the ground, inaccessible, while another's was wrapped around a bed wheel, also out of reach. The DON confirmed these deficiencies during interviews.
The facility failed to address ongoing concerns about the laundry service, as reported by residents over several months. Multiple residents experienced issues with missing or incorrectly returned clothing, leading some to have their families handle laundry instead. Staff interviews revealed a lack of a structured laundry schedule and issues with clothing being returned to incorrect rooms, contributing to the problem. Despite acknowledging these issues, the facility did not take prompt action to resolve the concerns.
The facility failed to develop and implement care plans for two residents diagnosed with UTIs. One resident, with a history of chronic conditions, did not have a care plan for their UTI despite having a physician's order for Keflex. Another resident, with multiple health issues, also lacked a care plan for their UTI and was not administered Doxycycline and Acidophilus as ordered. These deficiencies were confirmed by facility staff.
A resident experienced a 13.32% weight loss over three months while being NPO and on PEG tube feedings. The facility failed to revise the care plan to include a dietician consult and weekly weight monitoring, despite the DON acknowledging the weight loss exceeded concern thresholds.
The facility failed to maintain grooming and hygiene for several residents, including untrimmed nails and missed baths. A resident with diabetes had long fingernails despite a care plan for podiatrist monitoring. Another resident with Alzheimer's had dirty nails not cleaned during bathing. A resident with cerebral infarction had jagged nails, and a resident with depressive disorder had a cracked nail unaddressed for days. A resident with mobility issues had long toenails causing discomfort, and another resident reported not receiving scheduled baths, confirmed by missing records.
A resident with a history of blood clots and cellulitis did not receive prescribed ted hose for edema, as they had not arrived from the supplier. Observations confirmed the absence of ted hose on the resident's swollen legs. Additionally, the facility failed to monitor the resident for edema while on diuretics, and the care plan did not address edema. Staff interviews confirmed these oversights, highlighting a failure to adhere to physician orders and care planning.
A resident with a complex medical history and multiple pressure ulcers was readmitted to the facility without timely wound care treatment orders. The facility delayed obtaining and implementing these orders for several days, as confirmed by interviews with the RN/Unit Manager and DON.
The facility failed to conduct quarterly Registered Dietician assessments for a resident receiving tube feeding, with the last documented assessment being in 2021. Additionally, another resident's monthly weights were not recorded in the EHR for two months, despite a policy requiring monthly documentation. The resident had a history of cerebrovascular disease and was on enteral feeding, with a potential weight loss noted.
Failure to Protect Pressure Injuries and Post EBP Signage
Penalty
Summary
The facility failed to ensure that residents with pressure injuries received care and services consistent with professional standards of practice to promote healing. For one resident with a stage 3 right lateral ankle pressure injury, the wound was documented as stable on 04/07/2026 and later as subsequently worsening on 04/14/2026, with increased size and undermining. The wound care nurse reported the wound bed appeared frail and mushy, and stated the changes were consistent with the wound getting wet. The resident had diagnoses including hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes, and mild protein-calorie malnutrition, and was totally dependent on staff for bathing and transfers. The wound care nurse also reported that a family member had assisted the resident to shower over the weekend, and later stated the resident should never have been put in the shower. A registered nurse reported that on 04/05/2026 she brought a shower chair into the resident’s room, transferred the resident to the shower chair with the family member’s help, and showered the resident even though the resident had open wounds. She stated the wounds did not have dressings in place, she secured only a plastic bag over the right ankle wound, and the bag collected a little water. She further stated she did not report or document the shower incident and did not think showering the resident was a big deal. The facility also failed to ensure Enhanced Barrier Precautions signage was in place for two residents with wounds. Observations on 05/11/2026 showed one resident’s room and another resident’s room did not have EBP signage posted, and staff members acknowledged the signage should have been there. Both residents were dependent on staff for bathing and transfers and were care planned for EBP related to wounds.
Failure to Provide Scheduled Pain Medication Resulting in Uncontrolled Pain and Hospital Transfer
Penalty
Summary
A deficiency occurred when a resident with chronic pain and multiple medical conditions, including spinal cord injury and chronic pain syndrome, did not receive scheduled Morphine Sulfate as ordered for pain management. The resident's physician had prescribed Morphine 30 mg, two tablets by mouth every eight hours, but the facility ran out of this medication. The last documented dose was administered in the afternoon, after which three consecutive scheduled doses were missed. During this period, the resident experienced severe pain, including a headache and nausea, and reported that alternative pain medications such as oxycodone-acetaminophen and Tylenol were ineffective. The breakdown in medication administration was due to failures in the facility's refill and communication processes. Nursing staff identified that the resident was running low on Morphine and faxed refill requests to the physician. Although the physician indicated that a hard copy prescription was sent to the pharmacy, there was no confirmation that the pharmacy received the request, and the medication was not delivered. Nursing staff did not follow up with the pharmacy as instructed, nor did they escalate the issue to the Unit Manager, DON, or Administrator in a timely manner. The Unit Manager and other staff were aware that the resident was out of Morphine but did not take further action to resolve the situation or notify higher-level staff. As a result, the resident missed three consecutive doses of scheduled Morphine, experienced uncontrolled pain, and ultimately required transfer to the emergency room for severe headache, nausea, and ineffective pain control. Interviews with staff and review of documentation confirmed that the facility failed to ensure the resident received pain medication as ordered, and that communication and follow-up procedures were not properly executed, directly resulting in actual harm to the resident.
Failure to Develop and Implement Care Plans for PICC Line Management and Physician-Ordered Services
Penalty
Summary
The facility failed to develop and implement comprehensive care plans addressing the use of PICC lines for two residents who were admitted with these devices for IV antibiotic administration. Record reviews showed that neither resident had a care plan problem or approaches documented for the management of their PICC lines, as confirmed by the MDS Director. One resident had a PICC line in the left arm, while the other had a PICC line initially in the left jugular vein, later replaced in the right upper inner arm. Both residents' care plans lacked documentation regarding the use and management of these lines for IV antibiotics. Additionally, the facility failed to administer IV antibiotics as ordered for one resident, with medication administration records missing documentation for specific doses. The resident reported not receiving the antibiotics as prescribed, and the DON confirmed the missed doses. Another resident did not receive restorative nursing services as ordered by the physician, with staff interviews revealing that the resident was not placed on the restorative schedule, resulting in the omission of required care. These failures were confirmed through staff interviews and record reviews.
Failure to Elevate Head of Bed During Tube Feeding
Penalty
Summary
A deficiency occurred when a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube was observed receiving enteral feeding while lying flat in bed, contrary to physician orders and facility policy. The facility's policy and the resident's care plan both required the head of the bed to be elevated 30-45 degrees during tube feeding and for one hour after feeding. The resident, who had a history of traumatic brain injury and was rarely or never understood, was found supine with the feeding pump infusing, and the head of the bed was not elevated as required. Record review confirmed that the physician's orders specified continuous enteral feeding with the head of bed elevated, and this was also documented in the care plan. During the observation, facility leadership, including the DON and Administrator, acknowledged that the resident was not positioned correctly during the feeding process. The failure to elevate the head of the bed during tube feeding was directly observed and confirmed by staff interviews.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident was informed of the risks and benefits, treatment alternatives, or other options before psychotropic medications were administered. Review of the facility policy stated that psychotropic medications require informed consent and that, prior to administration, written and verbal education on the medication purpose, potential benefits and risks, and alternatives must be provided and documented in the medical record. During the survey, the Administrator confirmed that informed consents were not obtained before administration of psychotropic medications. Resident #165 was admitted with diagnoses including bipolar disorder, major depressive disorder, severe depression with psychotic features, and altered mental status. The resident’s orders included multiple psychotropic medications, including trazodone for insomnia, Cymbalta for major depressive disorder, buspirone for generalized anxiety disorder, mirtazapine for major depressive disorder, and hydroxyzine as needed for itching. The resident’s MDS showed moderate cognitive impairment with a BIMS of 10, along with depressive symptoms and behavioral symptoms. The EHR did not reveal informed consents were obtained before administration of the psychotropic medications.
Resident Council Concerns About Missing Clothing Were Not Resolved
Penalty
Summary
The facility failed to act promptly on concerns raised in resident council meetings about missing clothing and personal items. Review of resident council meeting minutes from multiple meetings showed repeated discussion of missing clothes among residents with no resolution. The grievance policy stated that residents have the right to voice grievances and that the facility will make prompt efforts to resolve them, but the record did not show prompt resolution of the concerns raised in council meetings. During interviews, Resident #178 reported missing clothes and said no one would do anything about it. Resident #139 reported hair grease, pants, and shirts going missing over the last 6 months, said she reported the issue to nurses and CNAs, and stated that nothing gets done, no replacements are provided, and she feels aggravated. Resident #37 reported missing underwear within the last 2 months and said the items were never replaced after being reported to Social Services and the Laundry Supervisor. Resident #170 reported that laundry goes missing all the time and that reports to CNAs and nursing staff over the last 3 months had not resolved the issue. Staff interviews and observations showed the laundry area was disorganized. Housekeeping reported resident clothing items go missing all the time and said the laundry was so unorganized that this was why items were missing. An observation revealed multiple large unorganized racks of laundry and blankets and a barrel piled high with laundry. The Laundry Supervisor stated items should be labeled, missing items were placed in a missing clothes section, donated clothes were mixed with the missing clothes pile, and there was no list of missing clothing items with dates. Social Services stated missing items should be found within about 3 days and, if not found, a grievance form should be completed and the facility would replace the items, but Social Services was not aware of the missing items reported by the four residents.
Failure to Provide Bed Hold Policy at Hospital Transfer
Penalty
Summary
The facility failed to provide the required bed hold policy documentation to Resident #110 and/or the resident's representative when the resident was transferred out of the facility for hospital treatment. Resident #110 had diagnoses including hyperkalemia, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, chronic kidney disease, essential hypertension, and osteoarthritis. The medical record showed the resident was transferred to a hospital for treatment of hyperkalemia on two occasions, and the record did not contain documentation that the facility's bed hold policy was provided to the resident or the resident's representative at either transfer. During interview, the Administrator confirmed the bed hold policy had not been provided.
Incomplete Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure resident assessments were encoded, transmitted, and completed for 1 of 3 residents reviewed for resident assessments. Resident #81 was admitted on 02/05/2025 and discharged on 03/14/2025 with diagnoses including heart failure, unspecified, and type 2 diabetes mellitus without complications. Review of Resident #81's MDS assessments did not reveal a discharge assessment, and during an interview on 07/23/2025 at 2:30 p.m., the MDS Nurse acknowledged that the discharge MDS assessment was not completed until that day.
Wheelchair Not Maintained in Safe Operating Condition
Penalty
Summary
The facility failed to ensure resident #158’s environment was free from accident hazards when the resident’s wheelchair was observed in need of repair. During observation, the wheelchair’s locks did not lock, the right wheel was loose and unstable, and the wheelchair did not have footrests. The report states the facility did not maintain the wheelchair in safe operating condition for the resident who used a manual wheelchair for mobility. Resident #158 had diagnoses including morbid (severe) obesity due to excess calories, effusion of the right knee, and muscle weakness. Review of the resident’s 5-day MDS dated 05/29/2025 showed functional ability and use of a manual wheelchair for mobility. During interviews, the DON stated that equipment needing repair should have a work order completed and sent to Maintenance, and if parts were needed, the resident would be placed in another wheelchair until the parts arrived. The Maintenance Director stated that work orders are entered into the TELS system, but when he searched for resident #158 by name and room number, no work order appeared and he reported that a work order had not been completed.
Failure to Consult RD for Resident with Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to provide care and services to maintain acceptable nutritional status for Resident #62, who was admitted on 05/02/2025 with diagnoses including other ulcerative colitis without complications, complete paraplegia, other idiopathic peripheral autonomic neuropathy, and a stage 4 pressure ulcer of the sacral region. Review of the resident’s record did not show any supplements for wound healing, and the record also did not show that a Registered Dietician consult was completed after admission. The resident’s weight decreased from 181 lbs. on 05/02/2025 to 171 lbs. on 06/02/2025, a 5.52% loss. During interviews, the Registered Dietician stated she had not received a consult for the resident, the WCN/LPN confirmed the resident was admitted with a stage 4 pressure ulcer and was not receiving wound-healing supplements, and the CNO acknowledged that the Registered Dietician consult was not completed.
Respiratory equipment not dated, labeled, or properly stored
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with accepted professional standards of practice for 5 of 6 residents reviewed for respiratory care. The deficiency involved oxygen tubing and humidification bottles that were not dated or labeled as required, and hand held nebulizer equipment that was not stored in a covered bag. Surveyors observed these issues during record review, resident observations, and staff interviews. Resident #2 had diagnoses including chronic respiratory failure with hypoxia and had an order for oxygen at 2 liters via nasal cannula as needed for shortness of breath. The resident’s care plan did not include a focus with measurable goals and appropriate interventions related to chronic respiratory failure with hypoxia and oxygen use. On two separate observations, the resident’s oxygen tubing was not dated or labeled and the humidification bottle was empty. LPNs confirmed both times that the tubing should have been dated and labeled and the humidification bottle should have been replaced. Resident #35 had diagnoses including chronic respiratory failure with hypoxia and COPD and an order for oxygen at 3 liters continuously. The resident’s oxygen tubing was observed not dated. Resident #109 had diagnoses including acute respiratory failure with hypoxia and COPD, with orders for oxygen continuously and respiratory supplies and tubing to be changed and dated; the humidifier was undated and hand held nebulizer tubing and mouth piece were left on the bedside table, not stored in a bag. Resident #128 had COPD and heart failure, with an order to change and date respiratory supplies weekly; the hand held nebulizer tubing was undated and not stored in a covered bag. Resident #188 had diagnoses including acute and chronic respiratory failure with hypoxia, COPD, and pleural effusion, with orders for continuous oxygen and weekly change and dating of respiratory supplies; the oxygen tubing and humidifier bottle were undated. An LPN acknowledged the undated tubing, humidifiers, and improper storage of nebulizer equipment.
Failure to Provide Ordered Restorative Services
Penalty
Summary
The facility failed to provide specialized rehabilitative services for resident #158 as required by the resident’s plan of care. During an interview, the resident stated she had therapy for three days and had not received any therapy since then, and said she had been told by therapy that she would be seen by Restorative but had not been seen. Review of the resident’s Physical Therapy Restorative Referral dated 05/27/2025 showed restorative services were to begin on 06/05/2025 for six weeks. During an interview, the Restorative CNA reported that restorative services were not provided for resident #158 and stated there are only two Restorative CNAs for the entire facility. The CNA said referrals are received from physical therapy and given to a supervisor, who schedules residents for restorative services, and reported that resident #158 was never placed on the schedule. Record review showed the resident had diagnoses including morbid obesity due to excess calories, effusion of the right knee, and muscle weakness. The resident’s 5-day MDS showed a BIMS score of 15, indicating cognitive intactness, and functional status requiring substantial to maximal assistance with bed mobility and dependent assistance with transfers. The comprehensive plan of care identified an ADL self-care performance deficit related to weakness and noted fluctuating assistance with ADLs and two-person assist with transfers.
Inaccurate PBJ Staffing Submission
Penalty
Summary
The facility failed to electronically submit accurate direct care staffing information to CMS based on payroll and other verifiable and auditable data. Review of the PBJ Report for FY Quarter 2 2025 (January 1 through March 31) showed triggers for a One Star Staffing Rating and Excessively Low Weekend Staffing. However, review of staffing pattern forms for weekends during FY 2025 Quarter 2 showed the facility provided more hours than required and did not show any days when it failed to provide enough hours. During interviews, the Administrator stated that corporate submitted the PBJ information and did not submit correct information, and the Chief Nursing Officer stated she did not know why the information submitted by corporate to PBJ was not accurate.
Infection Control Program and Sanitary Handling Deficiencies
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. During review of the infection control surveillance binder with the DON, infection surveillance was not done, including monthly trend and tracking of antibiotic therapy and treatment. The report also noted that the facility failed to maintain up to date monthly tracking and trending for infection prevention and control for the 176 residents present at the time of entrance. Observations identified multiple sanitation issues involving resident care equipment and handling of soiled items. In Resident #50’s bathroom shower area, two bath basins and a bedpan were observed on the shower floor and were not stored in bags or labeled on three separate observations. The Administrator and CNO acknowledged the items were not stored in bags and labeled and should have been. In another observation, a CNA exited a shared resident room where dirty linen and briefs were on the floor, then returned with a white trash bag; the CNA stated dirty linen and briefs should not have been on the floor and that a clear trash bag should be used for dirty briefs and blue bags for dirty linen. The CNA Supervisor also confirmed dirty linens and briefs should not have been placed on the floor. During a laundry tour, bed sheets and pillowcases were observed to be worn thin and discolored with yellowish and tan stains, and blankets were observed to be in very poor condition, thin, discolored, and scratchy.
Failure to Document and Offer Immunizations
Penalty
Summary
The facility failed to maintain and follow its policies and procedures for immunizations for 4 of 5 sampled residents (#55, #84, #87, and #186) related to influenza, pneumococcal disease, and COVID-19 vaccination. The facility’s Nursing Policy Manual stated that each resident is to be offered pneumococcal and influenza immunizations, with education provided to the resident or legal representative regarding benefits and potential side effects, and the opportunity to refuse the immunization. The COVID-19 vaccination policy likewise stated that eligible residents are to be offered the vaccine and have the opportunity to accept or refuse it. During interview, the Administrator stated that immunizations are offered during the admission process and documentation should be in the admission records. However, review of the admission records for residents #55, #84, #87, and #186, each admitted on 05/01/2025, failed to reveal any documentation that the residents and/or their representatives had been educated about or offered the pneumonia, influenza, and/or COVID-19 immunizations.
Unsafe and Unclean Resident Rooms with Missing Furnishings and Worn Linens
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for multiple residents. Resident #50, admitted with diagnoses including an unspecified fracture of the upper end of the right humerus, unsteadiness on feet, and cognitive communication deficit, was observed with clothing stored in a box on the floor next to the bed and clothing on the bathroom floor. A CNA acknowledged the clothes should not have been there. Resident #110, who had a BIMS score of 8 indicating moderately impaired cognition, was observed with a sticky floor with dark brown dirt and residue in the corners and on the baseboards, and the room’s closet did not have a door in place. The Maintenance Director confirmed the closet should have had a door and the floor should have been cleaned daily. The facility also failed to provide required furnishings and clean linens in good repair. Resident #88 and Resident #91, both with BIMS scores of 14 indicating intact cognition, were observed in shared rooms without chairs for residents or visitors to sit in; Resident #91 reported her daughter had to sit on the edge of the bed during visits, and Resident #88 reported visitors had to stand or sit on the bed. During a laundry tour, bed sheets and pillowcases were observed to be worn thin and discolored with yellowish and tan stains, and blankets were observed to be in very poor condition, thin, discolored, and scratchy. The Administrator confirmed each resident should have had a chair in the room.
Failure to Complete Baseline Care Plans for Newly Admitted Residents
Penalty
Summary
The facility failed to develop and implement a baseline care plan for 2 of 63 sampled residents, including Resident #110 and Resident #188. Resident #110 had an initial admit date of 11/06/2025 and a re-admission date of 02/16/2025, with diagnoses including hyperkalemia, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, chronic kidney disease, essential hypertension, and osteoarthritis. Review of the medical record did not reveal a baseline care plan completed when the resident was admitted and re-admitted. During an interview on 07/22/2025 at 1:00 p.m., the MDS Nurse confirmed the baseline care plan was not completed and should have been. Resident #188 was admitted on 07/11/2025 with diagnoses including malignant neoplasm of the upper lobe/left bronchus or lung, acute and chronic respiratory failure with hypoxia, COPD, and unspecified pleural effusion. Review of the medical record also failed to reveal a baseline plan of care completed upon admission, and during an interview on 07/24/2025 at 2:30 p.m., the MDS Nurse acknowledged that the baseline care plan was not developed and should have been.
Failure to Obtain Ordered Biannual Labs
Penalty
Summary
Facility failed to provide services according to the written plan of care for Resident #14 by not ensuring ordered labs were obtained. Resident #14 had an initial admission date of 12/15/2023 and a re-entry admission date of 02/10/2025, with diagnoses including schizoaffective disorder, bipolar type, dementia without behavioral disturbances, psychophysiological insomnia, and anxiety disorder. The July 2025 physician orders included biannual labs for CBC, CMP, hemoglobin A1C, TSH, lipid, B12, folate, Vitamin D, Magnesium, Thiamine, and an iron panel with ferritin for June and December. The quarterly MDS dated 04/30/2025 showed a BIMS score of 15 and documented use of antipsychotic, antidepressant, antiplatelet, hypoglycemic, and anticonvulsant medications. Review of the EHR did not show that the TSH, lipid, B12, folate, Vitamin D, Magnesium, Thiamine, and iron panel with ferritin were obtained as ordered, and the Administrator confirmed during interview on 07/22/2025 that the labs were obtained as ordered.
Failure to Provide and Document ADL Hygiene Care
Penalty
Summary
The facility failed to ensure residents who were unable to complete activities of daily living received the necessary services to maintain grooming and hygiene for four residents reviewed. The facility’s ADLs/Maintain Abilities policy stated residents unable to carry out ADLs would receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene, and the facility’s policies for fingernails/toenails, hair shampooing, and mouth care described cleaning hair and scalp, trimming nails to prevent infection, and cleansing the mouth to prevent infection. Survey findings showed that these services were not consistently provided or documented for the residents reviewed. Resident #50 was admitted with diagnoses including an upper extremity fracture, polyneuropathy, unsteadiness on feet, and cognitive communication deficit. The resident’s MDS showed partial/moderate assistance needs for shower/bathe and dressing, and setup assistance for eating/oral hygiene. Observations showed the resident sitting with disheveled hair and toenails long and curled over on both feet, and later with greasy hair and long curled toenails. The resident reported not getting a bath, and the Administrator confirmed bathing had not been added as a task and there was no documentation that a bath or shower had been received. Staff also acknowledged the resident needed a bath and toenail trimming. Resident #68 was dependent for oral hygiene, shower/bathe, and personal hygiene, and task records for July showed multiple missed or undocumented oral care entries and missed shower documentation. Observations found debris buildup on the teeth, heavy buildup behind the bottom front teeth, dirty nail beds, and dark brown debris under the left thumbnail. Staff stated oral hygiene supplies were not in the room, that oral care should be provided three times a day, and that nails should be cleaned with the bath. Resident #74 had MASD with an order for barrier cream every shift; observations showed bright red moist skin breakdown with caked-on white/yellow/gray substance on the buttocks and in the brief, and staff and wound care personnel stated the area should be cleaned and the cream should not remain caked on the skin. Resident #187, admitted with hemiplegia, weakness, contractures, muscle atrophy, and gangrene to all toes, reported not having had a bath since admission, and the Administrator confirmed there was no task documentation showing bath care had been provided.
Failure to Provide Ordered Splint Care and Complete Admission Labs and Care Planning
Penalty
Summary
The facility failed to provide care and services in accordance with orders and resident-centered needs for Resident #74 and Resident #110. Resident #74 had diagnoses including spastic diplegic cerebral palsy, chronic pain syndrome, muscle wasting and atrophy of both upper arms, and contracture of an unspecified joint. The record and observations showed a left hand splint was present on the bedside table, but the splint was not in the resident’s left hand during observations. The Rehab Director stated the resident had been discharged from OT with a left hand splint and restorative nursing was to apply it, and the restorative CNA later confirmed the resident was not on the restorative list for hand splint placement even though the resident had been discharged from OT in 11/2024 with use of the splint. Resident #110 had diagnoses including hyperkalemia, unspecified dementia, chronic kidney disease, essential hypertension, and osteoarthritis. The resident returned to the facility with a diagnosis of hyperkalemia, but the comprehensive care plan did not include a problem or approach for that diagnosis, and the MDS nurse confirmed no comprehensive plan had been initiated. The physician ordered admission labs including CBC, CMP, TSH, Hgb A1C, HIV, hepatitis C, vitamin D, RPR, and urinalysis with culture and sensitivity, but the record did not show results for HIV, hepatitis C, or RPR. CBC, CMP, TSH, HgbA1C, and vitamin D were not completed until 11/26/2025 after being ordered on 11/07/2025, and the administrator confirmed the ordered admission labs were not completed as ordered and were not done in a timely manner.
Survey Results Not Posted in Accessible Location
Penalty
Summary
The facility failed to have the most recent annual survey results posted in a place readily accessible to residents, family members, or anyone to review. During an observation near the front door, the survey results binder did not contain the annual survey from 2024. During an interview, the Administrator acknowledged that the previous year's annual survey results were not in the survey binder and should have been.
Missing Privacy Curtain in Shared Room
Penalty
Summary
Keep residents' personal and medical records private and confidential was not maintained when Resident #165, who was in a shared room, did not have a privacy curtain around bed A. Observation on 07/21/2025 at 10:00 a.m. showed the resident's room was shared with a roommate and there was no privacy curtain present. During that same interview, Resident #165 and a visitor stated that the resident did not have a privacy curtain. Resident #165's face sheet showed an admission date of 01/07/2025 and diagnoses of bipolar disorder, current episode depressed, and altered mental status. The Quarterly MDS assessment showed a BIMS score of 10, indicating moderately impaired cognition. On 07/23/2025 at 11:30 a.m., S19 CNA observed the room and confirmed there was no privacy curtain around bed A.
Missing Dementia Care Plan Focus
Penalty
Summary
The facility failed to develop an individualized, person-centered care plan for Resident #14, who had a diagnosis of dementia. Record review showed the resident was admitted on 12/15/2023 and re-entered on 02/10/2025 with dementia listed on the face sheet. July 2025 physician orders included Memantine HCl 5 mg by mouth twice daily for dementia and anxiety, but the resident’s care plan did not include a focus on dementia with measurable goals and appropriate interventions. During interview, the MDS nurse confirmed that Resident #14’s care plan lacked a dementia focus with measurable goals and appropriate interventions.
Bed Remote With Exposed Wires
Penalty
Summary
The facility failed to maintain electrical equipment in safe operating condition for 1 of 11 residents reviewed for environment. Resident #35 was readmitted on 06/02/2025 with diagnoses including chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease (COPD), and the quarterly MDS assessment showed a BIMS score of 15, indicating intact cognition. During observation on 07/21/2025 at 8:14 a.m., Resident #35's bed remote was found to have exposed wires. Later that day, S28 Maintenance confirmed the bed control had exposed wires, and S20 DON also confirmed that the bed control had exposed wires and should not have.
Failure to Honor Resident's Dietary Preference for White Meat
Penalty
Summary
The facility failed to honor a resident's documented dietary preference for white meat chicken during a lunch meal service. On the day of observation, the resident was served two baked chicken legs, which are dark meat, despite their meal card clearly indicating a preference for white meat. Staff interviews confirmed awareness of the resident's dislike for dark meat and acknowledged that the meal provided did not align with the resident's stated preference. The dietary manager also confirmed that the resident's preference should have been followed but was not in this instance.
Failure to Follow Physician Orders and Medication Administration Standards for Diabetic Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for one resident with Type 2 diabetes mellitus and hyperglycemia. Specifically, the facility did not ensure that high blood glucose levels were rechecked as ordered after administering sliding scale insulin for glucose readings greater than 400. Multiple instances were identified where blood glucose levels exceeded 400, insulin was administered per sliding scale, but no evidence was found that glucose was rechecked after three hours as required by the physician's orders. Additionally, the facility did not consistently perform blood glucose checks to determine if sliding scale insulin was needed, as ordered, on certain mornings. There were also multiple occasions where the resident's blood glucose levels were above the threshold requiring physician notification, but there was no documentation that the physician had been notified as ordered. These failures were confirmed through review of the electronic medication administration records (eMAR) and nursing notes, as well as by the Director of Nursing during an interview. Furthermore, the facility did not administer the resident's prescribed morning doses of Lantus insulin on specific dates, as indicated by the absence of documentation in the eMAR. The Director of Nursing confirmed that there was no evidence these doses were given or documented. The facility's medication administration policy requires medications to be administered and documented as ordered, including timely administration, proper documentation, and physician notification when required, but these standards were not met in the care of this resident.
Failure to Timely Implement Wound Care Orders for Pressure Ulcer
Penalty
Summary
A deficiency occurred when the facility failed to provide necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure ulcers for a resident with a gluteal cleft pressure injury. The resident, who had multiple diagnoses including type 2 diabetes mellitus with hyperglycemia, muscle weakness, and a nontraumatic intracerebral hemorrhage, was under the care of a wound nurse practitioner (NP) who recommended a specific wound care regimen. The NP's recommendations, which included cleaning the wound with cleanser, applying honey and a dry dressing, and changing the dressing three times per week or as needed, were documented in the resident's record. Despite these recommendations, the treatment administration record showed that the NP's wound care orders were not implemented until more than two weeks after they were made. Interviews with the treatment nurse revealed a misunderstanding regarding whether to continue the previous treatment until supplies were exhausted, despite no such instruction being documented. The NP confirmed that the new wound care orders should have been started as soon as they were given, and the treatment nurse acknowledged that the recommended care was not initiated as ordered.
Failure to Resolve Grievance Regarding Call Light Response
Penalty
Summary
The facility failed to adhere to its Grievance Policy by not resolving a grievance filed by a resident's responsible party regarding the resident's call light not being answered. The grievance, filed on January 31, 2025, highlighted incidents on January 25 and January 31, 2025, where the resident had to wait excessively long for assistance, specifically to be changed after being incontinent. Despite the grievance being filed, the facility did not provide a completed review of the grievance in writing or verbally to the resident or their responsible party. The resident involved had an intact cognitive status with a BIMS score of 15, indicating full cognitive function, but had physical limitations due to cardiopulmonary arrest and was on diuretic therapy. During a surveyor's visit, the resident confirmed that their call light was not answered, and the surveyor observed the call light being ignored. Interviews with staff confirmed that the grievance was not communicated back to the resident or their responsible party, indicating a failure in the facility's grievance resolution process.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect residents from sexual abuse and psychosocial harm, resulting in an Immediate Jeopardy situation. A resident with intact cognition was approached in his bed by another resident who exposed himself and made unwanted sexual advances. Despite the incident being reported, the perpetrator was not immediately separated from the victim or other residents in the shared room, and no one-on-one supervision was provided. The incident involved multiple residents, including a paraplegic resident with PTSD, who reported the abuse to the facility administrator. The staff's response was inadequate, as they did not believe the victim and failed to provide immediate protection or support. The resident was left in the same room with the perpetrator and other residents until later in the day, exacerbating his PTSD symptoms. Interviews with staff revealed a lack of immediate action and documentation regarding the incident. The RN on duty did not witness the abuse but heard the victim's distress and failed to ensure the perpetrator was monitored or separated. The facility's administration was not informed until hours after the incident, highlighting a breakdown in communication and adherence to abuse prevention policies.
Failure to Ensure Resident Safety and Proper Response to Abuse Allegation
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, resulting in a deficiency that affected the well-being of a resident. The incident involved a resident who was approached at his bedside by another resident with inappropriate behavior, including exposure and physical contact. Despite the resident's intact cognition and ability to report the incident, the facility staff did not take immediate action to separate the aggressor from the other residents in the shared room. The deficiency was further compounded by the lack of immediate response from the facility's administration. The administrator was not informed of the incident until the resident reported it directly to her office hours later. During this time, the aggressor remained in the shared room with the victim and other residents, without any one-on-one supervision or monitoring, which was a critical oversight in ensuring the safety and well-being of all residents involved. Interviews with facility staff revealed a lack of documentation and adherence to the abuse/neglect policy, particularly in terms of providing one-on-one care and monitoring for the aggressor. The Director of Nursing acknowledged the failure to implement necessary measures following the incident, and the administrator confirmed the absence of documentation for one-on-one supervision. This deficiency highlights a significant lapse in the facility's procedures for handling allegations of abuse and ensuring resident safety.
Failure in Pain Management for Post-Surgical Resident
Penalty
Summary
The facility failed to provide adequate pain management for a resident who required such services, resulting in actual harm. Resident #4, who had undergone surgery for the removal of metatarsals, reported pain at her surgical site and requested pain medication. Despite her request for Tylenol, the LPN on duty, S3, informed her that she could not administer any pain medication due to issues with the medication prescription. This led to Resident #4 experiencing unmanaged pain, which she rated as a 6 on a scale of 0-10. The facility's pain management policy, dated April 2022, outlines procedures for evaluating and managing pain, including both pharmacological and non-pharmacological interventions. However, the policy did not address the administration of pain medication as ordered. On the evening of the incident, S3 LPN did not conduct a pain assessment for Resident #4, as she was focused on arranging for the resident's transfer to the hospital. The lack of pain management led Resident #4 to call 911, resulting in her being admitted to the hospital ER, where she received Dilaudid for acute pain. Interviews with the staff and Resident #4 revealed that the resident was aware of the staff's attempts to resolve the prescription issue but was dissatisfied with the lack of immediate pain relief. The Director of Nursing acknowledged that Resident #4 should have received pain medication. The incident highlights a failure in the facility's pain management practices, as the resident did not receive any pain relief during the shift, leading to her hospitalization.
Failure to Timely Report Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to report an alleged incident of sexual abuse involving two residents within the required timeframe. Resident #1, who has diagnoses including unspecified paraplegia, anxiety disorder, depression, and PTSD, reported that Resident #2 approached him inappropriately during the early hours of 12/27/2024. Resident #1 captured the incident on video, showing Resident #2 with his genitals exposed and making inappropriate advances. Despite the incident being reported to the Assistant Director of Nursing (ADON) shortly after it occurred, it was not communicated to the facility's Administrator or the state agency within the mandated two-hour window. The facility's policy requires immediate reporting of such incidents to the Administrator and the state agency, but this protocol was not followed. The ADON acknowledged awareness of the incident but did not report it to the Administrator. The incident was not officially documented until several hours later, and the Administrator confirmed that the incident report was not submitted to the state agency as required. This delay in reporting constitutes a failure to adhere to the facility's abuse prevention policy and state regulations.
Inadequate Investigation of Sexual Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving two residents. Resident #1 reported that Resident #2 approached him inappropriately during the early hours of 12/27/2024. Resident #1, who has diagnoses including unspecified paraplegia, anxiety disorder, depression, and post-traumatic stress disorder, stated that Resident #2 grabbed him by the arms and shoulders and exposed himself while making inappropriate comments. Video evidence from Resident #1's cell phone corroborated his account, showing Resident #2 with his genitals exposed and engaging in inappropriate behavior. The facility's investigation into the incident was inadequate. The administrator, who is the designated abuse coordinator, only interviewed two employees who were not present during the incident. The investigation did not include interviews with all staff members who were on duty at the time of the incident, as required by the facility's Abuse Prevention Policy. The administrator acknowledged that a thorough investigation was not conducted, failing to adhere to the policy's standards for addressing and investigating allegations of abuse.
Lack of Documentation for Physician's Discharge Order
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for one of the sampled residents. Specifically, there was no documentation of a physician's discharge order for a resident who was discharged to the hospital. The resident had multiple diagnoses, including pain in the left wrist, chronic viral hepatitis C, cognitive communication deficit, and unspecified cannabis use. The resident's Minimum Data Set (MDS) indicated a Brief Interview of Mental Status (BIMS) score of 06, reflecting severely impaired cognition. During an interview, the Assistant Director of Nursing (ADON) admitted to misplacing the verbal discharge order from the physician and acknowledged the absence of a system for taking verbal orders.
Failure to Provide Transportation for Medical Appointments
Penalty
Summary
The facility failed to ensure that a resident had access to necessary medical services outside the facility, as evidenced by the lack of transportation provided for scheduled medical appointments. The facility's Transportation to Appointments Policy outlines that the Transportation Supervisor or designee is responsible for scheduling and ensuring transportation for residents' medical appointments. However, for a resident with a diagnosis of colon cancer with metastatic cancer to bone, there was no documentation indicating that the resident was transported to or attended their scheduled appointments on November 7, 2024. These appointments included a non-fasting lab, a hematology oncology visit, and a chemotherapy infusion. Interviews with facility staff, including the Director of Nursing and the CNA Supervisor, confirmed that there was no documentation of the resident being transported or attending the scheduled appointments. Additionally, there was no record of the resident refusing to attend these appointments. The lack of documentation and transportation for the resident's critical medical appointments represents a failure to adhere to the facility's policy and ensure the resident's right to access necessary medical care.
Failure to Update Care Plan for Resident
Penalty
Summary
The facility failed to revise the care plan for one of the nine sampled residents, identified as Resident #4. Resident #4 was admitted with multiple serious injuries, including fractures and hemorrhages, and initially required significant assistance with mobility and activities of daily living (ADLs). The care plan, initiated in April and June 2024, included interventions for impaired physical mobility and ADL self-care performance deficits, such as partial weight-bearing instructions and the use of a Miami J-Collar and cam boot. Despite a quarterly MDS assessment in July 2024 indicating that Resident #4 was cognitively intact and required only supervision and setup help for mobility and ADLs, the care plan was not updated to reflect the resident's improved condition. Interviews conducted in October 2024 revealed that Resident #4 was independently performing tasks such as getting out of bed, dressing, and bathing, and had stopped using the prescribed collar and boot. The MDS Director confirmed that the care plan should have been updated following the July assessment.
Failure to Accurately Assess and Report Pressure Ulcer Risk
Penalty
Summary
The facility failed to provide necessary treatment and services to a resident at risk for pressure ulcers, consistent with professional standards of practice. The resident, who had a history of Spastic Diplegic Cerebral Palsy, Type 2 Diabetes, and other conditions, was totally dependent on staff for bed mobility and transfers. Despite being care planned for potential skin integrity issues, the facility did not perform an accurate assessment or notify the MD/NP of the resident's skin condition. On 09/14/2024, a Licensed Practical Nurse noted a pinkish/red area on the resident's buttock, indicating a stage I and II pressure ulcer, but failed to successfully notify the NP. Subsequent assessments by the treatment nurse and unit manager revealed inconsistencies in the documentation and recognition of the resident's skin condition. The treatment nurse initially reported no skin issues, while the unit manager later identified Moisture Associated Skin Damage (MASD) to the resident's sacrum. The Director of Nursing acknowledged that the MD should have been notified of the initial assessment and that the treatment nurse's assessment was inaccurate, potentially leading to a worsening of the resident's condition.
Deficiencies in Care Plan Implementation and Medication Administration
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to deficiencies in meeting their medical and care needs. For one resident, the facility did not follow physician orders for administering Keflex, an antibiotic, via PEG tube. The medication was not administered on specific dates, and there was no activity recorded in the facility's automated medication dispensing system, indicating missed doses. The Director of Nursing acknowledged the oversight, which was due to a failure in communication and verification with the pharmacy. Another resident experienced multiple falls, but the facility did not revise the resident's care plan to include interventions for falls that occurred on two specific dates. Despite the resident being cognitively intact and requiring extensive assistance with mobility and transfers, the care plan was not updated to address the falls. The Director of Nursing confirmed that the care plan should have been revised following these incidents.
Failure to Notify Responsible Party of Change in Resident's Condition
Penalty
Summary
The facility failed to notify the responsible party of a resident when there was a change in the resident's medical condition. Specifically, the responsible party was not informed about the initiation of antibiotic treatment for a urinary tract infection. The facility's policy requires that the resident, their attending physician, and the responsible party be promptly notified of any changes in the resident's medical or mental condition. However, in this case, the responsible party was not notified when the resident was prescribed Keflex, an antibiotic, to be administered via PEG tube three times a day for seven days. The deficiency was identified through a review of the resident's medical records and interviews with facility staff. The records did not show any documentation that the responsible party was informed about the antibiotic order. During interviews, an LPN acknowledged making a progress note entry regarding the new order but could not recall notifying the family. The Director of Nursing also confirmed that the responsible party should have been notified about the antibiotics ordered for the urinary tract infection, indicating a lapse in following the facility's notification policy.
Inadequate Catheter Care Leading to Potential UTI Risk
Penalty
Summary
The facility failed to ensure that a resident with an indwelling catheter received appropriate care to prevent urinary tract infections. The deficiency was identified during a review of the facility's policy and procedure for preventing Catheter-Associated Urinary Tract Infections (CAUTIs), which mandates maintaining unobstructed urine flow and keeping the drainage bag below the level of the bladder without placing it on the floor. However, an observation revealed that the urinary catheter drainage bag of a resident was hanging from the bedframe with the drain port tubing touching the floor, which is against the facility's guidelines. The resident involved had multiple diagnoses, including acute respiratory failure with hypoxia, acute kidney failure, quadriplegia, and essential hypertension. The resident's physician's orders included specific instructions for the care of a suprapubic catheter, which required sterile procedures and monthly changes. Despite these orders, the improper positioning of the catheter drainage bag was noted during an observation, and an LPN confirmed that the bag should not have been touching the floor, indicating a lapse in following the established CAUTI prevention strategies.
Failure to Obtain Consent and Physician's Order for Bed Rails
Penalty
Summary
The facility failed to obtain a written order from a physician and informed consent for the use of bed rails for one of the sampled residents. According to the facility's Bed Rail Policy, it is essential to assess residents for safety risks, review these risks and benefits with the resident or their representative, obtain informed consent, and secure a physician's order before installing bed rails. However, the review of Resident #2's medical records did not reveal any informed consent or physician's order for the use of bed rails, which is a violation of the facility's policy. Resident #2, who was admitted with diagnoses including acute respiratory failure with hypoxia, traumatic subdural hemorrhage, and severe cognitive impairment, was found to have grab bars on their bed. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed the presence of mobility bars on the resident's bed and acknowledged the absence of the required informed consent and physician's order. This oversight indicates a failure to adhere to the established procedures for ensuring the safe and appropriate use of bed rails, as outlined in the facility's policy.
Failure to Complete Required Annual Training for CNA
Penalty
Summary
The facility failed to ensure that required annual training on abuse and dementia care was completed for one direct care staff member, a Certified Nursing Assistant (CNA), out of six direct care staff personnel records reviewed. According to the facility's Abuse Prevention Policy, all staff, including contractors and volunteers, are required to receive annual education and training on abuse, neglect, and exploitation. The personnel record of the CNA in question showed a hire date of September 25, 2018, and indicated that the last documented training on abuse and dementia was completed on June 1, 2023. During an interview conducted on August 13, 2024, the Staff Development Coordinator reviewed the CNA's personnel record and acknowledged the absence of documentation for the required annual training. This oversight highlights a lapse in adherence to the facility's policy on mandatory training, which is crucial for ensuring staff are equipped to handle situations involving abuse, neglect, and exploitation.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to accommodate the needs of two residents by not ensuring their call lights were within reach, as required by the facility's procedure. Resident #39 reported not having a call light during an interview, and observations confirmed that the call light was on the ground, wedged between the wall and a piece of furniture, making it inaccessible. This issue persisted over multiple days, as observed on June 3rd and June 5th, 2024. The Director of Nursing (DON) confirmed the deficiency during an interview, acknowledging that the call light should have been within the resident's reach. Similarly, Resident #67, who was at risk for falls due to decreased mobility and a history of falls, also had an inaccessible call light. Observations on June 3rd and June 4th, 2024, revealed that the call light cord was wrapped around and wedged in the bed wheel at the foot of the bed, making it unreachable for the resident. The DON acknowledged this issue during an interview, confirming that the call light was not within the resident's reach, contrary to the care plan's interventions to anticipate and meet the resident's needs.
Failure to Address Laundry Service Concerns
Penalty
Summary
The facility failed to adequately address and act upon the concerns raised by the resident council regarding issues with the laundry service. Over several months, multiple residents reported missing or incorrectly returned clothing items during resident council meetings. These grievances were documented from January to May 2024, with residents expressing dissatisfaction with the slow return of laundry, missing items, and receiving clothes that did not belong to them. Some residents, due to these ongoing issues, opted to have their families handle their laundry instead. The facility's grievance log for May 2024 also recorded complaints about missing clothing, with delayed responses from the facility. Interviews with staff revealed a lack of a structured laundry schedule and issues with clothing being returned to incorrect rooms or floors, contributing to the problem. The Activity Director and Housekeeping/Laundry Supervisor acknowledged the issues, with the latter noting that the return of clothes depended on various factors, including the absence of names on clothing and room changes by residents. Despite these acknowledgments, the facility did not take prompt action to resolve the residents' concerns, leading to continued dissatisfaction and potential impact on all 189 residents.
Failure to Develop and Implement Care Plans for UTIs
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents diagnosed with urinary tract infections (UTIs). Resident #25, who has a history of chronic congestive heart failure, primary hypertension, type 2 diabetes, and a UTI, did not have a care plan addressing the UTI despite having a physician's order for Keflex. The resident's electronic health record and comprehensive plan of care lacked any mention of the UTI diagnosis or treatment plan. This oversight was confirmed by an LPN/MDS Nurse during an interview. Similarly, Resident #98, with a medical history including UTI, generalized epilepsy, type 2 diabetes, cerebral infarction, essential hypertension, and aphasia, also lacked a care plan for their UTI. Although there was a physician's order for Macrobid, the care plan did not reflect this diagnosis. Additionally, Resident #98 was not administered Doxycycline and Acidophilus as ordered by the nurse practitioner, as these medications were not entered into the electronic health record or the medication administration record. This failure was confirmed by the Director of Nurses during an interview.
Failure to Revise Care Plan for Resident with Significant Weight Loss
Penalty
Summary
The facility failed to revise the care plan for a resident who experienced significant weight loss. The resident, who was NPO and receiving enteral feedings through a PEG tube, showed a weight decrease from 112.6 lbs to 97.6 lbs over a period of approximately three months, indicating a 13.32% weight loss. Despite this significant weight loss, the resident's care plan was not updated to include a dietician consult or the implementation of weekly weight monitoring. During an interview, the Director of Nursing (DON) acknowledged that the resident's weight loss exceeded the thresholds for concern, which should have triggered a dietician consult and weekly weight checks. However, these actions were not documented in the resident's care plan. The DON confirmed that the facility's protocol involves reviewing residents with significant weight loss in monthly meetings and implementing necessary interventions, but these steps were not taken for this resident.
Deficiencies in Resident Grooming and Hygiene Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living, specifically in maintaining grooming and hygiene for several residents. Resident #25, who has a diagnosis of diabetes mellitus and other health issues, was observed with long fingernails despite a care plan that included monitoring by a podiatrist. The resident expressed a need for nail trimming, which was confirmed by staff as not being performed. Similarly, Resident #57, with Alzheimer's disease and other conditions, was found with long, dirty fingernails, which were not cleaned or trimmed during bathing as required. Resident #98, with a history of cerebral infarction and diabetes, was observed with long, jagged fingernails, indicating a failure to follow the care plan that required nail care on bath days. Staff acknowledged the need for frequent trimming due to fast nail growth. Resident #141, with major depressive disorder, had a cracked thumbnail that had not been addressed for several days, despite the resident's request for trimming. This oversight was confirmed by staff, highlighting a lapse in the care plan's execution. Additionally, Resident #120, with multiple fractures and mobility issues, had long, thick toenails causing discomfort, and had not been seen by a podiatrist for about a year, contrary to the care plan. Resident #174 reported not receiving scheduled baths, confirmed by a review of the electronic health record, which showed no record of bathing since admission. The resident had to wash herself at the sink, indicating a failure in the facility's scheduling and documentation processes.
Failure to Follow Physician Orders for Edema Treatment
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with edema, as per physician orders and professional standards of practice. The resident, who had a medical history of blood clots and cellulitis, reported not wearing ted hose despite having a physician's order for them. Observations confirmed the absence of ted hose on the resident's swollen lower extremities on multiple occasions. The resident's medical records indicated a diagnosis of embolism and thrombosis, and orders for ted hose application during the day, as well as medication for DVT and CHF with edema. However, the facility did not ensure the resident received the prescribed ted hose, as they had not arrived from the medical supply company. Additionally, the facility failed to monitor the resident for edema while on diuretics, as required by the physician's orders. The resident's care plan did not address the issue of edema, and the EMAR did not include monitoring tasks for edema related to diuretic use. Interviews with facility staff, including an LPN and the DON, confirmed the oversight in monitoring and the lack of documentation regarding the order and follow-up for the ted hose. This lack of adherence to physician orders and care planning resulted in the resident not receiving the necessary treatment for their condition.
Failure to Timely Implement Wound Care for Resident
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with pressure ulcers, consistent with professional standards of practice. Upon readmission to the facility, the resident, who had a complex medical history including anoxic brain damage, cardiac arrest, and severe hypoxic ischemic encephalopathy, was not given appropriate wound care treatment orders. The resident was assessed to have a stage IV pressure ulcer on the sacrum, and stage II pressure ulcers on the right arm and left foot. However, the facility did not obtain or implement wound care treatment orders until several days after the resident's readmission. Interviews with facility staff, including a Registered Nurse/Unit Manager and the Director of Nursing, confirmed the delay in obtaining and implementing wound care treatment orders. The staff acknowledged that the orders were not put in place until four days after the resident's readmission, indicating a lapse in the facility's protocol for managing pressure ulcers and ensuring timely care for residents with such conditions.
Failure to Conduct Regular Dietician Assessments and Document Monthly Weights
Penalty
Summary
The facility failed to ensure that Resident #85 received at least quarterly Registered Dietician (RD) assessments as per the facility's policy. The policy required the RD to review all new admissions, tube feedings, and residents on dialysis at least quarterly. However, Resident #85, who was receiving Glucerna via a feeding pump and had multiple diagnoses including hemiplegia, diabetes, and malnutrition, did not have a documented RD assessment since 07/15/2021 until a mini assessment on 06/06/2024. The RD reported that the last assessment was on 03/21/2023, but could not provide documentation, and the mini assessment was conducted without seeing the resident, relying solely on the resident's record. Additionally, the facility did not document monthly weights for Resident #135 in the electronic health record (EHR) as required by the facility's weight management policy. Resident #135, who had a history of cerebrovascular disease and was on enteral feeding, had a recorded weight of 164.4 pounds on 03/01/2024, but no weights were documented for April and May 2024. A handwritten weight of 158.9 pounds was found for May 7, 2024, indicating a potential weight loss. The Director of Nursing confirmed that the weights were not recorded in the EHR for the specified months, which was against the facility's policy.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 116 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Shreveport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harmony House Nursing And Rehabilitation Center, I | 1.4 mi | ★★★★★ | 5 | 0 |
| Magnolia Manor Nursing And Rehab Ctr, Llc | 1.5 mi | ★★★★★ | 6 | 0 |
| Claiborne Healthcare Center | 1.5 mi | ★★★★★ | 7 | 1 |
| Shreveport Manor Skilled Nursing & Rehabilitation | 2 mi | ★★★★★ | 8 | 0 |
| Roseview Nursing And Rehabilitation Center | 2 mi | ★★★★★ | 12 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Highland Place Rehab And Nursing Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.