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 Rehabilitation & Health Care Center during CMS and state inspections, most recent first.
A resident with schizoaffective disorder, bipolar type, reported an alleged assault by another resident, and police were notified. An LPN notified the guardian using the office number instead of the required after-hours emergency number listed in the chart and agreed-upon protocol for significant changes in condition and law enforcement contact; the DON confirmed the wrong number was used.
A resident with schizophrenia, mood disorder, and a history of aggressive behavior was on 1:1 monitoring but was allowed to enter a shared bathroom unaccompanied, where another cognitively intact resident with schizophrenia and anxiety was already present and naked. The first resident crossed through the adjoining bathroom into the neighbor’s side and punched the second resident multiple times in the back and back of the head, while the assigned CNA remained seated in the hallway and did not follow into the bathroom. The assaulted resident later reported pain and fear, and another resident witnessed the punches before staff intervened. Nursing documentation showed no pain assessments or pain medication provided to the assaulted resident that day. This sequence of events reflects a failure to provide effective supervision and to protect a resident from abuse as required by the facility’s abuse prohibition policy.
A resident with severe cognitive impairment physically assaulted another resident after the latter grabbed a CNA's arm, resulting in a fractured jaw. Multiple staff and resident interviews confirmed that the incident involved deliberate kicking and punching, and the event was substantiated as abuse according to facility policy.
A resident with severe cognitive impairment and total dependence for mobility was transferred and repositioned in bed by a single CNA using a Hoyer lift, contrary to policy requiring two staff. The resident was left unsupervised on the edge of the bed and subsequently fell headfirst to the floor, sustaining multiple bruises and abrasions. Video evidence and staff interviews confirmed the policy violations and improper handling during and after the fall.
A resident with a history of mental illness, substance use, and prior elopement risk was left unsupervised during a smoke break, despite facility policy requiring supervision. The resident hid from view, climbed a second-floor fence, and jumped, resulting in a compound leg fracture that required surgery. Staff interviews confirmed that no one was monitoring the smoke deck at the time, and previous exit-seeking behaviors had been reported but not addressed with increased supervision.
The facility failed to meet food safety standards, as staff did not use hair restraints, and food items were improperly stored and labeled. Uncovered food and unlabeled personal items in the refrigerator were observed, with staff acknowledging the need for proper labeling and storage practices.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents, as staff did not consistently use gowns and gloves during high-contact care activities. A CNA and an RN did not wear gowns while providing care involving a catheter and feeding tube, respectively. Additionally, an AC did not perform hand hygiene or wear PPE while assisting a resident. Observations also revealed a catheter drainage bag and tubing on the floor, contrary to facility policy.
A resident with a suprapubic catheter was observed in a common area without a privacy cover on the catheter drainage bag, compromising their dignity. Despite facility policies emphasizing privacy, the assigned LPN forgot to cover the bag, and the facility lacked a specific policy addressing this issue.
A resident dependent on tube feeding was found to have dried formula splatters on their feeding pump, pole, and floor, indicating a failure to maintain cleanliness. Despite the facility's housekeeping routine requiring spill management, the spills were not addressed. Interviews with staff confirmed the issue, highlighting unclear responsibilities for cleaning around the feeding equipment.
A resident with Huntington's disease was improperly restrained by a CMT who picked them up and carried them inside to prevent them from taking another resident's cigarette. This action violated the facility's restraint policy, which requires that restraints only be used in emergencies with proper authorization. The facility's leadership acknowledged the action as inappropriate, emphasizing the need for alternative de-escalation techniques.
A resident with a history of substance use disorder left the facility and did not return as expected. The facility failed to conduct a thorough investigation, as required by their policy, by not interviewing staff or submitting a follow-up report to the State Survey Agency. The resident returned after four days with no recollection of the absence, highlighting a deficiency in the facility's handling of the incident.
The facility failed to update PASRRs for two residents diagnosed with new mental disorders. One resident, initially diagnosed with schizophrenia, later developed major depressive disorder, while another resident developed major depressive disorder and psychotic disorder with delusions. Despite these new diagnoses, the facility did not complete new PASRRs, as confirmed by the Administrator and Interim DON.
A facility failed to develop a comprehensive care plan for a resident with PTSD, resulting in staff being unaware of the diagnosis and lacking guidance on managing the resident's mental health needs. The resident had a history of PTSD from childhood abuse and was on multiple psychiatric medications. The MDS RN admitted to relying on automated systems, leading to care plan omissions, while the DON and Administrator stressed the need for documented triggers and approaches.
A resident with a history of alcoholism left the facility without returning as expected, and the staff failed to follow the facility's policy for monitoring and reporting missing residents. The resident signed out to go to the library but did not fill out the anticipated return time. The staff did not initiate the required follow-up actions promptly, resulting in a delay in reporting the resident as missing. The resident was found wandering and returned to the facility four days later.
A resident in an LTC facility did not receive several physician-ordered medications due to miscommunication and improper handling. The medications were delivered but not administered, as they were misplaced in the nurses' room instead of the CMT's cart. Staff failed to reorder the medications or notify the physician, resulting in missed doses for the resident with a history of hypothyroidism, hyperlipidemia, hypertension, and bradycardia.
A resident with cerebral palsy did not receive proper bathing care due to the facility's failure to update the care plan and ensure the use of a specialized shower chair. The resident's bathing schedule was inconsistent, and staff were unaware of the resident's specific needs and the location of the specialized equipment. The specialized shower chair was found in a locked room, indicating a lack of communication and coordination among staff.
A resident with multiple medical conditions was transferred to another facility without belongings, medications, or necessary paperwork. The DON instructed not to send medications, and the facility lacked a policy for medication disposition during transfers.
Failure to Use Correct Guardian Notification Protocol
Penalty
Summary
The facility failed to notify Guardian A using the agreed-upon after-hours protocol for a resident with schizoaffective disorder, bipolar type, when the resident experienced a change in condition. The resident’s record listed Guardian A’s emergency after-hours phone number, and the Public Administrator Emergency Call Information form specified that the on-call number was to be used for significant changes in the ward’s condition and for contact with law enforcement. After the resident reported that another resident grabbed the resident by the arm and said the resident would rape them, LPN A notified Guardian A using the guardian’s office number instead of the emergency after-hours number. The record also showed that police were notified of the alleged incident and that the resident spoke with police about it. During interviews, Guardian A confirmed the office number called was not the correct number and stated the facility had signed a form in 2025 acknowledging the correct after-hours notification protocol. LPN A said the number called was the one on the resident’s face sheet and did not see the after-hours number there, while LPN B and the DON stated staff were expected to use the after-hours emergency number and speak with someone when notifying the guardian of a change in condition. The DON stated LPN A had not followed the facility’s protocol.
Failure to Prevent Resident-on-Resident Physical Abuse in Shared Bathroom
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse when another resident physically assaulted him/her in a shared bathroom. Resident #3 had a history of behavior problems, restlessness, agitation, aggressive behavior, and pacing, with diagnoses including schizophrenia, schizoaffective disorder, mood disorder, personality disorder, anxiety disorder, and depression. Despite these conditions and the use of one-on-one monitoring, Resident #3 was allowed to go into the shared bathroom unaccompanied while the assigned CNA sat in the hallway outside the resident’s room. Resident #3 entered the bathroom that connected to Resident #4’s room, where Resident #4 was already present and naked, and then physically attacked Resident #4, striking him/her multiple times with a fist. Resident #4, who also had diagnoses of schizophrenia, anxiety, and depression but no documented negative behaviors, was cognitively intact and independent with most self-care. At the time of the incident, Resident #4 was in the bathroom without clothing when Resident #3 entered and began punching him/her in the back and the back of the head. Resident #4 later reported being hit three or four times, that it hurt, and that he/she was scared. Another resident in the room with Resident #4 witnessed Resident #3 throwing punches at the back of Resident #4’s head until staff intervened. The CNA assigned to one-on-one monitoring heard noises from the bathroom, then observed Resident #3 coming out of Resident #4’s side of the bathroom stating he/she had beaten the other resident up, and noted swelling and pain in Resident #3’s hand. Following the altercation, RN A documented that Resident #4 reported being hit on the back and back of the head but denied pain at that time, and the nurse’s assessment found no visible swelling, discoloration, bruising, or drainage. However, Resident #4 later stated that the incident hurt and that he/she was scared, and described praying for a reason to live afterward. The facility’s records showed no pain medication was administered to Resident #4 on the date of the incident and no pain assessments were documented in the EMR. Resident #3 refused a full assessment before being sent to the hospital, where his/her guardian was later informed that Resident #3 had a fractured right hand attributed to the altercation. The primary care physician for both residents stated that the incident of Resident #3 attacking and punching Resident #4 was abuse and noted that it would have been better if Resident #3 had not shared a bathroom with another resident. The facility’s abuse, prohibition, and intervention policy stated that each resident had the right to be free from abuse, defined as the willful infliction of injury with resulting physical harm, pain, or mental anguish. Despite this policy, Resident #3, who was on one-on-one monitoring due to unpredictable explosive behaviors, was not kept within immediate reach of staff when going into the shared bathroom, allowing access to Resident #4 while he/she was naked and vulnerable. CNA A acknowledged not following Resident #3 into the bathroom and remaining outside the doorway, and RN A reported that Resident #3 would not allow staff in his/her room, leading to one-on-one supervision being conducted from the hallway rather than in close proximity. These actions and inactions resulted in Resident #3 being able to physically assault Resident #4, causing fear, pain, and mental anguish, and constituted a failure to ensure the resident’s right to be free from abuse.
Resident-to-Resident Physical Abuse Resulting in Jaw Fracture
Penalty
Summary
A deficiency occurred when a resident with schizoaffective disorder and severe cognitive impairment physically assaulted another resident, resulting in a fractured jaw. The incident began when the cognitively intact resident, who also had schizoaffective disorder and anoxic brain damage, grabbed the arm of a CNA. The first resident, who was walking with the CNA, told the other to let go, but when the request was ignored, the first resident kicked and punched the other in the jaw, causing the resident to fall and sustain a fracture to the mandible. Multiple staff and resident interviews confirmed that the altercation involved deliberate physical contact, including kicking and punching, after an attempt to remove the resident's hand from the CNA's arm. The assaulted resident was sent to the emergency room, where an x-ray confirmed a fracture to the left jaw. The incident was witnessed by several staff members, including CNAs and an LPN, who described the sequence of events leading to the injury. Facility records and interviews with the DON, ADON, NP, and Administrator all acknowledged that the event constituted abuse as defined by facility policy and regulatory standards. The facility's abuse prevention policy specifically prohibits abuse by anyone, including other residents, and defines physical abuse as willful infliction of injury. The investigation substantiated that the physical altercation met the criteria for abuse, resulting in harm to the resident.
Failure to Provide Adequate Supervision and Safe Transfer Leading to Resident Fall
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide adequate care and supervision to prevent an accident involving a resident with severe cognitive impairment and a history of falls. The resident, who was totally dependent on staff for mobility and required a two-person assist with a Hoyer lift for transfers, was transferred and repositioned in bed by a single CNA, contrary to facility policy and the resident's care plan. The CNA positioned the resident on the edge of the bed, with the resident's head and leg hanging over the side, and then turned away from the resident, leaving them unsupervised and unsupported. As a result of this improper positioning and lack of supervision, the resident rolled off the bed headfirst onto the floor, sustaining multiple bruises and abrasions to the left arm, face, and hip. Video footage provided by a family member confirmed that the CNA was alone during the transfer and that the resident was not combative or resistive at the time of the fall. The CNA admitted to transferring the resident alone with the Hoyer lift and acknowledged that this was against facility policy, citing difficulty in obtaining assistance from other staff. Interviews with other staff members and review of facility policies confirmed that the use of the Hoyer lift required two staff members at all times and that residents should be positioned in the center of the bed during care to prevent falls. Despite these policies, it was revealed that single-person Hoyer transfers had occurred previously due to staffing issues. After the fall, the resident was lifted from the floor by staff without the use of a lift or assistive device, which was also against policy. The incident was initially reported as a non-injury fall, but subsequent assessment and family-provided photos documented significant bruising and swelling.
Failure to Supervise High-Risk Resident During Smoke Break Results in Serious Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents, specifically for a resident with a known risk of elopement and a history of mental health and substance use disorders. The resident had previously demonstrated exit-seeking behaviors, including walking along the fence on the second-floor smoke deck and expressing intentions to jump the fence. These behaviors were reported by staff and documented in the care plan, which included interventions such as moving the resident to a secure unit and requiring supervision during smoke breaks. However, there was no documentation of exit-seeking behaviors in the medical record for the month prior to the incident, and no additional monitoring was implemented after staff were notified of the resident's statements and actions. On the day of the incident, the resident participated in a scheduled smoke break on the second-floor patio. Facility policy required that all residents be supervised during smoke breaks, but interviews and records revealed that no staff were present on the smoke deck at the time. The resident hid from view as other residents returned inside, then climbed the fence and jumped from the second-floor ledge, resulting in a compound fracture of the left tibia that required immediate surgery. Another resident witnessed the event and alerted staff, but by the time staff responded, the resident had already sustained significant injuries. Multiple staff interviews confirmed that supervision was not provided during the smoke break, despite facility policies and the resident's known elopement risk. Staff members were unclear about their responsibilities for supervising residents during smoke breaks, and some believed others were assigned to the task. The lack of supervision allowed the resident to act on previously expressed intentions to elope, leading to a serious injury that required hospitalization and surgical intervention.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to ensure food safety standards were met in several areas, as observed during a survey. Staff were not adhering to the facility's policy on hair restraints, as evidenced by a Building Engineer entering the kitchen without covering their long hair and facial hair. This occurred in the presence of uncovered food items, such as oatmeal and scrambled eggs, which could lead to contamination. The Dietary Manager confirmed the expectation for staff to wear hair restraints, but the policy was not followed in this instance. Additionally, food storage practices were not in compliance with professional standards. Observations revealed that food items like sausage patties and chocolate chips were not stored in closed containers, leaving them exposed to air. Furthermore, several open food items, including preboiled eggs, diced pineapple, honey, and sausage gravy, were not labeled with dates to indicate when they were prepared or should be discarded. The Dietary Manager and staff acknowledged that these items should have been properly labeled according to the facility's policy. The facility also failed to manage residents' personal food items appropriately. In the fourth-floor dining room refrigerator, a pizza box was found without a label indicating ownership or date, and staff were unaware of its owner. A sandwich and a container with an unidentified substance were also found without proper labeling. The Assistant Director of Nursing noted that items should be labeled with a name and date, but there was confusion about who was responsible for maintaining the refrigerator contents.
Infection Control Deficiencies in EBP Implementation
Penalty
Summary
The facility failed to adhere to infection control standards for two residents, specifically in implementing Enhanced Barrier Precautions (EBP). Observations revealed that staff did not consistently use personal protective equipment (PPE) such as gowns and gloves during high-contact care activities. For instance, a Certified Nursing Assistant (CNA) did not wear a gown while emptying a catheter bag for a resident with an indwelling urinary catheter, and a Registered Nurse (RN) did not wear a gown while providing care involving a feeding tube. Additionally, the catheter drainage bag and tubing for one resident were found on the floor, contrary to facility policy. Resident #336, who had severe cognitive impairment and required a feeding tube and urinary catheter, was observed with their catheter drainage bag and tubing on the floor. Despite the presence of CDC signage indicating the need for EBP, staff failed to follow the required precautions. The CNA admitted to not wearing a gown and not performing hand hygiene after handling the catheter. Similarly, the RN acknowledged not wearing a gown while using the resident's feeding tube. Resident #103, who had a feeding tube and required EBP, was assisted by an Admissions Coordinator (AC) who did not perform hand hygiene or wear a gown and gloves while repositioning the resident. The AC admitted to not following the necessary infection control procedures. Interviews with the Assistant Director of Nursing (ADON) and the Interim Director of Nursing (IDON) confirmed that staff should have performed hand hygiene and worn appropriate PPE when providing care to residents requiring EBP.
Failure to Provide Privacy Cover for Catheter Drainage Bag
Penalty
Summary
The facility failed to provide a privacy cover for a urinary catheter drainage bag for Resident #63, compromising the resident's dignity. The facility's policy on resident rights emphasized the importance of privacy and confidentiality, yet there was no specific policy addressing the use of privacy covers for catheter drainage bags. On multiple occasions, Resident #63 was observed in a common area with the catheter drainage bag visible, containing approximately 100 cc of yellow urine, without a privacy cover. This visibility was noted by staff, residents, and visitors, indicating a lapse in maintaining the resident's dignity. Resident #63, who was admitted to the facility with a medical history of vascular dementia and obstructive and reflux uropathy, had a suprapubic catheter as part of their care plan. Despite the care plan's directive for catheter care every shift, the assigned LPN admitted to forgetting to place a privacy cover over the catheter drainage bag. The Interim Director of Nursing and the Administrator both acknowledged the importance of covering the catheter drainage bag to protect the resident's dignity, yet the oversight occurred, highlighting a gap in the facility's adherence to its own standards of resident care and dignity.
Failure to Maintain Cleanliness Around Tube Feeding Equipment
Penalty
Summary
The facility failed to maintain a clean and safe environment for Resident #103, who was dependent on tube feeding due to medical conditions including dysphagia and gastrostomy status. Observations revealed that the resident's feeding tube pump, pole, and the floor beneath them were splattered with dried tube feeding formula. These observations were made on multiple occasions, indicating a persistent issue with cleanliness in the resident's room. Interviews with facility staff, including a Registered Nurse and the Interim Director of Nursing, confirmed the presence of the spills. The facility's housekeeping routine required addressing spills and cleaning specific areas daily, yet the spills remained unaddressed. The Interim Director of Nursing stated that while nurses and CNAs should clean spills, housekeeping staff should not clean the tube feeding pump when in use, suggesting a lack of clarity in responsibilities for maintaining cleanliness around the resident's feeding equipment.
Improper Use of Physical Restraint on Resident
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as evidenced by an incident involving a staff member and a resident identified as Resident #386. The resident, who had a medical history including Huntington's disease and anxiety disorder, was observed attempting to take a cigarette from another resident on the smoking patio. In response, a certified medication technician (CMT) physically picked up and carried the resident back inside the facility, thereby restricting the resident's freedom of movement. This action was not in line with the facility's policy on restraints, which requires that restraints only be used in emergencies to prevent harm and with proper authorization. The incident was reported by the resident, who claimed to have been manhandled by staff, resulting in bruises and scratches. Interviews with staff members provided varying accounts of the event, with some confirming that the CMT picked up the resident to prevent them from taking another resident's cigarette. The CMT and other staff members involved did not report any intention to harm the resident, but the action taken was deemed inappropriate as it restricted the resident's ability to move independently. The facility's Interim Director of Nursing and Administrator acknowledged that the CMT's actions were a poor choice and violated the resident's rights. The facility's policy defines a restraint as any method that restricts a resident's freedom of movement, and the action of picking up the resident met this definition. The staff involved were expected to use other de-escalation techniques, such as verbal redirection or seeking assistance from other staff members, rather than physically restraining the resident.
Failure to Investigate Missing Resident Incident
Penalty
Summary
The facility failed to thoroughly investigate an incident involving a missing resident, identified as Resident #96. The resident, who had a history of substance use disorder related to alcoholism, left the facility and did not return as expected. The resident's care plan included interventions to address their substance use disorder, but on the day of the incident, the resident signed out to go to the library and did not return. The facility's policy required a thorough investigation of such incidents, including interviewing all staff on the relevant shift, but this was not completed. The resident's progress notes indicated that the facility was aware of the resident's absence and took steps to locate them, including notifying the police and local hospitals. However, the investigation folder provided by the facility lacked interviews from staff or residents and did not include a follow-up five-day final report submitted to the State Survey Agency. The administrator acknowledged the oversight in not conducting interviews and completing the required investigation documentation. The resident eventually returned to the facility with assistance from another person, who found them wandering and brought them back. Upon return, the resident was alert and not in distress, but had no recollection of being gone for four days. The facility's failure to conduct a thorough investigation and submit the necessary reports to the State Survey Agency constituted a deficiency in their handling of the incident.
Failure to Update PASRRs for Residents with New Mental Disorders
Penalty
Summary
The facility failed to ensure that Level I Preadmission Screening and Resident Reviews (PASRRs) were completed for two residents who were diagnosed with new mental disorders. Resident #45 was admitted with a diagnosis of paranoid schizophrenia, and later, a diagnosis of recurrent major depressive disorder was added. Despite this new diagnosis, there was no documented evidence that a new PASRR was completed. The resident's care plan indicated behaviors related to schizophrenia and a risk for depression, but the PASRR was not updated to reflect the new diagnosis. Similarly, Resident #23 was admitted without a major mental disorder diagnosis, but later developed major depressive disorder and psychotic disorder with delusions. Despite these new diagnoses, the facility did not complete a new PASRR. The resident's care plan included symptoms of depression, and psychiatric evaluations confirmed the new diagnoses, yet the PASRR remained outdated. Interviews with the Administrator and Interim Director of Nursing confirmed that the PASRRs for both residents should have been updated following the new diagnoses.
Failure to Address PTSD in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with a diagnosis of PTSD, among other mental health conditions. The resident, who had a history of PTSD stemming from childhood abuse, was admitted to the facility with diagnoses including psychotic disorder, anxiety, insomnia, major depressive disorder with severe psychotic symptoms, and schizophrenia. Despite these diagnoses, the resident's care plan did not include a focus area related to PTSD, and staff members, including CNAs, were unaware of the resident's PTSD diagnosis. This lack of awareness and documentation led to a failure in addressing the resident's mental and psychosocial needs effectively. The MDS RN acknowledged the oversight in care planning, citing reliance on automated systems and input from others, which resulted in inaccuracies and omissions. The Interim Director of Nursing and the Administrator both emphasized the importance of having triggers and appropriate approaches documented in the care plan to prevent re-traumatization and manage behaviors effectively. However, the facility's current practices did not align with these expectations, as evidenced by the absence of a care plan addressing the resident's PTSD and the lack of staff awareness regarding the resident's specific needs.
Inadequate Supervision Leads to Resident Absence
Penalty
Summary
The facility failed to provide adequate supervision for a resident, identified as Resident #96, who was reviewed for accidents. The resident, who had a history of substance use disorder related to alcoholism, left the facility and did not return as expected. The facility's policy required residents to sign out when leaving and to provide an anticipated return time. However, Resident #96 did not fill out the anticipated return time on the sign-out sheet, and the facility did not initiate the required follow-up actions in a timely manner. On the day of the incident, Resident #96 signed out to go to the library but did not return by the expected time. The facility staff, including a Certified Medical Technician (CMT) and a Licensed Practical Nurse (LPN), were aware of the resident's absence but did not follow the facility's policy to initiate a search or notify the appropriate authorities promptly. The Administrator was informed the following day, and only then were the police and other relevant parties contacted. The resident was eventually found wandering and returned to the facility four days later. The facility's failure to adhere to its own policy for monitoring residents who leave the premises resulted in a lack of timely action when Resident #96 did not return. The staff did not adequately check the sign-out logs or follow the procedure for contacting the resident or their designated contacts. This oversight led to a delay in reporting the resident as missing and in taking steps to ensure their safety, highlighting a deficiency in the facility's supervision and accident prevention measures.
Medication Administration Failure in LTC Facility
Penalty
Summary
The facility failed to provide physician-ordered medications to a resident, resulting in significant medication errors. The resident, who was admitted with a medical history of hypothyroidism, hyperlipidemia, hypertension, and bradycardia, did not receive several prescribed medications, including amlodipine, levothyroxine, lovastatin, and metoprolol, for multiple days following their admission. The medications were delivered to the facility, but due to miscommunication and improper handling, they were not administered as required. The Clinical Liaison received the medications and placed them in the nurses' room instead of the CMT's cart, leading to confusion about their availability. The CMTs documented the unavailability of medications in the MAR and informed the nurses, but the medications were not retrieved from the nurses' room or the emergency kit. The nurses failed to reorder the medications or notify the physician about the missing doses, resulting in the resident missing critical doses of their prescribed medications. Interviews with staff revealed a lack of clarity and communication regarding the handling and administration of medications. The CMTs and nurses did not follow the facility's policies for medication administration and reordering, leading to the oversight. Despite the medications being delivered and available, they were not administered to the resident, highlighting a breakdown in the facility's medication management process.
Failure to Provide Adequate Bathing Care and Use of Specialized Equipment
Penalty
Summary
The facility failed to ensure that a resident with cerebral palsy received proper bathing care and the use of a specialized shower chair. The resident, who was dependent on staff for activities of daily living, including bathing, was admitted to the facility and had a care plan that did not document the need for a specialized shower chair. The resident's bathing schedule was inconsistent, with missed baths and showers, and there was no documentation of bathing assistance on several occasions. The resident expressed a preference for showers over bed baths, yet reported having only one shower since admission. Observations and interviews revealed that the specialized shower chair, necessary for the resident's comfort and safety, was not readily available or used. Staff members, including CNAs and the Director of Nursing, were unaware of the resident's specific needs and the location of the specialized shower chair. The chair was eventually found in a locked room, indicating a lack of communication and coordination among staff regarding the resident's care requirements. The facility's failure to update the resident's care plan to include the need for a specialized shower chair and to ensure its use resulted in inadequate care. The Director of Nursing acknowledged the oversight in the resident's bathing schedule and the lack of documentation. The facility did not provide a policy for bathing or activities of daily living upon request, further highlighting the deficiency in care planning and execution.
Failure to Arrange Safe and Orderly Discharge
Penalty
Summary
The facility failed to arrange a safe and orderly discharge for a resident, who was cognitively intact and had multiple medical conditions including stroke, hypertension, muscle spasms, depression, and hyperlipidemia. The resident was on several medications, including anti-depressants, anti-coagulants, and anti-platelet medications. Upon discharge, the resident was transferred to another facility without any belongings, medications, or necessary paperwork. The receiving facility reported that the resident arrived without a report being called in, and the Director of Nursing (DON) had instructed not to send the resident's medications. Interviews with the DON and other staff revealed that it was not the usual practice to send medications with residents during transfers. The DON had emailed the resident's medication list to the receiving facility but did not ensure the physical transfer of medications. The Administrator was unaware of the situation and later arranged for the medications to be delivered to the receiving facility. The facility also lacked a policy for the disposition of medications when transferring residents to another facility, contributing to the oversight in this case.
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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 Kansas City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rehab Of Kansas City South | 1.5 mi | ★★★★★ | 2 | 0 |
| Armour Oaks Senior Living Community | 1.8 mi | ★★★★★ | 19 | 1 |
| Gregory Ridge Health Care Center | 1.9 mi | ★★★★★ | 13 | 1 |
| Hope Care Center | 1.9 mi | ★★★★★ | 14 | 0 |
| Parkway Health Care Center | 2.7 mi | ★★★★★ | 2 | 1 |
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