Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Highland House Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Two residents with cognitive impairment experienced frequent loose stools over an extended period, yet staff continued to administer constipation medications such as Miralax and senna and did not consistently use PRN loperamide as ordered. CNA documentation showed repeated loose stools and frequent incontinence care, and CNAs reported notifying medication aides and nurses, but the MAR reflected ongoing bowel care medications and minimal use of antidiarrheal treatment. Standing orders required holding bowel care with new onset diarrhea, and the DNS stated she expected staff to follow these orders and use appropriate PRN medications when residents had loose stools.
Low Hall and Room Temperatures: The facility failed to keep hall and room temperatures within the required range in two reviewed halls. Thermostats in the 100 Hall and 500 Hall displayed temperatures below 71 F, and room temperatures were measured as low as 66-68 F. A resident reported needing extra clothes because the room was cold, another resident said the room was very cold at times, and staff reported ongoing complaints about rooms being too cold and an ongoing problem with thermostats being set too low.
CBG Monitors Cleaned With Alcohol Wipes: A CNA was observed cleaning community use CBG monitors with alcohol wipes on two halls, and another CNA stated the same practice was used for monitors used by residents needing diabetic monitoring. Several residents with diabetes were identified on those halls, and their records showed no blood-borne pathogen diagnosis. The Interim DNS stated the monitors should not be cleaned with alcohol wipes but with a disinfectant that killed blood-borne pathogens.
A resident admitted with DM had an advance directive noted at care conference as being at home, but it was not found in the clinical record. The Social Service Director said the spouse had not brought it in, and the Administrator stated that any advance directive was to be in the resident's clinical file as soon as possible.
A resident with dementia had rising AIMS scores and documented tremors, lip smacking, and head tremors while receiving Risperdal. Nursing reported yelling and delusions, and the NP increased the evening dose after a staff communication, even though other documentation showed the resident was alert, able to make needs known, and at times easily redirected. Later observations noted marked shaking and involuntary movements of the hands and head.
Incomplete Pressure Ulcer Investigations: A resident admitted with heart disease developed pressure injuries to the lower spine, buttocks, and spine, with wound evaluations documenting facility-acquired DTIs and new treatment orders. The record lacked a root cause analysis for one pressure ulcer investigation and had no investigation for the buttock DTI because the nurse who identified it did not initiate one.
Failure to Notify Ombudsman of Resident Discharges and Hospitalizations: The facility did not notify the State LTC Ombudsman of a resident's hospital transfer and discharge, and did not notify the Ombudsman for two other residents who were hospitalized or discharged. One resident had stroke and respiratory failure, another had MSSA infection and diabetes, and a third had fractured ribs and a fractured arm; records showed no evidence of the required notifications, and staff acknowledged the omissions.
A resident admitted with kidney disease received dialysis and had a central line in the right chest for access, but the comprehensive care plan only noted dialysis and did not identify the access site or include emergency instructions if the line came apart or was accidentally pulled out. An LPN Resident Care Manager verified the missing details, and the Administrator acknowledged staff may not know what to do if emergency care was not on the care plan.
A resident with chronic curvature of the spine, dementia, and repeat falls had an inaccurate care plan that did not match current mobility and positioning needs. The resident was dependent for walking and transfers, was observed leaning to one side in bed with a pillow for support, and staff stated the resident needed a Hoyer lift, had not used a walker for almost a year, and had pain during repositioning; staff also confirmed the care plan lacked needed details and was not accurate in several areas.
A resident with COPD and epilepsy was observed with cigarettes and a lighter in the room despite the facility smoking policy prohibiting ignition sources in resident rooms. Staff gave inconsistent accounts about the resident’s smoking status and where smoking supplies were stored. Another resident with stroke, respiratory failure, and oxygen use had an unwitnessed fall, but the investigation lacked witness statements and complete documentation, and staff could not clearly determine how the fall occurred. A third resident was also found in bed with oxygen on and cigarettes and a lighter on the bedside table.
Failure to implement nutrition interventions for weight loss: A resident admitted with heart disease had a RD nutrition eval recommending fortified food if accepted, but the fortified meal order was not initiated until later and there was no documented communication to the MD or nutrition committee note when first recommended. A later nutrition eval documented weight loss, poor PO intake, and depression, with a recommendation to consider mirtazapine, but the record did not show staff communicated that option to the provider.
A resident with stroke and respiratory failure required O2 therapy at 3 L/min via NC and needed monitoring to keep O2 saturation at or above 90%. During transport for labs and imaging, only one O2 tank was available, the resident went without sufficient oxygen, and emergency oxygen was needed. Staff reported unclear expectations about assessing oxygen needs and the transportation company’s lack of backup oxygen.
The facility failed to provide necessary behavioral health services for multiple residents with anxiety, depression, suicidal ideation, trauma history, paranoia, and cognitive impairment. One resident had documented emotional distress and a psychologist’s plan for psychiatry and therapy, but no referral or therapy notes were found. Another resident had a long history of depression and suicidal thoughts with repeated recommendations for counseling, psychiatric care, and crisis planning that were not followed. A third resident showed paranoia, confusion, and aggressive behaviors, and staff confirmed psych follow-up had not been completed and no BH provider was available.
A resident with heart disease had an order for mildly thickened liquids, but staff gave unthickened Ensure on more than one occasion. The resident aspirated during a meal, and the medical provider was notified and ordered a chest x-ray. An LPN later confirmed that supplemental drinks such as Ensure were supposed to be thickened for residents on a thickened liquid diet.
Failure to Prevent, Identify, and Treat Pressure Ulcers: Two residents with significant risk factors such as DM, PVD, and stroke-related weakness developed heel wounds. One resident had CNA-documented skin changes that were not reflected in nursing notes, a morning skin check documented no issues, and later the same day both heels were found with facility-acquired DTIs covered with eschar. Another resident was found with a soiled right heel dressing and an unstageable PU, and the record showed no MD orders for the wound before it was investigated.
A resident with Parkinson's Disease receiving hospice care was not treated with respect and dignity when a CNA flicked the resident's hand and made a retaliatory comment during an episode of agitation. The CNA stated the actions were meant to be playful, but the administrator confirmed the interaction did not uphold the resident's dignity.
A resident with a history of intestinal bypass and failure to thrive was not properly assessed for a facility-acquired pressure ulcer. Although initially noted to have a red coccyx and identified as at risk, later wound evaluation described features of a Stage 3 ulcer but lacked measurements, staging, and incorrectly documented the wound as present on admission. An LPN acknowledged these assessment errors and incomplete evaluation.
A resident with a J-tube for enteral feedings had the tube dislodged when a CNA removed a blanket during transport to the shower room, resulting in hospital transfer for tube replacement. The facility did not document any evaluation or investigation of the incident to determine the cause or prevent recurrence, and no incident report was completed.
A resident on hospice care was administered 7.5 ml (75 mg) of methadone instead of the prescribed 0.75 ml (7.5 mg) after a CMA, following instructions from an LPN, misinterpreted the medication order. The error led to the resident requiring naloxone and oxygen, and the hospice nurse remained for observation.
A facility failed to protect residents from sexual abuse, as a resident with altered mental status was observed engaging in inappropriate sexual contact with two other residents diagnosed with dementia. Staff intervened in both incidents, but the affected residents had no recollection of the events. The facility was found in non-compliance with regulatory requirements.
A male CNA in a LTC facility was found to have sexually abused six residents, leading to immediate jeopardy. The abuse involved inappropriate touching and penetration during incontinence care, causing significant psychosocial harm. The incidents were reported by the residents, confirmed through interviews, and resulted in the CNA's arrest.
The facility failed to update care plans and conduct timely care conferences for several residents, leading to deficiencies in care. A resident diagnosed with schizophrenia had their care plan updated eight months late, while another with dental partials did not have their care plan revised. A resident requiring oxygen therapy did not have this need reflected in their care plan. Additionally, care conferences were not conducted as required for three residents, with staff acknowledging the lapses.
The facility failed to implement pharmacy recommendations for four residents, leading to potential risks. A resident with anxiety and depression did not receive a recommended dose reduction of aripiprazole, and another with insomnia continued temazepam despite discontinuation advice. A cancer patient continued unnecessary medications, and a resident with asthma did not follow recommended inhaler use instructions. Staff confirmed delays in addressing these recommendations.
The facility's medication error rate was 7.41%, exceeding the acceptable 5% threshold. Errors included improper application of a pain patch for a resident with chronic pain and incorrect timing of thyroid medication administration for a resident with low thyroid levels. Staff inconsistencies and failure to adhere to prescribed orders contributed to these errors.
The facility failed to treat residents with dignity and respect, affecting four residents. A resident with cancer felt disrespected when a CNA interrupted a conversation. Another resident with pain reported rude comments about body odor from a CNA, causing anxiety. A resident with depression experienced sarcasm and rushing from the same CNA, despite management's awareness. A resident with a femur fracture was called 'trash' by a former Physical Therapy Assistant.
The facility failed to maintain a safe and homelike environment, with unpainted patches in residents' rooms and a wheelchair with rough tape. Additionally, residents experienced disturbances from loud noises at night, including staff conversations and squeaky carts. Despite complaints, no changes were made to address these issues.
The facility failed to address grievances from six residents regarding staff behavior and dignity issues. Despite residents expressing discomfort and filing grievances, the facility did not document or investigate these concerns, leaving them unresolved.
The facility failed to follow physician orders and monitor residents, leading to deficiencies in medication administration and resident care. A resident with anxiety and depression received metoprolol despite contraindicated vital signs, and another with diabetes missed multiple doses of Senna without physician notification. A cancer patient did not receive post-fall neurological assessments, and residents with infections and kidney disease experienced lapses in antibiotic administration and urine sample collection, respectively.
The facility failed to post accurate and complete staffing information, with missing census documentation on several shifts. Observations showed incomplete Direct Care Staff Daily Reports (DCSDR) posted by the nurses' station, lacking information on resident census, number of staff, and hours worked. The Administrator, DNS, and Regional Director of Clinical confirmed the expectation for accurate DCSDR posting within one hour of a shift change.
The facility did not ensure CNAs completed the required 12 hours of annual in-service training. Three CNAs, hired in different years, completed only 6 to 10 hours of training within their annual periods. This was confirmed by the Administrator, DNS, and Regional Director of Clinical.
The facility failed to inform residents and their responsible parties about the risks and benefits of medications and dietary non-compliance, leading to a lack of informed consent. A resident was prescribed antipsychotic medication without a documented diagnosis, another was non-compliant with a diabetic diet without proper documentation, and a third was given medications without consent from their responsible party.
The facility failed to maintain the privacy and confidentiality of resident records in the Social Services office. The Social Services Director's office was left open with no staff present, exposing a resident's electronic health record and other sensitive documents. Multiple staff and residents had potential access to these records. The Social Services Director admitted to leaving the door open, and the Administrator confirmed that resident records should be secured.
A facility failed to assess a scoop mattress as a potential physical restraint for a resident with brain damage and anxiety, who was at risk for falls. Despite interventions in place to prevent falls, the resident was observed using a scoop mattress without documented assessment. Staff confirmed that an evaluation should have been completed.
A facility failed to comprehensively assess a resident with Schizoaffective Disorder for behavioral health needs. Despite an Annual MDS assessment indicating no behaviors, observations and staff interviews revealed the resident exhibited behaviors such as swearing, smearing feces, and resisting care. The facility's administrator and DNS acknowledged the expectation for comprehensive assessments, which was not met.
A resident experienced a significant change in condition, including cognitive decline, increased depression, and a new diabetes diagnosis, but the facility failed to conduct a required Significant Change MDS assessment. Despite the resident's increased need for assistance and multiple falls, there was no documentation of a significant change assessment, which was acknowledged by facility staff during an interview.
A facility failed to refer a resident with schizoaffective disorder, bipolar disorder, and PTSD for a Level II PASARR evaluation, despite the resident's mental health diagnoses. The resident's Annual MDS inaccurately indicated no serious mental illness, leading to the absence of a necessary evaluation. Staff interviews confirmed awareness of the oversight and the need for an effective referral system.
A resident was prescribed aripiprazole for schizophrenia despite lacking a documented diagnosis of the condition. The resident's medical records and assessments indicated no history of schizophrenia, yet the medication was administered based on incorrect MAR instructions. Staff interviews revealed inconsistencies in the resident's symptoms, and the facility's administration recognized the need for further investigation.
A resident with dementia, who required corrective lenses for adequate vision, was observed without glasses due to a broken lens. The issue had been ongoing since at least December, but the Social Service Director was unaware until June, and no vision appointments were scheduled.
The facility failed to ensure a safe environment for three residents, resulting in multiple falls. A resident with cancer fell due to a poorly fitting mattress lacking nonslip material. Another resident with a stroke history fell while attempting to transfer without assistance, exacerbated by wearing regular socks instead of nonskid ones. A third resident, requiring a bedside commode, fell multiple times due to its absence, contrary to the care plan.
A facility failed to provide a diabetic nutritional supplement to a resident after their readmission, placing them at risk for weight loss. The resident, diagnosed with diabetes, was supposed to receive the supplement twice daily. However, after a hospitalization, the supplement was not restarted, as confirmed by an LPN.
A resident with cancer was using a nasal cannula connected to an oxygen concentrator, which had a thick layer of dust on its vent, indicating neglect in cleaning. The resident's clinical record lacked physician orders for oxygen, which staff confirmed were necessary for continued use. The Director of Nursing Services verified the absence of these orders.
A facility failed to provide trauma-informed care for a resident with PTSD, lacking individualized interventions for specific triggers. The resident's care plan included general strategies but did not address unique needs, and staff were unaware of specific PTSD-related behaviors or triggers. This deficiency placed the resident at risk for re-traumatization and decreased quality of life.
A CNA was observed transporting dirty linens without using a bag, contrary to infection control protocols. The CNA admitted to not having bags and acknowledged the requirement to bag linens before transport. Facility leadership confirmed the expectation for staff to follow this protocol.
A resident was administered antibiotics for a UTI without proper indication. The resident, admitted with a UTI diagnosis, showed increased confusion and was sent to the hospital. A urine culture indicated improper collection, yet antibiotics were given. The facility's policy required a 72-hour review of test results, which was not documented, and the results did not support antibiotic use.
A resident with moderate cognitive impairment fell out of bed shortly after admission, but the facility failed to notify the resident's emergency contact. The incident was confirmed by an LPN and acknowledged by the DNS, who stated that the emergency contact should have been informed.
The facility failed to report a resident-to-resident altercation and did not investigate an abuse allegation involving a resident who claimed to have been pushed by a CNA. Despite staff recalling the incidents, there was no documentation or care plan updates, and the abuse allegation was not properly addressed or reported to the state.
The facility failed to develop baseline care plans for two residents within 48 hours of admission. One resident, with kidney disease, lacked a care plan for dialysis, while another, with a femur fracture and dementia, had no care plan addressing fall risk or psychotropic medications. Staff acknowledged these omissions, which were not rectified in the required timeframe.
Two residents experienced inadequate pain management due to the facility's failure to administer prescribed medications. One resident with fractures did not receive oxycodone or Percocet as prescribed, leading to moderate to severe pain. Another resident with a femur fracture did not receive pain medication until the day after admission, despite requests. The DNS confirmed that the emergency medication kit was accessible, but the medications were not administered.
A resident with kidney disease missed a scheduled dialysis treatment due to the facility's failure to arrange transportation. Despite being aware of the need for transportation, the facility did not ensure the resident attended the dialysis session, as confirmed by staff and a dialysis RN.
Failure to Follow Bowel Care Orders and Manage Loose Stools Appropriately
Penalty
Summary
The deficiency involves the facility’s failure to follow physician standing orders and provide appropriate bowel care for two residents experiencing loose stools. Standing orders signed by the physician directed staff to hold bowel care medications if a resident developed new onset diarrhea. For one resident admitted with adult failure to thrive and moderate cognitive impairment, CNA documentation showed frequent loose stools on numerous shifts throughout the month, yet the MAR reflected continued administration of Miralax for several days and no documented administration of loperamide or any other medication to address the loose stools during that period. A physician follow-up note referenced an episode of loose stools to be managed with loperamide and a temporary hold of bowel medications, but there was no documentation that loperamide was actually given. CNAs reported repeatedly informing nursing staff about the loose stools, with one CNA stating she sometimes changed the resident three to five times per shift but could only document one episode, and the DNS stated she would have expected staff to use appropriate PRN medication as prescribed when the resident complained of loose stools. For a second resident with Alzheimer’s disease and severe cognitive impairment, CNA documentation also showed multiple episodes of loose stools over two consecutive months. Despite this, the MAR showed that Miralax and senna for constipation were administered almost daily during these periods, with only one documented instance of senna being held due to loose stools. Loperamide was ordered PRN for loose stools but was administered only twice in one month and not at all in the following month, even though CNA records indicated frequent loose stools. A CNA stated the resident had loose stools frequently and that she reported this to the medication aide, who in turn reported it to the nurse, while a CMA stated she did not recall seeing documentation of loose stools for this resident. The DNS stated she would have expected staff to stop administering Miralax and senna when a resident had loose stools.
Low Hall and Room Temperatures
Penalty
Summary
The facility failed to keep air temperatures between 71 and 81 degrees Fahrenheit in 2 of 4 halls reviewed for environment, including the 100 Hall and 500 Hall. On 9/30/25, the thermostat in the 100 Hall displayed 67 F and a second thermostat in the hall displayed 68 F. Later that day, Resident 106 stated the room was cold in the morning and that extra clothes were needed, and Resident 65 stated the room was very cold at times and that the roommate frequently complained of being cold. On 12/2/25, temperatures taken in rooms 501, 505, and 506 ranged from 66-68 F, and Staff 12, the Maintenance Director, stated hall thermostats being set too low was an ongoing problem in the facility. Staff 24, a CNA, stated residents complained of rooms being too cold, Resident 111 stated the room was always cold, and Staff 1, the Administrator, observed 500 Hall thermostats below 71 F and stated he was frustrated by the problem of low air temperatures and had to continually remind staff not to adjust thermostats.
CBG Monitors Cleaned With Alcohol Wipes
Penalty
Summary
The facility failed to ensure community use CBG monitors were cleaned with an EPA-approved disinfectant for 2 of 5 halls, specifically 300 Hall and 400 Hall. On 9/30/25 at 11:14 AM, Staff 31, a CNA, was observed cleaning a community use CBG monitor with an alcohol wipe and stated she always used the wipes to clean the monitors. Staff 31 identified residents on 300 Hall who had CBGs checked as Residents 5, 11, 61, 80, and 90. Each of those residents had a diagnosis of diabetes, and their clinical records showed they did not have a blood-borne pathogen diagnosis. On 9/30/25 at 11:44 AM, Staff 32, a CNA, stated she cleaned the community use CBG monitors with alcohol wipes and identified Residents 66 and 76 as the residents who required diabetic monitoring on 400 Hall. Resident 66 and Resident 76 both had diagnoses of diabetes, and their clinical records showed they did not have a blood-borne pathogen diagnosis. On 9/30/25 at 12:10 PM, Staff 32, the Interim DNS, stated staff should not clean CBG monitors with alcohol wipes but with a disinfectant that killed blood-borne pathogens.
Advance Directive Missing From Clinical Record
Penalty
Summary
The facility failed to ensure that a resident's advance directive was present in the clinical record for one sampled resident. Resident 3 was admitted in 2/2025 with a diagnosis of diabetes, and the 8/14/24 care conference form indicated the resident had an advance directive at home. However, there was no evidence that the advance directive was included in the resident's clinical record. During interview, the Social Service Director stated the resident reported having an advance directive at home, but the spouse had not brought it to the facility. The Administrator stated that if a resident had an advance directive, it was to be in the resident's clinical file as soon as possible.
Antipsychotic Dose Increased Despite Involuntary Movements
Penalty
Summary
The facility failed to ensure a resident’s antipsychotic medication was not increased when adverse side effects were present. Resident 92 was readmitted with a diagnosis of dementia and had AIMS scores that increased from 2 on 1/11/25 to 7 on 8/15/25, then to 10 on 9/13/25. Progress notes showed the resident was alert, able to make needs known, and at times independent with eating, but also had tremors noted as baseline, later called for staff assistance frequently, and had no notes documented from 8/31/25 through 9/10/25. The 9/2025 ADL report documented behavior symptoms including yelling on multiple shifts, wandering, and abusive language, while the 9/2025 TAR did not document behaviors such as paranoia, distressing delusions, hallucinations, or yelling during 9/1/25 through 9/9/25. A communication form from the LPN Resident Care Manager to the NP stated night staff reported the resident yelled out most of the night after 10:00 PM, and the NP increased the resident’s antipsychotic medication. The resident was receiving Risperdal 2 mg in the morning and 4 mg in the evening, and the evening dose was increased to 4 mg on 9/9/25. The NP later documented that she had attempted to wean down Risperdal, but nursing reported increased behaviors screaming and delusions, so the dose was increased back to the prior level; the note also stated the resident had increased lip smacking and head tremors. On 10/2/25, the resident was observed shaking so much that she/he could not bring a straw to the mouth to drink, and staff observed involuntary movement of the hands and head. Staff also stated the resident could yell but was easily redirected and was able to make needs known.
Incomplete Pressure Ulcer Investigations
Penalty
Summary
The facility failed to ensure a resident’s pressure ulcers were thoroughly investigated for one resident reviewed for hospice services. The resident was admitted in 6/2025 with a diagnosis of heart disease. Progress notes showed that on 9/14/25 the resident was identified with a pressure injury to the lower spine, described as a small opening at the top of the wound, and treatment was provided. The clinical record also contained two Skin and Wound Evaluation forms dated 9/15/25, one for a facility-acquired DTI to the buttocks measuring 7.5 cm by 2.4 cm and another for a facility-acquired DTI to the spine measuring 6.6 cm by 2.6 cm; both forms described intact but discolored skin and new treatment orders were implemented. The 9/14/25 new pressure ulcer investigation documented the resident’s diagnosis, immediate interventions, interventions to be added, and notifications, but it did not include a root cause analysis to determine whether the pressure ulcer was avoidable or unavoidable, or whether neglect of care was suspected. The resident’s record also did not contain an investigation for the DTI to the buttocks identified on 9/15/25. During interview, the Administrator stated the team worked together to complete investigations so they would be complete and include root cause analysis to identify the cause of the problem and prevent recurrence, and stated this was not done for the resident’s 9/14/25 DTI investigation. The Wound Nurse stated the nurse who identified the 9/15/25 buttock DTI did not initiate an investigation, so it was not completed.
Failure to Notify Ombudsman of Resident Discharges and Hospitalizations
Penalty
Summary
The facility failed to ensure the Office of the State Long-Term Care Ombudsman was notified of residents' discharges or hospitalizations for 3 of 3 sampled residents reviewed for discharge and hospitalization. Resident 11 was admitted with diagnoses including stroke and respiratory failure and was discharged to the hospital on 8/30/25 and discharged from the facility on 10/15/25, but the clinical record contained no evidence that the Ombudsman was notified of either discharge. During interview, the Administrator acknowledged the Ombudsman was to be notified of discharges and transfers, and the Social Worker stated she was not aware of the required notification process. Resident 98 was admitted with diagnoses including Methicillin Susceptible Staphylococcus Aureus infection and diabetes, and an admission MDS indicated the resident was cognitively intact. The record showed the resident was hospitalized, but there was no evidence that the Ombudsman was notified of the hospitalization. Resident 100 was admitted with diagnoses including fractured ribs and fractured left arm, and an admission MDS indicated the resident was cognitively intact. The record showed the resident was discharged, but there was no evidence that the Ombudsman was notified of the discharge. The Administrator stated he was aware the Ombudsman should be contacted with all discharges and transfers to the hospital and acknowledged the facility had not notified the Ombudsman about Residents 98 and 100.
Incomplete Dialysis Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident admitted in 5/2025 with kidney disease who received dialysis. The resident’s admission MDS dated 5/20/25 indicated dialysis, and the Pre and Post Dialysis Assessment form showed a central line in the right chest for dialysis access. Although the comprehensive care plan initiated on 5/13/25 identified that the resident required dialysis, it did not identify the access site location or include instructions for what to do if the access site came apart or was accidentally pulled out. On 12/3/25, an LPN Resident Care Manager verified that the care plan did not identify the access site and did not include emergency instructions related to the central line, and the Administrator acknowledged that not all staff may know what to do if the emergency care was not on the care plan.
Inaccurate care plan for resident mobility and positioning needs
Penalty
Summary
The facility failed to revise the care plan interventions for one resident reviewed for positioning and mobility. The resident was admitted with chronic curvature of the spine, dementia, and repeat falls. The annual MDS dated 7/28/25 showed the resident required a wheelchair for transportation and was dependent on staff for walking and transfers, and the 10/2025 Documentation Survey Report showed the resident did not walk ten feet and was dependent on staff to ambulate for all recorded shifts. A revised care plan dated 11/10/25 stated the resident required extensive assistance of one staff with a walker to ambulate, used a cane for mobility, and used a sit-to-stand lift for transfers, but it did not include the use of a pillow for positioning comfort. During observation, the resident was seen in bed eating breakfast while leaning to the right with a pillow in place for support, and no walker was in the room. Staff stated the resident leaned to the right automatically, had pain during repositioning, and a pillow was used for comfort. Staff also stated a Hoyer lift was needed for transfers and the resident had not used a walker for almost a year because the resident was unable to stand. Other staff confirmed the care plan was inaccurate, that the resident needed a pillow for comfort, and that the resident's care plan was not accurate or revised in many areas.
Smoking Materials Kept in Rooms and Incomplete Fall Investigation
Penalty
Summary
The facility failed to ensure residents did not have cigarettes and lighters in their rooms. Resident 1 was admitted with diagnoses including COPD and epilepsy, had a BIMS score of 15, used a wheelchair independently, and was identified as a smoker who could light her/his own cigarettes. The facility’s smoking policy stated ignition sources were not permitted in resident rooms and lighters for independent smokers were to be stored in an assigned smoking locker. Despite this, Resident 1 was observed in the room with a lighter attached to the wheelchair and cigarettes in a dresser drawer, and staff gave inconsistent statements about whether the resident still smoked and where smoking supplies were supposed to be kept. The Administrator acknowledged the facility needed a new solution for storing the resident’s lighter and smoking supplies. The facility also failed to thoroughly complete a fall investigation for Resident 11. Resident 11 had diagnoses including stroke, respiratory infection, and respiratory failure, was cognitively intact, used oxygen at 3 liters per minute via nasal cannula, and required assistance of two staff for transfers. The care plan identified the resident as at risk for falls and included bilateral bed canes, fall mats, and a bed positioned in the lowest position against the wall. After an unwitnessed fall, the resident was found on her/his knees with the face and upper body leaning on the bed, stated an attempt to get out of bed to help a new roommate, and later became difficult to rouse with oxygen saturation at 59%. The fall investigation did not include all expected documentation. Staff stated there was a lack of documentation, witness statements were not requested, and the investigation did not determine how the resident fell. One CNA later stated the resident was confused and had been last seen in the room minutes before the fall, while another CNA stated the resident was found dangling from the bed with the head stuck between the bed and a bed cane and the nasal cannula dislodged. The Unit Manager acknowledged witness statements from all staff were not obtained and the fall investigation was not thorough. Resident 110 was also observed in bed with oxygen on and cigarettes and a lighter on the bedside table, despite the facility smoking policy stating ignition sources were not to be kept by residents and that lighters were to be stored in a smoking locker.
Failure to Implement Nutrition Interventions for Weight Loss
Penalty
Summary
The facility failed to implement nutritional interventions to prevent weight loss for one resident who was admitted with heart disease. A 6/16/25 nutritional evaluation documented that the dietary manager was to evaluate the resident for fortified food if the resident would accept typical offerings. Although a fortified meal diet order was later initiated on 8/3/25, the resident’s record did not show that the recommended fortified diet had been started in June, and the LPN Resident Care Manager stated there was no communication to the physician in 6/2025 about a fortified diet and no June nutrition committee note related to adding fortified meals. The resident’s 9/11/25 nutrition evaluation documented weight loss, refusal of oral intake, and concern for depression. The recommendation was to consider starting mirtazapine, but the clinical record did not show that staff communicated with the medical provider about whether mirtazapine was an option to support weight gain. The LPN Resident Care Manager stated he did not see a note in the record or nutrition committee notes related to the recommendation to add an antidepressant, and stated the resident was depressed and losing weight.
Insufficient Oxygen Support During Resident Transport
Penalty
Summary
The facility failed to provide sufficient respiratory services for one resident who was admitted with diagnoses including stroke and respiratory failure. The resident’s quarterly MDS indicated oxygen therapy was required, and the TAR specified 3 liters of oxygen per minute via nasal cannula, monitoring for shortness of breath, and maintaining oxygen saturation at or above 90%. A transportation request form showed the resident had appointments for labs and imaging and required a companion and oxygen during transport. During transport to the appointments, the resident went without sufficient oxygen and emergency oxygen was needed. A family member stated the resident went to appointments without enough oxygen. The CNA who accompanied the resident stated only one oxygen tank was available, a new appointment was added during the trip, and the transportation company did not have additional oxygen in the vehicle. Staff stated nurses were responsible for assessing oxygen needs before transport, but one LPN acknowledged he did not calculate a contingency for additional oxygen supply, another LPN was unaware the transportation company did not carry additional oxygen, and the Unit Manager-LPN and DNS acknowledged clearer expectations were needed regarding oxygen needs during appointments.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to ensure necessary behavioral health care and services were provided for three sampled residents with behavioral-emotional health needs. Resident 9 was admitted with kidney disease and later assessed by a psychologist as having anxiety, memory issues, fear of relocation, and emotional distress related to health and living situation. The psychologist’s plan included referral to psychiatry, low-dose antianxiety medication, and regular therapy, but the clinical record did not show a psychiatry referral or therapy notes. During interviews, Resident 9 stated feeling depressed, tearful, and hopeless, and staff later confirmed the resident was often sad and tearful. Facility leadership stated the behavioral health provider’s contract had ended and a new provider had not yet started, with no interim plan in place. Resident 19 had a long history of depression, mood disturbances, suicidal ideations, and PASARR Level I indicators of severe mental illness. The record contained multiple behavioral health notes and recommendations over several years, including counseling, psychiatric care, crisis planning, and follow-up for suicidal thoughts and worsening depression, but no documentation showed the facility followed up with those recommendations. The resident continued to report loneliness, isolation, hopelessness, passive suicidal ideation, and thoughts of self-harm, including statements about wanting to end life and considering using something sharp. Staff described worsening depression, self-sabotaging behaviors, and recent suicidal statements, while facility staff acknowledged the resident had not been receiving behavioral health treatment for several months after the provider contract ended. Resident 36 had a history of trauma, anxiety, paranoia, delusional disorder, and generalized anxiety, with provider notes recommending psychiatric evaluation for paranoia and possible delusional thinking. The resident was observed appearing frightened, avoiding eye contact, and making nonsensical statements, and later was seen frightened and confused while accusing staff of stealing belongings. Staff documented increased aggression and exit-seeking behavior, and the physician directed psych follow-up. Facility staff stated they did not know what behavioral health services the resident was receiving, and the administrator confirmed the facility had not followed up on physician recommendations and did not have a behavioral health provider available until a later date.
Failure to Provide Ordered Thickened Liquids
Penalty
Summary
The facility failed to ensure a resident received mildly thickened liquids as ordered. Resident 40, admitted with a diagnosis of heart disease, had a dietary order dated 9/16/25 for mildly thickened liquids. The record showed that on 9/21/25 the resident aspirated during a meal after drinking Ensure that was not thickened, and staff notified the medical provider, who ordered a chest x-ray. A communication form to the provider documented that the resident aspirated at lunch while drinking an unthickened Ensure, and the provider later noted the chest x-ray was negative. On 10/1/25, Staff 29 verified that a CNA gave the resident a supplemental drink that was not thickened, the resident aspirated, and the physician was notified. Staff 14 stated that supplemental drinks such as Ensure were to be thickened by a nurse, CMA, or dietary staff when a resident was on a thickened liquid diet.
Failure to Prevent, Identify, and Treat Pressure Ulcers
Penalty
Summary
The facility failed to ensure pressure ulcers were prevented, failed to identify pressure ulcers, and failed to provide physician-ordered treatments for 2 residents. One resident was admitted without a pressure ulcer and had diagnoses including diabetes, peripheral vascular disease, right hemiparesis from a stroke, heart disease, and kidney disease. The care plan directed staff to elevate the resident’s legs when sitting or sleeping and to report new skin issues. CNA documentation in March showed red and discolored areas on the resident’s skin, but there were no corresponding nursing notes for those dates, and progress notes did not document heel elevation. In May, a morning total body skin assessment documented no skin issues, but later that same day a CNA found wounds on both heels. The wounds were then identified as facility-acquired DTIs to the right and left heels, both covered with eschar and draining, with macerated edges. Staff statements indicated the resident initially could reposition but had leg weakness and impaired circulation, and staff said pillows under the legs were not used until after the pressure ulcers developed. The wound nurse stated she completed the morning skin assessment and documented no skin issues, and acknowledged the CNAs found the DTIs later that evening. The interim DNS acknowledged the morning assessment showed no skin issues and that approximately eight hours later the resident had two heel DTIs with eschar. The interim DNS also stated there was no skin assessment in the clinical record after the CNA identified skin issues on the March documentation survey report. A second resident admitted with diabetes and stroke was found with a soiled dressing on the right heel during a pressure ulcer investigation. When the dressing was removed, a 2 cm by 2 cm unstageable pressure ulcer was observed. The medical record contained no physician orders for the right heel wound before the investigation date. A CNA stated she had observed a skin tear on the right heel during a shower and reported it to the nurse, and the administrator confirmed there were no physician orders for the wound before the investigation.
Resident Not Treated with Respect and Dignity by CNA
Penalty
Summary
A deficiency occurred when a staff member failed to treat a resident with respect and dignity. The resident, who had Parkinson's Disease, was on hospice services and exhibited agitation, including spitting on the ground and toward staff while being assisted to sit in a wheelchair. During this interaction, a CNA flicked the resident on the back of the hand and stated, 'If you're going to be mean to me, I'm going to be mean to you.' The CNA later explained that the action and comment were intended to be playful and to calm the resident, as they had a history of working together. The administrator confirmed that the resident was not treated with respect or dignity during this incident.
Failure to Accurately Assess Facility-Acquired Pressure Ulcer
Penalty
Summary
The facility failed to accurately assess a facility-acquired pressure ulcer for one resident with a history of intestinal bypass and failure to thrive. Upon admission, the resident was noted to have a red coccyx, but the initial Minimum Data Set (MDS) indicated no pressure ulcers, despite the resident being at risk. A subsequent wound evaluation documented coccyx shearing with characteristics consistent with a Stage 3 pressure ulcer, including 90% granulation tissue, 10% slough, and light serosanguineous drainage. However, the evaluation did not include wound measurements or proper staging, and incorrectly recorded the wound as present on admission. The LPN Unit Manager later acknowledged these assessment errors and the lack of a comprehensive evaluation.
Failure to Investigate Dislodged Feeding Tube Incident
Penalty
Summary
A resident with a history of failure to thrive and malnutrition was admitted with a surgically placed J-tube for enteral feedings. During transport to the shower room, a CNA removed a blanket from the resident, at which point the J-tube became dislodged and fell out. The resident was subsequently transferred to the hospital for J-tube replacement. Review of the medical record showed no documentation that the incident was evaluated or investigated to determine how the J-tube became dislodged or to identify measures to prevent recurrence. The Director of Nursing Services confirmed that no incident report or facility investigation was completed, as the facility did not routinely investigate tubes that fell out. Family reported that staff told them the J-tube was pulled out when the blanket was removed.
Significant Medication Error Due to Methadone Overdose
Penalty
Summary
A significant medication error occurred when a resident, admitted with failure to thrive and receiving hospice care, was administered an incorrect dose of methadone. The hospice order on 3/20/25 instructed staff to discontinue the previous methadone order and increase the dose to 7.5 mg twice daily, specifying that 7.5 mg should be given as 0.75 ml. However, the medication administration record (MAR) indicated that the resident was given 7.5 ml (equivalent to 75 mg) of methadone at 8:00 PM on 3/20/25 by a certified medication aide (CMA). This error was based on a misinterpretation of the order, as the CMA consulted with the charge nurse (LPN), who reviewed the original order and instructed the CMA to administer 7.5 ml instead of the correct 0.75 ml dose. Following the administration of the incorrect dose, new hospice orders were issued for naloxone nasal spray and oxygen, and the methadone order was clarified to specify the correct volume. The resident required administration of naloxone and oxygen, and the hospice nurse remained with the resident for observation. The CMA later confirmed the error, and attempts to contact the charge nurse for further information were unsuccessful. The incident demonstrates a failure to ensure residents were free from significant medication errors due to miscommunication and improper verification of medication orders.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to ensure residents were free from sexual abuse, affecting two of the three sampled residents. Resident 1, who was admitted with altered mental status, was observed on two separate occasions engaging in inappropriate sexual contact with other residents. On the first occasion, Resident 1 was seen with their hand down the front of Resident 2's pants while both were in wheelchairs in the hallway. On the second occasion, Resident 1 was found in bed with Resident 3, with their hand on Resident 3's penis. Both incidents were witnessed by staff members who intervened and separated the residents. Resident 2 and Resident 3, both diagnosed with dementia, had no recollection of the incidents. Interviews with the residents revealed that they were alert but not oriented to place or time, and they did not express concerns about their care or recall having roommates. Staff interviews confirmed the inappropriate contact and acknowledged the sexual abuse incidents. The facility was found in non-compliance with the regulatory requirement at F600 due to these events.
Sexual Abuse by CNA Leads to Immediate Jeopardy
Penalty
Summary
A facility employee, identified as a male CNA, was found to have sexually abused six residents, leading to an immediate jeopardy situation. The abuse involved inappropriate touching and, in some cases, penetration during incontinence care. The incidents were reported by the residents themselves, who experienced significant psychosocial harm, including increased anxiety and difficulty sleeping. The abuse was confirmed through interviews with the residents, the CNA, and facility staff, as well as law enforcement. Resident 6, who was alert and oriented, reported that the CNA entered her room every hour under the pretense of providing incontinence care and inappropriately touched her. Resident 7, diagnosed with PTSD and depression, reported being molested multiple times by the same CNA, who also touched himself during these incidents. Other residents, including those with diabetes and kidney failure, were also victims of similar abuse, although some were unable to be interviewed due to discharge or cognitive impairment. The facility's investigation revealed that the CNA admitted to the inappropriate sexual contact with multiple residents. The abuse occurred after the most recent annual recertification survey and before the current survey. The facility reported the incidents to the State Survey Agency and law enforcement, leading to the CNA's arrest and criminal charges.
Removal Plan
- Alleged perpetrator suspended
- Cognitively intact residents interviewed to ensure no additional residents were sexually abused
- Staff interviewed from various shifts and departments to ensure there were no observations or complaints of abuse with cognitively intact or cognitively impaired residents
- Provider and residents' families notified
- Care plans for the residents involved in the allegation updated to include female-only caregivers
- Residents involved in the allegation placed on alert charting and referred to the facility's psychologist
- Skin assessments focused on identifying sexual trauma conducted
- Local law enforcement notified
- Audits conducted with verification of sustained compliance
- Audit trends reported to facility QAPI for review and further recommendations
Deficiencies in Care Plan Updates and Care Conferences
Penalty
Summary
The facility failed to revise and update care plans for several residents, leading to deficiencies in care. Resident 16, diagnosed with schizophrenia in October 2023, had their care plan updated only in June 2024, approximately eight months later. This delay in updating the care plan was acknowledged by the facility's staff, including the Administrator and the Regional Director of Clinical, who stated that the care plan should have been updated sooner. Similarly, Resident 19, who had dental partials since April 2024, did not have their care plan revised to reflect this change, and staff were unaware of the resident's dental needs. Resident 51, who required oxygen therapy, did not have their care plan updated to include this need, despite being observed with a nasal cannula and having been administered oxygen since March 2024. Staff confirmed that the care plan was not revised to reflect the resident's oxygen requirements. Additionally, the facility failed to conduct timely care conferences for Residents 21, 49, and 25. Resident 21 had only one care conference shortly after admission, with no subsequent conferences documented. Resident 49's representative was unaware of any care conferences since admission, and Resident 25 had not had a care conference in six months, despite the expectation of quarterly meetings. The lack of timely care conferences and updated care plans for these residents indicates a systemic issue within the facility's care planning process. Staff interviews revealed inconsistencies in the scheduling and documentation of care conferences, with some staff unaware of the required timelines. The facility's failure to adhere to these timelines and update care plans as needed placed residents at risk for unmet care needs, as acknowledged by the facility's Administrator and Director of Nursing Services.
Failure to Implement Pharmacy Recommendations
Penalty
Summary
The facility failed to follow pharmacy recommendations for four residents, leading to potential risks of adverse medication side effects. Resident 16, diagnosed with anxiety and depression, was recommended for a gradual dose reduction of aripiprazole, but the physician did not sign or provide a rationale for maintaining the current dosage. Additionally, an assessment for abnormal involuntary movement was due but lacked documentation of completion. Resident 33, with insomnia and anxiety, continued to receive temazepam despite recommendations for discontinuation or dosage reduction. The pharmacy's recommendation was not addressed promptly, with staff acknowledging delays in follow-up. Resident 51, diagnosed with cancer, continued to receive ferrous sulfate and docusate despite normal iron levels and ineffectiveness, respectively, with no documentation of the physician's decision to decline the pharmacy's recommendations. Resident 63, with anxiety and asthma, did not have the recommended mouth rinse after using Symbicort documented in the MARs until later, indicating a delay in implementing the pharmacy's advice. These oversights and delays in addressing pharmacy recommendations were confirmed by staff interviews, highlighting a pattern of inaction in responding to pharmacy consultations.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, with an observed rate of 7.41% due to two errors in 27 opportunities. One incident involved a resident with chronic pain who was prescribed a medicated pain patch to be applied to both knees. However, the patch was applied to the resident's right arm and right leg instead, based on the resident's preference, without clarifying the order with a physician. This deviation from the prescribed order was acknowledged by the staff involved, indicating a lack of adherence to the medication administration protocol. Another incident involved a resident with low thyroid levels who was prescribed levothyroxine, a hormone replacement medication. The medication was administered after the resident had consumed breakfast, contrary to the recommended practice of taking it on an empty stomach before meals. Staff members provided conflicting information regarding the timing of the medication administration, with some indicating it did not matter, while others stated it should be given before breakfast. This inconsistency in medication administration practices contributed to the facility's elevated medication error rate.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect, affecting four residents. Resident 51, who was cognitively intact and diagnosed with cancer, reported feeling disrespected when a CNA interrupted a conversation to pick up a lunch tray despite being asked to wait. The CNA acknowledged the interruption, and the facility administrator confirmed the incident. Resident 65, also cognitively intact and diagnosed with pain, reported a CNA made rude comments about their body odor, causing anxiety and fear of retaliation. The CNA admitted to making a comment about the resident's need for a shower, which was witnessed by another CNA who agreed the approach was offensive. The Director of Nursing Services noted previous concerns about the CNA's interactions with residents, leading to the CNA being moved to a different unit. Witness 2, a resident with depression, reported disrespectful behavior from the same CNA, including sarcasm and rushing during interactions. Despite management being aware of the issues, the CNA continued to be disrespectful, leading to multiple relocations within the facility. Resident 95, with a femur fracture, reported being called 'trash' by a former Physical Therapy Assistant, which was acknowledged by the administrator as inappropriate language.
Environmental and Noise Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several deficiencies observed during the survey. Resident 20's bathroom had a missing tile and an unpainted patched wall, which was acknowledged by the facility's administrator and maintenance staff. Similarly, Resident 29's room had an unpainted patch on the wall, and Resident 51's room had a patched area above the bed that had not been painted since admission. Maintenance staff indicated that patching was prioritized over painting, which contributed to the unhomelike conditions. Additionally, Resident 137's wheelchair armrests were covered with green tape, which was acknowledged by the LPN Resident Care Manager as potentially rough on the skin and difficult to clean. Resident 90 experienced disturbances due to loud noises at night, including fireworks, staff conversations, and the movement of carts with squeaky wheels. Despite complaints from residents and staff about the noise, no changes had been implemented to address these issues. The facility's administration acknowledged the expectation for quiet during sleeping hours, but the deficiencies persisted.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to provide a written grievance resolution or communicate effectively with residents or their representatives regarding the resolution of grievances. This deficiency was identified for six residents who had filed grievances related to abuse and dignity. For instance, Resident 8 expressed discomfort with a male CNA providing personal care and requested female CNAs. Despite this preference being communicated to staff, it was not documented in the care plan, and no written resolution was provided. Resident 90 reported that staff were rude and threw personal items, which was not investigated or documented as a grievance. The facility's staff, including the Administrator, acknowledged that the concern was not reported or addressed appropriately. Similarly, Residents 83, 84, 86, and 87 filed grievances about a CNA's rude behavior, but these grievances were not documented or investigated by the facility management. The report highlights a pattern of inaction by the facility in addressing grievances related to staff behavior and resident dignity. Despite multiple reports and grievances filed by residents, the facility failed to document, investigate, or resolve these issues, leaving residents' concerns unaddressed.
Failure to Follow Physician Orders and Monitor Residents
Penalty
Summary
The facility failed to adhere to physician orders and monitor residents appropriately, leading to several deficiencies. Resident 16, diagnosed with anxiety and depression, was administered metoprolol tartrate despite blood pressure and heart rate readings that were outside the physician-ordered parameters. Additionally, the resident's heart rate and blood pressure were not consistently documented, and there was a failure to administer Furosemide as needed for fluid retention due to inadequate weight monitoring. Resident 33, with a diagnosis of diabetes, had a physician order for Senna, a laxative, which was not administered 32 times over a period of two months. Despite the resident's refusals, there was no documentation that the physician was notified, as required. Resident 51, diagnosed with cancer, experienced an unwitnessed fall, but the facility did not conduct the necessary neurological assessments post-fall, as indicated by the lack of documentation in the clinical record. Resident 133, admitted with an infection, did not receive prescribed antibiotics on multiple occasions, with no documentation to explain the missed doses. Resident 134, with kidney disease, experienced pain with urination, and a urine sample was ordered but not obtained, as there were no results documented. These failures in medication administration and monitoring placed residents at risk for adverse effects and demonstrated a lack of adherence to physician orders and facility protocols.
Failure to Post Accurate Staffing Information
Penalty
Summary
The facility failed to post accurate and complete staffing information, as required, which placed residents at risk for incomplete and inaccurate staffing information. A review of the Direct Care Staff Daily Reports (DCSDR) from May 9, 2024, through June 9, 2024, revealed missing census documentation on several shifts, including the day and evening shifts on June 5, the evening shift on June 6, and the night shift on June 8. Observations on June 11 and June 12 showed that the DCSDR posted by the nurses' station was incomplete, with missing information on resident census, number of staff, and hours worked for various shifts. During an interview on June 14, the Administrator, Director of Nursing Services (DNS), and Regional Director of Clinical confirmed that it was expected to have an accurate DCSDR posted within one hour of a shift change.
Deficiency in CNA Annual Training Hours
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistant (CNA) staff received the required 12 hours of in-service training annually, as evidenced by a review of training records for three out of five randomly selected staff members. Specifically, CNA Staff 3, hired in 2006, completed only 10 hours of training; CNA Staff 5, hired in 2010, completed six hours; and CNA Staff 6, hired in 2016, also completed 10 hours of training within their respective annual periods. This deficiency was confirmed during an interview with the Administrator, Director of Nursing Services (DNS), and Regional Director of Clinical, who acknowledged the expectation for staff to complete the mandated training hours.
Deficiencies in Informed Consent and Documentation
Penalty
Summary
The facility failed to adequately inform residents and their responsible parties about the risks and benefits associated with antipsychotic medications and dietary non-compliance, leading to a lack of informed consent and decision-making. Resident 16, who was admitted with anxiety and depression, was prescribed aripiprazole without a documented diagnosis of schizophrenia. There was no evidence that Resident 16 was informed of changes in diagnosis or medication dosage. Interviews with staff revealed that while residents were notified of changes, new consents were not completed, and documentation of notification was lacking. Resident 33, diagnosed with diabetes, was non-compliant with a diabetic diet, consuming excessive amounts of soda and fast food, resulting in consistently high blood sugar levels. Despite staff acknowledging the need for a risk and benefits form, it was not completed. Resident 335, with dementia, was prescribed quetiapine fumarate and sertraline without documented consent from the resident's son. The lack of informed consent and documentation for these residents highlights deficiencies in the facility's communication and documentation processes.
Failure to Maintain Privacy and Confidentiality of Resident Records
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of resident records in the Social Services office. On June 14, 2024, at 10:18 AM, the Social Services Director's office was observed with the door open and no staff present. The left computer monitor displayed a resident's electronic health record, and the right monitor showed an open and accessible email. The office contained numerous papers with residents' names and information, including transportation forms, State of Oregon letters to residents, completed discharge checklists, completed requests to transfer, and individual resident care conference information. Between 10:18 AM and 10:38 AM, multiple staff and residents were observed in the vicinity of the office, with the potential to access the resident records. At 10:38 AM, the Social Services Director admitted to leaving the office door open to indicate her presence in the facility, acknowledging that unauthorized individuals could access the resident records. The Administrator confirmed the expectation that resident records should be secured and inaccessible to unauthorized individuals.
Failure to Assess Scoop Mattress as a Physical Restraint
Penalty
Summary
The facility failed to assess the use of a physical restraint for a resident who was reviewed for restraints. The resident, admitted in 2023 with diagnoses of brain damage and anxiety, had a history of multiple falls and was at risk for further falls due to balance issues and a seizure disorder. A care plan dated October 14, 2023, included interventions to mitigate fall risks, such as using a fall mat and ensuring commonly used items were within reach. However, during observations in June 2024, the resident was found in bed with a scoop mattress, which is a concave-shaped bed designed to prevent users from rolling off and falling. There was no documentation in the resident's clinical record indicating that the scoop mattress had been assessed for its potential as a physical restraint. Interviews with facility staff confirmed that an evaluation for the use of a scoop mattress would be expected.
Failure to Comprehensively Assess Resident's Behavioral Health Needs
Penalty
Summary
The facility failed to comprehensively assess a resident with a diagnosis of Schizoaffective Disorder, who was admitted in 2017, for behavioral health needs. The resident's Annual MDS assessment on May 6, 2024, indicated moderately impaired cognition and no exhibited behaviors. However, observations on June 12 and 13, 2024, revealed the resident engaging in behaviors such as talking to themselves, swearing at staff, and interacting aggressively with objects and people. Staff interviews confirmed ongoing behaviors including swearing, clashing with a roommate, smearing feces, and resisting care by shouting and hitting staff. The facility's administrator and DNS acknowledged the expectation for comprehensive and accurate behavioral assessments, which was not met in this case.
Failure to Conduct Significant Change MDS Assessment
Penalty
Summary
The facility failed to document and conduct a Significant Change Minimum Data Set (MDS) assessment within the required timeframe for a resident who experienced a significant change in condition. The resident was admitted in 2023 with a diagnosis of stroke and was initially assessed as cognitively intact, with no depression concerns, and requiring minimal assistance for personal care. However, by the time of the quarterly MDS assessment in May 2024, the resident's condition had deteriorated to moderately impaired cognition, increased depression, and a need for substantial assistance with personal hygiene. Additionally, the resident experienced frequent bladder incontinence, two or more falls, and was diagnosed with diabetes. Despite these changes, there was no documentation indicating that a significant change assessment was considered or conducted, placing the resident at risk for unassessed needs. During an interview, facility staff acknowledged the oversight but did not provide further information.
Failure to Complete Level II PASARR Evaluation
Penalty
Summary
The facility failed to ensure that a resident with mental health diagnoses was referred for a Level II PASARR evaluation, which is necessary for individuals with serious mental disorders or intellectual disabilities. The resident, admitted in 2017, had diagnoses including schizoaffective disorder, bipolar disorder, and PTSD. Despite these conditions, the resident's Annual MDS from May 6, 2024, indicated they were not considered to have a serious mental illness, and consequently, no Level II PASARR was completed. A review of the resident's electronic health record confirmed the absence of a Level II PASARR referral or evaluation. Interviews with the Social Services Director and the facility's Administrator and DNS revealed awareness of the resident's mental health issues and acknowledged the lack of a completed Level II PASARR, indicating a need for an effective referral system.
Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
The facility staff failed to adhere to professional standards of practice concerning the administration of medications for a resident diagnosed with anxiety and depression. The resident was admitted in 2023 and was prescribed aripiprazole, an antipsychotic medication, and escitalopram, an antidepressant, despite not having a documented diagnosis of schizophrenia. The March 2023 Medication Administration Record (MAR) incorrectly instructed staff to administer aripiprazole for schizophrenia, a condition not diagnosed in the resident's medical history. Throughout multiple assessments, including the Admission MDS and Quarterly MDS, the resident was noted to be cognitively intact without hallucinations, delusions, or behaviors indicative of schizophrenia. In October 2023, a nursing note added a diagnosis of schizophrenia, and the resident was prescribed aripiprazole for this condition. However, subsequent evaluations, including a psychiatric consultation and hospital history, did not support this diagnosis, and the resident denied any history of mental health treatment or hallucinations. Despite this, the facility's records indicated a diagnosis of schizophrenia as an admitting diagnosis created in October 2023. Interviews with staff revealed inconsistencies in the resident's reported symptoms and behaviors, with no observed hallucinations or delusions. The facility's administration acknowledged the need to investigate the resident's history further, but no additional information was provided.
Failure to Provide Corrective Lenses for Resident
Penalty
Summary
The facility failed to ensure that a resident had access to necessary vision services, specifically corrective lenses, which resulted in unmet vision needs. Resident 20, who was admitted in 2021 with a diagnosis of dementia, was noted in a March 2023 quarterly MDS to have adequate vision with corrective lenses. However, by June 2024, it was observed that the resident's glasses were broken, and the resident was seen reading without them. The resident's spouse confirmed the glasses were broken, and staff acknowledged the issue had persisted since at least December 2023. The Social Service Director was unaware of the problem until June 2024, when she found an unsigned note about the broken lens, and no vision appointments had been scheduled for the resident.
Failure to Maintain Safe Environment Leads to Resident Falls
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for three residents, leading to multiple incidents of falls. Resident 51, who was cognitively intact and diagnosed with cancer, experienced an unwitnessed fall due to a mattress that did not fit the bed frame properly. Despite interventions to prevent future falls, such as applying nonslip material and adjusting the mattress, these measures were not implemented. The mattress was observed to be too large for the bed frame, positioned on top of the brackets instead of within them, and lacking the nonslip material, which contributed to the resident's fall. Resident 57, with a history of stroke and moderate cognitive impairment, was at risk for falls due to impulsive behavior and poor safety awareness. Despite a care plan that included interventions like keeping a bedside commode nearby and ensuring the call light was within reach, these measures were not consistently followed. The resident was observed attempting to transfer without assistance, leading to a fall. Additionally, the resident was found wearing regular socks instead of nonskid socks, which was identified as a contributing factor to the fall. Resident 63, who required a bedside commode for toileting, experienced multiple falls while attempting to self-transfer in the bathroom. The absence of a bedside commode in the resident's room, as noted in the care plan, was confirmed by staff, indicating a failure to adhere to the care plan and contributing to the resident's falls.
Failure to Provide Nutritional Supplements
Penalty
Summary
The facility failed to ensure that nutritional supplements were provided to a resident, which placed them at risk for weight loss. The resident, who was admitted in 2018 with a diagnosis of diabetes, was supposed to receive a diabetic nutritional supplement twice daily as indicated in a nutritional screen dated February 1, 2024. However, after being hospitalized in April 2024 and returning to the facility on April 16, 2024, the resident's supplement was not restarted. This oversight was acknowledged by a Licensed Practical Nurse (LPN) Resident Care Manager on June 13, 2024, who confirmed that the supplement was not resumed upon the resident's readmission.
Failure to Obtain Oxygen Orders and Maintain Equipment Cleanliness
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident diagnosed with cancer, as evidenced by the lack of physician orders for oxygen and the unsanitary condition of the resident's oxygen equipment. The resident was observed using a nasal cannula connected to an oxygen concentrator, which had a thick layer of dust on its vent, indicating it had not been cleaned for a long time. Staff confirmed that the equipment should be cleaned weekly and that a nurse could initiate oxygen use but needed to obtain a physician's order for its continued use. However, the resident's clinical record did not contain any such orders, as verified by the Director of Nursing Services.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with PTSD, leading to a deficiency in care. The resident, admitted in 2017, was assessed with moderately impaired cognition and PTSD. The facility's care plan for the resident included general interventions such as approaching in a non-threatening manner and avoiding forced care. However, the care plan lacked individualized interventions to address specific triggers that could re-traumatize the resident. Interviews with staff revealed that they were unaware of specific PTSD-related behaviors or triggers for the resident, and the facility had not assessed or care planned for these individual needs. The deficiency was further highlighted by the lack of documentation in the resident's health record regarding the development and implementation of personalized interventions for trauma triggers. Staff members, including the Social Service Director and the Administrator, acknowledged the necessity of identifying triggers for residents with PTSD to prevent re-traumatization. Despite this acknowledgment, the facility did not have a resident-centered care plan that addressed the unique needs of the resident, placing them at risk for re-traumatization and a decrease in their quality of life.
Infection Control Breach on 200 Hall
Penalty
Summary
The facility failed to adhere to infection control standards on the 200 hall, as observed during a survey. A CNA, identified as Staff 37, was seen carrying dirty linens down the hall without placing them in a bag, which is against the facility's infection control protocol. This action was acknowledged by Staff 37, who admitted to not having bags in her pocket and being aware of the requirement to bag linens before transport. During an interview, the Administrator, DNS, and Regional Director of Clinical confirmed that the expectation for staff is to place dirty linen in a bag for transport from the resident room to the soiled linen room.
Antibiotic Administration Without Indication
Penalty
Summary
The facility failed to ensure that a resident was not administered an antibiotic without proper indication, which was identified during a review of three sampled residents for urinary tract infections (UTIs). Resident 86, who was admitted in 2023 with a diagnosis of UTI, experienced increased confusion on October 7, 2023, leading to a hospital evaluation and return on October 8, 2023. A urine culture from October 7, 2023, showed mixed growth of skin and genital organisms, indicating an improper collection and suggesting that a new sample should be submitted if clinically indicated. Despite this, the resident was administered antibiotics from October 10 to October 16, 2023, for a UTI. The facility's policy required a 72-hour review of test results after starting antibiotics to ensure their necessity, but no such review was documented for Resident 86, and the urine analysis results did not support the administration of antibiotics.
Failure to Notify Resident's Representative of Fall
Penalty
Summary
The facility failed to notify a resident's representative of a fall, which was a deficiency identified during the survey. Resident 89, who was admitted to the facility with a fractured leg and pelvis, experienced an unwitnessed fall out of bed shortly after admission. The resident had a BIMS score indicating moderate cognitive impairment. Despite the fall occurring on 12/23/22, the resident's emergency contact, identified as Witness 1, was not informed by the facility staff about the incident. Witness 1 only learned of the fall through the resident and expressed upset over not being notified by the facility. Staff 21, an LPN, confirmed the lack of notification, and Staff 2, the DNS, acknowledged that Witness 1 should have been informed as the emergency contact.
Failure to Report and Investigate Resident Altercations and Abuse Allegations
Penalty
Summary
The facility failed to report a resident-to-resident altercation involving two residents, one of whom was cognitively impaired and the other with a history of aggressive behavior due to a head injury. Despite multiple staff members recalling the incident where the aggressive resident hit the cognitively impaired resident, there was no documentation or update to the care plans to prevent recurrence. The incident was not reported to the management team, and no incident report was filed, leaving the residents at risk for ongoing abuse. Additionally, the facility did not adequately investigate or report an allegation of abuse involving another resident who claimed to have been pushed by a CNA, causing pain. The grievance was documented, but the investigation was incomplete, as there was no evidence that the allegation of physical abuse was addressed. The facility's administrator acknowledged the lack of evidence for a proper investigation or reporting to the state, indicating a failure in handling the abuse allegation appropriately.
Failure to Develop Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop a baseline care plan for two residents within 48 hours of admission, as required. Resident 134, admitted with a diagnosis of kidney disease, was scheduled for dialysis three times a week. However, the baseline care plan did not include information about the dialysis schedule or the type and location of the dialysis access, despite these details being present in the admission orders. Staff 30, an LPN Resident Care Manager, acknowledged that the baseline care plan for dialysis was not initiated. Resident 335, admitted with a left femur fracture and dementia, was prescribed psychotropic medications. Despite having severe cognitive impairment and being at high risk for falls, the baseline care plan did not address these issues. Multiple staff members, including CNAs and the Director of Rehabilitation, were unaware of Resident 335's fall risk and cognitive impairments. Staff 27 and Staff 30, both LPN Unit Managers, confirmed that the baseline care plan should have included fall risk, psychotropic medications, and dementia diagnosis but was not completed within the required timeframe.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to ensure the availability of pain medications for two residents, leading to increased pain levels. Resident 85, admitted with arm and leg fractures, was prescribed oxycodone every four hours while awake. However, from November 24 to November 27, 2023, the medication was not administered six times. Subsequently, Percocet was prescribed but was unavailable. No alternative pain relief medications were provided, resulting in Resident 85 experiencing moderate to severe pain levels ranging from four to nine. Despite being aware of the resident's pain and upcoming surgery, staff did not address the medication shortage, and no documentation was provided to show additional pain management measures were implemented. Resident 339, admitted with a left femur fracture, did not receive any pain medication from the time of admission until the morning of June 14, 2024, despite requesting it multiple times. The resident's family member confirmed the lack of pain medication, and a CNA reported informing the nurse of the resident's request. The Director of Nursing Services (DNS) acknowledged that the emergency medication kit contained the necessary pain medications and that all nurses had access to it, indicating a failure in administering the medication as needed.
Failure to Transport Resident to Dialysis
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of kidney disease was transported to dialysis, as required by hospital orders. The resident was admitted to the facility in 2023 and was scheduled to receive dialysis treatments on Mondays, Wednesdays, and Fridays. On December 11, 2023, the resident missed a dialysis treatment due to the facility's failure to arrange transportation to the dialysis center. This was confirmed by a former RN, Staff 43, who reported the incident to the State Survey Agency, and by Witness 10, a Dialysis RN, who verified the missed treatment was due to lack of transportation. Despite being aware of the resident's need for transportation, the facility did not follow through with the necessary arrangements, as indicated by Staff 2 (DNS) via email, who provided no additional rationale for the missed appointment.
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 16 citations issued within 25 miles in the last 12 months — 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 Grants Pass
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Royale Gardens Health & Rehabilitation Center | 0.1 mi | ★★★★★ | 13 | 0 |
| Laurel Hill Nursing Center | 1.4 mi | ★★★★★ | 1 | 0 |
| Regency Care Of Rogue Valley | 2.1 mi | ★★★★★ | 2 | 0 |
| Avamere Health Services Of Rogue Valley | 25.1 mi | ★★★★★ | 0 | 0 |
| Avamere At Three Fountains | 25.5 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Highland House Nursing & Rehabilitation 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 August 2026) and official state health department websites.