Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Highlands Rehabilitation And Healthcare during CMS and state inspections, most recent first.
Incorrect Medicare Non-Coverage Notices: The facility failed to issue the proper Medicare non-coverage notices for two residents. One resident’s NOMNC was verbally communicated to a family member but was not signed by the resident or representative, and the record did not show an attempt to obtain a dated signature. Another resident remained in the facility after Medicare coverage ended, but the facility used the wrong notice form and the form did not include the required date the resident would become financially responsible for non-covered care.
The facility failed to manage significant nutritional changes for three residents. One resident had severe weight loss with gaps in weight monitoring, delayed RD/MD review, and no evidence that ordered weekly weights were carried out. A second resident had significant weight gain, but the care plan was not updated to address it. A third resident had progressive weight loss, but follow-up was limited when the resident refused weights, and the record did not support the claimed refusals or show timely care plan updates.
Unsafe Food Storage and Unsanitary Kitchen Conditions: The main kitchen had food items stored under the sink, carafes and lids with white residue, open basins of pitchers and lids on shelving, dirty oven knobs, and burnt residue on the stovetop. The dry storage room contained bread and opened food items without use-by dates. The kitchen floor in front of the dishwasher had missing tiles covered by a board and rubber mat, which the dietary aide and cook identified as a tripping hazard.
A resident’s active physician order said DNR and allow natural death, but the resident’s POLST indicated a desire for CPR if no pulse or breathing. The discrepancy was identified during survey review and discussed with the DON and NHA, and the DON later confirmed staff obtained a verbal MD order to update the resident’s orders to match the POLST.
Dirty and marred conditions were observed in resident rooms and the main laundry area. A resident room had crumbs and dirty floors, other resident rooms had marred doors and walls, and the laundry area had a blanket on the floor with a dried, flaky buildup around it. The DON and NHA were made aware of the concerns.
Failure to Provide Written Transfer and Bed-Hold Notices: The facility did not provide written transfer notices and written bed-hold policy notices to the responsible parties for two residents transferred to the hospital. One resident had multiple representatives and was hospitalized for an AKA and later for infection related to kidney stones and ureteral stent revision; the other resident was hospitalized after a fall with a femur fracture. In both cases, the records showed notices were completed or verbalized, but there was no evidence that the required written copies were given to the residents' representatives, and one bed-hold notice was mailed after the transfer while another left the mailing/email section blank.
Inaccurate MDS assessments were identified for two residents. One resident’s quarterly MDS did not match OT documentation showing bilateral upper extremity ROM impairment, and another resident was incorrectly coded as using bedrails daily as a restraint despite having enabler bars on the bed. The RN assessment coordinator, NHA, and DON confirmed the coding discrepancies.
Failure to Incorporate PASARR II Recommendations Into Resident Care: A resident admitted with a family history of alcohol abuse and dependence had a PASARR Level II determination stating the resident could benefit from drug and alcohol services, but the chart contained no documentation that the facility recommended or provided those services. The SW confirmed there was no evidence the PASARR II recommendations were incorporated into the resident’s assessment, care plan, or transitions of care.
The facility failed to include a resident’s representative in care planning, failed to revise a care plan after significant weight loss, and failed to update a care plan related to a pacemaker and its transmittal device. A resident’s son was listed as the care conference contact, but there was no evidence he was invited or participated in care planning. Another resident had severe wt loss without any revision to the RD care plan, and a third resident’s care plan did not address the pacemaker transmittal device observed at the bedside.
Uncontrolled Chronic Pain Not Addressed: A resident with chronic pain reported constant pain in the stomach, legs, or back and had orders for Gabapentin, PRN Tramadol, and PRN Tylenol. The MAR showed frequent PRN pain med use, including repeated Tramadol administration, but there was no evidence the MD was notified of the amount used or that the resident’s uncontrolled pain was addressed.
Failure to provide behavioral health care for suicidal ideation: A resident with depression and poor insight made repeated suicidal statements to staff, including comments about wanting to go home and commit suicide and later saying she was thinking of committing suicide. Although staff documented brief monitoring and provider/psychiatry review, there was no evidence of 1:1 observation, individualized interventions, or timely social work follow-up, and no care plan addressing the suicidal ideation was in place until after the issue was brought to the facility’s attention.
A resident with Medicaid coverage did not receive routine dental care after admission, despite consent for annual dental services, x-rays, and cleanings through the facility’s contracted dental provider. The resident’s family reported concern that she needed dental work, and facility leadership confirmed she had not received professional dental services within 90 days of admission. Staff also acknowledged uncertainty about the frequency of routine dental services covered under the State Medicaid plan.
The facility failed to maintain emergency lighting in the basement mechanical room, affecting one floor. The emergency light did not function properly when the power was turned off, although it worked with the test button. This was confirmed during an interview with the facility administrator.
The facility failed to maintain its sprinkler systems, with deficiencies found in five locations across three floors. Missing escutcheons were noted in the 3rd floor Oxygen Storage room and corridor, an unsealed ceiling tile penetration was found in the 1st floor Dietary area, and the Basement Level had missing escutcheons and lacked a wrench for sprinkler head replacement. These issues were confirmed with the facility administrator.
The facility failed to maintain the soiled linen and rubbish chutes as the 1st floor laundry chute door did not latch properly, affecting three of four floors. This was confirmed during an interview with the facility administrator.
The facility was found to be in violation of building construction requirements as it was observed to be three stories in height, exceeding the maximum allowable story height for its documented construction type, Type II (000). This deficiency was confirmed by the facility administrator during an exit conference.
The facility failed to maintain or improve the range of motion and mobility for four residents due to unclear restorative nursing policies and inadequate documentation. Residents required specific ROM exercises and ambulation assistance, but the frequency and shift-specific instructions were not provided, leading to incomplete care across shifts.
A facility failed to provide written notice of its bed-hold policy to a resident and their representative during a hospitalization. The resident was transferred to the hospital with stroke-like symptoms, and although the resident's sister was informed of the transfer, there was no evidence of written communication regarding the bed-hold policy. The Bed Hold Notice contained conflicting information, and the facility could not provide evidence of compliance with resident rights.
A facility failed to ensure an accurate MDS assessment for a resident with Schizophrenia. The resident's PASRR Level 1 and Level 2 evaluations indicated a mental health condition and eligibility for services, but the MDS inaccurately stated the resident was not considered to have a serious mental illness. This discrepancy was confirmed by the Nursing Home Administrator and DON.
The facility failed to revise care plans for three residents, leading to deficiencies in care. A resident's care plan did not include interventions to minimize anxiety and aggression, another resident's dental issues were not addressed in their care plan, and a third resident's care plan was not updated to reflect missing dentures. Interviews confirmed these deficiencies.
A facility failed to maintain a resident's ability to perform daily activities, specifically ambulation, due to inadequate staff follow-through. Despite a good prognosis with consistent support, the resident reported infrequent assistance with walking. Documentation showed multiple instances where the ambulation program was not attempted or marked as refused without re-approaching the resident, resulting in limited program completion.
A facility failed to implement physician-ordered supplemental oxygen for a resident, as staff did not routinely assess the resident's oxygen saturation levels to determine the need for supplemental oxygen. Despite a physician's order to administer oxygen at two liters per minute to maintain saturation levels above 90%, records showed no routine assessments were conducted. An observation revealed no supplemental oxygen in use, and no evidence of saturation assessments was found in the clinical record.
A facility failed to create an individualized care plan for a resident with dementia, despite the diagnosis being confirmed in an MDS assessment. The lack of a person-centered care plan was only addressed after a surveyor highlighted the issue, which was acknowledged by the facility's administration.
A resident's partial dentures went missing for eight months to a year, and the facility failed to provide timely replacement. Despite assessments by the facility's dental provider, there was no documentation of when the dentures were lost, and the facility lacked a policy for handling such incidents.
The facility failed to document that two residents with severe cognitive impairment or their representatives were educated on the risks and benefits of influenza and pneumococcal vaccinations. One resident's consent form lacked a signature, and the other resident's forms were undated, with no evidence of education provided to their responsible parties.
The facility failed to document that a resident's representative was educated on the risks and benefits of the COVID-19 vaccine, despite the resident's severe cognitive impairment. The resident, diagnosed with dementia, signed the consent form and received the vaccine without evidence of the responsible party's informed decision. The issue was confirmed by the infection preventionist and reported to the Nursing Home Administrator and DON.
The facility failed to provide timely written notifications to residents and their responsible parties regarding hospital transfers, as required by regulations. Five residents were transferred without proper documentation of notifications, including necessary information such as reasons for transfer, appeal rights, and contact details for the State Ombudsman. The Nursing Home Administrator confirmed the lack of compliance, and the facility did not submit transfer notices to the State Ombudsman until after the issue was identified during the survey.
A facility failed to complete a discharge summary within 30 days of a resident's death. A review of the resident's closed clinical record showed that while the resident was documented as deceased, the required discharge summary, including the final diagnosis and cause of death, was not completed in the specified timeframe. This deficiency was identified through record review and staff interviews.
The facility failed to meet the required nurse aide staffing levels during the evening and overnight shifts on specific days. Discrepancies in staffing calculations were identified, as staff were recorded as providing more hours than scheduled, leading to incorrect data. Despite multiple requests, accurate staffing information was not provided, confirming the shortfall in nurse aide staffing.
The facility did not meet the required LPN staffing levels on three separate days. During the day shift, the facility had insufficient LPNs for the resident census on two occasions, and during the overnight shift, the facility also fell short of the required LPNs for the resident census on one occasion. These deficiencies were identified through a review of nursing care hours and discussed with the Nursing Home Administrator and the DON.
The facility did not meet the required minimum of 3.2 hours of direct resident care per patient per day on four occasions. The review showed deficiencies in nursing care hours on specific days, with PPD hours falling short of the mandated requirement. These findings were discussed with the facility's administration.
A resident with dementia was found with a fractured arm after being pushed out of bed by her roommate, who has bipolar disorder. The incident was unwitnessed by staff, but the roommate later admitted to the act. The facility moved the aggressive resident to a different room and placed her on 15-minute checks, but failed to prevent the abuse.
The facility failed to maintain safe and comfortable temperature levels, with readings exceeding the recommended range on both the second and third floors. Residents expressed discomfort due to the heat, and the issue was attributed to the need for a replacement of the chiller and control panel. Approval for the chiller replacement was received, but no date was set for repairs, and approval for the control panel was pending.
The facility failed to ensure an effective infection control program for outbreak testing and transmission-based precautions. A resident had droplet precautions discontinued prematurely, and another resident had no documented evidence of transmission-based precautions. The facility did not initiate proper testing protocols after identifying symptomatic COVID-19 cases, leading to at least 55 reported cases.
The facility failed to implement their abuse policy and investigate an allegation of abuse between two residents. Despite a physical incident being reported and witnessed by a housekeeper, there was no documented evidence of an investigation or assessment of injuries. The housekeeper's statement was observed being written during the surveyor's visit, despite being dated for a previous year. Interviews with the Administrator and DON confirmed these findings.
A facility failed to administer the correct dosage of physician-ordered Morphine Sulfate for a resident. The MAR showed that a nurse administered 0.5 ml instead of the prescribed 0.75 ml on two occasions, with no evidence of as-needed doses being given. The Administrator confirmed no reported medication errors and verified the findings.
Incorrect Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide the correct required notification when Medicare coverage ended for two residents. For Resident 114, the record showed Medicare-covered skilled nursing services began on November 19, 2025 and ended on December 31, 2025 when the resident discharged to the community. The facility issued a CMS-10123 Notice of Medicare Non-Coverage stating coverage would end on December 30, 2025, and documented that the notice was given verbally during a telephone conversation with the resident’s son on December 29, 2025. However, neither the resident nor a responsible party signed the notice, and the record did not show that staff attempted to obtain a dated signature when the son came to the facility to transport the resident home or after discharge. For Resident 109, Medicare-covered services began on July 1, 2025 and ended on July 31, 2025, while the resident remained in the facility. The facility did not provide the required CMS-10055 Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage and instead used a CMS-R-131 form. Although the resident signed the CMS-R-131 form on July 29, 2025, the form did not include the date on which the resident would become responsible for paying for care that Medicare was not expected to cover. Surveyor review with the NHA and DON confirmed the facility used the wrong notice form for the SNF non-covered stay.
Failure to Address Significant Weight Loss and Gain
Penalty
Summary
The facility failed to provide enough food and fluids to maintain residents’ health by not implementing timely interventions for three residents with significant nutritional concerns. The facility policy required weights to be monitored for unintended loss or gain, with significant changes to be confirmed, reported to the dietitian, and addressed through interdisciplinary care planning. In the records reviewed, the facility did not consistently act on weight changes, did not timely update care plans, and did not document timely interdisciplinary review for the affected residents. For one resident, repeated weights showed severe and ongoing weight loss over a short period, including an 11.8-pound loss in less than one month and later a 22.2-pound loss in six weeks. Although a nutrition note later identified the resident as at risk for malnutrition with variable oral intake and recommended weekly weights, the record did not show that the weekly weights were implemented as planned, and there was a six-week gap in documented weights. A weight entry showing additional severe loss was crossed out as incorrect documentation without a replacement weight being documented. The record also did not show evidence that the registered dietitian or physician had the information in the chart to review, and there was no evidence of a dietitian assessment during the two months reviewed. For another resident, the record showed significant weight gain over time, including a 9.1-pound gain in one week and a 20.5-pound gain over about three months. A full nutritional assessment noted the resident’s BMI was in the overweight category, and a later nutrition note recommended weekly weights to better track the gain. However, the resident’s care plan was not updated to reflect interventions addressing the significant weight gains, and the employee who completed the assessment stated there was no further documentation showing the issue had been addressed until the later nutrition note. For the third resident, the record showed progressive weight loss from 224 pounds to 200.5 pounds, including a 21.6-pound loss over three months. A nutrition note documented the significant loss and indicated weekly weights and a fortified food were to be put in place, but the record later showed the resident refused to be weighed and the employee stated she did not complete the January risk assessment because of that refusal. The employee also stated she did not follow up on the significant weight loss because there was no new weight, and there was no evidence in the clinical record supporting the claimed weekly weight refusals. The resident’s care plan was not updated to reflect the weight loss concerns.
Unsafe Food Storage and Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to store food items in a safe and sanitary manner and failed to maintain the kitchen environment in a safe and sanitary condition in the main kitchen. During observation of the kitchen on February 2, 2026, at 9:18 AM, four boxes of thickened coffee packets, three boxes of thickened tea packets, and a sleeve of lids were stored in the cabinet under the sink. Two bins containing carafes and lids were stored beside the sink, and all of the carafes and lids had a white residue on them. A silver four-tier open shelf had a large open basin of water/juice pitchers and a large open basin of lids on the bottom shelf. The oven knobs were dirty and there was burnt residue all over the stovetop. In the dry storage room, there was a loaf of bread with no use-by date, a half loaf of bread not secured, and opened packages of egg noodles, powdered sugar, vanilla tapioca quick pudding, and pie filling mix, all without use-by dates. Later observation of the kitchen on February 2, 2026, at 11:28 AM revealed three areas on the floor in front of the dishwasher with missing tiles, covered by a piece of board and a rubber mat. An interview with the dietary aide and cook indicated the boards and plastic mats were a tripping hazard when using the dishwasher. The maintenance director stated the floor repairs had been completed on December 23, 2025, that he ordered the floor tiles on December 29, 2025, and picked them up on January 21, 2026, and confirmed the three areas had approximately 19 missing tiles that were not placed until after the surveyor's questioning.
Advance Directive Orders Did Not Match Resident Wishes
Penalty
Summary
The facility failed to ensure that active physician orders reflected a resident’s end-of-life wishes for one resident reviewed for advance directive concerns. Clinical record review showed an active physician order dated [DATE] directing staff to not resuscitate the resident and to allow natural death if there was no pulse or breathing. However, review of a POLST form signed by the physician on [DATE] and signed by the resident showed that the resident desired CPR/attempt resuscitation if there was no pulse or breathing. During interview, the DON and NHA were informed of the discrepancy, and the DON later confirmed that staff obtained a verbal physician order after the surveyor’s questioning to update the active orders to match the POLST.
Dirty and Marred Resident Areas and Laundry Room
Penalty
Summary
The facility failed to provide a clean, comfortable, homelike environment on the Second and Third Floor nursing units and failed to maintain a safe and clean environment in the main laundry area. In the laundry area, a folded blanket was observed on the floor behind the washing machines and under the wall-mounted chemical dispensers, with an extensive build-up of a dried and flaky substance on the blanket and surrounding floor. The Nursing Home Administrator was informed of the laundry area findings shortly after the observation. In multiple resident rooms, the environment was observed to be dirty or marred. Resident 5's room had a marred door and dirty floor around the bed and under the dresser near the cove base. Resident 1's room had crumbs on the floor under the over-bed table and by the bed, and the door was marred. Resident 10's room had a marred room door and bathroom door. Resident 11 was seated in a recliner in his room, and the wall behind the recliner was marred; the resident stated it had been that way for a long time. The concerns regarding Residents 1, 5, 10, and 11's environments were reviewed with facility leadership.
Failure to Provide Written Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to provide written notice of transfer and written notice of the bed-hold policy to residents' responsible parties at the time of transfer for two residents reviewed for hospitalization concerns. For Resident 2, clinical records showed multiple resident representatives, including her mother, a male emergency contact, and an adult protective services county representative. On October 1, 2025, she was transferred to the hospital for a right above-the-knee amputation, and the facility completed a Notice of Transfer or discharge addressed to Resident 2 with a verbal review documented, but there was no indication that Resident 2 or one of her representatives received a written copy. The facility also did not provide evidence that Resident 2 and one of her representatives received written notice specifying the duration of the bed-hold policy within 24 hours of the transfer. Resident 2 was later sent to the hospital on November 21, 2025, after she was lethargic, difficult to arouse, and had low blood pressure; the hospital reported admission for an infection related to kidney stones and revision of ureteral stents. The facility again completed a Notice of Transfer or discharge addressed to Resident 2 and documented that she was unable to sign, but there was no indication that she or one of her representatives received a written copy. A Bed Hold Notice form documented that the resident was contacted and that the bed-hold election form was mailed three days after the transfer, and the facility did not provide evidence that written notice of the bed-hold policy was given within 24 hours. For Resident 6, who had a representative identified as her son, the record showed she was hospitalized after a fall with a broken femur and was on hospital leave starting December 26, 2025. The facility completed a Notice of Transfer or discharge addressed to Resident 6, which she signed, but there was no evidence that her representative received a written copy; the Bed Hold Notice documented verbal notification to the son, while the section for mailing or emailing the notice was left blank.
Inaccurate MDS Assessments
Penalty
Summary
The facility failed to ensure complete and accurate MDS assessments for two residents. For one resident, a quarterly MDS dated October 2, 2025, coded no upper extremity impairments, but the next quarterly assessment dated January 20, 2026, coded bilateral upper extremity impairments. Occupational therapy treatment notes from September 30, 2025, through October 27, 2025, documented impaired range of motion to both upper extremities, and the RN assessment coordinator confirmed that the therapy documentation from the lookback period showed limitations to both shoulders with active range of motion impairment. For another resident, observation on February 2, 2026, showed her in bed with bilateral enabler bars, which she said she used to help her turn and move in bed, and she stated she could not get out of bed on her own. Her quarterly MDS dated January 8, 2026, coded her as using bedrails daily as a restraint. The nursing home administrator and DON later stated this was an MDS coding error and that the resident had enabler bars on her bed, not bedrails used as a restraint.
Failure to Incorporate PASARR II Recommendations Into Resident Care
Penalty
Summary
The facility failed to incorporate the recommendations from a PASARR Level II determination and PASRR evaluation report into the assessment, care plan, and transitions of care for one resident. The resident was admitted with diagnoses including a family history of alcohol abuse and dependence. A PASARR Level II determination letter dated May 22, 2024, stated that the resident did not meet the mental health criteria for further review by the Office of Mental Health and Substance Abuse Services, but the submitted documentation indicated the resident could benefit from drug and alcohol services. Clinical record review found no documentation that the facility recommended or provided any drug and alcohol services to the resident based on the PASARR II recommendation. A social worker confirmed on interview that the facility had no documentation showing the PASARR Level II recommendations were incorporated into the resident’s care at any time while the resident lived at the facility. Surveyors reviewed these findings with the Nursing Home Administrator and DON, and there was no evidence at the time of survey that the facility had timely identified and coordinated specialized services for the resident.
Failure to involve representative and update care plans
Penalty
Summary
The facility failed to include a resident’s representative in care planning for Resident 6. Resident 6’s profile listed her son as the Care Conference Person, but care plan note documentation dated March 6, June 4, September 4, and December 1, 2025 showed no evidence that the facility attempted to include him in care planning. During interview, Resident 6 denied knowledge of care plan meetings and denied that her son or daughter-in-law participated. The DON and Nursing Home Administrator confirmed that the facility could not provide evidence of the representative’s participation in her care planning for the past year. The facility also failed to revise care plans for two residents after changes in condition. Resident 2 lost weight from 206.2 pounds on August 26, 2025, to 177.6 pounds on December 4, 2025, a 13.87 percent loss in less than six months, yet the plan of care initiated by the RD on September 3, 2025 for altered nutritional status showed no revisions despite the severe weight loss. Resident 86 had a physician order dated December 26, 2025 noting a pacemaker, and hospital documentation showed a permanent pacemaker insertion on February 15, 2023; an electronic pacemaker transmittal device was observed on the dresser next to the bed, but the current care plan did not address the device, including proper placement, troubleshooting, or contact information.
Uncontrolled Chronic Pain Not Addressed
Penalty
Summary
The facility failed to ensure safe, appropriate pain management for a resident with chronic pain. The resident reported constant pain, sometimes in the stomach and sometimes in the legs or back. Her clinical record showed a diagnosis of chronic pain, and her physician had ordered Gabapentin 100 mg every morning and at bedtime, Tramadol 50 mg every 4 hours as needed for pain, and Tylenol 325 mg, 2 tablets every 6 hours as needed for mild pain rated 1-3 on a 1-10 scale. Review of the medication administration record showed frequent use of the as-needed pain medications. In December 2025, the resident received Tramadol 45 times. In January 2026, she received Tramadol 26 times and Tylenol 3 times. From February 1-3, 2026, she received Tramadol 5 times. There was no evidence in the clinical record that the physician was informed of the amount of as-needed pain medication the resident was using, or that the physician addressed the resident’s uncontrolled chronic pain. The DON was informed of the concern on February 6, 2026.
Failure to Provide Behavioral Health Care for Suicidal Ideation
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for one resident who had suicidal ideation. On January 7, 2026, the resident was documented as stating that she wanted to be discharged so she could go home and commit suicide. The note indicated she was placed on frequent checks and was seen by a provider, who felt there was no immediate danger, no medical cause for the comments, and that she appeared more depressed related to her current situation; psychiatry follow-up was requested. The resident’s family was present and reported she had made similar comments in the hospital and had been cleared by psychiatry. A later psychiatry note on January 9, 2026, documented that the resident denied suicidal ideation at that time, but staff reported she had made comments about wanting to go home to commit suicide, and the psychiatrist noted poor insight, delusions, depression, and a family history that her daughter had committed suicide. The resident again made suicidal statements on January 27, 2026, telling a nurse aide that she was tired and thinking of committing suicide. The nurse approached the resident, who said she was tired and would talk in the morning, and the charge nurse was updated to closely monitor her and have social work follow up the next day. However, there was no social service follow-up noted in the clinical record, and there was no evidence that one-to-one observation, more frequent checks, or individualized interventions were initiated in response to the suicidal ideation on January 7 or January 27. Review of the care plan showed no care plan addressing suicidal ideation until after the surveyor brought the issue to the facility’s attention during a meeting on February 3, 2026. The social service director confirmed that the care plan with individualized interventions was not initiated until that date.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide routine dental care for one resident who was reviewed for dental concerns. The resident was admitted on November 7, 2025, had missing teeth on observation, and her primary payer source was Medicaid. Her responsible party signed consent for the facility’s contracted dental provider to perform an annual dental exam, necessary x-rays, and cleanings, and the authorization noted that Medicaid recipients are covered for these routine services. The resident’s daughter stated that she believed the resident needed dental work and that she had natural teeth that likely needed extraction, and she reported receiving a $90 bill for an initial exam. Facility staff and records showed that the resident did not receive professional dental services within 90 days of admission. The business office manager stated the facility knew the resident’s Medicaid application was approved less than one month after admission, and the nursing home administrator and DON confirmed that the contracted dental provider was at the facility but did not provide services to the resident. The administrator also confirmed that the facility policy and the dental provider letter did not state that residents would receive routine dental services as provided by the State Medicaid plan, and staff acknowledged they were not certain of the frequency of routine dental services covered under the State plan.
Emergency Lighting Deficiency in Mechanical Room
Penalty
Summary
The facility failed to maintain emergency lighting in the basement level mechanical room, affecting one of four floors. During an observation on January 29, 2025, at 10:50 am, it was noted that the emergency light did not function properly and failed to illuminate when the power was turned off in the room, although it worked when using the test button. This deficiency was confirmed during an interview with the facility administrator at the time of the exit conference on the same day.
Plan Of Correction
Emergency light in basement was rewired on 1/31/2025 and is now functioning properly. Maintenance director completed an audit to verify emergency lights in the facility are functioning properly. Maintenance Director was educated on maintaining emergency lighting by NHA. Maintenance director/designee will audit functionality of emergency lights weekly x4 and monthly x3 and report findings to monthly QAPI committee.
Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain its required sprinkler systems, as evidenced by observations and interviews conducted during a survey. The deficiencies were identified in five locations across three of the four floors of the facility. Specifically, on the 3rd floor, the Oxygen Storage room and a corridor near the Nurses' station were missing escutcheons. On the 1st floor, the Dietary area had an unsealed penetration of a ceiling tile near the dishwasher. In the Basement Level, the Maintenance Shop was missing an escutcheon, and the Tank Room's sprinkler box lacked a wrench for sprinkler head replacement. These deficiencies were confirmed during an exit conference with the facility administrator.
Plan Of Correction
Escutcheons were installed in the 3rd floor oxygen room, 3rd floor corridor, and maintenance shop on 2/3/2025. Ceiling tile in dietary was replaced on 1/30/2025. A sprinkler wrench was purchased and placed in the sprinkler box on 1/31/2025. The Maintenance Director audited facility sprinklers to verify escutcheons in place and ceiling tiles in the dietary department. The Maintenance Director was educated on maintaining the facility's sprinkler system by NHA. The Maintenance Director/designee will audit sprinklers to verify escutcheons are in place, the sprinkler box to verify the wrench is in place, and the dietary ceiling tiles weekly for 4 weeks and monthly for 3 months, and report findings to the monthly QAPI committee.
Failure to Maintain Laundry Chute Door Latching Mechanism
Penalty
Summary
The facility failed to maintain the soiled linen and rubbish chutes in compliance with NFPA 101 standards. During an observation on January 29, 2025, at 10:27 am, it was noted that the discharge laundry chute door on the 1st floor did not latch into the frame when tested. This issue affected three of the four floors in the facility. The deficiency was confirmed during an interview with the facility administrator at the time of the exit conference on the same day at 11:00 am.
Plan Of Correction
The laundry chute was repaired on 2/5/2025. Maintenance director/designee completed an audit to verify facility chutes function properly. Maintenance Director was educated on maintaining laundry chute latch by NHA. Maintenance director/designee will audit facility chutes to verify latching weekly x4 and monthly x3 and report findings to monthly QAPI committee.
Building Construction Type Violation
Penalty
Summary
The facility was found to be in violation of building construction requirements as it was observed to be three stories in height, which exceeds the maximum allowable story height for its documented construction type, Type II (000). According to the National Fire Protection Association (NFPA) 101 Life Safety Code, a Type II (000) building is not permitted to have any stories if it is non-sprinklered. This deficiency was identified during an observation on January 29, 2025, at 9:50 am. The facility administrator confirmed during an exit conference on the same day that the facility indeed exceeded the maximum allowable story height by one floor.
Plan Of Correction
FSES was completed on 8/26/2024. Facility will maintain an up to date FSES.
Failure to Maintain or Improve Residents' Range of Motion and Mobility
Penalty
Summary
The facility failed to provide adequate services to maintain or improve the range of motion (ROM) and mobility for four residents. The facility's policy on Restorative Nursing Services lacked specific guidelines on the frequency and expectations for completing restorative nursing program interventions. This lack of clarity contributed to the failure in implementing the necessary care for the residents. Resident 19 had a therapy restorative referral indicating a decrease in active ROM, requiring passive range of motion (PROM) exercises for their lower extremities. However, the frequency and specific shifts for these exercises were not documented, and the PROM task was only opened for completion during the day shift, leaving evening and night shifts without documentation of completion. Similarly, Resident 48 required ambulation assistance and PROM for their right elbow, but the frequency and specific shifts were not indicated, and the tasks were only documented during the day shift. Additionally, there was a failure to transition from an active ROM program to a PROM program as indicated by therapy. Resident 59's therapy referral indicated a decrease in ROM for their lower and right upper extremities, but the referral incorrectly implemented a program for the left upper extremity. The PROM task was only documented during day and evening shifts. Resident 74 required PROM exercises and orthotic application for their right hand, but the frequency and specific shifts were not indicated, and documentation was lacking for evening and night shifts. There was also no documentation for the application and removal of the orthotic, and several shifts were marked as not applicable or lacked documentation entirely.
Plan Of Correction
1. Residents 19, 48, 59, and 74 had their restorative programs reevaluated. 2. DON/designee audited current residents on a restorative program and were reevaluated with specific frequency. 3. Therapy/licensed staff will be re-educated on providing nursing with a frequency the restorative nursing program should be conducted. 4. NHA/designee will audit 5 random residents receiving restorative services to verify there is a frequency weekly x4 and monthly x3. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Failure to Provide Bed-Hold Policy Notice
Penalty
Summary
The facility failed to provide written notice regarding its bed-hold policy to a resident and the resident's representative during a hospitalization event. The resident, who was hospitalized with symptoms suggestive of a stroke, was transferred to the hospital from the facility. Nursing documentation indicated that the resident's sister was informed of the transfer, but there was no evidence that written information about the bed-hold policy was provided to her. A review of the Bed Hold Notice revealed inconsistencies, as it was documented that the resident was unable to sign, and the notice contained conflicting information about the resident's wishes regarding bed retention. The surveyor requested evidence of written communication to the resident's representative, but the facility could not provide it. This failure to provide written notice within 24 hours of the emergency transfer constitutes a deficiency in the facility's compliance with resident rights and responsibilities.
Plan Of Correction
1. Facility cannot retroactively correct bed hold notification to resident 63. 2. Business office manager/designee completed an audit of the last month of discharges and any missed bed hold notifications were addressed. 3. Nursing staff will be re-educated on providing bed hold notification to residents and resident representatives upon transfer out of the facility. 4. DON/designee will conduct random audits of transfers to verify proper bed hold notification weekly x4 and monthly x3. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Inaccurate MDS Assessment for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure a complete and accurate Minimum Data Set (MDS) assessment for one resident. Resident 34, who was admitted with a diagnosis of Schizophrenia, had a PASRR Level 1 form indicating a mental health condition that could lead to a chronic disability, necessitating a PASRR Level 2 evaluation. The PASRR Level 2 evaluation confirmed the presence of a mental health condition and eligibility for mental health services. However, the resident's last comprehensive MDS assessment inaccurately stated that the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. This discrepancy was identified during a review of the resident's clinical record and confirmed by the Nursing Home Administrator and Director of Nursing.
Plan Of Correction
1. Resident 34's MDS was corrected. 2. Social services/designee completed an audit of residents with PASRR level 2 to verify Section A1500 is correct. 3. Social Service director was re-educated on completing accurate MDS assessments. 4. Social worker/designee will conduct random audits of PASRR level 2 residents to verify Section A1500 accuracy weekly x4 and monthly x3. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to revise the care plans for three residents, leading to deficiencies in their care. For Resident 79, the care plan did not include interventions to minimize anxiety and aggression by attempting care with one staff member or offering diet soda as suggested by the resident's daughter. Despite documentation indicating these suggestions, the care plan was not updated, and staff continued to provide care with two staff members without offering the diet soda. Resident 81's care plan was not developed to address dental health concerns despite multiple indications of dental issues, including tooth pain and decaying teeth. The facility's consultant dentist had documented these issues, but the registered nurse assessment coordinator did not review the dental progress notes when completing the MDS assessment, resulting in an inaccurate assessment that did not trigger a dental care plan. Resident 86's care plan was not revised to reflect the loss of her partial dentures, which had been missing for eight months to a year. Although the facility's consultant dental provider had assessed Resident 86 for new dentures, the care plan still indicated that she had partial dentures, failing to address her current needs. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed these deficiencies in care plan revisions.
Plan Of Correction
1. Resident 79's care plan was updated to include attempt care with 1 staff member and their tasks updated to include providing a diet coke. Resident 81's care plan was updated with a dental plan of care. Resident 86's care plan was updated with her current dental status. Resident 81's care plan was updated to include a dental plan. Resident 86's care plan was updated with her current dental status. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary. 2. Care conferences and consultant dental visit notes from the last 30 days were reviewed by RNAC/designee to verify any interventions/changes that were noted were added to the resident's care plan. 3. DON or designee will re-educate IDT and licensed staff on care planning and consultant dental visit interventions/changes. 4. DON or designee will complete random audits of care plan meetings and consultant dental visit notes to verify interventions/changes are discussed are added to the resident's care plan and captured on the MDS weekly X 4 then monthly X 3. Results of the audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Failure to Maintain Resident's Ambulation Program
Penalty
Summary
The facility failed to maintain or improve the ability of a resident to perform activities of daily living, specifically ambulation, due to insufficient staff follow-through. Resident 12, who was discharged from physical therapy with a home exercise program (HEP) and a good prognosis contingent on consistent staff support, reported that staff rarely assisted her with walking due to staffing shortages. Documentation revealed that on multiple occasions, staff marked the ambulation program as not applicable or noted the resident's refusal without re-approaching her to encourage participation. Throughout November 2024 to January 2025, there were numerous instances where Resident 12's ambulation program was either not attempted or marked as refused without further attempts to engage her. This lack of consistent follow-up and encouragement from staff resulted in the resident completing the program on only a fraction of the days reviewed. The deficiency was discussed with the Nursing Home Administrator and the Director of Nursing, highlighting the facility's failure to provide adequate care and services to maintain or improve the resident's functional abilities.
Plan Of Correction
1. Facility cannot retroactively provide restorative program to Resident 12 the days restorative was not completed. Resident 12 is currently receiving physical therapy. 2. DON/designee audited documentation from the last week of residents receiving restorative nursing program to verify residents are provided their program. 3. CNAs will be re-educated on the documentation of and providing restorative nursing services. 4. DON/designee will audit 5 random residents on a restorative nursing program weekly x4 and monthly x3. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Failure to Implement Physician-Ordered Supplemental Oxygen
Penalty
Summary
The facility failed to implement physician-ordered supplemental oxygen for a resident, identified as Resident 63, in accordance with professional standards of practice. A physician's order dated November 11, 2024, required staff to administer supplemental oxygen at two liters per minute as needed to maintain oxygen saturation levels above 90 percent. However, a review of the resident's medication and treatment administration records for November 2024, December 2024, and January 2025 revealed that staff did not routinely assess the resident's oxygen saturation levels to determine the need for supplemental oxygen. On January 13, 2025, an observation of Resident 63 showed no supplemental oxygen in use, and there was no evidence in the clinical record that staff had assessed the resident's oxygen saturation to confirm that supplemental oxygen was not needed. This deficiency was discussed with the Nursing Home Administrator and the Director of Nursing on January 14, 2025.
Plan Of Correction
1. Resident 63's order was revised to evaluate the need for supplemental oxygen. 2. DON/designee conducted an audit of residents receiving oxygen to verify evaluation is conducted when indicated. 3. Nursing staff will be re-educated on obtaining oxygenation saturation assessments if indicated. 4. DON/designee will audit 5 random residents on oxygen to verify evaluation of oxygenation saturation when indicated weekly x4 and monthly x3. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Failure to Implement Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan for a resident diagnosed with dementia. The resident was admitted on October 31, 2024, with a diagnosis of dementia, which affects memory, language, problem-solving, and other cognitive abilities. The resident's most recent annual Minimum Data Set Assessment, dated November 6, 2024, confirmed the diagnosis of dementia. Despite this, the facility did not create a specific care plan to address the resident's cognitive loss until it was pointed out by a surveyor on January 15, 2025. This oversight was acknowledged by the Nursing Home Administrator and Director of Nursing during a review of the findings.
Plan Of Correction
1. Facility made revisions to individualize resident 43's care plan relating to her dementia. 2. Social services/designee reviewed residents with a dementia diagnosis to verify each had individualized dementia care plans. 3. Nursing staff and social services will be re-educated on implementing individualized person-centered care plans to address dementia and cognitive loss. 4. DON/designee will conduct random audits of 5 residents with dementia to verify their care plans are individualized weekly x4 and monthly x3. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Failure to Provide Routine Dental Services for Resident
Penalty
Summary
The facility failed to provide routine dental services for a resident, specifically concerning the replacement of missing partial dentures. Resident 86, who had partial dentures for both the upper and lower jaw, reported that her dentures had been missing for a period ranging from eight months to a year. Despite the resident's indication that the facility's consultant dental provider was supposed to be making new dentures, there was no documentation or grievance form available to confirm when the dentures went missing. An observation of Resident 86 revealed that she had natural teeth and was missing some teeth, which corroborated her claim of missing dentures. The clinical record review showed that the resident's plan of care, created upon admission, acknowledged her need for partial dentures. A progress note from the facility's consultant dental provider dated October 29, 2024, indicated that an assessment of the resident's bite for the molds of new partial dentures had been conducted, marking it as the second assessment. However, the facility lacked a policy or procedure to address the loss or damage of resident property, including dentures, as confirmed by the Nursing Home Administrator and the Director of Nursing. This deficiency highlights the facility's failure to ensure the timely replacement of essential dental appliances for the resident.
Plan Of Correction
1. Resident 86 has a follow up dental appointment to receive her new partials. 2. Social services/designee conducted an audit of residents with partial/ dentures to verify all are accounted for. Findings were addressed at the time of the audit. 3. Social services will be re-educated on notifying dental services within 3 days after partial/dentures are reported missing. 4. Unit manager/designee will conduct random audits of 5 residents with partial/ dentures to verify they are accounted for weekly x4 and monthly x3. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Failure to Document Immunization Education for Cognitively Impaired Residents
Penalty
Summary
The facility failed to ensure that residents' medical records included documentation that residents' representatives were provided education regarding the risks and benefits of immunizations. This deficiency was identified for two residents with severe cognitive impairment. Resident 21's clinical record showed no evidence that she or her responsible party received education about the risks and benefits of the influenza vaccination before it was administered. Despite a psychiatric note indicating that Resident 21 was awake, alert, and oriented, she was unable to confirm if she consented to the vaccination during an interview. Similarly, Resident 46's records revealed that she signed the consent forms for both influenza and pneumococcal vaccinations, but the forms lacked dates, and there was no evidence that her responsible party was informed about the risks and benefits of these vaccinations. Given Resident 46's diagnosis of dementia and severe cognitive impairment, she was not capable of making informed medical decisions independently. The facility's failure to provide the necessary education to the residents' representatives was confirmed by the infection preventionist during an interview.
Plan Of Correction
1. Facility cannot retroactively provide Influenza vaccine informed consent to resident 21 and 46's representatives. Facility cannot retroactively provide Pneumococcal vaccine informed consent to resident 46's representative. 2. Infection preventionist/designee conducted an audit of the last two weeks of influenza and pneumococcal vaccines given to verify resident representatives were provided the informed consent. 3. Infection preventionist will be re-educated on educating resident representatives on the Influenza and Pneumococcal vaccine informed consents prior to vaccination. 4. DON/designee will conduct random audits of Influenza and Pneumococcal vaccination consent forms weekly x4 and monthly x3. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Failure to Document COVID-19 Vaccine Education for Resident's Representative
Penalty
Summary
The facility failed to ensure that a resident's medical records included documentation that the resident's representative was provided education regarding the risks and benefits of receiving a COVID-19 immunization. This deficiency was identified for one of five residents reviewed for immunization concerns. Specifically, Resident 46, who had a severe cognitive impairment as indicated by a BIMS score of three, signed a consent form for the COVID-19 vaccine. However, the facility did not provide evidence that the resident's responsible party was educated about the vaccine's risks and benefits, which was necessary given the resident's incapacity to make informed medical decisions. The clinical record review revealed that Resident 46 had a diagnosis of dementia and was alert with confusion. Despite this, the resident signed the COVID-19 vaccine consent form, and the vaccine was administered. An interview with the facility's infection preventionist confirmed the lack of documentation regarding the education of the resident's responsible party. The Nursing Home Administrator and Director of Nursing were informed of these concerns, which were previously cited as a deficiency in February 2024.
Plan Of Correction
1. Facility cannot retroactively provide the COVID vaccine informed consent to resident 46's representative. 2. Infection preventionist/designee conducted an audit of the last two weeks of COVID vaccines given to verify resident representatives were provided the informed consent. 3. Infection preventionist will be re-educated on educating resident representatives on the COVID vaccine informed consent prior to vaccination. 4. DON/designee will conduct random audits of COVID vaccination consent forms weekly x4 and monthly x3. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Failure to Provide Required Transfer Notifications
Penalty
Summary
The facility failed to provide timely written notification to residents and their responsible parties regarding transfers to the hospital, as required by regulations. This deficiency was identified for five residents, who were transferred to the hospital due to changes in their conditions. The clinical records for these residents did not contain documentation of written notifications that included necessary information such as the reason for transfer, effective date, location, appeal rights, and contact information for the State Ombudsman and advocacy agencies. The Nursing Home Administrator confirmed that the facility did not provide the required written notices and had not submitted any transfer notices to the State Ombudsman for several months until after the survey process highlighted the issue. Specific cases included Resident 59, who was transferred on December 1, 2024, without the required written notification. Resident 91 and Resident 98 were also transferred without proper notification, and the State Ombudsman was not informed in a timely manner. Resident 63 experienced two hospitalizations, and in both instances, neither the resident nor the resident's representative received the required written notices. The facility was unable to provide evidence of compliance with notification requirements during interviews with the surveyor, indicating a systemic issue in adhering to regulatory standards for resident transfers.
Plan Of Correction
1. Facility cannot retroactively correct transfer notification to residents 59, 63, 91, 18, and 98. 2. Business office manager/designee completed an audit of the last month of discharges and any missed transfer notifications were addressed. 3. Nursing staff will be re-educated on providing notification to residents and resident representatives upon transfer out of the facility. 4. DON/designee will conduct random audits of transfers to verify proper notification weekly x4 and monthly x3. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Failure to Complete Discharge Summary Within 30 Days
Penalty
Summary
The facility failed to complete a discharge summary within 30 days of a resident's death, as required by regulation. A closed clinical record review for a resident revealed that nursing documentation noted the resident was without pulse or respirations and was pronounced deceased. However, the review also showed that no discharge summary, including the final diagnosis and cause of death, was completed within the required timeframe. This deficiency was identified during a closed clinical record review and confirmed through staff interviews.
Plan Of Correction
1. Facility cannot retroactively provide resident 100's discharge summary. 2. Medical records director/designee conducted an audit of the last 2 weeks of discharges to verify discharge summaries have been completed. 3. Providers will be re-educated on providing discharge summaries. 4. DON/designee will audit discharges to verify they have completed discharge summaries weekly x4 and monthly x3. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Deficiency in Nurse Aide Staffing Levels
Penalty
Summary
The facility failed to meet the required nurse aide staffing levels during the evening and overnight shifts for specific days reviewed. Specifically, the facility did not ensure a minimum of one nurse aide per 11 residents during the evening shift on two occasions and one nurse aide per 15 residents during the overnight shift on three occasions. This deficiency was identified through a review of nursing staffing hours and staff interviews conducted during an onsite survey. The survey revealed discrepancies in the staffing calculations, as staff were recorded as providing more hours of care than their scheduled shifts, leading to incorrect staffing data. Despite multiple requests from the surveyor, the facility was unable to provide accurate nurse staffing information. The review of nursing care hours for specific dates confirmed the shortfall in nurse aide staffing, which was discussed with the Nursing Home Administrator and the Director of Nursing.
Plan Of Correction
1. Facility cannot retroactively correct nurse aide staffing ratio. 2. Director of Nursing/Designee will conduct an initial audit of the past two weeks' schedule to determine if nurse aide ratio is in compliance. 3. Director of Nursing/Designee will re-educate the scheduler on the proper nurse aide staffing ratios. The facility will hold labor meetings Monday-Friday to verify ratios are made. 4. Director of Nursing/Designee will conduct random audits of nurse aide staffing weekly for four weeks, then monthly for two months thereafter to verify proper nurse aide ratios. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
LPN Staffing Deficiency on Day and Overnight Shifts
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) during specific shifts on three separate days. On two occasions during the day shift, the facility did not provide the minimum required number of LPNs per resident. Specifically, on October 6, 2024, and November 24, 2024, the facility had 4.03 and 4.0 LPNs respectively for a census of 103 residents, whereas 4.12 LPNs were required. Additionally, on October 12, 2024, during the overnight shift, the facility provided 2.06 LPNs for a census of 104 residents, falling short of the required 2.60 LPNs. These deficiencies were identified through a review of nursing care hours and were discussed with the Nursing Home Administrator and the Director of Nursing on January 16, 2025.
Plan Of Correction
1. Facility cannot retroactively correct LPN staffing ratio. 2. Director of Nursing/Designee will conduct an initial audit of the past two weeks schedule to determine if LPN ratio is in compliance. 3. Director of Nursing/Designee will re-educate the scheduler on the proper LPN staffing ratios. The facility will hold labor meetings Monday-Friday to verify ratios are made. 4. Director of Nursing/Designee will conduct random audits of LPN staffing weekly for four weeks, then monthly for two months thereafter to verify proper LPN ratios. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Deficiency in Meeting Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per patient per day (PPD) for four specific days across three different periods. The review of nursing staff care hours revealed deficiencies on October 6, 11, and 12, 2024, and November 24, 2024, with PPD hours recorded as 3.17, 3.08, 3.14, and 3.18, respectively. This shortfall was identified during a review of nursing staffing hours and confirmed through staff interviews. The findings were discussed with the Nursing Home Administrator and the Director of Nursing on January 16, 2025.
Plan Of Correction
1. Facility cannot retroactively correct staffing PPD. 2. Director of Nursing/Designee will conduct an initial audit of the past two weeks' schedule to determine if PPD is in compliance. 3. Director of Nursing/Designee will re-educate the scheduler on the proper PPD. The facility will hold labor meetings Monday-Friday to verify PPD is made. 4. Director of Nursing/Designee will conduct random audits of facility PPD weekly for four weeks, then monthly for two months thereafter to verify proper PPD hours. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Resident-to-Resident Abuse Incident
Penalty
Summary
Highlands Rehabilitation And Healthcare Center was found to be non-compliant with the requirement to protect residents from abuse, as evidenced by an incident involving two residents. Resident 1, who was admitted with unspecified dementia, was found on the floor with a fracture to her right arm after reportedly being pushed out of bed by her roommate, Resident 2. Resident 1 expressed fear and pain following the incident, which was unwitnessed by staff. The facility's documentation confirmed the injury and Resident 1's statement about being pushed. Resident 2, who has a diagnosis of bipolar disorder and was assessed with intact cognition, initially denied involvement but later admitted to pushing Resident 1. The incident occurred after Resident 2 was observed leaving the room and later admitted to the police and staff that she had pushed her roommate. The facility responded by moving Resident 2 to a different room and placing her on 15-minute checks for safety. Despite these measures, the facility failed to prevent the abuse from occurring. Interviews with staff revealed that Resident 2 had been acting differently due to the recent death of another resident she was close to. The Director of Nursing noted that Resident 2 was attention-seeking and initially denied the incident. The facility's investigation included witness statements from staff who confirmed Resident 2's admission of pushing Resident 1. The report highlights the facility's failure to protect Resident 1 from physical abuse by another resident, as required by federal and state regulations.
Plan Of Correction
1. R1 remains in the facility. Sling intact to right arm and pain controlled. She continues to have no recollection of the events and is happy in her new room. Social work visits completed. R2 remains in the facility. Medical follow up complete. ABT completed. Psych services continue to follow. Social work visits completed. She remains happy in her new room. 2. Residents on 3rd floor with a BIMS score of 8 or higher were interviewed/assessed for potential abuse. 3. DON/Designee reeducated abuse policies, investigation procedure and documentation process. Nurse aides and Licensed Nurses have been educated on documenting behaviors. 4. DON/SW/Designee will perform random audits of 5 resident's behaviors in nursing notes or EMAR/ETAR to ensure care plans updated weekly X 8, then monthly X 1. Results will be brought to QAPI.
Facility Fails to Maintain Safe Temperature Levels
Penalty
Summary
The facility failed to maintain comfortable and safe temperature levels between 71 and 81 degrees Fahrenheit on both the second and third floors. Observations on October 19, 2024, revealed that temperatures in various resident rooms and medication rooms exceeded the recommended range, with readings as high as 88 degrees Fahrenheit. Interviews with multiple residents confirmed that the facility was too warm, with several residents expressing discomfort and a preference for cooler temperatures. Fans were provided to help alleviate the heat, but residents reported that they were not very effective. The Director of Nursing and the maintenance director confirmed the warm temperatures and attributed the issue to the need for a replacement of the chiller and control panel. While approval had been received to replace the chiller, there was no scheduled date for the repairs, and approval for the control panel replacement was still pending. This deficiency was previously cited on February 9, 2024, under the regulation 483.10(i)(1)-(7) for maintaining a safe, clean, comfortable, and homelike environment.
Failure to Implement Effective Infection Control Program
Penalty
Summary
The facility failed to ensure an effective infection control program for outbreak testing and transmission-based precautions on one of its nursing units. The policy for COVID-19 testing requires immediate testing and follow-up tests 48 hours apart until no new cases are detected for 14 days. Additionally, residents with COVID-19 should be on transmission-based precautions for at least 10 days. However, Resident 1, who tested positive and was symptomatic, had droplet precautions discontinued after only seven days. Resident 2, who also tested positive and was symptomatic, had no documented evidence of how long transmission-based precautions were maintained, nor was there a physician order to start or discontinue droplet precautions. The facility did not initiate either contact tracing or a broad-based testing approach after identifying symptomatic COVID-19 cases starting on March 26, 2024. The facility's infection control preventionist quit at the end of March 2024, and a new infection control preventionist did not initiate facility-wide COVID-19 testing until April 3, 2024. Between March 26, 2024, and April 20, 2024, the facility reported at least 55 resident and staff cases of COVID-19 to the Department of Health. Interviews with the Administrator and Director of Nursing confirmed these findings, indicating a significant lapse in the facility's infection control measures during this period.
Failure to Implement Abuse Policy and Investigate Allegation
Penalty
Summary
The facility failed to implement their abuse policy regarding investigating an allegation of abuse for two residents. According to the facility's Abuse Policy, allegations must be reported to the Administrator or other officials, and an investigation must be initiated immediately. However, the facility did not provide documented evidence that an investigation was started regarding a physical incident between two residents. Nursing documentation indicated that one resident struck another in the face, which was witnessed by a housekeeper and reported to the Director of Nursing. Despite this, there was no documented evidence that the injured resident was assessed for injuries or that an investigation was initiated. The surveyor observed the housekeeper writing a statement about the incident during the on-site visit, despite the statement being dated for a previous year. The housekeeper confirmed that she had initially written a statement when the incident occurred but was unsure what happened to it after submission. Interviews with the Administrator and Director of Nursing confirmed these findings, indicating a failure to follow the facility's abuse policy and properly document and investigate the incident.
Failure to Administer Correct Dosage of Pain Medication
Penalty
Summary
The facility failed to provide the highest practicable care regarding the administration of physician-ordered pain medications for one resident. A review of the resident's closed clinical record revealed a physician's order for Morphine Sulfate 20mg/ml, 0.75 ml to be administered every four hours around the clock for pain. However, the Medication Administration Record (MAR) for April 2024 showed that a registered nurse only administered 0.5 ml of Morphine Sulfate on two occasions, instead of the prescribed 0.75 ml. There was no documented evidence that any as-needed doses of Morphine Sulfate were administered during the nurse's shift. An interview with the Administrator confirmed that there were no reported medication errors for April 2024 and verified the findings for the resident.
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 59 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 Laporte
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Darway Healthcare And Rehabilitation Center | 8.7 mi | ★★★★★ | 6 | 0 |
| Bonham Nursing And Rehabilitation Center | 19.2 mi | — | 1 | 0 |
| Muncy Place | 20.6 mi | ★★★★★ | 0 | 0 |
| Gardens At Millville, The | 21.4 mi | ★★★★★ | 11 | 0 |
| Gardens At Orangeville, The | 24.4 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Highlands Rehabilitation And Healthcare.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.