Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Highmore Health during CMS and state inspections, most recent first.
A resident with dementia and severely impaired cognition, previously identified as at risk for elopement with care plan interventions requiring all exit doors to remain alarmed, was able to leave the facility through an east exit door after an LPN turned off the door alarm to allow entry for another resident and family and forgot to reactivate it. Later that evening, an RN could not locate the resident, prompting a search of the building and surrounding area. The resident was ultimately found by a citizen sitting on the ground across the street in very cold weather conditions, was returned to the facility cold to the touch with a low body temperature, and initially exhibited combative behaviors not typical for him before returning to baseline.
Surveyors found that respiratory equipment such as nebulizers and BiPAP machines were not properly cleaned or stored between uses for several residents with COPD, with masks and tubing left uncovered and wet. Shared personal care items and an uncleanable whirlpool bath chair were observed in use, and clean linen closets contained unclean items, increasing the risk of contamination. The facility also lacked a water management plan to assess and prevent Legionella, and staff interviews confirmed gaps in infection control practices and policies.
A cook did not change gloves or wash hands after touching multiple surfaces and items during meal service, continuing to handle ready-to-eat foods with the same gloves. Unsanitary conditions were also observed in the kitchen, including food debris on equipment and uncleanable surfaces. Staff and management confirmed that cleaning schedules and infection control policies were not followed.
Multiple residents and their families reported concerns about the absence of a private area to meet within the facility. Staff confirmed that a previously available Family Room had been converted into a resident room, leaving no consistent private space for meetings. The only alternative provided was the dining room when not in use, which did not ensure privacy. The facility's own Resident's Rights document states that residents are entitled to proper privacy and living arrangements.
A resident with advanced dementia, dependent on staff for transfers, sustained a significant laceration during a mechanical lift transfer to a bath chair. The injury was witnessed and documented by staff, but no incident report or investigation was completed at the time, and the DON did not initially interview involved staff or document CNA competencies, contrary to facility policy requiring investigation of such injuries.
Failure to Maintain Exit Door Alarm Resulting in Elopement of High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision for a resident identified as at risk for elopement, resulting in the resident leaving the building through an east exit door that was not alarmed or monitored. On the evening in question, an RN was unable to locate the resident at approximately 9:00 p.m. and initiated a search of the building, including rooms, closets, bathrooms, beds, and ancillary rooms. During this process, staff noted that the east door alarm was turned off, even though the resident’s care plan and the facility’s elopement policy required exit door alarms to remain on at all times for residents at risk of elopement. The resident involved had a primary diagnosis of unspecified dementia with behavioral disturbances and a severely impaired cognition score on the Brief Interview for Mental Status. He had been assessed multiple times as having a potential risk for elopement, with elopement risk scores documented on admission and quarterly, and his care plan included interventions such as keeping all doors alarmed to alert staff and redirecting him if he was observed heading toward an exit. Despite these identified risks and care plan interventions, an LPN reported that she had turned off the east door alarm earlier that evening to allow another resident and family to enter without triggering the alarm and then forgot to turn it back on. Staff later confirmed that the door alarm did not sound when the resident exited the building. After the resident was discovered missing, staff and visitors searched the facility and surrounding area. A citizen and his dog ultimately found the resident sitting on the ground in a neighbor’s yard across the street and alerted the search party. Weather data from a nearby personal weather station showed that at the approximate time of the elopement, the outdoor temperature was 7°F with wind speeds of 7 mph, resulting in a wind chill of approximately -5°F. When the resident was brought back inside, he was described as very cold to the touch, with an initial temperature of 96.4°F, and was noted to be combative and resistive to care, grabbing at staff and attempting to hit others, which staff reported was not his normal behavior. Subsequent observations and skin assessments showed no signs of frostbite, and his behavior documentation indicated that his behaviors returned to baseline after the incident.
Infection Control Deficiencies in Respiratory Equipment, Shared Items, Linen Storage, and Water Management
Penalty
Summary
Surveyors identified multiple deficiencies in infection prevention and control practices within the facility. Observations revealed that nebulizer machines and equipment for three residents with chronic obstructive pulmonary disease (COPD) were not properly cleaned or stored. The nebulizer masks and tubing were left attached to the machines, uncovered, and with wet medication chambers between uses. In one case, a BiPAP machine mask was found resting in an uncovered basin on the floor, alongside other items, and was not cleaned or stored as required. Staff interviews confirmed that cleaning and storage protocols were not consistently followed, and care plans lacked specific instructions for these procedures. Further deficiencies were observed in the maintenance and use of shared equipment and personal care items. The whirlpool bath chair in the shower/tub room had rusted, cracked, and bubbled surfaces, making it uncleanable. Shared, partially used, and unlabeled personal hygiene products were available for use among residents, contrary to staff expectations that each resident should have their own products to prevent cross-contamination. There was no policy in place regarding the shared use of personal hygiene items, and staff acknowledged the risk of infection control concerns due to these practices. Additional issues were found in the storage of clean linens, where unclean items such as walkers, shoes, personal care items, and opened packages of briefs were stored alongside clean linens in designated linen closets. This practice was contrary to facility policy, which required that only clean linen be stored in these areas to prevent contamination. The facility also lacked a water management plan to assess, prevent, and monitor for Legionella and other waterborne pathogens, with no policies or testing protocols in place.
Failure to Follow Food Safety and Sanitation Practices in Dietary Services
Penalty
Summary
Surveyors observed that a cook failed to follow standard food safety practices during meal service by not changing gloves or washing hands after touching multiple surfaces and items, including food containers, utensils, meal cards, microwave doors, and food packaging. The cook continued to use the same pair of gloves throughout the meal service, including when handling ready-to-eat food items, and admitted that it was her normal practice not to change gloves during food service. The dietary manager and another cook confirmed that gloves should have been changed after touching multiple surfaces and that tongs should have been used to retrieve certain food items. Additionally, the kitchen environment was found to be unsanitary, with food spatter and debris observed on pans, lids, prep table shelves, and the steam table. The steam table also had exposed bare wood, making it uncleanable. The dietary manager acknowledged that cleaning schedules for kitchen equipment had not been followed, and records showed inconsistent documentation of cleaning. Facility policies required cleaning and sanitizing of work surfaces and equipment after each use, as well as proper glove use and handwashing, but these were not adhered to during the observed period.
Lack of Private Meeting Space for Residents and Families
Penalty
Summary
The facility failed to provide a private area for residents and their families to meet, as evidenced by multiple resident and family interviews. Several residents living in shared rooms expressed concerns about the lack of privacy during visits, with one resident stating discomfort when his roommate's visitors were present and another resident and her family noting the absence of a private space for family gatherings. Residents and their families reported these concerns to facility staff, including the social services director and administrator. The issue was further documented in a grievance filed by a family member, who expressed frustration over the lack of a private meeting area. Staff interviews confirmed that the facility previously had a Family Room available for private meetings, but it was converted into a resident room by the previous owner for financial reasons. Currently, the only alternative offered was the use of the dining room when not in use for meals or activities, which did not provide consistent privacy. The administrator acknowledged receiving complaints and confirmed that, at the time of the survey, there was no available private space for residents and visitors to meet. Review of the facility's Resident's Rights document indicated that residents are entitled to proper privacy, property, and living arrangements.
Failure to Investigate and Document Injury During Mechanical Lift Transfer
Penalty
Summary
A resident with Alzheimer's disease and dementia, who was non-verbal and dependent on staff for all mobility and transfers, sustained a 2.5-inch laceration on the tip of his penis during a transfer to a bath chair using a total mechanical lift. The incident was witnessed by two CNAs, and the injury was documented by an LPN, who noted the difficulty in bandaging the area and that the physician and POA were notified. However, there was no documentation detailing how the injury specifically occurred, which staff were involved, or whether the transfer was performed safely. The resident's medical record indicated ongoing assessments of the wound, but lacked an incident report or investigation at the time of the event. The Director of Nursing (DON) did not initially believe an investigation was necessary and did not interview the staff involved until prompted later. The facility's policies required that injuries such as bruises, abrasions, skin tears, or lacerations be investigated, and that incident reports be completed and reviewed by administration. Despite this, no investigation or incident report was completed at the time of the injury, and there was no documentation of the CNAs' competencies in using the mechanical lift. The DON later acknowledged that an investigation could have ruled out abuse or neglect, but this was not done in accordance with facility policy.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Highmore
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society Miller | 22.5 mi | ★★★★★ | 11 | 0 |
| Faulkton Senior Living | 38.9 mi | ★★★★★ | 3 | 0 |
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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.