Above average — CMS composite of the measures below.
The next survey window likely opens around April 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 Highland Meadows during CMS and state inspections, most recent first.
A facility failed to keep resident rooms free of hazards and to ensure fall-prevention measures were in place for several residents. Two residents were observed with disinfectant spray stored in their rooms, a fall-risk resident did not have her fall mat placed beside the bed, and another resident had a scoop mattress on the bed without physician orders. Staff, including the RN, LVN, ADON, and DON, acknowledged the items or equipment should not have been left that way.
A resident with COPD had a nebulizer mask left unbagged, another resident with COPD had a nasal cannula stored unbagged on a wheelchair, and a third resident with OSA had a nebulizer mask and CPAP mask left unbagged. Staff stated the devices needed to be bagged when not in use to avoid cross contamination, and the DON and ADON acknowledged that the resident with the nebulizer also lacked active physician orders for its use.
Medication Storage Lapses: A resident with dementia and damaged retina had eye drops on the bedside table, another resident with acid reflux and COPD had allergy and antacid meds on the nightstand, and a third resident with tremors and severe cognitive impairment had earwax removal on the nightstand. The LVN, ADON, and DON acknowledged the meds should not have been in the rooms, noting family members had brought them in and staff were expected to check for and remove them.
Kitchen Food Storage and Sanitation Deficiencies: Surveyors observed an uncovered tea dispenser, a stained ice scoop holder, a sanitizer bucket with 0 PPM sanitizer, and a tray of thawing raw meat stored above cooked foods. The DM, FSS, and Administrator acknowledged the concerns and discussed the observed storage and sanitation issues.
Care Plan Missing Fall Mat Intervention: A resident with a fractured thigh and intact cognition was identified as a fall risk, but the care plan did not include the fall mat that was observed placed beside the bed. Staff stated they were unsure whether the mat was being used and acknowledged the care plan had not been updated to reflect the intervention, despite a progress note showing the resident had previously been found on the mat.
A facility failed to complete a baseline care plan within 48 hours for a newly admitted resident with joint replacement, diabetes, and heart failure. An LVN initiated but did not complete the plan, and the DON acknowledged the lapse, citing staff communication to meet care needs.
A facility failed to prevent complications for a resident with a g-tube. A CNA did not inform the nurse to pause the feeding before providing care and lowered the resident's bed to a flat position while the feeding continued. This oversight could lead to complications such as aspiration. The resident had multiple diagnoses, including dementia and gastro-esophageal reflux disease, and required tube feeding due to dysphagia and weight loss. The facility lacked a specific policy for care during continuous g-tube feeding.
A resident with multiple health conditions had a PRN order for Lorazepam that exceeded the 14-day limit without re-evaluation by a physician. Facility staff, including ADONs and the DON, failed to follow up on the re-evaluation requirement, and the facility's policy on PRN psychotropic medication was not adhered to.
Two CNAs failed to perform proper hand hygiene during incontinent care for two residents, leading to potential cross-contamination and infection spread. One CNA did not wash hands after changing gloves following a bowel movement, while the other did not change gloves or wash hands after cleaning urine. Interviews with the DON and ADON confirmed that staff are expected to follow hand hygiene protocols, which are emphasized in the facility's infection control policies.
A resident with multiple health issues was found to have an open wound in the groin area, which was not reported to the primary care physician as required. The facility's staff assumed it was a moisture-related incident and only notified the wound care doctor. This oversight in communication and reporting could delay medical intervention and affect the resident's health.
A resident with multiple medical conditions was found to have a wound in the lower abdominal/groin area, which was not reported to HHSC as required. The facility's DON assumed the wound was moisture-related and did not consider it an injury of unknown origin, despite staff observations suggesting otherwise. This failure to report deviated from the facility's policy and could place residents at risk.
The facility failed to maintain an effective infection control program, with staff observed touching medications without gloves, not cleaning equipment between uses, and neglecting hand hygiene during incontinent care. Staff admitted to forgetting protocols despite recent training.
The facility failed to follow its policy on food storage, leading to unlabeled and undated items in the nourishment room refrigerator and lack of temperature documentation for personal refrigerators. Staff interviews revealed confusion over responsibilities, placing residents at risk of foodborne illness.
Hazards in resident rooms and missing orders for fall-related equipment
Penalty
Summary
The facility failed to keep resident rooms free of hazards for four residents reviewed for accident hazards. Resident #46, a male with depression and COPD and a BIMS score of 14, was observed with a can of disinfectant spray on his nightstand. Resident #55, a female with depression and a BIMS score of 6, was observed with a can of disinfectant spray in her bathroom. During interview, RN J stated the disinfectant should not have been in the residents’ rooms because it was a hazard, and that family members often bring these items in. The facility also failed to ensure Resident #70’s fall mat was placed alongside her bed. Resident #70 had diagnoses including repeated falls, a BIMS score of 12, and a care plan intervention requiring a fall mat beside the bed. During observation, the fall mat was found leaning against a 5-drawer chest rather than placed beside the bed. LVN E stated the resident was a fall risk and needed the mat in place, and that staff often forgot to return it after providing care. The facility further failed to ensure Resident #96 had physician orders for a scoop mattress that was on his bed. Resident #96 had a diagnosis of shaking, a BIMS score of 2, and a diagnosis of seizure disorder. The care plan reflected fall risk, but did not include the scoop mattress, and the physician’s orders reviewed did not include one. During interview, the ADON and DON stated physician orders were required for the device and acknowledged the resident had the scoop mattress without such orders.
Respiratory Equipment Left Unbagged and Nebulizer Lacked Orders
Penalty
Summary
The facility failed to ensure that respiratory equipment was stored in a bag when not in use for three residents who required respiratory care. Resident #46, a male with diagnoses of depression and COPD and a BIMS score of 14, had a physician order for Ipratropium-Albuterol inhalation solution via nebulizer, but during observation his nebulizer mask was found on his nightstand unbagged. Resident #70, a female with COPD and a BIMS score of 12, had an order for continuous oxygen at 2-4 LPM via nasal cannula, but during observation her oxygen tank attached to her wheelchair had a nasal cannula sitting on the wheelchair seat under a pair of sneakers and unbagged. Resident #71, a male with obstructive sleep apnea, chronic atrial fibrillation, and a BIMS score of 2, had an order to apply CPAP at bedtime and fit the mask for comfort, but had no physician orders for nebulizer use. During observation, his nebulizer mask and CPAP mask were found laying on top of the nightstand and unbagged. Staff interviews confirmed that the respiratory devices needed to be bagged when not in use to avoid cross contamination, and the DON, ADON, and RN staff acknowledged the unbagged equipment and the lack of active physician orders for the nebulizer.
Medication Storage Lapses
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in locked compartments under proper temperature controls and accessible only to authorized personnel. During observations on 05/12/26, Resident #29, who had diagnoses including dementia and damaged retina, had a container of eye drops on the bedside table. Resident #46, who had diagnoses of acid reflux and COPD, had a container of allergy medication and antacid medication on the nightstand. Resident #96, who had a diagnosis of tremors and a Quarterly MDS reflecting severe cognitive impairment with a BIMS score of 2, had a container of earwax removal on the nightstand. During interviews on 05/14/26, the LVN, ADON, and DON were informed of the medications found in the residents’ rooms. The LVN stated the residents were not allowed to have the medications in their rooms because they could overdose on them or ingest them. The ADON stated family members brought in medication, staff should be checking for this when checking on residents, and the facility checked daily and confiscated items when seen. The DON stated family members had repeatedly been educated not to bring in medication and that the risk of residents having medication in their rooms could result in overdose. The facility policy stated all drugs and biologicals are to be stored in locked compartments under proper temperature, light, and humidity controls, with access limited to persons authorized to prepare and administer medications.
Kitchen Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen. During observation of the kitchen, the tea dispenser contained tea and was not covered. A large tray of thawing raw meat was stored in the walk-in refrigerator above cooked foods. An ice scoop holder in the kitchen had white and brownish stains on the bottom inside of it. During interview and observation, the Dietary Manager stated the sanitizer bucket in the kitchen had sanitizer fluid in it and that she had tested the PPM that morning. When the solution in the container was tested, the PPM registered at 0, indicating no sanitizer solution was registered in the mixture. The Dietary Manager and Food Service Supervisor stated the tea dispenser needed to be covered to prevent something from falling into it, the raw meat tray needed to be placed on the bottom rack and not above other foods, and the ice scoop holder was cleaned at least once a week. The Administrator was informed of the kitchen concerns and stated she had been told the tea was uncovered because they were in the process of making more tea. She also stated she had been told the raw meat tray had a solid tray underneath it and the bags were sealed, and that she understood the ice scoop holder needed to be cleaned to avoid contamination. She further stated she had been informed the red bucket did not have sanitizer fluid in it, but that the DM said they would check it before using it if needed.
Care Plan Missing Fall Mat Intervention
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #46 that included measurable objectives and timeframes for the resident's identified needs. Resident #46 was a [AGE]-year-old male admitted with a fractured thigh, and his Quarterly MDS dated 04/22/26 showed a BIMS score of 14 and pain in an unspecified joint. His Comprehensive Care Plan dated 05/05/26 identified him as a fall risk, but it did not include the intervention of a fall mat placed alongside the bed. During observation on 05/12/26 at 10:32 a.m. and again on 05/14/26 at 9:00 a.m., Resident #46 had a fall mat placed alongside his bed. The ADON stated she was not sure whether the resident used a fall mat and later stated the fall mat should not have been there. The surveyor also referenced a progress note dated 03/12/26 indicating the resident was found on his knees on the fall mat. The DON stated it was the interdisciplinary team's responsibility to ensure care plans were updated and that if the resident's care plan was not updated with the interventions used as part of the plan of care, he may not receive the appropriate care.
Failure to Complete Baseline Care Plan for New Resident
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a newly admitted resident within the required 48-hour timeframe. The resident, a female with a history of joint replacement surgery, type 2 diabetes mellitus, and heart failure, was admitted to the facility. Although a baseline care plan was initiated by an LVN, it was not completed, leaving the resident without a comprehensive plan to address her immediate health and safety needs. Interviews with facility staff, including the LVN responsible for the care plan and the Director of Nursing, confirmed the oversight. The LVN admitted to forgetting to complete the baseline care plan, while the Director of Nursing acknowledged the requirement but downplayed the risk, citing close communication among staff to meet care needs. The facility's policy mandates the completion of a baseline care plan within 48 hours of admission, which was not adhered to in this case.
Failure to Prevent Complications in G-Tube Feeding
Penalty
Summary
The facility failed to provide appropriate care and services to prevent complications for a resident with a gastrostomy tube (g-tube). A certified nursing assistant (CNA) did not inform the nurse to turn off the resident's g-tube feeding prior to providing incontinent care. The CNA lowered the head of the resident's bed to a flat position while the g-tube feeding continued to infuse, which could place the resident at risk for complications such as aspiration and pneumonia. The resident involved was an elderly female with multiple diagnoses, including hypertension, dementia, and gastro-esophageal reflux disease, and was dependent on staff assistance for activities of daily living. The resident's care plan indicated a need for tube feeding due to dysphagia and weight loss, with a goal to remain free of complications related to tube feeding. Despite this, the CNA was unaware of the need to pause the feeding or keep the head of the bed elevated during care, and the facility lacked a specific policy regarding providing care to residents on continuous g-tube feeding.
Failure to Re-evaluate PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident's PRN order for Lorazepam, a psychotropic medication, was limited to fourteen days, as required by regulations. The resident, a male with multiple diagnoses including chronic systolic heart failure, COPD, and depression, had a PRN order for Lorazepam for anxiety that extended beyond the fourteen-day limit without physician documentation re-evaluating the necessity of the medication. The resident's care plan indicated the use of Ativan for anxiety, with a goal to decrease anxiety symptoms, but there was no evidence of re-evaluation or documentation justifying the continued PRN use of Lorazepam. Interviews with facility staff, including the ADONs and the DON, revealed a lack of awareness and follow-up regarding the re-evaluation of the PRN Lorazepam order. The ADONs acknowledged the requirement for a 14-day re-evaluation of psychotropic medications and admitted to not following up with the primary care provider after the resident was no longer on hospice. The DON was unaware of the pharmacy's recommendation for re-evaluation and could not provide a rationale for the prolonged use of the medication. The facility's policy required that PRN orders for antipsychotic medications not be renewed beyond 14 days without a documented evaluation and rationale, which was not adhered to in this case.
Inadequate Hand Hygiene During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of two CNAs during incontinent care for two residents. CNA A did not perform hand hygiene after changing gloves while assisting a resident who had a bowel movement. This oversight was acknowledged by CNA A, who admitted forgetting to complete hand hygiene, despite being aware of its importance in preventing infection spread. Similarly, CNA C did not change gloves or perform hand hygiene after cleaning a resident who was soiled with urine. Instead, CNA C continued to handle the resident's clean brief, linens, and bed remote with the same gloves. CNA C was unaware of the need for hand hygiene between care tasks unless a bowel movement was involved, indicating a gap in understanding of infection control practices. Interviews with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), who is also the infection preventionist, confirmed that staff are expected to perform hand hygiene during care. The facility's policies emphasize hand hygiene as a primary means to prevent infection spread, and staff are in-serviced on infection control monthly. However, the observed practices of the CNAs did not align with these expectations, leading to potential risks of cross-contamination and infection spread.
Failure to Notify Physician of Resident's Injury
Penalty
Summary
The facility failed to immediately inform a resident's attending physician and the resident's representative of a significant change in the resident's condition, specifically an injury of unknown origin. The resident, a female with multiple diagnoses including hypertension, dementia, and obesity, was found to have an open wound in the groin area. This wound was discovered by a family member and reported to an LVN, who treated the wound but did not notify the primary care physician, assuming it was a moisture-related incident. The facility's Director of Nursing stated that the wound care doctor was notified, which they believed satisfied reporting requirements. However, the primary care physician was not informed of the wound, which was later assessed by another physician as a laceration, not consistent with a moisture-related injury. The facility's policy requires that all injuries of unknown origin be reported to the attending physician, which was not done in this case. Interviews with staff revealed a lack of clarity and communication regarding the wound's origin and the appropriate reporting procedures. The LVN involved did not contact the primary care physician, and the Director of Nursing did not consider the wound an injury of unknown origin. This oversight could potentially delay medical intervention and affect the resident's health, as the primary care physician was unaware of the wound and its implications.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident, which was discovered on December 27, 2024. The resident, a female with multiple medical conditions including moderate cognitive impairment, was found to have a wound in the lower abdominal/groin area. The wound was initially assessed by an LVN, who treated it and notified the wound care doctor. However, the facility did not report this incident to the Health and Human Services Commission (HHSC) as required by their policy. The Director of Nursing (DON) believed the wound was moisture-related and did not consider it an injury of unknown origin, thus not reporting it to HHSC. The facility's policy mandates that all injuries of unknown origin be reported immediately, but the DON assumed the wound was covered under an existing order for moisture-related incidents. Interviews with staff, including the DON, CNA, and the physician, revealed that the wound did not appear to be pressure or moisture-related, but rather consistent with a laceration. The facility's failure to report the wound as an injury of unknown origin was a deviation from their established procedures. The policy clearly states that all such incidents should be reported to local, state, and federal agencies. Despite the wound being small and not resulting in serious bodily injury, the lack of reporting could place residents at risk for abuse, neglect, and other incidents, as the facility did not follow the required protocol for reporting injuries of unknown origin.
Infection Control Lapses
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple lapses in protocol by staff members. Specifically, a medication aide (MA A) was observed touching medications without gloves and administering them to a resident. Additionally, MA A did not clean the blood pressure machine between uses for two residents. In an interview, MA A acknowledged awareness of the proper procedures but admitted to forgetting them. The Assistant Director of Nursing (ADON) confirmed that the staff should not touch medications without gloves and should clean the blood pressure machine between residents, regardless of isolation status. Another incident involved a certified nursing assistant (CNA B) who failed to perform hand hygiene while providing incontinent care to a resident. CNA B was observed not washing hands after removing dirty gloves and before donning clean gloves. In an interview, CNA B admitted to forgetting the hand hygiene protocol despite recent in-service training on infection control. The Director of Nursing (DON) reiterated that staff should maintain infection control practices to prevent the spread of infection. The facility's hand washing policy, effective since May 2017, mandates hand hygiene as the primary means to prevent infection spread, requiring hand washing for at least 20 seconds after removing gloves.
Deficient Food Storage Practices in Facility
Penalty
Summary
The facility failed to adhere to its policy regarding the storage and handling of foods brought in by family members and visitors for residents. Observations revealed that nine residents did not have documentation of temperature checks for their personal refrigerators, which is a requirement to ensure food safety. Additionally, the nourishment room refrigerator contained several unlabeled and undated food items, including ice cream, pho, sandwiches, and pizza, along with visible stains, indicating a lack of proper maintenance and oversight. Interviews with facility staff, including the Director of Nursing, Dietary Manager, and Assistant Director of Nursing, highlighted a lack of clarity and responsibility regarding the management of both personal and nourishment room refrigerators. The Director of Nursing stated that the nursing and dietary staff were responsible for cleaning and dating items in the nourishment room, while personal refrigerators were the responsibility of residents and their families. However, the Dietary Manager admitted there was no schedule for cleaning the nourishment room refrigerator, and the Assistant Director of Nursing acknowledged the difficulty in maintaining it due to family access. Further interviews with nursing staff revealed inconsistencies in the understanding of responsibilities for cleaning and maintaining temperature logs. A Licensed Vocational Nurse and a Medication Aide both indicated that cleaning the refrigerators was not part of their job descriptions, and there was confusion about who was responsible for these tasks. This lack of clear procedures and accountability placed residents at risk of foodborne illness due to potential exposure to expired or improperly stored food.
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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 Rockwall
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rockwall Nursing Care Center | 2.3 mi | ★★★★★ | 10 | 1 |
| Broadmoor Medical Lodge | 2.4 mi | ★★★★★ | 5 | 0 |
| Beacon Harbor Healthcare And Rehabilitation | 4.5 mi | ★★★★★ | 2 | 0 |
| Rowlett Health And Rehabilitation Center | 4.9 mi | ★★★★★ | 0 | 0 |
| Wylie Oaks Healthcare And Rehabilitation | 9.7 mi | ★★★★★ | 2 | 0 |
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