Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Nursing Center during CMS and state inspections, most recent first.
Infection Prevention and Surveillance Program Not Established: The facility failed to maintain an infection prevention and control program with a system for surveillance of infections and communicable diseases. Infection tracking consisted of pharmacy worksheets and an anti-infective utilization report listing antibiotics, resident names, and prescribers, but not infection reasons, infection types, or infection rates. The CRN, who served as the Infection Preventionist, said she did not use a specific tracking method and relied on the antibiotic report and her knowledge of residents’ histories, while the DON said QAPI reviewed residents with active infections but not overall infection rates, trends, or surveillance data.
Staff COVID-19 Vaccination Not Offered or Documented: The facility failed to ensure staff were offered the 2025-2026 COVID-19 vaccine and did not provide records of staff acceptance or declination. Interviews showed the CRN and an RN stated the facility does not provide the vaccine to staff, and staff instead obtained it privately or through the contracted pharmacy using their own insurance or payment. The facility's Staff Vaccination policy did not include COVID-19 guidance.
Discharge planning was not developed or implemented for four residents. One resident with bipolar disorder and dementia had an attempted transfer, but the family said care plan meetings did not address discharge goals and requested records were not provided to the receiving facility. Three other residents, including cognitively intact residents with psychiatric, cardiac, mobility, and other diagnoses, had care plan conferences and care plans that did not include discharge planning; the DON confirmed no discharge care plans were in place, and the LSW said discharge goals were not routinely reviewed.
A resident with intact cognition, weakness, impaired mobility, and fall risk had 3 razors, rubbing alcohol, and mouth wash in his room, and he kept wine in a locked cabinet after buying it from a store. The A hall shower room was also found open with an unlocked cabinet containing razors. Staff stated the items were safety hazards, and the facility policy said razors were to be stored in secure locations so residents could not access them.
Kitchen food safety requirements were not followed when the ice machine was observed with black specks on the shaft, and a Maintenance Assistant with a short beard was observed in the kitchen without a beard guard. The Maintenance Assistant confirmed he was not wearing a beard guard and said he forgot, while the FSM and ADM stated staff in the kitchen needed hair restraints and the ice machine needed to be maintained to avoid contamination.
Incomplete resident medical records and missing provider progress notes. Surveyors found that multiple residents' charts lacked admission H&Ps and/or PCP progress notes, and some available notes were unsigned draft documents. The DON said provider notes were emailed to the Admin. for printing and filing, while the Admin. said he requested the records from the provider group but did not follow up further. The CRN stated she was unaware the documentation had to be maintained in the charts.
Rusted Kitchen Microwave Not Maintained in Safe Condition: A kitchen microwave was observed with a rusted spot in the corner exposing the inner area of the unit. The FSM, who was covering for the permanent FSM, stated she did not know the microwave was rusted, was unsure how long it had been that way, and confirmed the issue could make residents sick. The ADM stated he was not aware of the condition, and the facility policy required kitchen-essential equipment to be maintained in good repair.
A resident with depressive disorder, DM II, anxiety, bipolar disorder, impaired vision, and dependence for personal hygiene was observed with upper lip and chin hair while sitting in a wheelchair in the dining room. She said she was unaware of the facial hair and wanted staff to help her notice and address it. An LVN later confirmed the facial hair and said a CNA would take care of it, while staff and admin stated grooming and facial hair assistance were part of nursing/aide responsibilities and the facility grooming policy called for daily grooming.
Failure to include POA in care planning: A resident with bipolar disorder and dementia, and a BIMS score indicating severe cognitive impairment, was not shown to have his family member/POA included in care plan meetings or the formulation of his person-centered plan of care. The family member stated she was the legal POA for medical and financial decisions and had not been invited to any care plan meeting since admission, while the DON said family members were not routinely invited to participate in care plan meetings.
Failure to Report Alleged Financial Exploitation: A resident with bipolar disorder and dementia had a BIMS score indicating severe cognitive impairment. His POA alleged that the admin removed about $500 from the resident’s bank account after being added as a second POA, and the POA believed the act was theft. The DON was aware of the allegation, and the admin admitted taking the money but did not report the allegation to the SSA because he believed it was false.
Failure to Investigate and Report Alleged Exploitation: The facility did not thoroughly investigate or report an allegation that the Admin. was stealing money from a resident with bipolar disorder and dementia, whose BIMS score indicated severely impaired cognition. The resident’s family member said the Admin. admitted taking the money for business expenses, while the DON was unaware of any further investigation and the Admin., who served as the Abuse and Neglect Coordinator, said he did not report or investigate the allegation because he believed it was false.
Failure to include residents and families in care plan meetings. Two residents with documented care needs had care plans developed without documented resident or family signatures, and one resident stated she was not invited to meetings. The DON said she coordinated care plan meetings but did not routinely invite family members, and the LSW said she did not routinely attend care plan meetings.
Failure to provide routine dental services for a resident with bipolar disorder and dementia. The resident had severely impaired cognition, no documented routine or emergency dental provider care in the chart, and prior records showed dental pain, hot/cold sensitivity, and tooth pain. During observation, the resident had multiple missing teeth and brown discoloration to remaining teeth. The DON/Administrator stated the resident had not received dental care since 2024 because he had not complained of new issues and the facility had not pursued another dental provider.
Improper Dumpster Disposal and Maintenance: The facility failed to keep 1 dumpster properly secured and maintained. The dumpster had no plug in the bottom drain and the side door was partially open during observation. The FSM stated she was unaware the dumpster needed a plug and did not know who opened the side door, while the ADM stated the door should be closed and the dumpster should have a plug to prevent rodents.
The facility failed to provide adequate lighting and eliminate trip hazards in shower rooms, posing potential risks to residents. The B Hall shower lacked a light fixture, and the A Hall shower had a non-functioning bulb. Both showers had inclined ramps, with the A Hall ramp featuring a tiled bump that staff found challenging to navigate, potentially causing trips. Staff acknowledged these issues, and the DON and Administrator agreed on the need for corrective measures.
A resident had an unsigned consent for Thorazine, which was not prescribed, and the MAR lacked documentation. Another resident's care plan did not include an ordered abdominal binder, and a half side rail was inappropriately used for positioning.
A facility experienced a 55.56% medication error rate due to improper administration techniques. An LVN administered medications via g-tubes incorrectly by mixing them together instead of separately with water flushes. Additionally, a medication aide failed to administer prescribed medications to two residents due to misinterpretation of blood pressure parameters. These actions placed residents at risk of not receiving therapeutic effects and potential adverse reactions.
A LTC facility failed to maintain an effective infection prevention and control program. Staff did not adhere to standard precautions, such as changing gloves with hand hygiene between tasks and doffing PPE before exiting resident rooms. Additionally, oxygen concentrators were improperly stored in a public bathroom. These actions could lead to cross-contamination and increased infection risk.
Poor lighting and non-functional heaters were reported in shower rooms, with a resident expressing the need for improvements. A gap in the laundry door and improper placement of a shower curtain between dirty and clean areas were also noted. Additionally, a bump on a ramp and lack of lighting in the shower contributed to the deficiencies.
A resident with severe cognitive impairment and a history of pulling out her feeding tube did not have a comprehensive care plan that included the use of an abdominal binder, as ordered by the physician. Observations revealed the resident without the binder on multiple occasions, and staff interviews confirmed the oversight. The facility's DON acknowledged the risk of trauma or injury if the feeding tube was pulled out.
A deficiency was identified involving the inappropriate use of a 1/2 side rail for positioning a resident, which was not necessary for their needs. Additionally, an abdominal binder was ordered but not included in the resident's care plan. The facility failed to assess safety risks, review risks and benefits with the resident or representative, obtain informed consent, and ensure proper installation and maintenance of the bed rail.
A medication cart was left unsupervised and unsecured for 25 minutes in a hallway, allowing residents and staff to pass by freely. The cart was not assigned to the nurse who secured it, but to a medication aide on break. The DON and Administrator confirmed that carts should be secured when not in use.
The facility did not respect the guardian's request for two residents with dementia to be evaluated by a specific hospice company, instead defaulting to another company without consent. This action violated the residents' rights to make choices regarding their care.
Infection Prevention and Surveillance Program Not Established
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Record review showed the facility’s infection surveillance documentation consisted of 10 worksheets from the facility pharmacy that listed resident symptoms requiring antibiotic treatment and the antibiotic prescribed. An e-mail from the Admin. stated those 10 worksheets were the entirety of the infection surveillance documentation maintained by the facility. Record review of the facility’s anti-infective utilization report for February 2026 showed an undated pharmacy-generated summary of antibiotic treatments prescribed for residents, including resident names, medication names, administration directions, and prescribers. The report did not include the reason for antibiotics, type of infection, or infection rates. The CRN, who served as the Infection Preventionist, stated she did not use a specific method to track infections and relied on the antibiotic usage report to monitor infections, deducing the type of infection from the antibiotic prescribed and mentally calculating infection rates based on census. She was unsure how she used the report to monitor overall infection rates over extended time periods and was unsure of the overall infection rates or any trends since the prior survey. The DON stated the QAPI team reviewed residents with active infections but did not discuss overall infection rates, trends, or other surveillance data, and said the CRN managed infection surveillance. Requested infection control and infection surveillance policies were not provided prior to survey exit.
Staff COVID-19 Vaccination Not Offered or Documented
Penalty
Summary
The facility failed to implement policies and procedures to ensure each staff member was offered the COVID-19 vaccine for 1 of 1 facility reviewed for infection prevention. Surveyors requested records by e-mail for evidence of staff acceptance or declination of the 2025-2026 COVID-19 vaccination, but the facility did not provide those records before survey exit. The facility policy titled Staff Vaccination, dated 2003 and revised in March 2003, did not include guidance or policy related to COVID-19 vaccinations. During interviews, the CRN stated the facility does not offer COVID-19 vaccinations to staff and that staff may use the contracted pharmacy services provided to residents only if they provide payment or insurance information. She said most staff obtained vaccinations privately outside the facility and was unsure whether the facility maintained annual vaccination records for staff. RN A stated the facility does not provide COVID-19 vaccinations to staff and that she received her annual vaccinations at a local pharmacy without facility assistance. In a later interview, the CRN stated she believed the facility met the requirement because staff could obtain the vaccine through the facility pharmacy using their own health insurance, but she was unsure how staff without insurance coverage or the ability to pay would obtain the vaccination.
Discharge Planning Not Included in Care Plans
Penalty
Summary
The facility failed to ensure an effective discharge planning process that focused on residents’ discharge goals for 4 of 4 residents reviewed. Resident #3 was admitted with bipolar disorder and dementia and had a quarterly MDS showing a BIMS score of 06, indicating severely impaired cognitive status. During an attempted transfer in December 2025, the interdisciplinary care conference did not show discharge planning, and the resident’s family member reported she had not been invited to care plan meetings or discussed discharge planning with facility staff. She said she tried to transfer him to another nursing facility, but the receiving facility requested records that were never provided, and the resident was not accepted. For Resident #3, the record included an authorization signed by the family member for release of medical records to the proposed facility, but the facility did not provide evidence of documented discharge planning before survey exit. The family member reported that staff told her they were not aware of the records request, and she said the Administrator discouraged the transfer by discussing increased costs. The LSW said she did not review discharge or transfer goals with the resident or family and was not aware of the transfer request. The DON said the family member had not been invited to care plan meetings and was unaware of any discharge or transfer goals for the resident. The Administrator said records requests with a large volume of copies could have a fee and stated the records were not sent because the family member did not pay the fee. Resident #16, Resident #2, and Resident #1 each had care plan conferences and care plans that did not include discharge planning. Resident #16 was cognitively intact with a BIMS of 15/15 and had diagnoses including elevated myocardia, weakness, vitamin D deficiency, and reduced mobility. Resident #2 had diagnoses including depressive disorder, diabetes II, anxiety, and bipolar disorder and also had a BIMS of 15/15. Resident #1 had diagnoses including anxiety, schizophrenia, and depressive disorder and had a BIMS of 15/15. The DON stated there was no discharge care plan for Residents #16, #2, and #1, and the LSW said she did not routinely attend care plan meetings and did not review discharge or transfer goals unless staff requested it.
Unsafe Access to Razors and Alcohol
Penalty
Summary
The facility failed to ensure the environment remained free of accident hazards for Resident #16 and for the A hall shower room. Resident #16’s admission record showed diagnoses including elevated myocardia, weakness, vitamin D deficiency, and reduced mobility. His quarterly MDS showed a BIMS score of 15/15, and his care plan identified him as a fall risk with an unsteady gait, weakness, impaired mobility, and improved vision related to cataract surgery. During observation in his room, 3 razors, a 16-ounce bottle of rubbing alcohol, and 2 containers of mouth wash were found at the sink or in the medicine cabinet. Resident #16 stated he shaved himself in the room, kept razors there for that purpose, and bought alcohol and wine from the store, which he kept in a locked cabinet in his room. The A hall shower room was also observed with the door open and the cabinet unlocked, with 1 razor in the locked cabinet and 2 razors in the medicine cabinet. Staff interviews showed the charge nurse was not aware Resident #16 had razors, rubbing alcohol, and mouth wash in his room, and stated these were safety hazards. Other staff stated the shower room cabinet should be locked and razors kept at the nurse’s station, while the shower room should be closed and the cabinet containing razors should be locked. The facility policy stated razors in resident rooms and showers were to be documented and stored in secure locations so residents would not be able to access them.
Kitchen Food Safety and Hair Restraint Deficiencies
Penalty
Summary
Food safety requirements were not followed in the kitchen when the ice machine was observed with black specks on the ice machine shaft during initial rounds with the FSM. The observation was made in the kitchen area where food and ice are prepared and served, and the FSM later stated the black specks may have been dirt and that residents could get sick. The ADM also stated the ice machine needed to be kept maintained because it could contaminate the ice and cause residents to have stomach issues. The facility also failed to ensure a Maintenance Assistant with a short beard wore a beard guard while in the kitchen. On one observation, the Maintenance Assistant was near the microwave area without a beard guard, and on a later observation he was again in the kitchen without one. During interview, the Maintenance Assistant confirmed he was not wearing a beard guard and stated he forgot and was only in the kitchen for a short time. The Maintenance Supervisor later told him to wear a hairnet, and the FSM confirmed staff in the kitchen needed to have a hair restraint and that staff not wearing a hairnet or beard guard could affect residents by hair going into the food.
Incomplete resident medical records and missing provider progress notes
Penalty
Summary
The facility failed to ensure that medical records for 7 of 7 residents reviewed contained complete physician and other licensed professional progress notes. Residents #7, #5, #3, #22, #29, #30, and #33 all had paper charts that were missing admission histories and physicals or subsequent provider progress notes, or contained notes that were not signed and were marked as draft. The residents reviewed had diagnoses including dementia, hypertension, schizoaffective disorder, cerebral palsy, and schizophrenia. Record review showed Resident #7 and Resident #33 did not have an admission history and physical or any progress notes from later primary care provider visits in their charts. Resident #5 and Resident #30 had documentation of a most recent history and physical, but no additional provider evaluations were present after that date. Resident #3, Resident #22, and Resident #29 had a history and physical dated 4/22/2025 in the chart, but the document was watermarked draft and stated that it had not been signed. During interviews, the DON stated that provider progress notes were sent by email to the Admin., who printed them for filing in resident charts, and that she had previously requested access to the documentation to keep charts accurate and current. The Admin. said he had requested the documentation from the provider group in January 2026 but had not followed up further when no response was received. The CRN stated that maintaining admission histories, physicals, and provider progress notes was her responsibility along with the DON's, but she was unaware the documentation was required to be maintained in the charts and said the notes were not useful because they were based on nursing reports.
Rusted Kitchen Microwave Not Maintained in Safe Condition
Penalty
Summary
The facility failed to maintain kitchen essential equipment in safe operating condition when the microwave in the kitchen was observed with a rusted spot in the corner that exposed the inner area of the microwave. During the observation on 3/24/2026 at 10:00 AM, the FSM confirmed the microwave in the corner was rusted and exposing the inner area. On 3/25/2026 at 3:03 PM, the FSM stated she was new to the position and covering for the permanent FSM, did not know the microwave was rusted inside, and was not sure how long it had been in that condition. The FSM also stated the effect would be that it could make residents sick. At 5:23 PM the ADM stated he was not aware the kitchen microwave was rusted inside. Record review showed the facility policy, Kitchen Essential Equipment, required all kitchen-essential equipment to be maintained in good repair.
Failure to Maintain Resident Grooming and Dignity
Penalty
Summary
The facility failed to ensure Resident #2 was treated with respect and dignity by not addressing facial hair on her upper lip and chin area. Resident #2 was admitted and readmitted with diagnoses including depressive disorder, diabetes II, anxiety, and bipolar disorder. Her MDS summary indicated short-term and long-term memory issues, dependent personal hygiene, impaired vision, and verbal communication, while a later quarterly MDS showed a BIMS score of 15/15, impairment on one side of the upper extremity and both lower extremities, use of an electric wheelchair, and dependence for personal hygiene. Her care plan noted extensive assistance with self-care, a communication deficit, and poor vision. During observation, Resident #2 was seen sitting in her electric wheelchair in the dining room with upper lip and chin hairs. She stated she was not aware of the facial hair and would like staff to help and make her aware of it next time. A later observation again showed facial hair on her upper lip and chin, and LVN F confirmed it, stating she was not aware and would let a CNA take care of it. Interviews with staff and administration indicated that nursing staff or aides were responsible for grooming residents and offering assistance with facial hair, and the facility policy stated residents would be groomed daily, including shaving face/body hair for those who do not want it.
Failure to Include POA in Care Planning
Penalty
Summary
The facility failed to ensure that Resident #3 and his family member/POA were included in the development and implementation of his person-centered plan of care. Resident #3 was a male admitted on 3/02/2022 with diagnoses including bipolar disorder and dementia. His quarterly MDS reflected a BIMS score of 06, indicating severely impaired cognitive status. Record review of the quarterly care conference dated 12/12/2025 showed signatures from the DON, LSW, Activity Director, and one illegible signature, but the care plan did not show any discussion of Resident #3's capacity to make decisions or involvement of his family in the care planning process. During interview, Resident #3 declined to participate. His family member stated that she was his legal POA for medical and financial decisions, that he had mental health issues that prevented him from caring for himself or making decisions, and that she had not been invited to a care plan meeting since his admission to the facility. She said she contacted the facility or spoke with a nurse when she had questions, but found the process frustrating because it was difficult to get answers. The DON stated she coordinated care plan meetings and did not routinely invite family members to attend or participate in the formulation of the care plan, and said she would call family members by telephone if she had questions about a resident's care.
Failure to Report Alleged Financial Exploitation
Penalty
Summary
The facility failed to ensure that an allegation of exploitation involving a resident’s finances was reported to the State Survey Agency within the required timeframe. The resident was a male admitted in 2022 with diagnoses including bipolar disorder and dementia, and his quarterly MDS reflected a BIMS score of 06, indicating severely impaired cognitive status. His family member, who stated she was the legal POA for financial and medical issues, reported that in the fall of 2025 approximately $500 was removed from the resident’s bank account. She said the bank told her the administrator had been added as a second POA and that the money was withdrawn by the administrator, which she believed was suspicious because the resident only went to the bank when she took him. The family member said she confronted the administrator and DON about the withdrawal and was not given a clear explanation for why the money was taken or what it was used for. She told them she believed the act was theft and later reported her concerns to the State Attorney General’s office. The DON stated she was present when the allegation was made and was unsure why the administrator had taken money from the resident’s account or why the allegation was not reported to the SSA. The administrator acknowledged removing $500 from the account in October 2025, said he had been added as a POA to assist with the resident’s finances after a lapse in Medicaid coverage, and stated he did not report the allegation because he believed it was false.
Failure to Investigate and Report Alleged Exploitation
Penalty
Summary
The facility failed to ensure that an alleged violation of abuse, neglect, and exploitation involving Resident #3 was thoroughly investigated and reported to the SSA within five working days. Resident #3 was a male admitted to the facility with diagnoses including bipolar disorder and dementia, and his quarterly MDS reflected a BIMS score of 06, indicating severely impaired cognitive status. During record review, there was no evidence that the facility completed an investigation into the allegation that the Admin. was stealing money from Resident #3's bank account. Resident #3's family member reported that she confronted the Admin. about concerns that he was taking money from Resident #3's bank account, and she stated that he admitted taking the money and said it was for business expenses. The DON stated she was present during the allegation and was unsure why the Admin. did not report it to the SSA, and she was not aware of any further investigation. The Admin., who was also the Abuse and Neglect Coordinator, stated he did not report the allegation because he believed it was false and did not conduct an investigation because he already knew the allegation was untrue. The facility policy stated that all alleged violations must be thoroughly investigated and that evidence of such investigation must be maintained.
Failure to Include Residents and Families in Care Plan Meetings
Penalty
Summary
Comprehensive care plans were not developed with resident and representative participation to the extent practicable for 2 of 8 residents reviewed. Resident #2 was admitted with diagnoses including depressive disorder, diabetes II, anxiety, and bipolar disorder. Her records showed a BIMS score of 15/15, use of an electric wheelchair, impaired vision, dependence with personal hygiene, and care plan needs including extensive assistance with self-care, communication deficit, and poor vision. The care plan conference sheet did not document resident or staff signatures, and Resident #2 stated in interview that she had not been invited to care plan meetings. Resident #16’s record showed admission with diagnoses including elevated myocardia, weakness, vitamin D deficiency, and reduced mobility. His quarterly MDS showed a BIMS score of 15/15 and no history of falls, while his care plan identified him as a fall risk with unsteady gait, weakness, impaired mobility, ability to transfer self, and improved vision related to cataract surgery. In interview, the LSW stated she did not routinely attend care plan meetings. The DON stated she coordinated care plan meetings but did not routinely invite family members to attend or participate in the formulation of the care plan, and would call family members by telephone if she had questions about a resident’s care.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide routine dental services for one resident who was reviewed for dental care. The resident was a male admitted in 2022 with diagnoses including bipolar disorder and dementia, and his quarterly MDS submitted in February 2026 showed a BIMS score of 06, indicating severely impaired cognitive status. Section L of the MDS, which addresses oral/dental status, was not assessed. Review of the resident’s paper chart did not show documentation from a dental provider for routine or emergency care. The record included an email from the facility’s contracted dental provider to the Administrator dated December 2023 requesting an evaluation for the resident due to dental pain, and a New Patient Registration and Consent form dated March 2024 documenting a non-life threatening urgent dental need of hot/cold sensitivity and tooth pain. During observation in March 2026, the resident was noted to have multiple missing teeth in the upper and lower jaws and brown discoloration to the remaining teeth. In interview, the Administrator stated the resident had not received dental care since 2024 because he had not complained of new dental issues, was not aware the facility was required to assist residents with obtaining routine dental care including those with Medicaid, and had not sought an alternative or additional dental provider.
Improper Dumpster Disposal and Maintenance
Penalty
Summary
The facility failed to dispose of garbage and refuse properly for 1 of 1 dumpsters observed. During observation with the FSM, the garbage dumpster had no plug in the bottom drain and the side door was open about 1/4 of the way. On a later observation, the dumpster still did not have a plug. The FSM stated she was not aware the dumpster had to have a plug and was not sure who opened the side door. The ADM stated the dumpster door should be closed and the garbage dumpster should have a plug to prevent rodents. Record review of the facility's Garbage Dumpster policy stated the dumpster will have a plug in the bottom drain at all times to prevent vermin from entering and liquid waste from escaping.
Inadequate Lighting and Trip Hazards in Shower Rooms
Penalty
Summary
The facility failed to ensure safe and adequate lighting in the shower rooms, as well as to eliminate trip hazards, which could potentially place residents at risk for injuries. Specifically, the B Hall shower stall lacked a light fixture, resulting in dim lighting conditions, while the A Hall shower stall had a non-functioning light bulb, leaving the area inadequately illuminated. Additionally, both shower stalls featured inclined ramps leading into them, with the A Hall shower ramp having a tiled bump at the top, which was intended to prevent water drainage issues but posed a potential trip hazard. Observations and interviews with staff, including the Maintenance Director and CNAs, confirmed these deficiencies. The Maintenance Director acknowledged the absence of a light fixture in the B Hall shower and the non-functioning bulb in the A Hall shower, as well as the presence of the tiled bump on the A Hall ramp. CNAs expressed concerns about the difficulty in maneuvering residents over the bump and the potential for trips and falls, especially for residents who used the showers independently. The DON and Administrator agreed that the lighting issues needed correction and that the safety and necessity of the tiled bump required review. A policy was requested but not provided to the survey team before their exit.
Medication and Care Plan Deficiencies
Penalty
Summary
Resident #33 was involved in a deficiency related to medication management. The consent for Thorazine was not signed, and the medication was incorrectly associated with the resident, as they were not prescribed Thorazine. Additionally, the medication administration record (MAR) did not reflect the use of Thorazine for this resident. Resident #6 experienced a deficiency concerning the care plan and safety equipment. An order for an abdominal binder was not included in the resident's care plan, and the use of a half side rail for positioning was deemed inappropriate for this resident's needs.
High Medication Error Rate Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 55.56% error rate during the survey. This was observed in the administration of medications to four residents, where multiple errors were identified. LVN D administered medications to Residents #6 and #30 via their gastronomy tubes without following professional standards. Instead of administering each medication separately with a water flush in between, LVN D mixed all medications together and administered them simultaneously, which is contrary to the prescribed method. Additionally, the medications were administered late, with Resident #6 receiving them 11 minutes late and Resident #30 receiving them 50 minutes late. Further deficiencies were noted with Medication Aide I, who failed to administer prescribed medications to Residents #7 and #22. Resident #7 did not receive Amlodipine as prescribed due to a misinterpretation of blood pressure parameters, despite the blood pressure reading being within the acceptable range for administration. Similarly, Resident #22 did not receive Hydrochlorothiazide as prescribed, as Medication Aide I withheld the medication based on a low blood pressure reading, despite there being no stipulations in the physician's order to withhold the medication under such conditions. These practices placed residents at risk of not receiving the therapeutic effects of their medications and potential adverse reactions. The facility's failure to adhere to proper medication administration protocols, particularly for residents with feeding tubes, and the misinterpretation of medication administration parameters contributed to the high medication error rate. The lack of a policy for g-tube medication administration and medication errors further exacerbated the situation, as staff did not have clear guidelines to follow, leading to inconsistent and improper medication administration techniques.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations of staff not adhering to standard and transmission-based precautions. On one occasion, two CNAs assisted a resident with incontinent care but did not change gloves with hand hygiene between glove changes after handling soiled linens and supplies. This improper practice continued as they provided clean linens and adult briefs with the same contaminated gloves, and exited the resident's room without performing hand hygiene. Additionally, an LVN was observed administering medications to two residents without following proper infection control protocols. The LVN failed to change gloves with hand hygiene after touching residents' clothing and furniture before administering medications. Furthermore, the LVN did not doff potentially contaminated PPE gowns before exiting the residents' rooms, wearing them in the hallway, which could lead to cross-contamination. The facility also improperly stored oxygen concentrator equipment in a public bathroom, which is not a clean environment. This practice was confirmed by staff interviews, revealing a lack of space as the reason for this storage decision. The Director of Nursing and the Administrator acknowledged the expectations for infection control, which were not met, as evidenced by the staff's failure to adhere to standard precautions and enhanced barrier precautions for residents with g-tubes.
Environmental Deficiencies in Shower Rooms and Facility Areas
Penalty
Summary
Poor lighting was observed in shower rooms A and B, with a resident noting the need for better lighting and warmth, as the heaters in these rooms were not functioning. Additionally, there was a gap in the laundry door, and a shower curtain was improperly placed between dirty and clean areas. A bump was also noted on a ramp, and there was no light in the shower, contributing to the deficiencies identified.
Failure to Implement Care Plan for Resident with Feeding Tube
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with severe cognitive impairment and a history of pulling out her feeding tube. The care plan did not include the necessary intervention of applying an abdominal binder, as ordered by the physician, to prevent the resident from pulling out the feeding tube. This omission was observed during multiple instances where the resident was found without the abdominal binder in place, despite having a physician's order for its use at all times. Interviews with facility staff, including CNAs and an LVN, confirmed that the resident had a tendency to pull out her feeding tube and that an abdominal binder was supposed to be used to prevent this behavior. However, the binder was not consistently applied, and the facility's Director of Nursing acknowledged the potential for trauma or injury if the feeding tube was pulled out. Additionally, the facility was unable to provide a policy on care plan development and implementation when requested.
Inappropriate Use of Bed Rail and Unplanned Abdominal Binder
Penalty
Summary
The deficiency involves the inappropriate use of a 1/2 side rail for positioning a resident, which was not deemed necessary for the resident's needs. Additionally, there was an order for an abdominal binder that was not identified in the resident's care plan. The facility failed to assess the resident for safety risks associated with the use of the bed rail, review these risks and benefits with the resident or their representative, obtain informed consent, and ensure the correct installation and maintenance of the bed rail.
Unsupervised Medication Cart Poses Risk
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, and that only authorized personnel had access to the keys. This deficiency was observed when a medication cart was left unsupervised and unsecured for 25 minutes in the hallway near a resident's room. During this time, residents, housekeepers, and CNAs were able to walk freely past the unattended cart, which posed a risk of unauthorized access to medications. An observation and interview revealed that the medication cart was not assigned to the nurse who was alerted to the situation, but rather to a medication aide who was likely on a break. The Director of Nursing (DON) confirmed that all medication carts should be secured when not in use, and the Administrator agreed with this expectation. Despite a request for the facility's policy on medication cart security, it was not provided by the time of the survey exit.
Failure to Honor Guardian's Hospice Choice
Penalty
Summary
The facility failed to uphold the rights of two residents by not allowing their guardian to choose the hospice company for their evaluation. Both residents, who were diagnosed with dementia and had cognitive impairments, had a guardian who requested evaluations from Hospice Company C. However, the facility proceeded with evaluations from Hospice Company D without the guardian's consent. This action was contrary to the guardian's explicit request and the facility's policy that residents have the right to make their own choices regarding care and services. The clinical records and communications indicate that the guardian had requested Hospice Company C to assess the residents for hospice services, but Doctor B and the facility did not honor this request. Instead, Hospice Company D conducted the evaluations, and the residents were deemed ineligible for hospice services. Staff interviews revealed a lack of awareness or adherence to the guardian's choice, with one nurse stating that if a hospice company was not selected by the resident, Hospice Company D was used by default. This oversight in respecting the guardian's choice could potentially exclude the responsible party from being involved in the residents' medical care and treatment decisions.
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 940 citations issued within 25 miles in the last 12 months — including the 22 immediate-jeopardy cases — 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 San Antonio
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pecan Valley Rehabilitation And Healthcare | 1 mi | ★★★★★ | 9 | 0 |
| Buena Vida Nursing And Rehab-san Antonio | 1.1 mi | ★★★★★ | 26 | 5 |
| The Rio At Mission Trails | 1.4 mi | ★★★★★ | 19 | 0 |
| Southeast Nursing & Rehabilitation Center | 1.6 mi | ★★★★★ | 16 | 1 |
| Windsor Mission Oaks | 2.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Highland Nursing Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.