Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Highland Park Care Center during CMS and state inspections, most recent first.
A resident did not receive safe and appropriate respiratory care when needed, as required by their condition.
Two residents experienced a lack of dignity in their care. One resident with severe cognitive impairment had an uncovered catheter bag, while another was transported to the shower room partially exposed. Staff acknowledged the oversights, and the facility's policy emphasizes the importance of maintaining resident dignity and privacy.
A resident with severe cognitive impairment and an indwelling urinary catheter was found with a catheter bag not covered and tubing kinked, preventing urine flow. The catheter stabilizer was not secured, and the adhesive was ineffective. Staff interviews revealed reliance on CNAs to report issues, and the facility's policy on catheter care was not followed.
The facility did not post the daily nursing staffing information as required, with observations showing outdated information at the receptionist desk. Interviews confirmed that the receptionist was responsible for updating this information, which had not been done for two days. The DON acknowledged the requirement for daily updates, but the facility's staffing posting policy was not provided.
The facility failed to apply physician-ordered pressure-relieving heel protectors or off-load a resident's heels, leading to a deficiency in care. Observations showed the resident's heels were not floated, and the pressure offloading boots were not used as prescribed. The resident had a history of peripheral vascular disease, dementia, anemia, and pressure ulcers on both heels.
The facility failed to refer a resident with a newly diagnosed serious mental disorder for a Level II PASARR evaluation upon a significant change in status assessment. The oversight was identified during a review of the resident's medical records, revealing that no new PASARR evaluation was performed after the diagnosis of schizophreniform disorder.
The facility failed to create comprehensive resident-centered care plans for two residents. One resident did not have a documented care plan despite significant medical needs, and another had conflicting code statuses in his care plan, leading to potential confusion in emergency situations.
The facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate. A resident received incorrect doses of Famotidine, Furosemide, and Polyethylene Glycol 3350 due to MA B's failure to verify medication names and strengths properly. The ADON and DON confirmed the errors and noted the importance of adhering to medication administration policies.
The facility failed to maintain accurate and complete medical records for a resident with a PEG tube, leading to discrepancies in the documented feeding rate and water flushes. Staff interviews and observations revealed conflicting orders in the EMR and paper chart, and the April 2024 MAR for the resident's PEG feeding was missing.
The facility failed to maintain an infection prevention and control program when two CNAs did not wear appropriate PPE while providing incontinence care to a resident on Enhanced Barrier Precautions. Despite clear signage and the resident's care plan indicating the need for gowns and gloves, the CNAs only wore gloves, risking cross-contamination and infection spread.
The facility failed to provide necessary ADL care and hygiene services to residents, resulting in missed showers and inadequate incontinence care. Residents reported being left in soiled briefs and not receiving scheduled showers due to staffing issues, such as the absence of a shower tech. The deficiency affected residents with various medical conditions, including cognitive impairments and physical disabilities, who were unable to perform ADLs independently.
A resident with multiple medical conditions, including severe itching, was not administered her prescribed hydrocortisone cream for over three months. Despite the medication being listed on the MAR, staff were unaware of the order, leading to the resident experiencing significant discomfort. Observations and interviews confirmed the resident's requests for the cream were not fulfilled, highlighting a failure in pharmaceutical services.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate respiratory care for a resident when needed. The report indicates that the facility failed to ensure that a resident received necessary respiratory care, as required by their condition. Specific details about the actions or inactions of staff, the resident's medical history, or the circumstances at the time of the deficiency are not provided in the report excerpt.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to uphold the dignity and respect of two residents, leading to deficiencies in their care. Resident #1, a male with severe cognitive impairment and an indwelling catheter, was observed without a privacy cover on his catheter bag. This oversight was acknowledged by CNA A, who admitted the privacy covers were available but not used due to being busy. The wound care nurse confirmed that the privacy cover should have been used to maintain the resident's dignity, as it was part of the standard care procedure. Resident #2, a cognitively intact male requiring maximal assistance for bathing, was transported to the shower room partially uncovered. During the transport, his abdomen and chest were exposed, which was noted by the surveyor. CNA A and CNA B acknowledged the inadequate coverage, with CNA A suggesting that a fully opened sheet might have provided better coverage. The Director of Nursing and Assistant Director of Nursing both confirmed that the resident should have been fully covered to protect his dignity, and it was the responsibility of the CNAs to ensure this. The facility's policy on dignity and quality of life emphasizes the importance of treating residents with respect and maintaining their privacy during personal care. The policy explicitly prohibits practices that compromise dignity, such as failing to cover urinary catheter bags. These incidents highlight a failure to adhere to the facility's policy, resulting in a deficiency in maintaining the residents' dignity and quality of life.
Inadequate Catheter Care for a Resident
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter, which could lead to urinary tract infections and injuries. The resident, a male with severe cognitive impairment and multiple diagnoses including unspecified dementia and acute kidney failure, was observed with a catheter bag that was not covered and tubing that was kinked in the bed frame, preventing urine from flowing into the bag. A CNA moved the catheter bag to the correct hook and attempted to secure the tubing, which was not attached to the resident's leg. The catheter stabilizer was also not secured to the resident's thigh, and the adhesive was not sticking, which the CNA noted but had not checked prior. Interviews revealed that the wound care staff had not seen the resident during rounds and relied on CNAs to report issues with the catheter stabilizer. The wound care staff acknowledged that the tubing should be free from kinks to ensure proper urine drainage and that the catheter stabilizer is crucial to prevent the catheter from being pulled out or causing injury. The facility's policy on catheter care emphasizes maintaining unobstructed urine flow and securing the catheter with a leg strap, which was not adhered to in this case.
Failure to Post Daily Nursing Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nursing staffing information was posted and readily accessible for review. On 9/10/2024, observations at 8:40 a.m. and 12:10 p.m. revealed that the nursing staffing information posted at the receptionist desk was dated 9/8/2024, indicating it had not been updated for two days. Interviews with the receptionist, staffing coordinator, and Director of Nursing (DON) confirmed that the receptionist was responsible for updating the daily nursing staff information, which was intended to inform the public and others about staffing on each shift and the census. The DON acknowledged that the daily nursing staffing was supposed to be posted at the front of the facility each day. The facility's staffing posting policy was requested but not received at the time of exit.
Failure to Apply Pressure Relieving Devices
Penalty
Summary
The facility failed to ensure that a resident received care consistent with professional standards to prevent the development of pressure ulcers. Specifically, the facility did not apply the physician-ordered pressure-relieving heel protectors or off-load the resident's heels as required. Observations on multiple occasions revealed that the resident's heels were not floated and were resting on the mattress, and the pressure offloading boots were not being used as prescribed. Interviews with the wound care nurse confirmed that the resident had previously refused the boots but was now compliant, and the failure to apply the boots was likely due to staff not putting them back on after changing the resident. The resident in question was an elderly male with a history of peripheral vascular disease, dementia, anemia, and pressure ulcers on both heels. His care plan included specific interventions to off-load his heels and use pressure offloading boots, which were not consistently followed. The facility's policy on skin integrity and pressure sores emphasized the need to provide care consistent with professional standards to prevent pressure ulcers, but this was not adhered to in the case of this resident, leading to a deficiency in care.
Failure to Refer Resident for Level II PASARR Evaluation
Penalty
Summary
The facility failed to refer a resident with a newly diagnosed serious mental disorder for a Level II PASARR evaluation upon a significant change in status assessment. Specifically, Resident #28, who was diagnosed with schizophreniform disorder, was not referred to the appropriate state-designated authority for a Level II resident review. This oversight was identified during a review of the resident's medical records, which revealed that the only PASARR Level I screening dated back to 2017 and was negative for mental illness. No new PASARR evaluation was performed before the resident's admission in 2019 or after the diagnosis of schizophreniform disorder in March 2020. The MDS Coordinator, who had been in the position for about a month, acknowledged the oversight during an interview. She stated that she was in charge of filling out PASARR evaluations and was not aware of the resident's diagnosis when it occurred. The facility's policy on Resident Assessment Coordination of PASARR and Assessments mandates referring all residents with newly evident or possible serious mental disorders for Level II resident review upon a significant change in status assessment. The failure to adhere to this policy could result in residents missing out on necessary mental health services.
Failure to Create Comprehensive Care Plans
Penalty
Summary
The facility failed to create a comprehensive resident-centered care plan with measurable objectives for person-centered care for two residents. One resident, identified as CR #89, did not have a documented comprehensive resident-centered care plan. This resident was an elderly woman with multiple diagnoses, including pleural effusion, atherosclerotic heart disease, bradycardia, type 2 diabetes mellitus, Alzheimer's disease, and end-stage renal disease. Despite her significant cognitive impairment and need for assistance with all activities of daily living (ADLs) except eating, no care plan was available in either the electronic health record (EHR) or the physical file, only a baseline care plan was found. Another resident, identified as Resident #52, had conflicting code statuses in his care plan. The care plan listed both Do Not Resuscitate (DNR) and Full Code statuses, which could lead to confusion in an emergency situation. This resident was a male with severe medical conditions, including acute respiratory failure with hypoxia, acute myocardial infarction, anoxic brain injury, cardiac arrest, type 2 diabetes, hemiplegia, cerebral infarction, epilepsy, and gastrostomy. He was dependent on all ADLs, bedbound, and had an indwelling catheter. Despite the clear documentation of his DNR status in various parts of his medical records, the care plan still contained conflicting information. Interviews with facility staff, including the Wound Care Nurse (WCN), Director of Nursing (DON), MDS Nurse, and Administrator, revealed that the facility was transitioning from paper files to an EHR system. Staff acknowledged the importance of care plans in providing accurate and individualized care. However, they could not explain why CR #89's care plan was missing or why Resident #52's care plan contained conflicting code statuses. The facility's policies required care plans to be developed within seven days of the resident's Minimum Data Set (MDS) assessment and to include measurable objectives and timetables, but these requirements were not met for the two residents in question.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure that the medication error rate was not five percent or greater, resulting in an 8% error rate based on 3 errors out of 35 opportunities. Specifically, MA B administered incorrect doses of Famotidine, Furosemide, and Polyethylene Glycol 3350 to a resident. The resident, a [AGE] year-old male with diagnoses including hyperkalemia, acute kidney failure, hypertensive crisis, and rhabdomyolysis, received incorrect dosages due to MA B's failure to verify the medication name and strength properly. MA B admitted to not paying attention to the Furosemide dosage and being focused on the medication name and administration time instead. Additionally, she administered an incorrect dose of Polyethylene Glycol 3350 based on incorrect training from a different facility. The ADON and DON confirmed that nursing staff must verify the medication name and strength against the MAR and alert the nurse if there is a discrepancy. The DON noted that the resident received half of the prescribed dosage for Famotidine and Polyethylene Glycol 3350, which could result in inadequate therapeutic effects. The facility's policies on medication administration and maintaining a medication error rate below 5% were not adhered to, leading to these errors.
Failure to Maintain Accurate Medical Records for PEG Tube Feeding
Penalty
Summary
The facility failed to maintain complete, accurately documented, readily accessible, and systematically organized medical records for a resident with a PEG tube. Specifically, the facility did not correctly transcribe and clarify physician orders for the resident's PEG tube feeding rate. Additionally, the facility failed to maintain the resident's April 2024 Medication Administration Record (MAR) for his PEG tube feeding. This discrepancy was observed during a record review and confirmed through interviews with staff members, including the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). The resident in question was a male with multiple diagnoses, including acute respiratory failure, myocardial infarction, anoxic brain injury, cardiac arrest, type 2 diabetes, hemiplegia, cerebral infarction, epilepsy, and gastrostomy. The resident's care plan indicated the need for specific nutritional management through a PEG tube. However, there were conflicting orders in the Electronic Medical Record (EMR) and the paper chart regarding the feeding rate and water flushes. Observations revealed that the resident was receiving Diabetisource AC at 60ml/hr with a 30ml water flush every 3 hours, which was not consistently documented in the MAR. Interviews with the Nurse Practitioner (NP) and Licensed Vocational Nurse (LVN) indicated that they were aware of the correct PEG feeding rate, but the discrepancies in the documentation could lead to medication errors. The ADON and LVN were unable to locate the April 2024 MAR for the resident's PEG feeding, which was later reprinted and placed in the binder. The facility's policies on physician/medication orders and resident records were not followed, leading to incomplete and inaccurate medical records for the resident.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an infection prevention and control program, as evidenced by the actions of two CNAs who did not wear appropriate PPE while providing incontinence care to a resident on Enhanced Barrier Precautions. The resident, a [AGE] year-old male with multiple diagnoses including peripheral vascular disease, dementia, anemia, and pressure ulcers, required Enhanced Barrier Precautions due to a Stage 4 pressure ulcer. Despite clear signage on the resident's door indicating the need for gowns and gloves, the CNAs only wore gloves during the care procedure. This oversight was confirmed through observations and interviews with the CNAs, who admitted to not wearing the required PPE and mistakenly believed the precautions were for another resident in the room. The resident's care plan and medical records highlighted the necessity of Enhanced Barrier Precautions to prevent infection and cross-contamination. The Wound Care Nurse, who is also an Infection Preventionist, confirmed that staff must gown up for any resident care under these precautions. The facility's policy on Infection Prevention and Control, effective since 2017, mandates the use of isolation and enhanced barrier practices to prevent the transmission of infections. The failure to adhere to these guidelines could potentially place residents and staff at risk for cross-contamination and the spread of infection.
Deficiency in Providing ADL Care and Hygiene Services
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to perform activities of daily living (ADLs) independently, specifically in maintaining personal hygiene. This deficiency was observed in eight residents who did not receive scheduled showers three times a week, as required. Residents reported missed showers and inadequate incontinence care, with some residents not being changed for extended periods, leading to soiled briefs and dirty sheets. The lack of showers and incontinence care was attributed to staffing issues, such as the absence of a shower tech and insufficient staff to perform these duties. Resident #10, a female with hemiplegia and cognitive impairment, did not receive showers as scheduled and was left in soiled sheets. She reported not being changed since the morning and missing showers due to the facility's lack of a shower tech. Similarly, Resident #19, a male with end-stage renal disease and cognitive impairment, had only one shower in March and reported not being shaved or cleaned regularly. The facility's shower techs were responsible for these tasks, but inconsistencies in their performance were noted. Other residents, such as Resident #24, #33, #34, and #35, also experienced missed showers and inadequate incontinence care. Resident #24, with normal cognition, reported receiving showers only once or twice a week. Resident #33, with quadriplegia, was left in a soiled brief overnight, and Resident #35's family member noted that he had not been changed since the previous day. The facility's grievance logs and interviews with staff highlighted ongoing issues with staffing and the provision of care, contributing to the deficiency in maintaining residents' personal hygiene.
Failure to Administer Prescribed PRN Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically in the administration of a prescribed PRN medication. Resident #9, a 71-year-old female with multiple medical conditions including Guillain-Barre Syndrome and severe itching, was not administered her prescribed hydrocortisone cream for over three months. This medication was intended to be applied topically every 12 hours as needed for itching, but it was not given from January 1, 2024, to April 8, 2024. Observations and interviews revealed that Resident #9 experienced significant discomfort due to the lack of medication. On April 3, 2024, she was observed scratching her leg with a bamboo back scratcher. During interviews, the resident expressed that she had requested the cream from the nursing staff but did not receive it. A Spanish interpreter confirmed that the resident reported persistent itchiness on both legs and that the staff had previously provided lotion but had since stopped. Interviews with facility staff indicated a lack of awareness and communication regarding the resident's medication needs. The Treatment Nurse was unaware of why the medication was not administered and acknowledged that there should have been documentation explaining the omission. An LVN also admitted to not knowing about the hydrocortisone cream order, despite it being listed on the MAR. The facility's policy on administering medications requires adherence to orders, including topical treatments, which was not followed in this case.
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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 Houston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| West Janisch Health Care Center | 2 mi | ★★★★★ | 19 | 4 |
| Ashford Gardens | 2.2 mi | ★★★★★ | 24 | 0 |
| Caraday Of Houston | 2.4 mi | ★★★★★ | 1 | 0 |
| Houston Heights Nursing And Rehabilitation Center | 5.2 mi | ★★★★★ | 2 | 0 |
| Avir At Veterans Memorial | 6.9 mi | ★★★★★ | 22 | 3 |
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