Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Park Highlands Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Notify Cognitively Intact Dialysis Residents of Care Plan Meetings: Three cognitively intact residents receiving dialysis had no documentation showing they were notified of care plan meetings or included in care conference planning. Records showed only baseline care plan copies for two residents, no meeting documentation for one resident after the prior survey, and staff said residents were sometimes told the day of the meeting while documentation was kept in care conference assessments or progress notes.
Inaccurate PASARR Level 1 Screening: The facility failed to ensure a resident’s PASARR Level 1 screening accurately reflected indicators of mental illness. The resident had PTSD and depression documented in hospital records, the admission MDS, and physician orders, but the PASARR screen showed no mental illness indicators. The MDS coordinator stated she was responsible for accuracy and should have recognized the error and notified the local authority.
A facility with 132 beds failed to employ a qualified SW on a full-time basis. Record review showed the SW worked only 16 hours per week, and the SW stated she was part time and unaware the facility needed a full-time SW. The administrator said the census had been down, so the SW was hired part time.
Incomplete Care Plan for PTSD, Depression, and Psychotropic Use: A resident admitted with PTSD and depression had an MDS that triggered for psychosocial well-being, mood state, and psychotropic drug use, and had orders for divalproex, citalopram, and trazodone. However, the comprehensive care plan did not document concerns or interventions for his mental illness diagnoses or psychoactive medications, and the MDS Coordinator said this was an oversight.
Failure to complete trauma screening for a resident with PTSD. A resident admitted with an active PTSD dx had an incomplete trauma-informed care section in the social history, and the SW said she relied on the hospital PASARR and did not notice the PTSD dx in the hospital or facility admission records, or the trigger indicators on the MDS. The SW acknowledged that trauma history and potential triggers should be identified to help prevent re-traumatization.
Failure to Follow Hand Hygiene, PPE, and Incontinent Care Practices: A staff member provided incontinent care to a resident with Fournier's gangrene, a stage IV pressure ulcer, and bowel/bladder incontinence without washing or sanitizing hands first, used the same wipe for multiple body areas, did not change gloves before applying a clean brief, touched clean items with contaminated gloves, and left the room wearing PPE. She later removed the gown and gloves outside the room and disposed of them without performing hand hygiene.
The facility did not have a licensed administrator present or appointed, with the Administrator-in-Training not yet eligible for licensure and the corporate administrator not consistently present in the building. Staff interviews and record reviews confirmed the absence of a licensed administrator, and the required oversight and management were not provided.
The facility failed to maintain a sanitary environment in three shower rooms, with mold observed in the grout between tiles. The housekeeping supervisor acknowledged the issue, citing staffing shortages as a reason for inadequate cleaning.
The facility failed to ensure that a resident with a history of mental health disorders received an accurate PASRR Level 1 Screening. Despite documented diagnoses of anxiety disorder, depression, and bipolar disorder, the PASRR Screening incorrectly indicated no evidence of mental illness. The discrepancy was not corrected, and the Local Authority was not notified.
The facility failed to implement baseline care plans for two residents, neglecting to address critical needs such as an indwelling urethral catheter, acute renal failure, and a cervical collar for a neck fracture. This oversight led to inadequate care planning and risked the residents' health.
The facility failed to complete and implement a Safe Smoking Assessment for a resident, leading to unsafe smoking conditions. The resident, who was cognitively intact and had multiple diagnoses, was observed smoking without a smoke apron and had burn marks on his clothing. The required smoking assessment was missing from his medical chart.
A resident with significant weight loss and medical conditions did not consistently receive a prescribed daily nutritional supplement due to staff oversight and lack of proper checks, as observed and confirmed by interviews with facility staff.
Failure to Notify Cognitively Intact Dialysis Residents of Care Plan Meetings
Penalty
Summary
The facility failed to ensure that residents had the right to participate in the development and implementation of their person-centered care plans for 3 of 5 dialysis residents reviewed. Resident #6 was an adult male with ESRD, type 2 diabetes mellitus, dependence on renal dialysis, and COPD, and the record indicated he was his own responsible party. Resident #46 was an adult female with ESRD, type 2 diabetes mellitus, dependence on renal dialysis, acute and chronic respiratory failure, and major depressive disorder, and she was also her own responsible party. Resident #47 was an adult female with ESRD, type 2 diabetes mellitus, dependence on renal dialysis, and chronic ischemic heart disease, and she was her own responsible party. Each of these residents had a BIMS score of 15, indicating intact cognition. Record review showed that Resident #6 had documentation that a copy of the baseline care plan was provided, but there were no other care plan documents, no care plan meeting schedules or attendance records, and no documentation that he had been notified of care plan meetings. The electronic record showed the most recent care plan meeting for Resident #6 was held on 03/05/2025. For Resident #46, the record showed a copy of the baseline care plan was provided, but there were no other care plan documents, no meeting schedules or attendance records, and no documentation that she had been notified of care plan meetings. The electronic record showed the most recent care plan meeting for Resident #46 was held on 06/12/2025. For Resident #47, the record showed no documentation of care plan meetings since the last recertification survey on 06/12/2025 and no documentation that she had been notified of care plan meetings. The electronic record showed no documentation of any care plan conferences held after that survey date. During interview, the residents stated they would like to attend care plan meetings and said they used to go but it had been awhile and they could not remember when they were last invited. Staff interviews indicated care plan meetings were scheduled on Tuesdays and Thursdays, residents were sometimes notified in person the day of the meeting, and documentation of meetings could be found in care conference assessments or progress notes. The facility policy stated that each resident would have a person-centered comprehensive care plan developed and implemented and that the facility would provide advance notice of planning conferences to enable resident participation.
Inaccurate PASARR Level 1 Screening
Penalty
Summary
The facility failed to coordinate the assessment of one resident for the PASARR program and failed to ensure the resident’s PASARR Level 1 screening was accurately coded to reflect indicators of mental illness. Resident #9 was a male admitted on 04/30/2026 with diagnoses that included PTSD and depression. Hospital records dated 04/23/2026 also listed PTSD and depression, and the admission MDS and physician’s orders dated 06/02/2026 documented the same diagnoses. A review of Resident #9’s PASARR Level 1 screening dated 04/29/2026 showed that he had no indicators of mental illness. During interview, the MDS Coordinator stated she was responsible for ensuring the PASARR Level 1 screening was completed and accurate, and said she should have noticed the screening was incorrectly coded and did not reflect indicators of mental illness. She stated she should have notified the local authority about the incorrect screening and that the failure to address it resulted in Resident #9 not being evaluated for PASARR services and possibly not receiving PASARR services.
Failure to Employ Full-Time Social Worker
Penalty
Summary
The facility failed to employ a qualified social worker on a full-time basis for 1 of 1 social services staff reviewed. The facility had a maximum capacity of 132 beds, but the social worker in the personnel record was hired on 01/31/2022 and worked only 16 hours per week. During interview, the social worker stated she worked 16 hours a week, was employed part time, and was not aware the facility had to have a full-time social worker. The administrator stated the facility was licensed for 132 beds and said the census had been down, so she had only hired the social worker part-time.
Incomplete Care Plan for PTSD, Depression, and Psychotropic Use
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #9 that included measurable objectives and time frames to meet his medical, nursing, mental, and psychosocial needs. Resident #9 was a male admitted on 04/30/2026 with diagnoses that included PTSD and depression. The admission MDS indicated he had PTSD and depression, and Section V of the CAA Summary showed triggers for psychosocial well-being, mood state, and psychotropic drug use. A record review showed physician orders for three psychoactive medications: divalproex sodium 250 mg daily for mood stabilization, citalopram 40 mg daily for depression, and trazodone 100 mg daily for insomnia. However, the comprehensive care plan, initiated on 05/01/2026 and completed on 05/15/2026, contained no documented concerns or interventions addressing his mental illness diagnoses or psychoactive drug use. During interview, the MDS Coordinator stated the care plan should have addressed PTSD, depression, and the psychoactive medications, and said the omission was an oversight. The SW stated the MDS Coordinator was responsible for ensuring the care plans were complete and addressed the resident's medical and psychosocial health needs.
Failure to Complete Trauma Screening for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident with a history of PTSD received trauma-informed and culturally competent care by not completing a trauma screening on admission that identified possible triggers. Resident #9 was a male admitted with a diagnosis of PTSD, and the admission MDS reflected clear speech, that he was understood by others, a BIMS score of 12 indicating moderately impaired cognition, no behaviors or refusal of care, and an active PTSD diagnosis. A review of the resident’s initial social history showed the trauma informed care section was not completed until after surveyor intervention. During interview, the SW stated she was responsible for completing that section and said she relied on the PASARR completed by the hospital, but did not notice the PTSD diagnosis in the hospital records or the facility’s admission records. The SW also stated she did not notice the PTSD trigger indicators on the admission MDS and acknowledged it was important to screen residents for a history of trauma and identify potential triggers to minimize or prevent re-traumatization.
Failure to Follow Hand Hygiene, PPE, and Incontinent Care Practices
Penalty
Summary
The facility failed to implement infection control practices during incontinent care for a resident with Fournier's gangrene, a stage IV left buttock pressure ulcer, bowel and bladder incontinence, non-ambulatory status, and severely compromised cognition. The resident had an order for Enhanced Barrier Precautions and a care plan intervention to perform hand hygiene prior to entering and prior to exiting the room. During an observation, a staff member put on a disposable gown and gloves outside the resident's room without washing or sanitizing her hands first. Inside the room, she provided incontinent care but used the same pre-moistened wipe to clean multiple areas of the resident's pelvic region and groin, then cleaned the buttocks with a clean wipe. She did not change gloves or perform hand hygiene before putting on a clean brief, and while still wearing contaminated gloves she replaced the bed covers, repositioned the overbed table, handed the resident his call light, and placed the bed control within reach. The staff member then left the room while still wearing the gown and gloves, walked to the nurses' station area, removed the PPE there, carried the contaminated gown, gloves, and trash bag to the shower room, and disposed of them. She left the shower room without performing hand hygiene. The staff member stated she forgot to obtain a clean wipe each time she moved from one area to another, forgot to change gloves before applying the clean brief, and should have removed her gown and gloves in the room and washed her hands. The DON and ADON/IP Nurse stated the staff member was in training and was not supposed to provide incontinent care without a CNA present, and both stated proper hand hygiene, PPE use, and incontinent care technique were important for preventing the spread of infection.
Failure to Appoint and Maintain a Licensed Administrator
Penalty
Summary
The facility failed to have a governing body that appointed a licensed administrator, resulting in the absence of a licensed administrator since September 22, 2025. The Administrator-in-Training, who was not yet licensed, stated she was acting as the administrator but had not completed the required coursework to be eligible for state licensure. The corporate administrator, who was supposed to oversee the facility, was not physically present in the building for the required 40 hours per week and communicated only by phone. Multiple staff interviews confirmed that the corporate administrator had not been regularly present in the facility, and the Administrator-in-Training was not eligible to take the licensure exam until December 2025. Record review showed no licensed administrator listed on the staff roster, and during the survey, the administrator listed for the on-site visit was not present. The HR department head was unavailable to provide records, and other staff, including the DON and maintenance supervisor, confirmed the lack of a licensed administrator's consistent presence. The facility's failure to ensure a licensed administrator was physically present and responsible for managing the facility was directly observed and corroborated by staff interviews and documentation.
Failure to Maintain Sanitary Shower Rooms
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment in three shower rooms located in the North Wing, East Wing, and Rehabilitation hall. Observations revealed the presence of a black substance, identified as mold, in the grout between the tiles in these shower rooms. Specifically, the Rehabilitation hall shower room had mold on the right and back walls, the East Wing shower room had mold on the left wall, and the North Wing shower room had mold on the right wall. These observations were made during a survey on 03/25/24. During an interview, the housekeeping supervisor (HSKS) confirmed that she was responsible for the cleanliness of the facility and acknowledged the presence of mold. She explained that the showers were cleaned daily and as needed, but due to staffing shortages, she had been unable to perform her supervisory rounds for the past two months. The facility's deep cleaning process, dated 2015, indicated that all walls and floors should be cleaned and scrubbed, but this protocol was not followed adequately due to the staffing issues.
Failure to Ensure Accurate PASRR Screening for Resident with Mental Health Disorders
Penalty
Summary
The facility failed to ensure that Resident #48, who had a history of mental health disorders, received an accurate Preadmission Screening and Resident Review (PASRR) Level 1 Screening. The resident, a [AGE] year-old female, was admitted with diagnoses including anxiety, high blood pressure, and diabetes. Despite having a BIMS score indicating no impaired cognition and documented diagnoses of anxiety disorder, depression, and bipolar disorder, the PASRR Level 1 Screening completed on 06/20/2023 incorrectly indicated that the resident did not have evidence of a mental illness. This discrepancy was not corrected, and the Local Authority was not notified of the incorrect PASRR by the facility's MDS Nurse, who was responsible for PASRR and MDS processes at the time of the survey but not at the time of the resident's admission. The resident's medical records, including physician orders and psychiatric evaluations, consistently indicated diagnoses of major depressive disorder, anxiety disorder, and bipolar disorder. Despite these documented conditions and the resident receiving antianxiety and antidepressant medications, the PASRR Level 1 Screening failed to reflect the resident's mental health status accurately. The facility's policy on PASRR Level 1 Screenings, which was revised in 2019, required reviews for correctness to ensure accuracy and prevent regulatory problems, but this policy was not followed in this case, leading to the deficiency.
Failure to Implement Baseline Care Plans for Residents
Penalty
Summary
The facility failed to implement a baseline care plan for two residents, which included the necessary instructions to provide effective and person-centered care. For Resident #216, the baseline care plan did not address his indwelling urethral catheter, diagnoses of acute renal failure, inflammatory reaction due to the catheter, retention of urine, and antibiotic therapy. Despite the physician's orders and the resident's condition, the care plan was not updated to reflect these critical needs, leading to a lack of proper management and consistency in care. The Director of Nursing (DON) acknowledged that the care plan from the resident's previous stay was re-activated without incorporating the new diagnoses and treatment requirements, which was a significant oversight in ensuring the resident's immediate needs were met upon readmission. Similarly, the facility failed to address the needs of Resident #218 in her baseline care plan. The resident, who had a non-displaced fracture of the 5th cervical vertebra and required a cervical collar, did not have these needs documented in her care plan. Observations revealed that the resident was not consistently wearing the cervical collar, and there were no physician's orders or care plan instructions regarding its use. The DON and Assistant Director of Nursing (ADON) admitted that the diagnosis and the need for the cervical collar were overlooked in the care plan, which should have included interventions to promote healing and prevent further injury. These deficiencies highlight the facility's failure to develop and implement baseline care plans that reflect the residents' immediate needs based on their admission orders and medical conditions. The lack of proper documentation and communication among the nursing staff resulted in inadequate care planning, putting the residents at risk of not receiving the necessary care and interventions to address their health conditions effectively.
Failure to Implement Safe Smoking Assessment
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision to prevent accidents. Specifically, the facility did not complete and implement a Safe Smoking Assessment for a resident who was reviewed for smoking. The resident, a cognitively intact male with multiple diagnoses including chronic obstructive pulmonary disease and alcoholic cirrhosis of the liver, was observed smoking without a smoke apron on multiple occasions. Additionally, the resident's medical chart lacked the required smoking assessment, and the resident was seen wearing blue jeans with burn marks, indicating unsafe smoking conditions. During interviews and observations, it was revealed that the facility's smoking policy was posted and included in the admission packet, but the required smoking assessment was not found in the resident's electronic health records. The Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) confirmed the absence of the smoking assessment. Despite the presence of a supply employee monitoring the smoking area, the resident was not provided with a smoke apron, further contributing to the unsafe smoking conditions.
Failure to Provide Nutritional Supplement
Penalty
Summary
The facility failed to ensure that a resident received sufficient fluid intake and a daily nutritional supplement, which could place residents at risk for unplanned weight loss, malnutrition, and failure to thrive. Resident #15, a cognitively intact female with diagnoses including acute combined systolic and diastolic heart failure, dysphagia, and muscle weakness, experienced an 8% weight loss over six months. Despite a doctor's order for a daily nutritional supplement, the resident did not receive the supplement consistently. Observations and interviews revealed that the resident did not receive the prescribed supplement on multiple occasions, and staff were unable to confirm whether the supplement was provided as required. During an observation, Resident #15 was found eating her noon meal without the prescribed supplement. The Dietary Manager admitted that the omission was an oversight due to a busy kitchen and staff shortages. The Director of Nursing (DON) also could not confirm if the resident received the supplement, indicating a lack of proper checks and balances. The facility's Dietary Services Policy & Procedure Manual did not provide clear guidelines to ensure residents receive their nutritional supplements, contributing to the deficiency.
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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 Athens
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Athens | 1.1 mi | ★★★★★ | 9 | 0 |
| Avir At Commons | 2.5 mi | ★★★★★ | 14 | 1 |
| Cedar Lake Nursing Center | 9 mi | ★★★★★ | 0 | 0 |
| Mabank Nursing Center | 20.1 mi | ★★★★★ | 15 | 0 |
| Kerens Care Center | 22.6 mi | ★★★★★ | 1 | 1 |
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