Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 The Highlands Guest Care Center during CMS and state inspections, most recent first.
Failure to Provide Privacy During Feeding Tube Medication Administration: An RN administered medications through a resident’s feeding tube while the room door was open and the privacy curtain was not pulled, leaving the resident’s abdomen visible to the hallway and roommate. The resident had MS, aphasia, dysphagia, cancer, and HTN, and required feeding-tube medications; the RN stated she forgot to close the door and curtain and acknowledged the resident’s privacy and dignity were compromised.
Daily nurse staffing information was not posted with the current date, resident census, and actual staff hours worked at the beginning of each shift. The staffing sheet at the receptionist desk remained dated while the Staffing Coordinator, night shift nurses, and Weekend Supervisor each had roles in preparing or posting the information, and the DON was unaware it had not been displayed as required by facility policy.
A resident dependent on staff for transfers, with a history of multiple sclerosis and lack of coordination, was transferred alone by a CNA without a gait belt on two occasions, resulting in fractures to both legs. The care plan lacked transfer instructions prior to the incidents, and the CNA did not receive training after the first event. Additional observations revealed improper use of mechanical lifts and lack of adherence to safety protocols by staff.
A resident who was dependent on staff for transfers and had multiple medical conditions suffered fractures to both legs after being transferred without proper assistance or equipment by a CNA on two separate occasions. The care plan lacked transfer instructions prior to the incidents, and required safety protocols, such as using a mechanical lift and gait belt, were not followed. Additional observations revealed unsafe transfer practices for another resident, including improper sling use and failure to lock equipment, highlighting systemic issues with staff training and supervision.
A resident with multiple sclerosis and mobility dependence sustained fractures to both legs during transfers involving a shower chair. After the first fracture, there was a delay in notifying the NP and transferring the resident to the hospital, resulting in unmanaged pain. Pain assessments were inconsistently documented, and as-needed pain medication was not always administered. Staff interviews revealed confusion about notification procedures and pain management protocols, leading to inadequate care and delayed intervention.
A resident with multiple sclerosis and limited mobility sustained fractures to both lower legs on two separate occasions during transfers. In each case, x-ray results confirming the fractures were received by nursing staff, but there were significant delays in notifying the physician and sending the resident to the hospital. Staff relied on text messages for critical notifications and did not escalate when there was no response, resulting in delayed treatment and unmanaged pain for the resident.
Three residents with significant mobility and medical needs were found to have beds with missing or non-functioning brakes and a malfunctioning remote control, resulting in beds that could not be safely locked or adjusted. These deficiencies were confirmed through resident interviews and direct observation, with the maintenance supervisor unaware of the issues until the time of the survey.
A resident with multiple medical conditions and a DTI to the heel did not consistently receive the required intervention of heel offloading with a pillow as outlined in the care plan and physician's order. Observations showed the resident's heels were not offloaded, and staff interviews revealed a lack of awareness and documentation regarding the intervention, despite facility policy requiring comprehensive, measurable care plans.
A resident with significant risk factors for pressure ulcers, including immobility and multiple comorbidities, was not provided with consistent heel offloading as ordered by a physician. Despite an active order to keep a pillow under the resident's heels at all times while in bed, multiple observations found the resident without the required offloading, and staff were unable to account for the missing pillow. This failure resulted in noncompliance with professional standards for pressure ulcer prevention.
The facility failed to ensure call lights were accessible for several residents, including those with cognitive impairments and physical limitations, as observed in multiple instances where call lights were found on the floor. Staff acknowledged the importance of call lights for resident safety and communication, yet the facility did not comply with its policy to keep call lights within reach.
The facility failed to maintain an effective Infection Prevention and Control Program, with CNAs not changing gloves or performing hand hygiene during incontinent care, and LVNs not sanitizing blood pressure cuffs between residents. These actions increased the risk of cross-contamination and infection among residents.
A facility failed to maintain a resident's privacy during wound care when an LVN did not close the door or pull the privacy curtain. The resident, who had paraplegia and pressure wounds, did not notice the open door but mentioned it would be decent to have it closed. The LVN admitted forgetting to close the door, and the facility's policy requires staff to ensure privacy during care.
A resident with acute respiratory failure and sleep apnea did not receive proper respiratory care as their BiPAP mask was not stored correctly. The mask was observed hanging without being bagged, contrary to infection prevention standards. Staff interviews confirmed the need for bagging the mask to prevent infection, highlighting a lapse in following facility policy.
Failure to Provide Privacy During Feeding Tube Medication Administration
Penalty
Summary
The facility failed to ensure Resident #38’s right to privacy and dignity during medication administration through a feeding tube. Resident #38 was a cognitively impaired female with diagnoses including cancer, multiple sclerosis, aphasia, dysphagia, and hypertension, and she required assistance from one staff member for activities of daily living. Her physician orders directed that all medications be given by feeding tube, and her care plan noted that she had swallowing problems related to multiple sclerosis and required medications through the feeding tube to maintain nutritional status. During an observation, RN A administered medications through Resident #38’s feeding tube while the room door remained open and the privacy curtain was not pulled. Resident #38’s abdomen was visible to the hallway and to her roommate, who was eating lunch in the room, and other staff and residents were observed in the hallway nearby. RN A stated she forgot to close the door or pull the curtain and acknowledged that the resident’s privacy and dignity were compromised. The Administrator and DON stated that privacy should always be provided during care and that the door and privacy curtain should have been closed.
Daily nurse staffing posting not updated
Penalty
Summary
The facility failed to post the daily nurse staffing information with the current date, resident census, and the number of staff actual hours worked at the beginning of each shift. During an observation on 12/28/25 at 9:00 a.m., the daily staffing posting at the receptionist desk was dated 12/26/2025. Record review of the 24-hour turnover binder showed daily staff postings for 12/27/25 and 12/28/25, but the posting at the desk had not been updated. During interviews, the Staffing Coordinator stated she created the staff posting on Friday and placed it in the 24-hour turnover binder for the Weekend Supervisor to post on weekends, and said the night shift nurses completed the daily staffing posting. The DON stated the Staffing Coordinator was responsible for filling out the facility's daily posting and the Weekend Supervisor was responsible for putting it up on Saturday and Sunday. The DON was not aware that the staff posting had not been posted. The facility policy titled, Posting Direct Care Daily Staffing Numbers, revised August 2022, stated the facility will post staffing data on a daily basis for each shift and, within two hours of the beginning of each shift, the number of licensed nurses and unlicensed nursing personnel directly responsible for resident care is posted in a prominent location.
Failure to Ensure Safe Resident Transfers Resulting in Multiple Fractures
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident without using a gait belt and without the required assistance, resulting in the resident sustaining fractures to both lower extremities on two separate occasions. The resident, who had multiple sclerosis, lack of coordination, and was dependent on staff for all transfers, was transferred from a shower chair to the bed by a single CNA, despite care requirements for two-person assistance and the use of a mechanical lift. The care plan did not contain transfer instructions prior to the incidents, and the CNA did not receive training before or after the first incident. The resident reported that during both transfers, her legs became caught between the shower chair and the bed, resulting in pain and audible popping sounds, which were later confirmed as fractures by x-ray. The resident was not immediately sent to the hospital after the first fracture and experienced unmanaged pain until transfer to the hospital. The CNA involved admitted to performing the transfers alone and without a gait belt, and also stated that no training was provided after the first incident. Other staff interviews confirmed a lack of training and monitoring related to safe transfer techniques. Additionally, observations of another resident's transfer revealed improper use of a mechanical lift, including failure to lock the bed and wheelchair, use of an incorrectly sized sling, and mismatched sling loops, contrary to manufacturer instructions. Staff involved in these transfers expressed uncertainty about proper procedures and equipment sizing. Facility policies required review of care plans and use of two trained staff for mechanical lifts, but these were not consistently followed, contributing to the deficiencies identified.
Removal Plan
- In-service nursing staff on where to find the resident's care plan to determine how to care for the resident. The care plan is found on the electronic screen system on each hall and general area. The resident transfer section on the care plan will tell the nursing team member how the resident is to be transferred.
- Educate nursing team members on the process of transferring residents by using their proper body mechanics or using a transfer device for the safety of both residents and staff.
- Complete a skills check-off tool on the nursing team members so they can demonstrate the process of transferring residents by using their proper body mechanics or using a transfer device for the safety of both resident and staff.
- Any nurse not present or in-serviced will not be allowed to assume their duties until in-serviced. ADM will ensure these team members are removed from the time clock and PCC access removed, this will be monitored until 100% complete or the team members are terminated.
- Ongoing in-service will be completed by the DON, ADON D, and ADON E until all staff, weekend, and PRN are completed.
- Bring in a Licensed Physical Therapist to educate, complete a skills check-off list, and post-test on transferring a resident.
- PT to educate, complete a skills check-off list, and post-test on transferring a resident with body techniques and mechanical devices with DON, ADON D, and ADON E. After they completed and passed their education, PT observed DON and ADONs educate, complete a skills check-off list, and post-test on transferring a resident with body techniques and mechanical devices with 3 CNAs.
- Only DON, ADONs, and PT will be able to in-service, complete a skills check-off list, and post-test on transferring a resident with body techniques and mechanical devices.
- A resident can only be transferred using a Hoyer lift with a licensed nurse present. This practice will continue until the IDT Team decides the CNAs are able to complete this transfer without supervision.
- Monitor resident transfers by CNA every shift by the DON and ADONs. Administrator will monitor this process daily.
- Test nursing staff on where to find the resident's care plan every shift by the DON and ADONs. ADM will monitor this process daily.
- Hold Ad Hoc QA meeting to discuss causes, in-services and review interventions.
- Any negative findings in the monitoring and/or auditing system will be reviewed and addressed by the QAPI committee for a potential systemic change.
- Ensure that all mechanical transfer train-the-trainer sessions, center random skill checks, and instances where transferring is found to be done incorrectly, will be supervised, monitored, and approved by a licensed physical therapist.
Failure to Provide Adequate Supervision and Safe Transfer Practices Resulting in Resident Injuries
Penalty
Summary
The facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents, resulting in significant injuries to a resident. One resident, who was dependent on staff for all transfers and had diagnoses including multiple sclerosis, lack of coordination, and a prior left tibia fracture, was transferred by a CNA without the use of a gait belt and without proper assistance. This improper transfer from a shower chair to a bed resulted in a fracture to the resident's left tibia. The care plan for this resident did not contain any transfer information prior to the incident, and the required use of a mechanical lift was not documented until after the injury occurred. Despite the first incident, oversight and monitoring of direct care staff were not addressed. The same CNA, who had not received retraining or monitoring after the initial event, again transferred the same resident inappropriately, resulting in a fracture to the right tibia. Interviews revealed that the CNA performed both transfers alone, did not use a gait belt, and was not properly trained or supervised. The resident reported significant pain after both incidents and was not sent to the hospital immediately after the injuries. The facility's policies required two trained staff for mechanical lift transfers and emphasized the need to follow care plans, but these were not followed in practice. Additionally, observations of another resident's transfer revealed further deficiencies in safe transfer practices, including the use of an improperly sized sling, failure to lock beds and wheelchairs, and inconsistent application of manufacturer instructions for mechanical lifts. Staff interviews confirmed uncertainty about proper transfer techniques and equipment sizing. These failures resulted in an Immediate Jeopardy situation, as residents were placed at risk of serious harm and injury due to inadequate supervision, lack of adherence to care plans, and improper use of transfer equipment.
Removal Plan
- In-service nursing staff on where to find the resident's care plan to determine how to care for the resident, with care plan access available on the electronic screen system on each hall and general area.
- Educate nursing team members on the process of transferring residents by using proper body mechanics or using a transfer device for the safety of both residents and staff.
- Complete a skills check-off tool for nursing team members to demonstrate the process of transferring residents using proper body mechanics or a transfer device.
- Remove from duty any nurse not present or in-serviced until in-serviced; monitor and remove from time clock and PCC access until 100% complete or terminated.
- Bring in a Licensed Physical Therapist to educate, complete a skills check-off list, and post-test on transferring a resident.
- PT to educate, complete a skills check-off list, and post-test on transferring a resident with body techniques and mechanical devices with DON, ADON D, and ADON E.
- PT to observe DON and ADONs educate, complete a skills check-off list, and post-test on transferring a resident with body techniques and mechanical devices with 3 CNAs.
- Only DON, ADONs, and PT will be able to in-service, complete a skills check-off list, and post-test on transferring a resident with body techniques and mechanical devices moving forward.
- A resident can only be transferred using a Hoyer lift with a licensed nurse present until the IDT Team decides CNAs are able to complete this transfer without supervision.
- Monitor resident transfers by CNA every shift by DON and ADONs; Administrator to monitor this process daily.
- Test nursing staff on where to find the resident's care plan every shift by DON and ADONs; Administrator to monitor this process daily.
- Hold Ad Hoc QA meeting to discuss causes, in-services, and review interventions.
- Review and address any negative findings in the monitoring and/or auditing system by the QAPI committee for potential systemic change.
- Require all staff to receive in-services concerning safe transfers, accessing resident care plans, and complete hands-on transfer training by the DON or ADONs.
- Require a nurse to be in the room with two CNAs every time a mechanical lift is used, indefinitely, until further notice.
- Ensure all mechanical transfer train-the-trainer sessions, center random skill checks, and instances where transferring is found to be done incorrectly, will be supervised, monitored, and approved by a licensed physical therapist.
Failure to Provide Timely Pain Management and Hospital Transfer After Fracture
Penalty
Summary
A deficiency occurred when a resident with a history of multiple sclerosis, lack of coordination, and dependency for transfers sustained a fracture to the left tibia after an incident involving a shower chair. The resident reported pain and an x-ray was ordered, which confirmed the fracture. However, there was a significant delay in notifying the nurse practitioner (NP) of the x-ray results, and the resident was not transferred to the hospital until five days after the injury. During this period, documentation and communication regarding the resident's pain and the abnormal x-ray findings were inconsistent and unclear among nursing staff and the DON. Pain assessments documented in the medication administration record (MAR) did not consistently reflect the resident's reported pain levels, with most shifts indicating no pain despite the resident's statements of ongoing pain after the fracture. As-needed pain medication was not administered on the day of the injury, and the resident reported that the pain medication provided was not effective in managing her pain prior to hospital transfer. The resident also experienced a second fracture to the right leg under similar circumstances, again reporting pain and delayed transfer to the hospital. Interviews with staff revealed confusion about the process for notifying the NP and following up on critical results, as well as uncertainty about the appropriate steps to take when pain or injury was identified. The facility's policies required prompt assessment and management of pain, especially in cases of fractures, but these protocols were not followed. The failure to provide timely and appropriate pain management, accurate assessment, and documentation resulted in the resident experiencing unnecessary pain and delayed medical intervention.
Removal Plan
- All residents were immediately assessed for any change in condition from their baseline including pain assessment.
- Any resident who verbalized or showed nonverbal signs of pain was addressed at that time following that resident's physician orders for pain management.
- Either DON, ADON D, ADON E, or LVN CC will round the center and observe each resident every 12 hours looking for indications of pain or change of conditions; these rounds will be documented on the resident 24-hour report.
- The ADM will monitor this process daily.
- The following in-services were immediately initiated by the Chief Nursing Officer: any nurse not present or in-serviced will not be allowed to assume their duties until in-serviced.
- The ADM and HR will ensure these team members are removed from the time clock and PCC access removed; this will be monitored until 100% complete or the team members are terminated.
- Ongoing in-service will be completed by DON, ADON D, and ADON E until all staff, weekend, and PRN are completed.
- Post-test will be completed to evaluate team members' understanding of in-services covered; the passing score will be 80% - 100%.
- Licensed nurses were in-serviced on how to assess residents for signs and symptoms of pain using a pain scale appropriate for them.
- Licensed nurses were in-serviced on how to reassess pain after medication administration for effectiveness and process for if not effective.
- Each resident will have a pain management treatment plan as part of their plan of care.
- The medical director was notified of the immediate jeopardy situation by the DON.
- The Ombudsmen was notified of this Immediate Jeopardy situation by the ADM.
- Interviews were conducted with employees to verify understanding of pain assessment, notification, documentation, and identification of pain indicators.
- Record review of facility in-service titled Following Physician Orders to Address Pain revealed all nursing staff had signed indicating education was completed by all nurses.
- Record review of facility in-service titled Assessing the effectiveness of pain medication given revealed all nursing staff had signed indicating education was completed by all nurses and CNAs.
- Record review of facility in-service titled Comprehensive Pain Management Treatment Plan revealed all nursing staff had signed indicating education was completed by all nurses and CNAs.
- The facility will ensure that all mechanical transfer train-the-trainer sessions, center random skill checks, and instances where transferring is found to be done incorrectly, will be supervised, monitored, and approved by a licensed physical therapist.
Delayed Physician Notification of Abnormal X-ray Results Following Resident Fractures
Penalty
Summary
The facility failed to promptly notify the ordering physician of abnormal x-ray results for a resident, resulting in significant delays in medical intervention. On two separate occasions, the resident sustained fractures to the lower extremities after incidents involving transfers from a shower chair to the bed. In both cases, x-rays were ordered and results indicating fractures were received by the facility, but there was a delay in notifying the physician and in sending the resident to the hospital. For the first incident, the x-ray result showing a left tibia fracture was received, but the resident was not sent to the hospital until five days later. For the second incident, the x-ray result showing a right tibia fracture was received, but the resident was not sent to the hospital until the following day. Interviews and record reviews revealed that nursing staff either did not notify the nurse practitioner (NP) immediately or failed to follow up when no response was received. In some cases, staff relied on text messages to communicate critical results and did not escalate the situation when the NP did not respond. Documentation was inconsistent regarding how and when the NP was notified, and there was confusion among staff about the appropriate steps to take when a physician could not be reached. The Director of Nursing (DON) and other staff members confirmed that there was a lack of clarity and follow-through in the notification process, and that the facility's policies for prompt physician notification were not followed. The resident involved had a history of multiple sclerosis, lack of coordination, and was dependent on staff for transfers and personal care. After each incident, the resident experienced pain and reported that the pain was not adequately managed until she was sent to the hospital. The facility's failure to promptly notify the physician and act on abnormal diagnostic results led to delays in appropriate medical treatment for the resident.
Removal Plan
- The DON, ADON D, and ADON E completed a change of condition assessment focusing on pain on each resident to determine if they are not at their baseline. Each resident was documented on the outcome of their assessment in their progress note in Point Click Care. For any residents that were found not to be at their baseline, their physician was notified and documented on. Any conditions noted after this immediate assessment, and it was found that the physician was not notified, a re-education of physician notification was completed.
- Either DON, ADON D, ADON E, or LVN CC will round the center and observe each resident every 12 hours looking for indications of pain or change of conditions. These rounds will be documented on the resident 24-hour report. The ADM will monitor this process daily.
- In-services were initiated by the Chief Nursing Officer. Any nurse not present or in-serviced will not be allowed to assume their duties until in-serviced. The ADM and human resources will ensure these team members are removed from the time clock and PCC access removed. This will be monitored until 100% complete or the team members are terminated. Ongoing in-service will be completed by the DON, ADON D, and ADON E until all staff, weekend, and PRN are completed.
- Post-test will be completed to evaluate team members' understanding of in-services covered. The passing score will be 80% - 100%.
- Licensed nurses were in-serviced on: Notifying physicians during a change of condition in a resident; Physician on-call schedule; Process on what to do if a physician cannot be reached; Comprehensive Pain Management Treatment Plan for each resident.
- The medical director was notified of the immediate jeopardy situation by the DON.
- The Ombudsmen was notified of this Immediate Jeopardy situation by the ADM.
- The Corporate Nurse immediately audited the 24-hour facility resident summary to determine if there were any changes of conditions focusing on pain that were noted, and the physician was notified. These findings were sent to the DON, ADON D, and ADON E for follow-up.
- The chief nursing officer reviewed the administrative nurse's follow-up to ensure follow-up happened and will do this daily.
- DON, ADON D, and ADON E will monitor daily residents' current electronic records for a change of condition utilizing the Point Click Care Clinical Dashboard, which includes resident's Change of Condition, 24 Hour Resident Report, Progress notes, Incidents & Accidents, Weights & Vitals, and Diagnostic reports on all residents daily.
- To ensure accuracy, DON, ADON D, and ADON E will round the center and observe each resident every 12 hours looking for indications of pain or change of conditions. These rounds will be documented on the resident 24-hour report. The ADM will monitor this process daily.
- Interviews were conducted with nurses to verify understanding of on-call physician number access, notification process, change in condition identification, and escalation if unable to reach a provider.
- Record review of facility in-services titled Notifying Physicians During a Change of Condition, Physician On Call Schedule, and What to do if a Physician cannot be reached revealed all nursing staff had signed indicating education was completed by all nurses.
Failure to Maintain Safe and Functional Bed Equipment
Penalty
Summary
The facility failed to ensure that essential patient care equipment, specifically resident beds, was maintained in safe operating condition for three residents. One resident's bed lacked brakes on the foot of the bed, and the bed could be easily moved with minimal force. Another resident's bed had one brake on the foot that would not lock, and the other brake was not locked when checked, resulting in the bed being easily movable. A third resident's bed had a malfunctioning remote control, with only one button working incorrectly, and the resident was unable to control the bed's position as intended. In each case, the residents reported the issues, and observations confirmed the equipment was not functioning as required. The affected residents had significant mobility limitations and medical conditions, including muscle weakness, morbid obesity, anxiety disorder, multiple sclerosis, and recent fractures. Care plans indicated extensive assistance was needed for bed mobility and transfers, with one resident requiring a mechanical lift. Despite these needs, the maintenance supervisor was unaware of the equipment issues until the time of the survey and stated that he relied on staff to report problems. The deficiencies were identified through resident interviews, direct observation, and review of care plans and assessments.
Failure to Implement and Monitor Heel Offloading Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident with multiple complex medical conditions, including a deep tissue injury (DTI) to the heel. The care plan, revised to require offloading both heels with a pillow at all times while the resident was in bed, was not consistently followed. Multiple observations on the same day revealed that the resident's heels were not offloaded, and no pillow was present at the foot of the bed as required by the care plan and physician's order. The resident, an elderly female with diagnoses including non-traumatic acute subdural hemorrhage, Type 2 Diabetes, hypothyroidism, muscle weakness, chronic kidney disease, wedge compression fracture, dementia, and arthritis, was noted to have a very low level of cognition and total dependency for most activities of daily living. Despite the care plan and physician's order specifying the need for heel offloading to promote wound healing, staff failed to ensure this intervention was in place during several observations. There was no documentation in the resident's record indicating refusal of the intervention or interference with the offloading process. Interviews with facility staff, including the DON and MDS Coordinator, confirmed a lack of awareness regarding the resident's heels not being offloaded and a misunderstanding about the adequacy of general refusal notes in the care plan. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and regular updates, but these requirements were not met in this instance, as evidenced by the lack of implementation and monitoring of the prescribed intervention.
Failure to Consistently Offload Heels for Pressure Ulcer Prevention
Penalty
Summary
A deficiency occurred when a resident with multiple risk factors for skin breakdown, including immobility, diabetes, chronic kidney disease, and dementia, did not receive care consistent with professional standards to prevent pressure ulcers. The resident had an active physician's order requiring both heels to be offloaded with a pillow at all times while in bed to promote wound healing. Multiple observations on the same day revealed that the resident's heels were not offloaded, and no pillow was present at the foot of the bed as required. The resident was observed lying in bed without a pillow under her heels on several occasions, and staff interviews confirmed awareness of the order but could not explain why the pillow was not in place. The facility's policy required assessment and documentation of risk factors and current treatments for pressure ulcers, but the observed care did not align with these standards. The DON acknowledged that the resident's heels should have been offloaded and that the absence of the pillow was not noticed until brought to attention. The administrator was also unaware of the issue prior to the surveyor's findings. The failure to consistently offload the resident's heels as ordered constituted a lapse in pressure ulcer prevention for a resident at high risk.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach and accessible for five residents, which could place them at risk of being unable to obtain assistance when needed. Resident #13, a female with paraplegia and muscle weakness, was unable to find her call light and had to wait for someone to provide it to her. During an observation, the call light was found on the floor, and a Licensed Vocational Nurse (LVN) acknowledged the importance of having the call light accessible to residents. Resident #39, a male with muscle weakness and moderate cognitive impairment, was also found without access to his call light, which was observed on the floor. Similarly, Resident #49, a male with severe cognitive impairment and a risk for falls, was unable to locate his call light, which was also on the floor. Both residents expressed difficulty in finding their call lights, and staff members confirmed the necessity of having call lights within reach to prevent falls and ensure residents' needs are met. Residents #70 and #71, both with severe cognitive impairments and physical limitations, were observed with their call lights on the floor, rendering them inaccessible. Staff interviews revealed a consensus on the importance of call lights for resident safety and communication. The facility's policy mandates that call lights be within reach of residents, yet observations indicated a failure to comply with this policy, potentially compromising resident safety and care.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, resulting in multiple instances of improper hygiene practices by staff members. Specifically, two CNAs did not change their gloves or perform hand hygiene while providing incontinent care to residents. CNA D, while attending to a male resident with severe cognitive impairment and incontinence, did not change gloves after touching the trash can and handling soiled briefs, leading to potential cross-contamination. Similarly, CNA E, while caring for a female resident with muscle weakness and kidney failure, failed to change gloves or sanitize hands after handling soiled briefs, increasing the risk of infection transmission. Additionally, the facility's LVNs did not sanitize a blood pressure cuff between uses on different residents, which could lead to cross-contamination. LVN B used the same cuff on multiple residents with hypertension without sanitizing it, despite acknowledging the importance of doing so to prevent infection spread. LVN C also neglected to sanitize the blood pressure cuff between residents, even though a sanitizer was available on the medication cart. These actions were observed during medication preparation and administration for residents with hypertension. The facility's policies on perineal care, routine cleaning, and hand hygiene were not adhered to by the staff, as evidenced by the observations. The staff's failure to follow these procedures, such as changing gloves after contact with soiled items and sanitizing equipment between uses, contributed to the risk of cross-contamination and infection among residents. Interviews with the Administrator and DON confirmed the expectation for staff to follow infection control procedures, highlighting the deficiencies in practice observed during the survey.
Failure to Maintain Resident Privacy During Wound Care
Penalty
Summary
The facility failed to maintain the personal privacy of a resident during medical treatment. Specifically, an LVN did not close the door or pull the privacy curtain while performing wound care on a resident with paraplegia and pressure wounds on the right heel. The resident, who had intact cognition, did not notice the door was open but expressed that it would be decent for the door to be closed during treatment. The incident was observed during a survey, and the LVN acknowledged forgetting to close the door, stating that it should be closed to provide privacy and dignity to the resident. The facility's policy on dignity and privacy requires staff to promote and protect resident privacy during personal care and treatment procedures. Interviews with the Administrator and DON confirmed the expectation for staff to ensure privacy by closing doors or drawing curtains during care.
Improper Storage of BiPAP Mask
Penalty
Summary
The facility failed to provide proper respiratory care for a resident who required the use of a BiPAP machine due to acute respiratory failure and obstructive sleep apnea. The resident's BiPAP mask was not stored properly, as it was observed hanging beside the machine without being bagged. This improper storage was noted during an observation and interview with the resident, who confirmed that the nurses were responsible for putting the mask on and taking it off, and that the mask was sometimes not bagged. The resident expressed a desire to bag the mask herself but was unable to due to limited mobility. Further observations and interviews with facility staff, including an LVN and the DON, confirmed that the BiPAP mask should be bagged when not in use to prevent cross-contamination and respiratory infection. The facility's policy on infection prevention for respiratory therapy equipment was reviewed, which indicated that oxygen cannulas and tubing should be kept in a plastic bag when not in use, a practice that should also apply to the BiPAP mask. The failure to adhere to these standards placed the resident at risk for respiratory infection and compromised respiratory care.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
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| Presbyterian Village North Special Care Ctr | 0.3 mi | ★★★★★ | 1 | 0 |
| The Legacy Midtown Park | 1.5 mi | ★★★★★ | 3 | 0 |
| The Meadows Health And Rehabilitation Center | 1.7 mi | ★★★★★ | 8 | 0 |
| Walnut Place | 2 mi | — | 0 | 0 |
| Pure Health Transitional Care At Texas Health Pres | 2.3 mi | ★★★★★ | 0 | 0 |
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