Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Care Center during CMS and state inspections, most recent first.
A facility failed to transmit a resident's discharge MDS assessment to CMS within the required timeframe. The resident, with multiple diagnoses, was discharged with a completed MDS assessment. However, the MDS Coordinator incorrectly marked that the facility lacked Medicare or Medicaid certified beds, resulting in the data not being submitted.
A resident's antihypertensive medication was administered despite physician orders to hold it if the diastolic blood pressure was below 80. The medication was given multiple times when the DBP was below this threshold, indicating a failure to adhere to the specified parameters. Interviews with nursing staff revealed confusion and a lack of clarity regarding the physician's order, which was later changed to hold the medication if the DBP was below 90.
A resident on trazodone for insomnia did not receive the required gradual dose reductions (GDR) since 2022, despite no clinical contraindication. The facility's psychotropic review process failed to document attempts at GDR, as acknowledged by the DON, potentially due to the resident's spouse's involvement.
A resident had BMPs collected twice without a physician's order, despite having multiple diagnoses requiring careful monitoring. The facility's process for handling lab orders, as described by staff, revealed issues with tracking and documenting verbal orders, leading to unauthorized lab collections.
The facility failed to maintain food safety and hygiene standards in the kitchen. Observations included rusty and dirty surfaces in contact with food, open food containers, and staff not practicing hand hygiene. A dietary aide handled various items without washing hands, and the kitchen cleaning schedule initially omitted vent cleaning.
Failure to Transmit MDS Data to CMS
Penalty
Summary
The facility failed to electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the Centers for Medicare and Medicaid Services (CMS) system within 14 days of completing a resident's assessment. Specifically, for one resident, the facility did not transmit the completed discharge MDS assessment. The resident was admitted with multiple diagnoses, including polyosteoarthritis, cerebral infarction, and major depressive disorder, and was discharged with a completed MDS assessment on January 31, 2024. However, the MDS Coordinator mistakenly marked that the facility did not have Medicare or Medicaid certified beds on question A0410 of the assessment, leading to the decision not to submit the data to CMS.
Failure to Adhere to Antihypertensive Medication Parameters
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically concerning the administration of an antihypertensive medication, diltiazem. The physician's order specified that the medication should be held if the resident's diastolic blood pressure (DBP) was below 80. However, the medication was administered on multiple occasions when the DBP was below this threshold. This oversight was identified through a review of the resident's medication administration records for May and June 2024, which documented several instances where the DBP was below 80, yet the medication was still given. Interviews with nursing staff, including two registered nurses and the Director of Nursing (DON), revealed a lack of clarity and adherence to the physician's order. RN 1 expressed uncertainty about the order, while RN 2 and the DON acknowledged that the medication should have been held when the parameters were not met. The DON later stated that the physician had changed the order to hold the medication if the DBP was below 90, as the resident typically had DBP readings in the 70s. This change, however, was not reflected in the administration records at the time of the review.
Failure to Implement Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident who was using psychotropic drugs received gradual dose reductions (GDR) as required, unless clinically contraindicated. Specifically, a resident taking an antidepressant medication, trazodone, for insomnia had not received a GDR since 2022, despite the absence of a documented clinical contraindication. The requirement is that a GDR must be attempted in two separate quarters within the first year of admission or initiation of the medication, and then annually. However, for this resident, no such attempts were documented, indicating a lapse in compliance with regulatory requirements. The resident in question was admitted with multiple diagnoses, including hemiplegia, cerebral infarction, major depressive disorder, and insomnia. Despite the facility's monthly psychotropic meetings and tracking systems, the Director of Nursing (DON) acknowledged that the GDR for trazodone was overlooked, possibly due to the involvement of the resident's spouse. The facility's interdisciplinary team reviewed psychotropic medications, but the documentation was insufficient to demonstrate compliance with GDR requirements for this resident.
Unauthorized Lab Tests Conducted Without Physician Orders
Penalty
Summary
The facility failed to obtain laboratory services only when ordered by a qualified practitioner, resulting in a deficiency. Specifically, a resident had a basic metabolic panel (BMP) collected on two occasions without a physician's order. The resident, who had multiple diagnoses including hemiplegia, type 2 diabetes mellitus, and dementia, was admitted and readmitted to the facility. A physician's order initially required BMPs to be drawn three times weekly, but this order was discontinued. Despite this, BMPs were collected on two subsequent dates without documented orders. Interviews with facility staff revealed a lack of proper tracking and documentation for lab orders. A registered nurse and the Assistant Director of Nursing (ADON) described the process for handling lab orders, which included entering orders into the computer and maintaining a lab book. However, the ADON acknowledged challenges in tracking verbal orders from physicians. This lack of documentation and tracking led to the collection of labs without proper authorization, contributing to the deficiency identified by surveyors.
Food Safety and Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an inspection, several deficiencies were observed in the kitchen area. A metal rack used for storing clean meal trays was found to be rusty, with a meal tray in contact with the rusty surface, and a small red bug was seen crawling on the rack. A vent in the ceiling was covered in a thick layer of dust, and a metal storage cart used for clean baking sheets was dirty and covered in food crumbs. Additionally, a container of coffee grounds was left open to the air, and a stack of clean plates had food debris on the top plate. The ceiling above food preparation areas was stained and had food debris. Staff practices also contributed to the deficiencies. A dietary aide was observed handling a cell phone, writing on saran wrap, and touching various items without practicing hand hygiene. This included handling a cup of hot chocolate and meal trays without washing hands. An interview with the Assistant Dietary Manager revealed that the kitchen should be cleaned daily, but the vents were not initially included in the cleaning schedule. The vents were later added to the cleaning list after the inspection.
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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 Holladay
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Spring Creek Healthcare Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Monument Healthcare Millcreek | 1.1 mi | ★★★★★ | 10 | 0 |
| Holladay Healthcare Center | 1.4 mi | ★★★★★ | 0 | 0 |
| Mt. Olympus Rehabilitation Center | 1.6 mi | ★★★★★ | 2 | 2 |
| Monument Healthcare Murray Creek | 1.7 mi | ★★★★★ | 2 | 0 |
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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.