Highland Nursing Center

Inspectors wroteBased on interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections for 1 of 1 facility reviewed for infection prevention. The facility failed to develop and implement a system of infection surveillance program for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents and staff. These failures could result in the spread of illness or infection.

Inspectors wroteBased on interview and record review, the facility failed to implement policies and procedures to ensure each staff member is offered the COVID-19 vaccine for 1 of 1 facility reviewed for infection prevention. The facility failed to offer staff members the 2025-2026 COVID-19 vaccination. This failure could result in illness and the spread of infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure the development and implementation of an effective discharge planning process that focuses on the resident's discharge goals for 4 of 4 residents (Residents #3, #16, #2, #1) reviewed for discharge planning. The facility failed to ensure Resident #3's discharge goals were reviewed and implemented during an attempted facility transfer in December 2025. The facility failed to ensure Resident #16's care plan included discharge plans. The facility failed to ensure Resident #2's care plan included discharge plans. The facility failed to ensure Resident #1's care plan included discharge plans. These failures could result in loss of residents' autonomy and rights to determine care.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure that the facility must ensure that the residents' environment remains free of accident hazards for 1 of 8 (16) residents in that: 1. Resident #16 had in his room a sink with 3 razors, a bottle of rubbing alcohol and in the medicine cabinet, 2 containers of mouth wash. Resident #16 also kept drinking alcohol in his room that he drank at his leisure. 2. The A hall shower room door was open and the cabinet was unlocked and had razors in the cabinet. The failures could place residents at risk for harm and injuries.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure Food safety requirements store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 (1 kitchen) in that: The kitchen ice machine had black specks on the ice machine shaft, and the Maintenance Assistance was not wearing a beard guard while in the kitchen. This could affect all residents that eat from the kitchen and could cause gastric problems.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical records on each resident were complete and contained physician and other licensed professional's progress notes for 7 of 7 residents (Residents #7, #5, #3, #22, #29, #30, and #33) reviewed for resident records. The facility failed to ensure progress notes from physicians and other licensed professionals were included in the charts of Residents #7, #5, #3, #22, #29, #30, and #33. This failure could result in miscommunication between health care providers and inaccurate care provided to residents.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 (1 microwave) microwave in the kitchen in that: The microwave in the kitchen had a spot in the corner, rusting and exposing the inner area of the microwave. This deficient practice could affect all residents' foods and could cause illness to residents.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure the resident has a right to be treated with respect and dignity for 1 of 8 (Resident #2) residents in that:Resident #2 had facial hair on her upper lip and chin area. The failure placed residents at risk of embarrassment and low self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to participate in the development and implementation of his or her person-centered plan of care for 1 of 7 residents (Resident #3) reviewed for resident rights. The facility failed to ensure Resident #3's family member/POA was included in care plan meetings. This failure could result in loss of independence and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including misappropriation of resident property, are reported not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 7 residents (Resident #3) reviewed for abuse, neglect, and exploitation. The facility failed to report an allegation of exploitation of Resident #3 to the SSA when Resident #3's POA alleged the Admin. stole money from Resident #3's bank account in the fall of 2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations of abuse, neglect, and exploitation are thoroughly investigated, and the results of the investigation are reported to the SSA within five working days for 1 of 7 residents (Residents #3) reviewed for abuse, neglect, and exploitation. The facility failed to have evidence of an investigation of alleged exploitation of Resident #3. This failure could result in continued mistreatment of residents or lack of oversight.

Inspectors wroteBased on interview and record review the facility failed to ensure Comprehensive Care Plans, A comprehensive care plan must be to the extent practicable, the participation of the resident and the resident's representative. An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not to be practicable for the development of the resident's care plan for 2 of 8 (#2,#16) residents in that:Resident #2 and 16 Resident/Families were not offered to attend their care plan meetings. This could affect residents and could cause residents to decrease self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide routine dental services for 1 of 2 residents (Resident #3) reviewed for dental services. The facility failed to ensure Resident #3 received routine dental care in 2025 and 2026. This failure could result in tooth decay or loss, infection, and decreased quality of life.

Inspectors wroteBased on observation, interviews and record review the facility failed to dispose of garbage and refuse properly for 1 of 1 (1 dumpster) in that: There was no plug for the garbage dumpster, and the side door was open 1/4 of the way. This deficient practice could increase pests and rodents in the area.

Inspectors wroteBased on observation and interviews, the facility failed to ensure the resident received care and services safely and that the physical layout of the facility maximized resident independence and did not pose a safety risk, with housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior and adequate and comfortable lighting levels in all areas; for 2 of 2 shower rooms (A hall shower and B hall shower) reviewed for trip hazards and lighting. 1. The facility failed to have adequate safe lighting for the showers as evidenced by the B Hall shower having a shower stall with no light fixture within the shower stall and the A hall shower stall having no functioning light bulb in the fixture within the shower stall. 2. [...]

Inspectors wroteResident #6 FTag Initiation 01/10/25 03:31 PM Initiate F700 & F656 initiated d/t order for abdominal binder and fact that abdominal binder is not identified in the care plan and use of 1/2 side rail for positioning (not appropriate need for this resident). Resident #33 FTag Initiation 01/10/25 10:39 AM Thorazine consent not signed, wrong resident and theo [NAME] res was not on thorazine vns check was not on mar

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a medication error rate below 5%, for 27 medication administration opportunities with 15 errors resulting in a 55.56% medication error rate, for 4 of 4 residents (Residents #6, #7, #22, and #30) reviewed for medication administration. 1. LVN D administered Resident #6's medications by her gastronomy tube (often called a G tube, is a surgically placed device used to give direct access to a person's stomach for supplemental feeding, hydration, or medicine), contrary to professional standards by administering all the medications together rather than one by one, and late by 11 minutes. 2. LVN D administered Resident #30's medications by her gastronomy tube contrary to professional standards by administering all the medications together rather than one by one, and late by 50 minutes. 3. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, which must include, at a minimum, the following elements: A. Standard and transmission-based precautions to be followed to prevent spread of infections, and B. The hand hygiene procedures to be followed by staff involved in direct resident contact; for 2 of 2 residents reviewed for incontinent care and medication administration (Residents #6 and #30) reviewed for standard and transmission-based precautions for infection control and prevention. 1. [...]

Inspectors wroteFACILITY Environment 01/09/25 02:35 PM poor lighting in shower rooms. a and b, resident little stated she used shower and she could use a better light, and could be warmer, the heater in a and b were not working. 01/09/25 05:36 PM pm [NAME] stated laundry door gap ok, ok for concern and no tag for door gap, shower curtain in between dirty and clean, and toilet on pedestal, Resident #19 FTag Initiation 01/10/25 01:31 PM no light in shwr and bump on ramp.

Inspectors wroteBased on interview, record review and observation, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 12 residents [Resident #6] reviewed for care plans. The facility failed to develop the appropriate care plan intervention of implementing an abdominal binder to prevent Resident #6 from pulling out her feeding-tube per physician's order. This deficient practice could place resident at risk of trauma or injury.

Inspectors wroteResident #6 FTag Initiation 01/10/25 03:31 PM Initiate F700 & F656 initiated d/t order for abdominal binder and fact that abdominal binder is not identified in the care plan and use of 1/2 side rail for positioning (not appropriate need for this resident).

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys, for 1 of 3 medication carts (the medication aide cart) reviewed for supervision and security. The Medication cart was left unsupervised and unsecured for 25 minutes by an unknown staff member. This failure could place residents at risk for harm by not receiving the therapeutic effects of their medications.

Inspectors wroteBased on observation, interviews, and record reviews, it was determined the facility failed to ensure each resident was provided the right to a dignified existence, self-determination, for 2 of 6 residents reviewed for Resident rights (Resident #1 and #2). The facility failed ensure Resident #1 and #2's guardian the right to choose Hospice Company C to evaluate these residents for their eligibility for hospice; instead of Hospice Company D. This failure could place residents at risk of their responsible party not being involved in their medical care and treatment.

Inspectors wroteBased on record review and interview, the facility failed to include as part of its QAPI program, mandatory training that outlined and informed staff of the elements and goals of the facility's QAPI program, for 9 of the 16 staff members (the AADM, the DON, LVN C, LVN D, CNA E, CNA F, CNA G, CNA H, CNA I) reviewed for mandatory training, in that: Nine staff members (the AADM, the DON, LVN C, LVN D, CNA E, CNA F, CNA G, CNA H, CNA I) reviewed for mandatory training had not received training regarding the facility's QAA-QAPI program. This failure could place residents at risk of receiving inadequate care from staff who are unfamiliar with the facility's QAPI program.

Inspectors wroteBased on record review and interview, the facility failed to assess each resident quarterly using the Minimum Data Set form specified by the state and approved by CMS for 3 of 16 residents (Resident #12, #26, and #28) reviewed for quarterly assessments, in that: Resident #12, #26, and #28's quarterly MDS Assessment was not completed within 92 days of the previous quarterly assessment. This failure could place residents at-risk of not having their assessments completed timely.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 2 of 12 residents (Residents #4 and #20) reviewed for accidents and hazards in that: 1. The facility failed to ensure Resident #4 received supervision while using a needle point needle and scissors. 2. The facility failed to ensure Resident #20 received supervision while using a flat iron to style her hair. This failure could place residents at risk of harm or injury and contribute to avoidable accidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 medication carts (Treatment/Medication Cart) in that: The facility failed to ensure expired mediations were not found on the Treatment/Medication cart. This deficient practice could affect residents who received medications or treatments and could result in less potent or adverse effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: The facility failed to obtain pasteurized eggs for the purpose of serving undercooked eggs for residents. These failures could place residents at risk for cross-contamination and foodborne illness.

Inspectors wroteBased on record review and interview, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for 1 of 14 staff (the DOR) reviewed for background screenings, in that: The facility had failed to complete an Employee Misconduct Registry search for the DOR. This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that all alleged violations involving resident neglect, are reported immediately, but not later than 24 hours after the allegation is made for 2 of 16 residents (Residents #8 and #17) reviewed for, reporting neglect, in that: The facility failed to report an incident to the State Survey Agency (HHSC), when Residents #8 and #17 were observed in the dining room to be using profanity toward each other after Resident #17 threw a liquid-filled cup at Resident #8. This failure could place the residents at risk for unreported allegations of abuse, neglect, and injuries.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that all alleged violations involving resident neglect are investigated for 2 of 16 resident (Residents #8 and #17) reviewed for reporting neglect, in that: The facility failed to investigate an incident when Resident #8 and #17 were observed in the dining room to be using profanity toward each other after Resident #17 threw a liquid-filled cup at Resident #8. This failure could place the residents at risk for uninvestigated allegations of abuse, neglect, and injuries.

Inspectors wroteBased on record review and interview, the facility failed to assess each resident annually using the Minimum Data Set form specified by the state and approved by CMS for 1 of 16 residents (Resident #26) reviewed for annual assessments, in that: Resident #26's Annual MDS Assessment was not completed within 366 days of the previous annual assessment. This failure could place residents at-risk of not having their assessments completed timely.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 12 residents (Resident #4 and #20) whose assessments were reviewed in that: 1. Resident #4's most recent Quarterly MDS assessment dated [DATE] did not accurately reflect the resident's oral/dental status and oxygen use. 2. Resident #20's most recent annual MDS assessment dated [DATE] did not accurately reflect the resident's ability to maintain personal hygiene. This failure could place residents at-risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 12 residents (Resident #4 and #20) reviewed for comprehensive care plans in that: 1. Resident #4's comprehensive care plan did not address the resident's use of sewing needles and scissors. 2. Resident #20's comprehensive care plan did not address the resident's use of a flat iron used for styling hair. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding for 2 of 2 residents (Resident #1 and #13) reviewed for enteral feeding tubes in that: 1. LVN A did not rinse or discard the medication syringe after administering medications into Resident #1's enteral feeding tube. 2. LVN A did not rinse or discard the medication syringe after administering medications into Resident #13's enteral feeding tube. These failures could place residents at risk for complications of enteral feeding.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care was provided with such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Resident #4) reviewed for respiratory care in that: The facility failed to ensure Resident #4 had an oxygen sign posted outside her bedroom. This deficient practice could place residents at risk for inadequate care.

Inspectors wroteBased on an interview and record review, the facility failed to ensure that the facility's infection preventionist attended the QAA/QAPI meetings, for 1 of 1 facility, reviewed for QAA/QAPI. The facility failed to ensure the infection preventionist attended their QAA and QAPI meetings for any month since the last annual survey (09/23/2022). This failure could place residents at risk for quality deficiencies being unidentified and a lack of appropriate plans of action developed or implemented.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure the resident environment remains as free of accident hazards as is possible; and Each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 4 (Res #1) reviewed for elopements in that: Resident #1 had eloped from facility 3 times (7/26/2023, 8/8/2023, 8/26/2023) with a wander guard on. a. staff were not in-serviced following each elopement. b. no elopement assessment was completed for Resident #1 prior to or immediately following the elopements. c.no measurable (dated) care plan for elopement risk. d. an alarm was not in place on Resident #1's window as indicated on care plan. An IJ was identified on 10/07/2023. The IJ template was provided to the facility on [DATE] at 3:28 PM. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made for 2 of 2 (Residents #1 and#2) residents. 1. The facility failed to report on 3 separate elopement incidents Resident #1 elopement from the facility, no injuries. 2. The facility failed to report and submit Resident #2's left knee fracture, intake #379566 allegation of unknown origin. These failures could place residents at risk for not having allegations of abuse or neglect reported to the State Agency to ensure that allegations are fully investigated.