Park Highlands Nursing & Rehabilitation Center

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 care plan for 3 of 5 dialysis residents (Residents #6, #46, #47) reviewed for the right to participate in planning care. The facility failed to ensure Resident #6, Resident #46 and Resident #47 were included in the development and implementation of their personal care plans. This failure could place residents at risk of not receiving adequate and individualized care while residing at the facility.

Inspectors wroteBased on interview and record review, the facility failed to coordinate the assessment of 1 of 2 residents (Resident #9) reviewed for the pre-admission screening and resident review (PASARR) program and PASARR assessments and evaluations. The facility failed to ensure Resident #9's PASARR Level 1 screening was accurately coded to reflect he had indicators of mental illness. This failure could place residents with psychiatric diagnoses at risk for not being evaluated for PASARR services and potentially not receiving services for care and treatment.

Inspectors wroteBased on interview and record review, the facility, with a capacity of more than 120 beds, failed to employ a qualified social worker on a full-time basis for 1 of 1 social services staff reviewed for qualifications of Social Worker (SW). The facility failed to employ a SW on a full-time basis. This failure could place the residents at risk of not receiving social services to meet their needs. Record review of the Facility Summary Report from Tulip (Texas Unified Licensure Information Portal) dated 12/31/2018 revealed the facility had a maximum capacity of 132 beds. During a personnel record review on 06/03/2026 the file indicated the SW was hired on 01/31/2022. The record indicated she worked 16 hours per week. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 4 residents (Resident #9) reviewed for care plans. The facility failed to ensure Resident #9's care plan addressed diagnoses of PTSD and depression, and the prescribed use of psychoactive drugs. This failure could place residents with diagnoses of mental illness and psychoactive drug use at risk for not receiving care and services to meet medical, mental, psychosocial, and nursing needs.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 2 residents (Resident #9) reviewed for trauma-informed care. The facility failed to ensure Resident #9 had a trauma screening completed upon admission to the facility that identified possible triggers when Resident #9 had a history of trauma. This failure could place residents with a history of trauma at risk for psychological distress due to re-traumatization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Residents #42) reviewed for infection control. SA-A did not wash or sanitize her hands, used the same pre-moistened wipe to cleanse multiple areas, and did not change gloves while performing incontinent care for Resident #42 and after disposing of contaminated PPE. SA-A touched clean items with contaminated gloves. SA-A did not remove and dispose of PPE (gown and gloves) and perform hand hygiene before leaving Resident #42's room. These failures could place residents at risk of exposure to and transmission of communicable diseases and infections.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to have a governing body who appointed a licensed administrator for 1 of 1 facilitiy reviewed for governing body. The facility did not have a licensed administrator since 09/22/2025. This failure could affect the safety and overall wellbeing of the residents and day-to-day operation of the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding for 1 of 4 residents (Resident #35) reviewed for gastrostomy tube management. The facility failed to ensure Resident #35 was provided with the correct feeding administration set up (no name, date or feeding being administered) through gastrostomy tube (g-tube, feeding tube). This failure could place residents who received feedings by gastrostomy tube at risk for injury, aspiration into the lungs (fluid or food enter the lungs accidently), decreased quality of life, hospitalization and decline in health, weight loss and poor wound healing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment 3 of 3 shower rooms reviewed for environment. (North Wing, East Wing and Rehabilitation hall). The facility failed to ensure the shower rooms on the North Wing, East Wing and Rehabilitation hall were free of a black substance in between the tiles. This failure could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review Level 1(PASRR) Screening for 1 of 5 residents reviewed for PASRR (Resident #48). The facility failed to ensure Resident #48 had an accurate PASRR Level 1 Screening indicating a diagnosis of mental illness on 06/30/2023. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 2 of 3 residents (Residents # 216 and 218) reviewed for care plans. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 5 residents (Resident #23) reviewed for smoking. The facility failed to ensure the Safe Smoking Assessment was completed and implemented for Resident #23. The failure placed residents at risk of cigarette burns and unsafe smoking conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were offered sufficient fluid intake to maintain weight and health 1 of 8 residents (Resident # 15) reviewed for hydration. The facility failed to ensure Resident #15 received a daily nutritional supplement. This failure could place residents at risk for unplanned weight loss, malnutrition, and failure to thrive.