Inspection Reports for Highland Park Rehabilitation & Nursing Center
TX, 77022
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
157% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 2
Jun 27, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, specifically focusing on nutrition and respiratory care.
Findings
The facility was found to have immediate jeopardy deficiencies related to failure to maintain adequate nutrition and respiratory care for residents. Resident #67 experienced significant unmonitored weight loss and malnutrition risks, while Resident #43 did not receive appropriate respiratory care including oxygen and nebulizer treatments as ordered.
Severity Breakdown
Level of Harm - Immediate jeopardy to resident health or safety: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide enough food/fluids to maintain a resident's health, resulting in significant weight loss for Resident #67. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to provide safe and appropriate respiratory care including oxygen administration and nebulizer treatments for Resident #43. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Weight loss percentage: 14.5
Weight measurements: 171
Weight measurements: 146.2
Oxygen saturation: 90
Oxygen saturation: 80
Oxygen flow rate: 3
Oxygen flow rate: 5
Albuterol nebulizer dose: 2.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Monitored Resident #67's meal intake and administered feeding assistance; also administered Albuterol nebulizer treatment to Resident #43. | |
| RN E | Monitored Resident #67 and Resident #43's respiratory and nutritional status; provided observations during survey. | |
| Unit Manager A | Provided information on nutrition monitoring and respiratory care practices for Residents #67 and #43. | |
| DON | Director of Nursing | Oversaw nutrition and respiratory care interventions and education; confirmed implementation of plan of removal. |
| Administrator | Notified of Immediate Jeopardy findings and involved in education and corrective action plans. | |
| NP B | Nurse Practitioner | Provided clinical assessments and orders related to Resident #43's respiratory care. |
Inspection Report
Routine
Deficiencies: 4
Sep 10, 2024
Visit Reason
The inspection was conducted to assess compliance with resident rights, dignity, catheter care, and nursing staffing postings at Highland Park Care Center.
Findings
The facility failed to maintain resident dignity by not covering catheter bags and residents during transport, and failed to ensure proper catheter care including securing catheter stabilizers and preventing tubing kinks. Additionally, the facility did not post daily nursing staffing information as required.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Level of Harm - Potential for minimal harm: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Resident #1 did not have a privacy covering on his catheter bag. | Level of Harm - Minimal harm or potential for actual harm |
| Resident #2 was not fully covered and was partially exposed while transported to the shower room. | Level of Harm - Minimal harm or potential for actual harm |
| Resident #1's catheter stabilizer was not in place and catheter tubing was kinked, preventing urine flow. | Level of Harm - Minimal harm or potential for actual harm |
| The facility failed to post the daily nursing staffing information on 9/10/2024. | Level of Harm - Potential for minimal harm |
Report Facts
Residents reviewed for resident right: 7
Residents reviewed for incontinent care and indwelling urinary catheters: 3
Residents affected by dignity and catheter care deficiencies: 2
Residents affected by catheter care deficiencies: 1
Residents affected by staffing posting deficiency: Many
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Mentioned in relation to failure to cover Resident #1's catheter bag and Resident #2 during transport, and catheter care. | |
| CNA B | Mentioned in relation to Resident #2's transport and coverage. | |
| WC A | Responsible for catheter care; commented on catheter privacy cover and stabilizer. | |
| DON | Director of Nursing | Responsible for training aides on resident rights and nursing staffing postings. |
| ADON | Assistant Director of Nursing | Commented on dignity during resident transport and CNA training. |
| Receptionist | Responsible for posting daily nursing staffing information; failed to update for two days. | |
| Staffing Coordinator | Responsible for daily nurse staffing posting. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Apr 24, 2024
Visit Reason
The inspection was conducted due to complaints regarding inadequate pressure ulcer care for Resident #16 and inaccurate medical record maintenance for Resident #52.
Findings
The facility failed to provide appropriate pressure ulcer care for Resident #16 by not applying physician-ordered pressure relieving heel protectors or off-loading his heels, risking worsening of pressure ulcers. Additionally, the facility failed to maintain accurate and complete medical records for Resident #52, including failure to correctly transcribe physician orders for PEG tube feeding and maintain the April 2024 MAR, risking medication errors and malnutrition.
Complaint Details
The complaint investigation focused on pressure ulcer care deficiencies for Resident #16 and medical record inaccuracies for Resident #52. The facility was found to have failed in both areas, with substantiated findings of inadequate care and documentation.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to apply physician ordered pressure relieving heel protectors or off-load heels for Resident #16 with Stage 4 pressure ulcer. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain complete, accurate, and accessible medical records for Resident #52, including transcription errors and missing April 2024 MAR for PEG tube feeding. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Pressure ulcer size: 3.8
Pressure ulcer size: 3.3
Pressure ulcer size: 0.4
PEG tube feeding rate: 60
Water flush volume: 30
Fluid intake: 500
Weight maintenance goal: 130
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN H | Licensed Vocational Nurse | Knew the correct PEG feeding and rate for Resident #52 despite missing MAR |
| Wound Care Nurse | Responsible for treating wounds and performing skin assessments for Resident #16 | |
| NP A | Nurse Practitioner | Provided clarification on PEG tube feeding orders for Resident #52 |
| DON | Director of Nursing | Interviewed regarding PEG tube feeding orders and potential medication errors |
| ADON | Assistant Director of Nursing | Corrected PEG tube feeding orders and printed new MAR for Resident #52 |
Inspection Report
Deficiencies: 6
Apr 24, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, infection control, and medical record maintenance at Highland Park Care Center.
Findings
The facility was found deficient in multiple areas including failure to refer a resident for PASARR evaluation, incomplete and inaccurate resident-centered care plans, failure to provide appropriate pressure ulcer care, medication errors exceeding the acceptable rate, failure to maintain accurate and complete medical records, and inadequate infection prevention practices related to PPE use.
Deficiencies (6)
| Description |
|---|
| Failed to refer Resident #28 for level II PASARR evaluation after diagnosis of schizophreniform disorder. |
| Failed to create comprehensive resident-centered care plans for CR #89 and Resident #52, including conflicting code status documentation. |
| Failed to apply physician-ordered pressure relieving heel protectors and off-load heels for Resident #16 with Stage 4 pressure ulcer. |
| Medication error rate of 8% due to incorrect doses of Famotidine, Furosemide, and Polyethylene Glycol 3350 administered to Resident #3. |
| Failed to maintain complete and accurate medical records for Resident #52, including incorrect transcription of PEG tube feeding orders and missing April 2024 MAR for PEG feeding. |
| Failed to maintain infection prevention and control practices; CNA staff did not wear gowns as required by Enhanced Barrier Precautions when providing care to Resident #16. |
Report Facts
Medication error rate: 8
Stage 4 pressure ulcer size: 3.8
Stage 4 pressure ulcer size: 3.3
Stage 4 pressure ulcer size: 0.4
BIMS score: 12
BIMS score: 7
BIMS score: 10
BIMS score: 12
Feeding tube fluid intake: 500
Medication doses: 40
Medication doses: 20
Medication doses: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| MA B | Medication Aide | Administered incorrect doses of medications to Resident #3 |
| MDS Coordinator | Responsible for PASARR evaluations; acknowledged failure to re-evaluate Resident #28 | |
| WCN | Wound Care Nurse | Provided wound care for Resident #16 and commented on pressure offloading boots usage |
| DON | Director of Nursing | Provided information on care plans and medication administration procedures |
| ADON | Assistant Director of Nursing | Discussed medication administration and missing PEG feeding MAR for Resident #52 |
| LVN H | Licensed Vocational Nurse | Knew correct PEG feeding orders for Resident #52 despite missing MAR |
| CNA R | Certified Nursing Assistant | Failed to wear gowns during incontinence care for Resident #16 on Enhanced Barrier Precautions |
| CNA Z | Certified Nursing Assistant | Failed to wear gowns during incontinence care for Resident #16 on Enhanced Barrier Precautions |
| NP A | Nurse Practitioner | Clarified PEG tube feeding orders for Resident #52 |
| MD A | Physician | Ordered pressure ulcer care and PEG feeding orders for residents |
Inspection Report
Routine
Deficiencies: 3
Apr 8, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding care and assistance for residents unable to perform activities of daily living, and pharmaceutical services.
Findings
The facility failed to provide scheduled showers three times a week and timely incontinence care to multiple residents, placing them at risk of skin breakdown and infection. Additionally, the facility failed to administer prescribed hydrocortisone cream to a resident for over three months, potentially worsening the resident's condition.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide scheduled showers three times a week to Residents #10, #19, #24, #33, and #37. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide incontinence care every 2 hours and/or as needed to Residents #9, #33, #34, and #35. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to administer prescribed hydrocortisone PRN medication to Resident #9 for 3 months and 8 days. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Missed showers: 6
Missed showers: 8
Missed showers: 7
Medication non-administration duration: 98
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA J | Shower Technician | Provided showers on Mon/Wed/Fri for even beds and Tue/Thu/Sat for odd beds; reported procedures for refusals and shower scheduling. |
| Treatment Nurse | Spoke about shower and incontinence care issues, acknowledged medication administration failure for Resident #9. | |
| LVN N | Licensed Vocational Nurse | Acknowledged Resident #9's hydrocortisone medication was on the MAR but was not administered. |
| Administrator | Expressed expectation that residents receive showers three times a week and acknowledged issues with shower provision. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Feb 17, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to coordinate PASARR screenings, failure to provide necessary assistance with activities of daily living including scheduled showers, improper gastrostomy tube medication administration, and medication errors.
Findings
The facility failed to properly coordinate PASARR Level II assessments for residents with mental illness, failed to ensure scheduled showers and ADL assistance for several residents, improperly administered medications via gastrostomy tube including failure to check placement and crushing enteric coated medications, and had a medication error rate of 18% involving incorrect medication administration and timing errors.
Complaint Details
The complaint investigation revealed failures in PASARR screening coordination, ADL care including showering, gastrostomy tube medication administration, and pharmaceutical services leading to medication errors.
Deficiencies (5)
| Description |
|---|
| Failed to coordinate PASARR Level II assessments for residents with mental illness. |
| Failed to ensure residents received scheduled showers and necessary ADL assistance. |
| Failed to properly check gastrostomy tube placement and administered crushed enteric coated medication. |
| Failed to provide pharmaceutical services to meet resident needs, including administering incorrect medications and improper medication administration techniques. |
| Medication error rate of 18% due to multiple medication administration errors including wrong drug strength, timing, and dosage. |
Report Facts
Residents reviewed for PASARR: 6
Residents reviewed for ADLs: 10
Residents affected by ADL deficiencies: 3
Medication error rate: 18
Medication errors: 6
Medication administration opportunities: 32
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Failed to properly check gastrostomy tube placement and administered crushed enteric coated medication. |
| MA A | Medication Aide | Administered incorrect medication strengths and doses, including Lidocaine 4% instead of 5%, and incorrect Lactulose dose. |
| RN A | Registered Nurse | Administered Linzess medication late and regardless of food as ordered. |
| MDS Nurse | Failed to review and correct PASARR Level I forms prior to submission. | |
| Admin | Provided information on PASARR process and facility responsibilities. | |
| Shower Technician | Reported staffing shortages impacting ability to provide scheduled showers. | |
| Pharmacy Staff | Reported pharmacy did not fill Lansoprazole, only Pantoprazole was delivered. | |
| DON | Director of Nursing | Provided information on medication administration policies and errors. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Feb 17, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to coordinate PASARR screenings, failure to provide necessary assistance with activities of daily living including scheduled showers, and medication administration errors.
Findings
The facility failed to properly coordinate PASARR Level II assessments for residents with mental illness, failed to ensure scheduled showers and ADL care for several residents, and had multiple medication administration errors including incorrect medication administration and improper handling of enteric coated medications.
Complaint Details
The complaint investigation included issues with PASARR screening failures, inadequate assistance with activities of daily living, and multiple medication errors affecting several residents.
Deficiencies (5)
| Description |
|---|
| Failed to coordinate PASARR Level II assessments for residents with mental illness. |
| Failed to ensure residents received scheduled showers and necessary ADL care. |
| Failed to ensure appropriate care and medication administration for resident with gastrostomy tube, including improper placement check and crushing enteric coated medication. |
| Failed to provide pharmaceutical services to meet residents' needs, including administering incorrect medication and medication errors. |
| Medication error rate was 18%, including wrong medication strength, delayed administration, incorrect medication given, improper crushing of medication, and incorrect dosage administered. |
Report Facts
Residents reviewed for PASARR: 6
Residents reviewed for ADLs: 10
Medication error rate: 18
Medication errors: 6
Residents affected by medication errors: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Named in findings related to improper gastrostomy tube medication administration and crushing enteric coated medication. |
| MA A | Medication Aide | Named in findings related to medication errors including administering wrong medication strength and incorrect dosage. |
| RN A | Registered Nurse | Named in findings related to delayed medication administration and incorrect medication given. |
| MDS Nurse | Named in findings related to failure to properly review and forward PASARR Level I forms. | |
| Admin | Named in findings related to PASARR screening process and facility responsibilities. | |
| CNA A | Certified Nursing Assistant | Named in findings related to ADL care and shower assistance. |
| Shower Technician | Named in findings related to inability to provide all scheduled showers due to staffing. | |
| Pharmacy Staff | Named in findings related to pharmacy medication supply and errors. | |
| DON | Director of Nursing | Named in findings related to medication administration policies and facility oversight. |
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