Inspection Reports for
Highland Park Rehabilitation & Nursing Center
TX, 77022
Back to Facility ProfileCitations (last 3 years)
Citations (over 3 years)
8.7 citations/year
Citations are regulatory findings recorded during state inspections.
149% worse than Texas average
Texas average: 3.5 citations/yearCitations per year
20
15
10
5
0
Inspection Report
Annual Inspection
Citations: 2
Date: 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.
Citations (2)
Failure to provide enough food/fluids to maintain a resident's health, resulting in significant weight loss for Resident #67.
Failure to provide safe and appropriate respiratory care including oxygen administration and nebulizer treatments for Resident #43.
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
Citations: 4
Date: 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.
Citations (4)
Resident #1 did not have a privacy covering on his catheter bag.
Resident #2 was not fully covered and was partially exposed while transported to the shower room.
Resident #1's catheter stabilizer was not in place and catheter tubing was kinked, preventing urine flow.
The facility failed to post the daily nursing staffing information on 9/10/2024.
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
Citations: 10
Date: Apr 24, 2024
Visit Reason
State-compiled facility profile showing multiple inspections from April 2024 with deficiency history.
Findings
The facility had multiple deficiencies across health and life safety codes, including medication errors, incomplete care plans, infection control failures, and fire safety violations. All cited violations were corrected within specified timeframes.
Citations (10)
The facility did not prevent significant medication errors.
The facility did not develop a complete care plan that meets all of a resident's needs, with timeframes and actions that can be measured.
The facility failed to coordinate assessments with the PASRR process or incorporate PASRR recommendations into care planning and transitions.
The facility failed to make sure that the resident with pressure ulcers receives appropriate treatment and services.
The facility failed to establish and maintain an infection control program.
The facility did not keep accurate and appropriate records.
The facility failed to inspect individual sprinkler heads and maintain them in compliance with NFPA code requirements.
The facility failed to ensure electrical extension cords or multi-receptacle plug-in adaptors were not used as substitutes for approved wiring methods.
The facility failed to conduct fire drills on each work shift at least once per quarter and failed to complete required fire drill reports.
The facility failed to ensure the fire marshal inspects the facility annually.
Report Facts
Inspections on page: 2
Inspection Report
Complaint Investigation
Citations: 2
Date: 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.
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.
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.
Citations (2)
Failed to apply physician ordered pressure relieving heel protectors or off-load heels for Resident #16 with Stage 4 pressure ulcer.
Failed to maintain complete, accurate, and accessible medical records for Resident #52, including transcription errors and missing April 2024 MAR for PEG tube feeding.
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
Routine
Citations: 3
Date: 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.
Citations (3)
Failure to provide scheduled showers three times a week to Residents #10, #19, #24, #33, and #37.
Failure to provide incontinence care every 2 hours and/or as needed to Residents #9, #33, #34, and #35.
Failure to administer prescribed hydrocortisone PRN medication to Resident #9 for 3 months and 8 days.
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
Citations: 5
Date: 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.
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.
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.
Citations (5)
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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