Deficiencies (last 3 years)
Deficiencies (over 3 years)
6.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
91% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 5
Date: Jul 23, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, pharmaceutical services, food safety, infection control, and smoking policies at The Highlands Nursing and Rehabilitation.
Findings
The facility was found deficient in multiple areas including failure to provide appropriate occupational therapy services to a resident with limited mobility, incomplete narcotic log documentation, improper food handling and sanitation practices in the kitchen, inadequate infection prevention and control practices including improper handling of linens and reusable equipment, and failure to implement smoking policies and maintain a clean smoking area.
Deficiencies (5)
Failure to provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Failure to provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist, including incomplete narcotic logs and missing nurse signatures.
Failure to procure food from approved sources and store, prepare, distribute and serve food in accordance with professional standards, including improper hand hygiene, failure to wear beard nets, and inadequate cleaning and sanitizing of food processing equipment.
Failure to provide and implement an infection prevention and control program, including improper handling and storage of linens and failure to sanitize reusable equipment between residents.
Failure to have and implement policies on smoking, including failure to inform a resident of the smoking policy and maintain a clean smoking area.
Report Facts
Therapy visits: 5
Narcotic log missing signatures: 4
Residents affected: 4
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MA-A | Failed to sanitize blood pressure cuff between residents and passed medications. | |
| DOR | Director of Rehabilitation | Interviewed regarding therapy services and Medicaid pending status for Resident #22. |
| BOM | Back Office Manager | Interviewed regarding Medicaid application status for Resident #22. |
| DOO | Director of Operations | Interviewed regarding therapy approval process and staffing. |
| DON | Director of Nursing | Interviewed regarding therapy services and narcotic count policy. |
| MA-B | Reported agency nurses worked shifts with missing narcotic counts. | |
| MA-C | Explained narcotic count policy and infection control procedures. | |
| RN-A | Registered Nurse | Counted narcotics and discussed narcotic count policy. |
| LVN-A | Licensed Vocational Nurse | Worked weekend shifts with missing narcotic counts. |
| CK 1 | Cook | Observed failing to wear beard net properly and not sanitizing food processor between uses. |
| CK 2 | Cook | Observed not wearing gloves while plating food. |
| DM | Dietary Manager | Interviewed regarding food safety and sanitation policies. |
| LS-A | Observed pushing uncovered laundry cart. | |
| AD | Activity Director | Observed providing smoking breaks and interviewed about smoking policy enforcement. |
| LM | Interviewed regarding linen delivery policy. | |
| CNA-A | Certified Nursing Assistant | Interviewed regarding linen and reusable equipment cleaning policies. |
| RN-A | Registered Nurse | Interviewed regarding linen and reusable equipment cleaning policies. |
| ADM | Administrator | Interviewed regarding narcotic count and linen delivery policies. |
Inspection Report
Routine
Deficiencies: 5
Date: Jun 13, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, quality of care, food safety, infection control, and physical environment in a nursing and rehabilitation facility.
Findings
The facility was found deficient in multiple areas including failure to deliver mail on weekends affecting resident rights, failure to follow wound care orders for a resident, improper food safety practices in the kitchen, inadequate infection prevention and control practices including hand hygiene and equipment sanitization, and failure to maintain a working call light for a resident.
Deficiencies (5)
Failure to ensure residents had the right to send and receive mail on weekends, resulting in delayed mail delivery for 11 residents.
Failure to ensure Resident #31's wound care orders were followed daily, leading to missed dressing changes and potential risk of wound worsening or infection.
Failure to ensure kitchen staff cleaned and sanitized the blender between pureed food items, risking food contamination and foodborne illness.
Failure to establish and maintain an infection prevention and control program, including improper hand hygiene and failure to sanitize equipment between residents, placing residents at risk for communicable diseases and infections.
Failure to ensure Resident #40 had a working call light in the room, risking inability to call for assistance when needed.
Report Facts
Residents affected: 11
Residents affected: 1
Residents affected: 1
Residents affected: 5
Dates of wound care order missed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN-B | Licensed Vocational Nurse | Named in wound care deficiency related to Resident #31 dressing changes |
| DON | Director of Nursing | Named in wound care and infection control deficiencies |
| ADON | Assistant Director of Nursing | Named in wound care and infection control deficiencies |
| ADM | Administrator | Named in mail delivery, wound care, infection control, and call light deficiencies |
| MA | Medication Aide | Named in infection control deficiency related to hand hygiene and equipment sanitization |
| MNT | Maintenance Staff | Named in call light deficiency and maintenance of call light system |
| [NAME] E | Kitchen Staff | Named in food safety deficiency related to blender sanitization |
| [NAME] F | Kitchen Staff | Named in food safety deficiency related to blender sanitization |
| CNA-C | Certified Nursing Assistant | Named in wound care and infection control deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Dec 28, 2023
Visit Reason
The inspection was initiated due to a complaint investigation concerning the facility's failure to thoroughly investigate alleged violations of abuse, neglect, exploitation, or misappropriation of property related to Resident #1, who was diagnosed with a Fentanyl overdose on 12/25/2023.
Complaint Details
The complaint investigation was triggered by the Fentanyl overdose of Resident #1 on 12/25/2023. The facility failed to investigate the incident promptly and thoroughly. Resident #1's family members reported concerns about lack of visitor sign-in and possible drug access. The facility's Interim Administrator admitted to not reporting the incident promptly due to assumptions about Resident #1's drug history. The Immediate Jeopardy was identified on 12/28/2023 and removed on 12/29/2023 after corrective actions.
Findings
The facility failed to investigate the Fentanyl overdose incident involving Resident #1, who has a history of drug abuse, resulting in an Immediate Jeopardy (IJ) identified on 12/28/2023. The facility lacked a comprehensive care plan addressing Resident #1's drug abuse history, failed to ensure adequate supervision to prevent access to illegal drugs, and had no effective visitor sign-in process. The IJ was removed on 12/29/2023 after corrective actions, but the facility remained out of compliance at a severity of actual harm due to the need to evaluate corrective system effectiveness.
Deficiencies (4)
Failure to respond appropriately to all alleged violations of abuse, neglect, exploitation, or misappropriation of property, specifically failing to investigate Resident #1's Fentanyl overdose.
Failure to develop and implement a comprehensive person-centered care plan for Resident #1 that included measurable objectives and timetables to meet medical, nursing, and psychosocial needs, including history of drug abuse.
Failure to ensure adequate supervision to prevent accidents, specifically failure to prevent access to illegal drugs for Resident #1.
Failure to maintain a resident environment free of accident hazards, including lack of effective visitor sign-in process and enforcement.
Report Facts
Date of Fentanyl overdose: Dec 25, 2023
Date Immediate Jeopardy identified: Dec 28, 2023
Date Immediate Jeopardy removed: Dec 29, 2023
BIMS score: 12
Oxygen level: 81
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN C | Registered Nurse | Documented Resident #1's progress notes on 12/25/2023 and assessed Resident #1 during overdose incident. |
| ADM | Interim Administrator | Notified of Fentanyl overdose on 12/26/2023, admitted to delayed investigation and lack of reporting. |
| LVN D | Licensed Vocational Nurse | Resident #1's usual nurse, interviewed regarding visitation and drug requests. |
| [NAME] President of Clinical Operations | President of Clinical Operations | Responsible for staff education and monitoring corrective actions. |
| MDS Nurse | MDS Nurse | Responsible for care plans and updating Resident #1's care plan post-incident. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Dec 13, 2023
Visit Reason
The inspection was conducted as an annual survey of The Highlands Nursing and Rehabilitation facility to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection, indicating the facility met the required standards at the time of the survey.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 10, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to ensure accurate Pre-admission Screening and Resident Review (PASARR) Level I Screening for residents diagnosed with mental illness, specifically for Resident #3.
Complaint Details
The complaint investigation revealed that Resident #3's PASARR Level I screening was inaccurately completed, and no PASARR Level II screening was found after 01/26/22. The facility staff acknowledged the error and the potential for the resident to miss needed services. The complaint was substantiated based on interviews and record reviews.
Findings
The facility failed to ensure that Resident #3's PASARR Level I screening was completed accurately and that Resident #3 was provided with a PASARR Level II Screening. This failure could place residents at risk for inappropriate placement and lack of appropriate care and services. Interviews and record reviews confirmed inaccuracies in Resident #3's PASARR screenings and lack of Level II screening after 01/26/22.
Deficiencies (1)
Failure to ensure all PASARR Level I Screenings for residents diagnosed with mental illness were accurate and failure to provide PASARR Level II Screening for Resident #3.
Report Facts
Residents Affected: 2
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Responsible for checking accuracy of PASARR screenings and identified the error with Resident #3's PASARR | |
| ADM | Administrator | Stated MDS nurse and social worker are responsible for PASARR accuracy; was not aware of the error until informed by LVN A |
| DON | Director of Nursing | Stated LVN A was responsible for PASARR accuracy and was unaware of the inaccurate PASARR for Resident #3 |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 29, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding abuse and inadequate supervision of residents, specifically related to an incident where Resident #1 was assaulted by Resident #4 resulting in Resident #1's death.
Complaint Details
The complaint investigation substantiated that Resident #1 was assaulted by Resident #4 on [DATE], resulting in Resident #1's hospitalization and subsequent death. An Immediate Jeopardy (IJ) was identified and later removed after corrective actions, but the facility remained out of compliance due to incomplete staff training and inadequate supervision.
Findings
The facility failed to protect Resident #1 from abuse by Resident #4, who had a history of aggressive behavior. Resident #1, a known wanderer, was not adequately supervised and was assaulted in Resident #4's room, leading to serious injuries and death. The facility also failed to provide adequate supervision and devices to prevent accidents for both residents. Staff training on abuse/neglect and supervision was incomplete, and monitoring was insufficient.
Deficiencies (2)
Failed to protect Resident #1 from abuse by Resident #4 resulting in death.
Failed to provide adequate supervision and devices to prevent accidents for Resident #1 and Resident #4.
Report Facts
Residents reviewed for abuse: 8
Residents affected: 2
Staff trained on Dementia care: 73
Staff needing Dementia care training: 17
Staff trained on mealtime monitoring: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Provided one-on-one care and supervision on day of incident; witnessed Resident #1 in Resident #4's doorway |
| LVN B | Licensed Vocational Nurse | Observed Resident #1 wandering; trained on abuse/neglect; did not redirect Resident #1 prior to assault |
| LVN D | Licensed Vocational Nurse | Assaulted by Resident #2; described Resident #1 as wanderer and supervision efforts |
| ADM | Administrator | Provided statements on supervision and incident; informed of Immediate Jeopardy |
| DON | Director of Nursing | Described supervision practices and staff training; stated rounds every two hours |
| ADON | Assistant Director of Nursing | Described supervision and use of wander guard for Resident #1 |
| LE | Law Enforcement | Reported assault incident and investigation status |
| MD | Medical Doctor | Reported Resident #1's death due to injuries from assault |
| CNA A | Certified Nursing Assistant | Reported monitoring Resident #1 and Resident #4; described Resident #4's behavior |
| CNA B | Certified Nursing Assistant | Reported monitoring Resident #1 and Resident #4; described Resident #4's behavior |
| CNA C | Certified Nursing Assistant | Reported monitoring Resident #1 and Resident #4; described Resident #4's behavior |
| CNA D | Certified Nursing Assistant | Trained on abuse/neglect; described monitoring and reporting protocols |
| CNA E | Certified Nursing Assistant | Trained on abuse/neglect; described monitoring and reporting protocols |
| CNA F | Certified Nursing Assistant | Trained on abuse/neglect; described monitoring and reporting protocols |
| LVN C | Licensed Vocational Nurse | Described Resident #1 as wanderer and supervision practices |
Inspection Report
Routine
Deficiencies: 3
Date: Mar 10, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident environment, medication storage, and physical safety features at The Highlands Nursing and Rehabilitation facility.
Findings
The facility was found to have multiple deficiencies including an unclean resident room with soiled items on the floor, an unattended and unlocked medication/treatment cart, and a missing handrail in a hallway. These issues posed risks to resident safety, infection control, and quality of life.
Deficiencies (3)
Failed to provide a safe, functional, sanitary, and comfortable environment in Resident #6's room, including unclean floor, bedside table, and trash can with soiled clothing and linen on the floor.
Failed to ensure that all drugs and biologicals were stored in locked compartments; treatment cart on Hall 1 West was unattended and unlocked.
Failed to repair or replace missing handrail outside room in the middle hall of 1 West, posing a safety hazard.
Report Facts
Rooms reviewed: 42
Medication/treatment carts reviewed: 5
Length of missing handrail: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN B | Licensed Vocational Nurse | Interviewed regarding Resident #6's room cleanliness and treatment cart being unlocked |
| ADON | Assistant Director of Nursing | Interviewed regarding Resident #6's behavior and treatment cart keys |
| DON | Director of Nursing | Interviewed regarding expectations for resident room cleanliness and medication cart security |
| LVN C | Treatment Nurse | Interviewed regarding treatment cart locking procedures |
| Administrator (AD) | Administrator | Interviewed regarding medication cart security and missing handrail |
| Maintenance Manager | Maintenance Manager | Interviewed regarding missing handrail and maintenance responsibilities |
| CNA - A | Certified Nursing Assistant | Observed and interviewed regarding unlocked treatment cart |
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