Safety Report: Highland Manor Rehabilitation and Nursing Center
How to read this report. Every nursing home receives some citations. One citation does not mean a facility is unsafe. Look at how serious the findings were, whether the same problems keep coming back, and whether things are getting better or worse. Learn how inspections work.
Official ratings
Medicare's star ratings compare nursing homes within the same state for health inspections. A 5-star facility performed better than most in its state; a 1-star facility performed worse than most.
Stars are calculated by CMS, not by us. We do not create our own safety score.
Serious documented violations
0Immediate jeopardy citations (severity J–L)
1Actual harm citations (severity G–I)
5Requirements cited on more than one inspection
G
Government finding: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · Tag F689
Citations by topic
1Abuse, neglect & exploitation
1Infection control
4Medications & pharmacy
1Accidents & supervision
Topics use CMS's own deficiency categories; “accidents & supervision” counts tag F689 (free of accident hazards / adequate supervision). Counts cover the last three inspection cycles, including complaint investigations.
Is it getting better or worse?
Fewer citations in the most recent cycle (7) than in the cycle before (9).
An inspection cycle is roughly one year and includes the standard inspection plus complaint investigations. Counts depend partly on how many complaint investigations occurred, so treat small changes with caution. Red bars include at least one serious citation.
Staffing and rating trends will appear as we collect monthly CMS releases. We have one month so far, so a staffing trend cannot yet be determined.
Repeat findings
These requirements were cited on more than one inspection date in the last three cycles.
| Requirement | Times cited | Inspection dates |
|---|---|---|
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. (F584) | 3 | September 11, 2025; October 8, 2024; January 10, 2024 |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. (F761) | 2 | August 21, 2026; January 10, 2024 |
| Honor the resident's right to organize and participate in resident/family groups in the facility. (F565) | 2 | August 21, 2026; January 10, 2024 |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (F550) | 2 | June 18, 2025; March 6, 2024 |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. (F686) | 2 | December 19, 2024; January 10, 2024 |
Fines and enforcement
| Date | Type | Amount / length |
|---|---|---|
| November 14, 2023 | Fine | $19,760 |
Federal civil money penalties and Medicare/Medicaid payment denials. State-level penalties may not be included.
Complete inspection history
August 21, 2026 — 5 citations
D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F761
D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F755
D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F740
D
Provide safe and appropriate respiratory care for a resident when needed.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F695
D
Honor the resident's right to organize and participate in resident/family groups in the facility.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F565
May 27, 2026 — 2 citations · complaint investigation
E
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
No actual harm, but potential for more than minimal harm · Pattern · Nursing and Physician Services Deficiencies · F726 · complaint · corrected June 23, 2026
D
Ensure services provided by the nursing facility meet professional standards of quality.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F658 · complaint · corrected June 23, 2026
September 11, 2025 — 1 citation · complaint investigation
E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F584 · complaint · corrected October 7, 2025
June 18, 2025 — 1 citation · complaint investigation
E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F550 · complaint · corrected July 22, 2025
December 19, 2024 — 6 citations
D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F756 · corrected January 28, 2025
D
Provide safe, appropriate pain management for a resident who requires such services.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F697 · corrected January 28, 2025
D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F686 · corrected January 28, 2025
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · corrected January 28, 2025
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F656 · corrected January 28, 2025
D
Respond appropriately to all alleged violations.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F610 · corrected January 28, 2025
October 8, 2024 — 1 citation · complaint investigation
E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F584 · complaint · corrected November 5, 2024
March 6, 2024 — 2 citations · complaint investigation
E
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F807 · complaint · corrected April 2, 2024
E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F550 · complaint · corrected April 2, 2024
January 10, 2024 — 14 citations (includes serious)
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F689 · corrected February 8, 2024
F
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Widespread · Infection Control Deficiencies · F880 · corrected February 8, 2024
E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F761 · corrected February 8, 2024
E
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F744 · corrected February 8, 2024
E
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F690 · corrected February 8, 2024
E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F686 · corrected February 8, 2024
E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F584 · corrected February 8, 2024
E
Honor the resident's right to organize and participate in resident/family groups in the facility.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F565 · corrected February 8, 2024
D
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
No actual harm, but potential for more than minimal harm · Isolated · Nutrition and Dietary Deficiencies · F808 · corrected February 8, 2024
D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F698 · corrected February 8, 2024
D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F693 · corrected February 8, 2024
D
Ensure each resident receives an accurate assessment.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F641 · corrected February 8, 2024
D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F640 · corrected February 8, 2024
D
Assess the resident when there is a significant change in condition
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F637 · corrected February 8, 2024
November 14, 2023 — 1 citation · complaint investigation
E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
No actual harm, but potential for more than minimal harm · Pattern · Nursing and Physician Services Deficiencies · F725 · complaint · corrected February 8, 2024
Source: CMS Health Deficiencies dataset (data as of October 1, 2026); full inspection narratives on Medicare Care Compare