Highland House: Pain Meds Denied, Dialysis Missed - OR
Highland House Nursing & Rehabilitation Center failed to provide adequate pain management and medical services to multiple residents during a June inspection that revealed systematic breakdowns in basic care.
Resident 85 arrived at Highland House in 2023 following fractures to both arms and legs. Pain assessments showed the injuries disrupted sleep and social activities, with the resident reporting constant pain for five consecutive days during admission.
Staff prescribed oxycodone every four hours while awake starting November 24, 2023. Over the next four days, Resident 85 missed six scheduled doses. Medication records showed staff simply marked doses as "not administered" without explanation.
On November 27, doctors switched the prescription to Percocet every four hours. Nursing notes indicated this medication was also "not available." No alternative pain relief was provided.
During this period, Resident 85's pain levels ranged from four to nine on a 10-point scale. Levels of four to six indicate moderate pain, while seven and above represent severe pain.
A physical therapy session on November 27 documented Resident 85 reporting pain levels of six in the leg and eight in the wrist. The resident told therapists about frustration "with not having proper pain medications."
Former nurse Staff 43 confirmed to inspectors that Resident 85 "was not administered pain medications as prescribed." The Director of Nursing Services acknowledged an "oxycodone shortage" in November 2023 but could not provide documentation that alternative pain medications were added when prescribed drugs were unavailable.
A second pain management failure occurred during the inspection itself. Resident 339 was admitted on June 13, 2024, at 11:45 AM with a fractured left femur.
The resident called family members that night reporting no pain medication since admission. During inspector interviews the next morning, Resident 339 confirmed requesting pain medication multiple times after admission and again during the overnight hours, receiving nothing until 8:30 AM on June 14.
A nursing assistant working the night shift confirmed Resident 339 "requested pain medications during the night" and that she informed the nurse. Medication records showed the first dose was finally administered at 8:09 AM on June 14, nearly 20 hours after admission.
The Director of Nursing Services told inspectors that emergency pain medications were available in the facility's emergency kit, which "every nurse had access to." The DNS stated Resident 339 "should have received her/his pain medications when she/he requested it."
Beyond pain management failures, Highland House failed to ensure a kidney patient received life-sustaining dialysis treatment.
Resident 134 was admitted in 2023 with kidney disease requiring dialysis three times weekly on Mondays, Wednesdays, and Fridays. Hospital discharge orders clearly specified this schedule.
On December 11, 2023, Resident 134 missed a Monday dialysis appointment due to lack of transportation. A former facility nurse reported to state surveyors on December 12 that "the facility did not follow up with transportation for Resident 134."
The same nurse later confirmed to inspectors that Highland House "was aware Resident 134 required transportation to the dialysis unit, the paperwork was submitted, but they did not transport the resident."
A dialysis center nurse verified that Resident 134 missed the December 11 treatment "due to lack of transportation" and explained that nursing facilities are responsible for ensuring residents get to and from dialysis appointments.
When inspectors requested an explanation for the missed treatment, the Director of Nursing Services confirmed Resident 134 "did not go to dialysis" but provided no rationale for the failure.
The facility also failed to follow through on basic medical orders. Resident 134 experienced painful urination in December 2023, prompting a physician to order a urine sample on December 11. No results were found in the resident's medical record, and facility staff could not provide the missing test results when requested.
Similarly, Resident 133 was prescribed antibiotics every four hours for an infection but missed multiple doses. In November 2023, the resident did not receive prescribed antibiotics on five separate occasions. The following month, three more doses were missed.
A licensed practical nurse explained the electronic medication system required staff to mark each dose as administered, refused, or note if the resident was unavailable. The nurse stated medication records "should not be blank for scheduled medications."
Highland House also violated federal requirements for posting daily staffing information. Inspectors found multiple days in May and June 2024 where resident census numbers were missing from required staffing reports.
On June 11, the night shift section of the staffing report was completely blank, showing no resident count, staff numbers, or hours worked. Similar gaps appeared on June 5, 6, and 8.
The Administrator, Director of Nursing Services, and Regional Director of Clinical Services told inspectors that accurate staffing reports were expected within one hour of each shift change.
Staff training violations also emerged during the inspection. Three of five randomly selected certified nursing assistants had not completed required annual training hours. Federal regulations require CNAs to complete 12 hours of in-service training each year.
Staff 3, employed since 2006, completed only 10 hours of documented training. Staff 5, hired in 2010, completed just six hours. Staff 6, working at the facility since 2016, also completed only 10 hours.
The facility's leadership acknowledged that all staff were expected to complete the full 12 hours of annual training but could not explain why multiple employees fell short of requirements.
Highland House's failures span the most basic elements of nursing home care: pain relief for suffering residents, transportation to life-sustaining medical treatments, completion of physician-ordered tests, and proper medication administration. Each violation represents not just a regulatory failure, but a breakdown in the fundamental promise to provide competent, compassionate care to vulnerable residents who depend entirely on facility staff for their health and wellbeing.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Highland House Nursing & Rehabilitation Center from 2024-06-14 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Highland House Nursing & Rehabilitation Center
- Browse all OR nursing home inspections
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 15, 2026 · Our methodology
HIGHLAND HOUSE NURSING & REHABILITATION CENTER in GRANTS PASS, OR was cited for violations during a health inspection on June 14, 2024.
Resident 85 arrived at Highland House in 2023 following fractures to both arms and legs.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at HIGHLAND HOUSE NURSING & REHABILITATION CENTER?
- Resident 85 arrived at Highland House in 2023 following fractures to both arms and legs.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in GRANTS PASS, OR, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from HIGHLAND HOUSE NURSING & REHABILITATION CENTER or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 385149.
- Has this facility had violations before?
- To check HIGHLAND HOUSE NURSING & REHABILITATION CENTER's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.