The facility's chronic confusion and dementing illness unit reached dangerous conditions on June 21, with temperatures hitting 91 degrees outside and no working air conditioning inside. Staff watched condensation build up on hallway and dining room floors but failed to notify management or maintenance for hours.
"The unit got to the point of condensation on floors in the hallways and dining room when the air went out, so she became worried residents would have fallen," Licensed Practical Nurse Staff H told inspectors about her shift that evening.
Staff H described the unit as "hot, extremely hot" during her 6 p.m. to either 10 p.m. or 6 a.m. shift on June 21. The malfunction had never been repaired while she worked there, she said.
Registered Nurse Staff C confirmed the overnight shift from 10 p.m. to 6 a.m. brought "quite a bit of humidity" that caused floors to become wet and slippery as residents with dementia wandered throughout the unit. Certified Nursing Assistant Staff D spent the night periodically dry mopping to minimize moisture buildup.
Nobody called for help.
The next morning brought no relief. Certified Nursing Assistant Staff E worked the 6 a.m. to 2 p.m. shift and found conditions "really warm and humid, without any air flow." She observed water on floors inside resident rooms and confirmed that staff had failed to inform management about the dangerous temperatures.
The facility's 68 residents endured the conditions until a housekeeper finally made the call.
Staff F from housekeeping contacted the Director of Human Resources and Interim Administrator sometime on June 21 or 22, reporting that the chronic confusion unit was hot, floors were wet with humidity, and staff couldn't keep them dry. The administrator immediately called maintenance.
Staff G, the maintenance worker, received his first call on June 22 at 6:30 a.m. "When he arrived at the facility he knew something had been wrong," inspectors wrote. He cleaned the air unit, changed filters, and went home.
By 12:30 p.m. that same day, Staff F called again. The floors were still "sweaty." Staff G returned with more fans and dehumidifiers.
The facility had fans and dehumidifiers on hand, but Staff G purchased additional dehumidifiers and portable air units the following Monday for both the dementia unit and part of the assisted living area. Those were the only sections affected by the air conditioning malfunction.
The Director of Operations told inspectors that charge nurses should have called to inform him of the situation. If nurses failed to act, direct care staff should have called instead.
The breakdown in communication left vulnerable residents at risk. Dementia patients often wander and may not understand or communicate discomfort from heat. The combination of excessive warmth, humidity, and slippery floors created multiple hazards during a period when outdoor temperatures averaged 84 degrees with a high of 91.
Federal inspectors cited The Highlands for failing to provide adequate ventilation through windows or mechanical systems. The violation carried a designation of "minimal harm or potential for actual harm" and affected some residents.
The incident revealed gaps in the facility's emergency response procedures. Multiple staff members recognized dangerous conditions but failed to follow protocols for notifying management or maintenance. The delay in addressing the mechanical failure extended residents' exposure to unsafe conditions for at least 12 hours, possibly longer.
Staff members' accounts differed on timing. The interim administrator thought staff contacted her on June 21 but acknowledged the call could have come on June 22. The maintenance worker received his first call on June 22 morning, suggesting the problem persisted through at least one full overnight shift without intervention.
The facility's response once notified included immediate cleaning and filter replacement, followed by additional equipment when initial repairs proved insufficient. However, the delayed notification meant residents with cognitive impairments faced an extended period of dangerous environmental conditions.
Weather data confirmed the challenging conditions, with minimum overnight temperatures of 77 degrees on June 21. Combined with failed air conditioning in an institutional setting, these temperatures created the humid, overheated environment that staff described as "extremely hot" and dangerous for residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Highlands from 2025-09-23 including all violations, facility responses, and corrective action plans.