Highlands Health: Infection Control Gaps - TN
The infection control violations at Highlands Health and Rehabilitation Center involved basic hygiene failures during wound care and catheter maintenance that could spread dangerous bacteria between residents.
LPN B entered Resident 13's room on October 13 to change a dressing on the woman's left ankle wound. The resident had multiple sclerosis, dementia and other conditions requiring careful infection prevention. Her physician had ordered wound cleaning and calcium alginate dressing changes every other day.
The nurse removed the soiled dressing and cleaned the wound with gauze and wound cleanser. Then she removed her contaminated gloves without washing her hands before putting on new gloves to apply the fresh dressing.
When inspectors asked if gloves should be changed and hand hygiene performed after removing a soiled dressing, LPN B said yes, gloves should be changed after removing the dressing. She knew the correct procedure but hadn't followed it.
The nurse also wheeled her treatment cart directly into the resident's room, violating facility policy designed to prevent cross-contamination between patients. When asked about this, LPN B said the cart shouldn't go in resident rooms but claimed the resident didn't have space for supplies on her bedside table.
Would it be better to get an additional table instead of using the treatment cart in the room? Yes, it would, LPN B acknowledged.
She also failed to clean the outside of the treatment cart after use, potentially carrying contamination to the next resident.
A separate incident involved catheter care for Resident 10, a cognitively intact man with a feeding tube and indwelling urinary catheter. His physician had ordered catheter care every shift to prevent dangerous infections that can develop when bacteria enter the urinary tract.
On October 14 at 9:42 AM, CNA C performed the catheter care but made multiple infection control errors. The aide placed wet wipes directly on the side of the resident's bed without any protective barrier, then put two trash bags on top of the bed during the procedure.
After removing the resident's brief and performing catheter care, CNA C removed her gloves and discarded the trash bags. Then she put on new gloves without washing her hands first.
The contaminated wet wipes left on the bed without a barrier could transfer bacteria from previous residents or procedures directly onto the bed linens.
During interviews, the Director of Nursing confirmed staff should wear personal protective equipment when providing care to residents with wounds, feeding tubes and catheters. She said nurses should change gloves and perform hand hygiene after removing dressings, and that staff should wash hands before and after removing gloves.
Treatment carts should not be taken into resident rooms, the DON stated.
Both residents were cognitively intact, scoring 15 on cognitive assessments, meaning they were fully aware of the substandard care they received. Resident 13 watched as the nurse handling her infected wound skipped basic hand hygiene that could prevent spreading bacteria to other parts of her body or to other residents.
The violations occurred despite written policies requiring proper infection control. Resident 10's physician had specifically ordered catheter care every shift, recognizing the high risk of urinary tract infections in patients with indwelling catheters.
Catheter-associated infections can lead to sepsis, kidney damage and death in elderly residents. Wound infections can prevent healing, require amputation or become life-threatening if bacteria enters the bloodstream.
The inspection found that staff knew the correct procedures but chose not to follow them, even when caring for vulnerable residents who depended on proper infection control to prevent serious complications from their existing medical conditions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Highlands Health and Rehabilitation Center from 2025-10-14 including all violations, facility responses, and corrective action plans.
Additional Resources
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: August 5, 2026 · Our methodology
HIGHLANDS HEALTH AND REHABILITATION CENTER in MEMPHIS, TN was cited for violations during a health inspection on October 14, 2025.
LPN B entered Resident 13's room on October 13 to change a dressing on the woman's left ankle wound.
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.