MEMPHIS, TN - Federal health inspectors found that Highlands Health and Rehabilitation Center failed to properly implement its infection prevention and control program, according to findings from a complaint investigation completed on October 14, 2025.
Infection Prevention Program Fell Short of Federal Standards
The inspection, triggered by a complaint filed against the facility, resulted in a citation under federal regulatory tag F0880, which requires nursing homes to maintain and carry out a comprehensive infection prevention and control program. Inspectors determined the Memphis facility was not meeting this fundamental requirement.
The deficiency was classified at Scope/Severity Level D, meaning the problem was isolated in nature but carried the potential for more than minimal harm to residents. While inspectors did not document that any resident experienced actual harm at the time of the survey, the gap in infection control protocols represented a real risk to the vulnerable population living at the facility.
Infection prevention programs in nursing homes are not optional guidelines — they are federally mandated safeguards designed to protect residents who are among the most medically fragile people in any community. Nursing home residents typically have weakened immune systems due to advanced age, chronic illness, and the close-quarters nature of congregate living.
Why Infection Control Failures Pose Serious Risk
When a nursing home fails to fully implement its infection prevention program, the consequences can escalate rapidly. Respiratory infections, urinary tract infections, skin infections, and gastrointestinal outbreaks spread more easily in environments where hand hygiene protocols, equipment sanitation procedures, or isolation practices break down.
For older adults with compromised immune function, even a routine infection can trigger a cascade of medical complications. Urinary tract infections, for example, can cause confusion and delirium in elderly patients, leading to falls and further injury. Respiratory infections can progress to pneumonia within days, which remains one of the leading causes of hospitalization and death among nursing home residents nationwide.
The federal requirement under F0880 exists specifically because infection outbreaks in long-term care settings have historically resulted in significant morbidity and mortality. Facilities are expected to designate an infection preventionist, conduct surveillance for infections, implement evidence-based prevention strategies, and maintain an antibiotic stewardship program.
Federal Standards Require Active, Ongoing Programs
Under Medicare and Medicaid regulations, nursing homes must do more than simply have an infection control plan on paper. The program must be actively implemented, with staff trained on proper techniques and leadership ensuring compliance on an ongoing basis.
This includes proper hand hygiene before and after resident contact, appropriate use of personal protective equipment, routine cleaning and disinfection of surfaces and medical equipment, and protocols for identifying and isolating residents who develop communicable infections. When any of these elements break down, the entire resident population faces elevated risk.
The Centers for Medicare and Medicaid Services treats infection control as a core safety requirement precisely because nursing homes experienced devastating outbreaks during the COVID-19 pandemic, which exposed widespread weaknesses in how facilities managed infectious disease protocols. Since then, federal oversight of infection prevention practices has intensified.
Facility Reported Corrective Action
Highlands Health and Rehabilitation Center reported that it corrected the deficiency as of December 17, 2025, approximately two months after the inspection. The facility's correction plan would typically involve retraining staff, updating protocols, and demonstrating to regulators that the infection prevention program is being properly carried out.
However, the gap between the October inspection findings and the December correction date means residents were potentially exposed to inadequate infection control practices for a period of weeks while the facility worked to address the problem.
Families with loved ones at Highlands Health and Rehabilitation Center can review the full inspection report on the Centers for Medicare and Medicaid Services website or through the facility's publicly posted survey results, which nursing homes are required to make available to residents and their families.
The complaint-driven nature of this inspection indicates that concerns about conditions at the facility were serious enough for someone — whether a resident, family member, or staff member — to file a formal complaint with state or federal regulators, prompting the on-site investigation that uncovered the infection control deficiency.
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.