Highland Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible, and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 2 out of 41 sampled residents, two residents eloped from the facility that required supervision. Resident identifiers: 55 and 68.

Inspectors wroteBased on interview and record review, the facility did not electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the Centers for Medicare and Medicaid Services (CMS) system within 14 days of completing a resident's assessment. Specifically, for 1 out of 58 sampled residents, the facility did not transmit a resident's completed discharge MDS assessment to CMS. Resident identifier: 57.

Inspectors wroteBased on interview and record review, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, for 1 out of 58 sampled residents, a resident's antihypertensive medication was not held when the diastolic blood pressure (DBP) was below the physician's ordered parameters. Resident identifier: 8.

Inspectors wroteBased on interview and record review, the facility did not ensure that residents who used psychotropic drugs received gradual dose reductions (GDR) unless clinically contraindicated, in an effort to discontinue these drugs. A GDR must be attempted in two separate quarters, with at least one month between attempts, within the first year in which an individual was admitted on a psychotropic medication or after the facility had initiated such medication, and then annually. Specifically, for 1 out of 58 sampled residents, a resident taking an antidepressant medication for insomnia had not received a GDR on that medication since 2022, and the medication was not clinically contraindicated. Resident identifier: 23.

Inspectors wroteBased on interview and record review, the facility did not obtain laboratory (lab) services only when ordered by a physician; physician assistant; nurse practitioner, or clinical nurse specialist. Specifically, for 1 out of 58 sampled residents, a resident had a basic metabolic panel (BMP) collected on two occasions without a physician's order. Resident identifier: 12.

Inspectors wroteBased on observation and interview, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, several surfaces that came into contact with food or food preparation utensils were found to be dirty, staff were observed to not practice hand hygiene, food was exposed to open air, and there were several instances of potential physical food contaminants.

Inspectors wroteBased on observation and interview it was determined the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the facility did not have detergent for the dish machine, there was cardboard duct taped to the hood vent, refrigerators at the nurses stations were soiled and there were soiled areas in the kitchen.

Inspectors wroteBased on observation, interview, and record review, it was determined for 1 of 7 sample residents, that the facility did not ensure a therapeutic diet was offered when there was a nutritional problem and the health care provider ordered a therapeutic diet. Specifically, a resident was not provided a fortified/enhanced diet. Resident identifiers: 4.

Inspectors wroteBased on observation and interview it was determined the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. [...]

Inspectors wroteBased on interview and record review it was determined for 3 of 35 sample residents, that the residents were not able to make choices about aspects of their life in the facility, that were significant to the resident. Specifically, residents were not regularly showered three times a week, as was their preference. Resident identifiers: 6, 22, 48.

Inspectors wroteBased on interview and record review the facility did not develop and implement a comprehensive person-center care plan for 1 of 35 sampled residents, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, a resident did not have a care plan to attain or maintain the highest practicable physical, mental and psychosocial well-being when receiving psychotropic medications. Resident Identifier:

Inspectors wroteBased on interview and record review it was determined that the facility did not provide the necessary services to maintain good nutrition, grooming, and personal and oral hygiene to residents who were unable to carry out activities of daily living (ADLs). Specifically, for 4 out of 35 sampled resident, residents that were dependent on ADLs did not receive showers or bathing assistance in a timely manner and according to the facility schedule for showers. Resident identifiers: 6, 16, 22, and 48.

Inspectors wroteBased on interview and record review it was determined that the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, for 1 out of 35 sampled residents, the facility administered hypertensive medications when the blood pressure measurements were outside of the physician ordered parameters and administered insulin outside of physician ordered parameters. Resident identifier:

Inspectors wroteBased on observation and interview, it was determined that the facility did not store food in accordance with professional standards of food service safety. Specifically, food in the freeze and refrigerator was not sealed and was open to air.

Inspectors wroteBased on interview and record review the facility did not maintain a quality assessment and assurance (QAA) committee consisting of the required members. Specifically, the QAA Committee was held five times in 2021, however the medical director only attended one of those meetings.

Inspectors wroteBased on interview and record review the facility did not follow the Centers for Disease Control and Prevention (CDC) and Advisory Committee on Immunization Practices (ACIP) guidelines to offer pneumococcal immunizations for 1 of 35 sampled residents. Specifically, a current resident, who had resided in the facility since June 2017 was not offered the 23-valent pneumococcal polysaccharide vaccine (PPSV23, Pneumovax23) per CDC and ACIP guidelines. Resident Identifier:

Inspectors wrote2. Resident 3 was admitted on [DATE] and readmitted on [DATE] with diagnosis which included heart failure, fracture of left wrist and hand, fracture of nasal bones, atrial fibrillation, respiratory failure, dysphagia, encephalopathy, pain, hypertension, hyperlipidemia, insomnia, and muscle weakness. On 11/4/19 at 2:38 PM, resident 3 was observed lying in her bed. Resident 3 had no falls mats on the floor by her bed. Resident 3's call light was observed to be in her recliner which was not accessible from the bed. On 11/5/19 at 7:26 AM, an observation was made of resident 3's room. There were no fall mats observed to be anywhere in resident 3's room. On 11/5/19 at 9:52 AM, an observation was made of resident 3 sitting in her wheelchair in her room. Resident 3's call light was behind her on her nightstand, which was not accessible from her wheelchair. [...]

Inspectors wroteBased on observation, interview, and record review it was determined for 3 of 38 sample residents, that the facility did not ensure that the resident's environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, the facility staff did not provide adequate supervision to prevent falls from occurring and care planned interventions were not implemented. Resident identifiers: 3, 38, and 50.

Inspectors wroteBased on interview and record review it was determined, for 2 of 38 sample residents, that the pharmacist did not report irregularities in the drug regimen review to the attending physician, the facility's Medical Director, and Director of Nursing. Irregularities include, but are not limited to, any medication when used without adequate monitoring or without adequate indications for its use. Specifically, the pharmacist did not report the irregularity of the use of antipsychotics and antidepressants for residents that did not have a diagnosis of a serious mental illness, and to residents with dementia. Resident identifiers: 25 and 50.

Inspectors wroteBased on observation, interview and record review it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, staff were observed in the food prep area without a hairnet. Resident identifier: 9.

Inspectors wroteBased on interview and record review it was determined, for 2 of 38 sample residents, that the facility did not ensure that the resident assessment information was accurate. Specifically, a resident on dialysis was documented as not being on dialysis on the Minimum Data Set (MDS) Assessment, and a resident who had sustained multiple falls were not documented on two Quarterly MDS Assessments that documented the falls. Resident identifiers: 3 and 9.

Inspectors wroteBased on observation, interview and record review it was determined for 1 of 38 sample residents that the facility did not provide an ongoing program to support residents choice, of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychological well-being of each resident, encouraging both independence and interaction in the community. Resident identifier:

Inspectors wroteBased on interview and record review it was determined, for 1 of 38 sample residents, that the facility did not ensure that residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record and that the facility did not ensure that irregularities identified by the pharmacist were reported to the attending physician and director of nursing, and the reports were acted upon. Specifically, one resident had no irregularities noted by the facility pharmacist when taking an antipsychotic medication and one resident had a pharmacy recommendation that had not been followed up on in a timely manner. Resident identifiers: 50.

Inspectors wroteBased on observation, interview, and record review it was determined for 1 of 38 sample residents that the facility did not ensure that it was free from medication error rate of 5% or greater. Specifically, observations of thirty-three medication opportunities, on 11/6/19, revealed seven medication errors which resulted in a 21.21% medication error rate. Resident identifier: 51.

Inspectors wroteBased on interview and record review, the facility did not ensure that 2 of 38 sample residents was free of significant medication errors. Specifically, two residents were administered crushed potassium extended released (ER). Resident identifier: 51 and 206.

Inspectors wroteBased on observation and interview it was determined that the facility did not ensure safe storage of drugs and biologicals in accordance with accepted professional principles; or include the appropriate accessory and cautionary instructions, and the expiration date on the medications. Specifically, medications that had expired were still available for use.