Highland Manor Rehabilitation and Nursing Center

Inspectors wroteBased on review of clinical records, facility documentation, and staff interview, it was determined the facility failed to ensure licensed nursing staff possessed and demonstrated the appropriate competencies and skill sets to safely assess, manage, and provide care for residents requiring a coude catheter (a specialized urinary catheter with a curved tip used for residents with urinary obstruction and enlarged prostate) for 5 of 5 licensed nurses reviewed (Employees 1, 2, 3, 4, and 5).

Inspectors wroteBased on a review of clinical records, select facility policy, and resident and staff interviews, it was determined the facility failed to provide nursing services consistent with professional standards of practice by failing to ensure a Licensed Practical Nurse (LPN) timely monitored, recognized, communicated, intervened, and obtained appropriate supervisory assistance when a resident experienced a blocked indwelling urinary catheter (a flexible sterile tube inserted into the urinary bladder to drain urine) for one of 10 residents reviewed (Resident 9).

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to maintain a clean and orderly environment in the facility laundry department and the second hallway ice machine.

Inspectors wroteBased on a review of clinical records, resident grievances, observations, and resident and staff interviews, it was determined the facility failed to provide care in a manner that promotes and enhances each resident's dignity and quality of life by failing to respond in a timely manner to residents' requests for assistance for 5 residents out of 10 sampled. (Residents CR1, 2, 3, 4, and 5).

Inspectors wroteBased on a review of select facility policy, clinical records, information submitted by the facility, select investigative reports, and staff interviews, it was determined the facility failed to conduct a thorough investigation into an injury of unknown origin (a fractured humeral neck) for one resident out of 24 sampled (Resident 23).

Inspectors wroteBased on observation, clinical record review, and staff interviews, it was determined the facility failed to implement a person-centered fall and injury prevention plan of care for one resident out of 24 sampled (Resident 104).

Inspectors wroteBased on observation, review of clinical records, and resident and staff interviews it was determined the facility failed to provide services consistent with professional standards of practice by failing to follow physician orders for a medical treatment that manages chronic lung conditions and promotes lung capacity and recovery for one resident (Resident 15) out of 24 sampled residents.

Inspectors wroteBased on a review of clinical records, select facility policy, and staff interview, it was determined the facility failed to prevent the development of a pressure injury for one resident out of 24 sampled residents (Resident 26).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of a narcotic pain medication prescribed on an as needed basis for one resident (Resident 33) of 24 residents reviewed.

Inspectors wroteBased on a review of clinical records and staff interview, it was determined the attending physician failed to act upon pharmacist identified irregularities in the medication regimen of one of 24 residents sampled (Resident 1).

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to provide housekeeping and maintenance services to maintain a clean and safe resident environment.

Inspectors wroteBased on review of minutes from the Residents' Council meeting and resident and staff interviews it was determined that the facility failed to provide care in a manner and environment, which promotes each resident's quality of life, by failing to respond timely to residents' request for assistance as evidenced by experiences reported by five residents out of five sampled (Residents 14, 11, 9, 13 and 10 ).

Inspectors wroteBased on observation, review of clinical records and select facility policy, and resident and staff interviews, it was determined that the facility failed to ensure fresh water was consistently readily accessible to residents to promote adequate hydration, resident preference and comfort for five out of 14 residents reviewed (Residents 11, 9, 12, 13, and 2).

Inspectors wroteBased on an observation, review of clinical records, select facility policy and fall incident reports, and staff interviews, it was determined that the facility failed to consistently implement, and evaluate the effectiveness, of planned individualized fall prevention measures and provide sufficient staff supervision at the level and frequency required, of residents identified as at high risk for falls and known unsafe behaviors to prevent falls resulting in serious injuries, a fractured femur, for one resident (Resident 98) and a fractured neck for one resident (Resident 56), and failed to provide necessary assistance devices and assure that the resident's environment was free of potential accident hazards to prevent a fall and injuries, abrasions and bruises, to one resident (Resident 39) out of nine residents sampled for accidents.

Inspectors wroteBased on observation, and staff interviews it was determined that the facility failed to maintain infection control practices during medication administration on one out of two medication carts (Station A, Back Hall), failed to maintain ice machines and ice distribution areas in a sanitary manner on two of two resident units and failed to maintain the facility's laundry area in a clean and sanitary manner.

Inspectors wroteBased on a review of the minutes from resident group meetings and grievances lodged with the facility and resident and staff interviews, it was determined that the facility failed to demonstrate their response to resident complaints and grievances raised at group meetings, including complaints raised by four of the five residents (Residents 14, 40, 44, and 88) interviewed during a group interview.

Inspectors wroteBased on interviews with residents it was determined that the facility failed to maintain comfortable sound levels and reasonable protection of the resident's private space to maintain a homelike environment for residents including four of five interviewed during a group meeting (Residents 14, 40, 44, 88).

Inspectors wroteBased on observation, a review of clinical records, and resident and staff interviews, it was determined that the facility failed to consistently implement planned care and services consistent with professional standards of practice and the resident's plan of care to prevent the development and worsening of pressure ulcers for two residents out of the 24 sampled residents (Residents 49 and 29).

Inspectors wroteBased on a review of clinical records, and staff interview, it was determined that the facility failed to implement individualized approaches to prevent declines in bowel continency and restore normal bowel function to the extent possible for two residents (Resident 18 and 56) and failed to assess a resident's bladder function following removal of indwelling foley catheter for one resident (Resident 165) out of five sampled.

Inspectors wroteBased on observations, a review of clinical records, and resident and staff interviews, it was determined that the facility failed to ensure that a resident's individualized dementia care needs are consistently met and that the facility assessed, developed, and implemented interdisciplinary care planned approaches and provided resources necessary for management of dementia related behaviors for one residents out of eight sampled residents (Resident 65).

Inspectors wroteBased on observation, a review of select facility policy, and staff interview, it was determined that the facility failed to adhere to acceptable storage and use by dates for multi-dose medications on one of two medication carts observed (Station B, Back Hall, B Hall - Resident 4, 8, 31, 55, and 86) and failed to secure one of two medication rooms to prevent unauthorized access (A Unit Medication Room)

Inspectors wroteBased on a review of clinical records and the RAI manual and staff interview, it was determined that the facility failed to timely complete a significant change Minimum Data Set assessment for one of the 24 residents reviewed (Resident 98).

Inspectors wroteBased on a review of the Resident Assessment Instrument Manual and clinical records, and staff interviews, it was determined that the facility failed to transmit Minimum Data Set (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) assessments to the required electronic system, the CMS Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System, within the required time frame for one of three closed records reviewed (Resident 111).

Inspectors wroteBased on a review of clinical records and the Resident Assessment Instrument and staff interviews, it was determined that the facility failed to ensure the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one resident out of 24 sampled (Residents 29).

Inspectors wroteBased on review of select facility policy and clinical records, observations, and staff interview it was determined that the facility failed to ensure that the facility provided enteral feedings as prescribed and services designed to prevent potential complications associated with tube feedings for one resident out of two residents sampled receiving enteral tube feedings (Resident 67).

Inspectors wroteBased on a review of the clinical record and resident and staff interviews, it was determined that the facility failed to provide person-centered and coordinated care for one out of the one sampled resident receiving dialysis (Resident 14).

Inspectors wroteBased on a review of clinical records and the facility's planned cycle menus, observation and staff interviews it was determined that the failed to assure that a resident received foods with the appropriate nutritive content as prescribed by the physician to support the resident's treatment of kidney disease for one resident out of one sampled receiving dialysis (Resident 14).

Inspectors wroteBased on a review of nursing staffing hours and ratios, observations and resident, family and staff interviews it was determined that the facility failed to provide sufficient nursing staff to consistently provide timely quality of care, services, and supervision necessary to maintain the physical and mental well-being of the residents in the facility including Residents 1, 2, and 3.

Inspectors wroteBased on a review of clinical records and staff interview, it was determined that the facility failed to timely consult with the physician and notify resident's representative, of a significant weight loss, for one resident out of two sampled residents (Resident 26).

Inspectors wroteBased on a review of clinical records and the Resident Assessment Instrument and staff interviews, it was determined that the facility failed to ensure that the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of three residents out of 20 sampled (Resident 22, 43, and 96).

Inspectors wroteBased on a review of clinical records and select facility policy and staff interview, it was determined that the facility failed to accurately and consistently assess residents' nutritional status and parameters and timely implement measures to prevent weight loss for one of 19 residents sampled (Resident 67)

Inspectors wroteBased on observation, review of clinical records and nurse staffing, and staff and resident interviews it was determined that the facility failed to provide and/or efficiently deploy sufficient nursing staff to consistently provide timely and quality of care and assistance to residents' request for care via the facility nurse call bell system to maintain the physical and psychosocial well-being of two residents out of 20 sampled (Residents 27 and 35).

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to provide maintenance services to maintain a clean and homelike resident environment.