Highland Ridge Care Center, LLC

Inspectors wroteBased on observation, clinical record review and staff interviews, the facility failed to appropriately provided assessment and interventions for the necessary care and services, to maintain the residents' highest practical physical well-being for 2 of 3 residents reviewed (Resident #1 & #2). R#1 returned from a hospital stay, at which time staff failed to notice the resident had duplicate laxatives order for five days, and during that time the resident fell. R#2 complained of pain after a fall the facility staff failed to perform a thorough assessment, and call the physician provide intervention. The facility reported a census of 50 residents. 1. The Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #1 revealed the diagnoses of diabetes mellitus, kidney disease, dementia, anxiety, depression and required maximal assistance for toileting, shower or bathing and personal hygiene. [...]

Inspectors wroteBased on observation, clinical record review, family and staff interviews, the facility failed to provide appropriate and sufficient supervision to ensure each resident's individual safety and to prevent an avoidable accident for 2 of 3 residents reviewed for falls (Resident #1 & #2). The facility reported a census of 50 residents. 1. The Minimum Data Set (MDS) dated [DATE] for Resident #1 revealed the diagnoses of Diabetes Mellitus, kidney disease, dementia, anxiety, depression, visual hallucinations, osteoarthritis and required maximal assistance for toileting, shower or bathing and personal hygiene with moderate assistance for dressing. Resident #1 required moderate assistance to transfer into and out of the shower and was independent with sit to stand, chair to bed transfers, and toilet transfers. [...]

Inspectors wroteBased on clinical record review, family and staff interviews, and policy review, the facility failed to provide appropriate pain management for 1 out of 3 residents reviewed (Resident #2). The MDS dated [DATE] for Resident #2 revealed the diagnoses of type 2 diabetes mellitus, Alzheimer's disease, bone density disorder, macular degeneration, and had a history of falls. Resident #2 required the use of walker, one staff to assist and a wheelchair and able to self-propel. Resident #2 required maximum assistance with toileting, dressing upper body and showers, and was dependent on staff for dressing her lower body. Resident #2 was independent with moving in a bed and was continent of bladder but had frequent incontinent bowel movements. During the assessment, Resident #2 had no complaints of pain, experienced two falls without injury and one fall with a minor injury, no major injuries noted. [...]

Inspectors wroteBased on record review, staff interviews and facility assessment review, the facility failed to ensure there was a sufficient number of direct care staff to provide care for residents with dementia, mental and psychosocial disorder. The facility also failed to provide supervision and skills training for staff in how to approach a resident who may be agitated, combative, verbally or physically aggressive, or anxious, and how and when to obtain assistance in managing a resident with behavior symptoms. The facility reported a census of 50 residents.

Inspectors wroteBased on observation, clinical record review, review of facility policy, personnel file review, resident and staff interview, the facility to ensure staff provided care with dignity and respect for 4 of 33 residents reviewed (Residents #1, #18, #31 and #49). The facility reported a census of 51 residents.

Inspectors wroteBased on clinical record review, facility discharge list, facility policy review, and staff interview, the facility failed to notify the Office of the State Long-Term Care Ombudsman of the discharge of residents for 3 of 3 residents sampled (Resident #56, #58 and #59) with a discharge to home. The facility reported a census of 51 residents.

Inspectors wroteBased on clinical record review, observation, facility policy review, resident and staff interview, nursing staff failed to perform assessment and intervention of a resident (Resident #28) after a meal observation revealed staff served the resident food the resident had documented as an allergy. The facility reported a census of 51 residents.

Inspectors wroteBased on clinical record review, meal service observation, review of facility policy, resident and staff interview, the facility failed to ensure they did not serve a resident food that was known to cause an allergic response during 1 of 2 resident meal service observations (Resident #28). The facility reported a census of 51 residents.

Inspectors wroteBased on observation, clinical record review, and staff interviews the facility failed to investigate an injury of unknown origin for 1 of 6 residents (Resident #3) reviewed. The facility reported a census of 55 residents.

Inspectors wroteBased on clinical record review, interviews, and policy review the facility failed to complete neurological assessments after unwitnessed falls for 1 of 6 residents (Residents #2 )reviewed. The facility reported a census of 55 residents.

Inspectors wroteBased on clinical record review, family interview, physician interview, staff interviews, and facility policy review, the facility failed to provide appropriate assessment and interventions for 1 out of 3 residents (Resident #158). Clinical record review revealed on [DATE] at 9:30 p.m., Resident #158 fell and sustained a laceration to her head with a significant amount of blood loss. The facility staff failed to immediately call 911, call the physician, call the family, or conduct neurological assessments as per policy. The facility staff moved the resident to the shower and then to bed. Upon arrival of the next shift 9 hours later, the facility sent the resident to the emergency room (ER) where the resident was assessed to have fractures of the humerus and femur. [...]

Inspectors wroteBased on clinical record review, family interview, staff interviews, and facility policy review, the facility failed to provide appropriate pain management for 1 out of 3 residents (Resident #158). Clinical record review revealed on [DATE] at 9:30 p.m., Resident #158 fell and sustained a laceration to her head with a significant amount of blood loss. The facility staff moved the resident to the shower and then to bed and the resident reported pain that was not treated. Upon arrival of the next shift 9 hours later, the facility sent the resident to the emergency room (ER) where the resident was assessed to have fractures of the humerus and femur and immediately treated for pain; the resident admitting diagnoses included uncontrolled pain. The failure created an immediate jeopardy to the health and safety of the resident. The facility reported a census of 57 residents. [...]

Inspectors wroteBased on policy review and staff interviews the facility failed to provide an Infection Preventionist with specialized training or certification to monitor and provide oversight for the facility's Infection Prevention and Control Program. The facility reported a census of 57 residents. Findings Include: The policy, entitled Infection Prevention and Control Manual and dated 2020, documented the facility Infection Preventionist is responsible for the facility's Infection Prevention and Control Program. On 8/16/23 at 9:31 AM, Staff B, Clinical Coordinator for Infection Control and Education, provided documentation that her Infection Preventionist Training was incomplete. Staff B demonstrated a lack of understanding of information necessary to complete her duties as the facility Infection Preventionist. Staff B indicated she took over the Infection Preventionionist role in June 2023. [...]

Inspectors wroteBased on clinical record review, physician interview, family interview, staff interviews, and facility policy review, the facility failed to notify the physician and family in a timely manner when acute changes occurred in a resident's physical condition for 1 of 3 residents reviewed (Resident #158). Clinical record review revealed on 6/2/23 at 9:30 p.m., Resident #158 fell and sustained a laceration to her head with a significant amount of bleeding. The facility staff failed to immediately call 911, call the physician, and call the family for 9 hours. The facility reported a census of 57 residents. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #158 included the following diagnoses: dementia, anxiety, depression, glaucoma, high blood pressure and kidney disease. [...]

Inspectors wroteBased on personnel file review, staff interview and policy review the facility failed to assure 1 of 5 staff reviewed met the requirements for Mandatory Adult Abuse Training (Staff D). The facility reported a census of 57 residents. Findings Include: Record review of the personnel record for Staff D, Certified Nursing Assistant (CNA), shown a hire date of 1/4/22. Staff D completed the two-hour Dependent Adult Abuse Mandatory Training on 4/9/20. The Renewal training due to be completed by 4/9/23 was not documented. In an interview on 8/17/23 at 11:06 AM, Staff C, the Administrative Support Staff acknowledged the expectation for staff to complete the two-hour Dependent Adult Mandatory Reporter Training every three years. [...]

Inspectors wroteBased on clinical record review, staff interview, and facility policy review the facility failed to complete a follow-up Preadmission Screening and Resident Review (PASRR) for one out of one resident reviewed in the current sample who had a change in mental health diagnoses (Resident #12). The facility reported a census of 57 residents. Findings Include: The Minimum Data Set (MDS) Assessment at admission for resident #12, dated 7/1/21 included Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderate cognitive impairment. The MDS recorded Resident #12 diagnoses included heart disease, non-Alzheimer's dementia of uncertain or unknown etiology. The MDS coded that antipsychotics were not given during the last seven days. The Minimum Data Set (MDS) assessment dated [DATE] included a BIMS score of 5 out of 15, indicating severe cognitive deficit. [...]