Highlands Lake Center

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the narcotics policy was followed by nursing to ensure narcotic audits were accurate for three residents (#1, #8 and #9) out of three residents sampled for pain management.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure scheduled pain medication was provided as ordered for one resident (#1) out of three residents sampled for pain.

Inspectors wroteBased on record review and interviews the facility failed to implement an effective grievance program related to ensuring voiced concerns are acknowledged, documented, and resolved for the attending resident council members during six months (November, December, January, February, March and April) of six months reviewed.

Inspectors wroteBased on interview and record review the facility failed to obtain physician ordered cultures in a timely manner for two (#1 and #4) of three sampled residents. Findings Included: 1. Review of Resident #1's admission record revealed an admission date of 11/15/24 for short term rehabilitation with diagnoses to include myoneural disorder, acute respiratory failure with hypercapnia, sepsis, chronic obstructive pulmonary disease and other co-morbidities. Review of Resident #1's medical nurse practitioner progress note dated 12/12/24 revealed: Resident #1 has been having increased episodes of diarrhea, with recommendations to obtain a stool sample. Review of Resident #1's order summary report revealed a physician order dated 12/12/24 and 12/13/24 - obtain stool sample. Review of Resident #1's nursing note dated 12/13/24 revealed collected stool sample for lab. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure therapy gym equipment was maintained in a safe and operative manner for one of one sampled therapy rooms.

Inspectors wroteBased on interview and record review, the facility failed to ensure the grievance process was followed for one (#5) of eleven sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were secured for three (#6, #7, and #8) out of 11 sampled residents.

Inspectors wroteBased on interviews and record review, the facility 1) failed to provide appropriate notification when changes occur with the resident's coverage for two (#137 and #159) of 3 residents sampled for beneficiary notices, and 2) failed to provide one resident (#368) out of three residents sampled with a refund within 30 days after discharging from the facility.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure accuracy of comprehensive assessments for three (#135 and #83) of fifty two sampled residents.

Inspectors wroteBased on interviews and record review, the facility failed to complete the Preadmission Screening and Resident Review (PASRR) Level I upon admission for three residents (#43, #128, and # 98) of seven residents sampled for PASRR Level 1. Findings Included: Review of the admission Record, dated 03/06/2024, showed Resident #43 was admitted on [DATE] and readmitted on [DATE] with diagnoses to include but not limited to major depressive disorder, recurrent, moderate, dementia in other disease classified elsewhere, moderate, with mood disturbance. Review of Resident #43's PASARR, dated 09/14/2022, revealed no qualifying mental health diagnosis and no PASARR Level II was required. Review of an admission Minimum Data Set (MDS), dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. [...]

Inspectors wroteBased on observation, interviews, and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being related to outside provider appointments for 2 residents (#87 and #135) out of 2 sampled residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide treatment and care to meet the needs of residents by 1.) failing to ensure alterations in skin were identified and treated for one resident (#316) of two residents sampled for skin conditions, and 2.) failed to ensure residents were assessed for a change in condition for one (#366) of five residents sampled for discharges.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure physician orders were obtained related to care and services for catheters, and catheters were appropriately covered for 1 (#218) of 3 residents sampled for catheters.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure care and services related to Intravenous (IV) fluids were provided for a one resident (#68) out of 1 of four residents with IV access in the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide respiratory care and services in accordance with professional standards of practice by failing to ensure respiratory equipment was stored in a sanitary manner for two (#218 and #103) of two residents sampled for respiratory care.

Inspectors wroteBased on observation, record review and interviews the facility failed to ensure physician ordered pain medication was prescribed for one resident (#72) out of three residents sampled. Findings Included: During an observation on 03/05/24 at 11:59 AM., Resident # 72 was observed in the hallway, fully dressed, propelling in her wheelchair towards Staff M, Licensed Practical Nurse (LPN). Resident #72 said she was in a lot of pain since last night and she has not received any of her pain medicine. She said that she has been waiting for her pain medication all night and the nurse told her that they did not have her medication. Resident # 72 was presented with signs of distress on her face. During an observation on 03/06/2024 at 2:00 PM., Resident was observed laying down in her bed with her feet placed on her wheelchair. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain a medication error rate of less than 5%. A total of 25 medication administration opportunities were observed with 3 medication errors for two (#84 and #61) of three residents sampled for medication administration, which resulted in a medication administration error rate of 12%.

Inspectors wroteBased on observations, interviews, and review of facility policy, the facility failed to ensure proper storage, labeling, and security of medications and biologicals in one of four treatment carts in the facility, three of seven medication carts in the facility, and two of three medication rooms in the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an accurate medical record by documenting treatments, which were not completed, for one (#103) of fifty two sampled residents.

Inspectors wroteBased on observations, interviews, and review of facility policy, the facility failed to maintain an effective infection control and prevention program by 1.) failing to ensure hand hygiene was performed during medication administration and 2.) failing to ensure medications were dispensed in a sanitary manner for one (#84) of three residents observed during medication administration.

Inspectors wroteBased on observations and interviews the facility failed to provide a safe and home like environment for one resident (#154) out of 19 residents sampled. Finding Include During an observation on 03/04/2024 at 10:00 AM., Resident #154 was observed laying down in bed with an extension cord in her bed. She said that she uses the cord so that all her electronics can be plugged in to a location that she can reach. She said she has had her extension cord for a while, and she always places it in her bed. She said no one has told her that she the cord is a safety hazard and that she cannot have the cord in her room. During an observation on 03/05/2024 at 2:00 PM., Resident was observed laying down in bed with her call light in reach. Resident extension cord was observed on top of her dresser. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to maintain an effective pest control program, so the facility was free of pests when one resident (#90) was observed with black ants crawling on him while in bed out of 52 residents sampled.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure working systems were in place related to food choice, communicating menu options to residents, and assessing for food preferences for eleven (Residents #5, #65, #35, #63, #30, #117, #234, #103, #45, #23) out of 52 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that dignity was maintained related to catheter care for one resident (#374), of 10 residents sampled. Findings Included: On 11/15/21 at 10:44 a.m., an interview was conducted with Resident #374. She was observed sitting in her wheelchair with a [urinary] catheter bag containing amber colored urine, attached to the back of the chair. The [urinary] catheter bag was observed without a privacy bag. Photographic evidence obtained. On 11/16/21 at 11:08 a.m., an observation of Resident #374 was made. Resident #374 was in bed with room door open. The [urinary] catheter bag containing amber colored urine, was observed from doorway, without a privacy bag. Photographic evidence obtained. On 11/17/21 at 9:09 a.m., an observation of Resident #374 was made. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure that the Nursing Home Transfer and Discharge Notice form was provided to the appropriate parties and failed to ensure that the State Long-Term Care Ombudsman received a copy/notification of the Nursing Home Transfer and Discharge Notice for two (#95, #44) of three residents reviewed for admission, transfer, and discharge rights.

Inspectors wroteBased on record review and interview, the facility failed to ensure that at the time of transfer of a resident to the hospital or therapeutic leave, the Resident/Representative was provided with a written notice that would indicate the duration of a bed-hold for one (Resident #95) of three residents reviewed for admission, transfer, and discharge rights.

Inspectors wroteBased on record review, interviews, observations, and policy review the facility did no ensure weight loss was identified and addressed in a timely manner for two residents (#47 and #224) of six residents sampled for nutrition.

Inspectors wroteBased and observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for three (Residents #65, #68 and #176) of 18 sampled residents related to the use and storage of oxygen masks and tubing.

Inspectors wroteBased on interviews and record review the facility did not ensure two (Residents #123 and #225) of five residents reviewed for medication availability, received their physician ordered medications.

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure the medication error rate was below 5% for one (Resident #123) of four residents with twenty-seven opportunities observed during medication administration, resulting in a medication error rate of 7.41%.

Inspectors wroteBased on observation, interview and review of the facility policy, the facility did not ensure that refrigerated controlled Schedule II-IV medications were secured in a locked and permanently affixed compartment in 3 (Park Place, [NAME] Point, and [NAME] Court) medication storage rooms of 3 medication storage rooms.

Inspectors wroteBased on observation, record review, interviews, and policy review the facility did not ensure that the medication error rate was less than 5 percent in regards to 6 errors in 27 opportunities for one resident (#278) out of 7 sampled residents, resulting in a 22.2%. medication error rate.