Highland Ridge Care Center, LLC

In the surveyor’s words

From the most serious findings on record at Highland Ridge Care Center, LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Sep 20, 2023

  Based 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. […]

• Immediate jeopardy, isolatedF697Sep 20, 2023

  Based 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. […]

• Actual harm, isolatedF684Nov 19, 2025

  Based 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. […]

• Actual harm, isolatedF689Nov 19, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF882Sep 20, 2023

  Based 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. […]