Highland Ridge Care Center, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The MDS documented that the resident scored a 3 out 15 for the Brief Interview for Mental Status (BIMS), which indicated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings include:The Minimum Data Set (MDS) dated [DATE] for Resident #1 revealed the diagnoses of dementia, anxiety, depression, visual hallucinations and required maximal assistance for toileting, shower or bathing and personal hygiene with moderate assistance for dressing. Resident #1 rejected care for 3 of the 5 days reviewed and had physical behavior symptoms directed toward others. Resident #1 was incontinent of bowels and bladder. The brief interview for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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.Findings include: 1.The Minimum Data Set (MDS) assessment for Resident #1 dated 8/19/25 revealed the resident scored 9 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated moderately impaired cognition. The MDS revealed the resident had a diagnosis of Alzheimer's disease, used a wheelchair and was dependent on staff for toileting, transfers, and repositioning in bed. On 9/8/25 at 10:23 AM, interview conducted with the resident in Resident #1's room. The door to the room was shut to maintain the resident's privacy. At 10:29 AM during the interview Staff A, Certified Nurses Aide (CNA), opened the resident's room door and entered without knocking or announcing herself. Staff A dropped off the resident's breakfast, provided set up assistance, and left the room.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include:Review of list of resident discharged from the facility, dated 6/1/25 to present (9/8/25), revealed a total of 3 residents discharged from the facility to home, Residents #56, #58 and #59.1.The Minimum Data Set (MDS) assessment for Resident #56 dated 7/10/25 indicated the resident was admitted to the facility on [DATE] and discharged on 7/10/25. A Discharge Summary/Recapitulation of Stay dated 7/7/25, included documentation the resident planned to discharge home with home health services including skilled nursing, occupational and physical therapy services. On 9/10/25, review of the clinical record revealed a lack of documentation regarding notification of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: The Minimum Data Set (MDS) assessment for Resident #28 dated 8/17/25 revealed the resident scored 15 out of 15 on a Brief Interview for Mental Status exam, which indicated intact cognition. The Care Plan for Resident #28 included an intervention dated 9/22/24 to for staff to provide and serve the resident's diet as ordered. The main page of the electronic clinical record for Resident #28 identified the resident had a food allergy to shellfish (shrimp, crab, lobster, oysters, clams, mussels and scallops).A History and Physical report dated 8/8/25 scanned into the clinical record revealed Resident #28's had an allergic reaction of hives (small red bumps on the skin) to shellfish. On 9/8/25 at 12:16 PM, observation revealed Staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include:The Minimum Data Set (MDS) assessment for Resident #28 dated 8/17/25 revealed the resident scored 15 out of 15 on a Brief Interview for Mental Status exam, which indicated intact cognition. The Care Plan for Resident #28 included an intervention dated 9/22/24 to for staff to provide and serve the resident's diet as ordered. The main page of the electronic clinical record for Resident #28 identified the resident had a food allergy to shellfish (shrimp, crab, lobster, oysters, clams, mussels and scallops).A History and Physical report dated 8/8/25 scanned into the clinical record revealed Resident #28 had an allergic reaction of hives (small red bumps on the skin) to shellfish. On 9/8/25 at 12:16 PM, observation revealed Staff F,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: The Minimum Data Set (MDS) assessment for Resident #3, dated 2/14/24, revealed diagnoses of Alzheimer's disease, dementia with behavioral disturbance, and anxiety. The resident was unable to complete the Brief Interview for Mental Status (BIMS) due to short- and long-term memory problems. The MDS indicated a need for partial to moderate assistance with toileting and bathing, and supervision or touch assistance with personal hygiene. The Care Plan, dated 2/8/24, included focus areas for impaired skin integrity, and for risks of falls. The focus area for skin integrity included an intervention to assess/evaluate my risk status per policy, upon admission, quarterly and as needed. indicated the resident was at risk for impaired skin integrity. Another area indicated a psychosocial well-being problem related to anxiety, dementia with behavioral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: The Minimum Data Set (MDS) assessment for Resident #2, dated 3/5/24, included diagnoses of vascular dementia with psychotic disturbance, anxiety disorder, and insomnia. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 5 out of 15, which indicated severely impaired cognition. Progress notes dated 2/2024 x 2, 2/29/24, 3/11/24, 3/13/24 x 2, 3/15/24, 3/17/24, 3/19/24, 3/23/24, 3/24/24, 3/30/24, 4/18/24 x 2, 4/22/24, and 4/25/24 documented Resident #2 ' s unwitnessed falls. Facility documentation titled Neuro-Check Flow Sheet documented neurological assessments were completed for the fall that occurred on 3/23/24. The facility lacked neurological assessments for the other 15 unwitnessed falls. During an interview with Staff C, Registered Nurse (RN), on 5/14/24 at 9:21 AM she indicated that staff should…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. 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. On 8/17/23 at 9:21 AM Staff A, Director of Nursing (DON), indicated the last certified Infection Preventionist left in May 2023.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The MDS recoreded the resident's cognitive skills for daily decision making as moderately impaired and the resident required supervision with limited assistance of 1 person for bed mobility, toileting and personal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The facility Abuse Policy with a modified Date of January 2023, documented each employee shall be required to complete training including Iowa Dependent Adult Abuse Training for Iowa. The Iowa Department of Health and Human Services recorded, beginning 7/01/19 the two-hour Dependent Adult Abuse Training is required every three years for Mandatory Reporters.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The MDS recorded Resident #12 diagnoses that included heart disease, non-Alzheimer's dementia of uncertain or unknown etiology with additional…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.