Highland Pointe Health & Rehab Center

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to maintain the privacy and confidentiality of a resident’s protected health information (PHI) by sharing medical and care information with an individual who was not documented as an authorized contact. The resident had been admitted for post-surgical care with difficulty walking and a need for personal care assistance, and an MDS assessment showed intact cognition. The resident’s demographic sheet listed the resident as their own responsible party, with only a sister documented as the emergency contact and no other contacts listed. Despite this, a nurse documented a phone call with the resident’s daughter in which the nurse discussed the resident’s pain medications, pain level, and use of PRN pain medication, and encouraged the daughter to call daily for updates. A subsequent progress note by social services documented that a care conference was held in the resident’s room with the daughter present, during which medications, orders, therapy goals, and discharge plans were discussed. Further documentation showed that the facility administrator later noted the resident’s daughter had called requesting a return call from the DON, and the resident stated he would update his daughter himself and preferred that the facility not call her at that time. Communication records in the form of text messages between social services and a family member of the resident showed additional disclosures of PHI, including information about the therapy appeal process, an upcoming appointment, discharge plans, and home health care. During interview, the social services staff member stated that at the time of the care conference the resident had allowed his daughter to receive information, but later asked that she not receive any more information, and that the resident had given permission to share information with his family member. The social services staff member confirmed there was no documentation of the resident’s permission to share information. Review of the facility’s HIPAA privacy policy showed that PHI may not be disclosed except as specifically permitted, indicating the documented disclosures were not supported by documented authorization.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide routine bathing and personal hygiene care as ordered and care planned for two cognitively intact residents who required assistance with activities of daily living (ADLs). One resident, admitted with diagnoses including muscle weakness and need for personal care assistance, had a care plan indicating self-care deficits and interventions for assistance with grooming and dressing. The MDS showed this resident was dependent for bathing, personal hygiene, and toileting, and physician orders specified showers on Tuesdays and Fridays during day shift. Review of plan of care documentation for several months showed only one documented shower in January, with no showers documented in November or December. During interview, the resident reported having received only two showers since admission and stated that staff instead performed bed wipe-downs and often gave excuses when she requested a shower. A CNA interviewed at the same time stated she was unaware of the resident’s scheduled shower days, though she knew the resident had complained about not receiving showers. A second resident, also with muscle weakness and need for personal care assistance, required moderate assistance with bathing, personal hygiene, and bed mobility and was dependent for transfers. The care plan required assistance with ADLs and allowing extra time to complete them, and physician orders specified showers on Tuesdays and Fridays. Review of documentation for December and into January showed only one documented shower in January and none in December. During interview, this resident reported not being assisted out of bed or given a shower for about a month and stated that since changing rooms, staff told her she was not on a list and therefore had not been gotten out of bed. Observation at the time of interview noted the resident’s hair appeared matted and greasy and the resident had a slight odor. A regional RN confirmed the lack of documented showers for both residents. Facility policy on ADLs required appropriate staff to perform ADL care, including personal hygiene and transferring.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide timely incontinence care and toileting assistance to residents who were dependent on staff for these activities. One resident, admitted with muscle weakness and a need for personal care assistance, was care planned and assessed as incontinent of bowel and bladder and dependent on staff for toileting, with intact cognition. This resident reported being left soiled for several hours on multiple occasions, including one night when her call light for incontinence care remained on from 1:00 A.M. to 3:45 A.M. without staff response, and another night when she was not changed from approximately 5:00 P.M. until about 7:00 A.M. the next morning. She stated that when she requested help during the night, an aide told her she could not provide incontinence care due to a lack of linens, and the resident remained incontinent until the day shift provided care. A CNA confirmed that on a morning shift she found this resident saturated in urine and requiring a full bed change, and also stated she had frequently observed residents soiled at the start of her 7:00 A.M. shifts and that management was aware. Another resident, admitted with a history of stroke with left-sided weakness and muscle weakness, was also documented as cognitively intact, incontinent of bowel and bladder, and dependent on staff for toileting, with a care plan intervention to provide incontinence care after each episode. This resident, who served as resident council president, reported that multiple residents had complained about not receiving timely toileting assistance and remaining soiled for long periods. On a specific evening and night, this resident reported not being changed, and a CNA who arrived for the day shift stated that both this resident and another had been left incontinent overnight and required complete bed changes due to being heavily soiled. An LPN acknowledged being made aware that residents had not been changed during the evening and night shift, and a regional RN and the administrator confirmed that the CNA assigned to these residents during that time had failed to check and change residents on her assignment. Facility policy required staff to perform ADL care, including personal hygiene and toileting, but the observed and reported care did not meet these expectations.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to comprehensively assess and timely manage severe pain for a resident with a left hip/femur fracture. The resident, who had intact cognition and required extensive assistance with mobility and personal care, had PRN orders for Tylenol 650 mg every six hours and Methocarbamol 500 mg twice daily for pain and muscle spasms. The care plan identified the resident as being at risk for pain related to osteoarthritis, with interventions to administer medications as ordered and evaluate their effectiveness. On the evening in question, CNAs observed the resident’s left leg to be abnormally positioned, with the hip protruding and the resident yelling out in pain during incontinence care and repositioning. They immediately notified an LPN, who assessed the resident and noted the leg was rotated, with yellow-tinged bruising at the left hip, and the resident reporting pain in the left groin area. The physician was notified and an x-ray was ordered. Record review showed no evidence that a comprehensive pain assessment, including a pain rating and description of pain quality, was completed at the time the severe pain was identified. The x-ray later suggested a left hip fracture, and the resident was subsequently ordered to be sent to the hospital. The MAR indicated that only one dose of Methocarbamol was administered that day at 9:00 p.m., despite the resident having been yelling out in pain at approximately 6:30 p.m., and there was no documentation that Tylenol was given between the onset of pain and the resident’s transfer to the hospital. The self-reported incident and facility investigation initially indicated that pain medication had been administered, but review of the MAR confirmed that PRN pain medications were not given in a timely manner after the resident’s complaints of severe pain, and that documentation of pain assessment and pharmacologic intervention did not align with facility pain management policy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to prevent medications from being left unattended in a resident’s room, contrary to facility policy requiring that medications not be left unattended and that staff observe residents consuming medications. Resident #19, admitted on 05/25/25 with diagnoses including dementia, mild cognitive impairment, and hallucinations, had an MDS assessment indicating impaired cognition. On 01/14/26 at 12:38 P.M., surveyors observed two separate medication cups in the resident’s room: one on a dresser under the television containing three white pills, and another on the nightstand next to the bed containing eight medications. During the observation, Resident #19 stated she was unaware of when the medications had been delivered and reported that staff sometimes brought medications while she was sleeping, leaving her unaware they were present. At 12:42 P.M., LPN #234 reported having administered the resident’s morning medications between 8:00 A.M. and 9:00 A.M. and stated she had observed the resident consume them. Upon observing the two medication cups, LPN #234 confirmed that the cup with eight pills contained the resident’s morning medications and acknowledged she did not know what the three white pills were, as she had not administered them. LPN #234 acknowledged that medications should not be left unattended in resident rooms. This failure to ensure medications were not left unattended affected one resident out of four observed for unattended medications during the complaint investigation.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a sanitary area around the garbage dumpsters, as observed during a survey. Several large bags of garbage containing soiled briefs, latex gloves, wipes, plasticware, and food were found on the ground surrounding three dumpsters. The dumpster doors and lids were left open, which allowed raccoons to access and pull out the garbage. These findings were confirmed by both a resident and an LPN, who stated that raccoons frequently come from the woods and tear open the bags. Additionally, a review of facility policies revealed that there was no policy in place regarding the maintenance of a sanitary dumpster area. This deficiency was identified during a complaint investigation and had the potential to affect all residents in the facility.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a sanitary and homelike environment for its residents, as evidenced by observations of miscellaneous items and debris scattered on the floors throughout the halls, including silverware, plastic utensils, latex gloves, paper straws, and linen. Dinner trays full of food were left on carts in resident halls and in the dining room, and a medication cart was found with a powder-like substance along its bottom. These conditions were verified by two LPNs during interviews, who acknowledged the presence of debris and noted that the medication cart drawers had been cleaned only a few days prior. Additionally, a review of facility policies revealed that there was no policy in place regarding the daily maintenance of communal areas by staff. The facility census at the time was 77 residents.

Penalty

Inspection fine: $28,276

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to appropriately respond to an elevated International Normalized Ratio (INR) for a resident receiving Warfarin (Coumadin) for atrial fibrillation. On a specific date, the resident's INR was reported as abnormally high at 4.9, indicating that the resident's blood was too thin. Despite this, the nursing staff did not notify the physician or stop the administration of Coumadin, continuing to administer the medication on subsequent days. This oversight led to the resident experiencing nose and gum bleeding, prompting the resident to call 911 for emergency transport to the hospital. Upon arrival at the hospital, the resident's INR was found to be critically high at 7.2, necessitating treatment with Vitamin K to counteract the effects of the anticoagulant. The resident was hospitalized for ongoing care and treatment. The facility's failure to monitor and act on the elevated INR results placed the resident at significant risk for bleeding and continued blood loss. The deficiency was identified through a review of the resident's medical records, hospital records, and other documentation. It was found that the nursing staff, including specific LPNs, did not check the resident's PT/INR levels before administering Coumadin and failed to notify the medical provider of the abnormal INR levels in a timely manner. This lack of action and communication contributed to the resident's adverse health event.

Removal Plan

• Resident #11 was discharged to the hospital.
• The Director of Nursing (DON), Assistant Director of Nursing (ADON) #918 and Registered Nurse (RN) Unit Manager (UM) #922 reviewed Resident #11's medical record, medication administration record (MAR), progress notes and laboratory results (labs) to identify the root cause related to the bleeding incident.
• The facility identified the root cause as nursing staff including Licensed Practical Nurse (LPN) #883 and LPN #963 failed to check Resident #11's PT/INR level prior to administering Coumadin 7.5 mg to Resident #11 and failed to notify medical doctor (MD)/Certified Nurse Practitioner (CNP) #980 of Resident #11's abnormal INR level in a timely manner.
• The DON, ADON #918, RN UM #922 and Regional RN (RRN) #979 completed an in house audit and confirmed four residents resided in the facility who receive Coumadin including Residents #38, #44 #76 and #82.
• Resident records for Residents #38, #44, #76 and #82 were reviewed which included the lab reports, medication administration records (MARs), progress notes and care plans to ensure that abnormal labs were reported to Nurse Practitioner (NP) #980 in a timely manner and that Coumadin was not administered to residents with a PT/INR greater than 3.0, without negative findings.
• The DON, RN ADON #918, RN UM #922 and Regional RN #979 completed assessments/skin checks on Residents #38, #44, #76 and #82 (receiving Coumadin) to ensure the residents did not have signs of bleeding or bruising.
• RRN #979 completed competencies, in person with return demonstration, with the DON, ADON #918 and RN UM #922 to review PT/INR blood work prior to administering Coumadin and education was provided on reporting of abnormal labs to CNP #980 of the specific resident by the end of the shift.
• LPN #883 and LPN #963 (two nurses who were out of compliance related to the Immediate Jeopardy) were educated (in person) by the DON, with return demonstration, on checking residents PT/INR blood work prior to administering Coumadin and on reporting of abnormal labs to CNP #980 of the specific Resident by end of shift.
• RRN #979 completed an audit of the lab work for Residents #38, #44, #76 and #82. NP #980 was notified of all lab results.
• The audit revealed Resident #76's PT/INR lab work had an INR of 3.6 and the NP was notified and ordered to hold the Coumadin dose and repeat the INR.
• The DON, ADON #918 and RN UM #922 completed competencies with LPN #883 and LPN #963, in person with return demonstration, on checking residents PT/INR prior to giving Coumadin and to ensure that the lab results are reported to CNP #980 of the specific Resident by end of shift.
• The facility held an emergency Quality Assurance Performance Improvement (QAPI) meeting.
• The QAPI meeting was held to review the root cause, reviewed the facility abatement plan due to the nurses administering Coumadin prior to checking Resident #11's PT/INR labs and not notifying NP #980 responsible for Resident #11's care, by the end of the shift.
• The DON developed and implemented a PT/INR Coumadin flow sheet.
• ADON #918 and RN UM #922 were educated on the form, how to implement the form, when to use the form and what to do for abnormalities identified on the form.
• Both nurses would print Coumadin lab reports five days a week at Clinical Morning Meetings to review any changes in orders due to any abnormal lab results & to ensure the CNP of the specific resident was notified of the results by the end of the reporting shift.
• The Coumadin flow sheet was implemented by ADON #918 and RN UM #922.
• The form would be completed each time a blood draw was ordered with results received for each resident on Coumadin.
• The abnormal results would be reported to CNP #980 of the specific resident by end of the reporting shift.
• The DON, ADON #918 and RN UM #922 completed education in person and via phone to all 17 staff LPNs and all six staff RNs on checking residents' PT/INR results prior to giving Coumadin and to ensure that the lab results were reported to NP #980 of the specific resident by the end of the reporting shift.
• All 37 staff State tested Nursing Assistants (STNA) were educated on observing for abnormal effects of Coumadin including bleeding, bruising and black tarry stools and reporting abnormalities to the nurse.
• The facility also used agency staffing including four agency RN's, eight agency LPN's and five agency STNA's who work as needed in the facility.
• RRN #979 confirmed the agency staff members were educated over the phone and would not work in the facility unless they had received the education prior to their next scheduled shift.
• The facility indicated all new hires would receive the education during orientation.
• The DON, ADON #918 and RN UM #922 completed competencies to ensure 17 LPNs and six RNs were checking residents PT/INR prior to giving Coumadin and to ensure that the lab results are reported to NP #980 in a timely manner.
• To ensure ongoing compliance, the DON/ADON/UM/Designee would audit PT/INR lab results and timely notification of the residents' NP four times a week for three weeks.
• The audits would be completed beginning and the facility would then continue a monthly audit for the next two months, during clinical morning meetings, for verification the PT/INR results were reviewed and reported to the residents' NP as needed.
• The results of the audits would be forwarded to the facility QAPI committee for additional review and recommendations.

Penalty

Inspection fine: $28,276

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adequately and timely meet the care needs of its residents, leading to multiple instances where residents contacted local emergency services for assistance. This deficiency affected eleven residents, who made non-emergent calls to the police and fire departments due to unmet care needs, such as unanswered call lights and lack of assistance with pain management, basic care, and other routine needs. For example, one resident with dementia and moderate cognitive impairment called the police due to unaddressed leg pain, resulting in unnecessary hospitalization. Another resident with intact cognition called the police for help, but there was no evidence of assessment by the facility staff following the call. The report highlights several incidents where residents, including those with cognitive impairments and intact cognition, resorted to calling emergency services due to unmet care needs. One resident with dementia called the police twice in two days for assistance with a bedpan and vomiting, leading to hospitalization. Another resident reported abuse by a staff member, and yet another resident called the police to report a stolen wallet, which was not initially reported to the facility staff. These incidents indicate a pattern of residents feeling neglected or mistreated, prompting them to seek external help. Interviews with local police and fire department personnel revealed ongoing concerns about the frequency of calls from the facility's residents. The facility's administration acknowledged awareness of the issue but failed to implement effective interventions or measures to prevent residents from contacting emergency services for routine care and assistance. Despite attempts to investigate and address the root cause of the problem, the facility could not identify a specific pattern or cause for the increase in resident calls to emergency services.

Penalty

Inspection fine: $28,276

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure sufficient nursing staff with the appropriate competencies and skills were on duty, which resulted in delayed medication administration for 15 residents. On the night of June 4th, 2024, LPN #401 was called in to replace another LPN who reported off duty. However, LPN #401 did not receive timely access to the facility's electronic health records (EHR), delaying the start of medication administration until around 10:00 P.M. This delay affected the administration of medications scheduled between 7:00 P.M. and 11:00 P.M., with some medications not being administered until after 2:00 A.M. the following day. The report highlights specific instances where residents did not receive their medications as ordered due to the lack of access to the EHR system. For example, Resident #5's medications, including Atorvastatin and Travoprost eye drops, were administered hours late. Similarly, Resident #12's medications, which included several critical prescriptions such as Atorvastatin and Levetiracetam, were also delayed. These delays were consistent across multiple residents, indicating a systemic issue related to staffing and access to necessary systems. Interviews with residents and their family members further corroborated the issue of insufficient staffing, with reports of untimely care and unresponsive staff during the night shift. Additionally, external entities such as the fire department were contacted by residents due to unresponsive staff, further emphasizing the severity of the staffing inadequacies. The facility's policies on staffing and medication administration were not adhered to, contributing to the deficiencies observed during the survey.

Penalty

Inspection fine: $28,276

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to administer non-pressure skin treatments as ordered for a resident, leading to a deficiency. The resident, who was admitted with osteomyelitis, diabetes, and anemia, had a care plan that included interventions for skin breakdown. However, the facility did not document the administration of lac-hydrin cream to the resident's feet as ordered by the podiatrist from April 1 to May 13. Additionally, the wound care treatment for the resident's left calcaneus was not completed as ordered from April 1 to May 23. The resident's medical records and interviews revealed that the facility was unaware of new orders for the left heel dressing changes after the resident's wound clinic visit. The resident reported that the dressings on his feet were not changed from April 1 to May 23, and the lac-hydrin cream was not applied as ordered. The facility's records confirmed the lack of evidence for the completion of these treatments. Interviews with facility staff and outside wound clinic personnel indicated that the resident's wounds were vascular in nature and not pressure-related. The resident was noted to be non-compliant with care, including turning, repositioning, and bathing. Observations showed that the resident had an air mattress and prafo boots in place, but the facility failed to follow through with the prescribed treatments, leading to the deficiency.

Penalty

Inspection fine: $28,276

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to administer pain medications as ordered for a resident who had been discharged from the hospital with specific instructions for pain management. The resident, who had a history of charcot neuroarthropathy and had undergone left ankle fusion with an external fixator, was prescribed oxycodone ER and hydromorphone for pain management. However, the facility did not administer these medications according to the discharge orders. The resident's pain levels were monitored and recorded, showing varying levels of pain, but the administration of the prescribed medications was inconsistent and not in line with the orders. The issue was identified when a Certified Nurse Practitioner (CNP) assessed the resident and discovered that the hospital discharge orders had been transcribed incorrectly, leading to improper administration of the oxycodone ER. The resident reported that his pain was not being managed as effectively as before, and the CNP confirmed that the staff had not administered the narcotic pain medications as ordered. The facility's Medication Admin policy required medications to be administered according to prescribed times, but there was no specific Pain Management Policy available. This deficiency was investigated under multiple complaint numbers.

Penalty

Inspection fine: $28,276

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a medication error rate of less than five percent, resulting in a rate of 6.66%. This deficiency affected one resident, who was admitted with diagnoses including unspecified dementia, essential hypertension, and depression. The resident had physician orders for aspirin chewable 81 mg to be administered once daily and vitamin C 500 mg to be administered as two tablets once daily. However, during a medication administration observation, a registered nurse administered aspirin in an enteric-coated form instead of chewable and only one vitamin C tablet instead of the prescribed two. The nurse confirmed these errors during an interview. The facility's medication administration policy requires medications to be administered according to the physician's orders, which was not adhered to in this instance.