Resident #2 fell on October 26 at Highland Ridge Care Center. The next morning, she told nursing staff her right hip "hurts pretty bad" and cried out for them to stop when they tried to turn her in bed because "it's really hurting."
Staff transferred her to a wheelchair anyway. She rated the pain as 6 out of 10.
LPN Staff G admitted she didn't treat the pain at that time because it was "brief," even though the resident had complained consistently since the fall. The nurse waited until 1:08 pm to give Tylenol — over 13 hours after the resident first reported severe hip pain that morning.
During the delayed x-ray procedure, the resident screamed "Oh my god that hurts" and grabbed at her right hip when technicians tried to position her. The x-ray revealed a possible fracture.
Staff G told inspectors she "did not remember administering pain medication" because the resident "only complained of pain during care and she was not crying."
The facility's own Pain Assessment and Management Policy required staff to "properly identify, treat and manage pain" based on "observations and statements" from residents. The policy specifically mentioned evaluating "activities or care that exacerbate pain."
The resident's daughter grew concerned about the delay in getting x-ray results and drove to the facility. When she arrived at 4 pm, x-ray staff were leaving. At 6 pm, she approached the nurses' station requesting results.
That's when Staff G learned the x-ray showed a possible fracture.
The facility finally called an ambulance at 8:10 pm. The resident was transported to the hospital at 8:20 pm — nearly 24 hours after her fall.
The Medical Director was on vacation during the incident. He told inspectors the facility should have called the emergency department if there was "increased pain, no movement of an extremity or the family disagreed with the nurse recommendation."
All of those conditions were met. The resident had increased pain, limited movement of her right leg, and her daughter expressed concern about delays. Yet staff waited until x-ray results confirmed their suspicions before seeking emergency care.
Staff G documented that the resident "was able to move her left leg without issues" but "was not able to bend or raise" her right leg because of pain. She could only "slightly bend her right leg with support."
The nurse noted the resident was "usually up for meals and ambulated" but remained in bed the morning after her fall due to pain.
When staff finally attempted to get her up for breakfast, they had to use two people to stand and pivot her to the wheelchair. She said "ouch" multiple times during the transfer.
The Medical Director acknowledged the facility had 24-hour on-call staff "for anything serious" and could have faxed non-urgent situations to his office. A resident crying out in pain during routine care and unable to bear weight on her leg after a fall would typically qualify as urgent.
The inspection found the facility failed to ensure the resident received appropriate pain management following her fall, despite clear policy requirements and obvious signs of distress.
Staff G's decision to withhold pain medication because the resident wasn't "crying" contradicted both the facility's written policies and basic nursing standards. The resident had verbally reported severe pain, demonstrated physical limitations, and cried out during care — all indicators requiring immediate attention.
The 13-hour delay in pain treatment occurred while the resident experienced what x-rays would later confirm as a possible hip fracture, one of the most painful injuries common in elderly residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Highland Ridge Care Center, LLC from 2025-11-19 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Highland Ridge Care Center, LLC
- Browse all IA nursing home inspections