Highland Ridge Care Center, Llc

F 0684 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

nurse could call the Emergency Room. The Medical Director stated he reviewed Resident #2's situation with the fall, and initially the family declined to send her, but if there was a change or the nurse suspected a fracture and it was overnight, then they are to call the Emergency Room. There is staff on call 24/7 there for anything serious. The Medical Director stated the facility could send a fax for the non-urgent situations. The Policy titled Fall Prevention and Management Program Policy dated 2021 revealed the nurse will immediately evaluate the resident for any injury, change in status or pain and will proceed with emergency procedures and interventions as indicated.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Ridge Care Center, LLC

102 Highland Circle Williamsburg, IA 52361

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

direction, and the daughter told her to monitor her. Staff O stated she did not call and report to a physician but placed a report on the physician clip board. During an interview on 11/18/25 at 3:09 pm, Staff M, CNA stated on 10/26/25 she worked the 2p-6pm shift. Staff M stated after the evening meal time, she assisted Staff N, CNA with a transfer of a resident and was asked to check on Resident #2 in her room. Staff M stated Staff D, Certified Medication Assistant, reported Resident #2 was in her room and she was not to be

in her room by herself in the wheelchair because she would get up and fall. Staff M stated Resident #2 was

in her wheelchair in her room and stated she assumed that Staff N or Staff D would take care of her and returned to her assigned unit. Staff M stated she heard on the radio that Resident #2 was on the floor shortly after and returned to find Resident #2 on the floor with Staff M and the nurse. Staff M stated she did not remember Resident #2 moving her legs but she yelled out in pain when she was turned on her side for

the mechanical lift sling to be placed under her. During an interview on 11/19/25 at 2:46 pm, Staff D, CMA stated he was passing medication on 10/26/25 and was aware Resident #2's daughter pushed her into her room, left her in the wheelchair at 6:45pm with the TV was on, she was fine. Staff D stated he left the room to pass medication when Staff N, CNA called on the radio for assistance and when he responded, Resident #2 was on the floor. Staff D stated Staff N and the nurse were present and stated they did not need his assistance and no one requested for him to give prn pain medication to Resident #2.During an interview on 11/17/25 at 10:49 am, The Medical Director stated he was on vacation when Resident #2 fell, normally the facility will call the office or the emergency department team. The Medical Director stated if there was a significate change in a resident's condition, increased pain, no movement of an extremity or the family disagreed with the nurse recommendation, then the nurse could call the Emergency Room. The Medical Director stated he reviewed Resident #2's situation with the fall, and initially the family declined to send her, but if there was a change or the nurse suspected a fracture and it was overnight, then they are to call the Emergency Room. There is staff on call 24/7 there for anything serious. The Medical Director stated the facility could send a fax for the non-urgent situations. The IDT (Interdisciplinary Team) meeting was held on 10/28/2025 to review the event on 10/26/25. Root cause analysis determined that the resident had self-transferred from her wheelchair to bed and lost balance. The intervention established was to avoid leaving the resident in her wheelchair unattended in her room. The effectiveness of this intervention was to be monitored, and the care plan would be updated accordingly. Resident #2 was transferred to hospital for further evaluation and the investigation is ongoing. The Facility Assessment stated staffing levels were assessed to determine if capable of admitting additional patients, and may hold admissions based on staff levels or if staff are not trained in the areas of care that a new admission may require. Acuity management was based on the census report, related to activities of daily living needs and historical trends. The number of staff will be prioritized based on the residents with higher needs. Staff was instructed not to perform a task that they do not feel competent to perform. The assessment was reviewed with the Quality Assurance and Performance Improvements and Quality Assurance Committee on 4/16/25.The Policy titled Fall Prevention and Management Program Policy dated 2021 revealed the Clinical Coordinator was responsible for the supervision of the personnel in delivering safe and personalized care, to evaluate the effectiveness of interventions and to collaborate with the interdisciplinary team in the prevention of falls. The prevention interventions/strategies included the care plans will indicate the resident specific interventions to prevent falls. The nurse will notify 911, the primary physician and the nurse practitioner based on the initial evaluation.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Ridge Care Center, LLC

102 Highland Circle Williamsburg, IA 52361

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

shortening or external rotation of limbs noted. Resident #2 was able to move her left leg without issues.

Resident #2 was able to move her right lower leg a bit to the right but was not able to bend or raise it because of pain. Resident #2 was able to slightly bend her right leg with support. Called the POA to update resident's condition and requested to continue to monitor her mom, give pain pills as needed and do a portable Xray in the morning. On 10/27/25 at 3:44 am the Tylenol was effective. During an interview on 11/17/25 at 2:36 pm, Staff G, LPN stated Resident #2 was usually up for meals and ambulated, but in report on 10/27/25 at 6 am, she was informed of her fall and pain with range of motion focused on her right leg to hip. Staff G stated she peeked in to Resident #2's room at 7 am to find her asleep. Staff G stated the assessment at 9:45 am revealed pain in Resident #2's right hip, grabbed her upper thigh, but was unable to describe the pain. Staff G stated the CNA's then transferred Resident #2 to a wheelchair, who said ouch a couple of times when stood and reported the pain location in the right hip. Staff G stated she did not treat

the pain at that time as it was brief. Staff G stated she spoke with the daughter around lunch time, reported her mom had pain and the daughter was concerned with the time it was going to take for the x-ray, so she was making arrangements to come to see her mother. Staff G stated when the portable x-ray staff attempted to roll Resident #2, she verbalized pain, Oh my god that hurts and grabbed at her right hip. Staff G stated the daughter arrived when the x-ray staff left at 4 pm. Staff G stated at 6pm, she gave report to the oncoming nurse when the daughter approached the desk requesting the x-ray results. Staff G stated the result revealed a possible fracture and she had a concern with pain management during care. Staff G stated she did not remember administering pain medication as Resident #2 only complained of pain during care and she was not crying. The Progress Note on 10/27/25 at 7:30 am, Staff G, LPN documented she assisted staff with cares of Resident #2 who stated the right hip hurts pretty bad but not too bad at the moment. When attempted to turn Resident #2 in bed, she cried out to stop, it's really hurting. Resident #2 then stated that she wanted to get up for breakfast, two staff stood and pivoted to her to a wheelchair.

Resident #2 considered the pain of the transfer a 6/10, once she sat in the wheelchair, no further complaint of pain. At 1:08 pm Tylenol was administered for pain and was effective. At 6:35 pm the x-ray results were reviewed with the POA at bedside. At 8:10 pm the ambulance arrived with departure to the hospital at 8:20 pm. During an interview on 11/17/25 at 10:49 am, The Medical Director stated he was on vacation when Resident #2 fell, normally the facility will call the office or the emergency department team. The Medical Director stated if there was a significate change in a resident's condition, increased pain, no movement of

an extremity or the family disagreed with the nurse recommendation, then the nurse could call the Emergency Room. The Medical Director stated he reviewed Resident #2's situation with the fall, and initially

the family declined to send her, but if there was a change or the nurse suspected a fracture and it was overnight, then they are to call the Emergency Room. There is staff on call 24/7 there for anything serious.

The Medical Director stated the facility could send a fax for the non-urgent situations. Pain Assessment and Management Policy dated 2025 revealed the purpose was to properly identify, treat and manage pain and discomfort by the observations and statements of staff and resident feedback. The procedure included the evaluation of resident reports or signs of increased pain and factors such as activities or care that exacerbate pain.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Ridge Care Center, LLC

102 Highland Circle Williamsburg, IA 52361

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0741 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

work on halls by themselves and that was concerning. Staff F stated she thought they should put more experienced staff on those halls. Staff F stated she was aware that Staff B, CNA was only hired for a month,

a new CNA with no experience, who trained Staff A, CNA in the dementia unit, who was also a new CNA without experience. During an interview on 11/17/25 at 9:52 an, Staff Q, RN stated she had spoken with the Administrator about her concerns with guidance and training as the entire 2nd shift was new and they had

an increase in falls. Staff Q stated the census was down in the main area but the census was not down on

the dementia unit. Staff Q stated the charge nurse was required to sign off on the training the staff receive, provide care for 50 residents and may not get it everything but there was no time for follow-up. A review of staff training documents revealed Staff A, CNA was 80% completed with the resident rights and 80 to 90% completed with multiple dementia trainings. Staff B, CNA was 80% completed with multiple dementia trainings. Interview on 11/13/25 at 12:49 pm, The Administrator stated there must always be 2 certified staff

in the dementia unit during the day and evening shifts and 1 CNA on the night shift. The Administrator stated she was unaware that Staff A, CNA was the only CNA in the dementia unit on 10/29/25 at the time of Resident #1's fall, at the beginning of the shifts when staff came in late and at the time staff would take a break on multiple occasions. The Administrator stated dementia training for staff was to be completed

before the staff could work in the dementia unit. The Administrator stated the Clinical Coordinator's review resident documentation to monitor if interventions were effective and she was unaware that Resident #1's behavior interventions were not effective during care. The Facility Assessment stated staffing levels were assessed to determine if capable of admitting additional patients, and may hold admissions based on staff levels or if staff are not trained in the areas of care that a new admission may require. Acuity management was based on the census report, related to activities of daily living needs and historical trends. The number of staff will be prioritized based on the residents with higher needs. Staff was instructed not to perform a task that they do not feel competent to perform. The assessment was reviewed with the Quality Assurance and Performance Improvements and Quality Assurance Committee on 4/16/25.In an email on 11/17/25 at 7:45 am, The Administrator stated, While we do not have a standalone written staffing policy specifically for

this unit, our approach is guided by resident-centered care principles and regulatory requirements. To ensure appropriate coverage and quality of care, we continuously evaluate staffing levels and make adjustments as needed. We are committed to meeting or exceeding all state and federal staffing requirements.

Event ID:

Facility ID:

If continuation sheet