Inspection Reports for Highbridge Woodycrest Center

The facility failed to maintain a facility-specific water management plan for Legionella with all required components and did not ensure that the designated Infection Preventionist had completed specialized infection prevention and control training as required.

Deficiencies in infection control, infection preventionist qualifications, and life safety code issues including fire alarm system, HVAC, and illumination of means of egress; all corrected by September 2024 or earlier.

The facility was found to have a tampered bathroom doorknob in a shared resident room that posed an accident hazard, and the facility did not have a qualified Infection Preventionist with specialized training as required. The bathroom door handle was replaced during the survey, and interviews revealed lack of awareness about infection prevention training requirements.

Deficiencies in care plan timing and revision, accident hazards supervision, infection preventionist qualifications, and multiple life safety code issues including egress doors, electrical systems, emergency lighting, physical environment, sprinkler system installation and maintenance; all corrected by late 2022 or early 2023.

Deficiencies related to abuse and neglect prevention, reporting of alleged violations, and reporting of reasonable suspicion of a crime; all corrected by May 2022.

The facility failed to ensure that a physician reviewed and documented the clinical rationale for continued use of an antipsychotic medication for Resident #31. The resident was prescribed Zyprexa for an unclear diagnosis, with conflicting documentation regarding the diagnosis of dementia versus psychosis. The physician disagreed with pharmacist recommendations but did not document clinical rationale. Non-pharmacological interventions were used, and no inappropriate behaviors were observed. Additionally, expired influenza vaccines were found in the medication refrigerator.