Solaris Healthcare Lake Zephyr

Inspectors wroteBased on interviews and record review the facility failed to ensure a grievance process was followed for one resident (#5) of three residents sampled for grievances. Findings Included: Review of Resident #5's medical record revealed the resident was re-admitted to the facility on [DATE]. The medical diagnosis of the resident included: concussion with loss of consciousness status unknown, subsequent encounter trauma fall with laceration 3 centimeters with hematoma, major depressive disorder, recurrent, moderate, and adjustment disorder with anxiety. Review of Resident #5's Minimum Data Set (MDS), revealed the resident had a Brief Interview Mental Status (BIMS), score of 13 out of 15, indicating the resident's cognition was intact. During an interview at 9:54 a.m. [...]

Inspectors wroteBased on record reviews and interviews the facility failed to provide adequate and appropriate health care for one (#2) of three sampled residents as evidence by not obtaining a urinalysis with culture and sensitivity as ordered by the physician and not monitoring a surgical site for signs of infection, drainage, and/or a clean intact dressing.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement care plan interventions related to oxygen administration for four residents (#42, #56, #60, and #71) out of 4 residents reviewed for oxygen administration.

Inspectors wroteBased on observations, interviews, and record review. the facility 1) failed to adhere to infection control practice standards for personal protective equipment (PPE) while providing direct care for two residents (#98 and #319) out of eight residents on enhanced barrier precautions (EBP), and 2) failed to perform hand hygiene during medication administration during 3 out of 9 observations of medication administration.

Inspectors wroteBased on observations, interviews, and record review, the facility 1) failed to provide the necessary care and services for urinary catheter care, maintaining urinary flow into the urinary catheter bag and ensuring appropriate infection control techniques during urinary catheter care for one resident (#319) out of three residents reviewed for incontinence care, and 2) failed to document consent related to insertion of a catheter for one resident (#458) out of three residents reviewed.

Inspectors wroteBased on interviews and record review, the facility failed to report within two hours an injury of unknown source for one resident (# 41) of three sampled residents. Findings Included: On 7/10/2024 during the 7:00 a.m. to 3:00 p.m. shift, Staff O, Certified Nursing Assistant (CNA) observed a yellowish bruise near Resident's #41's vaginal area and did not report the observation to the nurse. On 7/11/2024 on 11:00 p.m. to 7:00 a.m. shift, Staff M, CNA said she observed a small bruise on Resident #41's left lateral thigh and did not report the observation to the nurse. Review of a Situation Background Assessment Recommendation (SBAR) form, dated 7/12/2024, showed Resident #41 had changes in skin color or condition and there were no medication changes in the past week. The blood pressure was 136/74, Pulse 82, Respiratory rate 18, Temperature 98.0 degrees and weight was 111.4 pounds. [...]

Inspectors wroteBased on interviews and record review, the facility failed to prevent an injury of unknown origin for one resident (# 41) out of three sampled residents for injuries/accidents. Findings Included: Review of a Situation Background Assessment Recommendation (SBAR) form, dated 7/12/2024, showed Resident #41 had changes in skin color or condition and there were no medication changes in the past week. The blood pressure was 136/74, Pulse 82, Respiratory rate 18, Temperature 98.0 degrees and weight was 111.4 pounds. Resident #41's skin evaluation showed Resident present bruising in the groin area and left hip, accompany by swelling of the left labia left thigh, left hip. X-ray Stat was ordered. The documentation was signed by Staff F, Registered Nurse (RN). [...]

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure residents, resident representatives, and visitors were notified of the COVID-19 status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all skin conditions were appropriately addressed for two (Residents #25, #26) of 36 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physician's orders for, assess the use of, and develop care plans for padded side rails which were attached to the beds of four (Residents #8, #31, #76, and #81) of 36 sampled residents .

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-five medication administration opportunities were observed, and two errors were identified for two (Residents #32 and #26) of six residents observed. These errors constituted a 8.00% medication error rate.

Inspectors wroteBased on observation, record reviews, and interviews, the facility failed to ensure that hot foods were held at 135 degrees Fahrenheit or higher on the steam table in one of one kitchen.

Inspectors wroteBased on record review and interview the facility failed to develop and implement a comprehensive careplan for 1 of 3 (#72) residents sampled for pain.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one Resident #184 was receiving oxygen according to professional standards of practice of three residents sampled. Findings Included: Observation of Resident #184 on 3/30/21 at 4:00 p.m. the resident was lying in bed on the Covid-19 positive unit with oxygen set at 3 liters via nasal cannula. Staff member B, LPN confirmed the oxygen was set at 3 liters. An interview with Staff member E, LPN on 3/30/21 at 4:02 p.m. confirmed the resident was on continuous oxygen. Observation of Resident #184 on 4/1/21 at 5:45 p.m. sitting up in bed on the Covid-19 positive unit with oxygen set at 2.5 liters via nasal cannula. Staff member B, LPN confirmed the oxygen was set at 3 liters via nasal cannula and stated the resident should have an order for the oxygen. [...]

Inspectors wroteBased on record review and interview the facility failed to notify the physician of pharmacy recommendations for 1 of 5 (#48) residents reviewed for unnecessary medications

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure that the medication error rate was less than 5.00%. Thirty-one medication administration opportunities were observed and two errors were identified for one Resident (#55) of ten residents observed. These errors constituted a 6.45% medication error rate. Findings Included: Observation of medication administration on 4/1/21 at 11:02 a.m. with Staff member D, LPN and Resident #55. Staff member D, checked the blood sugar for Resident #55 with a result of 154. Review of physician orders for the sliding scale of Novolog solution 100 unit/ml included 151 - 200 equals giving 2 units of insulin. Prime pen with 2 units air shot prior to insulin administration. Staff member D, verified the Novolog flex pen for resident #55 and placed a new needle on the pen. At 11:10 a.m. [...]