Solaris Healthcare Imperial

In the surveyor’s words

From the most serious findings on record at Solaris Healthcare Imperial, in the surveyor’s own words.

• Actual harm, isolatedF689Nov 22, 2024

  Based on review of facility policy and procedure, record review and staff interviews, the facility failed to thoroughly investigate falls and implement adequate interventions to prevent falls and fall related injury for 1 (Resident #24) of 3 residents reviewed who were identified as being at risk for falls and sustained multiple falls at the facility. The findings included: The facility policy Incident Report and Investigation Guidelines documented, All falls, altercations, elopements/unplanned exits, alleged neglect, alleged misappropriation or exploitation of resident property or other events leading to harm or injury to a visitor or resident (incidents) occurring in the facility or on facility property will be documented and investigated and recorded on an Incident Report and… […]

• No harm, potential for more than minimal, patternF690Nov 22, 2024

  Based of observation, medical record review and facility policy review, the facility failed to assess bladder incontinence for 2 (Residents #37, and #92) of 2 residents reviewed for incontinence, and failed to provide appropriate care of indwelling urinary catheters for 2 (Residents #64 and #50) of 2 sampled residents observed with urinary catheters. The findings included: Review of the facility policy for the BOWEL AND BLADDER REHABILITATION PROGRAM reads, General Guidelines 1. The initiation of a continence program requires the consent and cooperation of the resident/responsible party. 2. The continence program must be individualized and resident centered to decrease or prevent urinary incontinence in order to minimize or avoid negative consequences of incontinence. 3. […]

• No harm, potential for more than minimal, patternF725Nov 22, 2024

  Based on observation, interview, and record review the facility failed to maintain sufficient staffing to ensure call lights were answered in a timely manner for 7 (Resident #94, #70, #63, #37, #22, #73, and #200) of 7 residents sampled. The failure to respond to call lights in a timely manner places residents at increased risks for injuries related to falls. The findings included: On 11/18/24 at 11:05 a.m., in an interview Resident #94 said it can take between ten to thirty minutes for staff to respond to a call light. Resident #94 said the lack of staff response occurred more often on the 3:00 p.m. to 11:00 p.m. shift. Resident #94 was observed to activate the call light on 11/18/24 at 11:06 a.m. Resident #94 said he should not have to wait more than five minutes. […]

• No harm, potential for more than minimal, patternF880Nov 22, 2024

  Based on observation, review of facility policy and procedure, review of the clinical record and staff interviews the facility failed to store resident care equipment in a sanitary manner for 2 (Residents #23 and #53) of 6 residents reviewed and failed to follow infection prevention during wound care for 1 (Resident #50) of 1 resident observed for wound care. The findings included: The facility Policies and Practices- Infection Control documented This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. The objectives of our infection control policies and practices are to: a. […]

• No harm, potential for more than minimal, patternF760Aug 27, 2024

  Based upon interview and record review, the facility failed to ensure residents were free from significant medication errors by not administering medications in accordance with prescriber's orders for 1 (Resident #1) of 3 residents reviewed receiving anti-coagulant medications. The findings included: Record review of Resident #1's chart revealed he had been discharged to the facility from the hospital on 7/17/24. The hospital discharge indicated he was to continue receiving Lovenox 110 mg (milligrams) injections every 12 hours (anticoagulant medication that prevents blood clots from forming in the bloodstream). The hospital discharge paperwork also indicated the Lovenox injections were to continue for 1 month then likely convert to an oral anticoagulant after that. […]