Terrace at Solarbron the

In the surveyor’s words

From the most serious findings on record at Terrace at Solarbron the, in the surveyor’s own words.

• Actual harm, isolatedF689Oct 31, 2023

  Based on observation, interview, and record review, the facility failed to ensure a sit to stand lift was used according to facility policy for 1 of 6 residents reviewed for falls. This deficient practice led to a fall with a fracture requiring hospitalization and surgical repair. (Resident M) Finding includes: During a confidential interview on 10/24/23 at 11:13 A.M., it was indicated that a CNA (Certified Nurse Aide) dropped Resident M while using a sit to stand lift resulting in a broken ankle. On 10/25/23 at 10:19 A.M., Resident M's clinical record was reviewed. […]

• Actual harm, isolatedF689Jun 24, 2022

  Based on interview and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent falls for 1 of 3 resident reviewed for falls. The resident received two fractures in less than one month which resulted in multiple fractures to right arm. (Resident B) Finding includes: On 6/23/22 at 9:45 a.m., Resident B's record was reviewed. Diagnoses included, but not limited to, [CONDITION(S)], unspecified affecting right dominant side, [CONDITION(S)] following cerebral infarction, muscle weakness (generalized), age related physical debility, other abnormalities of gait and mobility, personal history of [CONDITION(S)] (TIA) and cerebral infarction without residual deficits. […]

• Actual harm, isolatedF689Mar 22, 2022

  Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance to prevent falls for 1 of 2 residents reviewed for accidents, which resulted in a fractured femur. (Resident 60) Finding includes: On 3/18/22 at 1:37 P.M., Resident 60 was observed sitting in a wheelchair in the dining room, slightly leaning head to the left side. On 3/21/22 at 8:36 A.M., Resident 60 was observed sitting in a wheelchair in the dining room, slouched forward and slightly leaning head to the left side. On 3/18/22 at 9:29 A.M., Resident 60's clinical record was reviewed. […]

• Actual harm, isolatedF689Jan 6, 2022

  Based on observation, interview, and record review, the facility failed to ensure supervision was provided to prevent falls, resulting in a fall that caused hospitalization and bleeding in the brain for 1 resident (Resident P); and failed to implement interventions to prevent falls, for 3 of 4 residents reviewed for falls (Residents P, D, and B). Findings include: 1. On 1/4/22 at 9:30 A.M., during the initial tour of the Memory Care unit, the Director of Nursing (DON) indicated Resident P was currently in the hospital. He had recently fallen at the facility. The clinical record of Resident P was reviewed on 1/5/22 at 3:15 P.M. […]

• Actual harm, isolatedF689Aug 11, 2021

  Based on observation, record review and interview, the facility failed to adequately supervise and implement specific interventions for 2 of 3 residents who were reviewed for falls. (Resident C and J) Resident C had multiple falls with two falls resulting in injuries. One resulted in a fracture of the right trochanter, and another a hematoma. A [NAME] monitor (portable electrocardiogram), used as an intervention, was misplaced and not replaced timely to monitor for [CONDITION(S)] symptoms. Findings include: 1. During the initial tour of the Memory Care unit, on 8/9/21 at 9:20 a.m., the Director of Nursing did not indicate Resident C had any falls or injuries with falls. During an observation on 8/9/21 at 12:30 p.m., Resident C was observed sitting in a recliner in her room. […]