SENIOR CARE OF HARBOR LAKES
LOCATED: 1300 2ND ST, GRANBURY, TX 76048

SENIOR CARE OF HARBOR LAKES was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies:

PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here.

FACILITY FAILED TO PROVIDE APPROPRIATE PRESSURE ULCER CARE AND PREVENT NEW ULCERS FROM DEVELOPING

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review, the facility failed to ensure residents with pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown or pressure ulcers for four (Residents #1, #2, #4 and #5 ) of four residents reviewed for pressure ulcers.

1. The facility failed to ensure weekly skin assessments were performed,
2. a) Resident #2 was re-admitted to the facility on [DATE] and had no weekly skin assessments performed since re-admission
3. b) Resident #1 did not receive a weekly skin assessment between 12/14/17 and 01/25/18
4. c) Residents #4 and #5 did not receive weekly skin assessments.

2) The DON failed to ensure weekly skin assessments were accurate,

18. a) Resident #1’s pressure ulcer was not documented on her weekly skin assessments and resulted in the ulcer going untreated from 12/13/17 until 01/26/18.
19. b) Resident #1 was discovered to have several skin wounds upon transfer to the emergency room on [DATE] severe enough that they contacted Adult protective Services. The [MEDICAL CONDITION] were not documented on the nursing facility’s weekly skin assessment sheet.

3) LVN-C failed to document Resident #2’s stage II pressure ulcer and was treating the ulcer with skin prep which was not  physician ordered.

These failures could place 14, documented at high risk for pressure ulcers at risk of inaccurate skin assessments and undocumented and untreated pressure ulcers.

Interview 02/14/18 at 4:10 p.m. with Resident #1’s Hospital Case Manager. She stated she contacted Adult Protective Services on 02/14/18 to report possible neglect of the resident by the Nursing Facility due to pressure ulcers and multiple other wounds discovered in the emergency room (ER) when the resident was admitted on [DATE]. She stated ER staff took photos of the wounds. She stated the resident was transferred to the Intensive Care Unit for low blood pressure and remained there at this time. Review of the photo’s reflected what appeared to be skin excoriation on the buttocks and inner thighs, an unstageable pressure ulcer to the right heel and a dark area on the left heel.

Personal Note from NHA–Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.

You can make a difference. If you have a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately.

We have helped many already and we can help you and your loved one as well by filing a state complaint, hiring a specialized nursing home attorney or helping you find a more suitable location for your loved one.

Contact us through our CONTACT FORM located on our website here below or on the sidebar or call our toll free hot line number: 1-800-645-5262.

You can make a difference even if your loved one has already passed away.