The resident arrived at her doctor's office on October 13 with wet dressings covering two open wounds on her left foot. Her family member discovered the problem when they accompanied her to the appointment.
Terra Bella Health and Wellness Suites had received explicit physician's orders the same day warning against exactly this scenario. The doctor's instructions, written in capital letters, read: "PLEASE DO NOT GET WOUND DRESSING WET IN SHOWER. PLEASE COVER WITH CAST COVER OR PLASTIC BAG ENSURING TAP WATER DOESN'T SOAK DRESSING."
The resident had an infected left heel and an open wound on top of her foot, approximately 2 centimeters in diameter. She also had cognitive communication deficits, according to her medical records.
CNA B told inspectors she had assisted the resident with her shower that morning before the appointment. She said she wrapped the resident's left leg and foot in plastic during the shower. But she also noted the floor was wet in the resident's room when the resident was transferred to her wheelchair.
Nobody changed the wet dressings before sending the resident to her appointment.
The facility's Director of Nursing explained to inspectors that wet wound dressings can cause tissue breakdown, a condition called maceration. She said if a dressing was wet, the nurse should have changed it.
Federal inspectors observed the resident's wound care the day after the appointment. LVN A removed the resident's left sock and kerlix gauze wrap, revealing two dry, intact dressings. The wound on top of the foot appeared superficial. When the nurse tried to examine the heel wound, the resident complained of pain when her leg was lifted. The inspector couldn't get a clear view.
LVN A stopped the procedure and wrapped the resident's foot, saying she would return after the resident received pain medication. She returned 46 minutes later and completed the wound care without any problems noted by inspectors.
The physician's orders from October 13 had been clear about shower precautions. Beyond the capitalized warning, the doctor wrote: "Avoid getting wound wet in showers/baths to prevent bacteria getting washed into wound. Cover with cast cover [available at most pharmacies] or take a sponge bath."
The resident's diagnoses included an unspecified wound of her left foot and a subsequent-encounter left heel infection, meaning this was an ongoing problem requiring careful management.
Inspectors tried three times to contact the wound care clinic to verify what happened during the appointment. They called on October 14 at 2:24 p.m., October 15 at 3:58 p.m., and October 16 at 3:10 p.m. All attempts were unsuccessful.
The family member who accompanied the resident to the appointment told inspectors by phone that both wounds on the left foot were noted to be wet when they arrived at the clinic.
Federal regulations require nursing homes to provide treatment and care according to physician orders and professional standards of practice. The inspection found Terra Bella failed to meet this standard for the resident with foot wounds.
The violation placed the resident at risk for not receiving necessary care and treatment, according to the inspection report. Wet wound dressings can introduce bacteria and delay healing, particularly problematic for someone with an active infection.
The resident was among four reviewed during the complaint investigation. Inspectors classified the harm level as minimal, but noted the potential for actual harm to residents.
The facility operates on Cityscape Avenue in Houston's southeast side. The inspection was completed November 26, following up on complaints about quality of care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Terra Bella Health and Wellness Suites from 2025-11-26 including all violations, facility responses, and corrective action plans.
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