Inspection·October 22, 2021

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide showers as per the resident's preference, and as scheduled for 1 of 5 residents reviewed for choices of a total sample of 57 residents, (#133). Findings: Resident #133 was admitted to the facility on [DATE] with diagnoses including, Corona Virus Disease 2019 (COVID-19), Diabetes type II, generalized muscle weakness, unsteadiness on feet, and acquired absence of right toe(s). The resident's admission Minimum Data Set (MDS) assessment with Assessment Reference Date of 9/30/21 revealed the resident's cognition was moderately impaired, with a Brief Interview for Mental Status (BIMS) score of 12/15. A question on the assessment, How important is it to you to choose between a tub bath, shower, bed bath , or sponge bath, was answered as very important. Resident #133 required extensive assistance with one person physical assist for dressing, and personal hygiene, and had total dependence on staff for bathing. On 10/18/21 at 1:02 PM, and 10/20/21 at 10:24 AM, resident #133 stated he had not received a shower since his admission to the facility. He explained he had bed baths, but wanted to have showers. On 10/20/21 at 12:15 PM, the Director of Nursing (DON) stated showers were scheduled at least twice weekly, and bathing was based on the resident's preference. She said showers/baths were documented in the resident's electronic record. The DON noted if the resident refused his/her showers/bath it would be documented in the electronic record in Point of Care Response History. Review of the Tasks and the Certified Nursing Assistant's (CNA) [NAME] revealed the resident preferred showers, and his preferred days were Wednesday and Saturday. Review of the Point of Care Response History form from 9/24/21 to present revealed the resident received a shower on 9/29/21 and on 10/06/21. There was no documentation to indicate the resident received/refused his showers on his scheduled shower days on 10/02/21, 10/09/21, 10/13/21 and 10/16/21. A review of the Point of Care Response History regarding showers for resident #133 was conducted with the DON. She acknowledged the findings, and verbalized there was no documentation to indicate showers were given on the resident's scheduled shower days. The DON stated the expectation was that showers be given on the resident's scheduled shower days, unless refused by the resident. She explained the Point of Care Response History had a category to document refusal, and no refusals were (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 105353 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Forest Lake 3355 E Semoran Blvd Apopka, FL 32703 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)