Health inspection·April 22, 2021

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to obtain physician orders and provide appropriate treatment and care for two lacerations in accordance with professional standards of practice for 1 of 1 resident reviewed for non-pressure skin conditions, of a total sample of 51 residents, (#28). Residents Affected - Few Findings: Resident #28 was admitted to the facility on [DATE]. Her diagnoses included heart failure, chronic kidney disease, dementia, and long term use of anti-coagulants. Review of resident #28's Quarterly Minimum Data Set assessment with an assessment reference date of 2/12/21 revealed a Brief Interview for Mental Status score of 4, indicating severe cognitive impairment. The assessment indicated there were no skin impairments. On 4/19/21 at 10:17 AM, resident #28 was seated in a recliner in her room. Her lower legs were discolored and she had two dressings on her right lower leg which were not dated or initialed. On 4/20/21 at 11:37 AM, and again on 4/21/21 at 10:59 AM resident #28 was seated in a recliner in her room. The same dressings were in place to her right lower leg. They were not dated or initialed. On 4/21/21 at 11:40 AM, Certified Nursing Assistant (CNA) E stated she regularly cared for resident #28. She said resident #28 had periods of confusion and scratched her skin often. CNA E recalled on the previous Saturday, five days before, resident #28 had scratched her legs and the lacerations were bleeding. She stated a nurse then put dressings on resident #28's right lower leg. On 4/21/21 at 1:18 PM, Licensed Practical Nurse (LPN) F acknowledged resident #28 had dressings on her right lower leg. She recalled during shift change report, the off-going night nurse told her of an injury/scratch to resident #28's right leg. LPN F was not sure if an incident report was made and could not recall which day the injury happened. LPN F explained, after change of shift report, a CNA informed her there were no dressings on resident #28's lacerations. The CNA also informed her the resident continued to scratch the area. LPN F stated she cleaned the lacerations with normal saline, and applied a dry dressing to them. She validated there should be an order for a treatment or dressing. LPN F stated she again cleaned the lacerations to resident #28's right lower leg and re-applied a dressing to them on 04/19/21. On 4/21/21 at 1:25 PM, resident #28's right leg lacerations were observed with LPN F. She said the physician should have been notified of resident #28's lacerations and a treatment order obtained. LPN F stated the dressings should be dated so staff would know how long they had been there. Page 1 of 8 105734 105734 04/22/2021 Solaris Healthcare Osceola 4201 W New Nolte Road Saint Cloud, FL 34772

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 4/21/21 at 1:34 PM, resident #28's right lower leg was observed with the North Wing Unit Manager (UM). The UM measured the lacerations at 0.5 centimeters (cm) x 0.2 cm on the right outer calf and 3.0 cm x 0.5 cm to the right shin. The right outer calf wound was partially scabbed. The wound to the right shin was not healed, and had a visible wound bed. The peri-wound area was red and the wound started bleeding during observation. The UM stated his expectation was that nurses would notify the physician of any skin injury, obtain an order, document the incident in a progress note and complete an incident report if indicated. He noted there were no standing orders for wound treatments, and said, there should absolutely be an order for a dressing. Review of the medical record revealed physician orders dated 12/12/19 to check resident #28's skin every week on Tuesday on 11:00 PM to 7:00 AM shift. The Physician Order report dated 3/18/21 to 4/22/21 revealed no active treatment orders for resident #28's right leg wounds until they were brought to the facility's attention on 4/21/21. A physician's wound treatment order was discontinued on 4/11/21 for a resolved right lower leg skin tear. Review of the nursing progress notes revealed no documentation of new skin injuries, lacerations or treatments for resident #28 between 4/11/21 and 4/21/21. Review of the Observation Detail List Report revealed the Monthly Nursing Summary dated 4/11/21 showed no skin impairments. The Weekly Skin assessment dated [DATE] showed no skin impairments. No further skin impairments were documented from 4/11/21 to 4/21/21. Review of the medical record revealed resident #28 had a care plan dated 6/5/19 for skin integrity. Interventions directed nurses to see the current physician's orders and Treatment Administration Record for treatments and to conduct weekly skin checks. Review of the facility's incident reports for April 2021 revealed no documentation of skin impairment or scratches for resident #28 between 4/11/21 and 4/21/21. On 04/21/21 at 2:01 PM, the Wound Nurse stated any new skin issues or incidents should be reported to the UM. She said nurses should initiate an incident report, notify the physician and the family, even for a scratch. The Wound Nurse said, There is no such thing as not having an order for a dressing. On 04/22/21 at 12:40 PM, resident #28's hospice physician stated she was never notified by the facility that resident #28 had lacerations to her right lower leg. The hospice physician said, I will have to look at it. 105734 Page 2 of 8 105734 04/22/2021 Solaris Healthcare Osceola 4201 W New Nolte Road Saint Cloud, FL 34772

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide dressing changes for a Peripherally Inserted Central Catheter (PICC) according to current professional standards of practice for 1 of 4 residents with intravenous (IV) access sites, of a total sample of 51 residents, (#44). Residents Affected - Few Findings: Resident #44 was admitted to the facility on [DATE] from an acute care hospital with a diagnosis of wound infection and sepsis. Sepsis is a body's extreme response to an infection. It is a life-threatening medical emergency which without timely treatment can rapidly lead to tissue damage, organ failure and death. (retrieved 4/23/21 from www.cdc.gov). Review of the medical record revealed a physician's order dated 2/16/21 for insertion of a PICC line for administration of IV antibiotics. Physician's orders dated 2/23/21 included PICC line dressing change as needed, ensure dressing is dated and initialed, once daily on Monday at 8:00 AM. An additional physician's order dated 2/23/21 directed nurses to observe the PICC line dressing every shift, ensure the dressing was dated, initialed, adherent and intact. A peripherally inserted central catheter .is a long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart . It's generally used to give medications . A PICC line requires careful care and monitoring for complications, including infection and blood clots .(retrieved 4/26/21 from www.mayoclinic.org) On 4/19/21 at 10:00 AM, resident #44 stated she currently received IV antibiotics for a severe wound infection. Resident #44 had a PICC line in her left upper arm with a clear dressing dated 4/08/21. The dressing was loose on the bottom edge near the PICC line insertion point. Resident #44 stated she thought the dressing needed to be changed. A review of the Treatment Administration Record (TAR) dated 4/01/21 to 4/22/21 revealed that nurses documented every shift that the PICC site dressing was observed as ordered. The PICC dressing change scheduled every week on Mondays was initialed by nurses to verify it was completed as ordered on 4/05/21, 4/12/21, and 4/19/21. There was no documentation on the TAR of a dressing change on 4/08/21. Review of progress notes by the Advance Practice Registered Nurse dated 4/09/21, 4/12/21, and 4/16/21 revealed PICC line care was included in resident #44's plan of care. Review of the admission Minimum Data Set with assessment reference date of 2/23/21 revealed resident #44 had a Brief Interview for Mental Status score of 14 indicating she was cognitively intact. The assessment showed she was receiving IV medications. Resident #44 had a care plan dated 2/17/21 for risk of developing complications to the IV line. The care plan goal was for resident #44 not to develop signs or symptoms of complications related to the IV. Interventions directed nurses to change the IV dressing as ordered and as needed if loose or soiled, and to observe the IV site every shift. 105734 Page 3 of 8 105734 04/22/2021 Solaris Healthcare Osceola 4201 W New Nolte Road Saint Cloud, FL 34772

F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 04/19/21 at 10:25 AM, the North Wing Unit Manager (UM) stated that IV dressings were ordered to be changed once a week. He stated that IV sites should be checked every shift, and the dressing changed as needed. On 4/19/21 at 10:32 AM, resident #44's PICC line dressing was observed with the North Wing UM. He validated the dressing was dated 11 days ago on 4/08/21. Resident #44 informed the UM that the dressing had not been changed in a while and she had asked the nurse to tape it down last night because the dressing was loose. The North Wing UM confirmed the dressing edge was rolled back leaving the insertion site partially exposed. He stated the IV dressing should be changed weekly and remain intact to prevent infection at the IV site. On 4/21/21 at 1:08 PM, Licensed Practical Nurse (LPN) F stated she checked resident #44's IV every shift. She said, I'm not IV certified. I looked at it but did not notice the date on it. LPN F explained she usually asked a nurse who was IV certified to perform care for her assigned residents with IV's. She did not recall who she asked to do resident #44's dressing change, and said she did not remember if she actually followed up. LPN F acknowledged she signed the TAR to indicate the dressing was changed. She said, I don't do anything with it. I was educated not to sign off on it since I am not IV certified. She stated she saw a piece of tape was placed to secure the loose edge of the dressing, but never reported it. On 4/22/21 at 12:17 PM, the North Wing UM confirmed LPN F documented the PICC line dressing change was performed on 4/05/21, 4/12/21, and 4/19/21, although she was not certified to care for the IV. He could not explain why she did what she did, and said the document is not accurate. He said the expectation was that a non-IV certified nurse should find someone who is certified to perform and document any IV care. He further clarified that all dressings should be initialed and accurately dated. He acknowledged resident #44's IV dressing dated 4/08/21 was not initialed. Review of the facility's policy and procedure, Midline Dressing Changes revised April 2016, read, The purpose of this procedure is to prevent catheter-related infections associated with contaminated, loosened or soiled catheter site dressings. Guidelines included, change dressing every five to seven days or if wet, dirty, not intact or compromised in any way. The policy noted the dressing should be labeled with initials, date and time, to report any signs or symptoms and intervene as necessary. 105734 Page 4 of 8 105734 04/22/2021 Solaris Healthcare Osceola 4201 W New Nolte Road Saint Cloud, FL 34772

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a physician's order was obtained for oxygen therapy for 1 of 1 resident reviewed for respiratory care of a total sample of 51 residents, (#164). Residents Affected - Few Findings: Resident #164 was admitted to the facility on [DATE]. Her diagnoses included acute embolism and thrombosis of right lower extremity, chronic obstructive pulmonary disease (COPD), and chronic respiratory failure. revealed the resident was discharged from the hospital on 4/16/21 with Treatment Devices listed as, Oxygen 4% PRN (as needed). The resident's Observation Report dated 4/16/21 read, Respiratory equipment uses: Oxygen while at rest .Oxygen is delivered: Per nasal cannula. Nursing progress note dated 4/16/21 read, no c/o (complaint of ) pain/discomfort upon arrival via stretcher .O2 (oxygen) at 4 (Liters) NC (Nasal cannula). A review of the resident's progress note documented by the Advance Practiced Registered Nurse dated 4/19/2, revealed the resident had a history of COPD, chronic respiratory failure, and was on home oxygen. The APRN's plan included, oxygen via nasal cannula. Review of the resident's physician orders revealed no orders for O2 therapy. On 04/19/21 at 11:17 AM, resident #164 had O2 via NC at 4 liters per minute (LPM). On 04/21/21 at 1:31 PM, the Licensed Practical Nurse (LPN)/ Infection Preventionist (IP) stated she was working on a medication cart, and resident #164 was on her assignment. The LPN/IP stated resident #164 received O2 but was not sure of the LPM. The resident's physician orders were reviewed with LPN/IP. An order for O2 could not be found. On 04/21/21 at 1:49 PM, observation conducted with LPN/IP showed resident #164 received O2 via NC at 3 LPM. The LPN/IP stated she would double check the resident's physician orders. She verbalized that O2 should only be administered by physician orders. She acknowledged that an order for O2 for resident #164 could not be identified. On 04/21/21 at 2:08 PM, the North Wing Unit Manager (UM) stated O2 could be placed in an emergent situation, if a resident was having respiratory distress, but a physician order had to be obtained for continued O2 therapy. The UM reviewed the resident's physician's orders, and verbalized that an order for O2 was not identified until the order was placed by LPN/IP during her interview with the surveyor. On 04/21/21 at 2:28 PM, the Interim Director of Nursing (DON) stated that O2 administration was by physician's orders. She noted that resident #164 had O2 on the 3008 transfer form and O2 should have been placed on the facility's physician's orders. 105734 Page 5 of 8 105734 04/22/2021 Solaris Healthcare Osceola 4201 W New Nolte Road Saint Cloud, FL 34772

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 04/22/21 at 12:55 PM, the LPN/IP indicated the resident's admitting nurse should have placed the order for O2 in the resident's clinical record. She added that nurses who cared for the resident should have ensured an order was in place for the resident's O2 therapy. On 04/22/21 at 12:57 PM, the North Wing UM said nurses should follow up to ensure orders for treatment were in place. He stated the Interdisciplinary Team reviewed the resident's physician orders and noted the oxygen orders fell through the cracks. The facility's policy Oxygen Administration revised 2/10/2019 read, Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 105734 Page 6 of 8 105734 04/22/2021 Solaris Healthcare Osceola 4201 W New Nolte Road Saint Cloud, FL 34772

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to store medications in appropriate and properly labeled containers on 1 of 2 medication carts of a total of 4 medication carts, (South Wing 200 hall). Findings: On 4/19/21 at 8:27 AM, Licensed Practical Nurse (LPN) G prepared to administer medications on the South Wing. LPN G did not have the medication Acidophilus in her medication cart and asked LPN A, who stood at a nearby medication cart if she had any. LPN A pulled a transparent plastic cup out of the drawer from the 200 hall medication cart and shook a pill out of the plastic cup into the medication cup held by LPN G. Acidophilus is a probiotic supplement commonly used to promote the growth of good bacteria in the body (retrieved on 4/26/21 from www.Mayoclinic.org). On 4/19/21 at 8:29 AM, LPN A showed the container from which she had provided the Acidophilus capsule to LPN G. The clear plastic cup contained 5 capsules and read, probiotic, handwritten in black marker. LPN A acknowledged she poured a capsule from the clear plastic cup into the medication cup held by LPN G. LPN A said there was no bottle of Acidophilus in the 200 hall medication cart. She noted it was not good practice to store and administer any medication that was not in its original container as nurses could not be sure what the medication was. On 4/19/21 at 8:33 AM, the Risk Manager (RM) was informed Acidophilus capsules were stored in an uncovered clear plastic cup on the 200 hall medication cart. LPN A handed the plastic cup with the Acidophilus capsules to the RM. The RM said, No, the nurse should not give medications out of a cup. She said medications should only be stored and dispensed from their original containers. On 4/19/21 at 8:36 AM, LPN G said nurses should not administer medications stored in a clear plastic cup. She acknowledged she should not have taken the Acidophilus capsule that was dispensed from a cup by LPN A. LPN G could not explain why she did. On 4/19/21 at 12:45 PM, the Director of Nursing stated nurses should not have used medications that were stored in a plastic cup. She said medications were only to be dispensed from original containers. On 4/20/21 at 1:33 PM, the South Wing Unit Manager (UM) verbalized that capsules kept in a uncovered plastic cup were not properly stored. She explained that nurses could not be certain of what the medication was, and the medication could become contaminated if uncovered. The South Wing UM said, Medication stored in a cup shouldn't happen. Review of the policy and procedure Medication Storage in the Facility revised 2018, read, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The provider pharmacy dispenses medications in containers that meet regulatory requirements, including standards set forth by the United States Pharmacopoeia (USP). The document revealed medications were to be kept in those containers and nurses may not transfer 105734 Page 7 of 8 105734 04/22/2021 Solaris Healthcare Osceola 4201 W New Nolte Road Saint Cloud, FL 34772

F 0761 medications from one container to another. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105734 Page 8 of 8