Inspection visit
Health inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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 provide wound care treatment in accordance
with physician's orders and acceptable standards of practice for two skin tears 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] with diagnoses which including dementia with
behavioral disturbances, Alzheimer's disease, and type 2 diabetes. Review of the Minimum Data Set
quarterly assessment dated [DATE] revealed resident #28 required extensive assistance from two staff for
bed mobility, toilet use and personal hygiene.
Review of the physician's order for resident #28 revealed an order for a sleeve arm dated 9/06/20. A sleeve
arm is a protective sleeve used on upper extremities to prevent abrasions, bruises, snags and tears
(retrieved on 5/14/21 from www.agingcare.com). A physician's order dated 4/23/21 directed nurses to
cleanse skin tears to left forearm with normal saline solution, then cover with a 4x4 bordered gauze
dressing and change every other day.
On 5/03/21 at 12:45 PM, resident #28 had a wrapped gauze dressing to her left arm initialed and dated
4/30/21, 7-3. The dressing was loosely applied and had slipped down her forearm to expose a skin tear with
2 wound closure strips. There was dark purple bruising above the skin tear close to her left elbow. Resident
#28 did not have a sleeve arm for protection as ordered.
On 5/03/21 at 12:48 PM, the Arbor Unit Manager (UM) verified the wrapped gauze dressing on resident
#28's arm was loose and dated 4/30/21. She acknowledged the dressing change should be done every
other day. The Arbor UM unwrapped the dressing which revealed a dried petroleum gauze and a 4x4 gauze
pad adhered to a second skin tear. The Arbor UM said there were 2 separate skin tears with 2 wound
closure strips on the upper skin tear and 3 wound closure strips on the lower skin tear.
On 5/03/21 at 12:53 PM, a review of the Order Summary Report with the Arbor UM noted no physician's
order for wound closure strips, petroleum gauze or 4x4 gauze pads for resident #28's dressing.
Review of the medication administration record (MAR) for April and May 2021 revealed documentation that
resident #28's dressing was changed on 4/29/21, 5/01/21 and 5/03/21. The MAR did not show the dressing
change was completed on 4/30/21 as observed with the Arbor UM.
On 5/05/21 at 12:35 PM, Registered Nurse (RN) C said she applied the dressing dated 4/30/21 to resident
#28's left arm. She acknowledged she did not document the dressing change on 4/30/21 and did
(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:
105782
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
105782
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/06/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Apopka
305 East Oak Street
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)
F 0684
Level of Harm - Minimal harm
or potential for actual harm
not call the physician to obtain an as needed (PRN) order. RN C acknowledged resident #28 was not
wearing a sleeve arm and stated they should be kept in her drawer. She searched all drawers of both
bedside tables and explained there were no sleeve arms in resident #28's room. She explained the reason
for a sleeve arm was to prevent further skin tears. RN C was informed resident #28 was also observed
without a sleeve arm on 5/03/21 at 12:45 PM, and 5:29 PM and on 5/04/21 at 2:26 PM.
Residents Affected - Few
Resident #28 had a care plan dated 2/26/21, revised 4/29/21 for risk for skin impairment. The care plan
interventions included encourage sleeve arm use for skin protection, to provide treatment per physician's
orders, and use caution during transfers and bed mobility to prevent striking her arms.
On 5/05/21 at 12:40 PM, the Wound Care Nurse (WCN) stated the expectation was nurses would do
dressing changes as ordered. The WCN stated he expected nurses to do wound care when it was due and
as ordered to prevent infection and help the wound heal. He said there were no standing orders for wound
care and nurses were supposed to call the physician for appropriate orders for a new wound. The WCN
said he had called the physician and obtained the order for the border gauze dressing for resident #28. He
stated he did not obtain an order for wound closure strips, petroleum gauze, 4x4 gauze pads or gauze
wrap. The WCN could not explain why a nurse applied another type of dressing without notifying him or
calling the physician.
On 5/05/21 at 2:00 PM, the Arbor UM stated although the MAR indicated Licensed Practical Nurse E
completed resident #28's dressing change on 5/1/21, this contradicted the actual date on the dressing.
The facility's Skin & Wound Care policy, reviewed 3/2021, read, The facility will promote dignity and
enhance the resident's quality of life and quality of care by maintaining or restoring resident's skin integrity.
The facility will implement preventative measures that meet the standards of care
The Physician Orders policy, reviewed 1/19/18, read, . 3. Physician orders will be transcribed, noted,
implemented, and followed in a timely manner.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105782
If continuation sheet
Page 2 of 4
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
105782
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/06/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Apopka
305 East Oak Street
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)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
Based on observation, interview, and record review, the facility failed to implement procedures to ensure
accurate narcotic reconciliation for 1 of 1 narcotic medication reviewed, and failed to ensure safe
administration of medications for 6 of 19 residents of a total sample of 51 residents, (#2, #35, #48, #72, #77
and #108).
Findings:
On 05/05/21 at 6:34 PM, an inspection of the Arbor Oaks medication cart assigned to Licensed Practical
Nurse (LPN) A was conducted with the Arbor Unit Manager (UM). The Arbor UM opened the top left drawer
of the medication cart and LPN A quickly returned to the cart and whispered to the Arbor UM who asked if
the medication cart inspection could be completed at a later time. Their request was declined and the
inspection of the Arbor Oaks medication cart continued with LPN A and the Arbor Oaks UM.
When the top left drawer of the Arbor Oaks medication cart was fully opened by the Arbor UM, eight pill
cups with pre-poured medications were sitting uncovered in the drawer. Each pill cup was labeled with a
handwritten room number. The Arbor UM said, I am very disappointed, shocked and angry. It is not the
expectation of any nurse to pre-pour medications.
When asked if he usually pre-poured medications, LPN A stated that was not his usual process. LPN A
explained his reason for pre-pouring medication was sometimes it makes me go faster. LPN A said, Yes, I'm
aware why it is not safe. I don't want to give the wrong medication to the wrong resident. LPN A stated he
had never been told not to pre-pour medications.
Further inspection of the Arbor Oaks medication cart revealed a Morphine Sulfate 60 milligram (mg)
narcotic medication card for resident #72 with 2 tablets remaining. Reconciliation with the narcotic inventory
sheet for resident #72, revealed there should have been 3 tablets remaining. LPN A acknowledged the
discrepancy between the narcotic medication card and the narcotic inventory sheet. He explained he
removed the narcotic tablet but did not sign it out on the narcotic inventory sheet. The Arbor UM
acknowledged the discrepancy between the Morphine Sulfate 60 mg medication card and the narcotic
inventory sheet. The UM said that nurses should document the removal of narcotic medication immediately
to ensure an accurate medication count.
On 5/05/21 at 7:02 PM, the Director of Nursing and the Assistant Director of Nursing noted administration
of pre-poured medication would be viewed as a potential medication error.
Review of the facility's Medication Pass Observation competency form for LPN A, dated 4/19/21 revealed
medications should be prepared just prior to administration.
Review of the facility's 6.0 General Dose Preparation and Medication Administration policy, read, . 3.2
Facility staff should only prepare medications for one resident at a time.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105782
If continuation sheet
Page 3 of 4
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
105782
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/06/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Apopka
305 East Oak Street
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)
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 ensure the controlled medication
compartment was properly secured on 1 of 6 medication carts, (Arbor Oak medication cart).
Findings:
On 5/05/21 at 6:34 PM, during an inspection of the Arbor Unit medication cart, the narcotic compartment
labeled Oak was not securely locked. Licensed Practical Nurse (LPN) A was easily able to lift the lid of the
narcotic compartment with one finger without using his key.
On 5/05/21 at 7:02 PM, the Director of Nursing (DON) stated nurses should not rely on the drawer closure
to lock and secure the narcotic compartment. The DON stated Licensed Practical Nurse (LPN) A should
have pushed down hard enough on the lid of the narcotic compartment to ensure it was locked before he
closed the drawer. The DON acknowledged nurses were responsible for ensuring the narcotic
compartments in medication carts were locked and secure to prevent unauthorized access.
On 5/06/21 at 11:52 AM, the Consultant Pharmacist stated he periodically checked medication carts at the
facility which included narcotic checks and reconciliation with the narcotic log. He stated the process was
for nurses to open the locked drawer, remove the narcotic medication and ensure the drawer was locked
afterwards. When asked about the unlocked narcotic compartment in the Arbor Oaks medication cart, the
Consultant Pharmacist said, Yes, it was an unsafe practice. The narcotic drawer is supposed to be double
locked. All narcotics should be double locked.
Review of the facility's policy 5.3 Storage and Expiration of Medications, Biologicals, Syringes and Needles,
revised on 10/31/16, read, . 3.1 Facility should store Schedule II Controlled Substances and other
medications deemed by Facility to be at risk for abuse or diversion in a separate compartment within the
locked medication carts and should have a different key or access device . 12.3 Facility should ensure that
all controlled substances are stored in a manner that maintains their integrity and security.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105782
If continuation sheet
Page 4 of 4
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Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F761 - Labeling of Drugs and Biologicals
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.
FAQ · About this visit
Common questions about this visit
What happened during the May 6, 2021 survey of SOLARIS HEALTHCARE APOPKA?
This was a inspection survey of SOLARIS HEALTHCARE APOPKA on May 6, 2021. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SOLARIS HEALTHCARE APOPKA on May 6, 2021?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.