Health inspection·April 6, 2023

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement medication regimen review (MRR) recommendations for medication administration parameters of physician's orders for 1 of 5 residents and failed to ensure MRRs were reviewed by the physician for 1 of 5 residents reviewed for unnecessary medications from a total sample of 39 residents. (#8, #43) Findings: 1. Review of the medical record revealed resident #8 transferred from the facility to an acute care hospital on 7/20/2022, readmitted to the facility on [DATE], and transferred to an acute care hospital on 4/05/2023. The resident had diagnoses that included, systolic congestive heart failure, hypotension (low blood pressure), essential hypertension (high blood pressure), sick sinus syndrome, coronary artery disease, atrial fibrillation, and presence of a cardiac pacemaker. Review of the pharmacy Consultation Report for resident #8 dated from 11/01/2022 to 11/30/2022 showed there were recommendations for the medication Midodrine, a medication to treat low blood pressure. The Consultant Pharmacist noted, CLINICALLY URGENT RECOMMENDATION: PROMPT RESPONSE REQUESTED .Please remind staff of the importance of administering/holding medication within the parameters ordered. The report indicated this medication should have been held in accordance with the physician's orders/parameters. The report was signed by the Registered Pharmacist on 11/26/2022, and the Director of Nursing (DON) on 11/28/2022. Review of resident #8's Medication Administration Record, (MAR) for December 2022, January 2023, February 2023, March 2023, and April 2023 showed physicians orders for Midodrine HCI tablet, 5 milligrams (MG), HOLD for SBP (systolic blood pressure) GREATER than 130 or DBP (diastolic blood pressure) GREATER than 70 for blood pressure, started 7/29/2022. The records documented nurses continued to administer the medication to the resident multiple times outside of the physician's parameters. On 4/6/2023 at 3:26 PM, the DON said she received the MRR for resident #8 from November 2022. She reviewed the resident's MARs from December 2022 to April 2023, and acknowledged there were multiple instances Midodrine was administered to the resident by nurses outside physician ordered blood pressure parameters. The DON explained it was particularly important for nurses to follow the medication orders correctly to avoid blood pressure complications. She stated additional monitoring should have been conducted to ensure nurses administered the medication correctly. On 4/06/2023 at 3:52 PM, the Registered Pharmacist Consultant was interviewed by telephone. He stated the pharmacy consultant submitted MRR reports to the DON monthly and as needed. He explained (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 2 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 04/06/2023 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)