Health inspection·October 31, 2024

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide evidence that an abuse allegation was thoroughly investigated for 1 of 3 residents reviewed for abuse, of a total sample of 3 residents, (#3). Residents Affected - Few Findings: Review of resident #3's medical record revealed an annual Minimum Data Set, dated [DATE] which indicated a Brief Interview for Mental Status score of 9 out of 15, mild to moderate cognitive impairment. On 10/30/24 at 12:30 PM, resident #3 was in her room alert and oriented to herself and place. She recalled an incident that occurred sometime in the past month or two when she reported to staff that a male staff member was rough with her. She was unable to recall who she had told or other details about what happened afterwards. On 10/31/24 at 8:00 AM, the Nightshift Supervisor stated he could recall, a couple of weeks ago resident #3 reported a staff person, whom she described as Certified Nursing Assistant (CNA) A, was rough with her. He said he did not ask resident #3 to explain what she meant by the word rough or to clarify any details of the alleged incident. The Nightshift Supervisor said he did not do a skin assessment for resident #3 at the time of the allegation. He said he did not direct resident #3's assigned female nurse, Registered Nurse (RN) A to do a skin assessment at the time of the allegation either. He said he put the paperwork he completed about resident #3's abuse allegation under the Risk Manager's office door at the end of his shift at approximately 7:00 AM. On 10/31/24 at 11:00 AM, the Risk Manager concurrently reviewed the investigation statements provided by facility staff persons, CNA A, CNA B, RN A, and the Nightshift Supervisor. She verified that resident #3's abuse allegation occurred on 10/23/24 and acknowledged there was no evidence of the time when resident #3's abuse allegation was made to the Nightshift Supervisor, or when the alleged incident occurred. The Risk Manager acknowledged they did not have evidence of verifying with the Nightshift Supervisor, RN A, CNA A, or CNA B regarding the time resident #3's alleged abuse incident occurred, or why the Nightshift Supervisor failed to immediately initiate any investigation into the alleged abuse incident. The Risk Manager did not say how the facility would be able to report any allegations in the required timeframe if they did not know what time the alleged abuse allegation was made. Review of the policy titled Resident Mistreatment, Neglect, and Abuse Prohibition Guidelines most current revision date 1/24/23 indicated that all employees were required to immediately report suspected instances of abuse to their supervisor, Abuse Coordinator, Administrator, and/or Director of Page 1 of 2 105783 105783 10/31/2024 Solaris Healthcare East Orlando 250 South Chickasaw Trail Orlando, FL 32825

F 0610 Level of Harm - Minimal harm or potential for actual harm Nursing so that the facility could protect the residents and promptly investigate the occurrence. If the alleged violation involved abuse the State Agency, Adult Protective Services, and local law enforcement must be reported to within two hours of the alleged violation. Residents Affected - Few 105783 Page 2 of 2