Health inspection·June 27, 2023

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on record review and interview, the facility failed to resolve grievances related to response to call lights in a timely manner for 4 (Residents #1, #4, #5, and #6) of 4 residents reviewed requiring assistance with activities of daily living (ADLs). The findings included: Record review of the facility's Quality Assurance Service Recovery Trending Log provided by Social Services revealed there had been six grievances filed in May 2023 related to timely call light response. 1. Record review of Resident #1's care plan indicated he was unable to self-toilet and required the assistance of one. It also indicated he was at risk for falls as related to history of multiple falls related to incontinence. During an interview on 6/26/23 at 12:57 p.m., Resident #1 said when he uses his call bell, sometimes he has to wait. He said he doesn't wear a watch, so he doesn't know how long but it was long enough to make him wonder. He said he had a couple of falls trying to get to the bathroom when no one responded to his call. 2. Record review of Resident #4's care plan indicated she requires extensive staff assistance with the majority of ADLs. Record review of Resident council minutes for March of 2023 indicated Resident #4 had voiced concerns regarding call bell response times. During an interview on 6/26/23 at 1:00 p.m., Resident #4 said there are times you can wait up to an hour for someone to respond to the call bell. She said the staff was running around doing a lot of work. She said it was especially at night. She said she hadn't been incontinent from it, because she would get herself on the toilet and then hope they come to get her off. 3. Record review of Resident #5's care plan indicated she had impaired toileting with decreased mobility, strength, endurance, transfers, ambulation and balance. During an interview on 6/26/23 at 2:03 p.m., Resident #5 said she has complained about call bell response time. She said sometimes it was hours before someone came. She said she hadn't been incontinent due to it because she holds it, but it was uncomfortable. She said nothing had improved since she complained. 4. Record review of Resident #6's care plan indicated she required extensive to total assist with Page 1 of 2 105859 105859 06/27/2023 Solaris Healthcare Charlotte Harbor 4000 Kings Hwy Port Charlotte, FL 33980

F 0585 most of her ADLs. Level of Harm - Minimal harm or potential for actual harm During an interview on 6/26/23 at 2:34 p.m., Resident #6 said she had complained about the call bell response time. She said the previous month she waited two hours for someone to respond. She said nothing had really improved and the previous evening she had to wait 45 minutes for someone to respond. She said her skin was very sensitive and if she has to sit in urine, it irritated her skin, it gets very red and feels raw. Residents Affected - Few On 6/26/23 at 1:30 p.m., the Administrator said their call bell system did not record response times. He said he hadn't really had any complaints about response times. On 6/26/23 at 1:39 p.m., the Risk Manager said Resident #5 had come to him with complaints about call bell response time. She had told him she was waiting up to an hour. He said wait times should be no more than 10 - 15 minutes tops and if people wait too long, he'd be afraid they will attempt to do things on their own and could fall. He said there was no system in place to audit response times, so it was hard to gauge it. Risk Manager said an hour was not acceptable. He said he had not seen the documentation about six grievances in May about timely call bell response and said six grievances filed in May about response to call bells was something he would look into for a pattern. He said he was a little concerned looking at it. He said waiting one hour could be seen as neglect. On 6/26/23 at 2:20 p.m., The Social Service Director said they read the grievances every morning in morning meeting. She said the whole team is there: Administrator, Director of Nursing, Risk Management. She said all grievances are discussed in Quality Assurance Performance Improvement meetings (QAPI), and she does a whole breakdown of what's trending, what's not, what's getting better. She agreed that six complaints in a month would indicate a trend. She provided the Social Services QAPI for May of 2023 which identified timely call lights for May as trending and said this was discussed in the QAPI meeting that was held on June 14. On 6/27/23 at 9:47 a.m., the Director of Nursing (DON) said she hasn't directly received any complaints about call lights but does get it in the customer satisfaction surveys that it could be faster. She said she is not aware of any audits or monitoring of call bell response time unless someone is doing their own type of thing. She says she does go to morning meetings and the QAPI monthly and agrees grievances are discussed in morning meeting. The DON Agreed six grievances in one month regarding timely call light response was a lot, and hadn't realized it was that much. 105859 Page 2 of 2