Health inspection·May 9, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, review of facility policy and procedures, staff and resident interviews the facility failed to provide the appropriate and necessary care and services to maintain personal hygiene for 3 (Resident #1, #900 and #999) of 4 residents reviewed for activities of daily living care. Residents Affected - Some The findings included: The facility policy Activities of Daily Living (ADL), supporting (revised 1/30/24) documented, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: Hygiene (bathing, dressing, grooming and oral care). If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate. 1. Review of the clinical record revealed Resident #1 had an admission date of 7/29/22 with diagnoses including dementia, heart failure and acute respiratory failure. The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 3/26/24 documented Resident #1 required moderate assistance with transfers and bathing. The MDS noted Resident #1's cognitive skills for daily decision making were moderately impaired. Review of the ADL care plan initiated on 4/12/23 identified Resident #1 had an alteration in ability to perform daily care tasks. The interventions included, encourage to assist with bathing and dressing self, encourage to be compliant with care, nail care weekly and as needed. On 5/9/24 at 11 :15 a.m., Certified Nursing Assistant (CNA) Staff A said the process for showers was, they are written on our daily assignment and there is a shower list at the desk. We offer the shower and if they refuse it, I try again and if the resident won't take it for me, I let the nurse know. It is documented in our charting; you can put refused. On 5/9/24 at 12:40 p.m., during an observation and interview, Resident #1 was noted with long (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 3 Event ID: 105859 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 105859 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Charlotte Harbor 4000 Kings Hwy Port Charlotte, FL 33980 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)