Health inspection·May 13, 2021

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide adequate supervision and a safe environment to prevent accidents for 1 of 6 residents reviewed for falls with injuries out of 49 sampled residents, (#7). Findings: Resident #7 was admitted to the facility on [DATE], with diagnoses that included history of falls, right hip fracture, dementia and adjustment disorder with anxiety. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], indicated resident #7 had a Brief Interview for Mental Status (BIMS) score of 7 which indicated severe cognitive impairment. He required extensive assistance from two staff for bed mobility, transfers, locomotion on and off the unit and toilet use. Resident #7 was assessed to have unsteady balance and was only able to stabilize with staff assistance for transfers. Resident #7 used an assistive device, a walker, for ambulation. A Significant Change in Status MDS assessment dated [DATE], was completed after resident #7 sustained a fall on 4/20/21, resulting in a left humerus fracture. At that time, the resident was assessed to have a BIMS score of 5 decreased from 7 on the previous assessment. Resident #7 now required more assistance from staff and was totally dependent on two staff for transfers and toileting. Review of the Fall Care Plan dated 2/4/21, revealed resident #7 had been assessed to be a fall risk related to history of falls, impaired cognition, poor safety awareness, unsteady balance, incontinence and required extensive assistance with care. Intervention dated 2/4/21, included remind the resident to call for assistance by using the call bell and cue for safety awareness even though the care plan indicated he had impaired cognition and poor safety awareness. The Care Plan directed staff to assist with mobility, transfers and locomotion but did not specify number of staff required to assist. Review of resident #7's Resident Profile under Falls, the instruction sheet for Certified Nursing Assistants (CNAs) to provide care indicated staff were to keep call light in reach and encourage resident to call for assistance. On 5/10/21 at 10:37 AM, resident #7 was observed lying in his bed with a sling around his left shoulder and arm. He stated he fell and hurt his shoulder, but was unable to recall when, where or how the accident happened. Page 1 of 7 105960 105960 05/13/2021 Solaris Healthcare Windermere 4875 Cason Cove Drive Orlando, FL 32811

F 0689 During an interview and review of Incident Reports and Investigations on 5/13/21 at 8:30 AM, the Risk Manager (RM) stated resident #7 had 5 falls in the facility on 2/5/21, 2/11/21, 4/11/21, 4/19/21 and 4/20/21. Level of Harm - Actual harm Residents Affected - Few The facility's investigation revealed on 2/5/21 at 10:36 AM, CNA F transferred resident #7 from bed to wheelchair as a 1-person transfer. The resident started to fall, and the CNA F lowered the resident to the floor. CNA F then left the resident to get help to make the transfer from the floor to the bed. The resident was assessed by Licensed Practical Nurse (LPN I), transferred back to bed with help from rehab staff. The resident later complained of back pain and the physician ordered a mobile x-ray of the pelvis/lumbar spine. The result was no acute fractures or dislocation. Review of the care plan and the facility's investigation report revealed no new interventions were developed and implemented to prevent resident #7 from falling during transfers. The report did not provide a detailed account of the last time the resident had been observed by staff or how often the resident was monitored for safety due to his risk for falls. Review of the Progress Note dated 2/9/21, at 8:40 PM, indicated resident (#7) had a history of recent falls in the facility and was assessed to be confused at times. The note revealed the resident was re-educated to not ambulate without assistance from staff. Six days later, on 2/11/21 at 9:30 PM, LPN G found resident #7 on the floor next to his bed. The resident was assessed by LPN G and transferred back to bed with help from 3 CNAs. He complained of right leg pain and a mobile x-ray of the right leg was ordered and reviewed by the physician, who ordered a follow-up with the orthopedic surgeon The Fall intervention added after the fall was continue to make frequent room rounds. The intervention did not include the required frequency of room round to prevent subsequent falls. The report showed the last time the resident had been observed by staff was at 7:30 PM, two hours prior to fall. Review of the Progress Note dated 2/12/21 at 4:02 PM, the day after the second fall indicated resident #7 was to be reminded to use call light for assistance. The intervention was not appropriate due to the resident's cognitive status and was ineffective in preventing his falls on 2/5/21 and 2/11/21. On 4/11/21 at 11:45 PM, the investigation report showed resident #7 suffered a third fall. LPN H found resident #7 on the floor next to his bed. When asked what happened, the resident stated he did not know. The resident was assessed to have no injuries and transferred back to bed. No documentation was available regarding staff who transferred the resident back to bed. The care plan was updated to include labs to rule out an infection and provide a high low bed. The incident report showed a new intervention to reconfigure the room but there was no indication this was done. Eight days later, on 4/19/21, at 7:00 PM, LPN J was called to the room by resident #7's roommate's visitor. LPN J observed the resident leaning on the bed with his feet resting against the wall. LPN J lowered the resident to the floor, assessed him to have no injuries and assisted him back to bed. The new fall care plan intervention noted in the investigation report was a scoop mattress for his bed which was not transcribe to the care plan that day. The report did not provide a detailed account of the last time the resident had been observed by staff. Less than twenty-four hours later, on 4/20/21 at 3:00 PM, LPN I was called to resident #7's room by his roommate. The resident was on the floor lying on his back and stated he was trying to go to the bathroom. LPN I assessed the resident, who had a bulge to his left shoulder and was not able to 105960 Page 2 of 7 105960 05/13/2021 Solaris Healthcare Windermere 4875 Cason Cove Drive Orlando, FL 32811

F 0689 lift his left arm. The resident was transferred back to bed by 4 staff members. The physician was called and ordered the resident be sent to the hospital. Level of Harm - Actual harm Residents Affected - Few The care plan was updated on 4/20/21, to include a scoop mattress and restated the existing intervention of frequent room checks. The intervention did not include the required frequency of room rounds to prevent subsequent falls. Review of a Progress Note dated 4/24/21 at 6:28 PM read the resident returned to the facility with a diagnosis of left humerus fracture. Surgery had not been performed related to the arm being too swollen. A sling was in place along with an order to follow up with the orthopedic surgeon. Review of the care plans revealed no new fall prevention interventions were developed on readmission. On 5/13/21 at 8:30 AM, the RM was asked how the facility staff would know how often to observe resident #7 as related to the term frequent checks. The RM was unable to be specific as a definite time frame had not been determined by the Interdisciplinary Team. The Risk Manager also stated she failed to get witness statements from all staff involved in resident #7's falls regarding frequency of safety checks by staff. The Risk Manager was unable to explain how staff would have been able to determine how often the resident needed to be observed. She said, staff need to check on the resident when they pass water, deliver meal trays and answer call lights. The Risk Manager was unable to explain how a resident (#7) with severely impaired cognition was going to remember to use his call light for assistance before getting out of bed unassisted. On 5/13/21 at 10:27 AM, LPN H said she was assigned to resident #7 on the night of his third fall but she did not remember when she last observed the resident before finding him on the floor. She said, We are supposed to check on the resident every two hours and as needed. She did not explain what as needed meant. On 5/13/21 at 10:39 AM, LPN J stated she was assigned to the resident on the evening of the fourth fall and did not remember the last time the resident had been observed before the fall. On 5/13/21 at 11:45 AM, Registered Nurse (RN) O stated she understood there needed to be a predetermined time frame for staff to do the safety checks to ensure safety of resident #7. She was not able to define frequent room checks and unable to state how staff would know how often to check on the resident. On 5/13/21 at 11:50 AM, LPN P stated the definition of frequent was not explicit enough to determine how often staff were required to check on resident #7. Review of the facility's policy Safety and Supervision of Residents reviewed 1/7/20, read Our facility strives to make the environment as free from accident hazards as possible. Resident safety, supervision and assistance are provided as facility-wide priorities. The document indicated staff would be trained and in serviced to prevent avoidable hazards. The policy read, Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. The type and frequency of resident supervision may vary among residents and over time for the same resident. 105960 Page 3 of 7 105960 05/13/2021 Solaris Healthcare Windermere 4875 Cason Cove Drive Orlando, FL 32811

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. 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 intravenous (IV) care and services according to standards of practice and plan of care for 1 of 1 residents reviewed for IV care of a total sample of 49 residents, (#42). Residents Affected - Few Findings: Resident #42 was re-admitted to the facility on [DATE] from an acute care hospital with diagnoses of Alzheimers disease, stroke, obstructive reflux uropathy, functional quadriplegia, stroke, and history of Methicillin Resistant Staphylococcus Aureus infection. He had a Midline IV line in the right arm for administration of IV antibiotics. He received Cefepime (IV antibiotic) daily through 5/9/21. He had additional orders in effect dated 4/7/21 for nurses to document the IV site appearance every shift (days and nights) and order dated 4/8/21 to flush IV every shift (days and nights). A midline catheter is put into a vein by the bend in the elbow or the upper arm .midline catheter may allow you to receive long-term intravenous (IV) medicine or treatments .(www.drugs.com). On 5/10/21 at 1 PM, resident #42 was sitting in a wheelchair in his room. He had a transparent dressing on his right upper arm midline IV site dated 4/30/21. The transparent dressing had dime sized brown substance around the site, under the dressing. The resident was not able to be interviewed and his daughter was present at the bedside. She said the resident had been in/out of the hospital due to pneumonia and urinary tract infections. A review of the Medication Administration Record (MAR) revealed documenting that resident refused right arm midline dressing change that was due on on 5/6/21. The nurses documented IV flushes and observations of the IV site and administered IV antibiotic on the day and night shifts. There was no documentation of any further attempts to change the outdated and soiled IV dressing. Resident #42's care plan initiated on 4/29/21 noted at risk of developing complication related to midline right upper extremity with goal the resident will not develop signs and symptoms of complications related to IV line. Interventions included to change IV site dressing as ordered and observe IV site every shift as needed for signs and symptoms of complications such as warmth, redness, edema, drainage or pain. On 5/10/21 at 1:25 PM, Licensed Practical Nurse (LPN) B was in resident #42's room and observed his right upper arm midline dressing dated 4/30/21 with brown substance under the dressing. She said she flushed the IV today but did not look at the dressing. She stated the standard of practice was to change IV dressings every week or more often if soiled. On 5/11/21 at 3:38 PM, the Director of Nursing (DON) said that although the resident refused IV dressing change on 5/6/21, the nurses should have attempted to change the dressing again when they administered antibiotics and flushes. On 5/13/21 at 8:45, LPN C stated she worked nights and was assigned to resident #42 from 5/7 to 5/9/21. She said she had flushed the IV, checked the site and administered the antibiotics. LPN C said she did not change the dressing as it was not assigned to her. She acknowledged the standard of practice was to change dressings every 7 days to reduce chances of complications and infection. 105960 Page 4 of 7 105960 05/13/2021 Solaris Healthcare Windermere 4875 Cason Cove Drive Orlando, FL 32811

F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few According to the facility policy and procedure for Midline Catheter Dressing Change revised 8/15/2008, The catheter insertion site is a potential entry site for bacteria that may cause a catheter related infection Licensed nurses caring for residents receiving infusion therapies are expected to follow infection control and safety compliance procedures Dressing changes using transparent dressings are preformed At least weekly Assessment of venous access site is performed before and after administration of intermittent infusions. At least once every shift when in use 105960 Page 5 of 7 105960 05/13/2021 Solaris Healthcare Windermere 4875 Cason Cove Drive Orlando, FL 32811

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 ensure respiratory therapy was provided as per physician orders for 2 of 4 residents of a total sample of 49 residents, (#209, #210). Residents Affected - Few Findings: 1. Review of resident #209's medical record revealed she was admitted to the facility on [DATE] with diagnoses that included respiratory failure, dependence on supplemental oxygen and history of Corona Virus Disease 2019 (Covid 19). On 5/10/21 at 9:30 AM, resident #209 was observed in her room sitting up in wheelchair. She was alert and oriented to person, place, and time. She received oxygen via nasal cannula attached to a portable oxygen concentrator set at 2.5 liters per minute (LPM). Review of the medical record revealed orders on the Agency for Health Care Adminstration (AHCA) Form 5000-3008 from the hospital dated 5/6/21, for oxygen rate of 2 LPM via NC (nasal cannula). A care plan initiated on 5/6/21 for risk of complications related to history of respiratory failure included interventions to provide oxygen as ordered. On 5/10/21 at 4:10 PM, the resident's assigned Licensed Practical Nurse (LPN) A checked the orders and said, resident #209 was ordered oxygen at 2 LPM. LPN C then went into the resident #209's room and checked the flow rate setting on the oxygen concentrator. He looked at the setting at eye level. The surveyor read 2.5 and LPN A read 2.25 LPM. He then adjusted the setting to 2 LPM and said this was the first time today he had looked at the resident's setting on the concentrator. He added that he worked 7 AM to 7 PM and was having a busy day. LPN C acknowledged the resident was admitted to the facility on [DATE] and did not receive oxygen as ordered by the physician. He explained that although the orders were on the AHCA 5000-3008 form, the oxygen orders had not been entered into the EMR (Electronic Medical Record) yet. On 5/11/21 at 3:38 PM, the Director of Nursing (DON) said the oxygen orders should have been entered in the EMR at admission. 2. Review of resident 210's medical record revealed he was admitted to the facility on [DATE] with diagnoses that included pneumonia and sepsis. The resident's care plan initiated on 5/7/21 noted at risk for respiratory complications and included interventions to give oxygen as ordered with goal the resident will not develop signs and symptoms of respiratory complications. On 5/10/21 at 10:45 AM, resident #210 was in his room. He was alert and oriented to person and place. The resident received oxygen via concentrator. The flow rate was set at 1.5 LPM. On 5/10/21 at 4:05 PM, LPN A said he was assigned to resident #210's care on the 7 AM to 7 PM shift. LPN A checked the EMR and said the resident was to have continuous oxygen at 2 LPM. LPN A then went into resident #210's room and checked the setting on the oxygen concentrator. He said it was set at 1.5 LPM. LPN A said he had not checked the oxygen setting until now and acknowledged the resident was not getting oxygen as ordered by the physician. 105960 Page 6 of 7 105960 05/13/2021 Solaris Healthcare Windermere 4875 Cason Cove Drive Orlando, FL 32811

F 0695 Level of Harm - Minimal harm or potential for actual harm Review of the policy titled, Oxygen Administration read, The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at ordered rate Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated Residents Affected - Few 105960 Page 7 of 7