Health inspection·March 23, 2023

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow the individualized plan of care to maintain and prevent decline in range of motion (ROM) for 2 of 3 residents reviewed for limited ROM from a total sample of 41 residents, (#1, #49) Findings: 1. Review of resident #1's medical record revealed the resident was admitted [DATE] and readmitted to the facility from the hospital on 1/03/2023 with diagnoses of right hand contracture, functional quadriplegia, paraplegia, Parkinson's disease, osteomyelitis, and dementia. The Minimum Data Set (MDS) significant change assessment with Assessment Reference Date (ARD) 1/07/2023 noted the resident's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The assessment showed the resident did not have any behaviors or reject care. The assessment indicated the resident was dependent on staff for activities of daily living (ADL), had functional limitations for ROM in his arms and legs on both sides of his body, and on 1/04/2023 the resident began treatment and services for Occupational Therapy (OT). On 3/20/2023 at 12:57 PM, resident #1 was observed with his eyes closed lying in bed. Both arms were placed across his chest. Both wrists were bent inward and the fingers on both hands were very close to his forearms. Review of resident #1's care plan dated 4/04/2016 to 3/23/2023 read, at risk for continued decline in functional mobility . , noted impaired ROM to bilateral upper and lower ext (extremities). The care plan included Interventions to provide ROM to maintain joint mobility, and splint treatment for contractures. Review of the Occupational Therapy Discharge Summary completed by Occupational Therapist C showed the resident was discharged from OT services on 2/01/2023. The note indicated the resident was to continue an established ROM program through trained nursing services for passive range of motion to both upper extremities to prevent further contractures, pain and maintain ROM. On 3/22/2023 at 11:58 AM, Restorative Certified Nursing Assistant (CNA) A said she was responsible for providing restorative nursing services to residents for ROM. She explained individualized treatment plans were created by therapy services and she kept a copy of each resident's plan in a binder with paper monthly logs to document dates she provided care. She stated the logs were scanned to the medical record at the end of each month. She recalled resident #1 had contractures and had required a splint that was recently discontinued by therapy services. She could not recall if the resident received ROM care and services. Review of the electronic medical record showed a scanned form titled, Referral to Restorative Occupational Therapy signed by Occupational Therapist C on 2/01/2023 and Restorative CNA A on 2/07/2023. The form outlined resident #1's individualized plan of care that included education for passive ROM provided to both upper extremities for 15 repetitions, 3 to 5 times per week so the resident will, maintain ROM to continue to assist with ADL's, prevent pain, further contractures, and increased perceived quality of life. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105960 If continuation sheet Page 2 of 4 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 105960 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Windermere 4875 Cason Cove Drive Orlando, FL 32811 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)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The electronic medical record did not include scanned monthly logs to show if restorative therapy was provided for resident #1. On 3/23/2023 at 2:32 PM, the facility could not provide any monthly log forms for resident #1. 2. Review of resident #49's medical record revealed the resident was admitted to the facility on [DATE] and had diagnoses of hemiplegia and hemiparesis following stroke affecting left non-dominant side, osteoarthritis, vascular dementia, and anxiety. The MDS quarterly assessment with ARD 2/10/2023 noted the resident had moderate cognitive impairment with a BIMS score of 8 out of 15. The assessment showed the resident did not have behavioral symptoms or reject care, was dependent on staff for ADL, and had functional limitations for ROM in his arms and legs on one side of his body. The assessment indicated resident #49 did not receive therapy, ROM, or splint/brace assistance during the look back period. On 3/22/2023 at 9:54 AM, resident #49 was observed awake while lying in bed. A splint was observed sitting on the resident's overbed table. Review of resident #49's care plan dated 9/19/2017 to 3/23/2023 read, noted with self care deficit r/t (related to) CVA (stroke) with left side weakness; at risk for further decline in functional mobility . The care plan included Interventions, hand splint during waking hours . Review of the Occupational Therapy Discharge Summary completed by Occupational Therapist C showed the resident was discharged from OT services on 1/27/2023. The note indicated the resident was to continue an established restorative program through trained nursing services for ROM, left hand splint and brace so the resident will, continue to benefit. Review of the Physical Therapy Discharge Summary completed by Physical Therapist D showed the resident was discharged from Physical Therapy services on 1/09/2023, and was to continue a bedside exercise program through trained nursing services for ROM. The note read resident #49 had, made substantial functional gains in response to skilled interventions. Review of the electronic medical record showed Referral to Restorative - Occupational Therapy form signed by Occupational Therapist C on 1/27/2023 and Restorative CNA A on 1/31/2023. The form outlined resident #49's individualized plan of care included education for Active ROM for right upper extremity and passive ROM for left upper extremity provided to both for 2 sets of 15 repetitions, and a splint/brace program for a left hand splint so the resident will, maintain ROM to continue to assist and participate from desired ADLs, and increase perceived quality of life. Review of the Restorative Therapy binder provided by CNA A contained a document with resident #49's name titled, Restorative Nursing Program Record dated 3/01/2023 to 3/22/2023. The form was signed by Restorative CNA for dates, 3/2/2023, 3/6/2023, 3/13/2023, 3/14/2023, 3/17/2023, 3/21/2023, and 3/22/2023 noting under a column titled minutes, 30/12 was provided. Review of the electronic medical record did not include any other scanned monthly log forms to document individualized ROM or splint/brace services were provided to resident #49. On 3/22/2023 at 11:46 AM, the [NAME] Unit Manager said nurses did not oversee the restorative therapy program. She explained a restorative CNA received the tasks from therapy and nursing did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105960 If continuation sheet Page 3 of 4 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 105960 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Windermere 4875 Cason Cove Drive Orlando, FL 32811 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)

F 0688 document if those services were provided. Level of Harm - Minimal harm or potential for actual harm On 3/23/23 at 10:46 AM, the Director of Nursing (DON) said nursing provided general ROM during ADL assistance for all residents with no individualized directions or plan of care. Residents Affected - Some On 3/23/23 at 10:47 AM, the MDS Coordinator stated the MDS assessments reviewed for residents #1 and #49 were coded correctly, and there was no documentation to show restorative services for ROM or splint/brace were provided. On 3/23/2023 at 2:32 PM, the DON said there were no other restorative program monthly logs of services provided for residents aside from the March 2023 logs contained in Restorative CNA A's binder. On 3/23/2023 at 11:25 AM, the Therapy Director said therapy services established restorative programs for ROM that were individualized to the resident's needs to establish a baseline, maintain functioning, and prevent decline. He stated the expectation was that the treatment plan continued per the recommendations, and explained the risk of decline and decompensation was high if a resident did not receive the services. The facility's policy and procedure titled, Restorative Nursing Services, read, 3. Restorative goals and objectives are individualized and resident-centered and are outlined in the resident's plan of care. The Facility's Assessment read, Part 2. Services and Care We Offer Based on our Residents' Needs . Activities of daily living . supporting resident independence in doing as much of these activities by himself/herself., and Therapy. management of braces, splints. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105960 If continuation sheet Page 4 of 4