Health inspection·May 11, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop a care plan for advance directive for code status and failed to update the current order for code status for 1 of 2 sampled residents reviewed for advanced directives, Resident #93. The findings included: Review of the facility's policy, titled, Do Not Resuscitate Order dated 02/27/20, included: Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life function on a resident when there is a Do Not Resuscitate Order in effect. Do not resuscitate orders must be signed by the resident's attending physician on the physician's order sheet maintained in the resident's medical record. The interdisciplinary Care Planning Team will review advance directives during quarterly care planning sessions to determine if the resident wishes to make changes in such directives. Record review for Resident #93 revealed the resident was admitted to the facility on [DATE], with diagnoses that included Unspecified Dementia, Urinary Tract Infection, Pressure Ulcer of Left Heel (Unstageable), and Type 2 Diabetes Mellitus. Review of the Minimum Data Set (MDS) for Resident #93, dated 03/17/23, included in Section C, a Brief Interview of Mental Status (BIMS) was not completed due to the resident is rarely/never understood. In Section G, for bed mobility, dressing, toilet use, and personal hygiene, all had a self-performance of extensive assistance with support of one person assist. Review of the care plans for Resident #93 revealed a care plan with a problem of 'Do Not Resuscitate: Patient does not wish to be kept alive without hope of recovery' that was not initiated until 05/10/23. Review of the face sheet for Resident #93 revealed the resident had a Do Not Resuscitate (DNR) code status. Review of the physician's orders for Resident #93 revealed an active order dated 12/15/22 for Code Status: Full Code. Record review for Resident #93 revealed a completed, signed and dated copy of DNR form, dated 03/13/23. Page 1 of 8 105979 105979 05/11/2023 Solaris Healthcare Coconut Creek 4125 West Sample Rd Coconut Creek, FL 33073

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review for Resident #93 revealed a Social Service progress note, dated 04/17/23 (late entry), that included: 'Resident reviewed at resident plan of care meeting for quarterly review on 03/28/23. Resident assessments were completed related to resident's communication status. Resident presents as an alert woman who is cognitively impaired, diagnosis of Dementia. The resident is very confused and presents with illogical speech. The resident has presented with episodes of agitation, screaming, anxiousness and restlessness and is followed by consulting psychiatrist for medication management. The resident was recently evaluated on 03/15/23 for capacity and it was determined the resident lacks capacity related to her advanced dementia. Advance directives were reviewed with daughter on the day of care plan and resident continues as a DNR status. Copy of living will, durable power of attorney (DPOA) and DNR are scanned into the resident's record. Care plan and approaches reviewed and updated to reflect current status addressing cognition, communication, behaviors, and efforts to enhance well-being and to meet resident's psychosocial needs. The Director of Social Services (DSS) will remain available to the resident and the resident's daughter to assist with needs/concerns.' An interview was conducted on 05/10/23 at 12:20 PM with the Social Service Director (SSD), who stated she has been with the facility for 12 years. She stated advance directives are initially addressed by nurses, then the social services department. The facility conducts a circle of care meetings held in the first 32 hours of a resident's admission to the facility to address advance directives. The advance directives are again discussed at the resident's care plan meetings that are held quarterly. When asked where she would find the code status for Resident #93, she stated it is located on the banner of the resident's electronic medical record (EMR) at the top. She then stated Resident #93 has a DNR in the EMR. When asked what the physician's order for code status for Resident #93 revealed, she stated it the EMR but it showed a physician order dated 12/15/22 code status as being full code. When asked who is responsible for updating the physician's orders for code status for a resident, she stated she does not have anything to do with getting the order for the resident for code status, that would be up to nursing. When asked what the process is for updating the resident's record when a resident representative provides a DNR to a staff member, she stated the advance directive is then discussed at the daily clinical meetings held in the morning (Monday Friday). The SSD stated on 03/28/23, a care plan meeting was held for Resident #93 and advance directives were discussed with the resident's daughter. The resident is a DNR, has a DPOA (Durable Power of Attorney) and living will. The SSD stated she is not sure why she did not write a care plan for advance directives that would list what advance directives the resident has. The SSD stated she would normally initiate an advance directives care plan that lists what forms are in the chart and the MDS Coordinator would write a care plan for the DNR code status. An interview was conducted on 05/10/23 at 12:50 PM with Staff E, (Registered Nurse/RN, Care Plan Coordinator), who stated she has been with the facility for more than 10 years. Staff E stated there was a care plan meeting held on 03/28/23 for Resident #93 with attendance by herself representing nursing, Physical Therapist who represented Therapy, Social Worker who represented Social Service, and the Dietician who represented nutrition. The daughter did not attend in person or via phone. The resident did not attend due to cognition. The Social Worker would review advance directives. The dietician will discuss diet/nutrition related issues. She will discuss nursing related issues. Orders are put in at the 'floor level' and discussed at morning meetings. If during the advance directive discussion, it is determined that the resident has a DNR, she would check to see if the resident has a care plan that addresses the DNR code status, if not, she will initiate a care plan to address DNR code status. The Care Plan Coordinator reviewed the morning clinical meeting notes for 03/13/23 and 03/14/23 and stated there was no mention or discussion of DNR 105979 Page 2 of 8 105979 05/11/2023 Solaris Healthcare Coconut Creek 4125 West Sample Rd Coconut Creek, FL 33073

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few code status for Resident #93. She stated she was never aware of Resident #93 having a DNR code status. She stated during the care plan meeting for Resident #93 on 03/28/23, she did not recall the SSD discussing a DNR code status or she would have initiated a DNR code status care plan for the resident. An interview was conducted on 05/11/23 at 9:20 AM with Staff F, Licensed Practical Nurse (LPN), who stated he has been with the facility for 2 years. When asked how he knows what the code status is for a resident, he stated he looks up the record for the resident and on the top (in the banner) it states the code status for the resident. An interview was conducted on 05/11/23 at 10:00 AM with Staff G, RN, who was asked how she identifies the code status for a resident. She stated she would look up the resident and on the top left side of the screen it states the code status for the resident. An interview was conducted on 05/11/23 at 10:10 AM with the ADON (Assistant Dr of Nursing), who was asked how she identifies the code status for a resident. She stated she would look at the top of the screen for the resident (in the banner) and if the resident was a DNR she would verify under documents that there was a DNR form completed, signed and dated. When she was asked to look up the code status for Resident #93, she stated it shows a DNR status at the top of the screen for the resident (in the banner). The ADON verified, under documents, that the resident had a completed, signed and dated (03/13/23) DNR form. She was also able to verify the date the document was attached to the resident's record as being 03/13/23. When asked to verify the code status order, she stated the code status was just updated on 05/10/23 to DNR. 105979 Page 3 of 8 105979 05/11/2023 Solaris Healthcare Coconut Creek 4125 West Sample Rd Coconut Creek, FL 33073

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure it maintained a safe and homelike living environment for residents that included 9 of the 29 sampled residents' rooms. The findings included: On 5/09/2023 at 10:03 AM, a tour of the facility was conducted with the Administrator, revealed the following: 1. In room [ROOM NUMBER], the bed footboard was broken and touching the floor. 2. In room [ROOM NUMBER], the footboard of bed B was in disrepair. 3. On 5/08/23 at 12:36 PM, the windows of room [ROOM NUMBER] were observed to be clouded with water marks and dirt, which reduced visibility and the residents' ability to clearly see outside. The resident in room [ROOM NUMBER] complained that staff had promised to have the windows cleaned up, but they have not done so yet. The laminate on the bed footboard was peeling off. The footboard of bed-A in room [ROOM NUMBER] was noted to be heavily scuffed. At the time of this tour, the Administrator acknowledged the above findings. 4. During an observation conducted on 05/08/23 at 10:00 AM, in room [ROOM NUMBER], there was peeling paint next to the closet closest to the window. 5. During an observation conducted on 05/08/23 at 11:00 AM in room [ROOM NUMBER]-W of the resident's armoire wardrobe missing a pull knob on the top right door and missing the top drawer located at the bottom. 6. During an observation conducted on 05/08/23 at 11:20 AM in room [ROOM NUMBER], there were two holes in the wall with dark marks on the wall located on the right wall as you walked into the room. 7. During an observation conducted on 05/08/23 at 12:20 PM, in room [ROOM NUMBER], the armoire wardrobe was missing a pull knob on the door located on the right side. 8. During an observation conducted on 05/09/23 at 9:05 AM in room [ROOM NUMBER], there are 3 cracked windowpanes. 9. During an observation conducted on 05/09/23 in room [ROOM NUMBER]-D, there were 6 stuffed animals on top of the overbed light. 105979 Page 4 of 8 105979 05/11/2023 Solaris Healthcare Coconut Creek 4125 West Sample Rd Coconut Creek, FL 33073

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, interview, and record review, the facility failed to assist during dining for 1 of 1 sampled resident reviewed for Activities of Daily Living (ADLs), Resident #16. Residents Affected - Few The findings included: Review of the facility's policy, titled, Activities of Daily Living (ADL), Supporting (no date), showed that residents who are unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. In an observation conducted on 05/08/23 at 10:20 AM, Resident #16 was observed in bed with the breakfast tray on the side table and not in front of the resident. The tray was noted to be 100% untouched. Continued observation at 10:55 AM showed that the tray was untouched on the side table. In an observation conducted on 05/08/23 at 12:15 PM, Resident #16 was noted in bed with the lunch tray at the side table and not in front of the Resident. No staff was noted in the room, and at 12:35 PM, the tray was still untouched at the side table. In an observation conducted on 05/09/23 at 8:25 AM, Resident #16 was noted in bed with the breakfast tray at the side table and not in front of the Resident. There were no staff observed in the room from 8:25 AM to 8:38 AM. At 8:38 AM, a staff entered the room to assist Resident #16 with her breakfast meal. Resident #16 was admitted to the facility on [DATE] with diagnoses of Dementia, Chronic Obstructive Disease, and Hypertension. The Quarterly Minimum Data Set (MDS), dated [DATE], documented under section G for eating, that Resident #16 needs extensive assistance with one person assist. Resident #16's Interview for Mental Status (BIMS) score showed that she is at a 04, indicating severe cognitive impairment. The care plan, dated 03/28/23, documented Resident #16 was at risk for Alteration in Parameters of Nutrition related to weight loss and decreased intake of meals. It further showed that one of the goals was to provide meal assistance as needed and as indicated. Review of the weight log showed that Resident #16 was at 163 pounds on 01/23/23 and dropped to 150 pounds by 05/05/23. The Clinical Dietitian note, dated 05/06/23, revealed Resident #16 had a weight loss of 9 pounds in 3 months and that her intake of meals is at around 25 percent (%) to 50%. Review of the Certified Nursing Assistant's (CNA) percent intake of meals showed that no documentation was provided on Resident #16 for breakfast and lunch on 05/08/23. An interview was conducted on 05/09/23 at 8:50 AM with Staff A, CNA, who stated Resident #16 sometimes needs help with her meals and had eaten about 50-75% of her breakfast meal this morning. An interview was conducted on 05/10/23 at 2:00 PM with Staff C, Minimum Data Set Coordinator (MDS), who stated Resident #16 needed extensive assistance with one person in the room for most of the meals. She further stated she obtains the information on the residents by looking at the nursing notes and the CNA's daily ADLs documentation. 105979 Page 5 of 8 105979 05/11/2023 Solaris Healthcare Coconut Creek 4125 West Sample Rd Coconut Creek, FL 33073

F 0677 An interview was conducted on 05/11/23 at 12:00 PM with the facility's Administrator, and she was told of the findings. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105979 Page 6 of 8 105979 05/11/2023 Solaris Healthcare Coconut Creek 4125 West Sample Rd Coconut Creek, FL 33073

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to follow tube feeding physician orders for 1 of 1 sampled resident reviewed for tube feeding, Resident #63. The findings included: Resident #63 was readmitted to the facility on [DATE] with diagnoses of Anemia, Dementia and Parkinson's Disease. Review of the physician's orders documented Isosource 1.5 tube feeding at 65 ml an hour for 18 hours to be off from 8:00 AM to 2:00 PM. Another order, dated 02/28/23, documented 'a diet with reduced concentrated sweets, no added salt'. The Quarterly Minimum Data Set (MDS), dated [DATE], documented Resident #63's did not have an Interview for Mental Status (BIMS) score because she could not answer any of the questions for the assessment. The care plan initiated on 01/27/23 documented Resident #63 is at risk for alteration in parameters of nutrition related to gastrostomy malfunction and to provide feeding as ordered for Isosource 1.5 tube feeding at 65 ml an hour 18 hours to be off from 8:00 AM to 2:00 PM. In an observation conducted on 05/08/23 at 10:25 AM, Resident #63 was in her room with the tube feeding Isosource 1.5 (tube feeding type) running at 65 milliliters (ml) an hour. Closer observation showed the tube feeding bag was started the day before at 8:00 PM. The tube feeding was at the 300 ml mark out of a 1000 ml capacity bottle. Review of the physician's orders documented the tube feeding should have stopped at 8:00 AM. Another observation was conducted on 05/08/23 at 12:20 PM showing Resident #63 was eating a lunch tray with ground roast turkey, sweet potato and green beans. Closer observation showed that she only ate 10% of her lunch meal. The tube feeding was still running at 65 ml an hour while Resident #63 was eating her lunch. In an observation conducted on 05/09/23 at 8:20 AM, the resident was noted in her bed with the tube feeding running at 65 ml/hour, starting on 05/09/23 at 8 AM. The tube feeding was noted at the 1000 ml mark out of the 1000 ml capacity bottle. At 8:30 AM, the tube feeding was held, but no breakfast tray was noted at the bedside. At 9:00 AM, the tube feeding was still on hold with no breakfast tray for Resident #63. An observation on 05/10/23 at 3:20 PM showed Resident #63 sitting in a chair. Closer observation showed no tube was feeding running at this time. A note dated 02/19/23 by the Clinical Dietitian documented Resident #63's current tube feed regimen meets estimated nutritional needs and Resident #63 tolerates the tube feeding. An interview was conducted on 05/10/23 at 3:25 PM with Staff D, Licensed Practical Nurse/LPN, who when asked why the tube feeding was not running at this time, stated Resident #63 did not want to have the tube feeding running at this time. 105979 Page 7 of 8 105979 05/11/2023 Solaris Healthcare Coconut Creek 4125 West Sample Rd Coconut Creek, FL 33073

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted on 05/10/23 at 3:30 PM with Resident #63, and when asked by the surveyor if she requested the tube feeding to be off, she was not able to answer the question or communicate with the surveyor. Review of a progress note written by Staff D after her interview with the surveyor documented that at 2:00 PM, Resident #63 refused to have the tube feeding and stated 'no later' to Staff D. It further documented that around 3:00 PM, Resident #63 agreed to start the tube feeding again. An interview was conducted on 05/11/23 at 12:20 PM with the facility's Administrator, and she was informed of the findings. 105979 Page 8 of 8