Health inspection·January 6, 2022

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. 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 a resident was assessed to self-administer medications for 1 of 48 total sampled residents, (#26). Residents Affected - Few Findings: Resident #26 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, type 2 diabetes mellitus, and generalized anxiety. The resident's annual Minimum Data Set (MDS) assessment with assessment reference date 9/26/21 revealed the resident's cognition was intact with a Brief Interview Mental Status score of 14/15. On 1/04/22 at 11:27 AM, 4 tablets and a medicine cup were observed on the floor under the resident's wheelchair. Resident #26 stated, the cup of pills fell out of my hand when I was trying to take them. My nurse always leaves the pills, and I take them by myself. I am [AGE] years old, I don't want anyone watching me take medications. I want to take them by myself. I tell the nurse to leave the medicine in the cup, and I will take them. On 1/04/22 at 11:29 AM, Registered Nurse (RN) A came into resident #26's room. RN A gathered the tablets into a medicine cup. The tablets were identified as 1 tablet of Metoprolol 50 milligrams (mg), 1 Glipizide 5 mg, 1 Sertraline 100 mg and 1 Lisinopril 20 mg. RN A stated, I left the medications on the overbed table for the resident to take. The resident does not want the nurse to watch her take her medications. I always tell her the medications are there, leave, and she takes them one by one. Review of the physician orders for resident #26 noted Glipizide tablet 5 mg two times a day for diabetes mellitus, Lisinopril 1 tablet 10 mg one time a day for hypertension, Metoprolol Tartrate 1 tablet 50 mg two times a day for hypertension and Sertraline HCL 1 tablet 100 mg one time a day for depression. On 1/05/22 at 10:42 AM, RN A stated, I should observe residents to ensure all medications are taken when given. RN A added resident #26 was not assessed to self-administer medications. RN A stated a resident who wants to self-administer medications must be evaluated to determine if they are safe to do so. She explained physician orders and care plans must then be in place, and the medicines would be kept in the medication cart. On 1/05/22 at 11:03 AM, the Care Plan Coordinator stated, Self-administration of medication Page 1 of 4 106024 106024 01/06/2022 Solaris Healthcare College Park 730 Courtland Street Orlando, FL 32804

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assessments are done for residents who would like to self-administrator their medications. The interdisciplinary team and physician would have to determine appropriateness based on the resident's ability. Resident #26 was not assessed to self-administer medications. On 1/06/22 at 11:49 AM, the west wing Unit Manager stated the resident was readmitted on [DATE] after a 3-day leave of absence with her daughter. The UM acknowledged there was no documentation of the resident being assessed for self-administering medications or requesting to self administer her medications. Review of the medical record revealed resident #26 was not assessed to self-administer medications. There were no recommendations or orders for self-administration of medications. Review of the most recent plan of care completed on 1/3/22 revealed no plan of care for self-administration of medications. The facility's Pharmacy Services and Procedures Manual, 6.0 General Dose Preparation and Medication Administration dated 1/1/13, read, During medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: observe the resident's consumption of the medication. 106024 Page 2 of 4 106024 01/06/2022 Solaris Healthcare College Park 730 Courtland Street Orlando, FL 32804

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement baseline care plans within 48 hours of admission to provide effective and person-centered care of residents as required for 5 residents of a total sample of 48 residents, (#201, #204). Findings: 1. Resident #201 was admitted to the facility on [DATE] with diagnoses including encephalopathy, dementia, Alzheimer's disease, and Charot's joint right/ left ankle. Clinical record review revealed a baseline care plan was not developed within 48 hours of admission for resident #201, and comprehensive care plans were not initiated until 1/05/22, 5 days after admission. On 1/05/22 at 3:27 PM, the Director of Nursing (DON) stated baseline care plans were initiated on admission. The care plans would be discussed with the resident/family, by the Minimum Data Set (MDS) lead coordinator, and a copy would be given to the resident/family. On 1/05/22 at 3:48 PM, the MDS lead coordinator stated the baseline care plan should be developed within 48 hours of admission. The resident's clinical records were reviewed with the MDS coordinator and revealed baseline care plans were not developed/initiated. This was verified by the MDS coordinator. She stated nursing was responsible to initiate baseline care plans within 48 hours of the resident's admission, and it was not done. 2. Resident #204 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy, repeated falls, generalized muscle weakness, and difficulty in walking. Review of progress note dated 10/19/21 revealed resident #204 was found in her room on the floor next to her bed. The resident complained of dizziness, and new orders were obtained for labs and medications. Review of the resident's clinical record showed no baseline care plan for falls although the resident was admitted with history of repeated falls, muscle weakness and difficulty walking. A comprehensive care plan for at risk for falls r/t (related to) deconditioning, gait/balance problems, hx (history) of falls prior to admit .actual fall was initiated on 10/20/21, eight (8) days after admission, and after the resident fell in the facility on 10/19/21. On 1/05/22 at 3:48 PM, the MDS coordinator stated baseline care plans should be developed within 48 hours of admission. She stated resident #204 did not have any baseline care plans, and care plan for fall was not initiated until 10/20/21, after the resident fell. She stated she just identified that baseline care plans were not initiated for resident #204. On 1/06/22 at 10:06 AM, the DON stated resident #204 diagnoses included a history of repeated falls. She stated baseline care plans should have been developed/initiated by the admission nurse. The DON stated the purpose for the baseline care plan was for evaluation of the resident, and to ensure interventions were in place for the resident's care. She stated the residents' clinical records were reviewed for completeness by the Interdisciplinary Team (IDT) in the morning clinical meetings and included ensuring baseline care plans were initiated/developed. The DON did not say why baseline care 106024 Page 3 of 4 106024 01/06/2022 Solaris Healthcare College Park 730 Courtland Street Orlando, FL 32804

F 0655 plans were not initiated for resident #204. Level of Harm - Minimal harm or potential for actual harm On 1/06/22 at 1:02 PM, the East Wing Unit Manager (UM) stated the IDT conducted clinical record review for resident #204 but did not identify that baseline care plans were missing/not initiated. The UM stated the purpose of the baseline care plan was that basic aspects of care could be addressed until the comprehensive care plan was completed. She stated the resident's initial fall risk evaluation completed on 10/12/21 indicated resident #204 had a history of fall. The UM did not identify if any interventions were in place for fall prevention prior to the resident's fall on 10/19/21. Residents Affected - Few 106024 Page 4 of 4