Health inspection·May 9, 2023

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to accurately report allegations of abuse to the Agency for Health Care Administration (AHCA) and conduct a thorough investigation for two abuse reports involving 3 of 3 residents of a total sample of 9 residents, (#1, #2, and #7). Residents Affected - Few Findings: 1. Review of resident #1's medical record revealed she was readmitted to the facility on [DATE] with diagnoses of Alzheimer's disease, dementia, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #1's Brief Interview for Mental Status (BIMS) score was 5 out of 15 which indicated she was severely cognitively impaired. Review of a Skin Observation form dated 1/9/23 revealed there was no skin condition present. 2. Review of resident #2's medical record revealed he was readmitted to the facility on [DATE] with diagnoses of dementia with psychotic disturbance and depression. Review of the MDS quarterly assessment dated [DATE] revealed resident #2's BIMS score was 3 out of 15 which indicated he was severely cognitively impaired. Review of resident #2's medical revealed the weekly Skin Observation was performed on 1/5/23 and 1/12/23. Review of the Nursing Homes Federal Reporting 5-day report submitted to AHCA on 1/13/23 revealed an alleged abuse incident for resident #1 on 1/9/23 at 4:47 PM. The AHCA report was completed by the Administrator. The report noted Certified Nursing Assistant (CNA) A found resident #2 in resident #1's bed taking a nap. The report included resident #2 was wearing a t-shirt and was covered with a towel, his pants were on the floor while resident #1 was fully dressed. The report noted resident #1 was also taking a nap. The report read, [resident #1's last name] skin was check [sic] by a licensed nurse and showed no signs of redness, bruising, irritation or trauma. [resident #2' last name] skin was check [sic] by licensed nurse and showed no indication of redness, irritation, or trauma. [resident #2's last name] was flaccid.Other residents were interviewed and voiced no concerns with resident-to-resident encounters. After a thorough investigation which included, but was not limited to, a review of the resident's medical chart, resident interviews, and staff interviews the facility determined that this allegation of abuse could not be substantiated. Page 1 of 4 106024 106024 05/09/2023 Solaris Healthcare College Park 730 Courtland Street Orlando, FL 32804

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 5/09/23 at 2:05 PM, during a telephone interview, CNA A stated she worked the 11 PM to 7 AM shift. She recalled on a night when she started her shift, she found resident #2 sleeping with resident #1 in bed. She indicated she redirected resident #2 back to his room, reported to the nurse working that night, wrote a statement, signed it, and gave it to the nurse. She indicated she did not recall which nurse she gave the written statement to but stated the Administrator called her the following day and inquired about the details of the incident, which she provided. 3. Review of resident #7's medical record revealed he was admitted to the facility on [DATE]. Resident #7's diagnoses included calculus of gallbladder, malignant neoplasm of pancreas, depression, and anxiety. Review of the MDS admission assessment dated [DATE] revealed resident #7's BIMS score was 15 out of 15 which indicated he was cognitively intact. The MDS assessment showed resident #7 needed supervision to transfer between surfaces, walk in his room and for locomotion off unit. The MDS assessment revealed he was not steady walking or turning around but was able to stabilize without staff assistance. The MDS assessment indicated resident #7 normally used a walker or a wheelchair. Review of resident #7's Progress Notes revealed a nursing progress note dated 1/28/23 which read, resident signed himself out at 9 AM. When asked where he was going? Resident stated he wanted to get a hair cut [sic]. Resident returned to facility at 3:30 PM. Resident approached front desk and stated he was attacked at the convenience store. Resident was assessed, right ear bleeding, right side temple contusion. Resident was observed with blood on his jeans and a rip to his right side sleeve. Resident disoriented, stated right side facial pain. When asked what happened? Resident stated he was standing at the entrance of the convenience store and was attached by two males and robbed of his cell phone. When asked if the police was called, resident stated the gas station manager called 911 and instructed him to walk back home. Res walked back to [facility's name] alone. MD (physician) and Daughter made aware of resident current status. MD order for resident to be sent to ER (emergency room) for further eval. Police and EMT (Emergency Medical Technician) were called to facility for report and transport to ER for further medical eval. On site officer [last name] took report on robbery, case num:23-6081. Review of the Skin Observation note with effective date 1/28/23 at 5:30 PM, revealed a new skin condition present listed as left ear bleeding, left side temple contusion with swelling. Review of a Change in Condition Evaluation with effective date of 1/28/23 at 5:46 PM revealed signs and symptoms identified included right ear bleeding, right side temple contusion and swelling, increased confusion, and abrupt significant change in cognitive function from usual. The evaluation noted the physician ordered resident #7 to be sent to the emergency room for evaluation. Review of a Change in Condition Evaluation with effective date of 1/30/23 at 7:52 PM revealed resident was transferred to the ER for abdominal pain. Review of the History and Physical note from the hospital dated 1/31/23 revealed resident #7 was readmitted to the hospital on [DATE] because of abdominal pain. Review of the Nursing Homes Federal Reporting 5-day report submitted to AHCA on 2/03/23 revealed an abuse incident for resident #7 on 1/29/23 at 10:00 AM. The AHCA report was completed by the Administrator. The report read, On 1.29.23, [resident's name] signed himself out of the facility . On the day of the event, 1-29-23, the resident returned and said his phone was stolen. The report noted, 106024 Page 2 of 4 106024 05/09/2023 Solaris Healthcare College Park 730 Courtland Street Orlando, FL 32804

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Licensed nurse completed skin evaluation on the resident and found no alteration in skin integrity and no change in mentation however [resident's last name] did complain of head pain. [resident's last name] was transferred to ER. Upon return to facility [resident's last name] was able to return to his normal activities with no further issues or change in condition. After a thorough investigation which included, but was not limited to, a review of the resident's medical chart, resident interviews, and staff interviews the facility determined that this allegation of abuse could not be substantiated. On 5/09/23 at 12:05 PM, the Administrator stated he was the facility's Abuse Coordinator and Risk Manager. He confirmed he was responsible for the investigation and reporting of adverse incidents and allegations of abuse and neglect. He explained when a potential allegation of abuse or neglect was identified, it was immediately reported to the appropriate agencies, and an investigation initiated. He reviewed the AHCA report involving residents #1 and #2 and stated during the investigation he spoke with the Unit Manager, CNAs and nurses in the long-term unit where the affected residents resided. He indicated skin checks were performed on the day of the incident with no negative findings. He noted the staff he interviewed did not recall seeing resident #2 in anyone's else rooms prior to this incident. He stated this was the first time resident #2 was found inside resident #1's room. When asked to provide evidence of the witness statements and interviews he conducted, he indicated the only statement he had was CNA C, who found the residents in bed. He stated he took notes from the interviews with his staff. The Administrator then looked at the printed AHCA report and indicated he had entered CNA C's name in error in his notes, but CNA A, listed in the AHCA report, was the correct staff who found the residents and reported the incident to a nurse. The Administrator then examined the investigation regarding resident #7. He stated resident #7 signed a LOA on 1/29/23 and returned to the facility hours later complaining his head hurt, reported he was mugged at the nearby gas station, and his cell phone was stolen. The Administrator stated LPN B called him with resident #7 present during the call. The Administrator stated he called the gas station twice and spoke to two different attendants but was not able to obtain any details from them. No evidence of witness statements or details of the calls made were provided for review. Later at 1:14 PM, the Administrator indicated he was notified of resident #7's event on 1/29/23 and acknowledged the incident occurred on 1/28/23. He noted the date and time of incident was entered incorrectly in the report submitted to AHCA. Both the DON and the Administrator conveyed they were not notified by LPN B on the day of the incident. He confirmed the AHCA report indicated the incident occurred on 1/29/23 at 10:00 AM and resident #7's had no alteration in skin or mentation, which was inaccurate. The Administrator stated he should have reviewed the report before he submitted it to ensure the information was accurate. On 5/09/23 at 3:10 PM, during a telephone interview, Licensed Practical Nurse (LPN) B explained a resident may be granted leave of absence (LOA) privileges if their BIMS was 15. She indicated the LOA was approved for 4 hours so residents did not miss taking their next scheduled medications. She recalled resident #7 left the facility in the morning and when she noticed he had not returned within 4 hours, she attempted to call his cellphone but there was no response. She indicated shortly after her attempts to contact him, she informed resident #7's assigned nurse and she received a call from the front desk receptionist informing her resident #7 had returned and he stated he had been robbed. She stated she went to the front, sat resident down in the lobby area, called a CNA to bring a wheelchair and assessed resident #7. She recalled he had blood coming from his left ear, not profusely, but some blood coming from his ear. She stated she asked what happened and resident #7 indicated someone stole his cell phone and wallet at the gas station. She stated he was not able to provide the exact time of the incident, but stated he got up, went inside the store, and told the attendant he 106024 Page 3 of 4 106024 05/09/2023 Solaris Healthcare College Park 730 Courtland Street Orlando, FL 32804

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few had been mugged. She indicated she called the store and spoke to the store manager, who assumed resident #7 was someone living on the street and told him he would call 911 but he didn't. She stated she called the physician who ordered him to be sent to the hospital for an evaluation. She stated she called 911 and requested the police to come to get a report. LPN B stated it was a busy day and this happened during dinner time, so she addressed the situation, but she notified management after midnight when she sat down to write the report. She stated she wrote a statement, and she recalled the nurse assigned to resident #7 also wrote a statement. She said she made a copy of it and left it in the Administrator, Director of Nursing (DON) and Assistant DON's boxes. She indicated she instructed resident #7's assigned nurse to do the same. She recalled she kept her copy for a week or so in case of any questions but shredded it afterwards. She noted the Administrator called her the day after the incident, and she explained what happened the night before. She said she wrote the witness statement and completed the required reports. She explained she spoke with his family and the physician. She could not recall if the Administrator spoke to the resident on the phone. On 5/9/23 at 4:15 PM, the Administrator explained they used an internal digital form to collect the data from an investigation which was utilized when submitting the report to AHCA. He stated they had used witness statements in the past, but witnesses wrote the statements in front of him, and he typed it into their online investigation system. He said he verified the information with whoever he was talking to while collecting the details. He noted, Accuracy is very important and agreed information provided in the AHCA reports was inaccurate and did not include details found in resident #7's medical record. He stated he should have done a better job. On 5/9/23 at 5:09 PM, the DON explained a skin check was completed for resident #1 but not for resident #2 as included in the AHCA report. Review of the job description for the Administrator undated revealed duties and job responsibilities included, Instituting policies, rules, and procedures for the facility to protect everyone involved and to comply with governmental regulations. Reviews, monitors, and follows-up on incident reports, adverse incidents, resident grievances, and deficiencies cited by the agency. Review of the facility policy and procedure titled Alleged Abuse/Potential Neglect/Exploitation/Misappropriation/Investigation dated 10/24/22, read Procedure/Guidelines: The Administrator, DON and/or designated individual are ultimately responsible for: Implementation of abuse prevention policies, and procedures; ongoing monitoring; investigation of alleged violations; reporting according to Federal, State, local laws and regulations and facility policies/procedures. The Investigation section included, A thorough investigation will be initiated as soon as any actual, suspected, or alleged abuse, neglect, misappropriation of resident property, exploitation, or mistreatment, including injuries of unknown source has been identified. Upon notification or identification, the facility administrator or designee will initiate and conclude a complete and through investigation . The investigation shall include, but is not limited to: . the date, time, and place the incident occurred, . interview statements, document review . Review of Exhibit 359 - Follow-up Investigation Report form not dated revealed the facility must provide in its report sufficient information to describe the results of the investigation. It is important that the facility provide as much information as possible, to the best of its knowledge at the time of submission of report. 106024 Page 4 of 4