Health inspection·February 16, 2023

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 ensure the baseline care plan summaries were reviewed with the resident or resident representative for 4 of 4 new admission residents out of a total sample of 42 residents (#15, #88, #273 & #274). Findings: 1. Resident #15's medical record revealed the resident was admitted to the facility on [DATE] with previous admissions on 12/01/22, 11/15/22, and 5/24/21 with diagnoses of acute kidney failure, pain, urinary tract infection, hypertension, history of traumatic brain injury. The Minimum Data Set (MDS) entry assessment had an assessment reference date (ARD) of 1/24/23. Nurses' notes from 1/24/23 at 10:00 PM through 2/16/23 at 2:29 PM did not contain any documentation of the resident's refusal to sign a baseline care plan summary. The medical record did not contain a copy of a baseline care plan summary provided to resident #15 or the resident's representative. On 2/13/23 at 9:37 AM, resident #15 stated she did not have any concerns with care plans and could not remember receiving a baseline care plan summary form. 2. Resident #88's medical record revealed the resident was readmitted to the facility on [DATE], and originally admitted on [DATE] with diagnoses of diabetes, post-acute respiratory failure with hypoxia, malignant neoplasm of brain, and abdominal aneurysm. The MDS Medicare 5-day had an ARD of 1/25/23. Nurses' notes from 1/06/23 at 3:03 PM through 2/16/23 at 2:23 PM did not contain documentation of the resident's refusal to sign a baseline care plan summary within 48 hours of admission, and there was no copy of a baseline care plan summary signed by resident #88 or a family representative in the medical record. On 2/13/23 at 10:45 AM, the resident stated he did not have any concerns with care plans and was not sure if he received a copy the baseline care plan. 3. Resident #273's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including previous spine fracture T7, T8, thoracic vertebra routine healing, chronic systolic heart failure, and epilepsy. The MDS entry assessment had an ARD of 2/08/23. The medical record did not contain any documentation from 2/08/23 at 8:27 PM through 2/15/23 at 6:51 PM for the resident's refusal to sign a baseline care plan, and there was no documentation that a copy of the baseline care plan summary was provided to resident #273 or the resident's representative. On 2/13/23 at 10:37 AM, the resident did not voice any concerns regarding care plans and did not Page 1 of 4 106127 106127 02/16/2023 Solaris Healthcare Celebration 1290 Celebration Blvd Kissimmee, FL 34747

F 0655 know if he received a copy of the care plan of if he had signed a care plan. Level of Harm - Minimal harm or potential for actual harm 4. Resident #274's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, chronic kidney disease, heart failure, and pneumonia. The MDS entry assessment had an ARD of 2/09/23. Nurses' notes from 2/09/23 at 10:23 PM to 2/16/23 at 2:19 PM did not contain documentation of the resident's refusal to sign the baseline care plan summary. The medical record did not contain a copy of a baseline care plan summary provided to resident #274 or the resident's representative. Residents Affected - Some On 2/13/23 at 10:43 AM, resident #274 stated she did not have any concerns with care plans and could not remember receiving a baseline care plan summary form. On 2/16/23 at 1:30 PM, a copy of the baseline care plan summary information provided to resident and/or family representative for residents #15, #88, #273, and #274 was requested from Director of Nursing (DON). The DON revealed that they discuss this with the resident and/or representative in their care plan meeting. On 2/16/23 at 1:59 PM, the MDS Director stated she handles all the care plans, and the nurses do the baseline care plans. She stated she is not aware that the resident or the resident's representative should have a copy of baseline care plan summary and said there was no MDS documentation. On 2/16/23 at 2:15 PM, the DON stated she is aware of residents receiving a baseline care plan summary. It is done by nursing and the residents are given a copy. She stated sometimes the baseline care plan is signed and sometimes it is not. She stated nursing is responsible for the baseline care plans. She stated if there is a refusal to sign a baseline care plan, nursing should make a note in the progress notes. She stated if the baseline care plan is signed, a copy is given to MDS staff, then MDS staff speaks to the resident, and MDS staff will write a progress note. The DON stated she is responsible for following up with nursing and she confirmed there were no baseline care plans for resident #15, #88, #273, or #274. She validated there was no documentation of baseline care plan summaries provided, or refusal to sign for residents #15, #88, #273, #274 or their family representatives. On 2/16/23 at 2:20 PM, the Social Services Director confirmed she does have any involvement with residents' baseline care plans. A review of the policy Care Plan, with a review date of 10/24/22, read in part, PROCEDURES . 2. An Interim Baseline Care Plan shall be initiated and implemented within 48 hours of admission that includes interventions to provide person-centered, culturally competent and trauma informed resident care as indicated. This interim care plan shall include but is not limited to: physician's orders, dietary orders, therapy services, social services and PASRR recommendations when applicable. 106127 Page 2 of 4 106127 02/16/2023 Solaris Healthcare Celebration 1290 Celebration Blvd Kissimmee, FL 34747

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 follow physician ordered liters of oxygen administration for 1 of 1 resident reviewed for oxygen therapy out of a total sample of 42 residents (#274). Residents Affected - Few Findings: Resident #274's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of anemia, chronic kidney disease, heart failure, COVID-19 and pneumonia. The Minimum Data Set (MDS) entry assessment with assessment reference date (ARD) of 2/09/23 did not show an oxygen order. Review of the care plan initiated and revised on 2/10/23 showed a problem of respiratory distress with a goal and an intervention to administer oxygen as ordered. On 2/13/23 at 10:43 AM, observation of resident #274 revealed oxygen via nasal cannula running at 3 liters per minute. The medical record revealed a physician's order dated 2/10/23 for oxygen at 2 liters per minute via nasal cannula every shift. On 2/13/23 at 3:16 PM, observation of resident #274 with Registered Nurse (RN) A revealed that oxygen was set at 3 liters per minute. Review of the physician's order with RN A revealed oxygen was ordered at 2 liters per minute. Upon observation of resident #274's oxygen rate with RN A, he confirmed oxygen was running at 3 liters per minute. He stated he last checked resident #274's oxygen dosage on 2/12/23. He stated oxygen rate for residents should be checked every shift and it is his fault that the oxygen was running at the wrong rate for resident #274. Physician's order for oxygen was not followed and resident #274 did not receive care and services appropriate with the plan of care. On 2/13/23 at 4:04 PM, the Director of Nursing (DON) stated the nurse is responsible to check the resident's ordered oxygen rate. On 2/15/23 at 11:03 AM, the DON stated, I am ultimately responsible, and the expectation is nursing will follow the physician orders. The facility's policy Physician Orders, reviewed 1/19/2018 read, PROCEDURES . 3. Physician orders will be transcribed, noted, implemented, and followed in a timely manner . The facility's policy Care Plan, reviewed 10/24/2022, read, PROCEDURES . 5. Person-centered and culturally competent care plan approaches shall be communicated to staff for use in providing care . 106127 Page 3 of 4 106127 02/16/2023 Solaris Healthcare Celebration 1290 Celebration Blvd Kissimmee, FL 34747

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, record review and interview, the kitchen staff failed to follow hygienic practices, during food distribution, to prevent the cross contamination of food, utensils, and clean equipment. Residents Affected - Some Finding: Review of the facility menu for 2/13/21 revealed the residents would be served Cinnamon Oatmeal, Cheese Omelet, Hashbrown Patty, and Raisin Toast for breakfast. Review of the facility's mealtimes noted that breakfast would start at approximately 7:30 AM. On 2/13/23 at approximately 8:09 AM, the cook and a dietary aide had already started the breakfast tray line. The cook wore gloves and was the actual staff person plating the food. Approximately 2-3 minutes later, the cook, who was still wearing the same gloves, lowered his surgical mask below his nose and mouth, and drank from a Styrofoam cup that did not have a lid. The cook could not explain why he was drinking during the tray line service but indicated he should not have done so. He indicated he was aware that eating and drinking was prohibited during tray line. Approximately 1-2 minutes later, the Certified Dietary Manager (CDM) said that the kitchen staff had been educated about not eating or drinking during the tray line service. The cook returned to the tray line, but he did not sanitize his hands and don new gloves. The cook used his gloved hand to plate a cheese omelet and a hashbrown patty. Chapter 2 of the 2022 Food and Drug Administration (FDA) Food code, delineates hygienic practices for foodservice employees. Eating and drinking is allowed only in designated areas where contamination/cross contamination to food, utensils and clean equipment can occur. Chapter 2 also notes that food service employees shall clean/wash their hands after eating or drinking. 106127 Page 4 of 4