Solaris Healthcare Lely Palms

Based on observation, review of the clinical record, review of facility policy and procedures, and staff interviews, the facility failed to develop a care plan that described the resident's medical, physical, mental and psychosocial needs and preferences and how the facility will assist in meeting these needs and preferences for 4 (Resident #46, # 54, #42 and #55) of 4 residents residing on the memory care unit. The failure to complete an individualized care plan has the potential to impact the resident's quality of life and quality of care. The findings included: The facility policy Baseline Care Plan and Summary documented the facility will develop and implement a care plan for each resident that includes the instructions needed to provide effective and person centered care of the resident. 1. Review of the clinical record revealed Resident #42 had a readmission date of 2/23/24. Diagnoses included severe dementia with behavioral disturbance, depression, degenerative disease of the nervous system, and anxiety. The clinical record documented a brief interview for mental status…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, review of facility policy and procedures, and staff interviews, the facility failed to ensure they provided an ongoing program to support the residents in their choice of activities which are designed to meet the resident's interests and support the resident's physical, mental, and psychosocial well-being for 5 (Resident #46, #54, #42, #55 and #5) reviewed for involvement in activity programs. The findings included: Review of the facility policy 2.8 Activity Programs revealed, Activity programs designed to meet the needs of each resident are available on a daily basis . are designed to encourage maximum individual participation and are geared to meet the individual needs . Review of the clinical record revealed Resident #42 had a readmission date of 2/23/24. Diagnoses included severe dementia with behavioral disturbance, depression, degenerative disease of the nervous system, and anxiety. The care plan initiated on 3/5/24 indicated Resident #42, Prefers not to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility policy and procedure, record review and staff interviews, the facility failed to treat 1 (Resident #46) of 22 residents observed on the memory care unit with respect and dignity during medication administration. The findings included: The facility Policy Quality of Life - Dignity documented Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality . Residents shall be treated with dignity and respect at all times . the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth . The facility policy IIBI: Administration Procedures For All Medications documented To administer medications in a safe and effective manner . Provide privacy for resident during administration of medications . Review of the clinical record revealed Resident #46 had an admission date of 8/1/23 with diagnoses including dementia with behavioral disturbance and seizures. Review of the Brief Interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interviews, the facility failed to provide Physical and Occupational therapy to 1 (Resident #130) of 2 residents reviewed for specialized rehabilitative services. The findings included: Review of the clinical record for Resident #130 revealed an admission date of 1/24/25. Diagnoses included Multiple Sclerosis, Urinary Tract Infection, Depression, Anxiety Disorder, and a history of falling. Review of the five-day Minimum Data Set, dated [DATE] revealed Resident #130 scored 10 on the Brief Interview for Mental Status, indicative of moderate cognitive impairment. On 2/3/25 at 11:00 a.m., in an interview Resident #130 said she felt like her husband had dumped her at the facility. She stated staff were not doing anything for her since her admission and she had not received any rehabilitative services. Review of the physician's order revealed an order dated 1/24/25 to admit Resident #130 to the facility for Rehabilitation services. A physician's order dated 1/24/25 read, PT…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, staff, family and resident interview, the facility failed to ensure ordered therapeutic diets were correctly provided for 3 (Residents, #1, #158, and #93) of 6 residents reviewed for food and nutrition. The findings included: 1. On 9/19/22 at 12:24 p.m., Resident #1 observed eating lunch which consisted of vegetables, mashed potatoes and mixed vegetables. No protein, meat or fish was observed on the plate for lunch. Resident #1 said she did not know why she did not get any meat or protein. She said, It would be nice to have some meat. Photographic evidence obtained Resident #1's lunch meal included a nonfat yogurt. Observation of the meal ticket showed the resident was lactose intolerant. Photographic evidence obtained On 9/20/22 clinical record review for Resident #1 revealed an order summary documenting the resident was lactose intolerance. The ordered diet was carbohydrate controlled, no added salt, mechanical soft texture. On 9/21/22 at 12:05 p.m., the Certified Dietary Manager (CDM) confirmed Resident #1 was on soft mechanical diet and was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, and resident record review, the facility failed to treat each resident with respect and dignity for 2 (Residents, #11 and #158) of 2 residents reviewed for dignity. The findings included: 1. Record review revealed Resident #11 was admitted on [DATE]. Review of the Minimum Data Set (MDS) assessments noted Resident #11 was discharged to an acute care hospital on 8/20/22 and returned to the facility on 9/1/22. The quarterly MDS dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. On 9/19/22 at 11:38 a.m., Resident #11 was observed sitting in her wheelchair wearing a hospital gown. Resident was asked if she wanted to be in a hospital gown. Resident #11 said, I don't have my clothes they are in the other room. I would get dressed if I had my clothes. Observation of the resident's closet with her permission showed one light mint colored t-shirt and no other clothes. On 9/20/22 at 9:05 a.m., Resident #11…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and resident interview the facility failed to provide reasonable accommodation to promote residents rights to receive visitors. The findings included: The resident rights and responsibilities included in the admission packet specified, Each patient has the right to . visiting with any person of your choice during visiting hours . Center visiting hours shall be flexible, taking into consideration special circumstances such as, but not limited to, out-of-town visitors and working relatives or friends . The Center for Medicare and Medicaid Services (CMS) memo QSO-20-39 (Revised Nursing Home Visitation) revised 3/10/21 read Facilities should allow indoor visitation at all times and for all residents (regardless of vaccination status) except for a few circumstances when visitation should be limited due to a high risk of COVID-19 transmission . These scenarios include limiting indoor visitation for: Unvaccinated residents, if the nursing home's COVID-19 county positivity rate is >…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident and staff interview, the facility failed to implement meaningful resident centered activities to meet the interest and well-being of 13 (Resident #45, #56, #57, #15, #6, #88, #80, #83, #27, #10, #38, #9, and #492) of 13 residents reviewed for activities. The lack of an individualized activity program had the potential to cause social isolation, apathy, and boredom. The facility also failed to promote communal activities and dining while adhering to core principles of COVID-19 infection prevention. The findings included: Review of the facility policy Activity and Recreation Service (dated July 2019) documented the activity programs are provided to enable patients to achieve the highest level of physical, mental, psychosocial, and spiritual well-being. The program of activities is designed to recognize and accommodate patient limitations while maximizing strengths, interests, and abilities. The Center for Medicare and Medicaid Services memorandum (QSO-20-39-NH) revised…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, review of facility policy, resident and staff interview, the facility failed to provide timely assistance in a manner to promote dignity for 3 (#492, #10, and #77) of 3 residents reviewed who are dependent on staff for activities of daily living. The findings included: Review of the facility's admission packet (undated) revealed a Florida Patient /Resident Rights and Responsibilities which read residents . have the right to be treated with courtesy, respect and full recognition of your dignity and individuality by all employees.with whom you come in contact . Each patient has the right to. Privacy in treatment and in caring for personal needs; to close room doors and to have facility personnel knock before entering the room . Be treated courteously, fairly, and with the fullest measure of dignity. 1. Review of the clinical record revealed Resident #492 had an admission date of 3/29/21. The care plan noted the resident had alteration in neurological status and required cueing and reorientation as needed. Resident #492 also had self-care deficit related to a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and staff interview, the facility failed to provide housekeeping and maintenance services to maintain a safe, sanitary, comfortable and home like environment for residents. Not maintaining a sanitary environment has the potential to spread disease causing organisms. The findings included: On 4/11/21 at 11:00 a.m., during a tour of the facility, the following observations were made: room [ROOM NUMBER] was observed with peeling wall with brown substance on the wall behind the resident's bed. The toilet was rusted and constantly flushing. The raised toilet seat was broken. Photographic Evidence Obtained room [ROOM NUMBER] was observed to have peeling baseboards. A large crack observed in the wall, and a hole in the wall behind the door. Photographic Evidence Obtained room [ROOM NUMBER] had a heavily soiled floor with grime and debris around the base of the toilet in the bathroom. Photographic Evidence Obtained room [ROOM NUMBER] had peeling baseboard walls behind the bed.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, and staff interview, the facility failed to ensure the MDS (Minimum data set) assessment accurately reflected the resident's urinary status for 1 (Resident #6) of 1 resident with an indwelling urinary catheter. Inaccurate MDS assessments can result in a resident not receiving appropriate health care. The findings included: On 4/11/21 at 10:30 a.m., and 4/12/21 at 11:07 a.m., Resident #6 was observed with an indwelling urinary catheter (Catheter placed in the bladder to drain urine). The catheter was in a privacy bag attached to the side of the bed. Record review on 4/12/21 at 3:30 p.m., showed a quarterly Minimum Data Set (MDS) assessment dated [DATE]. The assessment noted Resident #6 was always incontinent of urine but did not note the use of an indwelling urinary catheter. The clinical record did not include a care plan for the indwelling urinary catheter. On 04/13/21 at 9:17 a.m., in an interview Registered Nurse (RN) staff F said Resident #6 had a chronic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, review of facility policy and procedure and staff interviews, the facility failed to appropriately store and protect residents' medications in a manner to prevent loss and reduced efficacy for 1 of 3 medication carts and 1 of 2 medication rooms. The findings included: The facility policy 5.3 (October 2016) Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles specified . Facility should ensure that the medications and biologicals for each resident are stored in the containers in which they were originally received. On 4/13/21 at 9:20 a.m., reviewed medication cart for 500 hall with LPN Staff K. Observed four loose pills and two loose predated menthol medication patches in the cart. LPN Staff K, confirmed she could not identify the loose pills and which residents the loose medications belonged to. Observed a bag of intravenous micafungin (medication to treat fungal infection) 100 milligrams belonging to Resident #542 stored on the shelf, out of brown plastic bag and in direct light. The medication label from pharmacy specified to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.