Solaris Healthcare East Orlando

Based on interview, and record review, the facility failed to act promptly upon the grievances and recommendations of the resident council; and failed to demonstrate an active response for resolution of their complaints in a timely manner. Findings: On 6/02/25 during the initial resident screening, concerns about repeated complaints made to the facility without resolution were found. Multiple residents expressed they had previously complained at the resident council meetings, but nothing had changed and they felt the facility had never addressed their grievances. Review of the resident council meeting minutes for the prior six months from December 2024 to May 2025, revealed complaints about temperatures inside the facility being too cold were brought up by members during both the December 2024 and January 2025 meetings. The response from the facility revealed minutes from the January meeting indicated maintenance staff were aware to check the room thermostats. Complaints regarding food/nutrition services were brought up during the March 2025 meeting, but review of the April 2025 and…

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 interview, and record review, the facility failed to provide evidence that an abuse allegation was thoroughly investigated for 1 of 3 residents reviewed for abuse, of a total sample of 3 residents, (#3). Findings: Review of resident #3's medical record revealed an annual Minimum Data Set, dated [DATE] which indicated a Brief Interview for Mental Status score of 9 out of 15, mild to moderate cognitive impairment. On 10/30/24 at 12:30 PM, resident #3 was in her room alert and oriented to herself and place. She recalled an incident that occurred sometime in the past month or two when she reported to staff that a male staff member was rough with her. She was unable to recall who she had told or other details about what happened afterwards. On 10/31/24 at 8:00 AM, the Nightshift Supervisor stated he could recall, a couple of weeks ago resident #3 reported a staff person, whom she described as Certified Nursing Assistant (CNA) A, was rough with her. He said he did not ask resident #3 to explain what she meant…

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 interview and record review, the facility failed to notify emergency contacts of changes in condition for 2 of 4 residents reviewed for falls, of a total sample of 5 residents, (#1 and #4). Findings: 1. Review of the medical record revealed resident #1, an [AGE] year-old female, was admitted to the facility on [DATE] with diagnoses including right side sciatica, osteoarthritis, difficulty walking, and generalized muscle weakness. The admission Record or face sheet contained essential information including resident #1's selected emergency contacts with their associated telephone numbers. The document listed the resident's husband as emergency contact #1 and her daughter was emergency contact #2. Review of the hospital to facility transfer form, dated 5/16/24, revealed resident #1's emergency contact was her husband and his telephone number was the same number transcribed to the facility's admission Record. Review of the Minimum Data Set (MDS) admission assessment with assessment reference date (ARD) of…

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, interview, and record review, the facility failed to administer blood pressure medication as per plan of care to prevent the systolic blood pressure from rising above 160 for 1 of 1 resident reviewed for unnecessary medications out of a total sample of 44 residents, (#80). Findings: Review of the medical record revealed resident #80 was admitted to the facility on [DATE] from the hospital. His diagnoses included type II diabetes, congestive heart failure, hypertension, and paroxysmal atrial fibrillation. The Minimum Data Set (MDS) 5-day assessment with the assessment reference date (ARD) of 9/14/23 revealed resident's cognition was intact with a Brief Interview Mental Status (BIMS) score of 15 out of 15. Review of resident #80's medical record revealed a care plan related to hypertension, initiated on 9/23/2023. The interventions directed nurses to administer medications as ordered by the physician and monitor the dose to achieve desired effects and minimize adverse consequences, especially…

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, interview, and record review, the facility failed to verify placement of a gastric feeding tube prior to medication administration for 1 of 2 residents reviewed for Tube Feeding of a total sample of 44 residents, (#68). Findings: Review of the medical record revealed resident #68 was admitted to the facility on [DATE] and readmitted from an acute care hospital on 8/23/23 with diagnoses that included anoxic brain damage, respiratory failure, malnutrition, dependence on ventilator, and gastrostomy (feeding tube) status. The Minimum Data Set admission assessment with Assessment Reference Date of 9/12/23 noted the resident was rarely/never understood, had severely impaired cognitive skills for daily decision making, and did not have any behavioral symptoms. The resident was totally dependent, required two staff to complete Activities of Daily Living (ADLs), and he received nutrition and hydration through a feeding tube. The Comprehensive Care Plan included medication administration with crushed…

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 interview, and record review, the facility failed to provide Corona Virus Disease 2019 (COVID-19) vaccine for 1 of 5 residents and failed to offer the COVID-19 vaccine to 2 of 5 residents out of a total sample of 44 residents reviewed for immunizations, (#33, #64). Findings: 1. Review of resident #33's medical record showed no COVID-19 consent for the year 2022. The care plan initiated 7/24/20 and revised on 1/12/23 revealed a problem for COVID-19 infection with a goal and intervention to administer the COVID-19 vaccine through the pharmacy vaccine clinic. The medical record did not reveal a COVID-19 2022 consent for resident #33. On 10/06/23 at 4:13 PM, the Assistant Director of Nursing (ADON)/Infection Preventionist stated there was no COVID medication administration record from the previous facility where the resident resided. She noted administration would be documented on resident #33's COVID card if she received the COVID-19 vaccine. Review of the COVID-19 card for resident #33 revealed no administration of the vaccine for 2022. The ADON/Infection Preventionist…

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, interview and record review, the facility failed to accurately document medications/creams, ointments according to prescribed orders for 1 of 3 sampled residents reviewed for skin conditions (#24), failed to accurately document Physician's Orders for 1 of 3 sampled residents reviewed for pressure ulcers (#28), and for 1 of 1 resident reviewed for dialysis (#52), and failed to accurately document a partial bath instead of showers for 1 of 2 sampled residents reviewed for activities of daily living (ADLs) (#86), out of a total sample of 44 residents. Findings: 1. Resident #24 was admitted to the facility on [DATE] with the most recent readmission on [DATE]. Her diagnoses included Grover's disease. Grover's disease is a skin condition that causes the appearance of small, red spots. These spots usually develop on the chest or back, but may also form on other parts of the body that also causes itching. (https://rarediseases.info.nih.gov/diseases/6551/Grovers-disease a history of infectious and…

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 interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessment accurately reflected health conditions regarding insulin for 1 of 3 sampled residents reviewed for resident assessment (#97), and failed to accurately assess for antipsychotic medication for 1 of 5 sampled residents reviewed for unnecessary medications (#94), of a total sample of 44 residents. Findings: 1. Resident #97 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes. A physician's order read, Dulaglutide 0.75 milligrams (mg.) subcutaneous in the morning every Monday for diabetes. Dulaglutide (Trulicity) is an injectable medication used to lower blood sugar and is not considered insulin. (Retrieved from www.trulicity.com on 12/10/21). Section N, Medications of the admission MDS assessment, with assessment reference date 11/15/21, revealed resident #97 received insulin one day during the last 7 days or since admission. On 12/02/21 at 11:08 AM, the MDS Lead nurse explained she…

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, interview, and record review, the facility failed to document medication administration accurately, failed to follow physician's orders for blood glucose monitoring for 1 of 10 sampled residents reviewed for medication administration (#42), and failed to obtain and document a physician order for treatment for skin tear for 1 of 3 sampled residents reviewed for skin conditions (non-pressure related) (#68), out of a total sample of 44 residents. Findings: 1. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed resident #42's Brief Interview for Mental Status (BIMS) score was 13, which indicated intact cognition. The MDS showed the resident did not reject evaluation or care needed to achieve her goals for health and well-being. Review of resident's #42's medical record revealed a physician's order, dated 11/23/21, which indicated 6 units of Humalog to be administered before meals and at bedtime for diabetes, and to hold for blood glucose less than 150. There was 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, interview and record review, the facility failed to adequately manage pain for 1 of 3 sampled residents reviewed for pain management, of a total sample of 44 residents (#959). Findings: Resident #959 was admitted to the facility on [DATE] with diagnoses including wedge fractures of the first, third, fourth and fifth lumbar vertebrae, and the eleventh and twelfth thoracic vertebrae. Vertebrae are the 33 individual, interlocking bones that form the spinal column (retrieved on 12/03/21 from www.spinehealth.com). An admission evaluation note dated 11/23/21 at 4:40 PM revealed the resident had lower back pain that he described as a score of 4 on a 0 to 10 pain scale. The resident's chart revealed physician orders for Tylenol 650 milligrams (mg.) every 4 hours as needed for pain, and Robaxin 500 mg. every 8 hours as needed for muscle spasms. An Occupational Therapy progress note, dated 11/25/21, revealed resident #959 rated his pain as 10 during activity and 3 at rest. Resident #959's care plan…

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.