Solaris Healthcare Parkway

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, record review, and interview, the facility failed to ensure a properly executed DNR (Do Not Resuscitate) Order for 3 of 3 sampled residents, as evidenced by incomplete yellow copy DNR Order forms for Residents #134, #116, and #62.The findings included:Review of the policy Advance Directives dated [DATE], documented in part, 5. b. Do Not Resuscitate – Indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care DPOA, health care surrogate or health care proxy has directed that no cardiopulmonary resuscitation (CPR) or other life-saving methods are to be used. Review of the policy Do Not Resuscitate Order dated [DATE], documented in part, 3. Should the resident be transferred to the hospital, a photocopy of the DNRO form must be provided to the EMT personnel transporting the resident to the hospital. 1. Review of the record revealed Resident #134 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS) assessment dated…

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 and interviews, the facility failed to provide care and services for the treatment and prevention of wounds for 5 of 38 sampled residents as evidenced by failure to follow physician orders for the treatment of a wound for Residents #182 and #36, failure to ensure Resident #184 had treatment for a rash, and failure to complete weekly skin assessments for Residents #182, #27, and #134.The findings included:1. Record review revealed Resident #182 was admitted to the facility on [DATE]. Review of the comprehensive assessment dated [DATE] documented a Brief Interview Mental Status (BIMS) score of 15 on a 0-15 scale, indicating no cognitive impairment. During an observation on 12/01/25 at 11:09 AM, Resident #182 was observed sitting in his wheelchair wearing shorts and a white square dressing that was undated was noted to his right shin. During an interview on 12/01/25 at 11:09 AM, when asked why about the dressing on the right leg, Resident #182 stated, Well that happened in…

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 provide appropriate care and positioning equipment for 2 of 3 sampled residents as evidenced by failure to provide properly fitting wheelchair leg rests for Resident #118 and failure to provide a hand/towel roll for hand contractures to Resident #12. The findings included: 1. Review of clinical record revealed Resident #118 was admitted to the facility on [DATE] with a primary diagnosis of Cerebral Infarction. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #118 had a Brief Interview for Mental Status (BIMS) score of 13 on a 0-15 scale, indicating the resident had intact cognition. During an initial interview on 12/01/25 at 11:20 AM, Resident #118 stated that he would like to go to activities but cannot go since his knees do not bend anymore and sitting in the wheelchair causes his legs to hurt. Resident #118 stated that he thinks he is worse now than when he got here. Resident #118 was asked…

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, interviews and record reviews, the facility failed to assess residents for safe smoking for 2 of 3 sampled residents reviewed for smoking, Residents #38 and #170. The findings included: Review of the facility's policy, titled, 'Smoking Policy' with a reference date of 01/07/22, documented, in part: 'Procedure: 3. A smoking assessment will be completed upon admission, quarterly during care plan review, and upon a change in resident condition 1. Record review revealed Resident #38 was admitted to the facility on [DATE]. According to the resident's most recent complete assessment, a Quarterly Minimum Data Set (MDS) with a reference date of 09/03/25, Resident #38 had a Brief Interview for Metal Status (BIMS) score of 14, indicating the resident was cognitively intact. Resident #38's diagnoses at the time of the assessment included: Heart failure, Hypertension, DM, Hyponatremia, anxiety disorder, Depression, Chronic lung disease, Respiratory failure, Muscle weakness, Chronic pain, 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 policy review, observation, interview, and record review, the facility failed to ensure appropriate care and services for oxygen use for 1 of 3 sampled residents as evidenced by the lack of oxygen order and oxygen saturation assessment for Resident #124.The findings included:Review of the policy Oxygen Administration dated January 2020, documented in part, 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.Review of the record showed Resident #124 was admitted on [DATE] with a diagnosis including Heart Failure. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 4, on a 0 to 15 scale, indicating severe cognitive impairment.Review of the progress noted dated 10/18/25, revealed the resident had a productive cough and wheezing for which a chest X-ray was ordered. Based on the results, the resident was diagnosed with…

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 competency review, observation, and interview, the facility failed to ensure infection control practices during the medication pass observation with 1 of 6 licensed nurses (Staff C, Licensed Practical Nurse), as evidenced by the failure to dispose of gloves after use, failure to ensure hand hygiene with glove use, failure to properly disinfect a glucometer (device that measures the resident's blood sugar level), and failure to properly dispose of the used lancet. The medication pass observation was for Resident #38.The findings included:Review of the facility's competency for blood glucose monitoring revealed the following steps: 1. Perform hand hygiene before completing blood glucose testing or disinfecting. 2. Put on single-use gloves prior to blood glucose testing or disinfecting. 12. Dispose of lancet in biohazardous waste sharps container. 14. Clean the glucometer after each use, using the approved bleach disinfectant wipe and ensure all external surfaces of the glucometer remain wet for a period of no less than 3 minute, or contact time designated by manufacturer by…

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 ensure accessibility of the call bell for 1 of 1 sampled resident, Resident #99, observed needing assistance and unable to call staff. The findings included: Review of the record revealed Resident #99 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 8, on a 0 to 15 scale, indicating moderate cognitive impairment. This same MDS documented the resident usually understands and is usually understood and required partial to total assistance from staff for activities of daily living (ADLs). Review of the current resident care plans dated 06/06/24 for Visual impairment, Cognitive Loss/Dementia, ADLs, and Pain, all included the approach: call light within reach. During an observation and interview on 06/03/24 at 12:00 PM, Resident #99 was observed sitting in his wheelchair close to the footboard area of the…

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, interview, and policy review, the facility failed to ensure the anchoring of indwelling urinary catheter tubing for 2 of 3 sampled residents, one of whom had a history of urinary tract infections (UTIs), Residents #34 and #204. The findings included: Review of the policy, titled, Catheter Care, Urinary, revised 01/25/23, documented, in part, Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Changing Catheters . 2. Ensure that the catheter remains secured to reduce friction and movement at the insertion site. (Note: Catheter tubing should be secured to the resident's inner thigh.) 1. Review of the record revealed Resident #34 was admitted to the facility on [DATE], with readmission on [DATE]. Record review revealed a diagnosis of urinary retention with the placement of an indwelling urinary catheter. The physician order dated 05/29/24 documented to secure the indwelling urinary catheter with a leg strap. The current order dated…

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, interview, and policy review, the facility failed to ensure competent nurse staff for 2 of 7 sampled residents observed during the medication administration observation. Staff C, Licensed Practical Nurse (LPN), failed to follow the facility's process related to the administration and documentation of insulin for Resident #49; and Staff B, Licensed Practical Nurse failed to use proper technique during a nasal spray administration for Resident #74. The findings included: 1. A medication administration observation for Resident #49 was made with Staff C, LPN, on 06/04/24 beginning at 4:59 PM. Staff C prepared oral medications that were due at that time, along with an insulin pen stating the resident had 7 units due at that time and headed for the resident's room. At the entrance to the room, the surveyor stopped the LPN from entering the room, and asked the LPN the type of insulin she had for Resident #49. At this time the LPN stated Novolin R (regular insulin), showing the label to the surveyor. The LPN obtained the blood sugar level for Resident…

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, interview, and policy review, the facility failed to implement pharmacy recommendations approved by the physician for 1 of 5 sampled residents, Resident #38. The findings included: Review of the policy, titled, Medication Regimen Review, revised January 2018, documented, in part, Procedure: . G. Recommendations are acted upon and documented by the facility staff and/or the prescriber. Review of the record revealed Resident #38 was admitted to the facility on [DATE]. Review of the current orders revealed the order initiated on 05/31/23 for the anti-reflux medication, Protonix 40 milligrams (mg), ordered daily for Anemia. Review of the monthly pharmacy reviews revealed on 12/17/23 the pharmacist identified Resident #38 had been on the anti-reflux medication Protonix 40 mg daily for more than 12 weeks, and recommended the medication be discontinued. This recommendation also documented the need for appropriate documentation supporting an underlying chronic disease if continued. On 01/03/24,…

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 and policy review, the facility failed to prepare pureed food with the correct texture. This had the potential to affect 16 of 165 current residents who had a physician ordered pureed diet. The findings included: Review of the facility's written description of the pureed diet, reprinted from the Manual of Medical Nutrition Therapy 2022, documented, The pureed diet is designed to provide soft, smooth foods that minimize the amount of chewing required and are easy to swallow. Any regular or therapeutic diet may be pureed. The pureed diet is indicated for individuals with chewing or swallowing problems. On 06/05/24 at 11:50 AM, observations in the kitchen revealed the pureed diet Italian Parmesan Breaded Pork and the pureed Parslied Noodles did not look smooth. At this time, a sample of the pureed food prepared for the lunch meal was requested. Upon tasting the food, the pureed pork had chopped up strings in it and the pureed pasta had lumps. At this time, when asked about the process for ensuring the correct texture of the pureed foods, the Director of Food…

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 policy review, observation, interview and record review, the facility failed to ensure proper perineal care to residents with a history of and current Urinary Tract Infection (UTI) for 1 of 3 sampled residents observed during perineal care, Resident #3. The finding included: The policy titled perineal care, dated 11/01/2018, documented, in part: the purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritations, and to observe the resident's skin condition .; the following equipment and supplies will be necessary when performing this procedure: wash basin, towels, washcloth, soap (or other authorized cleansing agent) .; and steps in the procedure: #9 for a female resident: a) wet washcloth and apply soap or skin cleansing agent. Review of the in-house UTI [Urinary Tract Infection] list, dated from October 2023 to present (January 29, 2024), evidenced there were 25 cases of facility acquired UTIs during this time. Review of record for…

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, record review, and policy review, the facility failed to act on the voiced grievance for 1 of 3 sampled residents who utilize the sit-to-stand transfer device. Resident #49 voiced her concerns to Staff J, Certified Nursing Assistant (CNA), who failed to act upon the voiced grievance. The findings included: Review of the policy, titled, Grievance Policy (undated) documented, in part, All persons are encouraged to make requests, share concerns, and file grievances regarding care and/or services without fear of retribution or negative treatment. Customer Service/Grievance forms are available throughout the facility at the nursing stations and upon request. A concern or grievance may be given orally or in writing. The facility had the capacity to hold 177 residents, located on three different units, North, South, and East. The East unit where Resident #49 resided encompassed the 500, 600, and 700 halls. At the time of the survey there were 57 residents on that unit, and 6 utilized the…

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 initiate a care plan for newly identified behaviors for 1 of 26 sampled residents, whose care plans were reviewed, Resident #134. The findings included: The facility's policy, titled, Care Plans - Comprehensive, most recently revised on 01/25/23, documented, in part, the following: Policy Statement - An individualized comprehensive care plan that includes measurable objectives and timetables to meet the residents' medical, nursing, mental and psychological needs is developed for each resident. Policy Interpretation and Implementation 1. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive car plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 2. The comprehensive care plan is based on a thorough assessment that included, but is not limited to, the MDS. 3. Each…

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.