Solaris Healthcare Apopka

In the surveyor’s words

From the most serious findings on record at Solaris Healthcare Apopka, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF755May 6, 2021

  Based on observation, interview, and record review, the facility failed to implement procedures to ensure accurate narcotic reconciliation for 1 of 1 narcotic medication reviewed, and failed to ensure safe administration of medications for 6 of 19 residents of a total sample of 51 residents, (#2, #35, #48, #72, #77 and #108). Findings: On 05/05/21 at 6:34 PM, an inspection of the Arbor Oaks medication cart assigned to Licensed Practical Nurse (LPN) A was conducted with the Arbor Unit Manager (UM). The Arbor UM opened the top left drawer of the medication cart and LPN A quickly returned to the cart and whispered to the Arbor UM who asked if the medication cart inspection could be completed at a later time. […]

• No harm, potential for more than minimal, isolatedF756Apr 6, 2023

  Based on interview and record review the facility failed to implement medication regimen review (MRR) recommendations for medication administration parameters of physician's orders for 1 of 5 residents and failed to ensure MRRs were reviewed by the physician for 1 of 5 residents reviewed for unnecessary medications from a total sample of 39 residents. (#8, #43) Findings: 1. Review of the medical record revealed resident #8 transferred from the facility to an acute care hospital on 7/20/2022, readmitted to the facility on [DATE], and transferred to an acute care hospital on 4/05/2023. […]

• No harm, potential for more than minimal, isolatedF760Jun 7, 2022

  Based on observation, interview and record review, the facility failed to ensure residents were free of significant medication errors for 1 of 9 sampled residents, (#3). Findings: Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Another physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] Solution is used to treat [CONDITION(S)] (low red blood cell count) in people with long-term serious kidney disease (chronic kidney failure), .(www.webmd). Review of the Medication Administration Record (MAR) from 5/11/22 to 6/06/22 revealed [MEDICATION(S)] Solution had not been administered to the resident. […]

• No harm, potential for more than minimal, isolatedF684May 6, 2021

  Based on observation, interview and record review, the facility failed to provide wound care treatment in accordance with physician's orders and acceptable standards of practice for two skin tears for 1 of 1 resident reviewed for non-pressure skin conditions of a total sample of 51 residents, (#28). Findings: Resident #28 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set quarterly assessment dated [DATE] revealed resident #28 required extensive assistance from two staff for bed mobility, toilet use and personal hygiene. Review of the physician's order for resident #28 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, isolatedF761May 6, 2021

  Based on observation, interview, and record review, the facility failed to ensure the controlled medication compartment was properly secured on 1 of 6 medication carts, (Arbor Oak medication cart). Findings: On 5/05/21 at 6:34 PM, during an inspection of the Arbor Unit medication cart, the narcotic compartment labeled Oak was not securely locked. Licensed Practical Nurse (LPN) A was easily able to lift the lid of the narcotic compartment with one finger without using his key. On 5/05/21 at 7:02 PM, the Director of Nursing (DON) stated nurses should not rely on the drawer closure to lock and secure the narcotic compartment. […]