Solaris Healthcare Osceola

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Oct 31, 2024

  Based on interview, and record review, the facility failed to prevent an avoidable accident with major injury for a physically impaired resident by failing to ensure the care plan was followed for transfers with mechanical lifts for 1 of 4 residents sampled for accidents, (#1). These failures contributed to a staff member disregarding a resident's prescribed transfer method and resulted in the resident sustaining a left knee fibular head fracture. On 10/11/24 at approximately 11:45 AM, Certified Nursing Assistant (CNA A) was in resident #1's room to get her up for a shower. Resident #1 requested to use her personal four-wheel walker for the transfer from bed to wheelchair instead of the mechanical lift. […]

• Immediate jeopardy, isolatedF726Jan 22, 2022

  Based on interview and record review, the facility failed to ensure Personal Care Attendant (PCA) A was knowledgeable of her scope of practice and competent in transfer procedures to prevent unauthorized and unsafe use of a full body mechanical lift, for 1 of 8 residents reviewed for accidents of a total sample of 27 residents, (#1). On 12/08/21 at approximately 12:25 PM, resident #1 fell during or soon after a transfer from her bed to a wheelchair with a full body mechanical lift. PCA A transferred resident #1 to a wheelchair instead of a recliner as noted in the care plan, and performed the transfer without assistance, which was prohibited by the facility's policy and the PCA's scope of practice. […]

• Immediate jeopardy, isolatedF835Jan 22, 2022

  Based on interview and record review, the facility failed to effectively use its resources to maintain a Personal Care Attendant (PCA) program with adequate supervision, monitoring and evaluation to ensure staff competency and promote safety for 1 of 8 residents reviewed for accidents, (#1), of a sample of 27 residents; and failed to develop, implement, and monitor corrective actions to ensure the safety of all residents who received care from PCAs. On 12/08/21 at approximately 12:25 PM, resident #1 fell during or soon after a transfer from her bed to a wheelchair with a full body mechanical lift. […]

• No harm, potential for more than minimal, isolatedF684Apr 22, 2021

  Based on observation, interview and record review, the facility failed to obtain physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: Resident #28 was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident #28's Quarterly Minimum Data Set assessment with an assessment reference date of 2/12/21 revealed a Brief Interview for Mental Status score of 4, indicating severe cognitive impairment. The assessment indicated there were no skin impairments. On 4/19/21 at 10:17 AM, resident #28 was seated in a recliner in her room. Her lower legs were discolored and she had two dressings on her right lower leg which were not dated or initialed. […]

• No harm, potential for more than minimal, isolatedF694Apr 22, 2021

  Based on observation, interview and record review, the facility failed to provide dressing changes for a Peripherally Inserted Central Catheter (PICC) according to current professional standards of practice for 1 of 4 residents with intravenous (IV) access sites, of a total sample of 51 residents, (#44). Findings: Resident #44 was admitted to the facility on [DATE] from an acute care hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . [CONDITION(S)] is a body's extreme response to an infection. It is a life-threatening medical emergency which without timely treatment can rapidly lead to tissue damage, organ failure and death. (retrieved 4/23/21 from www.cdc.gov). Review of the medical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]