Solaris Healthcare Windermere

In the surveyor’s words

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

• Actual harm, isolatedF689May 13, 2021

  Based on observation, interview and record review, the facility failed to provide adequate supervision and a safe environment to prevent accidents for 1 of 6 residents reviewed for falls with injuries out of 49 sampled residents, (#7). Findings: Resident #7 was admitted to the facility on [DATE], with diagnoses that included history of falls, right [CONDITION(S)], dementia and adjustment disorder with anxiety. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], indicated resident #7 had a Brief Interview for Mental Status (BIMS) score of 7 which indicated severe cognitive impairment. He required extensive assistance from two staff for bed mobility, transfers, locomotion on and off the unit and toilet use. […]

• No harm, potential for more than minimal, patternF688Mar 23, 2023

  Based on observation, interview, and record review, the facility failed to follow the individualized plan of care to maintain and prevent decline in range of motion (ROM) for 2 of 3 residents reviewed for limited ROM from a total sample of 41 residents, (#1, #49) Findings: 1. Review of resident #1's medical record revealed the resident was admitted [DATE] and readmitted to the facility from the hospital on 1/03/2023 with diagnoses of right hand contracture, functional quadriplegia, paraplegia, Parkinson's disease, osteomyelitis, and dementia. The Minimum Data Set (MDS) significant change assessment with Assessment Reference Date (ARD) 1/07/2023 noted the resident's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. […]

• No harm, potential for more than minimal, isolatedF880Jun 18, 2026

  Based on observation, interview, and record review, the facility failed to ensure implementation and performance of appropriate isolation precautions including standard and enhanced precautions for infection prevention and control, for 3 of 3 residents reviewed for transmission-based precautions, of a total sample of 38 residents, (#132, #134, and #5).Findings: 1. Resident #132 was admitted to the facility on [DATE] with diagnoses that include Enterocolitis due to Clostridium difficile, hypertensive chronic kidney disease, adult failure to thrive, immunodeficiency and malignant neoplasm (cancer) of the left kidney. Review of the medical record revealed resident #132 had a current physician order for Contact Precautions. […]

• No harm, potential for more than minimal, isolatedF554Jul 11, 2024

  Based on observation, interview, and record review, the facility failed to ensure physician orders were obtained for safe self-administration of medications for 2 of 4 residents reviewed for choices, of a total sample of 47 residents, (#46, and #81). Findings: 1. Resident #46, a [AGE] year-old female was admitted to the facility on [DATE] with diagnoses including epilepsy, depression, and adjustment disorder with anxiety. Review of the resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference date (ARD) of 4/23/24 revealed the resident's cognition was intact with a Brief Interview of Mental Status (BIMS) score of 14/15. […]

• No harm, potential for more than minimal, isolatedF641Mar 23, 2023

  Based on interview, and record review, the facility failed to accurately reflect the resident's life expectancy and hospice services on the Minimum Data Set (MDS) Assessment for 1 of 41 sampled residents, (#62). Findings: Resident #62 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease and heart failure. The facility had a care plan in effect for Hospice since 11/2/21. The physician certified most recently from 12/27/22 to 2/24/23 and 2/23/23 to 4/25/23 that resident #62 had life expectancy of 6 months or less if the disease takes its natural course. […]