SOLARIS SENIOR LIVING NORTH NAPLES
Non profit - Other
60 Beds
SOLARIS HEALTHCARE
Data: November 2025
Trust Grade
63/100
#424 of 690 in FL
Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Solaris Senior Living North Naples has a Trust Grade of C+, which means it is considered decent and slightly above average among nursing homes. It ranks #424 out of 690 facilities in Florida, placing it in the bottom half, and #6 out of 11 in Collier County, indicating that there are only a few local options that are rated better. Unfortunately, the facility is trending worse, with issues rising from 2 in 2023 to 10 in 2025. Staffing is a strong point, with a top rating of 5 out of 5 stars and a low turnover rate of 15%, significantly below the state average, which suggests that staff are familiar with residents' needs. However, the facility has incurred fines totaling $16,150, which is concerning as it is higher than 76% of Florida facilities, reflecting potential compliance issues. Specific incidents noted by inspectors include a serious failure to prevent a resident from developing a severe pressure ulcer due to inadequate care, as well as failing to follow care plans to prevent falls and not adhering to infection control guidelines, such as improper hand hygiene. While there are strengths in staffing and some quality measures, the rising number of issues and these serious findings highlight that potential residents and their families should carefully consider these concerns before making a decision.
- Trust Score
- C+
- In Florida
- #424/690
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ✓ Good
- 15% annual turnover. Excellent stability, 33 points below Florida's 48% average. Staff who stay learn residents' needs.
- Penalties ○ Average
- $16,150 in fines. Higher than 64% of Florida facilities. Some compliance issues.
- Skilled Nurses ✓ Good
- Each resident gets 60 minutes of Registered Nurse (RN) attention daily — more than 97% of Florida nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 15 deficiencies on record. Higher than average. Multiple issues found across inspections.
63/100
Bottom 39%
Needs review
2 → 10 violations
★★★☆☆
3.0
Overall Rating
★★★★★
5.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2023: 2 issues
2025: 10 issues
The Good
-
5-Star Staffing Rating · Excellent nurse staffing levels
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Low Staff Turnover (15%) · Staff stability means consistent care
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover is low (15%)
33 points below Florida average of 48%
Facility shows strength in staffing levels, quality measures, staff retention, fire safety.
The Bad
3-Star Overall Rating
Near Florida average (3.2)
Meets federal standards, typical of most facilities
Federal Fines: $16,150
Below median ($33,413)
Minor penalties assessed
Chain: SOLARIS HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 15 deficiencies on record
1 actual harm
Apr 2025
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure that the call light was within reach for 1 (R...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure that the call light was within reach for 1 (Resident #26) of 1 resident sampled for accommodation of needs.
The findings included:
A record review showed Resident #26 was readmitted to the facility on [DATE] with diagnoses of Vascular Dementia, Depressive Disorder, and Hyperlipidemia. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #26 had a Brief Interview of Mental Status (BIMS) score of 07, which is severely cognitively impaired.
A progress note dated 3/18/25 showed Resident #26 on the floor between the bed and the nightstand in his room. He was unable to explain what happened and said he was trying to grab something off the table. Recently, Resident #26 overestimated his own ability and was encouraged by Staff to use the call light constantly. Further chart review showed that Resident #26 had four falls in the last five months in the facility.
The care plan initiated on 1/27/2025 revealed that Resident #26 was reminded to use the call bell for assistance when needed.
In an observation conducted on 4/21/25 at 11:00 AM, Resident #26 was noted in the bed, and no call light was within reach. After a few minutes of trying to find the call light, this Surveyor was able to locate the call light, which was attached to the back of the privacy curtain and not within reach of Resident #26. In this observation, Resident #26 was asked how he called Staff for assistance, and he looked for the call light and then said, It is here somewhere.
In an observation conducted on 4/22/25 at 9:32 AM, Resident #26 was noted in the bed, with the call light on his left side attached to the end of the bed not within arm reach. In this observation, this Surveyor asked Resident #26 if he could reach the call light and Resident #26 said no. Resident #26 then attempted to reach the call light but was not able too.
In an observation conducted on 4/22/25 at 10:45 AM, Resident #26 was noted in bed with the call light on his left side attached to the end of the bed, not within arm's reach. In this observation, Resident #26 stated he was told to use the call light when he needed help from Staff.
In an observation conducted on 4/23/25 at 8:56 AM, Resident #26 was sitting at the end of the left side of the bed eating breakfast. The call light was noted to be attached to the curtain on the right side of the bed, away from Resident's #26 reach.
In an observation conducted on 4/23/25 at 1:10 PM, Resident #26 was in his bed with the call light within reach. In this observation, Resident #26 was asked if he could use the call light, which was located near his right hand. Resident #26 was able to press the call light, and a light illuminated outside Resident #26's room indicating that the call light bell was used in Resident #26's room. After a minute, the Staff was seen walking toward Resident #26's room.
In an interview conducted on 4/22/25 at 11:40 AM with Staff A, Certified Nursing Assistant (CNA) stated, Resident #26 is at risk for falls, and they have to ensure that the call light is within reach of the Resident. She further reported Resident #26 sometimes uses the call light when he needs assistance but not always.
In an interview conducted on 4/22/25 at 12:02 PM with Staff C, the Licensed Practical Nurse stated that she had been working in the facility for about three years. When asked if Resident #26 was at risk for falls, she said, Not really, but kind of. Sometimes, he likes to do things by himself and gets out of bed without staff assistance. Resident #26 usually does not use the call light to call for assistance.
In an interview conducted on 4/23/25 at 10:49 AM with Staff D, the CNA stated that she had worked in the facility for 15 years. She was very familiar with Resident #26 and said he was at risk for falls. They need to make sure that the call light is within reach, and sometimes, Resident #26 gets out of bed without listening. He knows how to use the call light and uses it when he wants to. Sometimes, he will not use the call light and just get up.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review revealed Resident #37 was admitted to the facility on [DATE] with diagnoses of Sepsis, Cerebral Infarction, and...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review revealed Resident #37 was admitted to the facility on [DATE] with diagnoses of Sepsis, Cerebral Infarction, and Chronic Obstructive Pulmonary Disease (COPD). Her Brief Interview for Mental Status (BIMS) score was 15 on the quarterly Minimum Data Assessment (MDS) with an assessment reference date (ARD) of 3/12/25. This indicated the resident had intact cognition.
A review of the Electronic Health Record (EHR) and the physician orders for Resident #37 was done and revealed the resident was on Contact Precautions since 4/19/25 for a Urinary Tract Infection with ESBL (Extended-spectrum beta-lactamase). ESBL are a type of enzyme or chemical produced by some bacteria. Contact precautions are indicated for someone with ESBL in the urine.
A review of the resident's care plans revealed there was no care plan for contact precautions for Resident #37.
Based on observations, interviews, and record review the facility failed develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 out of 1 resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube (Resident # 56) and 1 out of 1 resident on Transmission Based Precautions (Resident #37).
The findings included:
Review of the facility's policy titled, Care Plans - Comprehensive with a revised date of 12/10/24 included in part the following: Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident. His/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. The comprehensive care plan is based on thorough assessment that includes but is not limited to the Minimum Data Set (MDS). Each resident's comprehensive care plan is designed to: incorporate identified problem areas. Incorporate risk factors associated with identified problems.
Record review for Resident #56 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Traumatic Subarachnoid Hemorrhage without Loss of Consciousness Subsequent Encounter, Cognitive Communication Deficit, and History of Falling.
The Minimum Data Set (MDS) for Resident #56 dated 4/3/25 documented in Section C a Brief Interview of Mental Status score of 5 indicating severe cognitive impairment. In Section K it was documented that on admission the resident had a feeding tube (abdominal PEG tube).
Review of the Physician's Orders for Resident #56 revealed in part the following:
An order dated 4/22/25 PEG tube stoma (surgical opening) care: Cleanse with NS (normal saline), pat dry skin prep (protective film) peri wound let dry. apply calcium alginate (W silver) and secure with clean bordered gauze split dressing once daily.
There was no order for EBP (Enhanced Barrier Precautions).
Review of the Care Plan for Resident #56 revealed no care plan for PEG tube or for Enhanced Barrier Precautions.
During an interview conducted on 4/21/25 at 10:30 AM with Resident #56 who stated he has a peg tube. Resident #56's wife was at bedside and said her husband has been eating for about a month now and they are not using the PEG tube, and it is scheduled to be removed next week at the doctor's office.
During an interview conducted on 4/23/25 Staff B MDS Coordinator who stated she has worked at the facility since July 2024 and Staff L MDS Coordinator who stated she has worked at the facility for 2 years. When asked who was responsible for putting in the nursing care plans for a resident, they said they were. When asked about Resident #56's care plan for having a PEG tube and EBP, they both acknowledged there was no care plan for the PEG tube or EBP. Staff L MDS Coordinator stated, I must have forgotten.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to ensure facility staff performed urinary indwelling c...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to ensure facility staff performed urinary indwelling catheter care technique consistent with accepted standards of practice and failed to follow the facility's policy titled, Catheter Care, Urinary as observed during indwelling urinary catheter care for 1 (Resident #22) of 1 resident sampled for urinary catheter.
The findings included:
Review of the facility's policy titled, Catheter Care, Urinary with a review date of 12/10/24 included in part the following: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter tubing free of kinks. Use standard precautions when handling or manipulating the drainage system. 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. Steps in the Procedure: 13. With nondominant hand separate the labia of female resident . maintain the position of this hand throughout the procedure. 15. For a female resident: use a washcloth with warm water and soap to cleanse the labia. Use one area of the washcloth for each downward stroke. Change the position of the washcloth with each downward stroke. Next, change the position of the washcloth cleanse around the urethral meatus. Do not allow the washcloth to drag on the resident's skin or bed linen. With a clean washcloth, rinse with warm water using the above technique. 18. Secure the catheter.
Record review for Resident #22 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Presence of a Right Artificial Hip Joint, History of Falling, and Need for Assistance with Personal Care. The Minimum Data Set, dated [DATE] documented in Section C a Brief Interview of Mental Status score of 15 indicating a cognitive response.
Review of the Physician's Orders for Resident #22 revealed in part the following orders:
An antibiotic order for Bactrim DS (sulfamethoxazole-trimethoprim) tablet; 800-160 mg oral every 12 hours for diagnoses of UTI (Urinary Tract Infection); E.coli (bacteria) from 4/18/25 to 4/255/25.
An order dated 3/13/25 for Indwelling Urinary Catheter; May change / re-insert as needed for occlusion/accidental removal. Size:16fr Coude catheter 10cc balloon as needed.
An order dated 3/13/25 to irrigate Indwelling Urinary catheter with 60cc normal saline as needed for blockage or leakage as needed.
There was no order for catheter care or for the catheter to be anchored to the resident's thigh.
On 4/21/25 11:30 AM an observation was made of Resident #22 lying in bed wearing pants with the legs pulled up above the knee, the resident had an indwelling urinary catheter tubing coming out from under her leg and the tubing was not anchored.
On 4/24/25 at 9:10 AM an observation of indwelling urinary catheter care performed by Staff H Certified Nursing Assistant for Resident #22. The resident's catheter tubing was unsecured. Staff H CNA gathered supplies, washed hands and began catheter care by wiping top groin and side of groin next to leg, the resident started having a bowel movement and the washcloth Staff H CNA was using along with her gloved hand became soiled with the bowel movement. Staff H CNA initially did not change her gloves and proceeded to fold over the soiled washcloth and continue cleaning the resident. Staff H CNA stepped back and stated I am sorry then changed her gloves without performing hand hygiene. Staff H CNA stood holding a clean washcloth for several minutes.
On 4/24/25 at 9:30 AM Staff I Certified Nursing Assistant (CNA) member knocked at the resident's door. The two CNAs proceeded to clean the bowel movement which included turning the resident from side to side without securing the catheter tubing. Staff H CNA then continued to provide catheter care by holding the left side of the resident's labia with her left hand and wiping with the washcloth from top to bottom and around the catheter tubing, then wiped the resident's groin from top to bottom over the catheter tubing, then folded over the towel, she changed gloves again without performing hand hygiene. Staff I CNA then proceeded to dress the resident with a pair of pants on the resident up to her knees. Staff I raised the drainage bag above the bladder to insert the drainage bag inside the left pant leg, decided the drainage bag needed to be emptied of the urine and lowered the drainage bag to empty the urine. Staff I proceeded to put the drainage bag inside the pant leg while the catheter tubing was being pulled. When asked of Staff H CNA and Staff I CNA if they were finished with the catheter care, they both agreed it was completed. The catheter tubing was never secured in place to the resident's leg.
During an interview conducted on 4/24/25 at 9:55 AM with Staff J Licensed Practical Nurse (LPN) stated she has worked at the facility since 2020. When asked if she was the nurse for Resident #22 today, she said yes. When asked who documents the catheter care, she said the CNAs document the care. When asked if the catheter tubing needs to be anchored, she said what does that mean? When explained anchored means secured, Staff J LPN said yes but she did not have a chance to look at the resident's catheter today. When asked if there was an order for catheter care, she acknowledged there was no order for catheter care.
During an interview conducted on 4/24/25 at 10:00 AM with Staff H CNA stated she has worked at the facility for 3.5 years. When asked if she documents the catheter care, she said document? When asked if she writes it down in the resident's chart that she did catheter care, she did not respond. Staff J LPN asked if she could help ask Staff H CNA the question. Staff J LPN asked Staff H CNA about documenting catheter care. Staff H CNA did not respond.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to complete a Quarterly Nutritional Assessment for 1 (R...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to complete a Quarterly Nutritional Assessment for 1 (Resident #48) of 2 residents sampled for Nutrition.
The findings included:
A record review showed Resident #48 was readmitted to the facility on [DATE] with diagnoses of Legally Blind, Dementia, and Psychosis Disturbances. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #26 had a Brief Interview of Mental Status (BIMS) score of 08, which is moderate to severe cognitive impairment. Section GG of the above MDS revealed that Resident #48 was coded for set-up or clean-up assistance for eating.
In an observation conducted on 4/21/25 at 11:55 PM, Resident #48 was noted in the room with her lunch tray. The staff set up the tray for Resident #48 and left the room. The lunch plate was noted with the following: hot dog on a plate, chocolate cake on a square plate, and mixed vegetables in a bowl with a tablespoon. The meal ticket noted the following: hot dog, mixed vegetables, chocolate cake, and to send sandwiches/hotdogs/or hamburgers instead of the meal. In this observation, Resident #48 said that they always give her the same foods (hamburger, hotdog, peanut butter sandwich, and grilled cheese) for lunch and dinner, and she would like to get what everyone else gets for dinner.
The care plan for Resident #48, revised on 3/14/2025, showed the following: Resident is at risk for altered nutrition due to end-stage Cerebral Atherosclerosis and is on hospice care. Potential for the unavoidable decline in parameters of nutrition with risk factors of Dementia, underweight, and Legally Blindness.
A review of the Quarterly Nutrition assessment dated [DATE] showed that Resident #48 has an inadequate oral and suboptimal intake, as evidenced by leaving 25% or more of most meals uneaten. The goal is to offer foods/fluids of choice to promote quality of life by the following review period. Further chart review did not reveal that a Quarterly Nutrition Assessment was completed on Resident #48 after 12/27/24.
A review of the Care Plan dated 3/14/25 did not show that it was updated or revised by the facility Clinical Dietitian.
In an interview conducted on 4/23/25 at 9:40 AM with Staff B, the MDS Coordinator stated that the Clinical Dietitian updates all the nutrition care plans. Staff B said that she had not made any of the changes or interventions under the nutrition plan and that it was the responsibility of the Clinical Dietitian.
In an interview conducted on 4/23/25 at 9:44 AM, the Dietary Manager said Resident #48 used to eat finger food and asked for regular food a few weeks ago. When they provided her with regular foods, she changed her mind and wanted finger food instead. Usually, they provide residents with the same choice on the daily menu, but last week, Resident #48's roommate's family said they would help Resident #48 with her menu selections. The Dietary Manager noted that the Registered Dietitian does a Quarterly Nutrition Assessment on all residents.
In a telephone interview conducted on 4/23/25 at 9:55 AM with the facility's Registered Dietitian, she stated that they do Quarterly Nutrition Assessments on all residents. She acknowledged that no Quarterly Assessment was done for Resident #48 and did not know why she did not complete the assessment. She is also responsible for updating the nutrition care plan for all residents.
A review of the Quarterly Nutrition assessment dated [DATE] showed the following: Resident #48 with inadequate oral suboptimal intake as evidenced by being underweight and leaving 25% or more of meals uneaten. It further showed Resident #48 eats 1-75% of her meals in her room with assistance. She has declined all facility supplements (not documented previously) and remains under hospice care. The above assessment did not document that the Clinical Dietitian visited Resident #48 and spoke to her to obtain food preferences, likes, and dislikes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to ensure accurate and effective system for reconciliati...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to ensure accurate and effective system for reconciliation of controlled drugs in sufficient detail to enable an accurate reconciliation (Resident #51) and remove discontinued medications (Resident #215) from the med cart for 2 of 2 med carts reviewed.
The findings included:
1. Record review for Resident #51 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Pleural Effusion and Necrotizing Enterocolitis Unspecified. The Minimum Data Set (MDS) dated [DATE] documented in Section C a Brief Interview of Mental Status (BIMS) score of 15 indicating a cognitive response.
Review of the Physician's Orders for Resident #51 revealed an order dated 4/8/25 for Xanax (alprazolam) 0.25 mg give 1 tablet oral every 6 hours PRN (as needed).
Review of the Controlled Medication Utilization Record for Resident #15 for Alprazolam 0.25mg documented on 4/9/25 at 9:12 AM and again on 4/13/24 at 9:15 PM the medication was removed from the med cart.
Review of the Medication Administration Record (MAR) for Resident #51 for the month of April revealed no documentation of Alprazolam 0.25mg being administered on 4/9/25 at 9:12 AM or on 4/13/24 at 9:15 PM.
During an interview conducted on 4/23/25 at 1:35 PM Staff C (LPN) stated she has worked at the facility for 3 years. The LPN stated when the med is removed from the med cart we document it on the Controlled Medication Record and once the medication is administered she will document it on the Medication Administration Record for the resident.
2. Record review for Resident #215 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Need for Assistance With Personal Care and Muscle Weakness (Generalized). The MDS dated [DATE] documented in Section C a BIMS score of 13 indicating a cognitive response.
Review of the Physician's Orders for Resident #215 revealed an order dated 3/18/25 for
Alprazolam 0.25 mg give 1 tablet orally every 8 hours as need for anxiety/agitation. The medication was discontinued on 4/2/25.
During an interview conducted on 4/23/25 at 1:45 PM Staff F LPN was asked about controlled medications. The LPN stated when the med is removed from the med cart we document it on the Controlled Medication Record and once the medication is administered she will document it on the Medication Administration Record for the resident.
During an interview conducted on 4/23/25 at 3:02 PM with the Director of Nursing (DON) who was asked about discontinued controlled medications, the DON stated the meds should be removed from the med cart within a couple of days of the med being discontinued. The night shift nurse is responsible to check the cart nightly.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review revealed Resident #19 was admitted to the facility on [DATE]. Diagnoses included Acute Respiratory Disease, Enc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review revealed Resident #19 was admitted to the facility on [DATE]. Diagnoses included Acute Respiratory Disease, Encephalopathy, unspecified, and Chronic Obstructive Pulmonary Disease.
The Brief Interview for Mental Status on the Quarterly Minimum Data Set assessment dated [DATE] was unable to be done. This indicated the resident had severe cognitive impairment.
The resident was selected for an unnecessary medication review. Review of the monthly medication regimen review for October 2024 through April 2024 provided by the Director of Nursing (DON) revealed no medication review for November 2024.
Review of the Electronic Health Record (EHR) failed to reveal a medication regimen review for Resident #19 for November 2024.
An interview was conducted via telephone with the consultant pharmacist on 4/23/25 at 9:43 AM. She stated she has been working as the consultant pharmacist with the current pharmacy since 2023. When asked about the missing November 2024 pharmacy recommendation for Resident #19 she stated she saw it on her computer screen.
An interview was conducted with the DON on 4/23/25 at 1:15 PM. She stated she contacted the Consultant Pharmacist to get a copy of the November 2024 recommendation. The pharmacist could not print it out because there was glitch in the system. She provided a screenshot without Resident #19's name on the screenshot. She verified that there was no recommendation for Resident #19 for November 2024 in the facility or in the resident's EHR.
Based on interviews and record review the facility failed to ensure the facility's Consultant Pharmacist reported the monthly drug regimen review to the facility for 1 (Resident #19) of 5 residents reviewed for Unnecessary Medications and failed to ensure irregularities identified by the Consultant Pharmacist were addressed with a rationale by the Physician for 1 (Resident #2) of 5 residents reviewed for Unnecessary Medications.
The findings included:
Review of the facility's policy titled, Medication Regimen Review with a revised date of January 2018 included in part the following: The consultant pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at least monthly. The findings are phoned, faxed, or e-mailed within (24 hours) to the director of nursing or designee and are documented and stored with the other consultant pharmacist recommendations in the residents' (active record). The prescriber is notified if needed. Notification is dependent on severity of irregularity and is determined through consultation between consultant pharmacist and the director of nursing. Recommendations are acted upon and documented by the facility staff and/or the prescriber. Prescriber accepts and acts upon suggestion or rejects and provides an explanation for disagreement.
Review of the facility's policy titled, Documentation and Communication of Consultant Pharmacist Recommendations with a revised date of January 2018 included in part the following: Comments and recommendations concerning medication therapy are communicated in a timely fashion. The timing of these recommendations should enable a response prior to the next medication regimen review. In the event of a problem requiring the immediate attention of the prescriber, the prescriber responsible or physician's designee is contacted by the consultant pharmacist or facility, and the prescriber response is documented on the consultant pharmacist review record or elsewhere in the resident's medical record.
1. Record review for Resident #2 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Urinary Tract Infection, Anxiety Disorder Unspecified, and Depression Unspecified. The Minimum Data Set, dated [DATE] documented in Section C a Brief Interview of Mental Status score of 15 indicating a cognitive response.
Review of the Physician's Orders for Resident #2 revealed in part the following:
An order dated 12/9/24 for Ambien (zolpidem) 5 mg; amt: 1 tablet oral at bedtime for sleep/insomnia.
An order dated 12/9/24 for Protonix (pantoprazole) tablet (reduces production of stomach acid), delayed release 40 mg oral once a day.
Review of the Pharmacy Recommendations for Resident #2 documented the following:
On 12/10/24 Pantoprazole 40 mg no stop date. On 12/11/24 the physician disagreed (with no rationale for disagreeing).
On 12/10/24 Zolpidem 5 mg pleas attempt dose reduction to zolpidem 2.5 mg at bedtime. On 12/11/24 the physician disagreed (with no rationale for disagreeing).
Review of the medical record for Resident #2 revealed no documentation of rationale for disagreeing with the pharmacy recommendations 12/10/24.
During a telephone interview conducted on 4/23/25 at 9:43 AM Staff M Consultant Pharmacist (CP) stated she has been working with the facility since 2023. The Consultant Pharmacist stated that the recommendation date is listed at the top of the form next to where the form states Recommendation Date. The Created date on located on the bottom of the form is the date when the PDF report was printed from the consultant pharmacy interface system. The Consultant Pharmacist stated she sends the report the facility on the date the report is printed. When asked about PRN (as needed) Psychotropic medications, she said they should only be for 14 days with a stop date, unless the doctor extends the order but still needs a stop date and documentation of rationale for the extended date. When asked about the Medication Regimen Review (MRR) for Resident #2 dated 12/10/24 in regard to the Pantoprazole 40 mg and the Physician disagreeing on 12/11/24, with no rationale, the CP stated the rationale may be written in the progress notes. When asked about the Medication Regimen Review (MRR) for Resident #215 dated 12/18/24 in regard to the Ativan 0.25 mg PRN greater than 14 days with the Physician documenting on 12/19/24 to continue the PRN order for 30 days with no rationale, the CP said again the rationale may be documented in the progress notes in the resident's record.
During an interview conducted on 4/23/25 at 11:00 AM Staff N Nurse Practitioner (NP) was asked about psychotropic medications ordered PRN. She stated she believes the medications can be extended longer than 14 days, as she has sometimes seen the pharmacist recommendations that gives that option. If the recommendation asks for the rationale she will document the rationale.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review revealed Resident #37 was re-admitted to the facility on [DATE] with Diagnoses of Anxiety Disorder and Major De...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review revealed Resident #37 was re-admitted to the facility on [DATE] with Diagnoses of Anxiety Disorder and Major Depressive Disorder.
The Quarterly MDS dated [DATE] revealed Resident #37 scored 15 on the BIMS, indicating intact cognition.
A review of the Pharmacy Recommendation to Prescriber dated 12/27/24 showed the following:
Resident #37 has been on Alprazolam 0.5 milligram PRN with a start date of 12/5/24. It is required that all psychotropic medication be limited to 14 days of use. If the medication cannot be discontinued at this time the order may be extended beyond 14 days if the Prescriber documents the rationale for extended use and indicate duration.
The recommendation was made 22 days after the PRN Alprazolam was started.
The continuing review revealed that the Prescriber addressed the recommendation on 1/30/25, more than a month after the pharmacy recommendation. The Prescriber noted to continue the PRN medication for three months with a rationale to continue for anxiety control.
A review of the Physician's orders dated 4/15/25 revealed an order for Alprazolam (Antianxiety Medication) 0.5 milligrams as needed (PRN) with an end date of 5/12/25.
During a telephone interview conducted on 4/23/25 at 9:43 AM Staff M Consultant Pharmacist (CP) stated she has been working with the facility since 2023. When asked about PRN (as needed) Psychotropic medications, she said they should only be for 14 days with a stop date, unless the doctor extends the order but still needs a stop date and documentation of rationale for the extended date.
When asked about the Pharmacy Recommendation to Prescriber for Resident #37 dated 12/27/24 in regard to the Alprazolam 0.5 mg PRN started 12/5/24 that was not addressed by the physician until 1/30/25 she said the physician has 30 days to review the recommendation. The Consultant Pharmacist did not acknowledge that the Alprazolam PRN medication was in place for longer than 14 days. The Consultant Pharmacist added that none of the issues discussed for Residents #20, #215, and #37 would be considered urgent.
In an interview conducted on 4/24/25 at 1:00 PM with the Director of Nursing, she said the Pharmacist sent them the reviews on 1/10/25 and not on 12/27/24, 35 days after the PRN medication of Alprazolam was started. She further acknowledged that this was too long and that they need to look into the process and make changes.
Based on interviews and record review the facility failed to ensure 2 (Residents #37 and #215) of 5 residents reviewed for unnecessary medications and 1 (Resident #20) of 6 residents reviewed for medication storage had a documented duration and/or rationale for use of psychotropic PRN (as needed) medications beyond 14 days.
The findings included:
1. Record review for Resident #20 revealed an admission date to the facility of 8/15/16. Diagnoses included in part: Unspecified Dementia Unspecified Severity Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety, and Epilepsy.
The Quarterly Minimum Data Set (MDS) with a target date of 2/26/25 documented Resident #20 scored 05 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment.
Review of the Physician's Orders for Resident #20 revealed an order dated 1/27/25 for Ativan (a psychotropic medication) 0.5mg give 1 tablet orally every 6 hours PRN (as needed) with no end date.
Review of Resident #20's medical record revealed no documentation of rationale or indication of the duration for the PRN Ativan order.
During an interview conducted on 4/23/25 at 3:02 PM the Director of Nursing (DON) was asked about the PRN order for Ativan for Resident #20. The DON acknowledged the PRN Ativan for Resident #20 was started on 1/27/25 was still an active order and had no stop date. The DON also acknowledged the recommendation from pharmacist in January identified the irregularity of PRN for more than 14 days with no stop date, but it was not addressed at that time.
2. Record review for Resident #215 revealed an admission date to the facility on [DATE]. Diagnoses included in part: Epilepsy Unspecified Not Intractable Without Status Epilepticus, Unspecified Dementia Unspecified Severity With Other Behavioral Disturbance, and Depression Unspecified.
The Quarterly MDS assessment dated [DATE] documented Resident #215 scored 00 on the BIMS, indicating severe cognitive impairment.
Review of the Physician's Orders for Resident #215 revealed an order dated 12/16/24 for Ativan (a psychotropic medication) tablet; 0.5 mg; amt: 0.25 mg; oral Special Instructions: Give 0.25 mg (1/2 of a 0.5 tab) for increased Anxiety Every 8 Hours - PRN (as needed).
Review of the Pharmacy Recommendations to Prescriber for Resident #215 revealed:
On 12/18/24, PRN antianxiety or hypnotic medication greater than 14 days, Ativan 0.25 mg PRN. CMS (Center for Medicare and Medicaid Services) requires all prn orders for psychotropic medications to be limited to 14 day use.
The Physician's response dated 12/19/24 was to continue the PRN order 30 days. There was no documentation of rationale.
Review of Resident #215's medical record revealed no documentation of rationale or indication for the duration of the PRN Ativan order.
On 12/27/24, the Consultant Pharmacist wrote a recommendation to the prescriber for PRN order for Ativan (Lorazepam) 0.5mg with a start date of 12/16/24.
The Physician response dated 1/20/25 documented to please discontinue PRN Lorazepam tab 0.5 mg.
The Ativan order was discontinued on 1/20/25. This indicated the PRN psychotropic medication had been in effect for longer than 14 days.
During a telephone interview conducted on 4/23/25 at 9:43 AM Staff M Consultant Pharmacist (CP) stated she has been working with the facility since 2023. When asked about PRN (as needed) Psychotropic medications, she said they should only be for 14 days with a stop date, unless the doctor extends the order but still needs a stop date and documentation of rationale for the extended date.
Reviewed the pharmacy recommendations dated 12/18/24, and 12/27/24 for the Ativan 0.25 mg prn with a start date of 12/16/24 for Resident #215.
When asked about the lack of documentation of a rationale to continue the Ativan 0.25 mg for 30 days for Resident #215 in the physician's response dated 12/19/24, the Consultant Pharmacist said the rationale may be documented in the progress notes in the resident's record.
Reviewed the pharmacy recommendation to the prescriber dated 12/27/24 and sent to the facility on 1/10/25 for the duration of the Ativan 0.25 mg PRN order for Resident #215 and the prescriber's response to the recommendation dated 1/20/25.
The Consultant Pharmacist did not acknowledge that the Ativan PRN medication had been in place for greater than 14 days with no end date.
During an interview conducted on 4/23/25 at 11:00 AM Staff N Nurse Practitioner (NP) stated she believes psychotropic medications ordered PRN, can be extended longer than 14 days, as she has sometimes seen the pharmacist recommendations that gives that option. If the recommendation asks for the rationale she will document the rationale.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to ensure medications were secured at all times for 2 (R...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to ensure medications were secured at all times for 2 (Residents #213 and #214) of 16 sampled residents.
The findings included:
Review of the facility's policy titled, Storage of Medications with a revised date of January 2018 included in part the following: Medications and biologicals are stored safely, securely and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.
Review of the facility's policy titled, Self-Administration of Medications with a revised date of January 2018 included in part the following: In order to maintain the residents' hi level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer. For those residents who self-administer, the interdisciplinary team verifies the resident's ability to self-administer medication by means of a skill assessment conducted on a quarterly basis or when there is a significant change in condition. The results of the interdisciplinary team assessment of resident skills and of the determination regarding bedside storage are recorded in the resident's medical record, on the care plan. For each medication authorized for self-administration, the label contains a notation that it may be self-administered.
Record review for Resident #213 revealed an admission date to the facility of 3/4/25. Diagnoses included in part: Fracture of Unspecified Part of Neck of Right Femur, Generalized Muscle Weakness, and Need for Assistance with Personal Care.
The admission Minimum Data Set (MDS) assessment with a target date of 3/25/25 documented Resident #213 scored 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition.
On 4/21/25 at 10:50 AM Resident #213 was observed sitting up in bed. The resident's spouse was sitting in a chair next to her. Two medicine cups were observed on the overbed table in front of Resident #213. One cup contained five different pills and a capsule. The other cup contained a liquid medication.
During an interview conducted on 4/21/25 at 10:50 AM Resident #213 was asked about the medications in front of her. She said she cannot take all of the medication at the same time.
Her husband then said he watches his wife take the medications. He said she takes too many medications at the same time, and she will get sick to her stomach. Resident #213 said she did not recognize all the medications in the cups, her husband was better at that.
During a side by side observation conducted at the bedside of Resident #213 on 4/21/25 at 11:05 AM with Staff F Licensed Practical Nurse (LPN), she acknowledged she left the medications at the bedside for the resident to take because the husband insists. She said Resident #213 has been at the facility for about five days and the husband has been insisting to have the medications left at the bedside. Staff F LPN added there should be a care plan and an order for the medications to be left at the bedside. When asked if the resident had an order for self-administration, she said she was not sure. When asked if the resident had a care plan for the meds to be left at the bedside or self-administration, she said she did not do the care plans.
During an interview conducted on 4/21/25 at 11:10 AM Staff E Registered Nurse (RN) stated she has worked at the facility for several years. When asked if Resident #213 had an order for self-administration of medications or an order to leave medications at the bedside, RN Staff E acknowledged there was no order. She also acknowledged the resident did not have a care plan or an evaluation for self-administration.
On 4/21/25 at 11:22 AM, observation of Resident #213's room revealed the medicine cup with five pills and one capsule and the medicine cup with the liquid medication remained at the resident's bedside.
Record review for Resident #213 revealed no order for self-administration of medications, no evaluation for self-administration of medications, and no care plan for self-administration of medications.
2. A record review for Resident #214 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part: Generalized muscle weakness, and need for assistance with personal care.
The admission MDS dated [DATE] documented Resident #214 scored 13 on the BIMS, indicating a cognitive response.
On 4/21/25 at 10:10 AM an observation was made of Resident #214 sitting up in bed. A bottle of Sterile Eye Drop Lubricant was observed on the overbed table in front of the resident.
During an interview conducted on 4/21/25 at 10:10 AM, Resident #214 was asked about the eye drops. She said she needed the eye drops. She said she had Macular Degeneration (eye disease), and her eyes get dry from reading. When asked if she put the drops in herself, she said no, her husband puts them in for her.
During a side-by-side observation conducted on 4/22/25 at 9:55 AM, Staff K Licensed Practical Nurse (LPN) acknowledged Resident #214 had eye drops at the bedside on her overbed table, did not have an order for eye drops nor was the resident evaluated for self-administration. Staff K LPN instructed Resident #214's husband to take the eye drops home and she would obtain an order from the physician for the eye drops.
Review of the clinical record for Resident #214 revealed no physician's order for eye drops, no evaluation for self-administration of the eye drops and no care plan for self-administration of medications.
The record for Resident #214 revealed no order for eye drops, no order to self-administer, no evaluation for self-administration, and no care plan for self-administration of medications.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, facility failed to follow care plan interventions to prevent further falls ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, facility failed to follow care plan interventions to prevent further falls for 1 (Resident #26) of 1 resident sampled for accidents.
The findings included:
Review of the facility's policy titled Care Plans-Comprehensive, revised on 12/10/24, showed the following:
Each Resident's comprehensive care plan is designed to:
a. Incorporate identified problem areas.
b. Incorporate risk factors associated with identified problems.
c. Build on the residents' strengths.
d. Reflect on the residents' expressed wishes regarding care and treatment goals.
e. Reflect treatment goals, timetables, and objectives in measurable outcomes.
f. Identify the professional services responsible for each element of care.'
g. Aid in preventing or reducing declines in the Resident's functional status and/or functional levels.
h. Enhance the Resident's optimal functioning by focusing on a rehabilitative program and reflecting currently recognized standards of practice for problem areas and conditions.
A record review showed Resident #26 was readmitted to the facility on [DATE] with diagnoses of Vascular Dementia, Depressive Disorder, and Hyperlipidemia. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #26 had a Brief Interview of Mental Status (BIMS) score of 07, which is severely cognitively impaired.
A record review of the Event Report dated 1/25/25 revealed Resident #26 had a fall on 1/25/25 in his room and had a non-skid sock at the time of the incident. Immediate measures taken were safe footwear and neuro checks. The report stated that the call bell was within reach and that Resident #26 did not call for assistance. The Care plan was updated on 1/27/25 to remind Resident #26 to use the call light for assistance when needed.
A record review of the Event Report dated 3/3/25 revealed Resident #26 had a fall on 3/3/25 in his room while ambulating to the bathroom wearing non-skid socks. Immediate measures taken were neuro checks on Resident #26. The call bell is within reach, and Resident #26 was encouraged to use it for assistance but does not always do so. The care plan was updated on 3/4/25 to remind Resident #26 not to ambulate unassisted.
A record review of the Event Report dated 3/16/25 revealed Resident #26 had a fall on 3/16/25 and was found in the bathroom. He had slippers on at the time of this incident. Resident #26 was reminded to call for assistance, and he said, I understand. The care plan updated on 3/17/25 reminded Resident #26 to ask for assistance with toileting needs.
A record review of the Event Report dated 3/17/25 revealed that Resident #26 fell in his room on 3/17/25. He had shoes on at the time of this incident. The bed was in the lowest position, and the call bell was within reach. The care plan updated on 3/18/25 for floor mats on the bilateral side of the bed.
In an observation conducted on 4/21/25 at 11:00 AM, Resident #26 was noted in the bed in the lowest position, but no call light was within reach. Further observations showed no fall mats on either side of his bed.
In an observation conducted on 4/22/25 at 9:32 AM, Resident #26 was noted in the bed, with the call light on his left side attached to the end of the bed not within arm's reach. Further observations showed no fall mats on either side of his bed.
In an interview conducted on 4/22/25 at 11:40 AM with Staff A, the Certified Nursing Assistant (CNA) stated that Resident #27 is a fall risk. There are floor mats on each side of his bed, and the call light is within reach by his side.
In an interview conducted on 4/22/25 at 11:50 AM, Staff B, MDS Coordinator, stated that after a resident falls, they will get together with the nursing team to review the care plan and the interventions in place. She will update or make changes to the interventions to reflect the circumstances of the fall and add any new interventions that are not already in place for the residents. Staff B reported adding the intervention of floor mats on 3/18/25 to the care plan for Resident #26. The Floor mats are placed as an order under the Physician's Orders tab.
A review of the Physician's orders did not show that Resident #26 had an order for floor mats.
In an observation conducted on 4/23/25 at 8:56 AM, Resident #26 was sitting at the end of the left side of the bed eating breakfast. The call light was noted to be attached to the curtain on the right side of the bed, away from Resident's #26 reach. Further observations showed no fall mats on either side of his bed.
In an interview conducted on 4/23/25 at 10:49 AM with a CNA, Staff D stated that Resident #26 was at risk for falls and ensured the call light was within reach and floor mats were on each side of his bed.
A review of the care plan initiated on 4/26/22 showed Resident #26 was at risk for falls related to weakness, unsteady gait at times, and a history of falls.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, review of facility's policies and procedures, and interviews, the facility failed to follo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, review of facility's policies and procedures, and interviews, the facility failed to follow infection prevention and control guidelines for 1 (Resident #37) of 1 resident on contact precautions. The facility failed to ensure the proper storage of respiratory care equipment for 2 (Residents #33 and #110) of 2 residents receiving nebulizer treatment and failed to perform hand hygiene as appropriate for 1(Resident #22) of 1 resident observed for catheter care.
The findings included:
The facility's policy titled Transmission Based Precautions reviewed 12/10/24 revealed Contact precautions are intended to prevent transmission of pathogens that are spread by direct or indirect contact with the resident or the resident's environment. PPE (personal protective equipment) utilized included gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident environment.
1. Record review for Resident #37 revealed an admission date to the facility of 5/5/23. Diagnoses included Sepsis (life threatening complication of an infection), Cerebral Infarction (stroke), and Chronic Obstructive Pulmonary Disease (COPD).
Review of the Quarterly Minimum Data Set (MDS) with an assessment reference date of 3/12/25 noted Resident #37 scored 15 on the Brief Interview for Mental Status, indicating intact cognition.
Review of the Electronic Health Record (EHR), including physician orders for Resident #37 revealed the resident was on Contact Precautions since 4/19/25 for a Urinary Tract Infection with ESBL (Extended-spectrum beta-lactamase). ESBL are a type of enzyme or chemical produced by some bacteria. Contact precautions are indicated for someone with ESBL in the urine.
On 4/24/25 at 9:00 AM, observed Registered Nurse (RN) Staff G prepare an injection of Ertapenem (antibiotic) solution 1 gram mixed with Lidocaine (anesthetic) for an intramuscular injection. RN Staff G prepared the injection by her medication cart and went into Resident #37's room. The sign on the door said contact precautions. RN Staff G went into the room with gloves on, pulled the curtain, repositioned the resident and pulled apart the brief to give the injection with gloves on. She did not don a gown or change her gloves prior to administering the injection. After she administered the injection, the resident asked the nurse reposition her. Staff G took off her gloves and repositioned the resident, the under pad, linen and blanket.
In an interview, Staff G was asked if she saw the contact precaution sign. She stated yes, my mistake.
On 4/24/25 at 10:00 a.m., during an interview the Administrator was informed of RN Staff G's failure to follow contact precautions for Resident #37.
2. Record review for Resident #33 revealed an admission date to the facility of 11/25/24. Diagnoses included Acute Respiratory Failure with Hypoxia (low oxygen level), Acute or Chronic Diastolic (Congestive) Heart Failure, and Type 2 Diabetes Mellitus without Complications.
Review of the Quarterly MDS assessment with an assessment reference date of 4/10/25 revealed Resident #33 scored 15 on the BIMS, indicating intact cognition.
On 4/21/25 at 1:42 PM observation of Resident #33's room revealed a nebulizer (machine used to inhale aerosol medications into the lungs) on top of the dresser next to the resident's bed. The nebulizer tubing and mask were observed lying on top on the nebulizer uncovered.
In an interview during the observation, Resident #33 stated she recently had a nebulizer treatment and the tubing and masks were put back on the machine uncovered.
3. Record review revealed Resident #110 was admitted to the facility on [DATE] with diagnoses that included Lymphedema (swelling), Polyneuropathy (peripheral nervous system disorder) and Unspecified Systolic (Congestive) Heart Failure.
Review of the admission MDS with an assessment reference date of 3/21/25 revealed Resident #110 scored 15 on the BIMS, indicating intact cognition.
On 4/21/25 at 10:49 AM an observation and interview were conducted with the resident.
A nebulizer tubing and mask were observed uncovered on the resident's bedside dresser.
In an interview Resident #110 said that he did not remember the last time he had a nebulizer treatment. He stated, It's supposed to be in a bag.
On 4/23/25 at 1:30 PM during an interview, the Administrator was informed of the nebulizer tubing and mask stored uncovered on Resident #110's bedside dresser.
4. Record review for Resident #22 revealed an admission date to the facility of 3/13/25 with diagnoses that included in part the following: Presence of a Right Artificial Hip Joint, History of Falling, and Need for Assistance with Personal Care.
The admission MDS dated [DATE] documented Resident #22 scored 15 on the BIMS, indicating a cognitive response. The MDS noted Resident #22 was always incontinent of bowel.
Review of the Physician's Orders for Resident #22 revealed in part the following orders:
An order dated 3/13/25 for Indwelling Urinary Catheter (Catheter inserted in the bladder to drain urine).
An order dated 3/13/25 to irrigate the Indwelling Urinary catheter with 60 cc normal saline as needed for blockage or leakage as needed.
There was no order for catheter care.
On 4/21/25 at 11:30 AM Resident #22 was observed lying in bed wearing pants with the legs pulled up above the knee. The resident had an indwelling urinary catheter.
On 04/24/25 at 9:10 AM Certified Nursing Assistant (CNA) Staff H was observed performing catheter care for Resident #22. As CNA Staff H began catheter care Resident #22 started having a bowel movement. CNA Staff H gloved hands became soiled with the bowel movement. CNA Staff H changed her gloves without performing hand hygiene. CNA Staff H changed her gloves an additional time during the catheter care procedure without performing hand hygiene.
During an interview conducted on 4/24/25 at 10:00 AM CNA Staff H stated she has worked at the facility for three and a half years. When asked about hand hygiene with changing gloves, she said she washed her hands before she started the catheter care for Resident #22 and washed her hands again when she was finished with the catheter care.
.
Sept 2023
2 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy review, and staff interviews, the facility failed to ensure 3 (Resident #3,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy review, and staff interviews, the facility failed to ensure 3 (Resident #3, #27 and #51) of 6 residents reviewed for accidents were assessed for alternative interventions prior to the use of side rails. This had the potential to have side rails installed when alternatives with less chance of negative consequences could be utilized. The facility census was 59 with 31 residents who had side rails in use.
The findings included:
The facility policy, Proper Use of Side Rails (revised 1/25/23) documented, The purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a residents' medical symptoms.
General Guidelines:
#6. Less restrictive interventions that will be incorporated include:
a. Providing restorative care to enhance abilities to stand freely and walk.
b. Providing trapeze to increase bed mobility
c. Placing the bed lower to the floor and surrounding the bed with a soft mat.
d. Equipping the resident with a device that monitors attempts to rise.
e. Providing staff monitoring at night with periodic assisted toileting for residents attempting to arise to use the bathroom.
f. Furnishing visual and verbal reminders to use the call bell for residents who can comprehend this information.
7. Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails.
1. Review of the clinical record showed Resident #3 was admitted [DATE] with diagnoses including dementia, weakness, and depression.
The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 6/21/23 documented Resident #3 required extensive assistance with bed mobility and limited assistance with transfers.
The MDS noted Resident #3's cognitive skills for daily decision making were moderately impaired.
The clinical record showed a physician order dated 3/16/23 for assist rails on bilateral sides of the bed for mobility.
On 9/5/23 at 2:34 p.m., and 9/6/23 at 10:27 a.m., Resident #3 was observed with side rails in the raised position on both sides of the bed. Resident #3 said she did not know how the side rails got there but they had been in place for a long time.
2. Review of the clinical record revealed Resident #27 was admitted on [DATE] with diagnoses including chronic kidney disease stage 3 unspecified, weakness, and unilateral primary osteoarthritis.
The Quarterly MDS dated [DATE] documented Resident #27 required supervision with transfers and ambulation. The MDS noted Resident #27's cognitive skills for daily decision making were intact.
The clinical record showed a physician order dated 12/1/21 for grab bars as enablers on both sides of the bed for mobility.
On 9/5/23 at 2:05 p.m., Resident #27 was observed with side rails raised on both sides of the bed. The resident said she did not ask to have the rails placed on the bed but said she did use them to move in bed.
3. Review of the clinical record revealed Resident #51 was admitted on [DATE] with diagnoses including dementia, history of falls, muscle weakness, anxiety, and depression.
The admission MDS with ARD 8/18/23 documented Resident #51 required extensive assistance of 1 with bed mobility and transfers. The MDS noted Resident #51's cognitive skills for daily decision making were severely impaired.
The physician order dated 8/19/23 specified assist rails to bilateral bedside for mobility.
On 9/5/23 at 3:05 p.m., Resident #51 was observed in bed with side rails in the raised position on both sides of the bed.
On 9/6/23 at 11:51 a.m., in an interview the Assistant Director of Nursing (ADON) said the process for side rails was for the therapy department to assess the resident to see if they can benefit from the side rails. The ADON said if the resident qualified to have the side rails placed, then we get a consent form signed by the resident or family. The ADON said once an order is received from the physician, maintenance will come and place the side rails.
On 9/6/23 at 12:25 p.m., in an interview the Director of Nursing (DON) said all bed rails in the facility are considered side rails. The DON said the process for side rails was for Occupational Therapist (OT) to complete an assessment to see if they can use the side rail or not. If they can benefit from the side rails to move in bed and transfer then the OT completes the Brief Initial Therapy Eval Review and the nurse obtains an order from the physician.
On 9/6/23 at 12:39 p.m., in an interview the Therapy Director, said OT completes the side rail evaluations for the residents and determines if they are necessary or not.
On 9/6/23 at 12:55 p.m., in an interview the OT said she completes the side rail screens with the Physical Therapist (PT) during treatment. If a resident can turn and use the side rail to reposition themselves then they would benefit from the use of the side rail. The OT said prior to initiating the side rails, we assess the resident for 30 minutes to 70 minutes and sometimes over 1-4 days to see if they benefit from the side rail use. The OT said all the interventions attempted prior to use of the rails were documented in the therapy notes.
On 9/6/23 at 1:37 p.m., a review of the OT notes for Residents #3, #27 and #51 revealed no documentation of a side rail assessment or interventions attempted prior to installation of the side rails.
On 9/6/23 at 2:26 p.m., the OT confirmed she did not have documentation of the interventions attempted prior to the use of the side rails for Residents #3, #27 and #51.
On 9/6/23 at 3:15 p.m., in an interview the Therapy Director said the therapy notes do not document any information regarding side rails or interventions attempted prior to use. The Therapy Director said the therapist completes the Brief Initial Therapy Eval Review for use of the side rails. She said if the residents benefit from it and they can turn, get up and reposition themselves with the side rails then we recommend it. The nurse is responsible for obtaining the physician order and the consent from the resident and or family. The Therapy Director confirmed the form used did not have documentation of interventions attempted or the reason for the side rails.
On 9/6/23 at 3:35 p.m., the DON, she said the facility used the Brief Initial Therapy Eval Review form as the assessment for use of the side rails. The DON said we call them side rails not enablers or assist bars. The therapy department determines if the resident should have the side rails or not. It is not used as a restraint; it is used to assist the resident and improve their function and ability. The DON said she was not aware alternate interventions were required before placing the side rails.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, review of facility policy and procedures and staff interviews, the facility failed to ensure eye drops and insulin were properly dated when opened and stored 2 of 3 medication ca...
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Based on observation, review of facility policy and procedures and staff interviews, the facility failed to ensure eye drops and insulin were properly dated when opened and stored 2 of 3 medication carts reviewed. Without an open date on the medication there was no way to know when it would expire. This had the potential for residents to receive medications that could create hazardous health consequences.
The findings included:
The facility policy Medication Storage in the Facility (revised 1/18) documented Medications and biological's are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier.
Expiration dates (beyond use date) of dispensed medications shall be determined by the pharmacist at the time of dispensing.
When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or recommendations/guidelines require different dating.
On 9/5/23 at 10:20 a.m., during an observation of medication cart #2 with Licensed Practical Nurse (LPN) Staff A the following was observed:
1. One open Humalog Kwik Pen insulin without a date of when it was opened.
The pharmacy label documented to discard after 28 days.
Photographic evidence obtained.
2. One open Humalog Kwik Pen insulin with the resident name partially removed from the label. There was no open date on the insulin pen and no open date on the pharmacy bag containing the insulin pen.
Photographic evidence obtained.
The findings in medication cart #2 were verified by Staff A.
On 9/55/23 at 10:43 a.m., during an observation of medication cart #3 with LPN Staff B the following was observed.
3. One Humalog Kwik Pen insulin with no open date on the pharmacy bag or the insulin pen. The pharmacy label specified to discard the medication after 28 days.
Photographic evidence obtained.
4. One opened bottle of Dorzolamide 2% eye drops with no open date on the bottle or pharmacy bag. The Pharmacy label specified to discard the eye drops in 60 days.
Photographic evidence obtained.
The findings in medication cart #3 were verified by LPN Staff B.
Nov 2022
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide care consistent with professional standards to...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide care consistent with professional standards to prevent the development of pressure ulcers for 1 (#1) of 3 Residents admitted to the facility without pressure ulcers but at risk for developing pressure ulcers. The lack of interventions resulted in the resident developing a stage 4 full thickness coccyx pressure wound with bone visible.
The findings included:
Review of the facility Policy Pressure injury(s)/Skin Breakdown - Clinical Protocol revised on 1/7/20, Assessment and Recognition #4 . The physician will assist the staff to determine the etiology and characteristics of the skin alteration . Monitoring #2 The physician will help the staff review and modify the care plan as appropriate, especially when new wounds develop.
Review of the Minimum Data Set (MDS) with an Assessment Reference date (ARD) of 11/16/21 Section C revealed Resident #1 was admitted to the facility on [DATE] with moderately impaired cognition and a Brief Interview of Mental Status Score of 12.
Section G for functional status indicated Resident #1 required the assistance of 2 staff for bed mobility, transfers, and toileting.
Section M indicated Resident #1 did not have any pressure wounds when she was admitted to the facility on [DATE].
Review of the (Agency for Health Care Administration) AHCA Form 5000-3008 (hospital transfer form) dated 11/9/21 revealed Resident #1 had redness to the coccyx. Review of the AHCA Form 5000-3008 dated 11/10/21 revealed Resident #1 had no pressure ulcers before she was admitted to the facility.
Review of Resident #1's Baseline Care Plan dated 11/12/21 revealed a summary of goals including, I will remain free from all preventable skin breakdown with all interventions in place .
Review of Resident #1's admission progress note dated 11/9/21 revealed the resident's skin was dry and intact with normal color and no skin issues when she was admitted to the facility. Review of the progress note of 11/10/21 revealed Resident #1 was unresponsive to verbal stimulus at the facility and was transferred to the hospital for evaluation.
Review of Resident #1's 2nd admission progress note dated 11/12/21 revealed the resident's skin was dry and intact with normal color and no skin issues when she was admitted to the facility the 2nd time.
Review of the nursing progress note of 11/20/21 revealed Resident #1 found to have a blister in the left buttock that was not open with no redness or warmness.
Review of Resident #1's orders included an order from the attending physician for Skin Prep to fluid filled blisters every shift to left buttock starting on 11/21/21.
Review of the nursing progress notes of 11/22/21 revealed Resident #1 had 2 blisters on her right coccyx yesterday and a new small one on her left buttock.
Review of the Advanced Registered Nurse Practitioner note of 11/23/21 revealed a change is the description of the blister including, Resident #1 has a blister that is ecchymotic (area of the skin forming a flat, rounded or irregular blue or purplish patch).
Review of Resident #1's Care Plan for alteration in skin integrity revealed an approaches/intervention was added on 11/20/21 to Apply treatment to rash/lesions as ordered and and another on 11/21/21 for Skin Prep to intact fluid filled blisters every shift to left buttocks as ordered. These 2 approaches/interventions were also in the physician's orders and not necessarily a new nursing approach/intervention to prevent pressure ulcers. Review of Resident #1's care plan did not include Repositioning and off-loading the coccyx as approaches/interventions to prevent pressure ulcers. Review of the medical record revealed no evidence an alternating air mattress to help with off loading was ever provided for Resident #1.
Review of the physician's orders for Resident #1 included House Supplement 120 milliliters by mouth once a day starting on 11/12/21.
Review of the physician's orders from 11/9/21 - 12/8/21 included an order for Skin prep to bilateral heels twice a day for preventative measures. There were no preventative orders put in place to prevent the development of pressure ulcers to the coccyx area at the time Resident #1 was admitted to the facility.
Review of the nursing progress notes dated 11/28/22 revealed Resident #1 has a dry flat blister to right lower buttocks and one clear filled blister intact to left lower buttocks.
Review of the progress note of 11/29/21 revealed Resident #1 has dry flat blisters to right lower buttock.
Review of the ARNP progress note of 12/13/21 revealed Resident #1 was examined at the request of family. A Stage 3 pressure ulcer was found on her coccyx. The entire wound bed was covered with slough tissue (a yellow material). Resident #1 to see wound care physician this week.
Review of the Initial Wound Evaluation and Management Summary by the Wound Care Physician dated 12/17/21 noted; Resident #1 had an unstageable coccyx wound for at least 10 days duration (due to necrosis, which means cell death in an organ or tissue). The wound size (Length x Width x Depth) was 2 centimeters (cm) x 1.5 cm x Not measurable for depth. The surface area was 3.00 cm squared. There was moderate serous exudate (any fluid or semisolid that has exuded out of a tissue or its capillaries, more specifically because of injury or inflammation). The etiology (cause of a disease or condition) was listed as pressure and the duration of the wound was listed as greater than 10 days. The tissue was 100% necrotic. The wound was surgically debrided during the evaluation to remove the necrotic tissue. The wound care physician recommended laboratory work for Hemoglobin A1C on 12/17/21 and Pre-Albumin on 12/17/21. The Individualized Treatment Plan Included Repositioning per the facility protocol and off-load wound.
Review of the subsequent Wound Evaluation and Management Summaries completed by the Wound Care Physician from 12/23/22 - 1/20/22 did not indicate Resident #1's pressure ulcer was unavoidable.
Review of the medical chart indicated there was lab work done for Resident #1 on 11/30/21, during the time she was at the facility. There was no Hemoglobin A1C or Pre-Albumin level included in the lab work. The lab work recommended by the Wound Care Physician during the Initial Evaluation of Resident #1 had not been completed.
On 10/31/22 at 1:59 p.m., in an interview, the Assistant Director of Nursing (ADON/wound care nurse) for the facility said Resident #1 came back to the facility with the blister, then it popped and turned into the wound. She said there was only 1 blister despite what the records say. She said the specialty wound care physician got involved with Resident #1's treatment once the blister became open. The ADON said the blister skin was the same color as the normal tissue, however raised. She said she is the wound care nurse at the facility, but she does not inspect every new resident's skin. She said turning and repositioning every 2 hours and sometimes every hour is necessary to prevent pressure ulcers or existing pressure ulcers from getting worse. The ADON acknowledged Resident #1's care plans did not include approaches/interventions of turning and repositioning and there was no documentation indicating it was ever done. She said the Certified Nursing Assistants (CNAs) do not document when they turn or reposition residents.
On 10/31/22 at 5:44 p.m. During a 2nd interview with the ADON/wound care nurse she said she first saw Resident #1's blister when she did rounds with the wound care physician on 12/17/21. She said staff did not make her aware of the blister when it was first discovered. She said obviously staff needs re-education regarding wounds. The ADON said she is responsible for staff development and training but she said there was no recent training on wounds for the nursing staff. She said staff were supposed to be turning Resident #1, but the nurses really must stay on top of it.
On 11/1/22 at 9:30 a.m., in an interview, the Registered Dietician (RD) said she was familiar with Resident #1 and ordered the House Supplement when she was first admitted to the facility. The RD said she was not made aware Resident #1 had a buttocks blister that evolved into a Stage 3 pressure ulcer. She said if she had known she would have included additional nutritional interventions for Resident #1.
On 11/1/22 at 11:16 a.m. during an interview with Registered Nurse (RN) Staff A said she's worked at the facility for one year and has been a Registered Nurse for 4-5 years. She said if there is a blister on the buttocks you are supposed to put a treatment in place and refer the resident to the wound-care specialists. She said the ADON reviews the Wound Evaluation Summary and Management and orders any new labs included in the summary.
On 11/1/22 at 12:53 p.m. the ADON said she did not recall when she first saw Resident #1's buttocks. She confirmed the wound care physician recommended lab work for a Hemoglobin A1C and Pre-Albumin when he saw Resident #1 on 12/17/21, but she did not put the orders in the computer and they were not drawn.
On 11/1/22 at 2:28 p.m. during a telephone interview with the wound care physician he said a blister to the coccyx with clear fluid would be a stage 2, but if you cannot see through the blister it would be unstageable. He said off-loading to decrease the pressure to the area is important as well as keeping the area dry. He said the repositioning and off-loading the wound is important regardless of whether the resident has an air mattress or not. He said he is usually involved when a resident gets a Stage 2 pressure ulcer and even with smaller pressure ulcers he is involved. He said the lab work is more for dietary to review and make recommendations. He said he does not include a wound is unavoidable unless there is a general decline in the resident.
Review of Resident #1's medical record showed no evidence of general decline. There was no documentation the pressure ulcer was unavoidable.
Dec 2021
2 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility's policy and procedure and staff interview, the facility failed to assess, evaluate, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility's policy and procedure and staff interview, the facility failed to assess, evaluate, and plan care to provide individualized approaches to restore as much normal elimination function as possible for 1 (Resident #4) of 6 residents reviewed with bladder incontinence.
The findings included:
The facility's Activities of Daily Living (ADL), supporting Policy Statement revised on 1/7/20 read, . Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with . Elimination (toileting) . Interventions to improve . a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals, and recognized standards of practice .
On 12/13/21 at 2:00 p.m., in an interview Resident #4 said when she presses the call light, she waits too long for staff to come and ends up having accidents and wets herself in her adult brief.
Review of the Quarterly Minimum Data Set (MDS) dated [DATE] showed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 9 (moderate cognitive impairment), was frequently incontinent of urine and required staff assistance with toileting.
The quarterly MDS with a target date of 12/8/21 showed Resident #4 had a BIMS score of 10 (moderate cognitive impairment), was frequently incontinent of urine and required limited physical assistance of one person with toileting.
Review of the facility Observation Detail List Reports completed on 9/15/21 and 12/13/21 showed a completed a bladder screen noting Resident #4's urinary pattern was upon arising, before meals, after meals and before going to bed. Each screen documented Resident #4 was a candidate for scheduled/prompted toileting.
The Certified Nursing Assistant (CNA) documentation for bladder function for September and December 2021 failed to show documentation of tracking over several days to establish the urinary pattern.
The care plan with a start date of 9/21/21 noted Resident #4 had episodes of bladder incontinence. The goal was to report a decrease in episodes of incontinence when asked and remain clean and comfortable daily. The approaches included to assist to the toilet upon rising, before and after meals, prior to sleep and as needed and desired.
On 12/14/2021 at 2:40 p.m., the MDS coordinator verified the lack of a bladder patterning to assess Resident #4's incontinence and develop individualized interventions to maintain or improve Resident #4's bladder continence. She said residents were to be evaluated for continence on admission and a monitoring record in place to assess elimination patterns. All incontinent residents were re-assessed on a quarterly basis using the Incontinence Reassessment form to determine if residents qualify for a toileting plan. Individualized plans and goals were developed based on the results of the assessment. Each resident on the monitoring program will have individual plans and goals established by the care plan team to assist the resident in acquiring lost functions or to maintain present function.
On 12/14/21 at 2:35 p.m., CNA Staff A said Resident #4 will alert staff when she needs to urinate, but sometimes has already urinated in her brief when she gets to her.
On 12/14/21 at 3:00 p.m., in a telephone interview, Resident #4's daughter said her mother is now incontinent, but it was not always that way. She said she visits twice a week on Wednesday and Saturday and spends two hours at the facility. Daughter said she used the call light during visits and witnessed that it takes a while for staff to answer the call bell. She said she has had to seek out staff herself so they would assist with toileting. Resident #4's daughter recalled that her mother once contacted her at 2:00 a.m. upset that staff would not come to assist her with toileting after she pressed her call bell.
On 12/16/21, the Director of Nursing (DON) confirmed resident #4 was not on a toileting program based on voiding pattern and the interventions were not individualized to assist staff (licensed nurses and certified nursing assistants) to maintain and promote continence. The DON confirmed the facility failed to implement a tailored approach to improve and maintain resident's urinary function.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, staff and resident interviews, the facility failed to ensure medications were secured and remained under direct observation during medication administration for 1 (Resident #16) ...
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Based on observation, staff and resident interviews, the facility failed to ensure medications were secured and remained under direct observation during medication administration for 1 (Resident #16) of 1 resident observed with unsecured medications at the bedside.
The failure to properly secure medications has the potential to lead to inaccurate amount of medication taken by the resident or possible ingestion of the medication by another resident.
The findings included:
On 12/13/21 at 9:55 a.m., seven unidentified pills were observed on a napkin on Resident #16's over the bed table. There was also a paper cup with a prescription bottle of Atrovent nasal spray inside a plastic bag.
Resident #16 said it took her a while to get the pills down so the nurse left the pills with her. During the Resident's interview Licensed Practical Nurse (LPN) Staff C walked into Resident #16's room to collect the bottle of Atrovent nasal spray. The resident told her she hadn't used it yet. Staff C left the nasal spray with the resident and left the room.
Photographic evidence obtained
On 12/14/21 at 11:30 a.m., in an interview, the Assistant Director of Nursing (ADON) said the facility currently did not have any resident who were allowed to self-medicate. She said when the nurses are doing medication pass, they are supposed to stay at bedside with the resident until all the medications are administered. Upon seeing the photographic evidence of the medications left at the bedside, the ADON said this was not part of facility practice. She said the nurse was new and she would reeducate her.
On 12/14/21 at 2:15 p.m., in an interview the Director of Nursing verified there were no residents in the facility self-medicating and the nurses were not allowed to leave any medication unattended at bedside.
On 12/15/21 at 9:50 a.m., in an interview LPN Staff C said she didn't know she couldn't leave medications unattended at the bedside for the residents. She said she was reeducated and would not leave medications at bedside anymore.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 15% annual turnover. Excellent stability, 33 points below Florida's 48% average. Staff who stay learn residents' needs.
Concerns
- • 15 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • $16,150 in fines. Above average for Florida. Some compliance problems on record.
Bottom line: Mixed indicators with Trust Score of 63/100. Visit in person and ask pointed questions.
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About This Facility
What is Solaris Senior Living North Naples's CMS Rating?
CMS assigns SOLARIS SENIOR LIVING NORTH NAPLES an overall rating of 3 out of 5 stars, which is considered average nationally. Within Florida, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Solaris Senior Living North Naples Staffed?
CMS rates SOLARIS SENIOR LIVING NORTH NAPLES's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes. Staff turnover is 15%, compared to the Florida average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Solaris Senior Living North Naples?
State health inspectors documented 15 deficiencies at SOLARIS SENIOR LIVING NORTH NAPLES during 2021 to 2025. These included: 1 that caused actual resident harm and 14 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Solaris Senior Living North Naples?
SOLARIS SENIOR LIVING NORTH NAPLES is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility is operated by SOLARIS HEALTHCARE, a chain that manages multiple nursing homes. With 60 certified beds and approximately 56 residents (about 93% occupancy), it is a smaller facility located in NAPLES, Florida.
How Does Solaris Senior Living North Naples Compare to Other Florida Nursing Homes?
Compared to the 100 nursing homes in Florida, SOLARIS SENIOR LIVING NORTH NAPLES's overall rating (3 stars) is below the state average of 3.2, staff turnover (15%) is significantly lower than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Solaris Senior Living North Naples?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Solaris Senior Living North Naples Safe?
Based on CMS inspection data, SOLARIS SENIOR LIVING NORTH NAPLES has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in Florida. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Solaris Senior Living North Naples Stick Around?
Staff at SOLARIS SENIOR LIVING NORTH NAPLES tend to stick around. With a turnover rate of 15%, the facility is 30 percentage points below the Florida average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly. Registered Nurse turnover is also low at 8%, meaning experienced RNs are available to handle complex medical needs.
Was Solaris Senior Living North Naples Ever Fined?
SOLARIS SENIOR LIVING NORTH NAPLES has been fined $16,150 across 2 penalty actions. This is below the Florida average of $33,240. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Solaris Senior Living North Naples on Any Federal Watch List?
SOLARIS SENIOR LIVING NORTH NAPLES is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.