Solaris Healthcare Bayonet Point

In the surveyor’s words

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

• Immediate jeopardy, patternF689Dec 4, 2022

  Based on observation, interview and record review, the facility failed to ensure supervision, staff assistance and instruction to staff were provided to prevent falls for 3 residents (#3, #4, #5) of sixteen sampled residents. Resident #3 was assessed to be at high risk for falls and to and overestimates/forget limitations. She was documented on a Scheduled 5 day (MDS) Minimum Data Set assessment dated [DATE] to require extensive assistance of two or more people to move from a lying position, turning side to side, and positioning her body while in bed. Her care plan showed a strength of extensive assistance, required the support of two persons for the activity of bed mobility. […]

• Immediate jeopardy, patternF726Dec 4, 2022

  Based on observation, record review, and interviews, the facility failed to ensure direct care staff had competencies, skill sets and direction to provide resident care safely for three (Residents #3, #4, and #5) of sixteen sampled residents. The bed mobility staff support needs of residents were not clearly assessed, care planned and communicated to direct care staff, direct care staff determined the bed mobility support needs of residents, training and supervision for direct care staff was found to lack clear processes for competency evaluation. […]

• Immediate jeopardy, isolatedF578Sep 26, 2025

  Based on record review, interview, and policy and procedure review the facility failed to ensure the residents rights were honored by failing to implement/follow formulated advance directives for one resident (#209) of one resident reviewed. Resident #209 had an Advanced Directive for Do Not Resuscitate (DNR) formulated, which staff did not follow. The DNR was not honored by the facility when they failed to obtain clarification of code status during the admission process, per facility policy. This failure resulted in the resident experiencing sternal and anterior chest wall pain, serious psychosocial harm by not honoring the resident's wishes for a natural, dignified death. […]

• Immediate jeopardy, isolatedF678Sep 26, 2025

  Based on interview, record review and policy and procedure review the facility failed to honor a resident's expressed Advanced Directive for end of life for one resident (#209) of one resident reviewed, by failing to ensure life saving measures of cardiopulmonary resuscitation (CPR) were not performed when Resident #209 was found unresponsive and absent of vital signs. Resident #209 was admitted to the facility on [DATE] with a fully executed State of Florida Do NOT RESUSCITATE ORDER (DNR) DH (Department of Health) form 1896,Revised [DATE] dated [DATE]. Resident #209's representative provided a copy to the facility on [DATE] at 12:40 PM. The facility's unlicensed staff did not provide the DNR order to a licensed staff member for processing. […]

• Immediate jeopardy, isolatedF600Dec 4, 2022

  Based on observation, record review, and interviews, the facility failed to ensure freedom from neglect by not implementing the facility's policy and procedures for Resident Mistreatment, Neglect and Abuse Prohibition for one (Resident #3) of sixteen sampled residents. The facility failed to recognize and report Neglect for Resident #3, assessed to be at high risk for falls and to overestimate/forget limitations. She was documented on a Scheduled 5 day Minimum Data Set (MDS) assessment dated [DATE] to require extensive assistance of two or more people to move from a lying position, turning side to side, and positioning her body while in bed. Her care plan showed a strength of extensive assistance and she required the support of two persons for the activity of bed mobility. […]