Solaris Healthcare Lely Palms

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jul 13, 2023

  Based on observation, record review, staff and family interview, the facility failed to implement processes to adequately supervise 1 (Resident #1) of 3 sampled cognitively impaired residents identified at risk for elopement to prevent unsafe wandering and elopement. On 7/7/23 at 3:00 a.m., Resident #1who was cognitively impaired, ambulatory, and actively exit seeking set off the alarm of an exit door. Staff did not know how to reset the alarm and left the exit door unsecured. Staff failed to adequately supervise Resident #1 until the alarm was reset. On 7/7/23 (unknown time after 4:00 a.m.) Resident #1 left the facility unsupervised through the unsecured exit door. […]

• Immediate jeopardy, isolatedF835Jul 13, 2023

  Based on observation, record review, job description review, staff and family interview, the facility's administration failed to utilize resources effectively to ensure a safe environment and adequate supervision of 1 (Resident #1) of 3 sampled cognitively impaired residents at risk for elopement to prevent unsafe wandering and elopement. On 7/7/23 at 3:00 a.m., Resident #1 who was cognitively impaired, was ambulatory, and actively exit seeking set off the alarm of an exit door. Staff on duty did not know how to reset the alarm and left the exit door unsecured. Staff failed to adequately supervise Resident #1 until the alarm was reset. On 7/7/23 (unknown time after 4:00 a.m.) Resident #1 left the facility unsupervised through the unsecured exit door. […]

• Actual harm, isolatedF600Jul 29, 2025

  Based on record review, review of facility's policies and procedures, and staff interviews, the facility failed to protect residents' rights to be free from neglect by failing to follow safety precautions during transfers resulting in an avoidable fall for 1 (Resident #999) of 3 residents reviewed for accidents and failure to ensure timely post-fall evaluation.The findings includedReview of the facility's policy #60.41 Alleged Abuse /Potential Neglect/ Exploitation revealed, It is the policy of this facility to provide an environment that promotes dignity and respect for all residents and one that prohibits abuse and/or neglect. […]

• Actual harm, isolatedF689Jul 29, 2025

  Based on record review, review of facility's policies and procedures, the facility failed to ensure staff followed safety precautions while transferring 1 (Resident #999) of 3 residents reviewed for accidents, resulting in an avoidable with major injury requiring emergency transfer to an acute care hospital.The findings included:Review of the facility policy Assessing Falls and Their Causes revealed, Steps in the Procedure after a Fall: If a resident has just fallen, or is found on the floor without a witness to the event, nursing staff will record vital signs and evaluate for possible injuries to the head, neck spine and extremities. If there is evidence of a significant injury such as a fracture or bleeding, nursing staff will provide appropriate first aid. […]

• Actual harm, isolatedF600Feb 6, 2025

  Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect for 1 (Resident #27) of 2 residents reviewed for incontinent care by failing to provide incontinent care and services to meet the needs resulting in prolong skin exposure to urine resulting in moisture associated skin damage. The findings included: Review of the facility's Job Description for Certified Nursing Assistants included Safety: the CAN (Certified Nursing Assistant) Reports all accidents and incidents observed on shift. […]