Inspection visit
Inspection
6 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
3. In an interview on 4/12/21 at 9:50 a.m., Resident #77 said staff did not respond to his call bell in a timely
manner and was a weak spot for the facility, especially on the weekends. The resident said on Saturday, he
rang his bell and had to wait 45 minutes to receive care after an incontinent episode with both bowel and
bladder. He said the nurse came in and confirmed his call light was functioning and said she would send
someone in. He said the incident made him feel worthless as he is dependent on staff for care. Resident
#77 said this was not the first time and had happened before. He said staff use the excuse as they were
busy. He said this is a regular occurrence on the weekends and he usually has to wait an average of 30
minutes for assistance from staff.
On 4/14/21 at 10:20 a.m., reviewed with the Director of Nursing (DON) the concern of Resident #77 not
being treated in a dignified manner by waiting 45 minutes to receive incontinent care. The DON
acknowledged that waiting for 30 to 45 minutes for the call bell to be answered was not acceptable and
would address this with staff.
Based on record review, review of facility policy, resident and staff interview, the facility failed to provide
timely assistance in a manner to promote dignity for 3 (#492, #10, and #77) of 3 residents reviewed who
are dependent on staff for activities of daily living.
The findings included:
Review of the facility's admission packet (undated) revealed a Florida Patient /Resident Rights and
Responsibilities which read residents . have the right to be treated with courtesy, respect and full
recognition of your dignity and individuality by all employees.with whom you come in contact . Each patient
has the right to. Privacy in treatment and in caring for personal needs; to close room doors and to have
facility personnel knock before entering the room . Be treated courteously, fairly, and with the fullest
measure of dignity.
1. Review of the clinical record revealed Resident #492 had an admission date of 3/29/21. The care plan
noted the resident had alteration in neurological status and required cueing and reorientation as needed.
Resident #492 also had self-care deficit related to a recent stroke with a goal to improve activities of daily
living self-performance.
On 4/11/21 at 9:25 a.m., observed Resident #492, on his bed wearing only an incontinence brief. The
resident was not covered, the bedroom door was open and the resident was clearly visible from the hallway.
Several staff members observed walking past the room in the hallway and did not intervene.
On 4/11/21 at 10:33 a.m., Resident #492 was observed in bed with his incontinent brief partially
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 15
Event ID:
105499
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105499
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/14/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Lely Palms
6135 Rattlesnake Hammock Road
Naples, FL 34113
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0550
Level of Harm - Minimal harm
or potential for actual harm
open, exposing his penis. The bedroom door was open and the resident was clearly visible from the
hallway.
On 4/13/21 at 11:29 a.m., observed resident #492 in a wheelchair in his room facing the doorway. Resident
#492 pants were lowered around his ankles exposing the incontinence brief.
Residents Affected - Few
On 4/13/21 at 12:50 p.m., observed resident #492 sitting in a chair in his room facing the window. The
resident's pants remained lowered around his ankles exposing his incontinent brief. The bedroom door to
the hall was open, the window curtain was open, and the Resident was clearly visible from hallway.
On 4/13/21 at 12:52 p.m., in an interview Registered Nurse (RN) Staff E said Resident #492 did not have
behaviors and was a very sweet man.
Certified Nursing Assistant (CNA) Staff A was present during the interview and said I check on him a lot.
RN Staff E and CNA Staff A said they were not aware the resident's brief was exposed and the door open.
They both went in the room to assist Resident #492.
On 4/14/21 at 10:19 a.m., the observations on 4/11/21 and 4/13/21 were shared with the Director of
Nursing (DON). The DON said, that is a dignity problem and not acceptable, I will follow-up with the team.
2. On 4/11/21 at 9:51 a.m., in an interview Resident #10 said, There is not enough staff or CNAs. The
longest I have had to sit in a wet brief is three hours.
On 4/12/21 at 1015 a.m., while conducting a second interview, observed CNA Staff A entering Resident
#10's room without knocking. Resident #10 said, They come in without knocking all of the time.
On 4/12/21 at 4:20 p.m., observed resident #10 telling RN Staff E he needed to be changed. During the
observation, CNA Staff L walked in room without knocking and was informed of resident's need.
On 4/12/21 at 4:53 p.m., observed CNA Staff L entering room to assist Resident #10, 33 minutes after
Resident #10 asked for assistance.
On 4/13/2021 review of the care plan for resident #10 revealed the resident has incontinence interventions
and required total assist with toileting and incontinence care.
On 4/14/21 at 9:45 a.m., in an interview Resident #10 resident said, I'm aggravated. The resident said he
had an incontinent episode of bowel and had been sitting in his feces for 45 minutes. He said he asked RN
Staff E to be changed 45 minutes ago. CNA Staff H said she would change him but that was a long time
ago.
On 4/14/21 at 10:03 a.m., The Assistant Director of Nursing (ADON) was observed leaving the resident's
room. In an interview the Assistant Director of Nursing (ADON) said residents should not wait more than 20
minutes for an incontinence brief change.
On 4/14/21 at 10:19 a.m., Resident #10's concerns were reviewed with the DON. The DON said, at most
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105499
If continuation sheet
Page 2 of 15
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105499
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/14/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Lely Palms
6135 Rattlesnake Hammock Road
Naples, FL 34113
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0550
a resident should only wait 15 minutes for a brief change . Informed of observation on 4/12/21 when
resident #10 waited 33 minutes for a brief change. The DON said, that's unacceptable.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105499
If continuation sheet
Page 3 of 15
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105499
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/14/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Lely Palms
6135 Rattlesnake Hammock Road
Naples, FL 34113
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0563
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, staff and resident interview the facility failed to provide reasonable accommodation to
promote residents rights to receive visitors.
Residents Affected - Some
The findings included:
The resident rights and responsibilities included in the admission packet specified, Each patient has the
right to . visiting with any person of your choice during visiting hours . Center visiting hours shall be flexible,
taking into consideration special circumstances such as, but not limited to, out-of-town visitors and working
relatives or friends .
The Center for Medicare and Medicaid Services (CMS) memo QSO-20-39 (Revised Nursing Home
Visitation) revised 3/10/21 read Facilities should allow indoor visitation at all times and for all residents
(regardless of vaccination status) except for a few circumstances when visitation should be limited due to a
high risk of COVID-19 transmission . These scenarios include limiting indoor visitation for:
Unvaccinated residents, if the nursing home's COVID-19 county positivity rate is > [greater than] 10%
and < [less than] 70% of residents in the facility are fully vaccinated;
Residents with confirmed COVID-19 infection, whether vaccinated or unvaccinated until they have met the
criteria to discontinue Transmission-Based Precautions; or
Residents in quarantine, whether vaccinated or unvaccinated, until they have met criteria for release from
quarantine.
1. On 4/12/21 at 2:31 p.m., in a confidential group interview, all members of the Resident Council present
for the meeting said nobody can come inside the facility to visit. Residents relayed this included immediate
family members who will visit them through the window if they are able. Another resident said his wife
wanted to come inside to visit and had not been allowed to do this for over a year. A council member
relayed there was no inside visitation but the facility had started allowing outside visits with a 6 foot table
between them which can be arranged with the Activity Director.
2. On 4/13/21 at 11:05 a.m., in an interview resident #38 said, Nothing to do at this place, I get an hour a
day of therapy and 23 hours to lay in this bed. They have not offered me anything to read or do. I am
trapped in this room like a prison. Resident #38 said, it is depressing, being sick since January and having
nothing to do. I have not been offered anything, not even a newspaper . When asked about visitation he
said when I was in the other room my wife could come to the driveway and we could wave at each other
and talk on the phone, now in this room no luck, she isn't going to climb over bushes. It's like a punishment
or bullying.
3. In an interview on 4/13/21 at 9:00 a.m., the Activity Director (AD) said all visitation was conducted
outside and at this time no inside visitation is allowed per facility policy regardless of vaccination status. The
outside visits are supervised by herself or her assistant to ensure the visitor and resident do not touch each
other and remain 6 feet apart. The AD said she would intervene and redirect them if that happened. They
allow one visitation to take place at a time and are usually for
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105499
If continuation sheet
Page 4 of 15
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105499
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/14/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Lely Palms
6135 Rattlesnake Hammock Road
Naples, FL 34113
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0563
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
30 minutes. The visitor screening log from September 2020 to April 2021 was reviewed. Inside visits were
noted to have been conducted on 4 occasions, 11/14/20, 11/23/20, 3/1/21 and 3/2/21. The AD said these 4
visits were for compassionate care.
4. On 4/11/21 at 2:30 p.m., in interview with Director of Nursing (DON) he said the facility has not been
allowing any visitor inside the facility at this time. He said they have allowed compassionate care visits to
Hospice resident who were actively dying but this has only happened a few times since the start of the
pandemic. The DON said the [NAME] County COVID positivity rate is 7.9%, 58 plus residents (Census of
95) and 78 staff have been fully vaccinated with the COVID-19 vaccine.
5. On 4/12/21 at 8:44 a.m. in interview with administrator He said the facility has allowed outdoor visitation
but has not allowed indoor visitation yet. The Administrator said he was aware of the most recent
memorandum from CMS and the Center of Disease Control (CDC) Regarding the updated Nursing Home
Visitation - COVID-19 guidelines.
6. On 4/12/21 at 11:34 a.m. in interview with Regional Corporate Nurse for the company she stated that the
facilities Administrator and Senior management all discussed the new update from CMS and CDC on a
virtual meeting on 3/12/21. It was discussed in depth the need to open up visitation as indicated in the
memo. She said that she knows the company has detailed plans and she does not know why this facility
has not started yet.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105499
If continuation sheet
Page 5 of 15
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105499
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/14/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Lely Palms
6135 Rattlesnake Hammock Road
Naples, FL 34113
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, and staff interview, the facility failed to provide housekeeping and maintenance services to
maintain a safe, sanitary, comfortable and home like environment for residents.
Not maintaining a sanitary environment has the potential to spread disease causing organisms.
The findings included:
On 4/11/21 at 11:00 a.m., during a tour of the facility, the following observations were made:
room [ROOM NUMBER] was observed with peeling wall with brown substance on the wall behind the
resident's bed. The toilet was rusted and constantly flushing. The raised toilet seat was broken.
**Photographic Evidence Obtained**
room [ROOM NUMBER] was observed to have peeling baseboards. A large crack observed in the wall, and
a hole in the wall behind the door.
**Photographic Evidence Obtained**
room [ROOM NUMBER] had a heavily soiled floor with grime and debris around the base of the toilet in the
bathroom.
**Photographic Evidence Obtained**
room [ROOM NUMBER] had peeling baseboard walls behind the bed.
**Photographic Evidence Obtained**
room [ROOM NUMBER] observed with peeling baseboards.
**Photographic Evidence Obtained**
room [ROOM NUMBER] had a hole in the wall behind the baseboard, a large gouge and crack in the wall
under the window. The residents personal care items (deodorant, toothpaste, and comb) were stored
uncovered on the toilet tank, which could become cross contaminated.
**Photographic Evidence Obtained**
room [ROOM NUMBER] observed with rusted and broken toilet seat riser.
**Photographic Evidence Obtained**
room [ROOM NUMBER] with gouged walls behind the dressers and beds.
room [ROOM NUMBER] heavily stained toilet, broken and hanging electrical outlet plates, toilet
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105499
If continuation sheet
Page 6 of 15
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105499
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/14/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Lely Palms
6135 Rattlesnake Hammock Road
Naples, FL 34113
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0584
constantly flushing.
Level of Harm - Minimal harm
or potential for actual harm
**Photographic Evidence Obtained**
300 hall day room observed with large hole in the wall.
Residents Affected - Few
**Photographic Evidence Obtained**
room [ROOM NUMBER] observed with peeling baseboards.
**Photographic Evidence Obtained**
room [ROOM NUMBER], bed pan in handrail in the bathroom and an uncovered hairbrush stored on the
sink not which could become cross contaminated.
**Photographic Evidence Obtained**
room [ROOM NUMBER], residents personal care items (toothbrush and toothpaste) stored uncovered on
the sink in the bathroom, which could become cross contaminated.
On 4/14/21 at 10:44 a.m., the same observations were made during a facility tour conducted with the
Maintenance Director. He verified and acknowledged the findings.
On 4/14/21 at 11:00 a.m., the Administrator was informed of the findings. He said he would get with the
Maintenance Director and fix the issues.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105499
If continuation sheet
Page 7 of 15
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105499
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/14/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Lely Palms
6135 Rattlesnake Hammock Road
Naples, FL 34113
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, clinical record review, and staff interview, the facility failed to ensure the MDS (Minimum data
set) assessment accurately reflected the resident's urinary status for 1 (Resident #6) of 1 resident with an
indwelling urinary catheter. Inaccurate MDS assessments can result in a resident not receiving appropriate
health care.
Residents Affected - Few
The findings included:
On 4/11/21 at 10:30 a.m., and 4/12/21 at 11:07 a.m., Resident #6 was observed with an indwelling urinary
catheter (Catheter placed in the bladder to drain urine). The catheter was in a privacy bag attached to the
side of the bed.
Record review on 4/12/21 at 3:30 p.m., showed a quarterly Minimum Data Set (MDS) assessment dated
[DATE]. The assessment noted Resident #6 was always incontinent of urine but did not note the use of an
indwelling urinary catheter.
The clinical record did not include a care plan for the indwelling urinary catheter.
On 04/13/21 at 9:17 a.m., in an interview Registered Nurse (RN) staff F said Resident #6 had a chronic
catheter that is usually changed on the day shift.
On 04/13/21 at 9:30 a.m., RN Staff M said he did not see any physician's orders for the Foley (indwelling
urinary) in the resident's clinical record.
On 04/13/21 at 9:32 a.m., in an interview MDS RN Staff N and MDS RN Staff O said they gather their
information to code the MDS from all sources, they interview the residents, family members, staff, review
progress notes and therapy notes.
On 04/13/21 at 10:15 a.m., MDS RN Staff O said there was an order dated 8/17/20 to discontinue the
catheter, but no other orders. She said, We did not know she had one.
Review of the progress notes showed the catheter was changed on 11/23/20.
On 04/13/21 at 10:45 a.m., in an interview the Director of Nursing (DON) said he did not know what
happened. He said Resident #6 had gone out to the hospital and came back with the Foley catheter. The
orders never got picked up. He said the last progress note was dated 11/23/20 for a Foley catheter change.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105499
If continuation sheet
Page 8 of 15
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105499
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/14/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Lely Palms
6135 Rattlesnake Hammock Road
Naples, FL 34113
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0679
Provide activities to meet all resident's needs.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, resident and staff interview, the facility failed to implement meaningful resident
centered activities to meet the interest and well-being of 13 (Resident #45, #56, #57, #15, #6, #88, #80,
#83, #27, #10, #38, #9, and #492) of 13 residents reviewed for activities. The lack of an individualized
activity program had the potential to cause social isolation, apathy, and boredom. The facility also failed to
promote communal activities and dining while adhering to core principles of COVID-19 infection prevention.
Residents Affected - Some
The findings included:
Review of the facility policy Activity and Recreation Service (dated July 2019) documented the activity
programs are provided to enable patients to achieve the highest level of physical, mental, psychosocial, and
spiritual well-being. The program of activities is designed to recognize and accommodate patient limitations
while maximizing strengths, interests, and abilities.
The Center for Medicare and Medicaid Services memorandum (QSO-20-39-NH) revised on 3/10/2021
read, While adhering to the core principles of COVID-19 infection prevention, communal activities and
dining may occur. Residents may eat in the same room with social distancing (e.g., limited number of
people at each table and with at least six feet between each person). Facilities should consider additional
limitations based on status of COVID-19 infections in the facility. Additionally, group activities may also be
facilitated (for residents who have fully recovered from COVID-19, and for those not in isolation for
observation, or with suspected or confirmed COVID-19 status) with social distancing among residents,
appropriate hand hygiene, and use of a face covering (except while eating). Facilities may be able to offer a
variety of activities while also taking necessary precautions. For example, book clubs, crafts, movies,
exercise, and bingo are all activities that can be facilitated with alterations to adhere to the guidelines for
preventing transmission.
1. On 4/11/21 at 11:30 a.m., Resident #45 was observed lying in bed wearing a hospital gown. The resident
said he had been here for 2 months and staff are not allowing him out his room. Resident #45 said he used
to live at an assisted living facility and participated in the entertainment they offered. He said there was no
activity here and TV is the activity.
Review of the clinical record for Resident #45 revealed an admission Minimum Data Set (MDS) 3.0
assessment dated [DATE]. Section F 0500 interview for Activity Preferences indicated the resident liked to
be around animals, keep up with the news, do things with groups of people, go outside, and participate in
religious services.
On 4/12/21 at 9:48 a.m., in an interview Registered Nurse (RN) Staff J said the residents do not leave the
unit unless going to rehab with therapy staff. She said they used to have activities in the day room but not
since the onset of COVID-19.
2. On 4/11/21 at 1:45 p.m., Resident #56 was observed lying in bed wearing a hospital gown. The resident
shared a room with his wife, Resident #57. The resident said no one had asked if he wanted to attend any
activities. He did not know if there was anything to do, no one has told us. We sit in the chair all day and
nobody takes us out of the room except for therapy. The resident said he would like to do something but
nobody tells us.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105499
If continuation sheet
Page 9 of 15
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105499
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/14/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Lely Palms
6135 Rattlesnake Hammock Road
Naples, FL 34113
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0679
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
On 4/13/21 at 1:20 p.m., in an interview the Activity Director said she has not done any group activities for
about a year due to COVID-19 but does give out packets for the activity listed on the activity calendar. The
packet includes the Daily Chronicles, independent bingo games, word search puzzles, Trivia, and other
items as per the calendar. A list of the residents who receive this daily activity packet was reviewed.
Resident #56 was identified as getting the Daily Chronicles and entire activity packet daily. The resident
was also to read it to his wife.
On 4/14/21 at 10:06 a.m., Resident #56 said he had never seen the activity packet, just the Daily Chronicle.
Review of the clinical record for Resident #56 revealed an admission MDS 3.0 assessment dated [DATE].
Section F 0500 interview for Activity Preferences indicated the resident liked music, to be around animals,
keep up with the news, do things with groups of people, go outside, and participate in religious services.
3. Review of the clinical record for Resident #57 revealed an admission MDS 3.0 assessment dated [DATE].
Section F 0500 interview for Activity Preferences indicated the resident liked to keep up with the news, do
her favorite activities, and go outside.
On 4/13/21 at 1:05 p.m., Resident #56 was observed in his room sitting in the wheelchair. The facility's
Daily Chronicle newsletter dated 4/12/21 was on the bed. The resident said he did get the facility's
Chronicle about once a week but would like to play bingo or any activity. Resident #57 was observed sitting
in the wheelchair next to Resident #56. She said in regards to activities, she likes to do anything.
4. On 4/12/21 at 2:31 p.m., in a confidential group interview, members of the Resident Council said they
used to play bingo but not any longer. They can color and the Daily Newsletter comes around but no
activities like they used to enjoy.
13. On 04/12/21 at 1:28 p.m., in an interview Resident #6 said there had been no activities at the facility
since COVID started. When asked what she does, she stated she watched television, there was nothing
else to do. She stated they were unable to leave their rooms.
On 4/14/21 at 9:00 a.m. Resident #6 said she had not received an activities packet and did not know what it
was.
15. On 4/12/21 at 1:28 p.m., in an interview Resident #15 said there had been no activities in the facility
since COVID started. When asked what she does, she stated she just stayed in her room, there was
nothing else to do. She stated they were unable to leave their rooms.
On 4/14/21 at 9:00 a.m., in an interview Resident #15 said she had not received an activities packet. She
did not know what it was.
On 04/13/21 at 3:32 p. m., the Activity Director said morning devotions was a devotional segment she
printed off the internet for the residents to read. She said We can't have groups as our policy states. We do
our devotions that way. The devotions are included in the packet. Plant appreciation stuff was printed out
and put in the packet. Trivia sheets are printed out and put in the packet. Bingo independent, word search
puzzle. Jeopardy is basically jeopardy questions with answers. Dolphin day, information about dolphins.
Coloring sheets with dolphins and the residents get colored pencils.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105499
If continuation sheet
Page 10 of 15
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105499
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/14/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Lely Palms
6135 Rattlesnake Hammock Road
Naples, FL 34113
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0679
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Afternoon art is an adult coloring sheet. Cranium sheets is like a picture puzzle. If they have a vision
impairment, I would sit with the resident I would give the resident the title of the puzzle and ask the resident
what some items of the title would be and cross them off. So, all activities are coming to the resident in
paper form. There is a different packet every day.
On 4/11/21 at 2:30 p.m., in an interview the Director of Nursing (DON) said the facility has not been
allowing any visitor inside the facility at this time. He said they have allowed compassionate care visits to
Hospice resident who were actively dying but this has only happened a few times since the start of the
pandemic. The DON said the facility has not been having communal dining or group activities even with
social distancing and wearing of mask. The DON said the [NAME] County COVID positivity rate was 7.9%,
58 plus residents and 78 staff have been fully vaccinated with the COVID-19 vaccine.
On 4/12/21 at 8:44 a.m., in an interview the Administrator said the facility has not started communal dining
or group activities since the start of the COVID pandemic. He said the facility has allowed outdoor visitation
but has not allowed indoor visitation yet. The Administrator said he was aware of the most recent
memorandum from CMS and the Center of Disease Control (CDC) Regarding the updated Nursing Home
Visitation - COVID-19 guidelines.
On 4/12/21 at 11:34 a.m., in an interview the Regional Corporate Nurse said Facilities Administrators and
Senior management all discussed the new update from CMS and CDC on a virtual meeting on 3/12/21. It
was discussed in depth the need to open up visitation as indicated in the memo. She said she knew the
company had detailed plans and she did not know why this facility had not started yet.
8. On 4/11/21 at 10:10 a.m., observed Resident #9 laying in his bed. Resident #9 said he would participate
in activities if the facility offered them but there was no activities program at this time.
On 4/12/21 at 9:47 a.m., observed Resident #9 laying in bed. He said there really was no activities to get
involved in. He said once in a while they would bring him outside but otherwise, we just stay in our rooms
and mostly in bed all day.
Review of the Minimum Data Set (MDS) assessment dated [DATE] showed Resident #9 was alert and
oriented, liked music, pets and keeping up with the news. It was very important to him to do his favorite
activities, and very important to be able to go out and get fresh air.
Review of Resident #9's Recreation/Activity Evaluation dated 1/19/21 showed the resident was interested in
group leisure activities, as well as outdoor leisure activities. It was also noted the resident liked to stay busy.
Resident #9's activity care plan goal stated the resident Prefers to pursue independent activities. The Goals
included the resident would participate in independent leisure activities of choice daily. Interventions
included to take resident outside as needed and on request, familiarize him with activity programs on a
regular basis and provide supplies and materials for leisure activities as needed.
5. On 4/11/21 at 11:00 a.m., observed resident #80 sitting in a wheelchair in her room dressed and
groomed, looking out the window. The television was not on and the resident was not participating in any
activity. Resident # 80 stated she has not had any activity, and no one has given her an
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105499
If continuation sheet
Page 11 of 15
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105499
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/14/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Lely Palms
6135 Rattlesnake Hammock Road
Naples, FL 34113
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0679
activity calendar or talked to her about activities.
Level of Harm - Minimal harm
or potential for actual harm
On 4/12/21 at 10:00 a.m., observation of resident #80 in room sitting in a wheelchair, reading church paper,
the television was not on and no activity observed.
Residents Affected - Some
On 4/13/21 at 9:45 a.m., observation of resident #80 sitting in a wheelchair in her room. Resident # 80
stated she was just sitting and waiting for lunch, as there was nothing more to do, she stated she would do
more if there were more activities to do. Resident # 80 said she never received any packets about activities,
so she watched television sometimes, but she could only do that for so long.
On 4/14/21 at 10:00 a.m., in an interview the Activity Director confirmed resident # 80 did not have an
activity care plan. She said she had no explanation as to why it was not completed.
6. On 4/11/21 at 11:18 a.m., observation of resident # 83 lying in bed in a hospital gown with the television
on. She stated there were no activities at the facility, she has not been given an activity calendar and no
one has spoken to her about activities. Resident #83 stated she would participate in activities if she knew
what activities were offered but she just watched television for the most part, and when she is up and
dressed, she just sits in her chair unless doing therapy.
On 4/12/21 at 11:30 a.m., observation of resident #83 sitting in her wheelchair, looking out the window. She
stated she was waiting for lunch, and just looking outside since there was nothing else to do. Resident # 83
stated she was never given any packet for activities or any books for reading, she had her friend bring a
book for her to read, as it gets boring at times, and she would love to go outside for some fresh air
sometimes.
On 4/13/21 at 11:32 a.m., observation of resident #83 in room sitting in a wheel chair looking out the
window, no activity, no television on, Resident # 83 stated she was just sitting, there was nothing to do, until
therapy came back again. She said she wished there was more to do but there was not, there was no
activities, and she was tired of reading her book, so she was just looking out the window.
7. On 4/12/21 at 9:09 a.m., observation of resident # 88 lying in bed in a hospital gown, no activity,
television not on. Resident #88 stated no one came to get her for activities, and no one has informed her of
any activities.
On 4/13/21 at 10:30 a.m., observation of resident #88 lying in bed, dressed in a hospital gown, no activity,
television not on. Resident #88 stated she would love to participate in card games if the facility was having
them, but nothing has been offered, no one has come to offer any activity and she has not received any
activity information, and no one has even offered individual activity to her.
On 4/13/21 at 4:06 p.m., review of Resident # 88's recreation/activity assessment revealed documentation
Resident #88 liked to keep busy and expressed interest in group activities and enjoyed participating in
outdoor leisure activities.
On 4/13/21 at 10:06 a.m., in an interview the Activity Director said the facility was not having any group
activities or outdoor activities, only independent activities for the residents. She said group activities were
canceled when the pandemic started and had not restarted. She stated the residents were currently having
independent activities by themselves, and residents were given activities packets. The Activity Director
provided the survey team with an activity packet and said she had no
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105499
If continuation sheet
Page 12 of 15
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105499
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/14/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Lely Palms
6135 Rattlesnake Hammock Road
Naples, FL 34113
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0679
documentation indicating when the residents received the activities packet.
Level of Harm - Minimal harm
or potential for actual harm
On 4/14/21 at 9:17 a.m., observation of Resident #88 in room, lying in bed in hospital gown, no television.
The surveyor reviewed with resident #88 the activity packet the Activity Director provided the survey team.
Resident # 88 said she had never seen the packet; she no one gave including the Activity Director gave her
such packet.
Residents Affected - Some
On 4/14/21 at 10:00 a.m., in an interview the Activity Director said she was responsible for performing the
recreation/activity assessment and activity care plan for the residents. The Activity Director confirmed
resident #88's recreation/activity assessment indicated she expressed interest in group activities and
playing cards. The Activity director stated she had not done any in room activity or played cards with
resident #88, and there were no group activities for the resident to participate in as indicated in her
assessment.
On 4/14/21 at 9:42 a.m., in an interview Certified Nursing Assistant (CAN) Staff H said she could not help
with activities as she was busy providing care services to her residents. CAN Staff H stated there was no
group activities at the facility, and she has not seen anyone from the activities department conducting one
on one activities with the residents.
9. On 4/11/21 at 12:35 p.m., in an interview Resident #38 said, There is no activities at this place. I'm only
allowed to be in my room.
On 4/13/21 at 11:05 a.m., in an interview resident #38 said, Nothing to do at this place, I get an hour a day
of therapy and 23 hours to lay in this bed. They have not offered me anything to read or do. I am trapped in
this room like a prison. The Resident said he has not been offered anything to keep him occupied the entire
time he has been here. Resident #38 said, it is depressing, being sick since January and having nothing to
do. I have not been offered anything, not even a newspaper . When asked about visitation he said when I
was in the other room my wife could come to the driveway and we could wave at each other and talk on the
phone, now in this room no luck, she isn't going to climb over bushes. It's like a punishment or bullying.
On 4/13/21 at 12:56 p.m., review of Resident #38's clinical record revealed an activity care plan which
included interventions to
familiarize with center environment and activity programs on regular basis,
provide supplies/materials for leisure activities as needed or requested.
The clinical record lacked documented recreation or activity notes for Resident # 38.
On 4/14/21 at 11:00 a.m., reviewed with Resident #38 an activity packet received from activities director as
sample of what was distributed to residents daily. Resident #38 said, Are you showing me what I am
supposed to be receiving? I have never seen that before, it's like being in jail here.
10. On 4/12/21 at 1045 a.m., in an interview resident #10 was asked if the facility had activities he'd like to
participate in. Resident #10 said, No they have no activities here and I have not been offered any activities.
I just watch TV or sleep.
On 4/13/21 at 3:00 p.m., record review showed a care plan dated 1/11/21 for Resident #10. The care
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105499
If continuation sheet
Page 13 of 15
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105499
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/14/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Lely Palms
6135 Rattlesnake Hammock Road
Naples, FL 34113
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0679
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
plan did not document activities or recreational interests. The Recreational / Activity assessment dated
[DATE] had no documentation. The clinical record showed no documented notes for recreational services
for Resident #10.
11. On 4/11/21 at 10:35 a.m., in an interview Resident #27 said, There are no activities at this facility. They
offer nothing to do.
On 4/12/21 at 10:09 a.m., in an interview Resident #27 said, we stay in this room and do nothing. Resident
# 27 said she was lucky she and her roommate liked each other since, we never get to leave the room.
On 4/13/21 at 3:02 p.m., review of the recreation/activities progress note dated 1/26/21 revealed when
resident #27 requested to go outside staff offered to take her out in 45 minutes but documented resident
was too tired at that time. Staff documented they would follow up the next day. The clinical record lacked
documentation of a follow-up the next day. The Resident's comprehensive care plan did not address
activities.
12. On 4/14/21 at 09:45 a.m., in an interview the activity packet received from the Activity Director as a
sample of what was distributed to residents daily was reviewed with Resident #492. Resident #492 said, I
don't think I have received those I don't see any in my room.
On 4/14/21 at 10:09 a.m., review of the clinical record for resident #492 revealed a care plan which did not
address any recreation or activities or choices. The clinical record had no documented recreation or activity
notes.
On 4/13/21 at 3:37 p.m., interviewed activities director who said, All residents should have an initial,
quarterly and annual note for recreation and activities. She confirmed the facility was not permitting visitors
inside, and said she provides a paper activity packet for residents.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105499
If continuation sheet
Page 14 of 15
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105499
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/14/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Lely Palms
6135 Rattlesnake Hammock Road
Naples, FL 34113
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on observation, review of facility policy and procedure and staff interviews, the facility failed to
appropriately store and protect residents' medications in a manner to prevent loss and reduced efficacy for
1 of 3 medication carts and 1 of 2 medication rooms.
The findings included:
The facility policy 5.3 (October 2016) Storage and Expiration Dating of Medications, Biologicals, Syringes
and Needles specified . Facility should ensure that the medications and biologicals for each resident are
stored in the containers in which they were originally received.
On 4/13/21 at 9:20 a.m., reviewed medication cart for 500 hall with LPN Staff K. Observed four loose pills
and two loose predated menthol medication patches in the cart. LPN Staff K, confirmed she could not
identify the loose pills and which residents the loose medications belonged to.
Observed a bag of intravenous micafungin (medication to treat fungal infection) 100 milligrams belonging to
Resident #542 stored on the shelf, out of brown plastic bag and in direct light. The medication label from
pharmacy specified to protect from light. RN Staff G confirmed the medication was not protected from light
as specified on the pharmacy label.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105499
If continuation sheet
Page 15 of 15
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Back to topCitations
6 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F563 - The resident has a right to receive visitors of his or her choosing at the time o
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F679 - Activities
Provide activities to meet all resident's needs.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
FAQ · About this visit
Common questions about this visit
What happened during the April 14, 2021 survey of SOLARIS HEALTHCARE LELY PALMS?
This was a inspection survey of SOLARIS HEALTHCARE LELY PALMS on April 14, 2021. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SOLARIS HEALTHCARE LELY PALMS on April 14, 2021?
Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.