Inspection·October 25, 2022

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and resident record review, the facility failed to treat each resident with respect and dignity for 2 (Residents, #11 and #158) of 2 residents reviewed for dignity. The findings included: 1. Record review revealed Resident #11 was admitted on [DATE]. Review of the Minimum Data Set (MDS) assessments noted Resident #11 was discharged to an acute care hospital on 8/20/22 and returned to the facility on 9/1/22. The quarterly MDS dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. On 9/19/22 at 11:38 a.m., Resident #11 was observed sitting in her wheelchair wearing a hospital gown. Resident was asked if she wanted to be in a hospital gown. Resident #11 said, I don't have my clothes they are in the other room. I would get dressed if I had my clothes. Observation of the resident's closet with her permission showed one light mint colored t-shirt and no other clothes. On 9/20/22 at 9:05 a.m., Resident #11 observed in bed wearing hospital gown. Asked if she wanted to stay in her hospital gown or if she would rather be dressed. Resident #11 replied, I don't have my stuff. Asked if she has asked staff for her items. Resident #11 replied, They know I don't have my stuff. On 9/20/22 at 11:08 a.m., Resident #11 was observed in bed wearing light mint green colored t-shirt and incontinence briefs. Resident #11 said she has been in this current room since she came back from the hospital. Resident #11 said no staff offered to get her clothes or personal items from her previous room, and no staff has told her if she will go back to her original room. On 9/21/22 at 10:00 a.m., Resident #11 was observed in wheelchair wearing a hospital gown over light mint green t-shirt. When asked if she wanted to be in a hospital gown, Resident #11 said, Who cares, but I don't want anyone messing with my stuff. I don't have my clothes or my things. On 9/22/22 at 9:00 a.m., observed Resident #11 in wheelchair in room wearing hospital gown. On 9/22/22 9:09 a.m., Certified Nursing Assistant (CNA), Staff B, assigned to Resident #11 said, She was in the 400 hall and then she came to the 500. She has been here a long time. Usually, residents in 500 hall are temporarily there. Since she is long term, I figured she would go back to her room (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 4 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 10/25/2022 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)