Health inspection·June 6, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on record review, review of facility's policies and procedures, and staff interviews, the facility failed to report allegation of resident to resident abuse involving 1 (Resident #8) of 3 sampled residents reviewed. Residents Affected - Few The findings included: The facility Patient Protection Guidelines dated 10/2021 stated, The center supports and protects patients, family members and staff from harm during an investigation for abuse. Patient protection actions include: immediately removing the patient form contact with the alleged abuser . Reporting the actual or suspicious event to the Abuse Prevention Coordinator and Administrator, Reporting allegations of abuse to other agencies or law enforcement. Review of the clinical record for Resident #8 revealed a progress note dated 3/26/23 at 10:51 p.m., which noted, Resident was found lying on the floor in her room, she stated that her roommate (Resident #9) pulled her out of bed on to the floor because she was coughing. Resident was assessed vitals, neurological observations, pain, and skin assessment completed and charted; a tiny skin tear was noticed on resident left arm was cleanse [sic] with saline and STERIS [sic] trip applied. Resident denied pain. MD (physician) and resident's niece informed. Records reviewed showed Residents #8 and #9 resided in the secured memory care unit. On 5/10/2023 at 4:20 p.m., the Director of Nursing (DON) said the facility did not submit a Federal Day 1 to the State Survey Agency as required. She said, We separated them and (Resident #9) who pulled her (Resident #8) out of the bed now does not have any roommates, but we did not report it. We talked about it as a group but did not think to report. But looking at the nursing note, I see we should have reported it. During the interview, the Administrator walked into the DON's office, reviewed the nursing progress note and agreed the incident should have been reported. 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 2 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 06/06/2023 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)