Inspection visit
Health inspection
9 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 9 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, clinical record review, review of facility's policy and procedure, resident and staff
interviews, the facility failed to provide the necessary assistance with activities of daily living for 1 (Resident
#53) of 1 resident observed with urine filled containers at bedside.
Residents Affected - Few
The findings included:
The facility policy Activities of Daily Living (ADL), Supporting documented Residents who are unable to
carry out activities of daily living independently will receive the services necessary to maintain good
nutrition, grooming, and personal and oral hygiene.
Review of the clinical record revealed Resident #53 had an admission date of 1/27/23 with diagnoses
including schizophrenia, depression, tremors, anxiety and dementia.
Review of the care plan initiated on 4/26/23 identified the problem: Incontinent of bowel and bladder. The
goal for the resident specified incontinent needs will be met. The approaches documented Assist with
changing brief when noted to be soiled or wet. Resident continues to keep urinals on floor. Continues to be
educated on infection control.
On 11/18/24 at 9:29 a.m., Resident #53 was observed in bed. The room had a pungent urine odor. Four
urinals were observed stored on the floor next to the bed. Two of the urinals were half full. In an interview
Resident #53 said he had to have four urinals since no one came to empty the urinals.
Photographic evidence obtained.
On 11/18/24 at 12:00 p.m., Resident #53 was observed in bed. Two urinals filled of urine and two empty
urinals were observed stored on the floor next to the resident's bed. In an interview Resident #53 said no
one had come to empty the urinals. The shared room remained with a pungent urine odor.
On 11/19/24 at 8:52 a.m., Resident #53 was observed in bed. The room remained with a pungent urine
odor. One urinal was on the floor. One urinal completely full of urine and one half full urinal were observe
stored on the floor in a wash basin. Resident #53 said he emptied the urinals during the day since staff do
not assist him. He said that was why he needed to have more than one urinal.
On 11/19/24 at 3:27 p.m., in an interview Certified Nursing Assistant (CNA) Staff P said Resident # 53 will
drink 10 cups of coffee and asks for ice water all night. He drinks a lot and does not like to get up and use
the toilet. He will only use the toilet for bowel movements. At night he uses the urinals. He keeps four of
them because he drinks so much that he urinates all the time. We will ask him to use the toilet, but he
refuses and you can't force him to do it. He is able to do everything
(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 18
Event ID:
105738
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
105738
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Imperial
900 Imperial Golf Course Blvd
Naples, FL 34110
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 0677
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
himself. The only time he wants us there is when he showers because he is afraid of falling. We empty the
urinals at the end of the shift and when needed. He can do it himself, but he won't.
On 11/19/24 at 3:40 p.m., in an interview CNA Staff P said he was assigned to Resident #53 for the
afternoon shift and said, The resident insists on keeping the urinals, four of them on the floor. They gave
him the washbasin yesterday to keep them off of the floor. He will go to the dining room and drink four to six
glasses of ice tea. Then he comes back to his room and uses the urinal. He can go to the bathroom, but he
won't do it. He urinates so much.
On 11/19/24 at 4:14 p.m., during a joint observation of the resident's room, the Director of Nursing (DON)
verified the resident's room had a very strong smell of urine. The DON said Resident #53 kept the urinals
on the floor and said it was addressed in his care plan. She said , He will put them on the floor, I know it is
an infection control issue, but the resident will not keep them in a basin, he puts them on the floor.
On 11/20/24 at 3:30 p.m., in an interview the DON said Resident #53 had a care plan for the use of the
urinals, and he was non-compliant. The DON said, He can use the toilet, and he can empty them, but he
won't. I have spoken to him, and he laughs at me and will not do it. The DON confirmed Resident #53
resided in the facility due to a diagnosis of schizophrenia and could not take care of himself. She said she
did not exactly how often the CNAs emptied the urinals. The DON confirmed it was the facility's
responsibility to take care of the resident and manage the infection control concern with the urinals stored
on the floor.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105738
If continuation sheet
Page 2 of 18
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
105738
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Imperial
900 Imperial Golf Course Blvd
Naples, FL 34110
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 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM
and/or mobility, unless a decline is for a medical reason.
Based on observation, review of the clinical record, review of facility policy and procedures and staff
interviews, the facility failed to provide care and services to prevent a decline in range of motion for 1
(Resident #50) of 1 resident reviewed with an orthotic device.
The findings included:
The facility policy Orthotic's documented, An orthotic is a device, sometimes called a brace or splint that is
used to properly position a body part for the purpose of function, rest or protection of a joint . A resident
with a condition that warrants the use of an orthosis will ideally be assessed through an interdisciplinary
process and a plan of care will be established to address the use of the orthotic device.
Benefits of orthotic:
Prevent or reduce contractures and deformity by applying prolonged, steady stretches of tight muscles/joint
structures.
Maintain proper joint positioning and alignment.
Reduce pain and or increase functional use of extremity by applying support for involved joint (s).
Promote skin integrity and improve hygiene.
Review of the clinical record revealed Resident #50 had a readmission date of 10/23/24 with diagnoses of
Parkinson's disease, sepsis, hemiplegia (partial or complete paralysis on one side of the body), protein
calorie malnutrition, and depression.
Review of the care plan initiated 12/28/21 noted the resident was at risk for skin integrity alteration due to
decreased mobility, history of cerebral vascular accident and left hand edema (swelling). The care plan
noted Resident #50 was to wear a left hand splint at all times, except for hygiene.
On 11/18/24 at 11:02 a.m., and 11/19/24 at 9:29 a.m., Resident #50 was observed in bed with a splint
applied to his left hand. The soft padded palm protector of the splint was positioned on the resident's wrist,
not the palm.
On 11/19/24 at 10:16 a.m., in a joint observation of the resident's splint, Occupational Therapists (OT) Staff
Q and Staff R confirmed the splint was not properly applied to Resident #50's left hand.
Staff Q and Staff R said they had no photograph or written instructions for the application of the splint. OT
Staff Q said the resident was not currently receiving therapy services and attempted to reapply the splint.
Staff Q said the resident had increased tone (tight muscles and stiff or rigid movements) and the Certified
Nursing Assistants (CNAs) should be opening the hand during care, cleaning the left hand and then placing
the splint. Staff Q said the large, rolled part of the splint should be placed in the residents hand and then
the Velcro straps applied. Staff Q said the splint is used to keep the resident's hand from contracting further
and keep the fingers from digging into his
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105738
If continuation sheet
Page 3 of 18
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
105738
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Imperial
900 Imperial Golf Course Blvd
Naples, FL 34110
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 0688
Level of Harm - Minimal harm
or potential for actual harm
palm. She said the resident's hand was very stiff and tight but was able to open the fingers to apply the
splint.
Review of the Treatment Administration Record dated 11/19/24 showed Registered Nurse Staff M signed
for the application of the splint to Resident #50's left hand.
Residents Affected - Few
On 11/20/24 at 9:22 a.m., during an observation of the resident's left hand, the splint was not properly
applied. The hand roll for the palm was around the resident's wrist.
On 11/20/24 at 10:00 a.m., in an interview CNA Staff S said she said she was not aware Resident #50 had
a splint for the left hand and said she did not know who was responsible to apply the splint. She said, I don't
know anything about it.
On 11/20/24 at 10:11 a.m., in an interview CNA Staff T said she was assigned to care for the resident
today. She said she did not know anything about the resident having a splint for his left hand. Staff T said I
do not know, and I don't know how to apply it. The CNA said I think someone else puts it on, maybe the
nurse.
On 11/20/24 at 11:13 a.m., in an interview with the Director of Nursing said the CNAs were responsible to
apply the splint for Resident #50. The DON confirmed she did not have documentation of education with the
staff regarding the proper application of the splint.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105738
If continuation sheet
Page 4 of 18
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
105738
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Imperial
900 Imperial Golf Course Blvd
Naples, FL 34110
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 0689
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Level of Harm - Actual harm
Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of facility policy and procedure, record review and staff interviews, the facility failed to thoroughly
investigate falls and implement adequate interventions to prevent falls and fall related injury for 1 (Resident
#24) of 3 residents reviewed who were identified as being at risk for falls and sustained multiple falls at the
facility.
The findings included:
The facility policy Incident Report and Investigation Guidelines documented, All falls, altercations,
elopements/unplanned exits, alleged neglect, alleged misappropriation or exploitation of resident property
or other events leading to harm or injury to a visitor or resident (incidents) occurring in the facility or on
facility property will be documented and investigated and recorded on an Incident Report and Investigation
form.
A thorough investigation of each incident shall be completed by the Director of Nursing (DON), Charge
Nurse or Supervisor, and the facility Risk Manager.
An adverse incident is an event over which the facility personnel could exercise control and which is
associated in whole or in part with the facility's interventions, rather than the condition for which such
interventions occurred, and which results in death, brain or spinal damage, permanent disfigurement,
fracture or dislocation of bones or joints, a limitation of neurological, physical or sensory function, any
condition that required the transfer of the resident within or outside of the facility to a unit providing a more
acute level of care due to the adverse incident.
The facility shall initiate an investigation and notify state and local authorities as required.
Review of the clinical record revealed Resident #24 was a vulnerable [AGE] year old female with an
admission date of 2/27/23. Diagnoses included syncope and collapse, dementia, muscle weakness, history
of falling and fracture of superior rim of right pubis, subsequent encounter for fracture with routine healing,
The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in
nursing home residents) with an assessment reference date of 8/8/24 documented Resident #24 required
partial to moderate assistance with toilet transfers.
The MDS noted Resident #24's cognitive skills for daily decision making were severely impaired.
The care plan initiated 2/27/23 identified the resident was at risk for falls related to weakness and history of
falls. The interventions included, maintain bed in low position when in use. Cue for safety awareness, place
call bell in reach.
Review of the record showed a fall report dated 8/3/24 at 4:36 am., indicating Resident #24 had an
unwitnessed fall and was found sitting on the floor next to her bed. The resident complained of pain to right
arm and leg. The physician was notified and ordered x-rays of the right arm and leg. There was no
documentation of the position of the resident's bed or the call light.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105738
If continuation sheet
Page 5 of 18
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
105738
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Imperial
900 Imperial Golf Course Blvd
Naples, FL 34110
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 0689
On 8/3/24 the care plan was updated with the intervention of one floor mat on the door side of the bed
when in bed.
Level of Harm - Actual harm
The follow up nursing documentation from 8/3/24 thorough 8/8/24 documented no reports of pain.
Residents Affected - Few
On 8/23/24, an incident report documented, Resident was being transferred to commode by certified
nursing assistant (CNA), resident's right leg gave out and staff lowered her to the floor. The form
documented the resident had right upper leg pain.
The physician was notified and ordered an X-ray of the hip with or without pelvis.
The X-ray results documented no evidence of acute fracture or dislocation.
Review of Resident #24's fall care plan revealed no evidence the care plan was updated with new
interventions based on the root cause of the incident to prevent further incidents of falls.
Review of the nursing progress notes documented the following:
On 8/24/24 at 2:38 p.m., no complaints of pain or discomfort.
On 8/24/24 at 6:32 p.m., denies any pain or discomfort.
On 8/25/24 at 10:08 p.m., no pain or discomfort referred.
On 8/26/24 at 6:17 a.m., no pain or discomfort referred.
On 8/27/24 at 7:50 a.m., the DON documented Resident grabbing right mid-thigh stated it hurts. Pain noted
called ARNP (Advanced Registered Nurse Practitioner) ordered stat femur right x-ray.
On 8/28/24 the ARNP documented, Patient seen and examined today for follow up visit. Patient seen in her
room, sitting in wheelchair. Nursing notes patient had a fall on 8/23/24 , she was being assisted by nursing
staff when her right leg gave way and she was lowered to the ground. X-ray of hip was ordered and
negative for any acute findings. Patient was complaining of right thigh pain yesterday and x-ray of femur
was ordered and negative for any acute findings. Patient reports she is having pain to her right thigh area.
Have ordered Voltaren gel (Medication applied to the skin to treat pain.) as well as a muscle relaxer. No
swelling or bruising noted on examination. Will continue to monitor closely for any changes.
On 8/28/24 at 8:56 p.m., the nursing progress note documented the resident was transferred to the dining
room for dinner. Observed resident grimacing and rubbing her right thigh at 4:40 p.m.
On 9/9/24 at 8:10 a.m., the DON documented Resident holding right leg up states it hurts. ARNP notified to
order possible CT (computerized tomography) scan since both x-rays were negative.
Resident #24 was sent to a diagnostic testing facility on 9/10/24 for a CT (computerized tomography) scan
of the upper right leg. The findings available on 9/11/24 documented acute mildly displaced fracture of the
right superior pubic ramus extending to the anterosuperior acetabular column and the posterior aspect of
the inferior pubic ramus adjacent to the ischial tuberosity.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105738
If continuation sheet
Page 6 of 18
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
105738
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Imperial
900 Imperial Golf Course Blvd
Naples, FL 34110
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 0689
Level of Harm - Actual harm
Residents Affected - Few
On 9/11/124 at 5:00 p.m., the progress note documented: Resident CT scan revealed a pelvic fracture.
DON arranged for Orthopedic consult for the end of the month. Notified resident's emergency contact of CT
scan result and resident to follow up with orthopedic at end of this month.
On 11/21/24 at 11:16 a.m., in an interview the DON said Resident #24 did not have pain from her fall on
8/3/24. She had a second fall on 8/27/24, she was lowered to the floor by a CNA. The aid had her in the
bathroom with a transfer of 1 assist and her leg gave out. The CNA lowered the resident to the floor. On the
fall on 8/3/24, a hip x-ray was negative and the nurses' notes all documented no pain. On 8/28/24 she was
complaining of pain in the right mid-thigh so they ordered a stat right femur x ray. The ARNP documented
on the fall and stated she had pain and the x-ray was negative. The resident reported pain in the right hip
area and the ARNP ordered Voltaren gel and a muscle relaxer, Tylenol as needed and she stated there was
no swelling or bring noted on her examination. On 9/9/24 the resident
started to complain of her right leg hurting and the ARNP was notified and ordered a CT scan. She went for
the CT scan on 9/10/24 and on 9/11/24 we got the results. The fracture was caused by her being lowered to
the floor. The DON confirmed she did not have documentation of a complete and thorough investigation
after the fracture was identified and said it was related to the fall on 8/23/24, not a fall but lowered to the
ground. The DON confirmed Resident #24's fracture was an injury of an unknown cause then clarified it
was from the lowering to the floor on 8/23/24. She confirmed she did not do an investigation of the fracture
and said the Risk Manager would have done that.
On 11/21/24 at 11:50 a.m., in an interview the Risk Manager said after the first fall on 8/3/24 Resident #24
did not complain of pain and during the three days post fall monitoring she had no additional pain. The Risk
Manager said it wasn't until the resident was lowered to the floor on 8/23/24 that she had reported pain. The
Risk Manager said You know how it can be they have an x- ray and it's negative and later an injury shows
up on further testing. I read the nurse's notes, and she had no pain. I based the fracture on the nurse's
documentation of no pain. She was lowered to the floor on 8/23/24 and that is how she sustained the
fractured identified on 9/10/23.
The Risk Manager confirmed she did not have documentation of a complete and thorough investigation of
the fall on 8/23/24 and did not report the event to the appropriate State Agency once the fracture was
identified. The Risk Manager said, I don't have an investigation; I told you already. I'm not answering that. I
know what you want me to say but I'm not going to say that. She said, the resident had no pain after the fall
on 8/3/24. I did not need to investigate the fracture because she did not complain of pain until after she was
lowered to the floor on 8/23/24.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105738
If continuation sheet
Page 7 of 18
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
105738
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Imperial
900 Imperial Golf Course Blvd
Naples, FL 34110
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 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based of
observation, medical record review and facility policy review, the facility failed to assess bladder
incontinence for 2 (Residents #37, and #92) of 2 residents reviewed for incontinence, and failed to provide
appropriate care of indwelling urinary catheters for 2 (Residents #64 and #50) of 2 sampled residents
observed with urinary catheters.
The findings included:
Review of the facility policy for the BOWEL AND BLADDER REHABILITATION PROGRAM reads,
General Guidelines
1.
The initiation of a continence program requires the consent and cooperation of the resident/responsible
party.
2.
The continence program must be individualized and resident centered to decrease or prevent urinary
incontinence in order to minimize or avoid negative consequences of incontinence.
3.
Steps to ensure that the resident receives appropriate treatment and services to restore urinary continence
include:
Determining if the resident is currently experiencing some level of incontinence or is at risk of developing
urinary incontinence.
Completing an accurate, thorough assessment of factors that may predispose the resident to having urinary
incontinence.
Restorative Nurse Manager or Licensed Nurse completing the Urinary Continence Evaluation on
admission, quarterly, annually, and when a significant change in resident condition occurs.
1. Clinical Record review revealed Resident #37 was admitted to the facility on [DATE] with a history of
Parkinson's Disease. Diabetes, Chronic Kidney Disease, and Depression.
The Quarterly Minimum Data Set (MDS) assessment dated [DATE] noted the resident's cognition was
moderately impaired with a Brief Mental Interview Status (BIMS) score of 10.
The MDS noted Resident #37 was frequently incontinent of bowel and bladder.
On 11/19/24 at 8:40 a.m., Resident #37 was able to answer interview questions appropriately. The resident
was oriented to time, place, and person. Resident #37 said staff told him to go in his brief.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105738
If continuation sheet
Page 8 of 18
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
105738
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Imperial
900 Imperial Golf Course Blvd
Naples, FL 34110
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 0690
Resident #37 said he did not have a problem with incontinence until he was admitted to the facility.
Level of Harm - Minimal harm
or potential for actual harm
Review of Resident #37's electronic record showed no documentation of a Urinary Continence Evaluation.
Residents Affected - Some
On 11/19/24 at approximately 2:00 p.m., in an interview the Director of Nursing verified Resident #37 had
not been assessed for Urinary Incontinence and the potential for bladder training.
2. Clinical record review revealed Resident #92 was admitted to the facility on [DATE] with a history of
Diabetes, General Weakness, Obesity, and Depression.
The admission MDS assessment with a target date of 10/23/24 noted the resident's cognition was intact
with a BIMS score of 15.
The MDS noted Resident #92 was frequently incontinent of urine and was not on a bladder retraining
program.
On 11/18/24 at 1:21 p.m., in an interview Resident #92 said she was incontinent of urine. She said at times
she cannot make to the restroom because she takes a diuretic and staff at times take 30 minutes to assist
her to the bathroom.
Review of Resident #92's electronic record showed no documentation of a Urinary Continence Evaluation.
On 11/19/24 at approximately 2:00 p.m., in an interview the Director of Nursing verified Resident #37 had
not been assessed for Urinary Incontinence and the potential for bladder retraining.
3. The facility policy Catheter Care, Urinary with a revision date of 1/7/20 documented Be sure the catheter
tubing and drainage bag are kept off the floor. Ensure that the catheter remains secured to reduce friction
and movement at the insertion site. (note: Catheter tubing should be secured to the residents inner thigh.).
Review of the clinical record revealed Resident #64 had an admission date of 5/28/24 with diagnoses
obstructive and reflux uropathy, chronic kidney disease with heart failure and stage 1 through stage 4
chronic kidney disease, history of malignant neoplasm of the prostate, and urinary tract infections (UTI's),
and chronic obstructive pulmonary disease.
Review of Resident #64's care plan identified a Problem: Has Supra pubic catheter related to obstructive
uropathy. The goal for the resident was to be free from any preventable infection or trauma related to the
catheter. The interventions instructed staff to secure the catheter to prevent pulling or accidental removal.
Provide assist with peri care every shift and as needed. Keep the catheter bag covered for privacy. Keep the
catheter tubing free of kinks.
The record showed on 10/23/24 Resident #64 had a positive urine culture with the bacteria Escherichia
Coli and was treated with antibiotics.
On 11/18/24 at 9:48 a.m., Resident #64 was observed in his room in his wheelchair. (w/c) The resident was
noted to have a suprapubic catheter. The tubing and drainage bag were coiled around the front
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105738
If continuation sheet
Page 9 of 18
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
105738
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Imperial
900 Imperial Golf Course Blvd
Naples, FL 34110
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 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
wheel of the w/c. The room had a very strong odor of urine. There was no drainage bag holder on the w/c
for the resident to secure the catheter drainage bag.
Photographic evidence obtained.
On 11/19/24 at 8:51 a.m., Resident #64's suprapubic catheter drainage bag was observed coiled up and
resting on the front wheel of the w/c. There was no drainage bag holder on the w/c,
On 11/19/24 at 4:10 p.m., in an interview the Director of Nursing said the resident will remove the catheter
from the bedside and wrap it around the front of the w/c while he goes into the bathroom. She said, I put a
black bag there for him and educated him.
4. Review of the clinical record revealed Resident #50 was admitted to the facility on [DATE] with diagnoses
including Parkinson's disease, sepsis, hemiplegia, and protein calorie malnutrition. Resident #50 had an
indwelling urinary catheter.
Review of the physician order showed an order dated 11/19/24 to secure the catheter tubing and check
every shift.
On 11/20/24 at 12:39 p.m., the resident's indwelling urinary catheter tubing was not secured to the
resident's thigh to prevent friction and movement at the insertion site.
Infection Preventionist Staff M was present during the observation and verified the urinary catheter tubing
was not secured.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105738
If continuation sheet
Page 10 of 18
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
105738
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Imperial
900 Imperial Golf Course Blvd
Naples, FL 34110
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 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, review of facility policy and procedure, review of the clinical record, resident and
staff interviews, the facility failed to maintain respiratory equipment in a sanitary manner for 2 (Residents
#64 and #23) of 2 residents reviewed.
Residents Affected - Few
The findings included:
The facility Policies and Practices- Infection Control documented This facility's infection control policies and
practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help
prevent and manage transmission of diseases and infections.
The objectives of our infection control policies and practices are to:
a. Prevent, detect, investigate, and control infections in the facility.
b. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors and the general
public.
1. Review of the clinical record revealed Resident #64 had an admission date of 5/28/24 with diagnoses
obstructive and reflux uropathy, chronic kidney disease with heart failure and stage 1 through stage 4
chronic kidney disease, history of malignant neoplasm of the prostate, and urinary tract infections (UTI's),
and chronic obstructive pulmonary disease.
On 11/18/24 at 9:23 a.m., during an observation, Resident #64 was noted to have a Bi -Pap (non-invasive
breathing machine that delivers pressurized air into the airways) and a nebulizer machine (turns liquid
medicine into a mist that is inhaled) on top of his nightstand. Both machines had a mask that was
uncovered and lying on top of the machines. Resident #64 said the facility takes care of the equipment and
he used both machines on a daily basis.
Photographic evidence obtained.
2. Review of the clinical record revealed Resident #23 had an admission date of 10/16/23. Diagnoses
included the need for assistance with personal care, muscle weakness, and emphysema (chronic
obstructive pulmonary disease that damages the air sacs in the lungs).
On 11/18/24 at 9:52 a.m., during an observation Resident #23 was in her room in bed. It was noted she
had a nebulizer machine on her nightstand and the mask was uncovered and lying on the night stand.
Photographic evidence obtained.
On 11/20/24 at 9:26 a.m., during an observation Resident #23's nebulizer mask was uncovered on the
nightstand. In an interview Resident #23 said she uses the nebulizer machine because she has difficulty
breathing at times.
On 11/19/24 at 4:05 p.m., in an interview the Director of Nursing (DON) confirmed the nebulizer and Bi-PAP
masks should be in a plastic bag and not lying on top of the nightstands when not in use. The DON said,
The nurse is responsible to ensure that the masks are covered after administration of
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105738
If continuation sheet
Page 11 of 18
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
105738
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Imperial
900 Imperial Golf Course Blvd
Naples, FL 34110
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 0695
the medication.
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:
105738
If continuation sheet
Page 12 of 18
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
105738
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Imperial
900 Imperial Golf Course Blvd
Naples, FL 34110
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 0725
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in
charge on each shift.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to maintain sufficient staffing to ensure call lights
were answered in a timely manner for 7 (Resident #94, #70, #63, #37, #22, #73, and #200) of 7 residents
sampled. The failure to respond to call lights in a timely manner places residents at increased risks for
injuries related to falls.
The findings included:
On 11/18/24 at 11:05 a.m., in an interview Resident #94 said it can take between ten to thirty minutes for
staff to respond to a call light. Resident #94 said the lack of staff response occurred more often on the 3:00
p.m. to 11:00 p.m. shift.
Resident #94 was observed to activate the call light on 11/18/24 at 11:06 a.m. Resident #94 said he should
not have to wait more than five minutes. On 11/18/24 at 11:18 a.m., Certified Nursing Assistant, Staff H
responded to the resident's call light.
When asked how long a resident had to wait for the call light to be answered, Staff H said two to five
minutes. Staff H said he could not answer the call light sooner since he was in another room assisting
another resident.
On 11/18/24 at 11:20 a.m., in an interview Resident #70 said when he uses the call light staff took 30
minutes all the time to respond. Resident #70 said he was incontinent because he did not get assistance to
the bathroom quick enough.
On 11/18/24 at 12:12 p.m., in an interview Resident #63 said she has to wait 30 minutes for staff to
respond to the call light. The resident said it happened every week, more often at night.
On 11/19/24 at 8:34 a.m., in an interview Resident #37 said he has to wait 30 minutes for staff to answer
the call light. Resident #37 happens a couple times each week and at no particular time.
On 11/19/24 at 9:30 a.m. in an interview Resident #22 said staff do not answer the call light at night.
Resident #22 said there were times she had to wait 45 minutes for staff to answer the call light. Resident
#22 said she did not feel she should have to wait more than 20 minutes for staff to respond to her call light.
Resident #22 said she stopped using her call light at night because staff do not respond.
On 11/19/24 at 9:35 a.m., in an interview Resident #73 said It takes up to 45 minutes for someone to
answer her call light.
Review of the grievance log for October 2024 showed grievances dated 10/10/24, 10/11/24, and 10/22/24
of residents complaining of call light response time. All three grievances documented the issue was
resolved.
On 11/20/24 at 11:41 a.m. The Social Service Director (SSD) said She has had complaints regarding call
light response time in the last three months. The SSD States the expectation for call light response time is
15 to 20 minutes. She could not say if this was a policy or verbally instructed to
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105738
If continuation sheet
Page 13 of 18
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
105738
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Imperial
900 Imperial Golf Course Blvd
Naples, FL 34110
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 0725
staff and residents. She said she would get back with me.
Level of Harm - Minimal harm
or potential for actual harm
On 11/20/24 11:48 a.m., in an interview the Administrator said the expectation of call light response time is
10 to 15 minutes. When asked about emergency call lights response in the bathrooms, the Administrator
responded, All call lights in general. She said this was not written in a policy. She indicated the expectation
was verbally passed on to residents and staff.
Residents Affected - Some
The Administrator provided documentation of staff receiving instructions in call light response times dating
to June of 2024. The Administrator provided documentation of weekly call light audits which had no
documentation of the time the call lights were being monitored, and, who was monitoring the call lights.
On 11/20/24 at 10:15 a.m., during a Resident Council meeting, members complained CNAs take 15
minutes or longer to answer call lights. The residents attending the meeting said it happens often.
On 11/20/24 at 1:18 p.m., the Resident Council Presidents said the call light response time does come up
in the meetings. She said her understanding is it should not take more than 15 minutes for staff to respond
to call lights. The Resident Council President said she had heard from other residents that at night it can
take more than an hour for staff to respond to the lights. She said in the council meeting she just
remembers residents complaining it takes longer than 15 minutes.
Review of the Resident Council minutes showed no documentation of residents complaining of call light
response times.
Review of the clinical record revealed Resident #200 was admitted to the facility on [DATE] with a history of
head injury and laceration above the right eye related to a fall.
On 11/22/24 at 12:30 p.m., Resident #200's call light was observed to be engaged. Upon entering the
room, Resident #200 was observed sitting next to his bed in a wheelchair. The resident was wearing a
surgical mask. A contusion and a wound was observed to the resident's right eye. The resident said he had
initiated his call light, and no one came. The resident said his call light had been on for about 10 minutes.
The resident said he was admitted to the facility on [DATE]. Resident #200 said he sustained the injury to
the left eye when he fell at home while attempting to go to the bathroom. The resident said he turned on his
call light because he was wondering why his lunch was not here yet.
The resident's call light was answered on 11/22/24 at 12:35 p.m.
On 11/22/24 at 12:35 p.m., in an interview the DON said during the initial care plan meeting, residents are
informed call light response time should be between 10 to 15 minutes but it was not documented.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105738
If continuation sheet
Page 14 of 18
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
105738
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Imperial
900 Imperial Golf Course Blvd
Naples, FL 34110
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 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and staff interviews, the facility failed to ensure 1 (Resident #70) of 5 residents reviewed had
a diagnosis, and rationale for the use of antipsychotic medication.
The findings included:
Clinical record review revealed Resident #70 was admitted to the facility on [DATE]. Diagnoses included
Anxiety Disorder, Mood Disorder, and Hallucinations.
A physician's order dated 11/5/24 read, quetiapine [Seroquel] tablet; 25 mg; 0.5 tablet at bedtime.
No diagnosis for the use of the Seroquel (antipsychotic) was documented in the order.
On 11/21/24 at 12:15 p.m., in an interview the DON verified there was no diagnosis documented on the
physician's order for Seroquel for Resident #70.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105738
If continuation sheet
Page 15 of 18
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
105738
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Imperial
900 Imperial Golf Course Blvd
Naples, FL 34110
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, review of facility policy and procedure, review of the clinical record and staff
interviews the facility failed to store resident care equipment in a sanitary manner for 2 (Residents #23 and
#53) of 6 residents reviewed and failed to follow infection prevention during wound care for 1 (Resident #50)
of 1 resident observed for wound care.
Residents Affected - Some
The findings included:
The facility Policies and Practices- Infection Control documented This facility's infection control policies and
practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help
prevent and manage transmission of diseases and infections.
The objectives of our infection control policies and practices are to:
a. Prevent, detect, investigate, and control infections in the facility.
b. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors and the general
public.
1. On 11/20/24 at 12:39 p.m., Registered Nurse (RN) Staff M, Infection Preventionist was observed
changing Resident #50's dressing to a left ischeal wound.
Two CNAs repositioned Resident #50 to the right side. A nonstick border dressing was observed on the
resident's left ischium and a very large foam dressing covered the resident's rectum and both upper
buttocks.
Staff M donned a disposable gown, entered the room, washed her hands and applied clean gloves. She
placed the dressings and the Dakins solution on a towel on the bedside table. She left the room, and
returned with additional wound care supplies. Staff M did not change the gown or the gloves upon
reentering the resident's room. She used wet wipes to clean feces around the dressing. Staff M did not
remove the soiled gloves or performed hand hygiene. With the soiled gloves on, she opened three drawers
of the nightstand looking for wet wipes. She then opened the bedroom door with the soiled gloves on and
asked staff to bring more wet wipes. Staff M used the wet wipes to clean more feces around the wound.
She doffed the gloves, and donned a pair of clean gloves without washing her hands or performing hand
hygiene. Staff M removed the soiled dressing exposing a foul smelling wound approximately the size of a
baseball with slough, necrotic tissue in the center of the wound bed. Staff M did not remove the gloves used
to remove the soiled dressing. She cleansed the wound with Dakins solution and applied skin prep to the
intact skin surrounding the wound. Staff M removed the gloves. She did not perform hand hygiene and
applied a new pair of gloves. She applied the Dakins solution to three 4 by 4 gauze dressings which she
inserted into the wound. She covered the wound with a Telfa (non stick) border dressing
On 11/20/24 at 3:17 p.m., in an interview Infection Preventionist Staff M said yes you have to change gloves
and do hand hygiene during glove changes. If touching other surfaces the gloves would be contaminated, I
would expect the nurses to change gloves.
2. On 11/18/24 at 12:00 p.m., Resident #53 was observed in bed. Two urinals filled of urine and two empty
urinals were observed stored on the floor next to the resident's bed. In an interview
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105738
If continuation sheet
Page 16 of 18
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
105738
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Imperial
900 Imperial Golf Course Blvd
Naples, FL 34110
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 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Resident #53 said no one had come to empty the urinals. The shared room remained with a pungent urine
odor.
On 11/19/24 at 8:52 a.m., Resident #53 was observed in bed. The room remained with a pungent urine
odor. One urinal was on the floor. One urinal completely full of urine and one half full urinal were observe
stored on the floor win a wash basin. Resident #53 said he emptied the urinals during the day since staff do
not assist him. He said that was why her needed to have more than one urinal.
On 11/19/24 at 3:27 p.m., in an interview Certified Nursing Assistant (CNA) Staff P said We empty the
urinals at the end of the shift and when needed. He can do it himself, but he won't.
On 11/19/24 at 4:14 p.m., during a joint observation of the resident's room, the Director of Nursing (DON)
verified the resident's room had a very strong smell of urine. The DON said Resident #53 kept the urinals
on the floor and said it was addressed in his care plan. She said , He will put them on the floor, I know it is
an infection control issue, but the resident will not keep them in a basin, he puts them on the floor.
On 11/20/24 at 3:30 p.m., in an interview the DON said Resident #53 had a care plan for the use of the
urinals, and he was non-compliant. The DON said, He can use the toilet, and he can empty them, but he
won't. I have spoken to him, and he laughs at me and will not do it. The DON confirmed Resident #53
resided in the facility because he had schizophrenia and could not take care of himself. She said she did
not exactly how often the CNAs were emptying the urinals. The DON confirmed it was the facility's
responsibility to take care of the resident and manage the infection control concern with the urinals stored
on the floor.
3 Review of the clinical record revealed Resident #23 had an admission date of 10/16/23 with diagnoses
including the need for assistance with personal care, muscle weakness, and emphysema (chronic
obstructive pulmonary disease that damages the air sacs in the lungs).
On 11/18/24 at 9:52 a.m., during an observation Resident #23 was in her room in bed. It was noted she
had a nebulizer machine on her nightstand and the mask was stored uncovered.
Photographic evidence obtained.
On 11/20/24 at 9:26 a.m., during an observation Resident # 23's nebulizer mask was uncovered on the
nightstand. In an interview Resident #23 said she uses the nebulizer machine because she has difficulty
breathing at times.
On 11/19/24 at 4:05 p.m., in an interview the Director of Nursing confirmed the nebulizer and Bi-PAP masks
should be in a plastic bag and not lying on top of the nightstands. She said the nurse was responsible to
ensure that the masks are covered after administration of medications
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105738
If continuation sheet
Page 17 of 18
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
105738
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Imperial
900 Imperial Golf Course Blvd
Naples, FL 34110
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 0882
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Designate a qualified infection preventionist to be responsible for the infection prevent and control program
in the nursing home.
Based on observation, record review, facility policy and practices review and staff interview, the facility
failed to ensure the Infection Preventionist had the required qualifications to perform the role of Infection
Preventionist.
The findings included:
The facility policy Infection Preventionist documented The Infection Preventionist is responsible for
coordinating the implementation and updating of our established infection prevention and control policies
and practices. The Infection Preventionist shall keep abreast of changes in infection prevention and control
guidelines and regulations to ensure our facility's protocols remain current and aid in preventing and
controlling the spread of infections.
On 11/20/24 at 12:39 p.m., Registered Nurse (RN) Staff M, Infection Preventionist was observed changing
Resident #50's dressing to the left ischeal wound.
Two CNAs repositioned Resident #50 to the right side. A nonstick border dressing was observed on the
resident's left ischium and a very large foam dressing covered the resident's rectum and both upper
buttocks.
Staff M donned a disposable gown, entered the room, washed her hands and applied clean gloves. She
placed the dressings and the Dakins solution on a towel on the bedside table. She left the room, and
returned with additional wound care supplies. Staff M did not change the gown or the gloves upon
reentering the resident's room. She used wet wipes to clean feces around the dressing. Staff M did not
remove the soiled gloves or performed hand hygiene. With the soiled gloves on, she opened three drawers
of the nightstand looking for wet wipes. She then opened the bedroom door with the soiled gloves on and
asked staff to bring more wet wipes. Staff M used the wet wipes to clean more feces around the wound.
She doffed the gloves, and donned a pair of clean gloves without washing her hands or performing hand
hygiene. Staff M removed the soiled dressing exposing a foul smelling wound approximately the size of a
baseball with slough, necrotic tissue in the center of the wound bed. Staff M did not remove the gloves used
to remove the soiled dressing. She cleansed the wound with Dakins solution and applied skin prep to the
intact skin surrounding the wound. Staff M removed the gloves. She did not perform hand hygiene and
applied a new pair of gloves. She applied the Dakins solution to three 4 by 4 gauze dressings which she
inserted into the wound. She covered the wound with a Telfa (non stick) border dressing
On 11/20/24 at 3:17 p.m., in an interview Infection Preventionist Staff M said yes you have to change gloves
and do hand hygiene during glove changes. If touching other surfaces the gloves would be contaminated, I
would expect the nurses to change gloves.
Review of the Infection Preventionist's personnel record revealed she started the Centers for Disease
Control Infection Preventionist training in 2019 but did not complete all 17 training modules required.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105738
If continuation sheet
Page 18 of 18
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Back to topCitations
9 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.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F725 - Nursing Services
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F882 - Infection preventionist
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
FAQ · About this visit
Common questions about this visit
What happened during the November 22, 2024 survey of SOLARIS HEALTHCARE IMPERIAL?
This was a inspection survey of SOLARIS HEALTHCARE IMPERIAL on November 22, 2024. The surveyor cited 9 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SOLARIS HEALTHCARE IMPERIAL on November 22, 2024?
Yes, 9 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide care and assistance to perform activities of daily living for any resident who is unable."
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.