Inspection visit
Inspection
7 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 7 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
Based on observation, interview, and record review the facility failed to implement fall prevention care plan
interventions for 1 of 4 residents, Resident #26, reviewed for accidents.
Residents Affected - Few
Findings include:
On 9/19/2022 beginning at 10:34 AM, Resident #26 was observed in her room. Resident #26 was initially
observed walking without an assistive device from her restroom to her bed. A three-prong cane was
available for use on Resident #26's side of the room. There was no wheelchair in Resident #26's room
available for her use. During the initial observation, Resident #26 attempted to sit on the top of the in-room
air conditioning unit, lost her balance and leaned over forward onto cardboard boxes. A staff member
standing nearby assisted Resident #26 up off of the cardboard boxes onto the in-room air conditioning unit.
During an interview on 9/19/2022 beginning at 10:34 AM, Resident #26 stated she falls real easy and when
she falls, she falls backwards. Resident #26 added that she had fallen 3 times and busted my head, I'm
supposed to be in a wheelchair or use a walker. I have doctor's orders not to walk without a wheelchair.
During an interview on 9/21/2022 at 8:36 AM, Staff A, Physical Therapist, reported Resident #26 had been
provided a high back wheelchair with a cushion and anti-roll back device.
On 9/21/2022 at 8:39 AM, an observation of Resident #26 and her room was completed with the Director of
Rehabilitation. There was no wheelchair in Resident #26's room available for her use.
During an interview on 9/21/2022 beginning at 8:47 AM, Staff B, Registered Nurse, stated, I always see her
ambulating in her room, even when she goes out with family, I see her ambulating. I did not know she
[Resident #26] did not have one [a wheelchair]. Staff B reported Resident #26 had taken a leave of
absence from the facility on 9/2/2022 and returned to the facility on 9/13/2022.
During an interview on 9/21/2022 beginning at 9:02 AM, Staff C, Certified Nursing Assistant, stated therapy
had taken Resident #26's wheelchair when Resident #26 left the faciity on leave of absence. Staff C
confirmed Resident #26 did not have a wheelchair available for her use on 9/19/2022 so she got her one for
transport.
Review of Resident #26's physician's orders, revealed a physician's order, start date 5/6/2022, for Resident
#26 to use a standard wheelchair with cushion and anti-roll back device.
(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 9
Event ID:
105769
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
105769
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/22/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Lake City
560 SW McFarlane Ave
Lake City, FL 32055
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Review of Resident #26's care plan, start date 8/8/2022, revealed Resident #26 was at risk for falls related
to weakness/debility and a history of syncope and collapse. Resident #26's care plan documented fall
prevention interventions that included OOB [Out of Bed] in Standard Wheelchair with cushion, ARBD [Anti
Roll Back Device] as tolerated.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105769
If continuation sheet
Page 2 of 9
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
105769
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/22/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Lake City
560 SW McFarlane Ave
Lake City, FL 32055
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 0658
Ensure services provided by the nursing facility meet professional standards of quality.
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, and interview, the facility failed to provide drainage tube dressing care and
services to meet professional standards of quality of care for 1 of 3 residents, Resident #263, sampled for
drainage tube care, and failed to provide Foley catheter drainage management for 1 of 3 residents,
Resident #458, sampled for catheter care.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #263, documented the resident, age [AGE], was admitted to the
facility on [DATE] with diagnoses including acute cholecystitis, heart failure, type 2 diabetes mellitus, and
heart disease.
Review of Resident #263's physician orders documented an order dated 9/14/22 which read, clean around
chole tube w/ NS [with normal saline] apply non-stick telfa, cover w/ 4 x 4 and top with green opsite [a
wound care dressing] daily.
During an observation conducted on 09/19/22 at 11:34 AM, Resident #263 was observed to have a
cholecystostomy [gallbladder] tube. The dressing surrounding the tube was not labeled or dated.
During an observation conducted on 09/19/22 at 1:54 PM, Resident #263 was observed to have a
cholecystostomy tube in place with the dressing not labeled or dated.
During an interview with Staff D, LPN (Licensed Practical Nurse) conducted on 09/19/22 at 1:55PM, she
confirmed Resident #263's dressing was not labeled or dated.
During an interview with the Director of Nursing conducted on 09/19/22 at 2:35 PM, she confirmed her
expectation is for all dressings to be labeled with the date applied and initials.
Review of the facility policy and procedure dated 01/2022, titled, Dressings, Dry/ Clean, reads, 10. Label
tape or dressing with date, time, and initials.
Review of the medical record for Resident #458 documented the resident was admitted [DATE] with
diagnosis to include: hematuria (blood in urine), urinary tract infection, retention of urine, renal mass,
dementia, neuropathy, encephalopathy (alters brain function), atherosclerotic heart disease (plague build
up in arteries), atrial fibrillation (irregular heartbeat), chronic obstructive pulmonary disease (block of air
flow in the lungs), asthma, dementia, and depressive disorder.
Review of the physician orders dated 9/13/2022 read, 24 fr [French] 30cc [cubit centimeter] Urinary
Catheter to BSD [bed side drainage] due to retention; Check Q [every] shift & PRN [as needed] to ensure
draining properly.
An observation on 09/19/2022 at 10:35 AM showed Resident #458 was lying on her left side. There was a
urinary catheter drainage leg bag observed attached to her right leg. The Foley tubing and the Foley
catheter urinary drainage leg bag were full of urine which did not allow for drainage from Resident #458's
bladder.
An observation on 9/20/2022 at 11:35 AM showed Resident #458 was lying flat on her back across the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105769
If continuation sheet
Page 3 of 9
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
105769
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/22/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Lake City
560 SW McFarlane Ave
Lake City, FL 32055
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 0658
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
bed with her feet flat on the floor. There was a Foley urinary drainage leg bag observed attached to the right
side of her upper leg. The Foley catheter tubing and the Foley catheter urinary drainage leg bag were full of
dark yellow colored urine which did not allow for drainage from Resident #458's bladder.
During an interview on 9/21/2022 at 09:10 AM the Director of Nursing (DON) stated the orders need to be
followed and the standard of care for foley leg bags are for when residents are up and about not laying
down or sleeping.
During an interview on 9/21/2022 at 09:16 AM with Resident #458's sister, who resides in the facility,
Resident #258 stated, I want the leg bag taken off and I did not request a leg bag to be worn all the time.
During an interview on 9/21/2022 at 10:22 AM Staff E, Certified Nursing Assistant (CNA) stated, Foley bags
are emptied once a shift and if needed. The amount is documented in the Metrics if the nurse needs the
information.
During an interview on 9/21/2022 at 12:50 PM Staff F, CNA stated, Bags are emptied once a shift, leg bags
are more frequently because they don't hold much.
Review of the policy and procedure dated 1/24/22, titled, Catheter Care, Urinary reads: Unobstructed urine
flow - 1) Check the resident frequently to be sure he or she is not lying on the catheter and to keep the
catheter and tubing free of kinks. 2) unless specifically ordered, do not apply clamp to the catheter. 3) The
urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in
the tubing and drainage bag from flowing back into the urinary bladder. Infection Control section 2: c Empty the drainage bag regularly using a separate, clean collection container for each resident. Avoid
splashing and prevent contact of the drainage spigot with the nonsterile container. d. Empty the collection
bag as needed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105769
If continuation sheet
Page 4 of 9
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
105769
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/22/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Lake City
560 SW McFarlane Ave
Lake City, FL 32055
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 - Minimal harm
or potential for actual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Based on observation, interview and record review the facility failed to ensure fall prevention devices were
available for 1 of 4 residents, Resident #4, reviewed for falls/accidents.
Residents Affected - Few
Findings include:
On 9/19/2022 beginning at 10:34 AM, Resident #26 was observed in her room. Resident #26 was initially
observed walking without an assistive device from her restroom to her bed. A three-prong cane was
available for use on Resident #26's side of the room. There was no wheelchair in Resident #26's room
available for her use. During the initial observation, Resident #26 attempted to sit on the top of the in-room
air conditioning unit, lost her balance and leaned over forward onto cardboard boxes. A staff member
standing nearby assisted Resident #26 up off of the cardboard boxes onto the in-room air conditioning unit.
During an interview on 9/19/2022 beginning at 10:34 AM, Resident #26 stated she falls real easy and when
she falls, she falls backwards. Resident #26 added that she had fallen 3 times and busted my head, I'm
supposed to be in a wheelchair or use a walker. I have doctor's orders not to walk without a wheelchair.
During an interview on 9/21/2022 at 8:36 AM, Staff A, Physical Therapist, reported Resident #26 had been
provided a high back wheelchair with a cushion and anti-roll back device.
On 9/21/2022 at 8:39 AM, an observation of Resident #26 and her room was completed with the Director of
Rehabilitation. There was no wheelchair in Resident #26's room available for her use.
During an interview on 9/21/2022 beginning at 8:47 AM, Staff B, Registered Nurse, stated, I always see her
ambulating in her room, even when she goes out with family, I see her ambulating. I did not know she
[Resident #26] did not have one [a wheelchair]. Staff B reported Resident #26 had taken a leave of
absence from the facility on 9/2/2022 and returned to the facility on 9/13/2022.
During an interview on 9/21/2022 beginning at 9:02 AM, Staff C, Certified Nursing Assistant, stated therapy
had taken Resident #26's wheelchair when Resident #26 left the faciity on leave of absence. Staff C
confirmed Resident #26 did not have a wheelchair available for her use on 9/19/2022 so she got her one for
transport.
Review of Resident #26's physician's orders, revealed a physician's order, start date 5/6/2022, for Resident
#26 to use a standard wheelchair with cushion and anti-roll back device.
Review of Resident #26's care plan, start date 8/8/2022, revealed Resident #26 was at risk for falls related
to weakness/debility and a history of syncope and collapse. Resident #26's care plan documented fall
prevention interventions that included OOB [Out of Bed] in Standard Wheelchair with cushion, ARBD [Anti
Roll Back Device] as tolerated.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105769
If continuation sheet
Page 5 of 9
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
105769
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/22/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Lake City
560 SW McFarlane Ave
Lake City, FL 32055
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of
Resident #80's medical record documented the resident was admitted on [DATE] with diagnosis to include:
myocardial infarction (heart attack), chronic obstructive pulmonary disease (block of airflow in the lungs),
tachycardia (fast heart rate), vascular congestion (fluid back up), anticoagulants (thins blood), atrial
fibrillation (irregular heart rate), heart failure (heart pumps weak), Takotsubo syndrome (heart attack from
broken heart), pneumonia (infection in the lungs), pulmonary fibrosis (stiff lung tissue), hypertension.
Residents Affected - Some
Review of Resident #80's physician orders dated 9/20/2022 reads, Change oxygen cannula every week
once a day on Tue [Tuesday] 07:00 AM - 3:00 PM and dated 8/26/2022 Oxygen 2 Liter per minute via nasal
canula every shift, day shift, night shift.
An observation on 09/19/22 at 10:35 AM of Resident #80 showed the resident was sitting on the side of the
bed. Oxygen was being administered at 2 liters via nasal cannula. There was no date labeled on the oxygen
tubing.
An observation on 09/20/2022 at 09:35 AM showed Resident #80 was sitting on the side of the bed.
Oxygen was being administered via nasal cannula at 2 liters per minute. The oxygen tubing is not dated.
During an interview on 9/20/2022 at 11:44 AM the Unit Manager confirmed Resident #80's oxygen tubing is
not dated.
Based on observation, interview, and record review, the facility failed to ensure respiratory care services
were provided consistent with professional standards of practice for oxygen administration for 4 of 7
residents reviewed for respiratory care, Resident #158, #82, #21 and #80.
Finding include:
Review of Resident #21's medical record noted the resident was admitted with a diagnosis of other
paralytic syndrome following cerebral infraction, bilateral, essential hypertension, hypertensive chronic
kidney disease with stage 1 through stage 4 chronic disease or unspecified chronic kidney disease, chronic
kidney disease stage 2, major depressive disorder , anxiety disorder, chronic obstructive pulmonary
disease, other speech and language deficits following cerebral infraction: note slurred, monoplegia of lower
limb following cerebral infraction affecting right dominant side, epileptic seizures related to external causes,
alcohol dependence, spondylosis without myelopathy or radiculopathy, paresthesia of skin, dizziness and
giddiness, syncope and collapse, white matter disease, hypo-osmolality and hyponatremia, long term use
of aspirin, shingles, personal history of transient ischemic attack, Vitamin D deficiency, shortness of breath,
hypoxemia, unspecified dementia without behavioral disturbance.
Review of Resident #21's medical record revealed an active physician order of ipratropium-albuterol
solution for nebulizer; 0.5mg-3mg (2.5mg base)/3ml [0.5 milligrams - 3 milligram/3 milliliters]; amount: 1
NEB [nebulizer]; inhalation special instructions: DX [diagnosis]: Wheezing.
On 09/19/2022 at 11:27AM, Resident #21's passive nebulizer treatment mask was observed to be hanging
from the resident's lamp located to the right side of the bed table. The nebulizer tubing was
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105769
If continuation sheet
Page 6 of 9
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
105769
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/22/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Lake City
560 SW McFarlane Ave
Lake City, FL 32055
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
Level of Harm - Minimal harm
or potential for actual harm
disconnected from the machine and was laying on the floor. There was no date labeled on the nebulizer
tubing.
On 09/20/2022 at 8:35AM, Resident #21's passive nebulizer treatment mask was observed laying on top of
the dresser. There was no date labeled on the tubing.
Residents Affected - Some
On 09/20/2022 at 11:35AM, Resident #21's passive nebulizer treatment mask was observed laying on top
of the dresser. There was no date labeled on the tubing.
During an interview on 09/20/2022 at 11:54 AM, the Unit Manager stated passive nebulizer treatment
masks should be stored in plastic bag, labeled with the resident's name and dated. Nebulizer tubing should
also be dated.
Review of Resident #82 's medical record noted the resident was admitted with a diagnosis of metabolic
encephalopathy, hypertensive heart and chronic kidney disease with heart failure and stage 1 through
stage 4 chronic kidney disease or unspecified chronic kidney disease, chronic kidney disease stage 3a,
hypertensive heart disease with heart failure, Heart failure, hypotension, Chronic obstructive pulmonary
disease, asthma, pleural effusion on other conditions classified elsewhere, unspecified dementia without
behavioral disturbance, major depressive disorder, single episode, anxiety disorder, hereditary and
idiopathic neuropathy, constipation, gastro esophageal reflux disease without esophagitis, seasonal allergic
rhinitis, bilateral primary osteoarthritis, spinal stenosis, acute kidney failure, anemia, hypothyroidism,
hyperlipidemia, dehydration, retention of urine, hypovolemic shock, hyperosmolality and hypernatremia,
hypokalemia, long term use of aspirin, 2019-nCoV [Coronavirus disease] acute respiratory disease,
unsteadiness on feet, and weakness.
Review of Resident #82's physician orders read, dated 08/24/2022 oxygen at 2 liters per minute via nasal
cannula special instructions: DX: COPD [chronic obstructive pulmonary disease] Every shift
07:00am-7:00pm, 07:00pm-07:00am
On 09/19/2022 at 11:25AM, Resident #82 was observed sitting in her wheelchair with oxygen being
administered at 3 liters per minute via nasal cannula.
On 09/19/2022 at 1:30PM, Resident #82 was observed resting in bed with oxygen being administered at 3
liters per minute via nasal cannula.
On 09/20/2022 at 8:30AM, Resident #82 was observed resting in bed with oxygen being administered at 3
liters per minute via nasal cannula.
On 09/20/2022 at 10:00AM, Resident #82 was observed resting in bed with oxygen being administered at 3
liters per minute via nasal cannula.
During an interview conducted on 09/20/2022 at 11:52AM, the Unit Manager stated, It [the oxygen for
Resident #82] is running at 3 liters.
Review of Resident #158 's medical record noted the resident was admitted with a diagnosis of chronic
obstructive pulmonary disease with exacerbation , hypertensive heart disease with heart failure, heart
failure, Atherosclerotic heart disease of native coronary artery without angina pectoris, emphysema,
chronic obstructive pulmonary disease, acute respiratory failure and hypoxia, peripheral vascular disease,
major depressive disorder, anxiety disorder, insomnia, chronic pain syndrome,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105769
If continuation sheet
Page 7 of 9
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
105769
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/22/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Lake City
560 SW McFarlane Ave
Lake City, FL 32055
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
gastro-esophageal reflux disease without esophagitis, osteoarthritis, other muscle spasm, age-related
osteoporosis without pathological fracture, shortness of breath, iron deficiency anemia, hyperlipidemia,
dependence on supplemental oxygen, weakness, other abnormalities of gait and mobility, constipation.
Review of Resident #158's physician's order dated 09/02/2022 read, Oxygen at 2.5 liters per min via nasal
cannula d/t [due to] chronic respiratory failure every shift; Day Shift, Evening Shift, Night Shift.
On 09/19/2022 at 11:24 AM, Resident #158's bed was observed to have nasal cannula and oxygen tubing
laying on top of the bed. The oxygen tubing was not property stored and was not labeled.
On 09/19/2022 at 12:24 PM, Resident #158 was observed resting in bed with oxygen being administered at
3.5 liters per minute via nasal cannula.
On 09/19/2022 at 2:00 PM, Resident #158 was observed resting in bed with oxygen being administered at
3.5 liters per minute via nasal cannula.
On 09/20/2022 at 8:00 AM, Resident #158 was observed resting in bed with oxygen being administered at
3.5 liters per minute via nasal cannula.
On 09/20/2022 at 11:30 AM, Resident #158 was observed resting in bed with oxygen being administered at
3.5 liters per minute via nasal cannula.
During an interview conducted on 09/20/2022 at 11:50 AM, the Unit Manager stated, It [the oxygen] is
running at 3.5 liters.
Review of the policy and procedure last reviewed on 01/24/22 titled, Specific Medication Administration
Procedures reads, T. Store equipment in a plastic bag with the resident's name and the date on it. U.
Change equipment and tubing every [seven days].
Review of the policy and procedure last reviewed on 01/24/22 titled Oxygen Administration reads, Steps in
procedure: 2. Turn on the oxygen. Unless otherwise ordered, start flow of oxygen at ordered rate. 4. Adjust
the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being
administered.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105769
If continuation sheet
Page 8 of 9
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
105769
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/22/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Lake City
560 SW McFarlane Ave
Lake City, FL 32055
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview, and record review, the facility failed to store food and maintain a clean and
sanitary environment in accordance with professional standards for food service safety.
Residents Affected - Some
Findings include:
During an observation conducted on 9/19/2022 at 9:55 AM, in the dry storage room on a shelf was an open
box of sweet potatoes with several potatoes oozing a liquid. Several small black flying insects were
observed in the box of potatoes. Water was observed dripping from the door of the upright steamer causing
a puddle of water on the table that was dripping onto the floor in the main kitchen.
During an interview conducted on 9/19/2022 9:55 AM, the CDM stated; We hadn't had time to check that
[box of sweet potatoes] over the weekend. That [upright steam table] shouldn't do that.
During an observation conducted on 9/19/2022 at 10:15 AM in the East Nourishment room, on a shelf in
the refrigerator there was a pitcher with liquid that was red in color that was not dated. There was a plastic
bag containing what appeared to be lasagna that was not dated or labeled with a resident's name.
During an interview conducted on 9/19/2022 at 10:15 AM, the Certified Dietary Manager (CDM) stated;
That [red liquid] is not dated. It [the plastic bag of food] should be dated, and the nurses are responsible for
checking the dates on food in the refrigerators.
Review of the policy and procedure titled Storage of Foods Brought to Residents by Family/Visitors dated
1/12/21 and reviewed on 1/24/2022 reads; Perishable foods must be stored in a manner which minimizes
risk of cross contamination in the designated resident refrigerators. The foods will be labeled with the
resident's name and dated.
Review of the policy titled Storage of Nonperishable Foods dated 1/12/21 with an annual review date of
1/24/2022 reads; Storeroom shall be maintained free from dirt, dust, insects, rodents, or any potential
source of contamination.
Review of the policy and procedure titled Preventive Maintenance-Kitchen Equipment reviewed on
01/24/2022 read; Preventive maintenance of kitchen equipment designates specific requirements to provide
a reasonably safe environment for staff during normal operating times in both new construction and existing
buildings. Conduct safety and operation inspections 1.) Visually inspect all appliances for damage.
Document findings in log book 1). remove damaged items from kitchen use.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105769
If continuation sheet
Page 9 of 9
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Back to topCitations
7 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.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F658 - Comprehensive Care Plans
Ensure services provided by the nursing facility meet professional standards of quality.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0222GeneralS&S Epotential for harm
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
F915 - Buildings must have an outside window or outside door in every
Have proper power supply for life support equipment.
FAQ · About this visit
Common questions about this visit
What happened during the September 22, 2022 survey of SOLARIS HEALTHCARE LAKE CITY?
This was a inspection survey of SOLARIS HEALTHCARE LAKE CITY on September 22, 2022. The surveyor cited 7 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SOLARIS HEALTHCARE LAKE CITY on September 22, 2022?
Yes, 7 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be ..."
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.