Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Solaris Healthcare Coconut Creek during CMS and state inspections, most recent first.
Call lights were not kept within reach for several residents who were in bed or seated, including residents with fall risk, cognitive impairment, hemiplegia, Parkinsonism, COPD, and other conditions. In addition, two residents did not receive showers as ordered or preferred; one resident’s shower schedule was entered on the wrong shift and the EHR showed only a limited number of showers offered, while another resident stated she wanted morning bathing and had not received a shower as scheduled.
Floor mats ordered as part of fall precautions were not properly placed for three residents with cognitive impairment and fall histories. Staff observed mats missing from one side of the bed, stacked on one side only, or resting against the wall, despite orders and care plans calling for mats on both sides while the residents were in bed. The DON stated that fall interventions included keeping mats in place, along with the call light within reach and the bed in the lowest position.
Failure to Address Significant Weight Loss: A resident with dementia and protein-calorie malnutrition had an 18.8% wt loss, poor meal intake, and a MNA score indicating malnutrition. Although the resident was on a no added salt diet with enhanced foods and a daily supplement, the RD did not update the POC or add further nutrition interventions despite documented low intake and observed difficulty eating, with staff reporting the resident needed supervision or touching assistance during meals.
A facility failed to ensure working emergency call devices were available in resident bathrooms and bathing areas in 2 of 11 rooms on one unit. Surveyors observed missing pulling cords by toilets and in showers, and in another room a resident used the bathroom but the emergency call device had no cord attached. Staff interviews confirmed concerns were expected to be reported through maintenance slips, and the DOM later observed the same missing cords during a unit tour.
A resident with diabetes received insulin inappropriately when an LPN used a syringe to extract insulin from a pen, despite available pen needles. The LPN admitted this was not best practice, and the DON confirmed pens should be used as designed.
A facility failed to manage the nutritional needs of a resident on tube feeding, resulting in significant weight loss and caloric deficits. The resident, with a history of metabolic encephalopathy and pressure ulcers, did not receive the full prescribed tube feeding, leading to insufficient calorie intake. Additionally, the facility did not consistently monitor the resident's weight, hindering accurate assessment of nutritional status.
The facility failed to change oxygen tubing timely for two residents receiving oxygen therapy, contrary to Professional Standards of Practice. One resident had continuous oxygen orders, and observations showed tubing dated over a week old without staff initials. Another resident had as-needed oxygen orders, with tubing found on the floor and dated over a week old. Staff interviews revealed confusion about the tubing change policy.
The facility failed to implement an effective QAPI program for monitoring resident weights, particularly for those on tube feeding. A resident was not weighed weekly as required, and two other residents had inconsistent weight records, missing both weekly and monthly weigh-ins. Interviews revealed that the Registered Dietitian was focused on monthly weights, neglecting weekly requirements, and there was no designated person responsible for taking weights.
A facility failed to follow infection control practices for a resident with low WBC, who was at high risk for infection. Observations showed staff and visitors not adhering to Neutropenic Precautions, such as wearing PPE and performing hand hygiene. Interviews revealed inconsistent understanding and implementation of these precautions, compromising the resident's safety.
Call Lights Left Out of Reach and Shower Schedules Not Followed
Penalty
Summary
The facility failed to ensure call lights were within reach for five sampled residents. The facility policy titled, "Answering the Call Light," dated 12/10/24, stated that when a resident is in bed or confined to a chair, the call light should be within easy reach. During observations and interviews, Resident #28, who had diagnoses including hemiplegia and hemiparesis following cerebral infarction, Alzheimer's disease, repeated falls, anxiety, depression, and a history of falling, was found crying in her room and stated she needed help, but her call light was on the floor beneath her bed and she did not know where it was. Staff G stated she had just provided care to the resident, and the DON stated nursing staff were responsible for ensuring call lights were within reach. Resident #72, who had Parkinsonism, hypertension, mild cognitive impairment, and a care plan addressing fall risk, was observed in bed with the call light behind the bed on the floor and not within reach. Resident #138, who had diagnoses including falls and difficulty walking, was observed in bed with the call light behind the side table and out of reach, and stated she could not reach it to call for help with changing clothes. Resident #13, who had hemiplegia and hemiparesis, severe cognitive impairment, and a fall care plan directing that items be kept within reach, was observed sitting in a chair with the call light on the floor behind her; the cord was too short for her to reach it, and she could not move her arm to reach it. Resident #45, who had COPD, diabetes, depression, anxiety, and a fall care plan stating the call light should be within reach and functioning well, was observed in bed with the call light hanging on the side of the bed and stated it was too difficult to reach. The facility also failed to honor shower preferences for two sampled residents. Resident #93 had diagnoses including multiple sclerosis, muscle weakness, schizophrenia, anxiety, and depression, and had an order for showers on Mondays, Wednesdays, and Fridays on the 3:00 PM to 11:00 PM shift. The resident stated she was not getting bathed on her scheduled days and later stated she preferred showers but they had not been offered. Review of the electronic record showed only three showers were offered during December 2025 and two so far in January 2026, despite five scheduled showers, and the second-floor shower schedule sheets listed the correct days but the incorrect shift. Resident #124, who had muscle weakness, anxiety, depression, overactive bladder, fatigue, and moderate cognitive impairment, had an order for showers on Monday, Wednesday, and Thursday during the 7:00 AM to 3:00 PM shift. She stated her bathing schedule was not when she wanted and that she wanted morning bathing, and later stated she did not receive a shower the day before, which was a Monday. The ADON was unable to locate a January 2026 shower task printout for this resident.
Floor mats not properly placed for residents on fall precautions
Penalty
Summary
The facility failed to ensure floor mats were properly placed as part of the fall intervention protocol for 3 of 20 sampled residents reviewed for floor mats: Residents #99, #38, and #13. The facility policy titled, "Falls- Clinical Protocol," stated that staff and the physician would identify interventions to prevent subsequent falls and that relevant interventions would be tried based on assessment until falling reduced or stopped. The Director of Nursing stated that fall interventions included making staff aware of resident risks, providing frequent supervision, keeping the call light within reach, placing the bed in the lowest position, and ensuring landing strips or floor mats were in place. Resident #99 had diagnoses including dementia with psychotic disturbance, urinary tract infection, contracture of both hands, cerebral atherosclerosis, anxiety disorder, and a history of falling. The resident's MDS documented a BIMS score of 10, indicating moderate cognitive impairment. The physician ordered floor mats on both sides of the bed while the resident was in bed. During observations, the resident was seen sleeping in bed with two floor mats resting sideways against the wall by the window, and later only one mat was on the left side of the bed while the other remained resting sideways against the wall by the window. Resident #38 had diagnoses including repeated falls, unspecified dementia, and hyperlipidemia, and the quarterly MDS showed severe cognitive impairment. The physician ordered floor mats on both sides of the bed while the resident was in bed. During three observations, the resident was in bed with both floor mats placed on the right side of the bed and no mat on the left side. Resident #13 had diagnoses including hemiplegia and hemiparesis, cerebral infarction, hypertension, atherosclerosis, diabetes, hyperlipidemia, anxiety, and depression, and the quarterly MDS documented severe cognitive impairment. The resident had an order for floor mats on both sides of the bed and a fall care plan that included mats on both sides. During observations, one mat was propped against the wall under the window and the other had the bedside table on it, and later both mats were piled on the left side of the bed with no mat on the right side. A CNA later observed the mats both on one side only.
Failure to Address Significant Weight Loss
Penalty
Summary
The facility failed to address a significant weight loss for one resident with diagnoses including muscle weakness, dementia, and unspecified protein-calorie malnutrition. The resident had physician orders for a no added salt diet with enhanced foods and a daily house supplement, and the care plan identified the resident as at risk for altered nutrition related to decreased intake, weight loss, and low BMI. Weights documented in the record showed a drop from 125.6 pounds on 12/05/25 to 102 pounds on 12/24/25, which was identified as an 18.8% weight loss. A Mini Nutritional Assessment completed on 12/24/25 showed severe decrease in food intake and a score of 2.0, indicating malnutrition. Record review also showed that meal intake was poor in the week before the resident went to the hospital, with multiple meals taken at 0% to 50% and only one meal at 76% to 100%. The nutritional assessment completed after the resident returned from the hospital acknowledged the significant weight loss and average meal intake of 25% to 50%, but the Clinical Dietitian did not make nutritional changes or update the plan of care, and there were no additional supplements, food preference changes, mealtime observation, or appetite stimulant noted. During observation, the resident was seen eating lunch in bed with tray setup assistance only, and the resident had difficulty eating independently with food falling onto the lap and tray, consuming only 15% of the meal by the end of the observation. The MDS coded the resident as needing supervision or touching assistance during eating, and staff stated this meant staff should be in the room during dining times.
Missing Emergency Call Cords in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that functioning emergency call devices were available in resident bathrooms and bathing areas in 2 of 11 rooms on the First Floor, 3 Unit. During the initial tour on 01/11/26, the emergency call light device in one room’s bathroom was observed missing the pulling cord by the toilet, and the cord was also missing in the shower. In a separate room, the resident stated he used the bathroom in the room, especially when he had a bowel movement, and said he could use the call light if he needed help; however, further observation of that bathroom showed no cord attached to the emergency call light device. On 01/12/26, during a medication administration observation with a nurse in another room, the emergency call device was again noted to be missing the pulling cord while the nurse was washing her hands in the bathroom. Staff interviews showed that CNAs and nurses were expected to report concerns to the nurse and complete maintenance request slips, and the Unit Manager stated maintenance rounds were done daily. The Director of Maintenance later toured the unit and observed the missing cord in one bathroom, stating he was not aware of it, and then continued to another room where the toilet was heard flushing and the resident exited the bathroom; that bathroom also had no pulling cord attached to the emergency call device.
Improper Insulin Administration Practice
Penalty
Summary
The facility failed to adhere to professional standards of quality practice during the administration of insulin for a resident with diabetes. The resident, who had moderate cognitive impairment, was observed receiving insulin in a manner inconsistent with the manufacturer's guidelines. Specifically, a Licensed Practical Nurse (LPN) used an insulin syringe to extract 18 units of insulin from an insulin pen, rather than using the pen as intended. This action was observed during a medication administration session, where the LPN was seen squinting and fumbling with the syringe plunger to obtain the correct dosage before injecting it into the resident's arm. The LPN admitted to the surveyor that using a syringe to extract insulin from the pen was not best practice, but claimed that the facility sometimes lacked the necessary pen needles. However, it was acknowledged that pen needles were available for the resident's insulin pen at the time. The Director of Nursing confirmed that insulin pens should be used according to their design, indicating a deviation from standard procedures in this instance.
Failure to Monitor Nutritional Needs and Weight of Resident on Tube Feeding
Penalty
Summary
The facility failed to properly manage and monitor the nutritional needs of Resident #87, who was receiving tube feeding. The resident, who had a history of metabolic encephalopathy, stage 4 pressure ulcer, and cachexia, experienced a significant weight loss of 6.6% over a period of time. The facility did not adhere to the prescribed tube feeding regimen, resulting in the resident receiving fewer calories than required. Observations revealed that the tube feeding was not administered in full, leading to a caloric deficit on multiple occasions. Additionally, the facility did not consistently obtain and verify the resident's weight as required. Despite the facility's protocol to record weights weekly for the first month after admission, only two weights were recorded for Resident #87 since her readmission. This lack of consistent weight monitoring hindered the ability to assess the resident's nutritional status accurately and adjust care plans accordingly. Interviews with staff, including the Registered Dietician, highlighted the absence of a designated person responsible for weight monitoring and the ongoing challenges in implementing a Process Improvement Project (PIP) for weight tracking. The Registered Dietician acknowledged the nutritional risk posed to residents like Resident #87, who rely entirely on tube feeding for their nutritional needs, and recognized the need for improved monitoring and intervention strategies.
Failure to Timely Change Oxygen Tubing
Penalty
Summary
The facility failed to ensure timely labeling and changing of oxygen tubing for two residents receiving oxygen therapy, which is inconsistent with the Professional Standards of Practice. Resident #22, who was admitted with diagnoses including Acute Bronchospasm and Degenerative Disease of the Nervous System, had physician orders for continuous oxygen at 2 Liters per minute through a nasal cannula. Observations on multiple occasions revealed that the oxygen tubing was dated 07/12/24, without staff initials, and had not been changed as per facility policy, which requires weekly changes on Sundays during the night shift. The Director of Nursing confirmed the expectation for routine monitoring and timely changing of oxygen tubing. Similarly, Resident #86, admitted with Acute Respiratory Failure with hypoxia, had orders for oxygen administration as needed. Observations showed that the oxygen tubing was dated 07/10/24 and was found on the floor, indicating it had not been changed according to the facility's policy. Interviews with nursing staff revealed a lack of clarity regarding the frequency of tubing changes, with some staff unable to recall the specific policy details. The Nursing Home Administrator was informed of these findings during an interview.
Failure to Implement Effective QAPI for Resident Weights
Penalty
Summary
The facility failed to develop and implement an effective Quality Assurance and Performance Improvement Program (QAPI) as evidenced by their inability to regularly review, analyze, and act on data regarding residents' weights. This deficiency was observed in three residents who were on tube feeding. The facility's policy required residents to be weighed upon admission or readmission and then weekly for four weeks, but this was not consistently followed. For instance, Resident #87 was readmitted and weighed initially, but subsequent weekly weights were not recorded. Similarly, Resident #96 and Resident #56 did not have their weights recorded weekly as required, with gaps in the weight logs indicating missed weekly and monthly weigh-ins. Interviews with facility staff, including the Registered Dietitian and the Administrator, revealed ongoing issues with obtaining and recording weights. The Registered Dietitian acknowledged the problem and mentioned that a Performance Improvement Plan (PIP) was in place, but it was not effectively addressing the weekly weight requirements. The facility lacked a designated person responsible for taking weights, and the Registered Dietitian was focused on ensuring monthly weights were recorded, neglecting the weekly requirements. Despite efforts to track and improve weight recording, the facility's QAPI goals for weekly weights were not being met, indicating a systemic issue in adhering to their own policies.
Failure to Implement Neutropenic Precautions
Penalty
Summary
The facility failed to adhere to infection control practices and the established standards for Neutropenic Precautions for a resident with a significantly low white blood cell count, placing them at high risk for infection. The resident, who was admitted with conditions including Hepatic Encephalopathy and Autoimmune Hepatitis, was under Neutropenic Precautions as per physician's orders. These precautions included the use of personal protective equipment (PPE) and hand hygiene protocols, which were not consistently followed by staff and visitors. Observations revealed multiple instances of non-compliance with the Neutropenic Precautions. A visitor was seen inside the resident's room without wearing a mask or gloves, and staff failed to educate him on the necessary precautions. Staff members were also observed entering the resident's room without wearing the required PPE, such as gowns, masks, and gloves, and did not perform proper hand hygiene before and after contact with the resident. Additionally, the resident's husband was observed interacting with the resident without wearing PPE and not following proper cough etiquette. Interviews with staff, including the Director of Nursing and Certified Nursing Assistants, indicated a lack of consistent understanding and implementation of the Neutropenic Precautions. Despite being educated on the necessary precautions, staff did not consistently follow the protocols, such as hand washing with soap and water and wearing appropriate PPE. The facility's failure to enforce these precautions compromised the resident's safety and increased the risk of infection.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Coconut Creek
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Margate Health And Rehabilitation Center | 1.6 mi | ★★★★★ | 3 | 0 |
| Pompano Health And Rehabilitation Center | 3.7 mi | ★★★★★ | 23 | 0 |
| Deerfield Beach Health And Rehabilitation Center | 3.9 mi | ★★★★★ | 1 | 0 |
| Willowbrooke Court Skilled Care Center - Edgewater | 4.2 mi | ★★★★★ | 0 | 0 |
| John Knox Village Of Pompano Beach | 4.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.