Average — CMS composite of the measures below.
A standard survey is most likely before around August 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 College Park during CMS and state inspections, most recent first.
The facility did not honor a resident's right to voice grievances without discrimination or reprisal and failed to establish a grievance policy or make prompt efforts to resolve complaints.
A resident with multiple medical conditions and a history of swallowing difficulties was found with medication left at the bedside for self-administration without a physician's order, assessment, or care plan in place. The RN confirmed leaving the medication at the resident's request, contrary to facility policy requiring physician authorization and assessment for self-administration.
A resident with bilateral lower extremity impairment and non-weight bearing status was injured during a transfer when two CNAs failed to use a mechanical lift as required by the care plan. Instead, they manually lifted the resident, resulting in a right distal femur fracture. The CNAs did not check the transfer status on the Kardex and relied on verbal information, leading to the incident.
A resident with multiple health conditions and non-weight bearing status was injured during a transfer when CNAs failed to use a mechanical lift as required by the care plan. Instead, they manually lifted the resident, resulting in a femur fracture. The incident highlighted a lack of adherence to established transfer protocols, leading to significant pain and injury for the resident.
Failure to Honor Resident Grievance Rights
Penalty
Summary
The facility failed to honor the resident's right to voice grievances without discrimination or reprisal. Additionally, the facility did not establish a grievance policy or make prompt efforts to resolve grievances as required. This deficiency was identified based on observations and findings that the facility did not have appropriate procedures in place to address and resolve resident complaints in a timely and non-retaliatory manner.
Failure to Assess and Authorize Medication Self-Administration
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact and had multiple diagnoses including chronic respiratory failure, dementia, functional quadriplegia, and a history of swallowing difficulties, was found with a cup of liquid medication at her bedside. The resident explained that the nurse had left the medication and a supplement for her to take later, at her request. The assigned RN confirmed leaving the medication at the bedside and was unable to confirm if there was an order for self-administration. The medication, Lactulose Solution, was documented as administered earlier in the morning, but was still present at the bedside hours later. Review of the resident's medical record revealed there was no assessment for self-administration of medications, no physician's order authorizing self-administration, and no care plan addressing self-administration. Facility policy required physician authorization and specific procedures for self-administration, which were not followed in this case. The incident was acknowledged by the Director of Nursing, who confirmed that medications should not have been left at the bedside without proper authorization and assessment.
Failure to Follow Transfer Protocols Results in Resident Injury
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse and neglect by not ensuring staff followed the resident's care plan for safe transfers. On the morning of November 7, two CNAs did not adhere to the care plan that required the use of a mechanical lift with the assistance of two staff members for transferring the resident from bed to wheelchair. Instead, they manually lifted and pivoted the resident, resulting in the resident experiencing extreme pain in his right leg shortly after the transfer. The resident, who was cognitively intact and had bilateral lower extremity impairment, was dependent on staff for all care and was determined to be non-weight bearing. The care plan, revised earlier, specified the need for a mechanical lift due to the resident's physical limitations and safety concerns. Despite this, the CNAs proceeded with a manual transfer, leading to a right distal femur fracture, which was confirmed by an X-ray. The resident was subsequently transferred to the hospital for evaluation. The incident was compounded by a lack of communication and adherence to protocol among the staff. CNA A, who was responsible for the transfer, did not check the resident's transfer status on the Kardex and instead relied on verbal information from another CNA. This oversight, coupled with the decision to proceed without the mechanical lift due to time constraints, directly contributed to the resident's injury. The facility's failure to ensure staff followed the care plan placed the resident and others requiring mechanical lifts at risk for serious harm.
Removal Plan
- Resident #1 was immediately assessed, X-ray completed and pain medication given. He was sent to emergency room.
- CNAs A and B were removed from service immediately and interviewed about the transfer.
- Residents' Plan of Care (POC)/Kardex reviewed prior to receiving care from Nursing Staff.
- Education of staff begun on all shifts regarding the importance of following residents' POC of transfer status and where to obtain transfer status from Kardex.
- 70 day shift staff, 20 evening shift staff, 11 night shift staff provided education that included post test of reporting of any allegation of abuse/neglect/exploitation (ANE), who to report to in facility i.e., abuse coordinator, DON, or supervisor and correlation to failure to provide care as outlined in Plan of Care.
- A group discussion with CNAs to ask what their barriers may or may not be to following POC and the importance of communicating those barriers immediately to their supervisor.
- All residents were reviewed to ensure POC accuracy for transfer.
- Interviews were conducted with 9 residents on the CNA's assignment to verify that staff are consistently following care planned transfer status.
- Interviews were conducted with 41 interviewable residents regarding abuse and neglect to determine any other concerns.
- Any staff member not present were educated prior to starting their shift.
- An Ad Hoc Quality Assurance and Performance Improvement (QAPI) Meeting held and attended by Administrator, Director of Nursing, Medical Director and Interdisciplinary team to review incident and investigation.
- 13 Clinical Nursing Staff on 7AM-3 PM shift, 8 Clinical Nursing on 3 PM-11 PM shift, and 5 Clinical Nursing Staff on 11 PM-7AM shift provided education regarding the importance of following residents' plan of care of transfer status and where to obtain transfer status from Kardex.
- Another Ad Hoc QAPI meeting with Administrator, Director of Nursing, Medical Director, Company President, Chief Nursing Officer, Regional Plant Operations Director and Interdisciplinary team to review incident and investigation.
- 8 Clinical Nursing Staff on 7 AM-3 PM shift, 6 Clinical Nursing Staff on 3 PM-11 PM shift, and 4 Clinical Nursing staff on 11 PM -7 AM shift provided education regarding the importance of following residents' plan of care of transfer status and where to obtain transfer status from Kardex. Any Clinical Nursing staff member not present received education prior to their shift. Education was continued regarding education of reporting of any allegation of abuse/neglect/exploitation, who to report to in facility i.e., abuse coordinator, DON, or supervisor and correlation to failure to provide care as outlined in Plan of Care.
- An Ad Hoc QAPI meeting attended by Regional Director of Operations, Quality Management Specialist, Nursing Home Administrator and Director of Nursing. Discussion completed to include needed re-education regarding where to find transfer status on the Kardex, ANE continued education review of assignments, review of current status of lifts/batteries. Review of monthly lift inspections- review of interviews and re-enactments.
- Education was continued with staff regarding education of reporting of any allegation of abuse/neglect/exploitation, who to report to in facility i.e., abuse coordinator, DON, or supervisor and correlation to failure to provide care as outlined in Plan of Care. 22 additional staff were provided education.
- Nurse Leadership completed quality monitoring, on all three shifts, to include verbal review and/or return demonstration to ensure following residents' plan of care of transfer status and where to obtain transfer status from Kardex.
- Audits/observations completed of resident transfers, where to obtain transfer status, how many staff needed to transfer - completed on all three shifts.
- Daily room rounds completed with guardian angel rounds- regarding abuse and neglect, observations made regarding transfers.
- Ad Hoc QAPI meeting held included review of education completed, and individual phone calls continued regarding mandatory education needed- staff to sign education and post test prior to working.
- Audits/observations completed of resident transfers, where to obtain transfer status, how many staff needed to transfer, completed on all three shifts.
- Daily room rounds completed with guardian angel rounds-completed with guardian angel rounds- regarding abuse and neglect, observations made regarding transfers.
- Ad Hoc QAPI meeting held-review of education completed, continued individual phone calls continue regarding mandatory education needed- staff to sign education and post test prior to working, discussed need to review Facility Assessment.
- Continued audits/observations completed of resident transfers, where to obtain transfer status, how many staff needed to transfer, completed on all three shifts. Daily room rounds completed with guardian angel rounds- regarding abuse and neglect, observations made regarding transfers.
- Ad Hoc QAPI meeting held-review of education completed, continued individual phone calls continue regarding mandatory education needed- staff to sign education and post test prior to working.
- Ad Hoc QAPI meeting held-review of education completed, continued individual phone calls continue regarding mandatory education needed- staff to sign education and post test prior to working.
- Daily room rounds completed with guardian angel rounds- regarding abuse and neglect, observations made regarding transfers, continued.
- 100% of Nursing staff was trained regarding resident transfer status, where to obtain information on the Kardex, and regarding Abuse and Neglect to include post test- (1 employee out of the country and 1 on family medical leave).
- Monthly QAPI meeting held-Facility Assessment reviewed, education, audits, post test reviewed- IDT has determined compliance. DON/designee will continue to complete random audits/observations of resident transfers to evaluate ongoing compliance. DON/designee will continue to complete random audits/interviews of staff to validate staff can articulate abuse/neglect reporting process.
Failure to Follow Transfer Protocols Results in Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision and a safe environment to prevent accidents for a resident who required transfers with a mechanical lift. On the morning of the incident, two CNAs did not follow the resident's care plan, which specified the use of a mechanical lift with the assistance of two staff members for transfers. Instead, they manually lifted and pivoted the resident from his bed to a wheelchair, resulting in the resident experiencing extreme pain in his right leg shortly after the transfer. The resident, who was cognitively intact and had a history of Alzheimer's disease, chronic lung disease, and other conditions, was dependent on staff for all care due to bilateral lower extremity impairment. The care plan and assessments clearly indicated that the resident was non-weight bearing and required a mechanical lift for transfers. Despite this, the CNAs proceeded with a manual transfer, which led to the resident sustaining a right distal femur fracture. The incident was reported by another CNA who noticed the resident's discomfort during a medical appointment. The resident expressed that the CNAs had been rough during the transfer, and an X-ray later confirmed the fracture. The facility's failure to ensure staff adhered to the care plan for safe transfers contributed to the resident's injury and placed other residents at risk for similar incidents.
Removal Plan
- Resident #1 was immediately assessed, X-ray completed and pain medication given. He was sent to emergency room.
- CNAs A and B were removed from service immediately and interviewed about the transfer.
- All residents' POC/Kardex reviewed prior to receiving care from Nursing Staff.
- Education of staff begun on all shifts regarding the importance of following residents' plan of care (POC) of transfer status and where to obtain transfer status from Kardex, including post test.
- A group discussion with CNAs to ask what their barriers may or may not be to following POC and the importance of communicating those barriers immediately to their supervisor.
- All residents were reviewed to ensure POC accuracy for transfer.
- Interviews were conducted with 9 residents on the CNA's assignment to verify that staff are consistently following care planned transfer status.
- Interviews were conducted with 41 interviewable residents regarding abuse and neglect to determine any other concerns.
- Any staff member not present were educated prior to starting their shift.
- An Ad Hoc Quality Assurance and Performance Improvement (QAPI) Meeting held and attended by Administrator, Director of Nursing, Medical Director and Interdisciplinary team to review incident and investigation.
- 13 Clinical Nursing Staff on 7 AM-3 PM shift, 8 Clinical Nursing on 3 PM-11 PM shift, and 5 Clinical Nursing Staff on 11 PM-7 AM shift provided education regarding the importance of following residents' plan of care of transfer status and where to obtain transfer status from Kardex.
- Nurse Leadership completed quality monitoring on all 3 shifts, to include verbal review and/or return demonstration.
- An Ad Hoc QAPI meeting with Administrator, Director of Nursing, Medical Director, Company President, Chief Nursing Officer, Regional Plant Operations Director and Interdisciplinary team (IDT). Discussion completed to include needed re-education regarding where to find transfer status on the Kardex, review of current status of lifts/batteries. Review of monthly lift inspections- review of interviews and re-enactments. Reviewed plan for the weekend to ensure that staff continue to be educated prior to working. Text blast sent regarding mandatory education needed.
- 8 Clinical Nursing Staff provided education that included testing and/or return demonstration as well during their shift of 7 AM-3 PM, 6 Clinical Nursing Staff provided education that included testing and/or return demonstration during their shift of 3 PM-11 PM, 4 Clinical Nursing staff provided education that included testing and/or return demonstration during their shift of 11 PM-7 AM regarding the importance of following residents' plan of care of transfer status and where to obtain transfer status from Kardex. Any Clinical Nursing staff member not present received education prior to their shift.
- An Ad Hoc QAPI meeting attended by Regional Director of Operations, Quality Management Specialist, Nursing Home Administrator and Director of Nursing. Discussion completed to include needed re-education regarding where to find transfer status on the Kardex, education review of assignments, review of current status of lifts/batteries. Review of monthly lift inspections- review of interviews and re-enactments.
- Nurse Leadership completed quality monitoring, on all three shifts, to include verbal review and/or return demonstration to ensure following residents' plan of care of transfer status and where to obtain transfer status from Kardex.
- Audits/observations completed of resident transfers, where to obtain transfer status, how many staff needed to transfer - completed on all three shifts.
- Daily room rounds completed with guardian angel rounds- observations made regarding transfers.
- Ad Hoc QAPI meeting held included review of education completed, and individual phone calls continued regarding mandatory education needed- staff to sign education and post test prior to working.
- Audits/observations completed of resident transfers, where to obtain transfer status, how many staff needed to transfer, completed on all three shifts.
- Daily room rounds completed with guardian angel rounds- observations made regarding transfers.
- Ad Hoc QAPI meeting held-review of education completed, continued individual phone calls continue regarding mandatory education needed- staff to sign education and post test prior to working, discussed need to review Facility Assessment.
- Continued audits/observations completed of resident transfers, where to obtain transfer status, how many staff needed to transfer, completed on all three shifts. Daily room rounds completed with guardian angel rounds- observations made regarding transfers.
- Ad Hoc QAPI meeting held-review of education completed, continued individual phone calls continue regarding mandatory education needed- staff to sign education and post test prior to working.
- Ad Hoc QAPI meeting held-review of education completed, continued individual phone calls continue regarding mandatory education needed- staff to sign education and post test prior to working.
- Daily room rounds completed with guardian angel rounds- observations made regarding transfers continued.
- 100% of Nursing staff was trained regarding resident transfer status, where to obtain information on the Kardex- (1 employee out of the country and 1 on family medical leave).
- Monthly QAPI meeting held-Facility Assessment reviewed, education, audits, post test reviewed- IDT has determined compliance. DON/designee will continue to complete random audits/observations of resident transfers to evaluate ongoing compliance- These findings will be submitted to the Quality Assurance/Performance Improvement until determined by QAPI members to no longer be needed.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 222 citations issued within 25 miles in the last 12 months — including the 11 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Orlando
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rehabilitation Center Of Winter Park | 1.3 mi | ★★★★★ | 0 | 0 |
| Ansley Cove Healthcare And Rehabilitation | 2 mi | ★★★★★ | 16 | 3 |
| The Gardens At Depugh | 2.1 mi | — | 0 | 0 |
| Aviata At Rosewood | 2.3 mi | ★★★★★ | 12 | 0 |
| Courtyards Of Orlando Care Center And Rehab | 3.5 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.