Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Forest Lake during CMS and state inspections, most recent first.
An LPN failed to follow proper medication administration protocols by not using two resident identifiers and leaving medications unattended at the bedside. The resident, who was cognitively intact and had multiple diagnoses, received medications without verification of identity beyond a photo check, and the LPN was unable to recall all five rights of medication administration, contrary to facility policy.
A resident with multiple chronic conditions received incorrect dosages of Losartan and Fluticasone Salmeterol ACT aerosol during a medication pass, as an LPN administered a discontinued dose and an extra inhalation, contrary to physician orders. The errors were documented on the MAR as if the correct dosages had been given, and discontinued medication was not properly removed from the medication cart, resulting in a medication error rate of 18.18%.
An LPN failed to follow infection control protocols by stacking medication cups on top of each other after placing them on an unsanitary medication cart surface, resulting in the administration of potentially contaminated medications to a resident with multiple chronic conditions. The DON confirmed that trays were available to prevent such contamination, in accordance with facility policy.
The facility failed to ensure accurate completion of Level I PASARRs for seven residents, leading to discrepancies between their medical records and PASARR forms. Despite having various mental health diagnoses, these conditions were not reflected in the PASARR forms. The admissions and social services staff did not verify the accuracy of the forms, resulting in incomplete documentation for residents with serious mental illnesses.
A facility failed to review and address pharmacist recommendations for a resident's medication regimen, including monitoring side effects of Buspirone and behaviors related to Bupropion XL. Despite repeated recommendations, no changes were made to the resident's orders, and no rationale was provided. Additionally, a recommendation to change potassium medication form was not addressed. The DON confirmed the process for reviewing recommendations was not followed, contrary to facility policy.
Failure to Follow Medication Administration Protocols
Penalty
Summary
A deficiency occurred when a licensed practical nurse (LPN) failed to follow proper medication administration protocols for a resident with diagnoses including Parkinson's disease, personality disorder, depressive disorder, persistent mood disorder, and hyperlipidemia. The resident was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status. During a morning medication pass, the LPN prepared multiple medications and identified the resident only by checking the photograph on the medication administration record (MAR) before entering the room. The LPN placed five medication cups on the resident's bedside table and began to explain the medications, but was unable to recall the name of one medication and left the room to check, leaving the prepared medications unattended at the bedside. Upon returning, the LPN administered the medications without using a second identifier to verify the resident's identity, such as asking for the resident's name or date of birth, or checking an armband. The LPN did not call the resident by name or use any other form of secondary identification, contrary to facility policy and standard practice. The LPN later acknowledged not using two identifiers and leaving medications unattended, and was unable to recall all five rights of medication administration. Facility leadership confirmed that the expectation was to use two forms of identification and not to leave medications unattended, as outlined in the facility's medication administration policy.
Failure to Follow Physician Orders Leads to Medication Errors
Penalty
Summary
The facility failed to prevent medication errors by not following physician orders during medication administration for a resident with multiple diagnoses, including asthma, hyponatremia, hypertension, gastro-esophageal reflux, osteoarthritis, and chronic kidney disease. During a medication pass, an LPN administered Losartan 50 mg instead of the physician-ordered Losartan 100 mg, and also gave two inhalations of Fluticasone Salmeterol ACT aerosol 500/50 mcg instead of the ordered one inhalation. The LPN signed off on the MAR as if the correct dosages had been administered, but a review of the medication bubble packages and the MAR revealed discrepancies in the number of tablets used and the dosages given. The LPN acknowledged the errors during the observation and confirmed that the medications were not administered as ordered. Further investigation showed that the process for handling discontinued medications was not followed, as the discontinued Losartan 50 mg package remained accessible in the medication cart instead of being removed and returned to the pharmacy. The facility's policy required that medication labels and MARs be compared before administration, and that any changes in orders be flagged and communicated to the pharmacy. However, these procedures were not adhered to, resulting in an 18.18% medication error rate during the observed medication pass.
Failure to Follow Infection Control Practices During Medication Administration
Penalty
Summary
A deficiency occurred when an LPN failed to adhere to proper infection control practices during medication administration for a resident with multiple diagnoses, including asthma, hyponatremia, hypertension, gastro-esophageal reflux, osteoarthritis, and chronic kidney disease. The LPN prepared several medications by placing them in separate medication cups, which were then stacked on top of each other to carry them to the resident's room. The bottom of each medication cup, which had been in direct contact with the unsanitary surface of the medication cart, touched the tablets in the cups below, resulting in the administration of potentially contaminated medications to the resident. The LPN stated that she stacked the cups because she could not carry all the medications in her hands and did not want to leave anything behind on the cart. She acknowledged that the top of the medication cart was not sanitary for stacking cups and that she had received recent in-service education on proper medication administration. The Director of Nursing confirmed that the cart surface was not considered sanitary and that trays were available for safe medication transport, as outlined in the facility's medication administration policy.
Inaccurate PASARR Documentation for Residents
Penalty
Summary
The facility failed to ensure the completion and accuracy of Level I Preadmission Screening and Resident Reviews (PASARRs) for seven residents. These residents were admitted with various mental health diagnoses, including anxiety, depression, bipolar disorder, and dementia, but their PASARR forms did not reflect these conditions. For instance, Resident #17 was admitted with diagnoses of generalized anxiety disorder and major depressive disorder, yet her PASARR form only listed anxiety. Similarly, Resident #199 was taking antianxiety and antipsychotic medications, but his PASARR form indicated no mental illness. The admissions process involved multiple staff members, including the Admissions Clerk, Admissions Director, and Social Services Director, who were responsible for reviewing PASARR forms. However, they failed to verify the accuracy of the forms, leading to discrepancies between the residents' medical records and their PASARR forms. The Social Services Director acknowledged that she reviewed PASARRs for accuracy during Gradual Dose Reduction meetings but did not provide an explanation for the inaccuracies found in the forms of the seven residents. The facility's policy required a complete and accurate PASARR upon admission, with the admissions department responsible for ensuring this. Despite this policy, the facility did not update the PASARR forms to reflect new or existing mental health diagnoses, resulting in incomplete documentation for residents with serious mental illnesses. This oversight was confirmed by the Director of Nursing, who expected accurate diagnoses to be listed in the PASARR screening forms.
Failure to Address Pharmacist Recommendations for Medication Regimen
Penalty
Summary
The facility failed to ensure that pharmacy reports of irregularities with medication regimens were reviewed and addressed for a resident with multiple diagnoses, including fibromyalgia, severe obesity, and chronic kidney failure. The consulting pharmacist made several recommendations regarding the monitoring of side effects for the anxiolytic medication Buspirone and behaviors related to the antidepressant Bupropion XL. Despite these recommendations being repeated over several months, there was no evidence that the attending physician reviewed or addressed them, as no changes were made to the resident's orders, and no rationale for not implementing the recommendations was provided. Additionally, the pharmacist recommended changing the resident's potassium medication from a tablet to a liquid form due to contraindications with delayed gastric emptying. This recommendation was also not addressed in the medical record, and no rationale was provided. The Director of Nursing confirmed that the process for reviewing and acting on pharmacist recommendations was not followed, as evidenced by the lack of documentation and action on the pharmacist's recommendations. The facility's policy required that pharmacist recommendations be acted upon and documented, which was not adhered to in this case.
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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 Apopka
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harborview Health Center West Altamonte | 2.1 mi | ★★★★★ | 5 | 0 |
| Solaris Healthcare Apopka | 3.1 mi | ★★★★★ | 0 | 0 |
| Village On The Green | 3.4 mi | ★★★★★ | 0 | 0 |
| Aviata At Rosewood | 4.9 mi | ★★★★★ | 12 | 0 |
| Apopka Health And Rehabilitation Center | 5.3 mi | ★★★★★ | 10 | 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.