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 August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Solaris Healthcare Imperial during CMS and state inspections, most recent first.
A resident with a history of falls and dementia experienced multiple falls at the facility. Despite the facility's policy requiring thorough investigation and documentation, the investigation into the resident's falls was incomplete, and the care plan was not updated with new interventions. The resident was found sitting on the floor after an unwitnessed fall and later lowered to the floor by a CNA, leading to a pelvic fracture. The DON and Risk Manager confirmed no thorough investigation was conducted, and the event was not reported to the State Agency.
The facility failed to assess bladder incontinence for two residents, both frequently incontinent, lacking Urinary Continence Evaluations. One resident, with cognitive impairment, was told to use his brief, while another faced delays in reaching the restroom. Additionally, two residents with urinary catheters received improper care; one had a suprapubic catheter coiled around a wheelchair wheel, and another had unsecured catheter tubing, contrary to facility policy.
The facility failed to ensure timely responses to call lights, with residents reporting delays of 10 to 45 minutes, particularly during certain shifts. This deficiency was acknowledged by the facility's administration, although not formally documented. Inconsistencies in monitoring and documentation were noted, and a resident with a head injury was observed with a contusion after waiting for a response.
The facility failed to maintain infection control standards, as observed in improper hand hygiene and glove use during a resident's wound care, unsanitary storage of urinals leading to a strong odor, and an uncovered nebulizer mask. The DON confirmed these practices did not meet infection control policies.
A resident with schizophrenia and dementia was found with multiple urine-filled containers at their bedside, leading to a strong urine odor in the room. Despite a care plan addressing incontinence, staff interviews revealed the resident's preference for using urinals over the toilet and non-compliance with keeping urinals off the floor. The facility acknowledged the infection control issue but did not ensure regular emptying of the urinals.
The facility failed to maintain respiratory equipment in a sanitary manner for two residents. A resident with chronic kidney disease and COPD had a Bi-PAP and nebulizer with uncovered masks on his nightstand. Another resident with emphysema had a nebulizer with an uncovered mask on her nightstand. The DON confirmed that masks should be stored in plastic bags when not in use, highlighting a lapse in infection control procedures.
A facility failed to document a diagnosis and rationale for a resident's use of an antipsychotic medication. The resident, admitted with Anxiety Disorder, Mood Disorder, and Hallucinations, had a physician's order for quetiapine (Seroquel) without a documented diagnosis. This was confirmed by the DON during an interview.
A facility's Infection Preventionist, an RN, failed to follow proper infection control practices during wound care on a resident, such as not changing gloves or performing hand hygiene. The RN had not completed the required CDC Infection Preventionist training, which may have contributed to the observed deficiencies.
A resident with a history of Parkinson's disease and hemiplegia was observed with a splint improperly applied to the left hand, with the palm protector positioned on the wrist. Occupational therapists confirmed the incorrect application, and staff interviews revealed a lack of awareness and training regarding the splint. The DON acknowledged the absence of documentation on staff education for the proper application of the orthotic device.
A resident received both Lovenox and Eliquis concurrently due to a transference error by a nurse, leading to a significant medication error. The resident, who was supposed to transition from Lovenox to Eliquis, received both medications simultaneously, increasing the risk of bleeding. This resulted in the resident experiencing weakness and vomiting blood, necessitating a transfer to the emergency room.
Failure to Investigate Falls and Update Care Plan
Penalty
Summary
The facility failed to thoroughly investigate falls and implement adequate interventions to prevent falls and fall-related injuries for a resident identified as being at risk for falls. The resident, a vulnerable elderly female with a history of syncope, dementia, muscle weakness, and previous falls, experienced multiple falls at the facility. Despite the facility's policy requiring thorough investigation and documentation of incidents, the investigation into the resident's falls was incomplete, and the care plan was not updated with new interventions based on the root cause of the incidents. The resident had an unwitnessed fall and was found sitting on the floor next to her bed, complaining of pain in her right arm and leg. Although the physician was notified and x-rays were ordered, there was no documentation of the position of the resident's bed or the call light. The care plan was updated with the intervention of a floor mat, but no further interventions were documented. Later, the resident was lowered to the floor by a CNA during a transfer, and she complained of right upper leg pain. Despite negative x-ray results, the resident continued to report pain, leading to a CT scan that revealed a pelvic fracture. The Director of Nursing (DON) and the Risk Manager confirmed that there was no complete and thorough investigation of the incidents, and the event was not reported to the appropriate State Agency once the fracture was identified. The Risk Manager based the fracture on the nurse's documentation of no pain and did not investigate further, as the resident did not complain of pain until after being lowered to the floor. This lack of investigation and failure to update the care plan with appropriate interventions contributed to the deficiency in providing adequate supervision and preventing accidents.
Deficiencies in Incontinence and Catheter Care
Penalty
Summary
The facility failed to assess bladder incontinence for two residents, both of whom were frequently incontinent of bowel and bladder. One resident, with a history of Parkinson's Disease, Diabetes, Chronic Kidney Disease, and Depression, was noted to have moderate cognitive impairment and reported that he was instructed by staff to use his brief, despite not having incontinence issues prior to admission. The facility's records lacked documentation of a Urinary Continence Evaluation for this resident. Similarly, another resident with intact cognition and a history of Diabetes, General Weakness, Obesity, and Depression, reported difficulty reaching the restroom due to diuretic use and delayed staff assistance. This resident also had no documented Urinary Continence Evaluation. The facility also failed to provide appropriate care for residents with indwelling urinary catheters. One resident with a suprapubic catheter, a history of obstructive uropathy, chronic kidney disease, and urinary tract infections, was observed with the catheter tubing and drainage bag improperly coiled around the front wheel of his wheelchair. This improper handling was noted on multiple occasions, and the room had a strong odor of urine. The Director of Nursing acknowledged the resident's habit of moving the catheter and attempted to educate him on proper handling. Another resident with an indwelling urinary catheter, diagnosed with Parkinson's disease, sepsis, hemiplegia, and protein-calorie malnutrition, had an unsecured catheter tubing, which was not attached to the resident's thigh as required to prevent friction and movement at the insertion site. This observation was confirmed by the Infection Preventionist present during the inspection. The facility's failure to adhere to its catheter care policy contributed to these deficiencies.
Deficiency in Call Light Response Times
Penalty
Summary
The facility failed to maintain sufficient staffing levels to ensure timely responses to call lights, as observed and reported by multiple residents. Residents reported waiting times ranging from 10 to 45 minutes for staff to respond to their call lights, with delays occurring more frequently during the 3:00 p.m. to 11:00 p.m. shift and at night. Interviews with residents revealed that these delays led to issues such as incontinence due to not receiving timely assistance to the bathroom. The facility's Social Service Director and Administrator acknowledged the expectation for call light response times to be between 10 to 15 minutes, although this was not documented in a formal policy. The report also highlighted inconsistencies in the facility's documentation and monitoring of call light response times. While the Administrator provided documentation of staff instructions and weekly call light audits, there was no record of the specific times or personnel involved in monitoring. Additionally, grievances regarding call light response times were noted in the grievance log, but the Resident Council minutes did not document these complaints. The deficiency was further underscored by an incident involving a resident with a history of head injury, who was observed with a contusion and wound after waiting for 10 minutes for a response to his call light.
Infection Control Deficiencies in Resident Care and Equipment Storage
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, as evidenced by several observations. During a dressing change for a resident with a left ischeal wound, the Infection Preventionist did not adhere to proper hand hygiene and glove-changing protocols. The staff member was observed re-entering the room without changing gloves or gown, handling various surfaces with soiled gloves, and failing to perform hand hygiene between glove changes. This resulted in potential contamination during the wound care process. Additionally, the facility did not store resident care equipment in a sanitary manner. One resident was observed with urinals filled with urine stored on the floor next to the bed, contributing to a strong urine odor in the room. Despite the resident's non-compliance with keeping urinals off the floor, the facility acknowledged its responsibility to manage the infection control concern. Another resident's nebulizer mask was found uncovered on the nightstand, contrary to the facility's policy that masks should be stored in a plastic bag. The Director of Nursing confirmed these practices were not in line with infection control standards.
Failure to Assist Resident with Urinary Needs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living for a resident who was observed with urine-filled containers at their bedside. The resident, diagnosed with schizophrenia, depression, tremors, anxiety, and dementia, was noted to have a care plan addressing incontinence of bowel and bladder, with specific instructions to assist with changing briefs when soiled or wet. Despite this, the resident was observed with multiple urinals filled with urine on the floor, and the room had a strong urine odor. The resident reported that staff did not come to empty the urinals, necessitating the use of multiple containers. Interviews with staff revealed that the resident consumed large amounts of fluids and preferred using urinals over the toilet, despite being capable of using the toilet. The CNAs reported that the resident was non-compliant with keeping urinals off the floor, and the Director of Nursing acknowledged the infection control issue but noted the resident's non-compliance. The DON confirmed the facility's responsibility to manage the infection control concern, although it was unclear how often the urinals were emptied by staff.
Failure to Maintain Sanitary Respiratory Equipment
Penalty
Summary
The facility failed to maintain respiratory equipment in a sanitary manner for two residents, leading to a deficiency in infection control practices. Resident #64, who has a history of chronic kidney disease, malignant neoplasm of the prostate, and chronic obstructive pulmonary disease, was observed with a Bi-PAP and nebulizer machine on his nightstand. Both machines had masks that were uncovered and lying on top of the machines. Resident #64 confirmed that he used both machines daily and that the facility was responsible for maintaining the equipment. Similarly, Resident #23, who requires assistance with personal care and has emphysema, was observed with a nebulizer machine on her nightstand, with the mask uncovered and lying on the nightstand. This observation was made on two separate occasions. Resident #23 stated that she uses the nebulizer machine due to breathing difficulties. The Director of Nursing confirmed that the masks should be stored in a plastic bag when not in use, indicating a lapse in the facility's infection control procedures.
Lack of Documented Diagnosis for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident had a documented diagnosis and rationale for the use of an antipsychotic medication. The clinical record review revealed that the resident was admitted with diagnoses including Anxiety Disorder, Mood Disorder, and Hallucinations. A physician's order was noted for quetiapine (Seroquel) at a specified dosage, but there was no documented diagnosis for its use in the order. This deficiency was confirmed during an interview with the Director of Nursing, who verified the absence of a documented diagnosis for the antipsychotic medication prescribed to the resident.
Inadequate Infection Control Practices by Unqualified Infection Preventionist
Penalty
Summary
The facility failed to ensure that the Infection Preventionist had the required qualifications to perform their role effectively. The Infection Preventionist, a Registered Nurse, was observed performing wound care on a resident with a left ischeal wound. During the procedure, the Infection Preventionist did not adhere to proper infection control practices. She failed to change her gown and gloves upon reentering the resident's room, did not perform hand hygiene after removing soiled gloves, and continued to handle clean supplies and the resident's wound with contaminated gloves. This lack of adherence to infection control protocols was acknowledged by the Infection Preventionist during an interview, where she confirmed the necessity of changing gloves and performing hand hygiene when contamination occurs. Further review of the Infection Preventionist's personnel record revealed that she had not completed the required training modules from the Centers for Disease Control Infection Preventionist training, which she began in 2019. This incomplete training may have contributed to her inadequate infection control practices observed during the wound care procedure. The facility's policy requires the Infection Preventionist to be responsible for coordinating and updating infection prevention and control policies, which underscores the importance of having a fully qualified individual in this role.
Improper Application of Orthotic Device for Resident
Penalty
Summary
The facility failed to provide appropriate care and services to prevent a decline in range of motion for a resident with an orthotic device. The resident, who had a history of Parkinson's disease, hemiplegia, and other medical conditions, was observed with a splint improperly applied to the left hand on multiple occasions. The splint's soft padded palm protector was positioned on the wrist instead of the palm, which was confirmed by occupational therapists during a joint observation. The resident was not receiving therapy services at the time, and there were no photographs or written instructions available for the correct application of the splint. Interviews with staff revealed a lack of awareness and training regarding the application of the splint. Certified Nursing Assistants (CNAs) responsible for the resident's care were unaware of the splint's existence and did not know how to apply it. The Director of Nursing confirmed that CNAs were responsible for applying the splint but acknowledged the absence of documentation regarding staff education on its proper application. This lack of training and communication contributed to the improper use of the orthotic device, potentially affecting the resident's range of motion and skin integrity.
Medication Error with Anticoagulants
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not administering medications in accordance with the prescriber's orders. The resident, who had been discharged from the hospital with instructions to continue receiving Lovenox injections every 12 hours for one month, was also prescribed Eliquis to start after the Lovenox course. However, due to a transference error by a registered nurse, Eliquis was entered with an incorrect start date, leading to the resident receiving both Lovenox and Eliquis concurrently. This error resulted in the resident receiving two anticoagulant medications simultaneously, which increased the risk of bleeding or hemorrhage. The resident subsequently exhibited symptoms of weakness and vomiting blood, prompting a transfer to the emergency room. The incident highlights a significant medication error involving the administration of anticoagulant medications, which was not in accordance with the physician's orders.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
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 71 citations issued within 25 miles in the last 12 months — including the 6 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 Naples
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bentley Care Center | 1.2 mi | ★★★★★ | 0 | 0 |
| Solaris Senior Living North Naples | 1.9 mi | ★★★★★ | 0 | 0 |
| Adviniacare At Naples | 4 mi | ★★★★★ | 4 | 0 |
| Renaissance At The Terraces | 4.5 mi | ★★★★★ | 1 | 0 |
| Premier Place At The Glenview | 4.9 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Solaris Healthcare Imperial.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.