Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 Parkway during CMS and state inspections, most recent first.
Incomplete DNR Order Forms: The facility failed to ensure properly executed DNRO forms for three residents with current DNR status. One resident was cognitively intact but had no incapacity form or evidence of a surrogate/POA, and the yellow DNRO lacked the resident’s signature and date. Another cognitively intact resident said she understood her DNR status but did not recall signing the form; her DNRO lacked DOB, date signed, and printed name. A third resident with moderate cognitive impairment and a surrogate/POA had a DNRO missing DOB and the representative’s signature date.
Failure to follow ordered wound care and weekly skin assessments: A resident with a skin tear had an undated dressing despite an order for daily dressing changes, another resident with a blood blister had an undated dressing, and two residents at risk for skin breakdown missed weekly skin checks. A severely cognitively impaired resident also had an untreated itchy rash on the chest that staff observed over several days before a provider order was obtained.
A resident with CVA, bilateral hemiplegia, and worsening lower-extremity contractures reported pain when seated in a wheelchair, yet staff continued using standard leg rests instead of adaptive support, and a lift transfer was stopped because his knees bent in the sling and he could not tolerate the pain. A second resident with severe cognitive impairment, CVA with L hemiparesis, and hand contractures had an order and care plan for a rolled washcloth in the right hand, but observations showed no hand support in place while an RN gave inconsistent statements about whether the resident used a wrist guard or a rolled towel.
Failure to complete required smoking safety assessments for two residents. One resident with multiple chronic conditions, including CHF, chronic lung disease, and respiratory failure, was observed coming from the smoking patio wearing oxygen, and another resident with dementia, CAD, CHF, and respiratory failure had been smoking in the room. Although both had prior smoking assessments stating they could smoke safely without supervision, the facility did not complete the assessments at least quarterly as required, and the ADON and RN/UM acknowledged they were missed.
A resident with heart failure, severe cognitive impairment, and pneumonia was documented as receiving 2L O2 via NC and breathing txs, but the record lacked a physician order for oxygen and lacked O2 saturation documentation for the dates oxygen therapy was noted. Surveyors observed the resident resting in bed with O2 in place, and the ADON confirmed there was no current or prior oxygen order.
Infection control practices were not followed during a blood glucose check when an LPN wore used gloves between tasks, failed to perform hand hygiene, did not properly dispose of a lancet, and used the wrong disinfectant wipe on a glucometer. The LPN also wrapped the device in a dry tissue instead of maintaining the required wet contact time and later reused gloves while assisting a resident with medication.
A resident with moderate cognitive impairment was repeatedly observed unable to access the call bell, resulting in unmet needs for assistance. The call bell was often placed out of reach, and the resident was unaware of its location, leading to difficulties in requesting help.
The facility failed to properly anchor indwelling urinary catheter tubing for two residents, despite documented orders and care plans. Both residents were observed multiple times without the required anchoring devices, leading to taut catheter tubing.
The facility failed to ensure competent nurse staff during medication administration for two residents. An LPN administered insulin without a second nurse verification and documented another nurse's initials incorrectly. Another LPN did not follow the proper technique for nasal spray administration.
A resident continued to receive an incorrect dosage of Protonix despite a physician's order to decrease it, due to a lapse in the facility's process for handling pharmacy recommendations.
The facility failed to prepare pureed food with the correct texture for residents with physician-ordered pureed diets. Observations revealed stringy pork and lumpy pasta, which the DFS did not initially taste or acknowledge. Later, the pureed foods served in the dining room had a smoother texture.
Incomplete DNR Order Forms
Penalty
Summary
The facility failed to ensure properly executed DNR orders for 3 of 3 sampled residents, with incomplete yellow copy DNRO forms for Residents #134, #116, and #62. Facility policy stated that a DNR indicates that, in the event of respiratory or cardiac failure, no CPR or other life-saving methods are to be used, and that a photocopy of the DNRO form must be provided to EMT personnel if the resident is transferred to the hospital. Review of the records showed that each of the three residents had a current DNR code status, but the corresponding yellow copy DNRO forms were incomplete. Resident #134 was cognitively intact with a BIMS score of 13, and the record lacked an incapacity form or evidence of a health care surrogate or power of attorney; the yellow DNRO form had the resident’s printed name but lacked the resident’s signature and the date signed. Resident #116 was cognitively intact with a BIMS score of 15; her yellow DNRO form lacked her date of birth, the date signed, and her printed name, and she stated during interview that she understood her DNR status but did not recall signing the form. Resident #62 had moderate cognitive impairment with a BIMS score of 8 and had evidence of a health care surrogate or power of attorney; the yellow DNRO form had the printed names of the resident and representative but lacked the resident’s date of birth and the date the representative signed the form. Staff D, an LPN, stated that the nurse or social worker speaks with the resident and/or family to obtain the DNR order and confirmed that each section must be completed, signed, and dated for the form to be valid.
Failure to follow ordered wound care and weekly skin assessments
Penalty
Summary
The facility failed to provide ordered wound care and skin monitoring for multiple residents. Resident #182, who had a BIMS score of 15 and no cognitive impairment, had a physician order dated 11/21/25 to cleanse a skin tear on the right shin with normal saline, apply xeroform, and cover with a dry dressing daily on day shift. During observation, the resident had a white square dressing on the right shin that was not dated, and he stated the dressing had been changed the day before and was supposed to be changed every 2-3 days. On a later observation, the dressing was still present and undated, and the resident stated it had not been changed the prior day and that it still needed a dressing. Although the TAR showed staff documenting daily dressing changes, the dressing observed on the resident was not dated as ordered. Resident #182 also had a physician order dated 11/07/25 for weekly skin checks every Friday on the 7 AM to 3 PM shift. The record showed only one documented skin assessment on 11/25/25, while the TAR contained documentation that skin checks were completed every Friday as ordered. Resident #27, who had severe cognitive impairment and was at risk for pressure injuries, had a care plan and physician orders for weekly skin checks every Thursday on the 3 PM to 11 PM shift, but the most recent weekly skin check was completed on 11/21/25 and there was no skin check for the week of 11/23/25 through 11/29/25. Resident #134, who had moderate cognitive impairment, an unhealed pressure injury, and risk for further pressure injuries, also had care plan and physician orders for weekly skin checks, but the most recent weekly skin check was completed on 11/21/25 and there was no skin check for the week of 11/23/25 through 11/29/25. Resident #184, who had severe cognitive impairment, was observed repeatedly scratching the left chest area over several days. Staff observed the resident rubbing and scratching the area, and the resident showed a reddened area with small pimples and scratches. The area later appeared more red, with tiny pimples and scratches on both sides of the chest. Staff H acknowledged noticing the behavior but had not gone into the room when first seeing it from the hallway. The record did not show any physician order for the rash until 12/04/25, when a new order was written for triamcinolone acetonide cream to the chest daily for 10 days. Resident #36, who had moderate cognitive impairment and multiple diagnoses including dementia, aphasia, malnutrition, and chronic pain, had a physician order for skin prep to the right elbow blood blister and to cover it with a foam dressing daily. During observation, the dressing on the right arm near the elbow was not dated. Staff later acknowledged that the dressing should have been dated and was not. The facility policy also required dressings to be labeled with the date and initials, but the observed dressing did not meet that requirement.
Failure to Provide Ordered ROM and Positioning Support
Penalty
Summary
The facility failed to provide appropriate care and positioning equipment to maintain and/or improve range of motion and mobility for two residents. One resident with a history of cerebral infarction, bilateral hemiplegia, and foot drop reported that sitting in the wheelchair caused pain in his legs and that he had not been in the wheelchair for at least 2 to 3 weeks. His care plan identified decreased mobility and dependence for wheelchair use, and later therapy evaluations documented impaired ROM in both lower extremities with functional limitations due to contractures in the hips, knees, and ankles. Although the resident stated he wanted to attend activities and later said he would get up in a wheelchair if it had leg rests that supported his legs, the wheelchair observed by the Rehabilitation Director had standard non-elevating leg rests rather than the adaptive equipment needed to accommodate his lower extremity contractures. Staff interviews showed that multiple staff members knew the resident usually refused to get up in the wheelchair and that he complained of pain when seated, but they did not identify the wheelchair as the source of the problem. The Rehabilitation Director stated there were no orders for adaptive wheelchair equipment until she personally assessed the wheelchair and found standard leg rests. During a transfer attempt using a mechanical lift, the resident was unable to tolerate the transfer because his knees were bending in the sling and he had too much pain to continue, requiring him to be lowered back to bed. The resident later stated that his pain was related to his knees, hips, and ankles rather than fear of falling, and he said he would have started therapy if staff could have helped him. A second resident with severe cognitive impairment and a history of CVA with left hemiparesis had contracted hands and a physician order to place a rolled-up washcloth in the right hand once daily. The care plan also included a rolled washcloth in the right hand as an approach. However, observations on multiple days showed the resident sitting in a chair with contracted hands and no splint, brace, or rolled towel noted to the right hand. Although the MAR documented that an RN had signed for application of the rolled towel on two dates, the RN later stated the resident had a wrist guard, then corrected herself and said it was actually a rolled towel, indicating confusion about the ordered hand support and whether it had been applied.
Failure to Complete Required Smoking Safety Assessments
Penalty
Summary
The facility failed to assess residents for safe smoking for 2 of 3 sampled residents reviewed for smoking, Resident #38 and Resident #170. The facility’s Smoking Policy stated that a smoking assessment would be completed upon admission, quarterly during care plan review, and upon a change in resident condition. Resident #38 was admitted with diagnoses including heart failure, hypertension, diabetes mellitus, hyponatremia, anxiety disorder, depression, chronic lung disease, respiratory failure, muscle weakness, chronic pain, and bronchiectasis. The resident’s quarterly MDS showed a BIMS score of 14, indicating cognitive intactness. The care plan for nicotine use documented that the resident was observed coming from the smoking patio wearing oxygen, and a Smoking Data Collection and Assessment concluded the resident could smoke safely without supervision; however, no additional smoking assessments were found to have been completed at least quarterly or after the observation of smoking while wearing oxygen. Resident #170 was admitted and later readmitted to the facility, and the most recent annual MDS showed a BIMS score of 11, indicating moderate cognitive impairment. Diagnoses included anemia, atrial fibrillation, GERD, CAD, heart failure, hypertension, diabetes mellitus, Alzheimer’s disease, non-Alzheimer’s dementia, anxiety disorder, depression, chronic lung disease, and respiratory failure. The nicotine use care plan documented that the resident had been smoking in the room and had been educated on the dangers of smoking inside the building. A Smoking Data Collection and Assessment concluded the resident could smoke safely without supervision, but no additional smoking assessments were found to have been completed at least quarterly. During interview, the ADON and RN/UM stated that the assessments were missed.
Lack of Oxygen Order and Saturation Monitoring
Penalty
Summary
Appropriate respiratory care was not provided for Resident #124 when oxygen was being used without a corresponding physician order and without documented oxygen saturation assessments. The resident was admitted with a diagnosis including heart failure and had severe cognitive impairment, with a BIMS score of 4. On 10/18/25, the resident had a productive cough and wheezing, a chest X-ray was ordered, and the resident was diagnosed with pneumonia based on the results. A progress note dated 10/20/25 documented that the resident's oxygen saturation was in the 70%s and that 2 liters of oxygen by nasal cannula and breathing treatments were prescribed and administered. Subsequent Infectious Disease physician entries on 10/22/25, 10/24/25, 10/27/25, and 10/31/25 documented that the resident was on 2L O2 via nasal cannula, but the record contained no corresponding oxygen order for the amount to administer. The record also lacked oxygen saturation levels for the dates the resident was documented to be on oxygen therapy. During observation on 12/01/25, the resident was resting in bed with oxygen at 2L via nasal cannula, and during interview on 12/04/25, the ADON confirmed there was no current or October 2025 oxygen order.
Infection Control Lapses During Blood Glucose Monitoring
Penalty
Summary
Infection control practices were not followed during blood glucose monitoring for one resident when an LPN performed a medication pass observation. The LPN gathered supplies for the blood sugar check, including a canister of strips, one lancet, and an alcohol wipe, and wore gloves while leaving the medication cart and walking to the resident’s room. After obtaining the resident’s blood sugar level, the LPN returned to the cart still wearing the used gloves, entered information into the computer with gloved hands, and discarded the lancet into the sharps container without ensuring it fell fully into the secured section. The LPN then removed the gloves inside-out and placed them on top of the cart. The LPN used a Micro-Kill Two Germicidal wipe to clean the glucometer even though the manufacturer’s instructions identified Medline Micro-Kill Bleach Germicidal Bleach Wipes for disinfection. After wiping the glucometer, she immediately wrapped it in a dry tissue rather than keeping the surface wet for the required contact time. During the same observation, the LPN did not perform hand hygiene during the blood sugar check or after assisting two residents, and she later donned the same gloves again to give the resident Tylenol and returned to the cart wearing those gloves. The DON was informed of the observation and agreed with the findings.
Failure to Ensure Accessibility of Call Bell for Resident
Penalty
Summary
The facility failed to ensure the accessibility of the call bell for a resident with moderate cognitive impairment. The resident, who required partial to total assistance for activities of daily living, was observed on multiple occasions unable to locate or reach the call bell. During an observation, the resident was found sitting in a wheelchair and unaware of the call bell's location, which was clipped to the upper corner of the bed and out of reach. The resident expressed a need for assistance but was unable to call staff due to the inaccessible call bell. Further observations revealed the resident in bed with the call bell placed in locations that were not easily reachable. Despite being prompted, the resident was unable to navigate his hand to touch the call bell. On another occasion, the resident struggled to drink juice due to a defective straw and was unable to call for assistance until the call bell was placed within sight by the surveyor. The resident demonstrated understanding and ability to use the call bell when it was accessible. The unit manager acknowledged the issue and indicated the need to devise a plan to provide better access to the call bell.
Failure to Anchor Indwelling Urinary Catheters
Penalty
Summary
The facility failed to ensure the proper anchoring of indwelling urinary catheter tubing for two residents, both of whom had specific medical conditions requiring catheter use. Resident #34, who had a diagnosis of urinary retention, was observed on multiple occasions without an anchoring device for the catheter tubing, which was noted to be taut and coming out of the bottom of the adult brief. Despite a physician's order and care plan approach to secure the catheter with a leg strap, staff did not address the missing anchor during personal care or subsequent observations by the unit manager and ADON. Similarly, Resident #204, who had a history of urinary retention and a recent UTI, was also found without an anchoring device for the urinary catheter tubing during multiple observations. The resident confirmed the absence of the anchor when asked. It was only after a subsequent observation with the ADON that a thigh strap was noted to secure the catheter tubing. Both residents had documented orders and care plans specifying the use of catheter holders to prevent pulling, which were not adhered to by the facility staff.
Failure to Ensure Competent Nurse Staff During Medication Administration
Penalty
Summary
The facility failed to ensure competent nurse staff for two residents during medication administration observations. For Resident #49, an LPN administered 7 units of Novolin R insulin without following the facility's process for a second nurse verification. The LPN incorrectly documented the initials of another nurse on the Medication Administration Record (MAR) and claimed to have verified the dose with the surveyor, which is against the facility's protocol. The Director of Nursing (DON) confirmed the requirement for a second nurse verification but admitted that it was not a written process, only part of the facility protocols. For Resident #74, another LPN administered a nasal spray without occluding the opposite nostril, contrary to the facility's policy on nasal administration. The policy, revised in January 2018, clearly outlines the procedure for nasal spray administration, including the need to close the opposite nostril. The Risk Manager was informed of this observation, and the policy was reviewed to confirm the correct procedure.
Failure to Implement Pharmacy Recommendations
Penalty
Summary
The facility failed to implement pharmacy recommendations approved by the physician for a resident. The resident was admitted to the facility and had an order for the anti-reflux medication, Protonix 40 mg, for Anemia. The pharmacist recommended discontinuing the medication after identifying that the resident had been on it for more than 12 weeks. The physician agreed to decrease the dosage to 20 mg daily. However, the resident continued to receive the original 40 mg dosage, and subsequent monthly reviews did not address this discrepancy. During an interview, the Unit Manager explained the process for handling monthly pharmacy reviews, which involves the pharmacist providing the reviews to the Director of Nursing, who then distributes them to the Unit Managers. The Unit Managers are responsible for discussing the recommendations with the physician and entering new orders into the electronic medical records. The Unit Manager was unsure why the physician's order to decrease the Protonix dosage was not implemented, indicating a lapse in the facility's process for handling pharmacy recommendations.
Improper Preparation of Pureed Food
Penalty
Summary
The facility failed to prepare pureed food with the correct texture, as required for residents with physician-ordered pureed diets. During an observation in the kitchen, it was noted that the pureed Italian Parmesan Breaded Pork and pureed Parslied Noodles did not appear smooth. Upon tasting, the pureed pork contained chopped up strings, and the pureed pasta had lumps. The Director of Food Services (DFS) admitted to usually tasting the pureed food but did not do so on that day. When asked to taste the food, the DFS did not acknowledge the stringy pork or lumpy pasta but stated she would puree the foods again. An observation of the pureed foods served in the main dining room later revealed a smoother texture.
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 78 citations issued within 25 miles in the last 12 months — 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 Stuart
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stuart Rehabilitation And Healthcare | 0.6 mi | ★★★★★ | 6 | 0 |
| Waters Edge Health And Rehabilitation | 2.1 mi | ★★★★★ | 0 | 0 |
| Palm City Nursing & Rehab Center | 3 mi | ★★★★★ | 0 | 0 |
| Seabranch Health And Rehabilitation Center | 4.3 mi | ★★★★★ | 3 | 0 |
| Life Care Center Of Port Saint Lucie | 7.3 mi | ★★★★★ | 15 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Solaris Healthcare Parkway.
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 July 2026) and official state health department websites.