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 Senior Living North Naples during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of falls did not have required fall prevention interventions, such as accessible call lights and floor mats, consistently in place as outlined in the care plan. Multiple observations showed these safety measures were missing, despite staff statements and care plan updates indicating they should be present.
Staff failed to follow infection control protocols, including not wearing required PPE during care for a resident on contact precautions, improper storage of nebulizer equipment for two residents, and lack of hand hygiene during catheter care for a resident. These actions did not comply with facility infection prevention policies.
A resident with severe cognitive impairment and a history of falls was frequently observed without the call light within reach, despite care plan instructions and staff awareness of fall risk. Multiple observations showed the call light was often inaccessible, and the resident was unable to use it to request assistance.
Two residents did not have comprehensive care plans addressing their specific medical needs: one with a PEG tube lacked care planning for tube management and Enhanced Barrier Precautions, while another on contact precautions for ESBL UTI had no care plan for infection control measures. Staff interviews confirmed these omissions, which were not in line with facility policy.
Staff failed to anchor a resident's indwelling urinary catheter, did not follow proper hand hygiene during catheter care, and used soiled materials after a bowel movement. The resident, who required assistance with personal care and was being treated for a UTI, did not have catheter care or anchoring orders in place. Interviews revealed staff confusion about documentation and catheter care requirements, resulting in noncompliance with facility policy and infection control standards.
A resident with cognitive impairment and multiple health conditions did not receive a required Quarterly Nutrition Assessment, and the nutrition care plan was not updated by the Clinical Dietitian. The resident consistently received limited food choices, expressed dissatisfaction, and had documented inadequate oral intake, but there was no evidence of recent assessment or care plan revision as required.
The facility did not ensure accurate reconciliation of controlled drugs or timely removal of discontinued medications from med carts. For two residents, there were discrepancies between controlled drug records and MAR documentation, and discontinued alprazolam was not promptly removed. Interviews with LPNs and the DON confirmed lapses in following established procedures for controlled substances.
The facility did not ensure that a licensed pharmacist consistently reported monthly drug regimen reviews or that medication irregularities were addressed with documented physician rationale. For one resident, pharmacy recommendations regarding pantoprazole and zolpidem were not accompanied by a physician's rationale for disagreement, and for another resident, there was no documented medication review for a specific month. Staff interviews revealed inconsistent understanding and documentation of medication review requirements, leading to noncompliance with facility policy.
Two residents were found with medications left unsecured at their bedsides without required physician orders, interdisciplinary assessments, or care plans for self-administration. In one case, multiple pills and a liquid medication were left at the bedside at the insistence of a spouse, and in another, eye drops were accessible to a resident whose husband administered them. Facility staff confirmed that these actions were not in accordance with facility policy or regulatory requirements.
Failure to Implement Fall Prevention Interventions for Cognitively Impaired Resident
Penalty
Summary
Facility staff failed to follow care plan interventions designed to prevent further falls for a resident with a history of multiple falls and severe cognitive impairment. The resident, diagnosed with vascular dementia, depressive disorder, and hyperlipidemia, experienced several falls over a period of time, each resulting in updates to the care plan, such as reminders to use the call light, not to ambulate unassisted, and to request assistance with toileting. After a fall, the care plan was updated to include the use of floor mats on both sides of the bed, and staff interviews indicated that these interventions were expected to be in place. Despite these documented interventions, multiple observations revealed that the resident's call light was not consistently within reach and that floor mats were not present on either side of the bed as required by the care plan. Additionally, a review of physician's orders did not show an order for floor mats, despite staff statements to the contrary. These failures to implement and maintain care plan interventions contributed to the ongoing risk of accidents for the resident.
Failure to Follow Infection Control Protocols for Contact Precautions, Equipment Storage, and Hand Hygiene
Penalty
Summary
The facility failed to adhere to infection prevention and control guidelines in several observed instances. For one resident on contact precautions due to a urinary tract infection with ESBL, a registered nurse entered the resident's room wearing only gloves, without donning a gown as required by the facility's contact precaution policy. The nurse administered an intramuscular injection and then, after removing her gloves, repositioned the resident and handled linens without appropriate personal protective equipment or hand hygiene between tasks. Additionally, two residents receiving nebulizer treatments were found to have their nebulizer tubing and masks stored uncovered on their bedside dressers. One resident confirmed that after a recent treatment, the equipment was left uncovered, while the other resident stated the equipment was supposed to be stored in a bag but was not. These observations indicate improper storage of respiratory care equipment, contrary to infection control protocols. In another instance, a certified nursing assistant performed catheter care for a resident with an indwelling urinary catheter. During the procedure, the resident had a bowel movement, resulting in the CNA's gloves becoming soiled. The CNA changed gloves multiple times during the procedure but did not perform hand hygiene between glove changes, despite facility policy and standard infection control practices requiring hand hygiene at these points.
Failure to Ensure Call Light Accessibility for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that the call light was consistently within reach for a resident with severe cognitive impairment and a history of falls. The resident, diagnosed with vascular dementia, depressive disorder, and hyperlipidemia, had a BIMS score indicating severe cognitive impairment and had experienced four falls in the past five months. The care plan directed staff to remind the resident to use the call bell for assistance. However, multiple observations over several days revealed that the call light was frequently not within the resident's reach, being attached to the back of a privacy curtain or the end of the bed, making it inaccessible. On several occasions, the resident was unable to locate or reach the call light when asked, despite being instructed to use it for assistance. Staff interviews confirmed awareness of the resident's fall risk and the need to keep the call light within reach, but also noted that the resident sometimes attempted to get up without assistance and did not always use the call light. Despite these known risks and care plan interventions, the call light was not reliably placed within the resident's reach, as evidenced by repeated observations. Only on one occasion was the call light observed to be within reach and usable by the resident.
Failure to Develop and Implement Comprehensive Care Plans for Residents with Specialized Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for residents with specific medical needs. For one resident with a PEG tube, the care plan did not address the presence of the feeding tube or Enhanced Barrier Precautions (EBP), despite physician orders for PEG tube stoma care and the resident's ongoing transition away from tube feeding. Interviews with MDS Coordinators confirmed that the required care plans were not created, with one staff member acknowledging the omission was an oversight. Additionally, another resident who was on contact precautions for a urinary tract infection with ESBL did not have a care plan addressing these precautions. Review of the electronic health record and physician orders confirmed the resident was on contact precautions, but this was not reflected in the care planning documentation. Both deficiencies were identified through observations, interviews, and record reviews, and were not in accordance with the facility's own care planning policy.
Failure to Provide Proper Catheter Care and Adhere to Infection Control Protocols
Penalty
Summary
Facility staff failed to perform urinary indwelling catheter care in accordance with accepted standards of practice and the facility's own policy. Observations revealed that catheter tubing was not anchored to the resident's thigh as required, and staff did not follow proper hand hygiene protocols during catheter care. Specifically, a CNA continued to use a soiled washcloth and gloves after the resident had a bowel movement, only changing gloves without performing hand hygiene, and then resumed care. Additionally, the catheter tubing remained unsecured throughout the procedure, and the drainage bag was raised above the bladder during dressing, which is inconsistent with best practices. Record review for the resident involved showed a history of conditions including a right artificial hip joint, history of falls, and a need for assistance with personal care. The resident had an indwelling urinary catheter in place, with physician orders for catheter management and irrigation, but there was no specific order for routine catheter care or for securing the catheter tubing. The resident was also being treated for a urinary tract infection with antibiotics at the time of the observations. Interviews with staff indicated a lack of understanding and adherence to documentation and catheter care protocols. The LPN was unaware of the need for an order for catheter care and did not know if the catheter should be anchored. The CNA responsible for the care did not respond when asked about documentation practices. These actions and omissions contributed to the facility's failure to provide appropriate catheter care and to follow established infection prevention procedures.
Failure to Complete Quarterly Nutritional Assessment and Update Care Plan
Penalty
Summary
The facility failed to complete a required Quarterly Nutritional Assessment for one resident who was readmitted with multiple diagnoses, including legal blindness, dementia, and psychosis. The resident had a moderate to severe cognitive impairment and required set-up or clean-up assistance for eating. Observations showed that the resident was routinely provided with the same limited food choices and expressed dissatisfaction with the lack of variety. The care plan identified the resident as being at risk for altered nutrition due to end-stage cerebral atherosclerosis, underweight status, and legal blindness, and noted inadequate oral intake with 25% or more of most meals uneaten. Despite these risks, there was no evidence that the Clinical Dietitian completed or updated the Quarterly Nutrition Assessment or revised the care plan after a specified date. Interviews with facility staff confirmed that the Clinical Dietitian was responsible for updating nutrition care plans and completing Quarterly Nutrition Assessments, but the assessment was not completed for this resident. The Dietary Manager and Registered Dietitian both acknowledged the lapse, with the Registered Dietitian unable to explain why the assessment was missed. Additionally, the most recent assessment did not document any direct interaction with the resident to determine food preferences, likes, or dislikes, and there was no documentation of the resident's refusal of supplements prior to the assessment.
Deficient Controlled Drug Reconciliation and Removal of Discontinued Medications
Penalty
Summary
The facility failed to maintain an accurate and effective system for the reconciliation of controlled drugs and the timely removal of discontinued medications from medication carts. For one resident, there was a discrepancy between the Controlled Medication Utilization Record and the Medication Administration Record (MAR) for alprazolam 0.25 mg, with documentation showing the medication was removed from the med cart on two occasions, but no corresponding administration was recorded on the MAR. The LPN interviewed confirmed that the process is to document removal on the Controlled Medication Record and administration on the MAR, but this was not done for the identified dates. For another resident, alprazolam 0.25 mg was discontinued per physician's order, but the medication was not promptly removed from the med cart. The DON stated that discontinued medications should be removed within a couple of days and that the night shift nurse is responsible for checking the cart nightly. However, the medication remained in the cart beyond the discontinuation date, indicating a lapse in the facility's process for handling discontinued controlled substances.
Failure to Ensure Timely Pharmacist Review and Documentation of Medication Irregularities
Penalty
Summary
The facility failed to ensure that the consultant pharmacist consistently reported the results of monthly drug regimen reviews and that identified medication irregularities were properly addressed with documented physician rationale. For one resident, the consultant pharmacist's recommendations regarding the use of pantoprazole and zolpidem were disagreed with by the physician, but there was no documentation in the medical record providing a rationale for these decisions, as required by facility policy. The consultant pharmacist indicated that such rationales might be found in progress notes, but a review of the record did not reveal any such documentation. Additionally, the facility did not have evidence of a completed monthly medication regimen review for another resident for a specific month. The consultant pharmacist stated that the review was visible on her computer, but due to a system glitch, she was unable to provide a printed or electronic copy with the resident's name. The Director of Nursing confirmed that there was no documentation of the review in the facility or in the resident's electronic health record for that month. Interviews with facility staff, including the consultant pharmacist and nurse practitioner, revealed inconsistencies in understanding and documenting the requirements for medication regimen reviews and the handling of pharmacy recommendations, particularly regarding the need for stop dates and rationales for continued or PRN psychotropic medication orders. These lapses resulted in noncompliance with the facility's own policies and federal requirements for medication management and documentation.
Failure to Secure Medications and Ensure Proper Authorization for Bedside Storage
Penalty
Summary
The facility failed to ensure that medications and biologicals were secured at all times, as required by policy and regulation, for two of sixteen sampled residents. For one resident, who had diagnoses including a femur fracture and generalized muscle weakness and was assessed as cognitively intact, medications were observed left at the bedside in two medicine cups, one containing multiple pills and a capsule, and the other containing a liquid medication. The resident and her spouse stated that the medications were left at the bedside because the spouse insisted, and the resident did not recognize all the medications. Facility staff confirmed that there was no physician's order, care plan, or evaluation for self-administration of medications for this resident, and acknowledged that medications should not have been left at the bedside without these in place. For a second resident, who had generalized muscle weakness and required assistance with personal care, a bottle of sterile eye drop lubricant was observed on the overbed table. The resident stated that her husband administered the eye drops for her, but she did not self-administer them. Staff confirmed that there was no physician's order for the eye drops, no evaluation for self-administration, and no care plan for self-administration of medications for this resident. The staff instructed the resident's husband to take the eye drops home and indicated they would obtain an order from the physician. In both cases, the facility's own policies required that medications be stored securely and only accessible to authorized personnel, and that self-administration of medications be permitted only after an interdisciplinary team assessment, a physician's order, and appropriate care planning. These requirements were not met for either resident, resulting in unsecured medications at the bedside without proper authorization or assessment.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
A prioritized, do-first checklist
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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) |
|---|---|---|---|---|
| Solaris Healthcare Imperial | 1.9 mi | ★★★★★ | 0 | 0 |
| Adviniacare At Naples | 2.2 mi | ★★★★★ | 4 | 0 |
| Bentley Care Center | 2.9 mi | ★★★★★ | 0 | 0 |
| Premier Place At The Glenview | 4.2 mi | ★★★★★ | 3 | 0 |
| Chateau At Moorings Park, The | 4.7 mi | ★★★★★ | 1 | 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 August 2026) and official state health department websites.