Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Solaris Healthcare Coconut Creek during CMS and state inspections, most recent first.
A resident with diabetes received insulin inappropriately when an LPN used a syringe to extract insulin from a pen, despite available pen needles. The LPN admitted this was not best practice, and the DON confirmed pens should be used as designed.
A facility failed to manage the nutritional needs of a resident on tube feeding, resulting in significant weight loss and caloric deficits. The resident, with a history of metabolic encephalopathy and pressure ulcers, did not receive the full prescribed tube feeding, leading to insufficient calorie intake. Additionally, the facility did not consistently monitor the resident's weight, hindering accurate assessment of nutritional status.
The facility failed to change oxygen tubing timely for two residents receiving oxygen therapy, contrary to Professional Standards of Practice. One resident had continuous oxygen orders, and observations showed tubing dated over a week old without staff initials. Another resident had as-needed oxygen orders, with tubing found on the floor and dated over a week old. Staff interviews revealed confusion about the tubing change policy.
The facility failed to implement an effective QAPI program for monitoring resident weights, particularly for those on tube feeding. A resident was not weighed weekly as required, and two other residents had inconsistent weight records, missing both weekly and monthly weigh-ins. Interviews revealed that the Registered Dietitian was focused on monthly weights, neglecting weekly requirements, and there was no designated person responsible for taking weights.
A facility failed to follow infection control practices for a resident with low WBC, who was at high risk for infection. Observations showed staff and visitors not adhering to Neutropenic Precautions, such as wearing PPE and performing hand hygiene. Interviews revealed inconsistent understanding and implementation of these precautions, compromising the resident's safety.
Improper Insulin Administration Practice
Penalty
Summary
The facility failed to adhere to professional standards of quality practice during the administration of insulin for a resident with diabetes. The resident, who had moderate cognitive impairment, was observed receiving insulin in a manner inconsistent with the manufacturer's guidelines. Specifically, a Licensed Practical Nurse (LPN) used an insulin syringe to extract 18 units of insulin from an insulin pen, rather than using the pen as intended. This action was observed during a medication administration session, where the LPN was seen squinting and fumbling with the syringe plunger to obtain the correct dosage before injecting it into the resident's arm. The LPN admitted to the surveyor that using a syringe to extract insulin from the pen was not best practice, but claimed that the facility sometimes lacked the necessary pen needles. However, it was acknowledged that pen needles were available for the resident's insulin pen at the time. The Director of Nursing confirmed that insulin pens should be used according to their design, indicating a deviation from standard procedures in this instance.
Failure to Monitor Nutritional Needs and Weight of Resident on Tube Feeding
Penalty
Summary
The facility failed to properly manage and monitor the nutritional needs of Resident #87, who was receiving tube feeding. The resident, who had a history of metabolic encephalopathy, stage 4 pressure ulcer, and cachexia, experienced a significant weight loss of 6.6% over a period of time. The facility did not adhere to the prescribed tube feeding regimen, resulting in the resident receiving fewer calories than required. Observations revealed that the tube feeding was not administered in full, leading to a caloric deficit on multiple occasions. Additionally, the facility did not consistently obtain and verify the resident's weight as required. Despite the facility's protocol to record weights weekly for the first month after admission, only two weights were recorded for Resident #87 since her readmission. This lack of consistent weight monitoring hindered the ability to assess the resident's nutritional status accurately and adjust care plans accordingly. Interviews with staff, including the Registered Dietician, highlighted the absence of a designated person responsible for weight monitoring and the ongoing challenges in implementing a Process Improvement Project (PIP) for weight tracking. The Registered Dietician acknowledged the nutritional risk posed to residents like Resident #87, who rely entirely on tube feeding for their nutritional needs, and recognized the need for improved monitoring and intervention strategies.
Failure to Timely Change Oxygen Tubing
Penalty
Summary
The facility failed to ensure timely labeling and changing of oxygen tubing for two residents receiving oxygen therapy, which is inconsistent with the Professional Standards of Practice. Resident #22, who was admitted with diagnoses including Acute Bronchospasm and Degenerative Disease of the Nervous System, had physician orders for continuous oxygen at 2 Liters per minute through a nasal cannula. Observations on multiple occasions revealed that the oxygen tubing was dated 07/12/24, without staff initials, and had not been changed as per facility policy, which requires weekly changes on Sundays during the night shift. The Director of Nursing confirmed the expectation for routine monitoring and timely changing of oxygen tubing. Similarly, Resident #86, admitted with Acute Respiratory Failure with hypoxia, had orders for oxygen administration as needed. Observations showed that the oxygen tubing was dated 07/10/24 and was found on the floor, indicating it had not been changed according to the facility's policy. Interviews with nursing staff revealed a lack of clarity regarding the frequency of tubing changes, with some staff unable to recall the specific policy details. The Nursing Home Administrator was informed of these findings during an interview.
Failure to Implement Effective QAPI for Resident Weights
Penalty
Summary
The facility failed to develop and implement an effective Quality Assurance and Performance Improvement Program (QAPI) as evidenced by their inability to regularly review, analyze, and act on data regarding residents' weights. This deficiency was observed in three residents who were on tube feeding. The facility's policy required residents to be weighed upon admission or readmission and then weekly for four weeks, but this was not consistently followed. For instance, Resident #87 was readmitted and weighed initially, but subsequent weekly weights were not recorded. Similarly, Resident #96 and Resident #56 did not have their weights recorded weekly as required, with gaps in the weight logs indicating missed weekly and monthly weigh-ins. Interviews with facility staff, including the Registered Dietitian and the Administrator, revealed ongoing issues with obtaining and recording weights. The Registered Dietitian acknowledged the problem and mentioned that a Performance Improvement Plan (PIP) was in place, but it was not effectively addressing the weekly weight requirements. The facility lacked a designated person responsible for taking weights, and the Registered Dietitian was focused on ensuring monthly weights were recorded, neglecting the weekly requirements. Despite efforts to track and improve weight recording, the facility's QAPI goals for weekly weights were not being met, indicating a systemic issue in adhering to their own policies.
Failure to Implement Neutropenic Precautions
Penalty
Summary
The facility failed to adhere to infection control practices and the established standards for Neutropenic Precautions for a resident with a significantly low white blood cell count, placing them at high risk for infection. The resident, who was admitted with conditions including Hepatic Encephalopathy and Autoimmune Hepatitis, was under Neutropenic Precautions as per physician's orders. These precautions included the use of personal protective equipment (PPE) and hand hygiene protocols, which were not consistently followed by staff and visitors. Observations revealed multiple instances of non-compliance with the Neutropenic Precautions. A visitor was seen inside the resident's room without wearing a mask or gloves, and staff failed to educate him on the necessary precautions. Staff members were also observed entering the resident's room without wearing the required PPE, such as gowns, masks, and gloves, and did not perform proper hand hygiene before and after contact with the resident. Additionally, the resident's husband was observed interacting with the resident without wearing PPE and not following proper cough etiquette. Interviews with staff, including the Director of Nursing and Certified Nursing Assistants, indicated a lack of consistent understanding and implementation of the Neutropenic Precautions. Despite being educated on the necessary precautions, staff did not consistently follow the protocols, such as hand washing with soap and water and wearing appropriate PPE. The facility's failure to enforce these precautions compromised the resident's safety and increased the risk of infection.
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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 Coconut Creek
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Margate Health And Rehabilitation Center | 1.6 mi | — | 0 | 0 |
| Pompano Health And Rehabilitation Center | 3.7 mi | — | 21 | 0 |
| Deerfield Beach Health And Rehabilitation Center | 3.9 mi | — | 1 | 0 |
| Willowbrooke Court Skilled Care Center - Edgewater | 4.2 mi | — | 0 | 0 |
| John Knox Village Of Pompano Beach | 4.3 mi | — | 0 | 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.