Solaris Healthcare Bayonet Point: DNR Ignored - FL
The resident had been in therapy when she became unresponsive. A nurse rushed to assess her, found no vital signs, no heartbeat, no respirations. The nurse checked the chart. Full code. CPR began.
It was only when a clerk returned from a break and mentioned, in passing, that a family member had given her a DNR form about an hour earlier, that anyone understood what had just happened.
Federal inspectors who reviewed the incident assigned it Immediate Jeopardy status, the most serious classification available under Medicare oversight, reserved for situations where a facility's failure has already caused, or is likely to cause, serious injury or death.
The resident had been admitted as a full code, meaning staff were required to attempt resuscitation, until the facility received documentation of a DNR. That documentation existed. A family member had physically delivered it to the building. It had simply never reached a nurse.
The inspection report does not name the resident, describe her condition after CPR was performed, or say whether she survived.
What the report does describe is a facility that, by its own account in the plan of correction, had no reliable system for what should happen when a family walks through the door carrying a form that says: do not resuscitate. The form went to a clerk. The clerk went on break. The resident coded.
Solaris's plan of correction, filed after the inspection, is a document of institutional scrambling. Within what the report describes as a single corrective period, administrators completed a full chart review of all 174 residents to verify code status. They cross-checked every advance directive against the electronic medical record. They brought in the Medical Director by telephone for a meeting with eight staff members. They educated, by their own count, 201 employees, including the activities director, two bookkeeping staff, fifteen housekeepers, six laundry workers, three receptionists, and the payroll administrator, on what to do if a family member hands them an advance directive.
The answer, going forward: hand it immediately to a nurse or unit manager. Do not set it down. Do not take it to a desk. Do not go on break.
That this instruction required a facility-wide emergency training session, delivered to 201 people including the dietary department, suggests it was not a known expectation before.
Inspectors interviewed more than 70 staff members following the incident, including 11 registered nurses, 10 licensed practical nurses, 20 certified nursing assistants, rehabilitation and therapy staff, maintenance workers, receptionists, and social services employees. All of them, according to the report, verified they had received the new education and could articulate what advance directives are, where to find code status in the chart, and what to do if a resident is found unresponsive.
The Regional Risk Manager was brought in to separately train nursing administration, MDS staff, social services, admissions, the Director of Nursing, the Assistant Director of Nursing, and the facility's Administrator.
None of that training existed in the form it now does before a family's final wish for their relative sat in a clerk's hands while a therapy session continued down the hall.
The inspection report does not say how long the resident had been in therapy before she became unresponsive. It does not say how long CPR continued. It does not name the clerk, the nurse, or anyone else involved in the sequence of events. It does not say what the family was told afterward, or when.
What it says is that the nurse followed the plan of care. The plan of care said full code. The nurse had no reason to know otherwise.
The family had done what families are supposed to do. They brought the paperwork. They handed it to someone inside the building. And for roughly an hour, while their relative was still alive, that piece of paper sat somewhere it could not change anything.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Solaris Healthcare Bayonet Point from 2025-09-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 26, 2026 · Our methodology
Solaris Healthcare Bayonet Point in HUDSON, FL was cited for violations during a health inspection on September 26, 2025.
The resident had been in therapy when she became unresponsive.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.