Health inspection·July 19, 2023

F 0578 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few (DNR) status was initiated [DATE]. The document read, Advance Directives will be honored and assistance provided with changes as needed. Review of resident #1's electronic medical record (EMR) revealed a State of Florida Do Not Resuscitate Order (DNRO) form signed by resident #1 on [DATE]. The Facility's policy and procedure for Do Not Resuscitate Order revised [DATE] read, Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect. In a phone interview on [DATE] at 4:08 PM, Registered Nurse (RN) B described the sequence of events on [DATE], the day resident #1 received CPR. He recalled sometime close to 5:00 AM, resident #1's spouse came out of the room and asked for someone to check on the resident. The Respiratory Therapist (RT) C assigned to him was busy, so he went to the room. RN B stated when he entered the room, the resident was very pale, unresponsive and did not have a pulse. RN B pushed the code blue button on the wall to get assistance and then went out to check resident #1's code status. He looked in the EMR and saw resident #1 had an order for DNR. He stated RN Supervisor G came to the desk about that time and he informed her of the resident's code status (DNR order). RN B recalled RN Supervisor G informed him CPR was already in progress and had to continue. He stated his first impression was the chest compressions should stop since the resident had an order for DNR. She told him they had to keep doing CPR and wait for EMS to arrive. RN B stated he took the emergency cart which contained resuscitation equipment and went to resident #1's room. When he entered the room with the cart, RT C and RT E were taking turns with the manual resuscitation bag and doing chest compressions. He explained EMS arrived shortly after and were informed of the DNR status. EMS instructed staff to cease CPR efforts. In a phone interview on [DATE] at 7:40 AM, RT C confirmed she was the RT assigned to resident #1 the morning of [DATE]. She recalled the resident's spouse came out to the station and stated resident #1 was having difficulty breathing. RT C explained she started to go to resident #1's room, but forgot the keys to the breathing treatment cart and went back to get them from another RT. As she was headed back to the room, she saw the code blue light on outside resident #1's room. RT C stated when she entered the room, she began assisted manual ventilation with a manual resuscitation bag in the event there was a mucous plug that needed to be cleared. She explained RT E was in the room and started chest compressions when they could not find a pulse. RT C recalled another RT entered the room and informed them resident #1 had an order for a DNR, but RN Supervisor G told them they had to keep going since CPR was already started. RT C stated they continued with CPR until EMS arrived. EMS asked resident #1's spouse if she wanted them to continue and she told them to stop. In a phone interview on [DATE] at 12:36 PM, RN Supervisor G confirmed she was on the phone when she heard the code blue alert. When she entered the room, she observed two RTs had initiated CPR. She acknowledged she went to the nurse station and RN B informed her resident #1 had an order for DNR. She explained she was on the phone with the DON (former) and was instructed to continue CPR until EMS arrived which she shared with RN B. On [DATE] at 9:37 AM, RN Unit Manager H stated she was not present in the facility the day of the incident, but was informed afterward. She explained each resident's code status was in the EMR and it was the responsibility of staff to verify code status prior to initiating CPR. RN Unit Manager H stated she was always told to stop CPR if you found someone had an order for a DNR after it was initiated. She explained, you have to honor their wishes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105353 If continuation sheet Page 2 of 9 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Forest Lake 3355 E Semoran Blvd Apopka, FL 32703 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0578 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few In a phone interview on [DATE] at 10:28 AM, resident #1's spouse stated she usually visited earlier in the day, but on [DATE] she woke up during the night and just wanted to go in and sit with the resident. She recalled early in the morning, she went to the nurse station and told RT C that resident #1 needed some attention. RT C told her she would be there in a minute. Resident #1's spouse stated she told her the resident needed someone now. She heard a code blue being announced and saw the emergency cart. She explained there was a lot going on and she tried to remember if her spouse had signed a DNRO. She stated she said something about a DNRO and the EMS crew must have overheard her. The EMS person asked if she wanted them to stop. She told them if the resident was going to have broken ribs or brain damage, she wanted them to stop. Resident #1's spouse recalled a conversation she had with the resident when he was in the hospital. She stated he expressed to her and her son that he did not want to have his ribs broken or suffer brain damage. She recalled resident #1 said he just wanted to die in peace. She stated it was his decision to not be resuscitated if he stopped breathing or his heart stopped. Review of the immediate corrective measures implemented by the facility revealed the following, which were verified by the survey team at the time of the survey: *On [DATE], the attending physician, Medical Director, Administrator, Director of Nursing and family were notified of the incident and an investigation was initiated. Immediate education done with all in-house staff regarding verification of code status prior to initiating CPR. Advance Directive audit and code blue drills initiated. *On [DATE], an Ad Hoc Quality Assurance and Performance Improvement (QAPI) committee meeting was held and included the following staff: Medical Director, NHA, DON, ADON, RM, Evening Nurse Supervisor, RSSD, CEO, CEO of Consulting Group, RNC, RICP, RT Supervisor, and RT Manager. A Performance Improvement Plan on advance directives was started. Education and audits were started which included code blue drills with test and audit of code status for all residents. 100% chart audit completed by [DATE]. * The Ad Hoc QAPI meeting on [DATE] included the following staff: MD, NHA, DON, ADON, RNC, RM, RN Unit Manager for 400 unit. The content of the QAPI meeting included: Discussion of the process to verify code status, system changes to put into place, and monitoring tools that will be used. Reviewed education and audits completed to date. Updated content of education message. *The Ad Hoc QAPI meeting on [DATE] included the following staff: MD, NHA, DON, Risk Preventionist, ADON, Director of Education, UMs, and other department heads. The content of the QAPI meeting included: Reviewed all the education that had been provided to clinical staff, the education provided to other staff, reviewed mock code drills performed, and audits conducted. Came to consensus that facility was in compliance for education and audits/mock drills. Continued to review the advance directives, code status and CPR. Reviewed audit tools to ensure they were being done correctly. *From [DATE] to [DATE], the facility educated clinical staff on the topics of Advance Directives, Code Blue alert and when to start/stop CPR which included a post-test. Education included the instructions, In the event CPR is initiated when there is an order for DNR, CPR is to be discontinued upon confirmation of DNR status, consistent with physician orders for DNR. *On [DATE] all clinical staff had been received training/in-service education and had participated in a code [NAME] drill. Education for non-clinical staff and any new employees after [DATE] is ongoing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105353 If continuation sheet Page 3 of 9 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Forest Lake 3355 E Semoran Blvd Apopka, FL 32703 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0578 *From [DATE] to [DATE], the facility took actions to reduce the risk of future Level of Harm - Immediate jeopardy to resident health or safety occurrences. All staff were educated on the Policy and Procedure related to Advance Directives with a focus on Code Status and Following the Physician's orders with post-test; New Hire staff orientation to include Code Blue response and verification of code status in EMR; Code status and Advanced Directives confirmed at the time of admission and orders placed in EMR; Code status and Advanced Directives reviewed with all residents at the time of care plan meetings and Code Blue Drills (includes verifying Code Status, Advance Directives and DNRO). Residents Affected - Few Interviews conducted on [DATE] with 15 staff members (4 Certified Nursing Assistants, 3 Licensed Practical Nurses, 1 RN, 1 Maintenance Assistant, 1 Certified Occupational Therapy Assistant, 1 housekeeper, 3 Respiratory Therapists and 1 unit secretary) indicated they were knowledgeable of advance directives and where to verify the code status in the EMR prior to providing CPR. The surveyors validated the education with attendance sheets for code blue drills and in-services. From [DATE] to [DATE], 427 staff members received in-service/education. Review of QAPI audits revealed daily code blue drills were conducted per performance improvement plan. The resident sample was expanded to include three additional residents who elected DNR status. Interviews and record reviews revealed no concerns for residents #2, #3, #4, #5, #6, #7, and #8 related to advance directives. Based on the facility's corrective actions, the survey team determined the facility was in substantial compliance on [DATE]. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105353 If continuation sheet Page 4 of 9 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Forest Lake 3355 E Semoran Blvd Apopka, FL 32703 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, licensed nurses and respiratory therapists failed to follow the facility's policy and procedure for Cardiopulmonary Resuscitation (CPR) related to verification of physician orders for resuscitation or code status in an emergency and process for following the Do Not Resuscitate Order (DNRO) for 1 of 8 residents reviewed for advance directives (#1). On [DATE] at approximately 4:47 AM, resident #1 was found unresponsive with no heart rate and no respirations. A Respiratory Therapist (RT) initiated CPR without first verifying the resident's physician orders and advance directives (code status) in the medical record. Emergency Medical Services (EMS) arrived at the facility and spoke to the resident's spouse who confirmed the resident had a DNRO. CPR was discontinued and resident #1 was pronounced dead at 4:52 AM. The facility failed to follow their policies and procedures for Cardiopulmonary Resuscitation by not checking the resident's code status prior to initiating CPR. This resulted in failure to honor the resident's wishes and physician order for Do Not Resuscitate. The facility's failure to ensure staff followed procedures related to honoring an advance directive to withhold CPR contributed to resident #1 suffering unwanted, aggressive resuscitation efforts and placed all residents who had valid DNROs at risk for serious injury/impairment/prolonged death. This failure resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE] and compliance was achieved on [DATE] after verification of corrective actions. Findings: Cross reference F578. Resident #1, a [AGE] year-old male, was admitted to the facility on [DATE] with diagnoses including respiratory failure, dependence on respiratory [ventilator] status, tracheostomy status and gastrostomy status. Review of the Minimum Data Set (MDS) significant change in status assessment with assessment reference date of [DATE] revealed resident #1 had a Brief Interview for Mental Status score of 15 which indicated he was cognitively intact. The document indicated the resident was tracheostomy and ventilator dependent and received oxygen and suctioning. Review of resident #1's electronic medical record (EMR) revealed a State of Florida Do Not Resuscitate Order (DNRO) form dated [DATE] that was signed by the resident and his attending physician. The document showed the resident's signature under the statement, Being informed of my right to refuse cardiopulmonary resuscitation (CPR), including artificial ventilation, cardiac compression, endotracheal intubation and defibrillation, I direct that CPR be withheld or withdrawn from me. The physician's statement read, I direct the withholding or withdrawal of CPR from the patient in the event of the patient's cardiac or respiratory arrest. Resident #1's EMR contained a physician order dated [DATE] which read, Do Not Resuscitate. A Nurses Progress Note dated [DATE] at 7:17 AM revealed Registered Nurse (RN) B was called to the room by resident's spouse. Upon entering, he observed resident #1 was pale and unresponsive. RN B (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105353 If continuation sheet Page 5 of 9 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Forest Lake 3355 E Semoran Blvd Apopka, FL 32703 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few immediately called for help and left the room to check on his code status. The note indicated resident #1 had a DNRO. RN B notified RN Supervisor G who came to the nurse station. He was told that CPR had already commenced and CPR had to keep going as per policy until relieved by EMS. EMS arrived at 4:52 AM and called out time of death. A Respiratory Progress Note dated [DATE] at 6:03 AM indicated resident #1's spouse requested the RT to come check on the resident as he was short of breath. The note indicated upon entering the room, RT C noted the resident looked pale, with a weak pulse. Her note read, CPR was initiated with 100% manual resuscitation bag . Suction for scant amount of thick pale/yellow secretions. Review of the facility's policy and procedure 14.1 Emergency Procedure - Cardiopulmonary Resuscitation revised [DATE] read, If an individual is found unresponsive, briefly assess for abnormal or absence of breathing, Verify or instruct a staff member to verify the DNR or code status of the individual. If the resident is a full code begin CPR. The Facility's policy and procedure for Do Not Resuscitate Order revised [DATE] read, Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect. On [DATE] at 11:15 AM, The Administrator and Interim Director of Nursing (DON) discussed the incident investigation and Root Cause Analysis related to resident #1 receiving CPR despite documentation of a DNRO. The Administrator and DON stated during the investigation, several staff statements were taken and it was discovered RT E entered the room during the code blue and began chest compressions on resident #1 without verifying his code status. The Administrator explained that RT E gave conflicting statements during a couple of interviews. The Administrator stated the facility had identified the root cause as the RT saw the Code Blue alert and provided CPR without verifying the resident's code status. He confirmed that first and foremost, staff have to check the wishes of the resident and honor those wishes. The Administrator acknowledged that once the staff discovered the resident had an order for DNR, they should have stopped CPR. They could not provide CPR if they did not have a physician order to do so. He explained staff were educated on code blue alerts, honoring Advance Directives and where to verify a resident's code status. Training also included if a resident was found to be a DNR, CPR should stop if already initiated in order to honor the resident's wishes., Attempts were made to reach RT E, but he did not answer the phone and did not return phone calls. In a phone interview on [DATE] at 4:08 PM, Registered Nurse (RN) B described the sequence of events on [DATE], the day resident #1 received CPR. He recalled sometime close to 5:00 AM, resident #1's spouse came out of the room and asked for someone to check on the resident The Respiratory Therapist (RT) C assigned to him was busy, so he went to the room. RN B stated when he entered the room, the resident was very pale, unresponsive and did not have a pulse. RN B pushed the code blue button on the wall to get assistance and then went out to check resident #1's code status. He looked in the EMR and saw resident #1 had an order for DNR. He stated RN Supervisor G came to the desk about that time and he informed her of the resident's code status (DNR order). RN B recalled RN Supervisor G informed him CPR was already in progress and had to continue. He stated his first impression was chest compressions should stop since the resident had an order for DNR. She told him they had to keep doing CPR and wait for EMS to arrive. RN B stated he took the emergency cart which contained resuscitation equipment and went to resident #1's room. When he entered the room with the cart, RT C and RT E were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105353 If continuation sheet Page 6 of 9 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Forest Lake 3355 E Semoran Blvd Apopka, FL 32703 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few taking turns with the manual resuscitation bag and doing chest compressions. He explained EMS arrived shortly after and were informed of the DNR status and EMS instructed staff to cease CPR efforts. In a phone interview on [DATE] at 7:40 AM, RT C confirmed she was the RT assigned to resident #1 the morning of [DATE]. She recalled the resident's spouse came out to the station and stated the resident was having difficulty breathing. RT C explained she started to go to resident #1's room but forgot the keys to the breathing treatment cart and went back to get them from another RT. As she was headed back to the room, she saw the code blue light on outside resident #1's room. RT C stated when she entered the room, she began assisted manual ventilation with a manual resuscitation bag in the event there was a mucous plug that needed to be cleared. She explained RT E was also in the room and started chest compressions when they could not find a pulse. RT C recalled RT F entered the room and asked if resident #1 was a DNR. She stated they did not know and RT F went out to check. RT F returned and informed them he was a DNR, but RN Supervisor G told them they had to keep going since CPR was already started. RT C stated they continued with CPR until EMS arrived. EMS asked resident #1's spouse if she wanted them to continue and she told them to stop. In a phone interview on [DATE] at 7:30 AM, RT F confirmed she was at the respiratory station where they sit to document in the medical record. She recalled the spouse of resident #1 came to the station and called the RT C to come to the room. RT C asked for the keys from RT F and left. RT F observed the Code Blue light flashing and went into the room. Upon entering, she observed RT E doing chest compressions and RT C using the manual resuscitation bag. She asked what resident #1's code status was and did not get a response. She stated she left the room and went to the nurse station to verify code status. RT F spoke with RN B and was informed the resident had an order for a DNR. She explained RN Supervisor G was in the hall and said they had to continue with CPR once started because it was the policy of the facility. RT F returned to the room and shared the information with RT C and RT E. In a phone interview of [DATE] at 1:08 PM, RT D stated he was the lead RT the night of the incident. He recalled seeing the code blue alert went to resident #1's room. He stated as he entered, he observed RT E doing chest compression and RT C was using the manual resuscitation bag. RT D asked if he could help and RT C stated she was trying to see if the resident had a mucous plug in his airway. He stated LPN A entered and assisted RT E and RT C with chest compression. He recalled RT F checked resident #1's code status and informed them the resident had an order for a DNR. RT D reported RN Supervisor G told them they had to continue with CPR once initiated. When EMS came, he exited the room. He acknowledged staff had to verify code status before initiating CPR. In a phone interview on [DATE] at 12:36 PM, RN Supervisor G confirmed she was on the phone when she heard the code blue alert. When she entered the room, she observed two RTs had initiated CPR. She acknowledged she went to the nurse station and RN B informed her resident #1 had an order for a DNR. She explained she was on the phone with the DON (former) and was instructed to continue CPR until EMS arrived which she shared with RN B. In a phone interview on [DATE] at 8:36 AM, Licensed Practical Nurse (LPN) A stated he was the medication cart when resident #1's spouse asked him to go to the resident's room. LPN A explained he directed her to RN B who was resident #1's nurse. He observed RN B enter the room and then saw the code blue light. He stated he locked his cart and went to the room. LPN A recalled he observed RT E doing chest compressions when he arrived. He explained he asked loudly if anyone knew the code status of the resident and no one answered. LPN A stated he asked if they needed help and RT E said they did, so he did one round of CPR and RT E took over again. He recalled RN B entered the room and LPN A (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105353 If continuation sheet Page 7 of 9 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Forest Lake 3355 E Semoran Blvd Apopka, FL 32703 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few asked what the resident's code status was. LPN A stated RN B told him resident #1 had an order for a DNR. LPN A then said they should stop CPR. He explained RN B informed him RN Supervisor G said the policy was to continue CPR once started until EMS arrived. LPN A confirmed EMS asked about resident #1's code statue and were informed he was a DNR. LPN A stated he left the room at that point because it was getting crowded. On [DATE] at 9:37 AM, RN Unit Manager H stated she was not here the day of the incident but was informed the following day. She explained each resident's code status was in the EMR and it was the responsibility of staff to verify code status/orders for DNR prior to initiating CPR. RN Unit Manager H stated she was always told to stop CPR if you found someone had an order for a DNR after it was initiated. She explained, you have to honor their wishes. In a phone interview on [DATE] at 10:28 AM, resident #1's spouse stated she usually visited earlier in the day but on [DATE] she woke up during the night and just wanted to go in and sit with him. She recalled early in the morning, she went to the nurse station and told RT C that the resident needed some attention. RT C told her she would be there in a minute. Resident #1's spouse stated she told her he needed someone now. She heard a code blue being announced and saw the emergency cart. She explained there was a lot going on and she tried to remember if the resident had signed a DNRO. She stated she said something about a DNRO and the EMS crew must have overheard her. The EMS person asked if she wanted them to stop. She told them if he was going to have broken ribs or brain damage, she wanted them to stop. Resident #1's spouse recalled a conversation she had with the resident when he was in the hospital. She stated he expressed to her and her son that he did not want to have his ribs broken or suffer brain damage. She recalled resident #1 said he just wanted to die in peace. She stated it was his decision to have an order for DNR. Review of the immediate corrective measures implemented by the facility revealed the following, which were verified by the survey team at the time of the survey: *On [DATE], the attending physician, Medical Director, Administrator, Director of Nursing and family were notified of the incident and an investigation was initiated. Immediate education done with all in-house staff regarding verification of code status prior to initiating CPR. Advance Directive audit and code blue drills initiated. *On [DATE], an Ad Hoc Quality Assurance and Performance Improvement (QAPI) committee meeting was held. A Performance Improvement Plan on advance directives was started. Education and audits were started which included code blue drills with test and audit of code status for all residents. 100% chart audit completed by [DATE]. *On [DATE], [DATE], [DATE] and [DATE], Ad Hoc QAPI meetings were held with Administrator, Director of Nursing, Medical Director and administrative staff. Education, audits and drills were reviewed and revised as indicated. *From [DATE] to [DATE], the facility educated all clinical staff on the topics of Advance Directives, Code Blue alert and when to start/stop CPR which included a post-test. Education included the instructions, In the event CPR is initiated when there is an order for DNR, CPR is to be discontinued upon confirmation of DNR status, consistent with physician orders for DNR. On [DATE], 100 percent of clinical staff were trained and had participated in a code blue drill. Education continued to include all staff and new employees. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105353 If continuation sheet Page 8 of 9 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Forest Lake 3355 E Semoran Blvd Apopka, FL 32703 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0678 *From [DATE] to [DATE], the facility took actions to reduce the risk of future Level of Harm - Immediate jeopardy to resident health or safety occurrences. All staff were educated on the Policy and Procedure related to Advance Directives with a focus on Code Status and Following the Physician's orders with post-test; New Hire staff orientation to include Code Blue response and verification of code status in EMR; Code status and Advanced Directives confirmed at the time of admission and orders placed in EMR; Code status and Advanced Directives reviewed with all residents at the time of care plan meetings and Code Blue Drills (includes verifying Code Status, Advance Directives and DNRO). Residents Affected - Few Interviews conducted on [DATE] with 15 staff members (4 Certified Nursing Assistants, 3 Licensed Practical Nurses, 1 RN, 1 Maintenance Assistant, 1 Certified Occupational Therapy Assistant, 1 housekeeper, 3 Respiratory Therapists and 1 unit secretary) indicated they were knowledgeable of advance directives and where to verify the code status in the EMR prior to providing CPR. The surveyors validated the education with attendance sheets for code blue drills and in-services. Review of QAPI audits revealed daily code blue drills were conducted per performance improvement plan. The resident sample was expanded to include three additional residents who elected DNR status. Interviews and record reviews revealed no concerns for residents #2, #3, #4, #5, #6, #7, and #8 related to advance directives. Based on the facility's corrective actions, the survey team determined the facility was in substantial compliance on [DATE]. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105353 If continuation sheet Page 9 of 9