Inspection·July 13, 2023

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few The facility's Behavior Crosswalks dated 11/2021 listed possible root cause of exit seeking, including anger over admission, placement, fire alarms or special events and circumstances, and included possible interventions options, including identifying possible triggers for exit seeking, monitor exits during fire alarm drills, preplan activities and events to include monitoring of exit seeking patients. The facility's behavior management guidelines with an original date of 03/2022 noted, Wandering and exit seeking are behavioral symptoms of special concern in the elderly and, or dementia population. Patients are evaluated upon admission for a history of, or risk factors for wandering and, or exit seeking. Interventions to consider include . Patient room placement in relation to egress doors, personal security bracelet, safe wandering interventions . On 7/12/23, record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses not limited to Alzheimer's dementia, weakness, failure to thrive, altered mental status and cognitive communication deficit. The baseline care plan noted Resident #1 had alteration in neurological status, functional mobility, Activities of Daily Living self-care deficit, and risk for falls. Review of the History and Physical from the hospital dated 6/27/23 noted Resident #1 is a [AGE] year old male presenting with his daughter/caregiver with complaints of progressive decline and inability to care for patient. Patient has history of Alzheimer's dementia (diagnosed in July 2022) . Daughter reports his behaviors have been rapidly progressing whereby he cannot be left alone. Patient is experiencing bouts of confusion with auditory and visual hallucinations. He does not eat or drink unless he is fed. He has had significant weight loss. He has wandered away from home. The Medical Certification for Medicaid Long-Term Care Services and Patient Transfer form (Agency for Health Care Administration form 3008) dated 7/3/23 from the hospital, noted Resident #1's risk alerts included elopement. On 7/12/23 at 9:56 a.m. in a telephone interview Resident #1's daughter said he went to hospital because she was not able to look after him. She said he was diagnosed with Alzheimer's dementia, he was confused and could not be left home alone. She said he got lost many times, they had to call the police many time. She said she secured the house as best she could and had a camera alert. He was always wandering around, trying to go out. She said the last three weeks he had gotten worse and started falling (before admission). She said she told the hospital and the facility he needed to be supervised and not left alone. She said she told the first lady she saw at the facility about him not being left unsupervised. Review of the progress notes revealed: On 7/4/23 at 8:10 a.m., Resident is alert and confused. Slept off and on. Upon awakening, resident wandered in residents room, in hallways and no staff can stop him because he became aggressive when we [sic] redirecting him. On 7/5/23 at 12:36 a.m., Resident was alert and very confused, combative, he tried to wander all the shift . He remains at high risk for fall. On 7/5/23 at 12:05 p.m., a history and physical noted Resident #1 has had a progressive decline and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105499 If continuation sheet Page 2 of 10 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 105499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Lely Palms 6135 Rattlesnake Hammock Road Naples, FL 34113 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few family is unable to care for him. He was diagnosed with Alzheimer's dementia back in July 2022. His behaviors had rapidly gotten worse as well and was unable to be left alone . He wanders a lot and just says random words . Not sure he is good to follow commands. On 7/6/23 at 11:30 a.m., a nursing progress note read, Patient confused, combative, don't following commands, throwing stuff in the room. Refused staff to change brief, or take care of him. Risk of fall in the room due to behaviors. Patient scratch [sic] and punched nurse staff while trying to give care. Ativan (medication used to treat agitation) PRN (as needed) given as ordered by floor nurse. Unable to redirect. Resident was sent to the hospital for assessment. On 7/6/23 at 5:07 p.m., a progress note documented, Resident came back from the hospital via stretcher. he is positive for covid (Coronavirus Disease 2019) therefore he is on respiratory isolation. He refused to stay in his room . he kept going to 400 hall three times. He does have wander guard [a wander management device] around his ankle . On 7/7/23 at 6:05 a.m., the nurse documented, 0330 (3:30 a.m.): Pt (patient) was with writer and CNA (Certified Nursing Assistant) as pt was trying to elope. 0445 (4:55 a.m.) CNA went to pt room to provide personal care. CNA noticed pt not in room. CNA notified writer. Writer announced code green as CNA was looking inside the other pts room. Pt was located outside. Pt alert. Pt noted to be very confused and agitated. Pt was wandering throughout the whole night and going in and out of pts room. Scheduled medication that was given was ineffective . On 7/12/23, review of witness statements included in the facility's elopement investigation revealed on 7/7/23 at approximately 3:00 a.m., Resident #1 attempted to exit through an exit door on the 500 hall. He pushed on the door and set off the alarm but did not exit. None of the staff in the facility knew the code to reset the alarm. The nurse on the 500 hall called two supervisors for assistance but neither returned the call. The nurse then called the maintenance director who told her he was on vacation. The alarm continued to sound. The CNA saw Resident #1 at approximately 4:00 a.m. and then, when she went to check on him at approximately 4:40 a.m., he was not in his room. The nurse and the CNA did a quick check of the unit, did not locate him so the nurse called Code [NAME] (missing person alert). Staff responded and Resident #1 was found outside the facility, about 100 feet from the 500 hall exit door, sitting on the ground, playing with the grass at approximately 5:00 a.m. She said the alarm was still activated throughout the sequence of events until a Maintenance Assistant came to the facility at about 5:00 a.m. and reset the code. There was no documentation staff increased supervision when Resident #1 attempted to leave the facility unsupervised on 7/7/23 at 3:00 a.m. There was no documentation staff monitored the exit door of the 500 hall after Resident #1 triggered the wander alarm and staff was not able to reset the alarm, leaving the exit door unsecured. On 7/12/23 at approximately 4:00 p.m., observation with the Maintenance Director revealed outside of the 500 hall exit door there was a lake/retention pond with red warning posted signs that read, DANGER. ALLIGATORS AND SNAKES IN AREA. STAY AWAY FROM THE WATER. DO NOT FEED THE WILDLIFE. Photographic evidence obtained. The lake was surrounded by a fence approximately five feet high. The gate that did not latch and was in disrepair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105499 If continuation sheet Page 3 of 10 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 105499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Lely Palms 6135 Rattlesnake Hammock Road Naples, FL 34113 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 0689 Photographic evidence obtained. Level of Harm - Immediate jeopardy to resident health or safety The outside area had bright lights that light up automatically when it is dark and stay on until daylight. The facility is located next to a busy six lane divided highway. Residents Affected - Few On 7/12/23 at the time of the observation, the Maintenance Director said the gate broke while he was on vacation. On 7/12/23 at 7:32 a.m., Licensed Practical Nurse (LPN), Staff A said she was on duty the night of 7/7/23 and Resident #1 was part of her assignment. She confirmed the sequence of events involving Resident #1. She said after Resident #1 attempted to leave the first time; it was not possible to assign anyone to supervise him because of the workload. She confirmed she called two supervisors but there was no return call. She confirmed she called the Maintenance Director who told her he was on vacation, and would not give her the code to reset the alarm. LPN Staff A said at the time Resident #1 went missing, she had an emergency with another resident which took a lot of time. On 7/12/23 at 8:06 a.m., Registered Nurse Staff C said she was working the overnight shift on 7/7/23. She said she was on a different unit and had about 29 residents. She heard Code [NAME] and asked who was missing and Staff A told her it was Resident #1. He said, The alarm for 500 door was going off, we looked inside, could not find him so I went out the 500 door. He was sitting on the walkway behind the therapy door. He was a wanderer and combative. On 7/12/23 at approximately 4:15 p.m., the Administrator confirmed the sequence of events involving Resident #1 on 7/7/23. She confirmed Resident #1 was not placed on increased supervision after the first exit seeking attempt on 7/7/23 at approximately 3:00 a.m. and should have been. She confirmed LPN Staff A attempted to contact two supervisors and there was no return call. She confirmed the Maintenance Director was called and he said he was on vacation. She said at the time, the only staff that had the code to reset the alarm on the 500 unit exit door was the maintenance staff. She confirmed the location of Resident #1 was unknown from approximately 4:00 a.m. until approximately 5:00 a.m. when he was found outside. The facility submitted an acceptable Immediate Jeopardy removal plan. On 7/13/23 the Immediate Jeopardy was removed after surveyor verification of the immediate actions which included: Resident #1 was placed on 1:1 supervision to prevent further incident on 7/7/2023. Verified through record review and observation. Resident #1 care plan was updated to include new intervention. The surveyor verified throug record review. Door codes were obtained to reset the alarming/ unlocked door for safety. The surveyor verified through record review. Door codes were posted and shared in multiple places including nurse stations to reset the alarm /unlocked door for safety. The surveyor verified through observation. Education was initiated to include availability/ location of secure door codes, how to reset doors when alarming, missing resident process, and administrator notification. Facility staff educated include activities, administration, dietary, housekeeping, laundry, maintenance, medical records, nursing, rehab, and social services. The surveyor verified through record review, and staff interviews. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105499 If continuation sheet Page 4 of 10 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 105499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Lely Palms 6135 Rattlesnake Hammock Road Naples, FL 34113 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Current residents' records were reviewed to validate appropriate interventions in place for those at risk for exit seeking. This was completed on 7/12/2023. The surveyor verified through record review. The Wander Guard (exit security alarm) was validated to be working properly. The surveyor verified through record review, and observation during survey. Exit doors were reviewed and validated with proper functioning as the result on 7/7/2023 at 10:00 a.m. The surveyor verified through record review, and observation during survey. Audit completed on current residents with a wander guard to validated to be working properly. This was completed on 7/7/2023. The surveyor verified through record review. Completed 11 missing patient drills on all shifts from 07/07/2023 to 07/11/2023. The surveyor verified through record review. The Administrator notified the Medical Director on July 7, 2023 of occurrence and of this plan. The surveyor verified through record review. The Administrator held an ad-hoc (unplanned) QAPI (Quality Assurance and Performance Improvement) meeting to discuss self-identified findings on July 7, 2023 at 12:00 pm resulting in this plan. The surveyor verified through record review. Education was completed on 7/10/2023. Topics include door codes, resetting doors when alarming, missing resident process, and administrator notification. Staff not present during education was educated prior to their next shift. Facility staff educated include activities, administration, dietary, housekeeping, laundry, maintenance, medical records, nursing, rehab, and social services. The surveyor verified through record review and random interview of three nurses. Education provided to supervisory staff and maintenance director related to responsibilities of being on call, returning calls, and notification of administrator. This education was completed on 7/12/2023. The surveyor verified through record review, and random staff interviews. The Director of Nursing (DON) or designee will review new admission H&P (History and Physical), 3008, and discharge summary for evidence of elopement or wandering risk. The surveyor verified through record review. Education on supervisor on call, monitoring exit door, and putting exit seeking patient on 1:1. The surveyor verified through record review. Facility staff educate include activities, administration, dietary, housekeeping, laundry, maintenance, medical records, nursing, rehab, and social services. This was completed on 7/13/2023. The surveyor verified through record review. Fence gate outside by the lake was fixed on 7/12/2023. The surveyor verified through observation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105499 If continuation sheet Page 5 of 10 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 105499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Lely Palms 6135 Rattlesnake Hammock Road Naples, FL 34113 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, job description review, staff and family interview, the facility's administration failed to utilize resources effectively to ensure a safe environment and adequate supervision of 1 (Resident #1) of 3 sampled cognitively impaired residents at risk for elopement to prevent unsafe wandering and elopement. Residents Affected - Few On 7/7/23 at 3:00 a.m., Resident #1 who was cognitively impaired, was ambulatory, and actively exit seeking set off the alarm of an exit door. Staff on duty did not know how to reset the alarm and left the exit door unsecured. Staff failed to adequately supervise Resident #1 until the alarm was reset. On 7/7/23 (unknown time after 4:00 a.m.) Resident #1 left the facility unsupervised through the unsecured exit door. On 7/7/23 at 4:50 a.m., Resident #1 was found unharmed, sitting on the concrete outside of the facility approximately 50 feet from a lake with a broken fence with a clear danger warning from alligators and snakes. The facility is located on a busy six lanes road. Resident #1 had a likelihood for serious harm, injury, or death due to the risk of serious injury from a fall, drowning in the lake, being attacked by an alligator, or getting hit by a car crossing the busy road. The facility's administration failure to ensure effective measures to ensure a safe environment and prevent unsafe wandering of cognitively impaired residents at risk for elopement resulted in the determination of Immediate Jeopardy at a scope and severity of isolated (J) starting on 7/7/23. The Administrator was notified of the Immediate Jeopardy on 7/13/23 at 3:05 p.m. and provided the IJ templates. On 7/13/23 after the facility submitted an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed and the scope and severity were reduced to D, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. The findings included: Cross reference to F689. The Administrator's job description revised 01/21 noted, Safety . Follows established safety policies and procedures. Ensures potential safety/health hazards are eliminated . Ensures all supervisors are trained in and implement the organization's policies and procedures . Review of the facility's incident investigative findings dated 7/12/23 submitted to the Agency for Health Care Administration in which the facility substantiated neglect revealed, on 7/7/23 around 3:30 a.m., Resident #1 got out of his room and activated the alarm at the emergency exit door in the 500-hall unit. Resident #1 was redirected into his room. Resident #1 had an alert bracelet (to alert (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105499 If continuation sheet Page 6 of 10 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 105499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Lely Palms 6135 Rattlesnake Hammock Road Naples, FL 34113 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 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few staff when resident leaves a safe area) attached to his ankle. Supervisor and unit manager were attempted to call, and no response. The Maintenance Director was called related to the alarm since the nurse did not have the code on hand. The Maintenance Director was on vacation and did not have the code on hand. The Maintenance Director texted the maintenance assistant to come into the facility to put the code in the emergency exit door. The resident was found outside of the facility sitting on the concrete by the physical therapy gym. The resident was in no sign of distress. Body audit completed and the resident had an abrasion to his left lateral knee. On 7/12/23, record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses not limited to Alzheimer's dementia, weakness, failure to thrive, altered mental status and cognitive communication deficit. Review of the History and Physical from the hospital dated 6/27/23 noted Resident #1 is a [AGE] year old male presenting with his daughter/caregiver with complaints of progressive decline and inability to care for patient. Patient has history of Alzheimer's dementia (diagnosed in July 2022) . Daughter reports his behaviors have been rapidly progressing whereby he cannot be left alone. Patient is experiencing bouts of confusion with auditory and visual hallucinations. He does not eat or drink unless he is fed. He has had significant weight loss. He has wandered away from home. The Medical Certification for Medicaid Long-Term Care Services and Patient Transfer form (Agency for Health Care Administration form 3008) dated 7/3/23 from the hospital, noted Resident #1's risk alerts included elopement. Review of the progress notes from 7/3/23 through 7/7/23 revealed multiple entries of wandering behavior. On 7/4/23 at 8:10 a.m., Resident is alert and confused. Slept off and on. Upon awakening, resident wandered in residents room, in hallways and no staff can stop him because he became aggressive when we [sic] redirecting him. On 7/5/23 at 12:36 a.m., Resident was alert and very confused, combative, he tried to wander all the shift . He remains at high risk for fall. On 7/5/23 at 12:05 p.m., a history and physical noted Resident #1 has had a progressive decline and family is unable to care for him. He was diagnosed with Alzheimer's dementia back in July 2022. His behaviors had rapidly gotten worse as well and was unable to be left alone . He wanders a lot and just says random words . Not sure he is good to follow commands. On 7/6/23 at 5:07 p.m., a progress note documented, Resident came back from the hospital via stretcher. he is positive for covid therefore he is on respiratory isolation. he refused to stay in his room . he kept going to 400 hall three times. he does have wander guard around his ankle . On 7/7/23 at 6:05 a.m., the nurse documented, 0330 (3:30 a.m.): Pt (patient) was with writer and CNA (Certified Nursing Assistant) as pt was trying to elope. 0445 (4:55 a.m.) CNA went to pt room to provide personal care. CNA noticed pt not in room. CNA notified writer. Writer announced code green as CNA was looking inside the other pts room. Pt was located outside. Pt alert. Pt noted to be very confused and agitated. Pt was wandering throughout the whole night and going in and out of pts room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105499 If continuation sheet Page 7 of 10 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 105499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Lely Palms 6135 Rattlesnake Hammock Road Naples, FL 34113 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 0835 Scheduled medication that was given was ineffective . Level of Harm - Immediate jeopardy to resident health or safety On 7/12/23, review of witness statements included in the facility's elopement investigation revealed on 7/7/23 at approximately 3:00 a.m., Resident #1 attempted to exit through an exit door on the 500 hall. He pushed on the door and set off the alarm but did not exit. None of the staff in the facility knew the code to reset the alarm. The nurse on the 500 hall called two supervisors for assistance but neither returned the call. The nurse then called the maintenance director who told her he was on vacation. The alarm continued to sound. The CNA saw Resident #1 at approximately 4:00 a.m. and then, when she went to check on him at approximately 4:40 a.m., he was not in his room. The nurse and the CNA did a quick check of the unit, did not locate him so the nurse called Code [NAME] (missing person alert). Staff responded and Resident #1 was found outside the facility, about 100 feet from the 500 hall exit door, sitting on the ground, playing with the grass at approximately 5:00 a.m. She said the alarm was still activated throughout the sequence of events until a Maintenance Assistant came to the facility at about 5:00 a.m. and reset the code. Residents Affected - Few On 7/12/23 at 9:56 a.m. in a telephone interview Resident #1's daughter said he went to hospital because she was not able to look after him. She said he was diagnosed with Alzheimer's dementia, he was confused and could not be left home alone. She said he got lost many times, they had to call the police many time. She said she secured the house as best she could and had a camera alert. He was always wandering around, trying to go out. She said the last three weeks he had gotten worse and started falling (before the original admission). She said she told the hospital and the facility he needed to be supervised and not left alone. She said she told the first lady she saw at the facility about him not being left unsupervised. On 7/12/23 at approximately 4:00 p.m., observation revealed outside of the 500 hall exit door there was a lake/retention pond with red warning posted signs that read, DANGER. ALLIGATORS AND SNAKES IN AREA. STAY AWAY FROM THE WATER. DO NOT FEED THE WILDLIFE. Photographic evidence obtained. The lake was surrounded by a fence approximately five feet high. The gate that did not latch and was in disrepair. Photographic evidence obtained. On 7/12/23 at 7:32 a.m., Licensed Practical Nurse (LPN), Staff A said she was on duty the night of 7/7/23 and Resident #1 was part of her assignment. She confirmed the sequence of events involving Resident #1. She said after Resident #1 attempted to leave the first time; it was not possible to assign anyone to supervise him because of the workload. She confirmed she called two supervisors but there was no return call. She confirmed she called the Maintenance Director who told her he was on vacation, and would not give the code to stop the alarm. On 7/12/23 at 10:23 a.m., the Administrator confirmed Resident #1 had been wandering. They talked about it during clinical meetings and placed a wander alert bracelet on him. They talked about transferring him to the secured unit but there was no room available. On 7/12/23 at approximately 4:15 p.m., the Administrator confirmed the sequence of events involving Resident #1 on 7/7/23. She confirmed Resident #1 was not placed on increased supervision after the first exit seeking attempt on 7/7/23 at approximately 3:00 a.m. and should have been. She confirmed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105499 If continuation sheet Page 8 of 10 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 105499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Lely Palms 6135 Rattlesnake Hammock Road Naples, FL 34113 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 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few LPN Staff A attempted to contact two supervisors and there was no return call. She confirmed the Maintenance Director was called and said he was on vacation. She said at the time, the only staff that had the code to reset the alarm on the 500 unit exit door was the maintenance staff, and he was not on site. She confirmed the location of Resident #1 was unknown from approximately 4:00 a.m. until approximately 5:00 a.m. when he was found outside. On 7/13/23 at approximately 4:00 p.m., the Administrator confirmed there was no one designated to be in charge, and responsible for the delivery of care on the overnight shift on 7/7/23. She verified the facility failed to have systems in place to protect Resident #1 from unsafe wandering and elopement. The facility submitted an acceptable Immediate Jeopardy removal plan. On 7/13/23 the Immediate Jeopardy was removed after verification of the immediate actions implemented by the facility in accordance with their removal plan which included: 1:1 (one to one) supervision to prevent further incident was initiated on 7/7/2023. The surveyor verified by record review and observatio of Resident #1. Door codes were obtained and posted/ shared in multiple places to reset the alarming/ unlocked door for safety. The surveyor verified by observation. Education was initiated to include availability/ location of secure door codes, how to reset doors when alarming, not to leave doors if they cannot be reset/ locked and the missing resident process. This education was completed on 7/10/2023 and staff not present were educated prior to next shift. Facility staff educated include activities, administration, dietary, housekeeping, laundry, maintenance, medical records, nursing, rehab, and social services. The surveyor verified by record review. Education on supervisor on call, monitoring exit door, putting exit seeking patient on 1:1, and administrator notification was completed on 7/13/2023 and staff not present will be educated prior to next shift. Facility staff educated include activities, administration, dietary, housekeeping, laundry, maintenance, medical records, nursing, rehab, and social services. The surveyor verified through record review. Like residents were reviewed for exit seeking interventions, exit security system (wanderguard), exit doors functioning, and accurately working wander guards. The surveyor verified through record review. The Administrator notified the Medical Director on July 7, 2023 of occurrence and of this plan and held an ad-hoc (unplanned) QAPI (Quality Assurance and Performance Improvement) meeting to discuss self-identified findings on July 7, 2023 at 12:00 p.m., resulting in this plan. The surveyor verified through record review. Education provided to supervisory staff and maintenance director related to responsibilities of being on call, returning calls, and notification of administrator. This education was completed on 7/12/2023. The surveyor verified through record review. Fence gate outside by the lake was fixed on 7/12/2023. Verified through observation. Director of Nursing (DON) or designee will review new admission H&P (History and Physical) , 3008, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105499 If continuation sheet Page 9 of 10 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 105499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Lely Palms 6135 Rattlesnake Hammock Road Naples, FL 34113 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 0835 Level of Harm - Immediate jeopardy to resident health or safety and discharge summary for evidence of elopement or wandering risk. The surveyor verified through record review. Administrator or designee will conduct missing patient drills three times a week to include weekends (one on each shift) weekly for four weeks then monthly to observe and validate proper response. The surveyor verified through record reviews of drills conducted. Residents Affected - Few The DON or designee will review residents at risk for exit seeking weekly for four weeks to validate appropriate interventions in place. The surveyor verified through record review. Findings will be reported back to the QAPI committee for further review, adjustment, or completion of plan. The surveyor verified by record review. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105499 If continuation sheet Page 10 of 10