Health inspection·November 18, 2021

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Staff A, LPN addressed Resident #21's Progress Notes, which revealed that Resident #21 brought up a concern related to missing personal items. Staff A, LPN stated that a grievance should have been filed for Resident #21 in order to locate her missing items. An interview was conducted on 11/18/2021 at 1:57 PM with the SSD, who was also serving as the facility's Grievance Official. The SSD stated that when a resident or resident representative expressed a concern related to the facility, the staff member who received the concern would fill out a grievance form. The grievance would then be discussed in the morning meeting by the care team and be assigned to the related department. Once the concern was investigated, the grievance would be returned to the SSD in order to be filed. The SSD stated that when the concern related to a missing personal item, all care team members look to locate then missing items. The SSD also stated that the nursing staff on the floor could attempt to locate the item initially, but a grievance should be filed for the resident. The SSD reviewed the facility grievance logs from August 2021 to October 2021, but was not able to locate a grievance filed for Resident #21 related to missing personal items. The SSD addressed that a grievance should have been filed for Resident #21 related to her concerns. An interview was conducted on 11/18/2021 at 2:08 PM with the facility's NHA. The NHA stated that a resident of the facility could express concerns to any staff member, who would then report the concern to their supervisor. The staff member that received the concern would usually be the person who fills out the grievance form for the resident. Resident grievances were discussed in the morning meeting with the care team and would then be assigned to the related department. A concern related to missing items would typically be assigned to the housekeeping or laundry department. The NHA stated that Resident #21's concern related to her personal items should have been communicated properly by the facility staff so that the concern was investigated thoroughly. A review of the facility policy titled Grievance Policy, with no effective date, revealed the following policy statement: - All persons are encouraged to make requests, share concerns, and file grievances regarding care and/or services without fear of retribution or negative treatment. Customer Service/Grievance forms are provided on admission and are available throughout the facility in the lobbies and nursing units. A concern or grievance may be given orally or in writing. If you have a concern or grievance, you may contact our Grievance Official. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105515 If continuation sheet Page 2 of 5 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 105515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Plant City 701 N Wilder Rd Plant City, FL 33566 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure assessment, consent, and proper fitting of bed rails for one (#115) of four residents sampled for accidents out of a total resident sample of 43. Findings included: According to the Food and Drug Administration (FDA), accessed at https://www.fda.gov/medical-devices/consumer-products/bed-rail-safety, indicated that Bed rails are used by many people to help create a supportive and assistive sleeping environment in homes, assisted living facilities and residential care facilities. This type of equipment has many commonly used names, including side rails, bed side rails, half rails, safety rails, bed handles, assist bars, or grab bars, hospital bed rails, and adult portable bed rails. On 11/16/21 at 10:28 a.m., Staff Member D, Agency Registered Nurse (RN), identified that Resident #115 had both left-sided and right-sided side rails. Observation with Staff D revealed the side rails were approximately 8-10 inches, shoulder level, and the middle portion of one rail held the bed controller. The left side rail was observed to have a gap of approximately 5 inches between the mattress and the rail. Staff D confirmed that the bed rail on the left side of the bed was not properly spaced. Staff D stated, it should be like that one pointing to the right side rail. On 11/17/21 at 1:45 p.m., Resident #115 was observed lying in bed on a scoop mattress, with her eyes closed. The bed was above knee-level, and the bilateral 1/8 side rails were raised. Staff Member C, Agency Licensed Practical Nurse (LPN) stated, at 1:47 p.m. on 11/17/21, that she had not done any admissions while at the facility. The staff member confirmed the gap between the mattress and the left side rail but was not sure how to move it inwards. The side rail was attached to the bed frame at the bottom. The Director of Nursing (DON) stated on 11/17/21 at 1:59 p.m., that the facility did do side rail assessments at the time of admission and that consents for use were obtained. She viewed the rails attached to the side of Resident #115's bed and confirmed that the side rail could be moved inward and that it did not fit like the right side rail. The side rail swung toward and away from the bed and could not be lowered. The DON called maintenance staff to the residents' unit for assistance. Staff Member E, Maintenance Assistant, was able to adjust the side rail by unlocking it from the bottom of the bed frame and moving it inwards. The DON stated that she wondered if the gap was due to the scoop mattress as this was not the original mattress. The DON stated that the original mattress had been changed to a bolstered one following a fall. Both Staff Member E and the Maintenance Director identified, at 2:17 p.m. on 11/17/21, that all side rails need to be observed and reported if needing to be adjusted. A review of Resident #115's clinical record revealed an original admission date in October of 2021. The Face Sheet for the resident included diagnoses of subsequent encounter for closed fracture with routine healing (of) displaced intertrochanteric fracture of left femur, dementia in other diseases classified elsewhere without behavioral disturbance, and unspecified Alzheimer's disease. Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105515 If continuation sheet Page 3 of 5 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 105515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Plant City 701 N Wilder Rd Plant City, FL 33566 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 0700 #115's Face Sheet identified a family member as the Healthcare Surrogate. Level of Harm - Minimal harm or potential for actual harm Resident #115's admission Minimum Data Set (MDS) dated [DATE], indicated that the Brief Interview of Mental Status score for the resident was 4, indicating severe cognitive impairment. The MDS identified the resident required extensive 2-person assistance for bed mobility and transfers and that a bed rail was not used. Residents Affected - Few The clinical record of Resident #115 revealed that the admission Observation, completed at 6:24 p.m. on 10/12/21, did not include a side rail assessment. Subsequent observations from 10/12 to 11/16/21 did not identify a side rail assessment had been completed for Resident #115. A review of attached documents for the resident did not include a consent was given by the resident representative for the use of side rails. The Care Plan Approval Form, completed on 10/18/21 at 3:11 p.m., indicated that the care plan approval was obtained by a telephone discussion and that the Health Care Surrogate and resident had signed it on 10/18/21. The Approval form identified I DO NOT consent to the use of side rail(s) and understand the related liabilities. The Director of Nursing (DON) stated, on 11/17/21 at 4:30 p.m., that the devices on the sides of Resident #115's bed were not side rails so there was not an evaluation done and consents were not needed. On 11/18/21 at 12:58 p.m., the DON reiterated that Resident #115 did not have side rails, she stated that a side rail was able to move down or up, the resident's did not, and they were attached to the head of the bed. She identified that the facility had received 100 beds that came with assist bars. A review of the Care Plan Approval form and the portion of side rails was conducted with the DON. She stated that yes, consents were given for side rails but again, identified that the devices on Resident #115's bed were not side rails. The definition of a side rail was reviewed with the DON. The DON stated, okay and stated that, very few persons have side rails within the facility. An interview was conducted , on 11/18/21 at 1:42 p.m., with Staff Member F, RN and Staff Member G, Agency RN. They identified that neither knew where a side rail evaluation was documented (in the record). The Care Plan for Resident #115 identified the following problems and approaches: - At risk to develop impaired skin integrity due to decreased mobility, need for assistance with mobility tasks, and risk of incontinence. The approaches included assist me to turn and reposition regularly using assist rails as an enabler, started 10/13/21 and edited on 11/18/21. Review of the facility policy titled Proper Use of Side Rails revised 1/17/2018, 2/10/2019, and 01/07/2020, indicated The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. The guidelines identified the following: .3. An assessment will be made to determine the resident's symptoms or reason for using side rails. When the side rails are used for mobility or transfer, an assessment will include a review of the resident's: --a. bed mobility; and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105515 If continuation sheet Page 4 of 5 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 105515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Plant City 701 N Wilder Rd Plant City, FL 33566 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 0700 --b. ability to change positions, transfer to and from bed or chair, and to stand and toilet . Level of Harm - Minimal harm or potential for actual harm 8. The risks and benefits of side rails will be considered for each resident. Residents Affected - Few 9. Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks. (Note: Federal regulations do not require written consent for using restraints. Signed consent forms do not relieve the facility from meeting the requirements for restraint use, including proper assessment ad care planning. While the resident or family (representative) may request a restraint, the facility is responsible for evaluating the appropriateness of that request . 12. When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk of entrapment (the amount of safe space may vary, depending on the type of bed and mattress being used.) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105515 If continuation sheet Page 5 of 5