Inspection·September 26, 2025

F 0578 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few this time patient is a full code, [family member] made aware and stated understanding. Patient does not smoke. Call light within reach. Denies of any pain @ this time. No distress noted.Review of Resident #209's physician order dated [DATE] read, Code status: Full code.Review of Resident #209's social service progress note dated [DATE] at 7:16 am read, 72 - hour note: Resident lives in an independent living apartment @ [name of ALF]. Resident was independent with functional mobility and ADL's (activities of daily living) prior to her fall. Resident utilized a 4 wheeled rolling walker. Resident's support system includes [two family members named]. Resident's discharge plan is to return home once rehab(rehabilitation) is complete. Will ask [family member] to provide copy of any advanced directives resident may have. Resident is currently a full code.Review of Resident #209's nursing progress note dated [DATE] at 2:12 PM read, Pt (patient) unresponsive in wheelchair brought to desk by Therapist. Nursing returned pt to bed as this nurse called code blue. Called 911.Review of Resident #209's nursing progress note dated [DATE] at 4:28 PM read, Shortly after 2 PM called to assess patient sitting slumped down in wheelchair nonresponsive to verbal stimuli or sternal rub. Listened for heartbeat with stethoscope and felt for radial pulse, no detected heartbeat. Called out to charge nurse to check code status, told she is full code. Grabbed wheelchair to take to room and called for someone to grab backboard. CPR chest compressions started. Opened AED (automated external defibrillator) no shock needed. Pt (patient) began to slowly respond, opened her eyes breathing on her own, faint radial pulse noted. Oxygen applied initial VS (vital signs) 96/64, HR (heart rate) 46, 84% oxygen saturation. As resident became more alert encouraged to take deep breaths, through her nose and oxygen increased to 3 liters with resulting saturation 94% the [sic] increase to 97 %. As paramedics arrived B/P (blood pressure) 113/58, HR 53 saturation 97% and patient was alert. Paramedics transferred to stretcher. For transport.Review of the [Name of Hospital] document titled ED (emergency department) Provider Report dated [DATE] at 15:06 (3:06 PM) read, Rapid Initial Assessment: Pt (patient) by EMS (Emergency Medical Services) from [Name of Nursing Home], facility reported pt was found unresponsive and they started CPR. Pt A&O (alert and oriented) x 4 by the time EMS arrived. Active DNR. Pt now complaining of 10/10 sternal pain. HPI (history of present illness) Notes: Patient arrives by EMS complaining of sternal and anterior chest wall pain. Per EMS staff at nursing home was concerned she was in cardiac arrest and administered CPR. Patient states she was just sleeping but now her chest hurts. She has mild shortness of breath related to chest pain. No other new complaints. She has her left lower extremity in a Cam boot for a distal tib(tibia) fib(fibula) fracture no swelling of the leg. Clinical Impression, Primary Impression: Chest Wall contusion, Secondary impression: Chronic hyponatremia, hyponatremia, syncope. Disposition Decision: Hospitalize.During an interview on [DATE] at 12:05 PM Staff I, Registered Nurse (RN) stated she (Resident #209) was very confused, using word salad (a term used to describe incoherent speech that is difficult to understand). Staff I stated, The floor nurse tried to speak with the resident, but she couldn't say whether she had a DNR, and she ended up having to call family. The [family member] told the nurse Resident #209 had a DNR. The nurse told Resident #209's family member that she needed to provide the copy of it (the DNR), and she was supposed to E-mail me something, and she didn't. Our policy is we require the paper (the DNR form), and we spoke to [family member] and told her that. The next day Resident #209's family member gave the unit secretary a wallet card. We don't accept cards, they are usually not correct or complete. I believe it was incorrect. No, I did not see the card. I just know it's our policy to only have the paper copy until then anyone will be a full code until we get that. I'm not sure exactly what the policy says. I would have to look at it. I did not tell the nurse that she would have to be a full code, that was the charge nurse that night. That's how we have always done it. I'm not sure, but (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105544 If continuation sheet Page 2 of 28 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 105544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Bayonet Point 7210 Beacon Woods Dr Hudson, FL 34667 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 no, I don't think I knew if the daughter-in-law was able to make decisions. I don't think anyone asked to speak to her son. No, I don't think that the DNR was discussed with the APRN (Advanced Practice Registered Nurse), but I don't really know. A yellow DNR is a physician order, yes, it should be honored. We should, once the form is provided, obtain the order and carry out the residents right for their wishes. She should not have had CPR.During an interview on [DATE] at 12:55 PM, Staff C, RN stated, I can tell you that I believe therapy brought her (Resident #209) to the desk not responding, I personally assess her, for a heartbeat, she had no HR (heart rate). I asked the charge what her code status was, then took her to the room, lifted her and placed her on a backboard and initiated CPR. Then I ran and got the AED (Automated External Defibrillator), no shock was advised. She was responding when the paramedics pointed out to me that she was a DNR, as they had the paperwork in their hands. I was not provided the DNR form by the unit secretary that day. Normally, the unit secretary should make copies and will let the Charge Nurse know, then files it in the binder and the charge nurse gets in and changes the order in the computer after contacting the physician. After that it gets scanned into the system. The unit secretary should have provided that DNR to the charge nurse or myself. That is the process we would immediately contact the doctor and get the orders. I would not have done CPR if I had known, but I didn't.During an interview on [DATE] at 1:54 PM the Facility Risk Manager (RM) stated, the family stated Resident #209 had a DNR, but it was not provided to us. On [DATE] at around 2 PM the family member provided the card (wallet card), handed it to the unit secretary who let her know it would not be valid. The RM stated, No, I don't think the secretary showed the wallet card to anyone else, not a nurse. Then on [DATE] the secretary was provided the form (the DNR) at about 12:40 PM. She (the unit secretary) did not hand it to the charge nurse or the nurse taking care of her (Resident #209). I think the charge nurse gave direction to the floor nurse that without the form she needed to be a full code. I don't think that it was addressed with the doctor (that Resident #209 had a yellow DNR form) that night when they gave orders for a full code status, but I don't know for sure.During an interview on [DATE] at 3:12 PM, Staff A, RN stated, I did her admission assessment. She was very confused used the word salad. I asked her about any advance directives, and she couldn't answer. I called the family member who stated she's been confused. The family member stated the resident had a Yellow DNR on her refrigerator at the ALF. I gave her the email, so she could provide it to us. I said she would be a full code as there was no paper. So that's what order I got. No, I did not tell the practitioner that she had a DNR or that we were waiting for the paper. The charge nurse advised me she would be a full code until we get the paper. Staff A stated the family member seemed okay with that and assured us that she would get it to us. Staff A stated the DNR paper should have been relayed to the nurse and the nurse at the desk should have checked the document and changed the order in the chart. Staff A stated the unit secretary should have given the DNR form to the nurse so they could get the order. Staff A stated, We should follow the residents wishes when it comes to a DNR of full code.During a telephone interview on [DATE] at 6:55 PM, Resident #209's family member stated, I told them on the day she was admitted that she was a DNR, I had a health care surrogate, not a POA (power of attorney), they told me that she would have to be a full code. I told them that I couldn't understand why they needed to make her a full code when I told them she was a DNR. I didn't really understand why. The next day I showed them the wallet card, and the clerk said they could not accept this. I took to the wallet card to the nurses station, and the unit secretary told me that I needed the larger sheet. The unit secretary did not take it to be seen by anyone else. The family member stated she did not show the DNR form to the nurse or anyone else. The family member said, I did not show it to anyone else but her. I needed to get it off the refrigerator (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105544 If continuation sheet Page 3 of 28 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 105544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Bayonet Point 7210 Beacon Woods Dr Hudson, FL 34667 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 from the ALF she was in before I could get it to them. I arrived at the facility at about 12:39 PM. The clerk made a copy of the DNR form and gave it back to me. I got a call at about 2 :15 PM that she was unresponsive and they were doing CPR. I cried, No stop she is a DNR, I gave you the paperwork about one and a half hours ago, you should not be doing that, that's not what she wanted. The family member stated, when she was first admitted the facility told her they would not honor the DNR until I brought the paperwork in for them to see. The family member said, I said she does not want to be resuscitated she has had this DNR since 2018. I believe it was May of 2018. I can't understand why they wouldn't do what she wanted, she was a DNR. The family member stated this event had caused all of them distress and really it caused Resident #209 pain in her last few days. The family member stated, No one from social services or the nurses spoke with me again about the DNR or the paperwork. I only spoke to the secretary who told me that the wallet DNR wasn't good enough. No one asked to speak to my spouse about any of this. They told me they wouldn't honor the DNR until I got it in.During an interview on [DATE] at 6:20 AM the Director of Nursing (DON) stated, We found that the secretary had gotten the paper, the DNR ,at about 12:30 pm and this happened at about 2:15 pm. It really was the perfect storm. It really is unfortunate this happened. The secretary had been given the small card the day before (on [DATE]), she did tell her we wouldn't accept that, no I don't think she showed it to any nursing staff. I do suppose she should have. The secretary should have gotten the paperwork to the charge nurse right away, but she got busy helping residents and forgot and then went to lunch. No, we should not have performed CPR. It has been our policy to make sure that the DNR paperwork is physically here, we have to physically see the paper before we can get orders for the DNR, that has been our policy and she (the family member), she didn't have any proof that she could make the decision. We didn't have any paperwork saying she was the POA or health care surrogate. I don't think that we tried to talk with the [family member's spouse]. It was only the family member that came here I think. I think we followed our policy. I'm not sure if our policy does say we need the paper. The resident couldn't tell the nurse one way if she had a DNR, she was confused had used the word salad. I don't know if anyone spoke to the APRN who gave the orders about whether she had a DNR. The charge nurse told the nurse without the paper we needed to keep her a full code, until there was the paper here. We didn't try any other way to get the paperwork. I think it was just nursing who spoke to her [family member]. I don't think social services or admissions spoke to the family again. I do think maybe they should have reached out to the family again. A yellow DNR is an order. We should honor any residents advanced directives wishes.During an interview on [DATE] at 8:30 AM the Medical Director (MD) stated, The DNR form should have gone to staff who could get the order changed. It is not within a nurse's ability to make a decision or write an order for full code or DNR. If they know that a newly admitted person has a DNR at home, they should let the doctor know and they can determine the order. The MD stated, I actually have blank forms that I can fill out and fax over or the staff can take a verbal order with two witnesses and place the order. The MD stated the doctor should have been notified that she had a DNR at her home so they can make an appropriate decision regarding their code status. During a telephone interview on [DATE] at 9:34 AM Staff D, Unit Secretary stated, I did get a card, the DNR from her [family member]and the Health care surrogate paper on 8/13. I told her we couldn't accept the card, and she needed to bring in the full copy. She said she would bring it in the next day. I did not show the card to any nurse, no, not the charge nurse or her nurse. I assumed, which I shouldn't have, when a new patient comes in and if they are DNR and then the nurse does their communication with the patient if they have a DNR they have the patient sign a temporary DNR so that it goes into the computer as a DNR and then when the family brings in the full (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105544 If continuation sheet Page 4 of 28 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 105544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Bayonet Point 7210 Beacon Woods Dr Hudson, FL 34667 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 sheet, then I usually take out the temporary one and put in the permanent one. Staff D stated, I assumed that she was already in the computer as a DNR. Once her [family member] brought the DNR to me, then I made copies. I put it in the front of the binder. I didn't give the paper to anybody. I just put it in the binder because I just I usually don't give it to the charge nurse. I usually just put it in the binder. I assumed that she was already marked as a DNR in the computer. I just shouldn't have done that.During a telephone interview on [DATE] at 9:39 AM the Advanced Practice Registered Nurse (APRN) stated, I was not told by the nurse that the resident had any DNR in place at the time she was admitted to (name of facility). I would have considered having her at DNR status until the paperwork arrived to the facility, but I would have wanted to make sure the family member had the right to make that determination as the next of kin. I certainly could have given an order and then faxed the DNRO signed while we waited for the original DNRO. The nurse did not discuss that with me when she got the orders. The APRN stated they had the ability to get the facility the right paperwork and not have any type of delay in making sure that wish is acted on. Performing CPR in the elderly can lead to many complications like rib fracture, lung contusion, chest wall pain, difficulty breathing and taking deep breaths which could lead to pneumonia. The APRN said, No, if a resident's wishes are no CPR, it should not be performed.During an interview on [DATE] at 12:11 PM Staff B, Social Service Director, stated, We did not readdress the advance directives with the resident or the family. Ultimately, it should be done, we should reach out to the family and get that done. It has been our policy to have a copy of this provided by the family prior to make sure everything is correct on the form. We could get that completed here if they don't have any and want to be a DNR.Review of the policy and procedure titled, Advance Directives last review date of [DATE] read, Policy Statement: Advance Directives will be respected in accordance with state law and facility policy. Policy interpretation and implementation: 1. Prior to or upon admission of a resident to our facility, the Admissions Director or designee will provide written information to the resident concerning his /her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advanced directives.2. Each resident will be informed that our facility's policies do not condition the provision of care or discriminate against individual based on whether or not the individual has executed an advanced directive.3. Prior to or upon admission of a resident, the Admissions Director or designee will inquire of the resident, and or his/ her family members, about the existence of any written advanced directives. 5. In accordance with current OBRA definitions and guidelines governing advance directives, our facility has defined advanced directives as preferences regarding treatment options and include, but are not limited to: . b. Do Not ResuscitateIndicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care DPOA, health care surrogate or health care proxy has directed that no cardiopulmonary resuscitation (CPR) or other life- saving methods are to be used. 9. Nursing Will notify the attending physician of pertinent changes in advanced directives so that appropriate orders can be documented in the resident's medical record and plan of care. The Immediate Jeopardy (IJ) was removed on site on [DATE], after the receipt of an acceptable IJ removal plan.Review of the facility's Removal Plan dated [DATE] read, F578: On [DATE] facility staff failed to honor Resident 209 Advance Directives. The Center has taken the following steps to remove immediacy and ensure substantial compliance with advanced directives of our residents:1. Immediate verbal education with written attestation completed with 100% in-house staff on [DATE] regarding: a. Advance Directives; b. Policy and procedure for following physician orders for Do Not Resuscitate; e. Regional Risk Manager provided education to Administrator, DON, ADON, Risk Manager; d. Formal written training with signatures for available staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105544 If continuation sheet Page 5 of 28 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 105544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Bayonet Point 7210 Beacon Woods Dr Hudson, FL 34667 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 on roster ( available roster fluctuates daily).2. 211/219 staff received written education on [DATE].100% of all staff had received written training. RN 87% 20/23, CNA 93.8 61/65, 67 % 3/4 HIM (Health information Management), Administrative 100% 10/10, 100% Maintenance 4/4, 100% EVS (environmental services),100% Dietary 22/22, 100% Recreation 3/3 and 100% therapy 21/21.3. 214/219 additional staff received written education on [DATE] total available staff on roster completed at 97%,4. 218/219 staff received written education on [DATE] total available staff on roster completed at 99%(RN 23/23 100%, CNA 65/65 100%, HIM 3/4 67%.5. 219 /219 staff received written education on [DATE] total available staff on roster completed at 100%.6. Staff types trained; a. 219 total staff, b. 3 recreation(Activities Director and 2 assistants); c. 21 therapy dept (department); d.9 administrative staff (Business Office Manager, 2 bookkeepers, 1 billing supervisor), 1 payroll, 5 receptionists, e. 22 dietary; f. 22 environmental services (one EVS supervisor, 6 laundry, 15 housekeeping), g. 4 plant operations (1 director and 3 assistants), h. 120 nursing employees (23 RN,19 LPN, 65 CNA, 13 PCA); i. 10 nursing administration (5 MDS, 1 staff development, DON, ADON); j. 7 social services (3 admissions, 4 social services); k. Administrator education provided by Regional Risk Manager.7. On [DATE] initiation of audit of 100% resident medical records for verification of code status, physician orders as they pertain to code status, and care plans, and advanced directives as they pertain to code status. A. completed on [DATE].8. QAPI (Quality Assurance and Performance Improvement) meeting (including Ad hoc and regularly scheduled) on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE].a. Reported to QAPI on [DATE].b. Next QAPI on [DATE] [sic].9. Orientation of new employees and annual orientation of employees includes. a. Advanced Directives: b. policy and procedure for following physician orders for do not resuscitate; c. Verification of code status prior to implementing CPR in the electronic medical record; d. the definition of employee includes actual employees on the center payroll, contracted employees.10. Code status/Advance Directives with all admissions and with residents at the time of care plan meetings. A. Frequency and Percent of staff audited may be modified by QAPI committee based on reports submitted each month. 8.Education regarding advanced directives mailed to all next of kin for residents on [DATE]. 9. Education provided during resident council to residents on [DATE] regarding advanced directives.10. Code status verified drill completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and ongoing to ensure compliance. 11. Individual education provided to staff regarding code status for the following: [3 staff names].On [DATE] full house audit of 175 resident records were reviewed for code status, orders, advanced directives, care plans as they pertain to code status and were accurate. 122 DNR, 53 full code. On [DATE] review of staff education showed that 100% of staff received education to include 3 recreation (activities director and 2 assistants); 21 therapy dept (department), 9 administrative staff (Business office manager, 2 bookkeepers,1 billing supervisor, 1 payroll, 5 receptionists); 22 dietary; 22 environmental services (1 EVS supervisor, 6 laundry, 15 housekeeping); 4 plant operations (1 director and 3 assistants); 120 nursing employees (22 RN, 19 LPN, 65 CNA, 13 PCA);10 nursing administration (15 MDS, 1 staff development, DON, ADON by regional risk manager) 7 social service(3 admissions, 4 social services); Administrator education provided by regional risk manager we respectfully request that this plan be reviewed or [SIC] past noncompliance of [DATE].Review of the facility's Corrective Action Plan revealed the following:Review of AD HOC (meaning when necessary or needed) Quality Assurance and Performance Improvement meeting dated [DATE] reads, Reason for AD HOC meeting: CPR initiated on Resident that had full code orders/family brought DNR form in an hour before and handed to clerk.Opportunity for improvement (OFI): Resident code status was full code upon admission due to resident was unable to verify status and family did not have paperwork to say for positive her code status. The family was notified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105544 If continuation sheet Page 6 of 28 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 105544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Bayonet Point 7210 Beacon Woods Dr Hudson, FL 34667 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 FORM CMS-2567 (02/99) Previous Versions Obsolete at admission that she would be a full code until they could provide documentation of DNR.Data assess current situation - what were the results/trends: Resident became unresponsive during therapy, resident was assessed and no vital signs noted, no apical heart sounds, no respirations. Nurse verified code status in chart as full code, CPR initiated. Upon clerk returning from break she informed clerical staff that family had gave her the DNR form to her about an hour ago.Analysis (Root Cause Analysis): Non direct care staff member was handed a DNR form by the residents family shortly before the resident became unresponsive. Nurse followed plan of care for resident full code as well as orders for full code.Plan: Full house audit completed to verify code status of each resident. All staff educated via on shift or in person regarding procedure for handling a DNR form being brought into facility, it is to be handed to the nurse or unit manager immediately so that code status can be updated immediately. Code status verification drill.Responsible team member(s): DON, UM's, Administration, DON, supervisors, unit managers, administration, and supervisors.On [DATE]: System changes (if any please list) Nurse must be given the DNR, not a secretary or other staff. 8 staff members were documented as in attendance including the Medical Director via telephone.Review of the house wide full chart review of resident records including cross checking DNR /advance directives, ensure DNR orders with the EMR (electronic medical record) reflect resident current status were documented as completed for 174/174 residents on [DATE] by the Director of Nursing (DON).Review of the training and education on verbal education with written attestation regarding: a. Advance Directives; b. Policy and procedure for following physician orders for Do Not Resuscitate, c. What to do if family hands you an Advance Directive or DNR form was completed on [DATE] documented that 100% of staff received education to include: 3 recreation (activities director and 2 assistants); 21 therapy dept (department) ;9 administrative staff ( Business office manager, 2 bookkeepers,1 billing supervisor, 1 payroll, 5 receptionists); 22 dietary; 22 environmental services (1 EVS supervisor, 6 laundry, 15 housekeeping); 4 plant operations (1 director and 3 assistants); 120 nursing employees (22 RN, 19 LPN, 65 CNA, 13 PCA). Review of the training and education regarding a. Advance Directives and b. Policy and procedure for following physician orders for Do Not Resuscitate was completed on [DATE] for 10 nursing administration staff (15 MDS,1 staff development, DON, ADON by the Regional Risk Manager) 7 social service staff (3 admissions staff, and 4 social services staff) and the Administrator.During staff interviews completed on [DATE] through [DATE], 11 RN's, 10 LPN's, 20 CNA's, 4 PCA's, 6 environmental services, 3 receptionists, 8 rehabilitation/therapy staff,2 maintenance staff, 3 activities staff,3 social services staff, the Admissions Director, the Administrator, the DON, the ADON verified having received education and verbalized understanding of advanced directives, facility policy regarding code status, where to find the code status, residents rights, identifying and responding to a resident found to be unresponsive, and when to initiate/withhold CPR. Event ID: Facility ID: 105544 If continuation sheet Page 7 of 28 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 105544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Bayonet Point 7210 Beacon Woods Dr Hudson, FL 34667 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to ensure a resident a minimum data set assessment was transmitted within 14 days after completion for one resident (#12) of two residents reviewed for resident assessment. Findings included:Review of Resident #12's electronic medical record on 9/25/2025 showed a resident assessments history that documented Resident #12's annual minimum data set assessment (MDS) was completed on 8/3/2025 with a designation of Production Batch. The review showed Resident #12's MDS assessment was not transmitted to CMS on 8/3/2025 and was past the 14-day transmittal requirement. During an interview on 9/25/2025 at 8:40 AM, the Care Plan Coordinator/Registered Nurse (RN) stated that once a minimum data set assessment is completed, the assessment is sent to the corporate office for review before submission to the Centers for Medicare and Medicaid Services (CMS). She explained the corporate office reviews the assessment and sends a validation report to the facility for corrections if needed. She specified the assessment should be forwarded to the CMS 14 days following completion. During an interview on 9/25/2025 at 8:42 AM, the Care Plan Minimum Data Set Coordinator/Licensed Practical Nurse (LPN) stated the production batch designation meant the minimum data set assessment had been completed and was ready to be submitted to the corporate office for an initial review, and had not been submitted to CMS. During interview on 9/25/25 at 10:58 AM, the Care Plan Minimum Data Set Coordinator / Licensed Practical Nurse reported the facility had not received a validation report from the corporate office because the assessment was not transmitted to the corporate office for review when completed. She verified Resident #12's minimum data set assessment had not been forwarded to the corporate office for initial review until 9/25/2025. She confirmed their failure to submit the MDS for Resident #12 to their corporate for approval resulted in their failure to meet the CMS transmittal requirement of within 14 days. Review of Resident #12's MDS record revealed it should have been transmitted to CMS by 8/17/2025. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105544 If continuation sheet Page 8 of 28 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 105544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Bayonet Point 7210 Beacon Woods Dr Hudson, FL 34667 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 interview, record review and policy and procedure review the facility failed to honor a resident's expressed Advanced Directive for end of life for one resident (#209) of one resident reviewed, by failing to ensure life saving measures of cardiopulmonary resuscitation (CPR) were not performed when Resident #209 was found unresponsive and absent of vital signs. Resident #209 was admitted to the facility on [DATE] with a fully executed State of Florida Do NOT RESUSCITATE ORDER (DNR) DH (Department of Health) form 1896,Revised [DATE] dated [DATE]. Resident #209's representative provided a copy to the facility on [DATE] at 12:40 PM. The facility's unlicensed staff did not provide the DNR order to a licensed staff member for processing. Resident #209 was found unresponsive and absent of vital signs on [DATE] at 2:12 PM. The resident's wishes were not honored, and CPR was initiated. Resident #209 survived and was transferred to an area hospital. Findings included: Review of Resident #209 medical record documented an admission date of [DATE] with medical diagnoses to include displaced bimalleolar fracture of lower leg, subsequent encounter for closed fracture with routine healing, s/p (status post) ORIF(open reduction internal fixation), sprain of tibiofibular ligament of left ankle, subsequent encounter, s/p fixation, presence of right artificial hip joint, hypo-osmolality (a condition where the levels of electrolytes, proteins and nutrients in the blood are lower than normal) and hyponatremia (a condition where the levels of sodium in the blood is low), polyneuropathy (a condition where the peripheral nerves are damaged), unspecified, and gastroesophageal reflux disease (a condition where stomach acids flows back into the esophagus causing heartburn) without esophagitis (an inflammation of the esophagus).Review of Resident #209 medical record documented a form titled State of Florida Do NOT RESUSCITATE ORDER (DNR) DH (Department of Health) form 1896, Revised [DATE], dated [DATE]. The form was signed by Resident #209 and a physician.Review of Resident #209's nursing progress note dated [DATE] at 11:30 PM read, Patient arrived per stretcher via stretch limo transportation. Alert with confusion @ (at) times word salad (a term used to describe incoherent speech that is difficult to understand), speaks loudly. Resp (respirations) non labored. Abdomen soft, non-distended, with BS (bowels sounds) x 4 quads(quadrants), had BM (bowel movement) today. With IUC (indwelling urinary catheter) Fr (French) #14/10 ml(milliliter) patent, draining well to [sic] yellow colored urine. Patients dx(diagnosis) post left ankle ORIF (open reduction internal fixation) done on 8-7/25 by [Medical Doctors name]. NWB (non-weight bearing) to LLE (left lower extremity). Wears cam boot @ all times, unable to assess fully the surgical site. Observed BUE (bilateral upper extremities) and BLE (bilateral lower extremities) has multiple bruises. RLE (right lower extremity) with edema and some bruise marks. Obtained further data/information about patient from [family member]. Patient lives in ALF (Assisted Living Facility) [Name of the ALF], she's independent with everything, apparently she fell while waiting for a ride to go to her doctor's appointment, and left leg gave out causing her to fall and fracture left ankle. Patient had h/o (history of) multiple falls but this time a bad one. According to [family member] patient is a DNR (Do Not Resuscitate) and she will send it to this facility via e mail directly through ADON (Assistant Director of Nursing) email address tomorrow, @ this time patient is a full code, [family member] made aware and stated understanding. Patient does not smoke. Call light within reach. Denies of any pain @ this time. No distress noted.Review of Resident #209's physician order dated [DATE] read, Code status: Full code.Review of Resident #209's social service progress note dated [DATE] at 7:16 am read, 72 - hour note: Resident lives in an independent living apartment @ [name of ALF]. Resident was independent with functional mobility and ADL's (activities of daily living) prior to her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105544 If continuation sheet Page 9 of 28 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 105544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Bayonet Point 7210 Beacon Woods Dr Hudson, FL 34667 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 fall. Resident utilized a 4 wheeled rolling walker. Resident's support system includes [two family members named]. Resident's discharge plan is to return home once rehab(rehabilitation) is complete. Will ask [family member] to provide copy of any advanced directives resident may have. Resident is currently a full code.Review of Resident #209's nursing progress note dated [DATE] at 2:12 PM read, Pt (patient) unresponsive in wheelchair brought to desk by Therapist. Nursing returned pt to bed as this nurse called code blue. Called 911.Review of Resident #209's nursing progress note dated [DATE] at 4:28 PM read, Shortly after 2 PM called to assess patient sitting slumped down in wheelchair nonresponsive to verbal stimuli or sternal rub. Listened for heartbeat with stethoscope and felt for radial pulse, no detected heartbeat. Called out to charge nurse to check code status, told she is full code. Grabbed wheelchair to take to room and called for someone to grab backboard. CPR chest compressions started. Opened AED (automated external defibrillator) no shock needed. Pt (patient) began to slowly respond, opened her eyes breathing on her own, faint radial pulse noted. Oxygen applied initial VS (vital signs) 96/64, HR (heart rate) 46, 84% oxygen saturation. As resident became more alert encouraged to take deep breaths, through her nose and oxygen increased to 3 liters with resulting saturation 94% the [sic] increase to 97 %. As paramedics arrived B/P (blood pressure) 113/58, HR 53 saturation 97% and patient was alert. Paramedics transferred to stretcher. For transport.Review of the [Name of Hospital] document titled ED (emergency department) Provider Report dated [DATE] at 15:06 (3:06 PM) read, Rapid Initial Assessment: Pt (patient) by EMS (Emergency Medical Services) from [Name of Nursing Home], facility reported pt was found unresponsive and they started CPR. Pt A&O (alert and oriented) x 4 by the time EMS arrived. Active DNR. Pt now complaining of 10/10 sternal pain. HPI (history of present illness) Notes: Patient arrives by EMS complaining of sternal and anterior chest wall pain. Per EMS staff at nursing home was concerned she was in cardiac arrest and administered CPR. Patient states she was just sleeping but now her chest hurts. She has mild shortness of breath related to chest pain. No other new complaints. She has her left lower extremity in a Cam boot for a distal tib(tibia) fib(fibula) fracture no swelling of the leg. Clinical Impression, Primary Impression: Chest Wall contusion, Secondary impression: Chronic hyponatremia, hyponatremia, syncope. Disposition Decision: Hospitalize.During an interview on [DATE] at 12:05 PM Staff I, Registered Nurse (RN) stated she (Resident #209) was very confused, using word salad (a term used to describe incoherent speech that is difficult to understand). Staff I stated, The floor nurse tried to speak with the resident, but she couldn't say whether she had a DNR, and she ended up having to call family. The [family member] told the nurse Resident #209 had a DNR. The nurse told Resident #209's family member that she needed to provide the copy of it (the DNR), and she was supposed to E-mail me something, and she didn't. Our policy is we require the paper (the DNR form), and we spoke to [family member] and told her that. The next day Resident #209's family member gave the unit secretary a wallet card. We don't accept cards, they are usually not correct or complete. I believe it was incorrect. No, I did not see the card. I just know it's our policy to only have the paper copy until then anyone will be a full code until we get that. I'm not sure exactly what the policy says. I would have to look at it. I did not tell the nurse that she would have to be a full code, that was the charge nurse that night. That's how we have always done it. I'm not sure, but no, I don't think I knew if the [family member] was able to make decisions. I don't think anyone asked to speak to [the family member]. No, I don't think that the DNR was discussed with the APRN (Advanced Practice Registered Nurse), but I don't really know. A yellow DNR is a physician order, yes, it should be honored. We should, once the form is provided, obtain the order and carry out the residents right for their wishes. She should not have had CPR.During an interview on [DATE] at 12:55 PM, Staff C, RN stated, I can tell you that I (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105544 If continuation sheet Page 10 of 28 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 105544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Bayonet Point 7210 Beacon Woods Dr Hudson, FL 34667 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 believe therapy brought her (Resident #209) to the desk not responding, I personally assess her, for a heartbeat, she had no HR (heart rate). I asked the charge what her code status was, then took her to the room, lifted her and placed her on a backboard and initiated CPR. Then I ran and got the AED (Automated External Defibrillator), no shock was advised. She was responding when the paramedics pointed out to me that she was a DNR, as they had the paperwork in their hands. I was not provided the DNR form by the unit secretary that day. Normally, the unit secretary should make copies and will let the Charge Nurse know, then files it in the binder and the charge nurse gets in and changes the order in the computer after contacting the physician. After that it gets scanned into the system. The unit secretary should have provided that DNR to the charge nurse or myself. That is the process we would immediately contact the doctor and get the orders. I would not have done CPR if I had known, but I didn't.During an interview on [DATE] at 1:54 PM the Facility Risk Manager (RM) stated, the family stated Resident #209 had a DNR, but it was not provided to us. On [DATE] at around 2 PM the family member provided the card (wallet card), handed it to the unit secretary who let her know it would not be valid. The RM stated, No, I don't think the secretary showed the wallet card to anyone else, not a nurse. Then on [DATE] the secretary was provided the form (the DNR) at about 12:40 PM. She (the unit secretary) did not hand it to the charge nurse or the nurse taking care of her (Resident #209). I think the charge nurse gave direction to the floor nurse that without the form she needed to be a full code. I don't think that it was addressed with the doctor (that Resident #209 had a yellow DNR form) that night when they gave orders for a full code status, but I don't know for sure.During an interview on [DATE] at 1:31 PM Staff G, Certified Occupational Therapy Assistant (COTA) stated, [Resident #209] had finished PT (physical therapy) and was resting in the chair when I went to get started. She looked tired, took a breath and leaned to one side. I began calling her name, and she was not responding to me, so I called her name and did a sternal rub and got nothing. She was not responding but she was breathing. So, I wheeled her to the nurses station. [Staff C's name] took her pulse and the rest happened they called a code. I did not participate in the code.During an interview on [DATE] at 3:12 PM, Staff A, RN stated, I did her admission assessment. She was very confused used the word salad. I asked her about any advance directives, and she couldn't answer. I called the family member who stated she's been confused. The family member stated the resident had a Yellow DNR on her refrigerator at the ALF. I gave her the email, so she could provide it to us. I said she would be a full code as there was no paper. So that's what order I got. No, I did not tell the practitioner that she had a DNR or that we were waiting for the paper. The charge nurse advised me she would be a full code until we get the paper. Staff A stated the family member seemed okay with that and assured us that she would get it to us. Staff A stated the DNR paper should have been relayed to the nurse and the nurse at the desk should have checked the document and changed the order in the chart. Staff A stated the unit secretary should have given the DNR form to the nurse so they could get the order. Staff A stated, We should follow the residents wishes when it comes to a DNR of full code.During a telephone interview on [DATE] at 6:55 PM, Resident #209's family member stated, I told them on the day she was admitted that she was a DNR, I had a health care surrogate, not a POA (power of attorney), they told me that she would have to be a full code. I told them that I couldn't understand why they needed to make her a full code when I told them she was a DNR. I didn't really understand why. The next day I showed them the wallet card, and the clerk said they could not accept this. I took to the wallet card to the nurses station, and the unit secretary told me that I needed the larger sheet. The unit secretary did not take it to be seen by anyone else. The family member stated she did not show the DNR form to the nurse or anyone else. The family member said, I did not show it to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105544 If continuation sheet Page 11 of 28 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 105544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Bayonet Point 7210 Beacon Woods Dr Hudson, FL 34667 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 anyone else but her. I needed to get it off the refrigerator from the ALF she was in before I could get it to them. I arrived at the facility at about 12:39 PM. The clerk made a copy of the DNR form and gave it back to me. I got a call at about 2 :15 PM that she was unresponsive and they were doing CPR. I cried, No stop she is a DNR, I gave you the paperwork about one and a half hours ago, you should not be doing that, that's not what she wanted. The family member stated, when she was first admitted the facility told her they would not honor the DNR until I brought the paperwork in for them to see. The family member said, I said she does not want to be resuscitated she has had this DNR since 2018. I believe it was May of 2018. I can't understand why they wouldn't do what she wanted, she was a DNR. The family member stated this event had caused all of them distress and really it caused Resident #209 pain in her last few days. The family member stated, No one from social services or the nurses spoke with me again about the DNR or the paperwork. I only spoke to the secretary who told me that the wallet DNR wasn't good enough. No one asked to speak to my spouse about any of this. They told me they wouldn't honor the DNR until I got it in.During an interview on [DATE] at 6:20 AM the Director of Nursing (DON) stated, We found that the secretary had gotten the paper, the DNR ,at about 12:30 pm and this happened at about 2:15 pm. It really was the perfect storm. It really is unfortunate this happened. The secretary had been given the small card the day before (on [DATE]), she did tell her we wouldn't accept that, no I don't think she showed it to any nursing staff. I do suppose she should have. The secretary should have gotten the paperwork to the charge nurse right away, but she got busy helping residents and forgot and then went to lunch. No, we should not have performed CPR. It has been our policy to make sure that the DNR paperwork is physically here, we have to physically see the paper before we can get orders for the DNR, that has been our policy and she (the family member), she didn't have any proof that she could make the decision. We didn't have any paperwork saying she was the POA or health care surrogate. I don't think that we tried to talk with the [family member's spouse]. It was only the family member that came here I think. I think we followed our policy. I'm not sure if our policy does say we need the paper. The resident couldn't tell the nurse one way if she had a DNR, she was confused had used the word salad. I don't know if anyone spoke to the APRN who gave the orders about whether she had a DNR. The charge nurse told the nurse without the paper we needed to keep her a full code, until there was the paper here. We didn't try any other way to get the paperwork. I think it was just nursing who spoke to her [family member]. I don't think social services or admissions spoke to the family again. I do think maybe they should have reached out to the family again. A yellow DNR is an order. We should honor any residents advanced directives wishes.During an interview on [DATE] at 8:30 AM the Medical Director (MD) stated, The DNR form should have gone to staff who could get the order changed. It is not within a nurse's ability to make a decision or write an order for full code or DNR. If they know that a newly admitted person has a DNR at home, they should let the doctor know and they can determine the order. The MD stated, I actually have blank forms that I can fill out and fax over or the staff can take a verbal order with two witnesses and place the order. The MD stated the doctor should have been notified that she had a DNR at her home so they can make an appropriate decision regarding their code status. During a telephone interview on [DATE] at 9:34 AM Staff D, Unit Secretary stated, I did get a card, the DNR from her [family member]and the Health care surrogate paper on 8/13. I told her we couldn't accept the card, and she needed to bring in the full copy. She said she would bring it in the next day. I did not show the card to any nurse, no, not the charge nurse or her nurse. I assumed, which I shouldn't have, when a new patient comes in and if they are DNR and then the nurse does their communication with the patient if they have a DNR they have the patient sign a temporary DNR so that it goes into the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105544 If continuation sheet Page 12 of 28 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 105544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Bayonet Point 7210 Beacon Woods Dr Hudson, FL 34667 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 computer as a DNR and then when the family brings in the full sheet, then I usually take out the temporary one and put in the permanent one. Staff D stated, I assumed that she was already in the computer as a DNR. Once her [family member] brought the DNR to me, then I made copies. I put it in the front of the binder. I didn't give the paper to anybody. I just put it in the binder because I just I usually don't give it to the charge nurse. I usually just put it in the binder. I assumed that she was already marked as a DNR in the computer. I just shouldn't have done that.During a telephone interview on [DATE] at 9:39 AM the Advanced Practice Registered Nurse (APRN) stated, I was not told by the nurse that the resident had any DNR in place at the time she was admitted to (name of facility). I would have considered having her at DNR status until the paperwork arrived to the facility, but I would have wanted to make sure the family member had the right to make that determination as the next of kin. I certainly could have given an order and then faxed the DNRO signed while we waited for the original DNRO. The nurse did not discuss that with me when she got the orders. The APRN stated they had the ability to get the facility the right paperwork and not have any type of delay in making sure that wish is acted on. Performing CPR in the elderly can lead to many complications like rib fracture, lung contusion, chest wall pain, difficulty breathing and taking deep breaths which could lead to pneumonia. The APRN said, No, if a resident's wishes are no CPR, it should not be performed.During an interview on [DATE] at 12:11 PM Staff B, Social Service Director, stated, We did not readdress the advance directives with the resident or the family. Ultimately, it should be done, we should reach out to the family and get that done. It has been our policy to have a copy of this provided by the family prior to make sure everything is correct on the form. We could get that completed here if they don't have any and want to be a DNR.Review of the policy and procedure titled, Advance Directives last review date of [DATE] read, Policy Statement: Advance Directives will be respected in accordance with state law and facility policy. Policy interpretation and implementation: 1. Prior to or upon admission of a resident to our facility, the Admissions Director or designee will provide written information to the resident concerning his /her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advanced directives.2. Each resident will be informed that our facility's policies do not condition the provision of care or discriminate against individual based on whether or not the individual has executed an advanced directive.3. Prior to or upon admission of a resident, the Admissions Director or designee will inquire of the resident, and or his/ her family members, about the existence of any written advanced directives. 5. In accordance with current OBRA definitions and guidelines governing advance directives, our facility has defined advanced directives as preferences regarding treatment options and include, but are not limited to: . b. Do Not Resuscitate- Indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care DPOA, health care surrogate or health care proxy has directed that no cardiopulmonary resuscitation (CPR) or other life- saving methods are to be used. 9. Nursing Will notify the attending physician of pertinent changes in advanced directives so that appropriate orders can be documented in the resident's medical record and plan of care. The Immediate Jeopardy (IJ) was removed on site on [DATE], after the receipt of an acceptable IJ removal plan.Review of the facility's Removal Plan dated [DATE] read, F678: Failed to Honor a Resident expressed Advance Directive for end of life failing to ensure life saving measures of cardiopulmonary resuscitation (CPR) were not performed when Resident 209 was found to be non-responsive. The center has taken the following steps to remove immediacy and ensure substantial compliance with advanced directives of our residents:1. Immediate verbal education with written attestation completed with 100% in-house staff on [DATE] regarding: a. Advance Directives; b. Policy and procedure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105544 If continuation sheet Page 13 of 28 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 105544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Bayonet Point 7210 Beacon Woods Dr Hudson, FL 34667 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 for following physician orders for Do Not Resuscitate; e. Regional Risk Manager provided education to Administrator, DON, ADON, Risk Manager; d. Formal written training with signatures for available staff on roster ( available roster fluctuates daily).2. 211/219 staff received written education on [DATE].100% of all staff had received written training. RN 87% 20/23, CNA 93.8 61/65, 67 % 3/4 HIM (Health information Management), Administrative 100% 10/10, 100% Maintenance 4/4, 100% EVS (environmental services),100% Dietary 22/22, 100% Recreation 3/3 and 100% therapy 21/21.3. 214/219 additional staff received written education on [DATE] total available staff on roster completed at 97%,4. 218/219 staff received written education on [DATE] total available staff on roster completed at 99%(RN 23/23 100%, CNA 65/65 100%, HIM 3/4 67%.5. 219 /219 staff received written education on [DATE] total available staff on roster completed at 100%.6. Staff types trained; a. 219 total staff, b. 3 recreation(Activities Director and 2 assistants); c. 21 therapy dept (department); d.9 administrative staff (Business Office Manager, 2 bookkeepers, 1 billing supervisor), 1 payroll, 5 receptionists, e. 22 dietary; f. 22 environmental services (one EVS supervisor, 6 laundry, 15 housekeeping), g. 4 plant operations (1 director and 3 assistants), h. 120 nursing employees (23 RN,19 LPN, 65 CNA, 13 PCA); i. 10 nursing administration (5 MDS, 1 staff development, DON, ADON); j. 7 social services (3 admissions, 4 social services); k. Administrator education provided by Regional Risk Manager.7. On [DATE] initiation of audit of 100% resident medical records for verification of code status, physician orders as they pertain to code status, and care plans, and advanced directives as they pertain to code status. A. completed on [DATE].8. QAPI (Quality Assurance and Performance Improvement) meeting (including Ad hoc and regularly scheduled) on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE].a. Reported to QAPI on [DATE].b. Next QAPI on [DATE] [sic].9. Orientation of new employees and annual orientation of employees includes. a. Advanced Directives: b. policy and procedure for following physician orders for do not resuscitate; c. Verification of code status prior to implementing CPR in the electronic medical record; d. the definition of employee includes actual employees on the center payroll, contracted employees.10. Code status/Advance Directives with all admissions and with residents at the time of care plan meetings. A. Frequency and Percent of staff audited may be modified by QAPI committee based on reports submitted each month. 8.Education regarding advanced directives mailed to all next of kin for residents on [DATE]. 9. Education provided during resident council to residents on [DATE] regarding advanced directives.10. Code status verified drill completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and ongoing to ensure compliance. 11. Individual education provided to staff regarding code status for the following: [3 staff names].On [DATE] full house audit of 175 resident records were reviewed for code status, orders, advanced directives, care plans as they pertain to code status and were accurate. 122 DNR, 53 full code. On [DATE] review of staff education showed that 100% of staff received education to include 3 recreation (activities director and 2 assistants); 21 therapy dept (department), 9 administrative staff (Business office manager, 2 bookkeepers,1 billing supervisor, 1 payroll, 5 receptionists); 22 dietary; 22 environmental services (1 EVS supervisor, 6 laundry, 15 housekeeping); 4 plant operations (1 director and 3 assistants); 120 nursing employees (22 RN, 19 LPN, 65 CNA, 13 PCA);10 nursing administration (15 MDS, 1 staff development, DON, ADON by regional risk manager) 7 social service(3 admissions, 4 social services); Administrator education provided by regional risk manager we respectfully request that this plan be reviewed or [SIC] past noncompliance of [DATE].Review of the facility's Corrective Action Plan revealed the following:Review of AD HOC (meaning when necessary or needed) Quality Assurance and Performance Improvement meeting dated [DATE] reads, Reason for AD HOC meeting: CPR initiated on Resident that had full code orders/family brought DNR form in an hour before and handed to clerk.Opportunity for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105544 If continuation sheet Page 14 of 28 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 105544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Bayonet Point 7210 Beacon Woods Dr Hudson, FL 34667 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 FORM CMS-2567 (02/99) Previous Versions Obsolete improvement (OFI): Resident code status was full code upon admission due to resident was unable to verify status and family did not have paperwork to say for positive her code status. The family was notified at admission that she would be a full code until they could provide documentation of DNR.Data assess current situation - what were the results/trends: Resident became unresponsive during therapy, resident was assessed and no vital signs noted, no apical heart sounds, no respirations. Nurse verified code status in chart as full code, CPR initiated. Upon clerk returning from break she informed clerical staff that family had gave her the DNR form to her about an hour ago.Analysis (Root Cause Analysis): Non direct care staff member was handed a DNR form by the residents family shortly before the resident became unresponsive. Nurse followed plan of care for resident full code as well as orders for full code.Plan: Full house audit completed to verify code status of each resident. All staff educated via on shift or in person regarding procedure for handling a DNR form being brought into facility, it is to be handed to the nurse or unit manager immediately so that code status can be updated immediately. Code status verification drill.Responsible team member(s): DON, UM's, Administration, DON, supervisors, unit managers, administration, and supervisors.On [DATE]: System changes (if any please list) Nurse must be given the DNR, not a secretary or other staff. 8 staff members were documented as in attendance including the Medical Director via telephone.Review of the house wide full chart review of resident records including cross checking DNR /advance directives, ensure DNR orders with the EMR (electronic medical record) reflect resident current status were documented as completed for 174/174 residents on [DATE] by the Director of Nursing (DON).Review of the training and education on verbal education with written attestation regarding: a. Advance Directives; b. Policy and procedure for following physician orders for Do Not Resuscitate, c. What to do if family hands you an Advance Directive or DNR form was completed on [DATE] documented that 100% of staff received education to include: 3 recreation (activities director and 2 assistants); 21 therapy dept (department) ;9 administrative staff ( Business office manager, 2 bookkeepers,1 billing supervisor, 1 payroll, 5 receptionists); 22 dietary; 22 environmental services (1 EVS supervisor, 6 laundry, 15 housekeeping); 4 plant operations (1 director and 3 assistants); 120 nursing employees (22 RN, 19 LPN, 65 CNA, 13 PCA). Review of the training and education regarding a. Advance Directives and b. Policy and procedure for following physician orders for Do Not Resuscitate was completed on [DATE] for 10 nursing administration staff (15 MDS,1 staff development, DON, ADON by the Regional Risk Manager) 7 social service staff (3 admissions staff, and 4 social services staff) and the Administrator.During staff interviews completed on [DATE] through [DATE], 11 RN's, 10 LPN's, 20 CNA's, 4 PCA's, 6 environmental services, 3 receptionists, 8 rehabilitation/therapy staff,2 maintenance staff, 3 activities staff,3 social services staff, the Admissions Director, the Administrator, the DON, the ADON verified having received education and verbalized understanding of advanced directives, facility policy regarding code status, where to find the code status, residents rights, identifying and responding to a resident found to be unresponsive, and when to initiate/withhold CPR. Event ID: Facility ID: 105544 If continuation sheet Page 15 of 28 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 105544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Bayonet Point 7210 Beacon Woods Dr Hudson, FL 34667 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to administer insulin according to professional standards of practice for two residents (#152 and #5) of four residents reviewed for insulin administration and failed to administer cardiovascular medications according to professional standards of practice for one resident (#185) of four residents reviewed for cardiovascular medication administration. Residents Affected - Few Findings included: 1.Review of Resident #152’s medical record documented diagnosis that include hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, type 2 diabetes mellitus with diabetic polyneuropathy, type 2 diabetes mellitus with hyperglycemia (high blood sugar), atherosclerotic heart disease of native coronary artery (heart disease) without angina pectoris (chest pain), long term use of insulin, and hypoglycemia (low blood sugar). Review of Resident #152's physician orders dated 9/13/2025 read, Insulin Semglee (insulin-glargine-yfgn) pen 100 unit/ml(milliliter)(3ml) amount to administer: 30 units SQ (subcutaneous) at bedtime for DM (diabetes mellitus).” Review of Resident #152's physician orders dated 9/8/2025 read, Finger stick blood sugar QD (every day) notify MD (Medical Doctor) if below 60 or above 250 twice a day: 5. Monitor patients vital signs and blood sugar every 15 minutes until stable. Review of Resident #152's physician orders dated 9/8/2025 read, Hypoglycemic protocol #2:1.Check blood sugar via finger stick glucometer machine procedure if blood sugar is less than 60 notify MD and follow protocol below, 2. If patient is able to swallow, or for 4 ounces of orange juice with two packets of sugar, 3. If patient is not able to swallow, administer Glucagon or 20 to 30 CC's (cubic centimeter) of D50 (Dextrose) IV (intravenously) initially, additional amounts if no response. 4. Notify physician ASAP of crisis and for further orders. Review of Resident #152’s September medication administration (MAR) record documented that Insulin was not administered on 9/12/2025 at 9:00 PM, and on 9/13/2025 at 9:00 PM. Review of Resident #152’s MAR documented a blood sugar of 59 on 9/9/2025 at 6:00 AM. Review of Resident #152’s nursing progress notes on 9/10 /2025 document no physician notification of low blood sugar. There were no progress notes on 9/12/2025 and on 9/13/2025 for physician notification of insulin being held. During an interview on 9/25/2025 at 6:40 AM Staff T, Licensed Practical Nurse (LPN) stated, I'm not sure why I held it (the insulin). I think her (Resident #152) blood sugar was low. I don’t think I told the doctor, there are no parameters to hold it.” During an interview on 9/26/2025 at 6:40 AM the Director of Nursing (DON) stated all medications should be administered if ordered, insulin should be given as ordered and if it doesn’t have parameters, we should notify the doctor or nurse practitioner if they are hypo (hypoglycemic) or hyperglycemic. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105544 If continuation sheet Page 16 of 28 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 105544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Bayonet Point 7210 Beacon Woods Dr Hudson, FL 34667 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the policy and procedure titled “Diabetes-Clinical Protocol” last approval date of 11/26/2024 reads, “Monitoring and Follow- Up: 4. the physician will order desired parameters for monitoring and reporting information related to diabetes or blood sugar management, a. The staff will incorporate such parameters into the medication administration record and care plan. 5. The staff will identify and report complications such as foot infections, skin ulcerations, increased thirst, or hypoglycemia. b. The physician will help staff clarify and respond to these events. “ Review of the facility policy and procedure titled “Administration Procedures for all Medications” with a last approval date of 11/26/2024 read, “Procedures: C. Review 5 Rights (3) times: d. check for vital signs, other tests to be done during/prior to medication administration. I, Obtain and record any vital signs or other monitoring parameters ordered or deemed necessary prior to medication administration. P. Notification of Physician/Prescriber.2) Held medication for pulse, blood pressure , low or high blood sugar, or other abnormal test results vitals signs, resulting in medication being held.” 2)Review of Resident #5's physician order dated 8/22/2025 read, “Lisinopril tablet 2.5mg [milligrams] amount to administer 2.5 mg oral once a day for HTN [Hypertension].” Review of Resident #5's Medication Administration Record (MAR) for the month of September 2025 documented Lisinopril 2.5mg was not given at 9:00AM on 9/3/2025 Not Administered: Due to Condition Comment: BP (blood pressure) 100/60, 9/6/2025 Not Administered: On Hold, 9/10/2025 Not Administered: Due to Condition Comment: hypotension 9/16/2025, 9/18/2025, 9/20/2025, 9/21/2025: Not Administered: On Hold , 9/23/2025 Not Administered: Due to Condition Comment: BP 102/59. Review of Resident #5's Medication Administration Record for the month of August 2025 documented Lisinopril 2.5mg was not given at 9:00AM on 8/11/2025 Not Administered: Due to Condition Comment: BP 99/58, 8/14/2025 Not Administered: Due to Condition Comment: BP: 85/50 , 8/18/2025 Not Administered: Due to Condition, 8/21/2025 Not Administered: On hold Comment BP Low, 8/22/2025 Not Administered: Due to Condition Comment: BP 88/50, 8/23/2025 Not Administered: On hold, 8/24/2025 Not Administered: Other Comment : BP 98/57, 8/25/2025 Not Administered: Due to Condition, 8/26/2025 Not Administered: Due to Condition Comment: hypotension, 8/27/2025 Not Administered: Due to Condition Comment: BP 97/58, 8/28/2025 Not Administered: Due to Condition Comment: BP 96/56. During an interview on 9/24/2025 at 10:02 AM with Staff O, Registered Nurse (RN), stated, I did not notify the doctor all the time I held the medication because I just used my nursing judgement and I didn’t feel it was safe to give the medication. The resident has parameters for one of the medications but not that one. I don’t want to leave a note every single day that I held the medication.” During an interview on 9/25/2025 at 11:34 AM with Staff N, Licensed Practical Nurse (LPN), stated “He [Resident #5] has blood pressure medication that has parameters and he trends low and I let the charge nurse know which is my charge nurse and with using my nursing judgment I don’t feel comfortable giving it to him. The charge nurse will let the doctor know. She is not here right now. I leave her a note sometimes she will call the doctor, she might leave it in the book and other times the doctor is here and she will hand it to the doctor.” During an interview on 9/25/2025 at 12:25 PM Staff I, RN, stated, We would reach out to the provider right there and then if the patient is symptomatic if not symptomatic we would hold using nursing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105544 If continuation sheet Page 17 of 28 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 105544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Bayonet Point 7210 Beacon Woods Dr Hudson, FL 34667 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 0684 judgement. Level of Harm - Minimal harm or potential for actual harm During an interview on 9/26/2025 at 8:40 AM with the Director of Nursing (DON) stated, If the nurses have to hold the medication they should let the physician know so they can review the medication. The standard is after a couple of time let the doctor know if the nurses are holding the medication. The physician review the medications. A lot of the physician come two or three times a week and most of the physicians have a binder in the station and we leave notes for them and we also have nurse practitioners that are here and they review all mediations as well. It’s hard to say if the nurses should be calling before holding the medication. The physician does get notified at some timely point maybe that day or next day. The nurses look at the full picture of the patient’s condition. Residents Affected - Few Review of the facility policy and procedure titled “Administration Procedures for all Medications” with a last review date of 11/26/2025 read, “Procedures: C. Review 5 Rights (3) times: d. check for vital signs, other tests to be done during/prior to medication administration. P. Notification of Physician/Prescriber.2) Held medication for pulse, blood pressure, low or high blood sugar, or other abnormal test results vitals signs, resulting in medication being held.” 3)Review of Resident #185 physician order dated 8/14/2025 Novolin N Flex Pen 12 units Hold If Blood Sugar Less than 100. Review of Resident #185 Medication Administration Record for month of September 2025 documented Novolin N was held on 9/10/2025 at 5:00PM was 130 During an interview on 9/25/2024 at 4:29 PM Staff P, RN, stated, I might have confused it the order with the sliding scale and held the insulin when it should not have been held. Review of Resident #185 physician order dated 8/22/2025 read, Lantus Solostar U-100 Insulin amount to administer 35 units. Review of the Resident #185’s Medication Administration Record for the month of August 2025 documented Lantus Solostar on 8/27/2025 at 9:00 AM blood sugar was 98 not administer due to condition. Review of Resident #185 physician order dated 8/22/2025 read, Metformin tablet 1000mg amount to administer. Review of Resident #185’s Medication Administration Record for the month of August 2025 documented metformin on 8/27/2025 at 5:00PM not administered due to condition. During an interview on 9/25/2025 at 12:25 PM with Staff I, RN, stated, “I really don’t remember what happen [SIC] those days. During an interview on 9/26/2025 at 8:47 AM with the Director of Nursing stated, Nursing staff should follow parameters and document accurately. The nurses should discuss the blood sugar level with charge nurse and the physicians. Depending on the doctor orders long-acting insulin should be held. Again, nurses should use their nursing judgement.” During an interview on 9/26/2025 at 10:35 AM with Medical Doctor #1 stated, Each time the nurses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105544 If continuation sheet Page 18 of 28 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 105544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Bayonet Point 7210 Beacon Woods Dr Hudson, FL 34667 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete hold a medication they do not notify me they typically put it on a list of blood pressure, and I will review them on Friday. I rather the nurses use their nursing judgement rather than having a resident fall and injured themselves. If they were to call me every time I would call them right back. There has been no medical concerns regarding nurses and the antidiabetic medication administered to [Resident #185's name]. Review of the facility policy and procedure titled “Injectable medication Administration” with a last review date of 11/26/2025 read, “Purpose: To administer medications via subcutaneous, intradermal and intramuscular routes in a safe, accurate, and effective manner. Procedure: Check order on the medication administration record to see that an injection is currently ordered and due. Close or secure MAR to keep other from viewing it. Document administration, site, used and any unusual reactions. Notify physician if reactions occur. Event ID: Facility ID: 105544 If continuation sheet Page 19 of 28 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 105544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Bayonet Point 7210 Beacon Woods Dr Hudson, FL 34667 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to ensure physician ordered parameters were followed for blood pressure medications resulting in the administration of unnecessary medications for three residents (#157, #10 and #91) of five residents reviewed for unnecessary medications.Findings include:1.Review of Resident #157's medical record documented diagnosis that include fracture of unspecified part of the neck of right femur, subsequent encounter for closed fracture with routine healing, presence of right artificial hip joint, other sequalae of other cerebrovascular disease, urinary tract infection site not specified, sepsis due to Escherichia coli, hypothyroidism unspecified, hyperlipidemia unspecified, hypertensive chronic kidney disease with stage 1 through 4 chronic kidney disease, and orthostatic hypotension (a form of low blood pressure that happens when standing up from sitting or lying down).Review of Resident #157's physician order dated 9/5/2025 read, Midodrine tablet: 2.5 mg (milligram); amt(amount);2.5 mg; oral; special instructions: Hold if SBP (systolic blood pressure) is greater than 120 for hypotension, three times a day.Review of Resident #157's medication administration record (MAR) for September 2025 documented that midodrine was administered on 9/6/2025 at 12:00 PM for a blood pressure (B/P) of 137/69, on 9/10/2025 at 6:00 AM for a B/P of 130/73, on 9/12/2025 at 6:00 PM for a B/P of 126/75, and on 9/24/2025 at 1200 PM for a B/P of 125/70.Review of Resident #157's comprehensive care plan read, Problem Cardiac problems: at risk for as evidenced by occasional hypotension with diagnosis HTN (hypertension), CVA (cerebrovascular accident), hypothyroidism, hyperlipidemia recent hospitalization d/t (due to) AMS (altered mental status)/ febrile dx (diagnosis) acute metabolic encephalopathy 2/2 E-coli UTI, orthostatic hypotension. Goal included Patient will reduce the risk of CP (chest pain)/ SOB(shortness of breath)/complications r/t cardiac/anemia dx by taking meds/ having labs as ordered with approaches that included vital signs per protocol, some meds have B/P and/or pulse parameters administer as ordered and medications administer as ordered.2. Review of Resident #10's medical record documented diagnosis that include multiple fractures of pelvis without disruption of pelvic ring, subsequent encounter for fracture with routine healing, hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease, end stage renal disease, type 2 diabetes mellitus without diabetic neuropathy unspecified, unspecified atrial fibrillation (an irregular heart beat), other cervical disc degeneration unspecified cervical region, hemiplegia (partial paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (a stroke) affecting left non dominant side, and dependence on renal dialysis.Review of Resident #10's physician order dated 7/24/2025 read, Clonidine HCL tablet, 0.1 mg (milligram), amount 0.1 mg, oral, special instructions DX ( diagnosis) HTN (hypertension)hold for SBP (systolic blood pressure) less than 165 every 6 hours.Review of Resident #10's medication administration record for September 2025 documented that clonidine 0.1 mg was administered outside of the physician ordered parameters on 9/1/2025 at 12:30 PM with a blood pressure (B/P) of 160/69, on 9/3/2025 at 6:30 PM with a B/P of 160/70, on 9/6/2025 at 12:30 AM with a B/P of 125/71,and at 6:30 PM with a B/P of 152/70, on 9/10/2025 at 12:30 AM with a B/P of 152/64, on 9/11/2025 at 6:30 PM with a B/P of 133/78, on 9/12/2025 at 6:30 PM with a B/P of 157/77, on 9/13/2025 at 6:30 AM with a B/P of 149/83, and at 6:30 PM with a B/P of 137/65,on 9/14/2025 at 12:30 PM with a B/P of 161/67, on 9/17/2025 at 6:30 AM with a B/P of 164/65, on 9/18/2025 at 12:30 AM with a B/P of 148/64, on 9/21/2025 at 6:30 AM with a B/P of 163/70 and on 9/22/2025 at 6:30 AM with a B/P of 163/69 and at 6:30 PM with a B/P of 160/80.Review of Resident #10's Comprehensive care plan read, Problem Cardiac problems at risk for as evidenced by occasional HTN with dx of ESRD (end stage renal disease)/CKD(chronic kidney disease) 5 w (with)/hemodialysis, a fib (atrial fibrillation), dependent on a pacemaker, hx CVA Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105544 If continuation sheet Page 20 of 28 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 105544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Bayonet Point 7210 Beacon Woods Dr Hudson, FL 34667 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete w/L(left) hemiplegia, chronic metabolic acidosis, anemia. Goal included Patient will reduce the risk of chest pain/SOB/complications r/t cardiac /anemia/respiratory dx by taking meds/having labs as ordered with approaches that included some BP meds (medications) have parameters and medications administer as ordered.During an interview on 9/25/2025 at 6:28 AM Staff U, Registered Nurse (RN stated, I did give the clonidine and I shouldn't have based on the parameters. His pressure was under 165. I should have followed the order and held it.During an interview on 9/25/2025 at 6:40 AM the Director of Nursing (DON) stated all staff should follow orders for med (medication) administration. They should follow the orders.During an interview on 9/25/2025 at 10:40 AM Staff H, Licensed Practical Nurse (LPN) stated, I should have held the medicine, I don't know really (if I gave it or not) but my initials mean I gave it.3.Review of Resident #91's medical record documented diagnosis that include encounter for surgical aftercare following surgery on the respiratory system note status post bronchoscopy with lung biopsy, malignant neoplasm (cancer) of lower lobe, right bronchus or lung, weakness, unspecified and check, unspecified severity without behavioral disturbance, psychotic disturbance mood disturbance and anxiety, personal history of transient ischemic attack (TIA) and cerebral infarction (a stroke) without residual deficits, personal history of malignant neoplasm (cancer) of breast history of mastectomy,Review of Resident #91's physician order dated 9/5/2025 read, oxycodone-acetaminophen-Schedule II tablet 5-325 mg amt; 5-325 mg; oral; special instructions for moderate to severe non acute pain scale 8-10 every 6 hours prn.Review of Resident #91's medication administration (MAR) for September 2025 documented that oxycodone was administered on 9/5/2025 at 7:00 PM with a documented pain scale of 7, on 9/13/2025 at 2:44 PM with a documented pain scale of 6 and on 9/14/2025 at 8:21 AM with a documented pain scale of 6. During an interview on 9/25/2025 at 6:15 AM Staff T, Licensed Practical Nurse (LPN) stated, I should have tried to give a different medicine, there are parameters that I should have followed.A request for a following physician orders policy and procedure was made to the DON on 9/26/2025 at 7:20 AM. One was not provided at the time of the survey exit.Review of the facility policy and procedure titled Administration Procedures for all Medications with a last review date of 11/26/2024 read, Procedures: C. Review 5 Rights (3) times: d. check for vital signs, other tests to be done during/prior to medication administration. 2. I, Obtain and record any vital signs or other monitoring parameters ordered or deemed necessary prior to medication administration. P. Notification of Physician/Prescriber.2) Held medication for pulse, blood pressure , low or high blood sugar, or other abnormal test results vitals signs, resulting in medication being held. Event ID: Facility ID: 105544 If continuation sheet Page 21 of 28 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 105544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Bayonet Point 7210 Beacon Woods Dr Hudson, FL 34667 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review the facility failed to properly store medications for two residents (#212 and #213) in one unit (200) out of 3 units observed.Findings included: 1.) During an observation on 9/22/2025 at 9:38 AM Resident #212 was sitting up on her bed. There was an Arnica cream on top of her bedside table.During an interview on 9/22/2025 at 9:38 AM Resident #212 stated, I use the cream at times for pain. I will apply it [arnica cream] to my shoulder and it helps me.During an observation on 9/25/2025 at 12:19 PM Resident #212 was sitting up on her bed. There was an Arnica cream on top of her bedside table.During an interview on 9/25/2025 at 12:32 PM Staff I Registered Nurse (RN) confirmed Resident #212 had an Arnica cream in the resident's room.Review of Resident #212's physician orders did not document the resident was able to self-administer medications.2.) During an observation on 9/22/2025 at 9:45 AM Resident #213's room was observed empty. On top of her bedside table there was a Vicks Vaporub cream. [photographic evidence obtained]During an observation on 9/25/2025 at 12:18 PM Resident #213 was resting in bed with eyes closed. There was a Vicks Vaporub cream on top of Resident #213's bedside table.During an interview on 9/25/2025 at 12:29 PM with Staff I, RN, Staff I stated In order for a resident to self-administer medication we will do a paper observation and determine if the resident meets the criteria. The resident would then be given a lock box with a key and instructed to keep medication lock. There is an order for the medication and in that order it will say patient can self-administer the medication. Staff I stated [Resident #212's name] and [Resident #213's name] do not have orders to self-administer medication. I do not have any residents on this unit at this time that are able to self-administer medication.During an interview on 9/25/2025 at 12:30 PM Staff I, RN, confirmed Resident #213 had Vicks vaporub in her room.During an interview on 9/26/2025 at 8:32 AM the Director of Nursing (DON) stated, Daily activities, is not to have the meds at bedside. Angel rounds are done on Friday and Certified Nursing Assistants do rounds on the weekends. The DON stated to determine if a resident is able to self-administer medications, an observation would be made that they do and the care plan team reviews that it is adequate. Residents would have a lock box that we give them. The DON stated, It should always be stored in locked container and not left unattended.Review of the facility policy and procedure titled Administration Procedures for all Medications with a last review date of 11/26/2024 read, Policy: To administer medications in a safe and effective manner. Procedures: A. Security: All medication storage areas are locked at all times unless in use and under the direct observation of the medication nurse/aide.Review of the facility policy and procedure titled Bedside Medication Storage with a last review date 11/26/2024 read, Policy: Bedside medication storage is permitted for residents who wish to self-administer medications, upon written order of the prescriber and once self-administration skills have been assessed and deemed appropriate in the judgement of the facility's interdisciplinary resident assessment team. Procedures: C. For residents who self-administer medications, the following conditions are met for bedside storage to occur: 1) The manner of storage prevents access by other residents. Lockable drawers or cabinets are required only if unlocked storage is deemed inappropriate. Event ID: Facility ID: 105544 If continuation sheet Page 22 of 28 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 105544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Bayonet Point 7210 Beacon Woods Dr Hudson, FL 34667 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews and review of facility policy, the facility failed to ensure food was stored safely and properly labeled in one reach-in cooler out of one reach-in cooler observed in the kitchen.Findings included:A walk-through tour of the kitchen was conducted on 9/22/25 at 08:47 AM with the Dietary Manager (DM).An observation was made of several containers of food in the walk-in cooler without an identifying label or date.An interview was conducted with the Dietary Manager (DM) 9/22/2025 at 9:09AM. The DM stated all items placed in the cooler should have a label and be dated and there were no identifying labels on food that had been placed in the walk-in cooler from the breakfast meal.A policy titled Food Receiving and Storage dated 10/10/18 read, 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated. Event ID: Facility ID: 105544 If continuation sheet Page 23 of 28 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 105544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Bayonet Point 7210 Beacon Woods Dr Hudson, FL 34667 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and record review the facility failed to accurately and adequately document medication administration for antidiabetic and cardiovascular medications for three residents (#35, #85 and #185) of seven residents reviewed for medication management. Findings included: 1.) Review of Resident #35's physician order dated 6/2/2025 read, Lantus Solostar U-100 Insulin (insulin glargine) insulin pen; 100 unit /ml [milliliters] (3ml) amt [amount] 44 units subcutaneous special instructions hold FBS <100 [fasting blood sugar less than 100].Review of Resident #35's physician order dated 9/5/2025 read, Lantus Solostar U-100 Insulin (insulin glargine) Insulin pen; 100 unit /ml (3ml) amt 46 units subcutaneous special instructions hold FBS <100.Review of Resident #35's Medication Administration Record (MAR) for the month of September 2025 for Lantus Solostar with parameters to hold if fasting blood sugar was less than 100 documented as given on 9/1/2025 at 7:30 AM blood sugar level was 80, 9/10/2025 at 7:30 AM blood sugar level was 79, 9/16/2025 at 7:30 AM blood sugar level was 95, and on 9/20/2025 at 7:30 AM blood sugar level was 88.Review of Resident #35's Medication Administration Record (MAR) for the month of August 2025 for Lantus Solostar with parameters to hold if fasting blood sugar was less than 100 documented as given on 8/23/2025 at 7:30 AM blood sugar level was 68.During an interview on 9/24/2025 at 1:04 PM with Staff K, Licensed Practical Nurse (LPN), stated, We put in the blood sugar and give her something to eat then recheck blood sugar and then give it to her. I will from now make a note that I have rechecked the blood sugar and include the new blood sugar reading. I do not always write a progress note.During a interview on 9/25/2025 at 10:52 AM with Staff L, Licensed Practical Nurse (LPN), stated, I always give her a snack and the recheck the blood sugar level and then give her the insulin, I don't recall documenting the new blood sugar level normally I will include it in the MAR under comments.Review of Resident #35's progress notes did not show documentation of staff rechecking blood sugars and documenting the blood sugar levels for dates: 9/1/2025, 9/10/2025, 9/16/2025, and 9/20/2025.Review of Resident #35's MAR did not show any documentation or additional comments on blood sugar rechecks on 8/23/2025.During an interview on 9/26/2025 at 8:35AM the Director of Nursing (DON) stated, Nursing staff should be documenting the new blood sugar level in the system. They could include it in the comments section or nurses note. Sometimes they get distracted and forget.During an interview on 9/26/2025 at 11:00 AM the DON stated, The facility did not have a policy for documentation.2) Review of Resident #85's physician order dated 7/28/2025 read, Hydralazine tablet 25 mg amount to administer 25 mg oral hypertension hold for sbp [systolic blood pressure] below 150.Review of Resident #85's physician order dated 9/3/2025 read, Hydralazine tablet 25 mg amount 25 mg oral special instructions Dx [Diagnosis]: Hypertension Hold for SBP below 150.Review of Resident #85's MAR for the month of August 2025 for Hydralazine tablet 25 mg with parameters to hold for sbp below 150, documented hydralazine was given on 8/11/2025 at 10:00 PM SBP 128, 8/14/2025 at 10:00 PM SBP 127, 8/16/2025 at 10:00 PM SBP 118, 8/18/2025 at 10:00 PM SBP 133, 8/21/2025 at 6:00 AM SBP 145, 8/22/2025 at 10:00 PM SBP 120, 8/23/2025 at 10:00 PM SBP 137, 8/24/2025 at 10:00 PM SBP 106, and on 8/26/2025 at 10:00 PM SBP 126.Review of Resident #85's MAR for the month of September 2025 for Hydralazine tablet 25 mg with parameters to hold for sbp below 150, documented hydralazine was given on 9/2/2025 at 10:0 0PM with SBP 121, 9/6/2025 at 7:00 PM SBP 123 , 9/8/2025 at 6:00 AM SBP 118, 9/12/2025 at 7:00 PM SBP 119, 9/15/2025 at 1:00 PM SBP 123, 9/19/2025 at 6:00 AM SBP 124, and on 9/23/2025 at 6:00 AM SBP 142.During an interview on 9/24/2025 at 9:37 AM with Staff M, LPN, stated, I would not be able to give it [Hydralazine] if it was out of parameters. I would not have given the medication. I am not sure why it shows as administered the system would not have allowed me completed the administration (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105544 If continuation sheet Page 24 of 28 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 105544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Bayonet Point 7210 Beacon Woods Dr Hudson, FL 34667 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete if the blood pressure was out of parameters.During an interview on 9/25/2025 at 12:09PM with Staff N, LPN, stated, I know I didn't give it to him [Resident #85] because it is rare when he gets it. I know his parameters are 150. I hate to say it like that but it could be a documentation error.During an interview on 9/25/2025 at 12:38PM with Staff L, LPN, stated I don't remember what happened. I am pretty good about holding and following parameters. Sometimes you will pull the medication separate and take the blood pressure and not administer, but I might have hit complete by mistake.3) Review of Resident #185's physician order dated 8/22/2025 read, Lantus Solostar U-100 Insulin (insulin glargine) insulin pen; 100 unit/mL [milliliters] (3 mL); amt [amount]: 35 units; subcutaneous.Review of Resident #185 Medication Administration Record for the month of August 2025 for Lantus Solostar 35 Units documented insulin was not administer on 8/23 at 9:00 PM blood sugar 107, 8/24/2025 at 7:30 AM blood sugar level was 71 not administered: Other Comment below parameter, 8/25/2025 at 9:00PM no blood not administered: On Hold, 8/27/2025 at 9:00PM blood sugar 98 not administered due to condition, 8/29/2025 at 9:39PM blood sugar 113 Not Administered Other Comment n/a.Review of Resident #185 physician order dated 9/10/2025 read, Lantus Solostar U-100 Insulin (insulin glargine) insulin pen; 100 unit/mL [milliliters] (3 mL); amt [amount]: 20 units; subcutaneous.Review of Resident #185 Medication Administration Record for the month of September 2025 Lantus was not given on 9/12/2025 at 7:30 AM Blood sugar level was 78 and on 9/19/2025 at 7:30 AM Blood sugar level was 96.Review on Resident #185 physician order dated 6/29/2025 read, Novolin N Flexpen (Insulin nph isoph u-100 human) [OTC] (over the counter) Insulin pen; 100 unit/ml (3mL); amt; 15 units; subcutaneous.Review of Resident #185 Medication Administration Record for the month of August 2025 for Novolin 15 units documented medication was not given on 8/3/2025 at 7:16 AM blood sugar 87, 8/5/2025 at 4:49 PM blood sugar 130, and on 8/14/2025 at 7:49 AM blood sugar was 70.During an interview on 9/25/2025 at 12:13 PM Staff C, RN stated, [Resident #185's name] has many issues with his blood sugar going low. I will let my charge nurse and she will call the provider. I normally do not do a note in the system.During an interview on 9/26/2025 at 9:28 AM Staff Q, Licensed Practical Nurse (LPN), stated, [Resident #185's name] is a brittle diabetic. I notify the provider and charge nurse about holding his insulin. I should make a note in the system that I am notifying them.During an interview on 9/26/2025 at 9:35 AM Staff R, LPN, stated, If am not comfortable with blood sugar level I will hold the medication and notify the provider. I can't remember if I did or not for those days but I usually do notify the provider.During an interview on 9/26/2025 at 8:38 AM with the Director of Nursing stated, Sometimes the nurse may mark it [medication administration record] and they forget that they checked it off. The nurses are to check the medication if they have to hold or resident refuses the medication they should go back and document the accurate administration of the medication. Nurses should document accurate the medication administration. Event ID: Facility ID: 105544 If continuation sheet Page 25 of 28 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 105544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Bayonet Point 7210 Beacon Woods Dr Hudson, FL 34667 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review and policy and procedure review, the facility failed to prevent the possible spread of infection and communicable diseases by failing to ensure staff used appropriate Personal Protective Equipment (PPE) and performed hand hygiene upon entering and exiting residents rooms while providing care to residents on enhanced barrier precautions for (Resident # 194), and contact precautions for (Resident #188) and did not perform hand hygiene upon entering and exiting resident's rooms during five observations of ten observations of medication administration. Findings included: During an observation of medication administration for Resident #41 on 9/26/2025 at 5:04 AM , Staff V, Registered Nurse (RN) approached the medication cart without performing hand hygiene, retrieved keys from their pocket, and unlocked the medication cart. Staff activated and typed on the computer. Staff prepared all medications and assembled supplies to perform an accucheck. Staff V entered Resident #41's room, without performing hand hygiene, donned gloves and performed the accucheck. Without doffing gloves or performing hand hygiene Staff V, RN administered the oral medications, doffed gloves and exited the room without performing hand hygiene and returned to the medication cart and began preparing medications for another resident.During an observation of medication administration on 9/26/2025 at 5:12 AM Staff V, RN approached the medication cart, retrieved keys from their pocket, unlocked the medication cart, activated and typed on the computer keyboard and prepared medications without performing hand hygiene and entered Resident #194's room. There was enhanced barrier precautions signage on the doorway indicating that Resident #194 was on enhanced barrier precautions. Staff W, Certified Nursing Assistant (CNA) was observed at Resident #194's beside changing an adult brief and performing incontinence care without a gown on. Staff W, CNA was observed exiting the room to obtain supplies. Staff W did doff gloves without performing hand hygiene, went to the hallway linen cart and returned to Resident #914's room. Staff W, CNA donned gloves without performing hand hygiene, did not don a gown and continued to perform incontinence care and change the resident. Staff V, RN assisted Staff W to reposition Resident #194 in bed, adjusted the linens under the resident and administered Resident #194's medications, doffed gloves without performing hand hygiene and returned to the medication cart without performing hand hygiene.During an observation of medication administration for Resident #214 on 9/26/2025 at 5:17 AM Staff V, RN approached the medication cart without performing hand hygiene, retrieved keys from their pocket unlocked the medication cart, activated and typed on the computer keyboard and prepared medication without performing hand hygiene. Staff V, RN donned gloves without performing hand hygiene, entered the residents room, administered the medications and exited the room, doffed gloves without performing hand hygiene and began to prepare another residents medications.During an interview on 9/26/2025 at 5:47 AM Staff V, RN stated,I should have used hand sanitizer after I took off my gloves. [Resident #194's name] is on enhanced barrier precautions for a wound. We should have had on gowns when we were providing care to him.During an interview on 9/26/2025 at 6:40 AM Staff W, CNA stated, Yes, he (Resident #194) was on enhanced barrier precautions, I should have a gown on, I should have washed my hands when I took off my gloves to get the pad for him.During an observation of medication administration for Resident #202 on 9/25/2025 at 5:25 AM Staff U, RN approached the medication cart, retrieved keys from their pocket, unlocked the medication cart, activated and typed on the computer and prepared medications. One medication was not available. Staff U, RN locked the medication cart and picked up the medication cup with his bare hand, Staff U's thumb and index finger were observed touching the inside of the medication cup that contained 3 medications. Staff U's fingers were observed to touch the medications as they walked to the medication room. Staff U, RN obtained the medications from the medication room, returned to the medication Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105544 If continuation sheet Page 26 of 28 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 105544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Bayonet Point 7210 Beacon Woods Dr Hudson, FL 34667 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some cart removed the keys from their pocket, unlocked the cart, unlocked the narcotic drawer and placed the medications cards in the drawer after obtaining Resident #202's medication and documenting on the narcotic record. Staff U entered Resident #202's room and administered the medication without performing hand hygiene, exited the room and returned to the medication cart and began preparing medications for another resident.During an observation of medication administration for Resident #188 on 9/26/2025 at 5:35 AM Resident #188 have contact isolation signage present on the doorway and PPE supplies of gowns and gloves. Staff U,RN retrieved keys from their pocket, unlocked the medication cart, activated and typed on computer, donned gloves, locked the medication cart, went to the medication room, unlocked the door, opened the medication refrigerator to obtain a refrigerated medication, with gloves on. Staff U,RN poured the medication, returned to the medication cart, donned a gown without removing gloves and performing hand hygiene. Entered Resident #188's room and administered medications. Staff U, RN doffed PPE and did not wash hands or use hand sanitizer and began preparing medications for another resident.During an interview on 9/26/2025 at 5:42 AM Staff U, RN stated, I should have washed my hands. I should have used soap and water, she (Resident #188) has C diff (Clostridium Difficile Colitis).Review of Resident #188's physician order dated 9/23/2025 read, Transmission based precautions r/t (related to) C-diff until 9/27/2025. Every shift, Days, Evenings, Nights. Review of the facility policy and procedure titled Administration Procedures for all Medications with a last review date of 11/26/2024 read, Procedures: 2. F. Cleanse hands using antimicrobial soap and water or facility-approved hand sanitizer before beginning a med pass, before handling medication, and before contact with resident. G. Use a barrier (e.g., clean disposable tray or plastic cup) to carry medication containers into resident's room. [If the resident has a known contagious condition or infection]. This will serve as a barrier between the supplies and the over-the-bed table or other surface on which the supplies are placed while the medication is administered.Review of the policy and procedure titled Handwashing/Hand Hygiene last approval date of 11/26/2024 read, This facility considers hand hygiene the primary means to prevent the spread of infections. Policy interpretation and implementation: 2. All personnel shall follow the following hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.6. Wash Hands with soap and water for the following situations: b. After contact with the resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella, and C difficile.7. Use an alcohol- based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: b. Before and after direct contact with residents; c. Before preparing or handling medications: m. After removing gloves; n. Before and after entering isolation precautions settings. 8. Hand hygiene is the final step after removing and disposing of personal protective equipment.9. The Use of gloves does not replace hand washing/hand hygiene, integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare- associated infections. Review of the policy and procedure titled, Enhanced Barrier Precautions, last approval date of 11/26/2024 read, Policy Statement: This Facility follows recommended CDC(Center for Disease Control) enhanced barrier precautions, to interrupt the spread of multidrug resistant organisms (MDROs) within the facility. For the purposes of this guidance, the MDRO's for which the use of EBP (enhanced barrier precautions) applies are based on local epidemiology. At a minimum, they should include resistant organisms targeted by CDC but can also include other epidemiologically important MDRO's. Policy Interpretation and Implementation: 1. While In the building, employees are required to strictly adhere to established infection prevention and control policies, including: a. hand hygiene; c. Appropriate use of PPE; d. Transmission based precautions where indicated. 3. Enhanced (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105544 If continuation sheet Page 27 of 28 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 105544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Bayonet Point 7210 Beacon Woods Dr Hudson, FL 34667 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete barrier precautions is an approach of targeted gown and glove use during high contact resident care activities for residents known to be colonized were infected with a MDRO as well as those at risk of MDRO acquisition.6. High contact resident care activities include: a. Dressing; b. Bathing; c. Transferring; d. Providing hygiene; e. Changing linens; f. Changing briefs or assisting with toileting. 12. Initiation of Enhanced barrier precautions. C. When a resident is placed on enhanced barrier precautions, appropriate notification signage is placed at the room entrance that employees are aware of the need for precaution.1) The signage inform the staff of the type of CDC precaution(s), instructions for use of PPE, and/ or instructions to see a nurse before entering the room and complies with the resident's right to confidentiality and privacy. e. PPE will be readily available near the entrance of the resident's room, these and entering room to provide high contact resident care activities will don appropriate PPE. Event ID: Facility ID: 105544 If continuation sheet Page 28 of 28