Health inspection·January 13, 2023

F689) An interview was conducted with the Director of Nursing (DON) on 1/13/23 at 9:56 AM. The DON stated that resident #90 exited both sets of doors at the lobby, the door that enters the lobby and the door that exits the building. The resident exited via the front door with the group of visitors and the receptionist had to unlock both doors for the resident and group to exit, then the resident sat on the bench outside the front door. Further interview was conducted with the DON on 1/13/23 at 10:04 AM. The DON stated the facility determined the root cause of the event was staff did not follow process and should have redirected the resident back into the facility. The visitor came in and asked the receptionist if he could take resident #90 across the street to the ER (emergency room) and the receptionist said yes. The DON stated the resident's photo was in the elopement book at the time of the event and the DON indicated that the receptionist acknowledged she was aware of the resident's picture being in the elopement book. A telephone interview was conducted with employee B (former receptionist) on 1/12/23 at 3:16 PM. Employee B stated resident #90's picture was not in the elopement book at the time of the event on (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 10 Event ID: 105561 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 105561 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Pensacola 8475 University Parkway Pensacola, FL 32514 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 0656 1/1/23 and refused to answer further questions regarding the event. Level of Harm - Minimal harm or potential for actual harm The facility was not able to provide any documentation or evidence to support the facility implemented the plan of care for resident #90, who was identified at risk for elopement. The facility did not educate the visitor regarding the resident's exit seeking, did not redirect and intervene when the resident exited the facility, and did not report the verbalization of the resident wanting to go home prior to the resident exiting the facility. Residents Affected - Few Review of the facility policy for Comprehensive Care Plans (revised 1/7/2020) revealed an individual comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident. Each resident's comprehensive care plan is designed to incorporate identified problem areas and risk factors associated with identified problems, build on the resident's strengths, reflect the resident's expressed wishes regarding care and treatment goals, reflect treatment goals, timetables, and objectives in measurable outcomes, identify professional services that are responsible for each element of care, aid in preventing or reducing declines in the resident's functional status and/or functional levels, enhance the optimal functioning of the resident by focusing on a rehabilitative program, and reflect currently recognized standards of practice for problem areas and conditions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105561 If continuation sheet Page 2 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105561 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Pensacola 8475 University Parkway Pensacola, FL 32514 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and policy review, the facility failed to provide adequate supervision of a vulnerable resident identified to be at risk for elopement due to exit seeking, by allowing the resident to exit the facility unescorted by staff, and subsequently leave the facility grounds with a visitor unknown to the resident. This affected Resident #90 who was 1 of 2 sampled residents reviewed for accidents and supervision. The facility staff failed to intervene or report to nursing staff when the visitor reported to the receptionist that he was going to escort the resident across the street to the emergency room per the resident's request on 1/1/23 at approximately 5:50 PM. Facility nursing staff did not become aware the resident was not in the facility until approximately 7:45 PM on 1/1/23 when the resident's son called the facility to inform them she was at the emergency room receiving treatment for shoulder pain. This failure allowed the resident who had a documented diagnosis of dementia and moderate cognitive impairment to leave the facility premises with a visitor unknown to the resident, placing the resident at risk for serious injury, harm, abduction, elopement, or death. The situation resulted in a finding of Immediate Jeopardy. The facility's Administrator and the Director of Nursing were notified of the findings of Immediate Jeopardy on 1/13/23 at approximately 11:44 AM. The Immediate Jeopardy was ongoing as of the survey exit on 1/13/23. The findings include: Review of resident #90's electronic medical record revealed the resident was admitted to the facility on [DATE] and had a current diagnosis of dementia. The admission MDS (Minimum Data Set) with an assessment reference date of 11/15/22 indicated the resident had a BIMS (Brief Interview for Mental Status) score of 8, indicating moderate cognitive impairment. An elopement risk observation, documented on 11/30/22, indicated the resident was at risk for elopement with a score of 3, and proceed with safety interventions. The record revealed a current plan of care dated 12/10/22 stating the resident was at risk for elopement due to noted exit seeking and she exhibited fluctuations in level of cognition and understanding. The care plan goal included the resident's risk for elopement will be minimized through the next review date with a target date of 3/10/23. The care plan interventions dated 12/10/22 included inform staff and the resident's visitors about risk for elopement and exit seeking, monitor for verbalizations of wanting to leave, picture in elopement book, redirect and provide support when wandering or requesting to exit the facility, and report observations and concerns to physician/nurse practitioner as needed. A psychiatric progress note dated 12/28/22 revealed resident #90 had a history of dementia and presented as pleasantly confused. Progress notes reviewed over the previous 30 days noted intermittent confusion, wandering, restlessness, and placing herself on the floor. Resident limitations listed cognitively impaired and hearing impaired, alert to person and partial to date. The resident progress notes dated December 1, 2022 through January 1, 2023 revealed 14 documented observations of the resident wandering in the facility and being redirected by staff on 12/1/22, 12/2/22, 12/3/22, 12/4/22, 12/5/22, 12/10/22, 12/11/22,12/12/22, 12/22/22, 12/24/22, 12/30/22, and 1/1/23. The resident progress notes dated 1/1/23 recorded as a late entry on 1/11/23 indicated the facility was notified by the resident's son that she had left the facility and gone to the emergency room. The resident did not sign out of the facility upon leaving the facility and did not have a staff member escort her. She returned to the facility with her sons via personal vehicle. The resident was placed on one-to-one supervision due to risk for elopement. Review of the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105561 If continuation sheet Page 3 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105561 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Pensacola 8475 University Parkway Pensacola, FL 32514 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few investigation revealed on 1/1/23 at approximately 5:45 PM employee B (former receptionist) observed resident #90 to enter the front lobby, exit the facility, and sit on a bench outside the front of the facility. She then observed the resident speaking with a visitor of another resident. The visitor then walked into the facility and stated the resident had asked to be assisted to the hospital across the street to get assistance for her arm. He stated he was going to walk her across the street, and they left the facility property on 1/1/23 at approximately 5:50 PM. The registered nurse house supervisor reported he was notified by the resident's son on 1/1/23 at approximately 7:45 PM that she had left the facility and gone to the emergency room. Review of the facility investigation and staff statements of the event revealed prior to the event the resident had asked a staff member to go home while she was ambulating the halls on 1/1/23, and the resident was observed going to the doors looking for a way to get outside on 1/1/23. An interview was conducted with the Director of Nursing (DON) on 1/12/23 at 2:43 PM. She stated the visitor was at the facility to visit another resident. She called that resident's sister, and she did not have any contact information for the visitor. A telephone interview was conducted with employee B (former receptionist) on 1/12/23 at 3:16 PM. Employee B stated resident #90's picture was not in the elopement book at the time of the event on 1/1/23 and refused to answer further questions regarding the event. A telephone interview was conducted with the resident's son on 1/12/23 at 3:25 PM. He stated the resident was in the hospital, had just had surgery, and was being placed on hospice for terminal care. An interview was conducted with the DON on 1/13/23 at 9:56 AM. The DON stated the resident tailgated with a group of visitors out the front lobby door when the receptionist unlocked the front lobby door for the visitors to exit. The DON clarified the resident exited both sets of doors at the lobby, the door that enters the lobby and the door that exits the building. The resident exited via the front door with the group of visitors and the receptionist had to unlock both doors for the resident and group to exit, then the resident sat on the bench outside the front door. Further interview was conducted with the DON on 1/13/23 at 10:04 AM. The DON stated the facility determined the root cause of the event was staff did not follow process and should have redirected the resident back into the facility. The facility had no evidence to support the resident knew the visitor that escorted her to the emergency room (ER). The visitor came in and asked the receptionist if he could take resident #90 across the street to the ER and the receptionist said yes. She stated the resident's photo was in the elopement book at the time of the event and the receptionist acknowledged she was aware of the resident's picture being in the elopement book. The DON stated the only policy the facility had that covers the resident sign out procedure is the transfer or discharge policy stating they would provide verbal or written notice of intent to leave and there is not a specific policy of who can sign the resident out of the facility. Review of the facility policy Transfer and Discharge (effective date 11/1/18) revealed therapeutic leave is a type of Resident-initiated transfer. A Resident-initiated transfer or discharge is one in which the Resident has provided written or verbal notice of their intent to leave the facility, which is documented in the Resident's record. A Resident's expression of a general desire to return home or to the community or elopement of a Resident who is cognitively impaired will not be taken as a notice of intent to leave. Review of the facility policy for Resident Elopement Risk Management Guidelines (revised 1/12/2020) revealed the facility will strive to provide a safe environment for residents and implement measures to identify residents at risk for elopement, as well as preventative (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105561 If continuation sheet Page 4 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105561 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Pensacola 8475 University Parkway Pensacola, FL 32514 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety measures to minimize elopement occurrences. The policy defines elopement as: An elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. Page 2 number 6 of the policy indicates when a a resident is observed to be wandering to an unsafe situation or exiting the facility, the nearest staff should intervene or summon help if unable to safely manage the event. If wandering behavior escalates, safety checks should be implemented, and the resident should be evaluated for possible cause and new interventions implemented as needed. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105561 If continuation sheet Page 5 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105561 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Pensacola 8475 University Parkway Pensacola, FL 32514 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm Based on record review, staff interviews, and Administrator job description review, the facility failed to utilize its resources effectively to develop and implement policies to ensure resident safety is maintained when residents leave the facility with other individuals and to ensure the appropriate staff are aware of the resident's departure from the facility. This has the potential to affect all residents in the facility who exit the facility for leave of absence. (Cross reference F689). Residents Affected - Some The findings include: On 1/1/23, a cognitively impaired resident, identified at risk for elopement (resident #90), was allowed to exit the facility and leave the facility grounds with a visitor unknown to the resident. Review of the facility investigation revealed the nursing staff were not aware the resident had left the facility for approximately 1 hour and 55 minutes. An interview was conducted with the Director of Nursing (DON) on 1/12/23 at 2:43 PM. She stated the visitor was at the facility to visit another resident. She called that resident's sister, and she did not have any contact information for the visitor. A follow-up interview was conducted with the DON on 1/13/23 at 10:04 AM, who stated that the visitor came in and asked the receptionist if he could take resident # 90 across the street to the emergency room and the receptionist said yes. She stated the resident's photograph was in the elopement book at the time of the event and the receptionist acknowledged she was aware of the resident's picture being in the elopement book. The DON stated the only policy the facility had that covers the resident sign out procedure is the transfer or discharge policy stating they would provide verbal or written notice of intent to leave and there is not a specific policy of whom can sign the resident out of the facility. An interview was conducted with the Administrator on 1/13/23 at 10:12 AM. He stated he works with the DON in every aspect and trusts the DON with everything to keep the residents safe and ensure the staff are properly educated. He assisted to ensure the facility staff were educated, post tests were completed, and staff understood the risk and how they have to keep the residents safe and healthy. During the survey, the facility was not able to provide evidence of a process to educate visitors to ensure only authorized persons are allowed to escort a cognitively impaired resident from the facility or a policy regarding the process for signing a resident out of the facility and ensuring the appropriate staff are aware of the resident's departure from the facility. Review of the Administrator job description (dated 3/2018) revealed the purpose of the position is to manage all business-related activity to achieve the facility's vision and supporting strategies and assures that the company image as an ethical and high quality provider of health services is developed and maintained. Duties and responsibilities include: intervenes as appropriate in potentially threatening situations and follows-up with staff after crisis has been resolved; manages safety according to facility procedures/guidelines; ensures that potential safety/health hazards are eliminated or controlled through regular reviews of work activities, materials, and facilities; provides employees with training and instructions on safe work practices in all aspects of their employment; ensures that potential safety/health hazards are eliminated or controlled through regular reviews of work activities, materials, and facilities; provides employees with unsurpassed training and instructions on safe work practices with every aspect of their employment; and ensures that employees are adequately oriented and trained (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105561 If continuation sheet Page 6 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105561 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Pensacola 8475 University Parkway Pensacola, FL 32514 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 to perform their duties. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105561 If continuation sheet Page 7 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105561 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Pensacola 8475 University Parkway Pensacola, FL 32514 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on record review, staff interviews, quality assurance performance improvement plan review, and policy review, the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies related to supervision of residents with cognitive impairment, a process to ensure resident safety when leaving the facility with visitors and educating staff and visitors of such process for 1 of 2 residents sampled for accidents and supervision. (Resident # 90) Cross reference F689 The findings include: On 1/1/23, a cognitively impaired resident, identified at risk for elopement (resident # 90) was allowed to exit the facility and leave the facility grounds with a visitor unknown to the resident. Review of the facility investigation revealed the nursing staff were not aware the resident had left the facility for approximately 1 hour and 55 minutes. Review of the facility Performance Improvement Plan Worksheet dated 1/1/23 indicated the event to be investigated: Resident #90 left facility property without staff escort. The resident went to the hospital with a visitor escort, staff was not notified of resident leaving the property and the resident did not sign out LOA (Leave of Absence). Resident independently ambulatory with cognitive deficits, worked as nurse prior to retirement, voiced an intent and request to go to the hospital for medication and sling for her arm. Upon investigation, it was determined the resident tailgated someone exiting the facility. She was observed by the staff in the front lobby to walk out the front doors and sit under the entrance awning. The resident was observed by staff members to speak with a visitor and the resident requested this visitor walk her to the hospital. The visitor notified the staff members of this request, and the resident was assisted to the hospital by the visitor. Root cause analysis- the staff members voiced being aware of the elopement book at the front desk and voiced understanding of the elopement process. For unknown reason neither staff member intervened and did not notify other staff of resident leaving the facility. Design and implement changes: All exit doors were observed, and appropriate signage was observed to be in place. All elopement observations were reviewed, and all were observed to be up to date and appropriate. Elopement books were reviewed, and all observed to be up to date with appropriate pictures and information available. Care plans have all been reviewed and observed to be appropriate. Resident placed on on to one (staff supervision). Observation of awareness of staff and others when exiting to ensure not followed by resident. Both staff members who observed the resident exit the facility have been suspended with termination pending due to failure to follow established facility protocols. Adult protective services notification completed via online reporting portal. Immediate Federal report completed. Measurements: Decrease risk of resident's ability to exit building without assistance through the following interventions- elopement observation completed on all residents, elopement drills completed on each shift for one week then weekly for one week, door alarms checked daily for appropriate function by maintenance/nursing on weekends-start date 1/2/23, all door codes were changed to exit doors in the facility completed 1/2/23, Administrator or designee to audit door checks at least weekly for 4 weeks start date 1/1/23, staff observations related to elopement prevention completed daily to monitor staff comprehension and compliance start date 1/1/23. The facility action plan failed to identify the need for education to staff and visitors regarding whom may escort a cognitively impaired resident from the facility, ensuring adequate supervision for resident's voicing a request to leave the facility, and policies to address the process of resident's signing out of the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105561 If continuation sheet Page 8 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105561 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Pensacola 8475 University Parkway Pensacola, FL 32514 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An interview was conducted with the Director of Nursing (DON) on 1/12/23 at 2:43 PM. She stated the visitor was at the facility to visit another resident. She called that resident's sister, and she did not have any contact information for the visitor. A follow-up interview was conducted with the DON on 1/13/23 at 9:56 AM. The DON stated the resident tailgated with a group of visitors out the front lobby door when the receptionist unlocked the front lobby door for the visitors to exit. The DON clarified the resident exited both sets of doors at the lobby, the door that enters the lobby and the door that exits the building, with a group of visitors and the receptionist had to unlock both doors for the resident and group to exit, then the resident sat on the bench outside the front door. Further interview was conducted with the DON on 1/13/23 at 10:04 AM. The DON stated the facility determined the root cause of the event was staff did not follow process and should have redirected the resident back into the facility. The facility had no evidence to support the resident knew the visitor that escorted her to the emergency room (ER). The visitor came in and asked the receptionist if he could take resident # 90 across the street to the ER and the receptionist said yes. She stated the resident's photo was in the elopement book at the time of the event and the receptionist acknowledged she was aware of the resident's picture being in the elopement book. The DON stated the only policy the facility had that covers the resident sign out procedure is the transfer or discharge policy stating they would provide verbal or written notice of intent to leave and there is not a specific policy of who can sign the resident out of the facility. Review of the undated facility policy for Quality Assurance and Performance Improvement (QAPI) Program revealed it is the policy of the facility to develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life for our residents. The QAPI program is ongoing, comprehensive, and addresses the full range of care and services provided by the facility. Established and implemented written policies and procedures include processes for feedback, data collection systems, and monitoring, including adverse event monitoring. The procedure includes maintain documentation and demonstrate evidence of its ongoing QAPI program that meets the requirements of 483.75 Code of Federal Regulations. This may include but is not limited to systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105561 If continuation sheet Page 9 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105561 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Pensacola 8475 University Parkway Pensacola, FL 32514 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, staff interviews, record review, and policy review, the facility failed to ensure staff followed appropriate isolation precautions during the provision of housekeeping services for 1 of 1 sampled residents on transmission-based precautions. (Resident # 209) Residents Affected - Few The findings include: An observation of resident #209 was conducted on 1/10/23 at approximately 9:30 AM. The resident was in his room and there was a sign beside the door stating special enteric precautions (related to the intestines) in addition to standard precautions. The sign indicated visitors and staff should cleanse hands upon entering with sanitizer or soap and water and cleanse out of the room using only soap and water. Gown and gloves are required prior to entering the room. (Photographic evidence obtained.) Employee A (housekeeper) was observed in the room at this time, mopping the floor with only gloves on and no gown. She then exited the room and placed the used mop on her housekeeping cart. She then walked to another room across the hall and entered the room. She began dusting with the same gloves on she used to mop in resident # 209's room and did not wash her hands. An interview was conducted with employee A on 1/10/23 at 9:37 AM. She stated the gloves she had on to clean the room across the hall from resident #209's room were the same gloves she had on to clean resident #209's room. She stated she should have changed her gloves. Employee A stated she was told if she was not having contact with the resident in the special enteric precautions room, she did not have to wear a gown. She confirmed she did not wear a gown. Review of resident #209's medical record revealed a current physician order dated 1/6/23 for contact isolation until 2/5/23 for C-diff (Clostridioides difficile). According to the Centers for Disease Control and Prevention website accessed on 1/17/23 at 2:37 PM, C. diff (also known as Clostridioides difficile or C. difficile) is a multi-drug resistant germ (bacterium) that causes diarrhea and colitis (an inflammation of the colon) and it is contagious. An interview was conducted with the Director of Nursing (DON) on 1/12/23 at 9:51 AM. The DON stated staff should don a gown and gloves to enter an enteric precautions room and should not clean another room with the same gloves. The DON verified resident # 209 was on contact isolation for C-diff. Review of the undated facility policy for Enteric Contact Precautions revealed examples of infections requiring Enteric Contact Precautions include but are not limited to bacterial diarrhea associated with Clostridium Difficile. In addition to Standard Precautions, implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. The decision on whether precautions are necessary will be evaluated on a case-by-case basis. In addition to wearing gloves as outlined under Standard Precautions, wear gloves (clean, non-sterile) when entering the room. Remove gloves before leaving the room and perform hand hygiene. After removing gloves and washing hands, do not touch potentially contaminated environmental surfaces or items in the resident's room. Wear a disposable gown upon entering the isolation room or cubicle. After removing the gown, do not allow clothing to contact potentially contaminated environmental surfaces or items in the resident's room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105561 If continuation sheet Page 10 of 10