Inspection·November 3, 2022

F 0636 Level of Harm - Minimal harm or potential for actual harm The facility's Nursing Services Policy and Procedure Manual revised 1/13/2021 page 3 titled, MDS Completion and Submission Timeframes (2.) contained the regulatory timeframes and read, timeframes will be observed by the facility. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105701 If continuation sheet Page 2 of 25 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 105701 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Merritt Island 500 Crockett Blvd Merritt Island, FL 32954 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to electronically transmit Minimum Data Set (MDS) assessments timely for 2 of 4 residents reviewed for MDS assessments, from a total sample of 62 residents, (#105, #123). Residents Affected - Few Findings: Resident #105 was admitted to the facility on [DATE]. A review of the resident's medical record revealed the MDS comprehensive annual assessment dated [DATE] had not been transmitted. On 11/2/2022 at 10:10 AM, the Registered Nurse (RN) MDS Coordinator reviewed the resident's medical record and stated the assessment dated [DATE] was not transmitted timely. Resident #123 was admitted to the facility on [DATE]. On 11/2/2022 at 10:10 AM the RN MDS Coordinator reviewed the resident's medical record and stated the assessment dated [DATE] had not been transmitted. She validated the assessment should have been transmitted 14 days after completion. The facility's Nursing Services Policy and Procedure Manual revised 1/13/2021, page 3 titled, MDS Completion and Submission Timeframes item 2 contained the regulatory timeframes and noted, timeframes will be observed by the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105701 If continuation sheet Page 3 of 25 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 105701 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Merritt Island 500 Crockett Blvd Merritt Island, FL 32954 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for life expectancy for 1 of 5 residents reviewed for unnecessary medications, (#81) and failed to accurately reflect the discharge status for 1 of 3 residents reviewed for discharges, (#176), of a total sample of 62 residents. Residents Affected - Few Findings: 1. Review of resident #81's medical record revealed she was 98-years-old, admitted to the facility on [DATE] with a recent readmission of 10/04/22. Her diagnoses included chronic kidney disease stage 4, schizoaffective disorder, dementia, and history of malignant neoplasm of skin. Review of the resident's physician orders revealed an order dated 8/22/22 that read, Terminal condition cerebral atherosclerosis. Given the information available, and per my examination, the patient has a life expectancy of 6 months or less. The resident's care plan for terminal/end stage diagnosis of cerebral atherosclerosis was created on 8/22/22. Review of the resident's admission MDS, with Assessment Reference Date (ARD) of 8/26/22 revealed the question in Section J1400 Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months?' was coded 0 indicating No. On 11/03/22 at 9:44 AM, the MDS Assistant Coordinator explained she gathered information from the resident's clinical records, including the physician's order sheet, and do a seven day look back to complete the assessment. The resident's admission MDS with ARD of 8/26/22, and the resident's physician's order dated 8/22/22 were reviewed with the MDS Assistant Coordinator. She acknowledged the resident had an active physician's order for a terminal condition and life expectancy of 6 months or less, and that Section J1400 was coded with a 0 meaning No. The MDS Assistant Coordinator stated the MDS assessment was coded incorrectly, and the section for prognosis should have been coded with a 1, indicating yes for life expectancy of 6 months or less. The Center for Medicare and Medicaid Services Resident Assessment Instrument Version 3.0, revised October 2019 Section J1400 directions for coding read, Code 0, no: if the medical record does not contain physician documentation that the resident is terminally ill and the resident is not receiving hospice services. o Code 1, yes: if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services. 2. Resident #176 was admitted to the facility on [DATE] with diagnoses including heart failure, chronic kidney disease, arteriosclerotic heart disease, type 2 diabetes, and acute pulmonary edema. Review of resident #176's medical record revealed a physician order dated 9/28/22 to discharge home with son on 10/01/22. A nursing progress note dated 10/02/22 read, Resident discharged to home with sister and niece at 11:30 this morning. Review of the MDS discharge assessment with assessment reference date 10/02/22 inaccurately reflected the resident was discharged to an acute hospital on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105701 If continuation sheet Page 4 of 25 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 105701 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Merritt Island 500 Crockett Blvd Merritt Island, FL 32954 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 11/02/22 at 1:35 PM, the MDS Director reviewed resident #176's discharge assessment and acknowledged the assessment reflected a discharge to an acute hospital rather than home. She explained the assessment was inaccurate. The facility policy and procedure Resident Assessment Instrument revised 1/17/18 read, All persons who have completed any portion of the MDS Resident Assessment Form must sign such document attesting to the accuracy of such information. Event ID: Facility ID: 105701 If continuation sheet Page 5 of 25 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 105701 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Merritt Island 500 Crockett Blvd Merritt Island, FL 32954 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop a comprehensive care plan for activities within seven days after completion of the comprehensive assessment for 1 of 12 residents reviewed for activities, of a total sample of 62 residents, (#81) . Findings: Review of resident #81's medical record revealed she was admitted to the facility on [DATE] with a recent readmission of 10/04/22. Her diagnoses included chronic kidney disease, stage 4, schizoaffective disorder, dementia, and history of malignant neoplasm of skin. Review of the resident's admission Minimum Data Set (MDS) assessment, with Assessment Reference Date (ARD) of 8/26/22 revealed the resident's cognition was impaired with a Brief Interview Of Mental Status (BIMS) score of 08/15. Section F Preferences for customary routine and activities revealed it was very important for the resident to have books/listen to music/do things with groups of people/ go outside to get fresh air when the weather was good and participate in religious services. Review of the resident's care plans revealed a care plan for Recreation/Wellness that noted the resident prefers independent and some group activities, with start date of 10/10/22. A prior care plan for activities could not be identified. On 11/03/22 at 11:23 AM, and 11/03/22 at 12:45 PM, the Activities Director explained that on admission, an interview was conducted with the resident and/or the responsible person to obtain activity preferences. She stated a care plan was developed by her based on the assessment as soon as possible after the completion of the MDS assessment. The resident's care plan for Recreation/Wellness with start date of 10/10/22 was reviewed with the Activities Director. She explained she could not recall if a prior care plan for activities was developed and stated she could not access or find it in the resident's electronic medical record. On 11/03/22 at 1:10 PM, the MDS Coordinator stated comprehensive care plans were developed within seven days of completion of the MDS assessment, and activities care plans were developed by the Activities Director. The resident's clinical records were reviewed with the MDS Coordinator and she said a prior care plan for activities could not be found for resident #81. The MDS Coordinator stated the only care plan developed for activities was created on 10/10/22. She said the resident's admission MDS's ARD was 8/26/22, and the resident's care plan for activities should have been developed before 10/10/22. The facility's policy Care Planning-Interdisciplinary Team revised on 1/13/2021 read, A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105701 If continuation sheet Page 6 of 25 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 105701 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Merritt Island 500 Crockett Blvd Merritt Island, FL 32954 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #479 was admitted to the facility on [DATE] with diagnoses that included cancer of the main bronchus, shortness of breath, chronic pain syndrome, and multiple sclerosis. Residents Affected - Some Review of resident #479's admission Observation Nursing assessment dated [DATE] revealed the resident was alert and oriented to person, place, time, and situation. Review of his baseline care plan dated 10/25/22 for activities of daily living included approaches to assist the resident with bathing, grooming, dressing, and personal hygiene as needed. On 10/31/22 at 10:57 AM, resident #479 was observed sitting in a wheelchair by his bed. He was unshaven with facial hair about 1/3 inch to 1/2 inches long. On 11/1/22 at 1:20 PM, and on 11/2/22 at 12:50 PM, resident #479 remained unshaven. He indicated he needed help to shave as he tired easily and was short of breath. He said he had not shaved since he came to the facility and staff had not offered to assist him. On 11/2/22 at 1 PM, the resident's CNA C and CNA B said shaving would typically be done during shower days which were scheduled twice per week, and sometimes during morning care. CNA C indicated she did not know resident #479 well, and had not asked him if he wanted to be shaved today. At this time, CNA C went to the resident's room and confirmed the resident wanted help to be shaved a little later in the day. At 5 PM, the resident was still not shaved. On 11/3/22 at 11:45 AM, resident #479's CNA documentation for the level of assistance required for personal hygiene was reviewed with the Minimum Data Set (MDS) Coordinator. The ADL flowsheets revealed that from 10/26/22 through 11/2/22 the resident consistently required limited to extensive assistance with personal hygiene and bathing care. There was not any documentation that indicated he had refused to be shaved. On 11/3/22 at 3 PM, the Director of Nursing (DON) said staff were expected to offer and/or provide shaving needs with showers twice per week and as needed. Review of the facility's ADL Supporting Policy and Procedure read, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Based on observation, interview, and record review, the facility failed to ensure nail care was provided for 3 of 6 dependent residents, (#1, #4, #119) and failed to ensure facial hair was removed for 1 of 6 dependent residents, (#479) reviewed for Activities of Daily Living (ADL) out of a total sample of 62 residents. Findings: 1. Review of resident #1's medical record documented she was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbances, anxiety disorder, Transient Ischemic Attack (TIA) and major depression. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105701 If continuation sheet Page 7 of 25 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 105701 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Merritt Island 500 Crockett Blvd Merritt Island, FL 32954 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 0677 Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] documented resident Level of Harm - Minimal harm or potential for actual harm #1 had short-term and long-term memory problems, severely impaired cognitive skills for daily decision making and she required total assistance of one staff member with personal hygiene and bathing. Residents Affected - Some Review of resident #1's comprehensive ADL care plan dated 12/09/19 documented she required total assistance from staff with ADLs. On 11/01/22 at 10:05 AM, and on 11/02/22 at 10:05 AM, the resident's fingernails to both hands were noted to be long and jagged. Review of the 400 unit shower schedule documented resident #1 received bed baths or showers on Monday and Thursday on the 2 PM - 10 PM shift. 2. Review of resident #4's medical record showed she was admitted to the facility on [DATE] with diagnoses of fractured right femur, major depressive disorder, dementia, anxiety disorder and TIA. Review of the quarterly MDS assessment dated [DATE] documented resident #4 had short-term and long-term memory problems and severely impaired skills for daily decision making. She required total assistance of one staff member with personal hygiene and bathing. Review of resident #4's comprehensive ADL care plan dated 04/01/21 documented she required staff assistance with ADL's. On 10/31/22 at 1:24 PM, 11/01/22 at 10:02 AM, and on 11/02/22 at 9:54 AM, resident #4's fingernails to both hands were noted to be long and jagged. Review of the 400 unit shower schedule documented resident #4's showers were on Tuesdays and Fridays on the 6 AM -2 PM shift. 3. Review of resident #119's medical record documented he was admitted to the facility on [DATE] with diagnoses including cerebral ischemia, major depressive disorder, assistance with personal care, and vascular dementia. Review of the quarterly MDS assessment dated [DATE] noted he was cognitively intact and required extensive assistance with personal hygiene and bathing. Review of resident #119's comprehensive ADL care plan dated 09/14/20 showed he was unable to complete ADL's independently related to weakness, and end stage diagnosis. The goal included to have ADLs met daily with staff assistance. The approach was for one person to assist with ADLs and ADL assistance was expected to fluctuate due to his end stage diagnosis. Observations conducted on 10/31/22 at 10:00 AM, 11/01/22 at 9:58 AM, and on 11/02/22 at 9:51 AM revealed resident #119's fingernails were long, and jagged with a brown substance under the fingernails. Review of the 400 Unit shower schedule indicated resident #119's showers were to be given on Wednesdays and Saturdays on the 2 PM - 10 PM shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105701 If continuation sheet Page 8 of 25 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 105701 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Merritt Island 500 Crockett Blvd Merritt Island, FL 32954 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 11/02/22 at 10:15 AM, Registered Nurse (RN) D stated all staff were responsible for residents' ADLs. She explained the Certified Nursing Assistants (CNAs) were responsible for providing ADL care daily. She explained each resident had a schedule and would receive 2 bed baths or showers per week based on the schedule. RN D said ADL care included brushing teeth, shaving, dressing, nail and hair care. On 11/02/22 at 11:43 AM, the 400 Unit Manager stated residents received a bed bath or shower 2 days per week based on unit schedule or preference. She noted ADL care included a head to toe bed bath or shower, hair and nail care, and shaves. It is the same with a shower and fingernails are to be kept clean, short, and trimmed. On 11/02/22 at 11:55 AM observations of resident #1, #4 and #119's fingernails were completed with the 400 Unit Manager. She stated all 3 residents' fingernails needed to be cut and cleaned. On 11/03/22 at 12:54 PM, CNA F stated routine resident care included cleaning of face, hands, teeth, toileting, dressing, and incontinent care. She indicated bed baths and/or showers were done 2 times a week per schedule or resident preference. We wash the body, wash and dry hair, nail care, and shaves. Review of the Facility's Guideline CNA Sheet/Skin Inspection, dated January 18, 2017, read, Purpose: Documentation of showers and skin inspection completed with showers. Procedure: . 4. CNA is to trim nails with shower . If resident is diabetic or on anti-coagulants file nails only. Notify nurse if resident refuses nail care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105701 If continuation sheet Page 9 of 25 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 105701 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Merritt Island 500 Crockett Blvd Merritt Island, FL 32954 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities to meet the preferences and needs for 6 of 12 residents reviewed for activities of a total sample of 62 residents, (#10,#21,#51,#118,#137,#139). Residents Affected - Some Findings: 1. Resident #10 was admitted to the facility on [DATE] with diagnoses of dementia, brief psychotic disorder, and memory loss. Review of the resident's Minimum Data Set (MDS) quarterly assessment with Assessment Reference Date (ARD) 7/13/22, revealed the resident had a Brief Interview for Mental Status (BIMS) score of rarely or never understood which indicated she had severe cognitive impairment. The assessment indicated it was somewhat important for the resident to listen to music, do her favorite activities, and go outside to get fresh air. Resident#10 required extensive assistance of two persons for transfers and total assist of one person for locomotion. Review of resident #10's Activity care plan included interventions to adapt activities of preference to cognitive level and skill function. Observe resident's response to activities. On 11/01/22 at 3:53 PM, resident#10 was observed lying in bed with her eyes open, looking at the ceiling. There was no music playing in the room. On 11/02/22 at 3:44 PM, the resident was observed lying in bed looking at the ceiling. There was no music or television on in the room. On 11/03/22 at 9:19 AM, resident#10 was observed lying in bed looking at the ceiling. There was no television or music in the room. 2. Resident #21 was admitted to the facility on [DATE] with diagnoses of dementia, pain, and pressure ulcer. Review of the resident's MDS significant change assessment with ARD of 9/16/22, indicated the resident was rarely or never understood which indicated she had severe cognitive impairment. The assessment indicated it was very important for her to have books, newspapers, and magazines to read and it was somewhat important for her to keep up with the news and to go outside for fresh air. Resident #10 required extensive assistance of two persons for transfers and was totally dependent on staff for locomotion. Review of the resident's Activity care plan included interventions to adapt activities of preference to cognitive level and skill function. Observe resident's response to activities. Provide small group activities such as music and crafts. On 11/01/22 at 12:21 PM, resident #21 was observed lying in bed, with no activities observed. On 11/01/22 at 3:53 PM, the resident was observed lying in bed with her eyes open, looking at roommate's television. At this time, there was a music activity taking place in the dining room. On 11/02/22 at 3:44 PM, the resident was observed lying in bed looking around the room. There was no music or television in the room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105701 If continuation sheet Page 10 of 25 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 105701 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Merritt Island 500 Crockett Blvd Merritt Island, FL 32954 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. Resident #51 was admitted to the facility on [DATE] with diagnoses of schizoaffective disorder, dementia, and cirrhosis of the liver. Review of the resident's MDS assessment for change in condition with ARD of 9/13/22 indicated resident #51's BIMS was 09 which indicated significant cognitive impairment. The assessment noted she required supervision of one person for bed mobility, transfers, and walking. Review of resident #51's Activity care plan included interventions to adapt activities of preference to cognitive level and skill function. On 11/01/22 at 12:02 PM, resident #51 was observed in the dining room sitting in a chair with no activities being provided. On 11/02/22 at 10:13 AM, the resident was observed sitting in the day room with the television on but no activities provided. On 11/02/22 at 2:06 PM, the resident was sleeping in her chair in the day room and no activities. On 11/02/22 at 3:56 PM, the resident remained sleeping in her chair in the the day room with television on and no activities being provided. On 11/03/22 at 9:27 AM, resident #51 slept in her chair in the day room with television on and no activities in progress. 4. Resident #118 was admitted to the facility on [DATE] with diagnoses of schizoaffective disorder, dementia, and depression. Review of the resident's MDS quarterly assessment with ARD of 9/14/22 revealed the resident had a BIMS score of 5 which indicated she had severe cognitive impairment. The assessment indicated she required supervision of one person for transfers and walking. Resident #118's Activity care plan included interventions to adapt activities of preference to cognitive level and skill function. Observe resident's response to activities. Invite/encourage resident to attend/participate in offered live music programs. On 11/01/22 at 12:19 PM, resident#118 was observed lying in bed with her eyes closed with no activities in progress. On 11/01/22 at 3:54 PM, resident#118 was observed lying in bed while live music activity in progress in the dining room. On 11/02/22 at 10:08 AM, the resident sat in the day room with no activities. The television was on but the resident was not watching it. On 11/03/22 at 9:27 AM, resident#118 was observed sitting in day room with no activities. 5. Resident #137 was admitted to the facility on [DATE] with diagnoses of congestive heart failure and bipolar depression. Review of the resident's MDS quarterly assessment with ARD of 10/13/22 revealed the resident had a BIMS score of 04 which indicated severe cognitive impairment. Review of resident #137's Activity care plan included interventions to adapt activities of preference to cognitive level and skill function. Observe resident's response to activities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105701 If continuation sheet Page 11 of 25 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 105701 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Merritt Island 500 Crockett Blvd Merritt Island, FL 32954 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 11/02/22 at 10:08 AM, resident#137 was observed sitting in the day room, with no activities. The television was on but the resident did not pay any attention to it. On 11/03/22 at 9:27 AM, resident#137 was observed sitting in day room with no activities. 6. Resident #139 was admitted to the facility on [DATE] with diagnoses that included dementia, depression, delusional disorder, and schizoaffective disorder. Review of the resident's MDS quarterly assessment with ARD of 9/09/22 revealed the resident had a BIMS score of 99 which indicated she had severe cognition impairment. Review of resident #139's Activity care plan included interventions to adapt activities of preference to cognitive level and skill function. Observe resident's response to activities. On 11/01/22 at 12:39 PM, resident #139 was observed in her room with no activities noted. On 11/01/22 at 3:52 PM, the resident was observed lying in bed with eyes closed. On 11/02/22 at 10:10 AM, resident#139 was observed lying in bed with eyes closed. On 11/02/22 at 11:22 AM, the resident was observed lying in bed with eyes closed and lunch tray on the over bed table next to her bed untouched. On 11/02/22 at 3:43 PM, the resident was observed lying in bed with her eyes closed. On 11/02/22 at 2:35 PM, Certified Nursing Assistant (CNA) Q stated they used to have a full-time activity person on the unit but now they only had someone from activities department occasionally. She added there also used to be three CNAs on the unit and it was much more manageable to provide activities for all the residents. She said there was no time for CNAs to provide activities as most of the residents needed a lot of care. On 11/03/22 9:30 AM, Registered Nurse (RN) N stated, we used to have an activity CNA who was in the day room with the residents all the time but not anymore. On 11/03/22 at 10:26 AM, CNA P said they had a CNA who stayed in the day room with the residents and did activities, but we don't have her anymore. She said, We try to do the best we can with providing some sort of activities but we are too busy providing care and do not really have time to sit in the day room and do any activities with them. I love these residents but I feel so bad because I just do not have time to give them what they need. On 11/03/22 at 11:23 AM, the Activities Director (AD) stated when new residents were admitted , she interviewed the resident or family member to determine their activity preferences and develop a plan of care. She said, if the resident was bed bound, we do friendly room visits, lotion therapy, read to them, talk to them. Make sure they are comfortable. We have 1 on 1 logs for documenting what was done during room visits. She stated activities department had 3 staff and one of them was full time on the memory care unit. On 11/03/22 at 11:54 AM, the memory care Unit Manager stated the memory care unit did not have a full time activities person. She said the CNA staff tried to provide activities when they had some spare time. Observation of the Memory Care unit from 10/31/22-11/03/22 revealed an activities staff on the unit on 10/31/22 who handed out popcorn and put a movie on the television and left the unit. On 11/01/22 live music was provided in the dining room from 3:00 PM-4:00 PM. On 11/02/22 an activity staff sat at a table with three residents. One of the residents was sleeping in her chair and the other two (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105701 If continuation sheet Page 12 of 25 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 105701 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Merritt Island 500 Crockett Blvd Merritt Island, FL 32954 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 0679 Level of Harm - Minimal harm or potential for actual harm had ice cream with the associate. Review of the activities calendar indicated the residents should have had an activity almost every hour. None of the activities listed on the calendar were being followed. Review of the residents' 1 to 1 logs for activities revealed no activities provided to any of the residents at any time from 10/22/22-11/02/22. All documentation indicated the residents were either asleep or refused. The activities logs were not documented in chronological order. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105701 If continuation sheet Page 13 of 25 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 105701 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Merritt Island 500 Crockett Blvd Merritt Island, FL 32954 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow physician orders for splint application for 2 of 2 residents reviewed for limited Range Of Motion (ROM) of a total sample of 62 residents, (#117, #143). Residents Affected - Some Findings: 1. Record review of resident #117's clinical records revealed the resident was a [AGE] year-old female, admitted to the facility on [DATE], with a recent readmission on [DATE]. Her diagnoses included hemiplegia and hemiparesis following cerebral infraction affecting right dominant side, major depressive disorder, and stiffness of unspecified joint. An active physician's order dated 9/23/22 noted right resting hand splint to be donned and doffed daily as needed. Special instructions read Clarify duration and frequency when entering order. Review of the resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date of 10/11/22 indicated the resident was rarely/never understood and required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident's Occupational Therapy Discharge Summary with dates of service from 6/17/22 to 9/13/22, read, Patient will tolerate RHS [right hand splint] to R [right] hand for 4 hours for contracture management. On 10/31/22 at 10:48 AM, 10/31/22 at 3:54 PM, on 11/01/22 at 9:32 AM, 11/01/22 at 11:10 AM, 11/01/22 at 3:42 PM, and on 11/02/22 at 11:35 AM, resident #117 was observed in bed. Her right hand was contracted, and she was not wearing a splint. A splint was observed in the wall mounted container to the right of the resident's bed. On 11/01/22 at 3:26 PM, Licensed Practical Nurse (LPN) L stated resident #117 had two strokes and her right hand was contracted. The LPN indicated Restorative Nursing Program (RNP) was working with resident for donning/doffing of her splint. On 11/01/22 at 3:46 PM, the Oceanside Registered Nurse (RN) Unit Manager (UM) stated splint orders were usually placed by therapy, and she confirmed resident #117 had an active order dated 9/23/22 for right resting hand splint to be donned and doffed daily as needed. The UM said if the task was done, documentation would be in the facility's electronic documentation system. She noted RNP was responsible for donning /doffing of the resident's splint, and for completing documentation regarding splinting. On 11/01/22 at 4:08 PM, Certified Nursing Assistant (CNA) M stated she had not seen the resident with splints. CNA M said RNP would don and doff the resident's splint. On 11/01/22 at 4:25 PM, and on 11/02/22 at 9:55 AM, the MDS Coordinator, and the Assistant MDS Coordinator stated donning/doffing of splints were done by the RNP Certified Nursing Assistants (CNA). The MDS Coordinator explained when therapy gave an order for RNP, the RNP CNA would take the order to the Assistant MDS Coordinator, who would then enter the order in the resident's clinical records, notify the resident's family/responsible person, and develop a care plan that addressed the splint. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105701 If continuation sheet Page 14 of 25 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 105701 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Merritt Island 500 Crockett Blvd Merritt Island, FL 32954 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 - Some The MDS Coordinator said she would document a weekly note, and document evaluation of the splint/RNP, and both she and the Assistant MDS Coordinators would discuss the resident's progress with the RNP CNAs. She stated resident #117's order for splint was a general nursing order and was never for RNP. On 11/02/22 at 10:48 AM, the Director of Rehab stated resident #117 was on Occupational Therapy (OT) caseload from 6/17/22 to 9/13/22. She explained the resident was hospitalized on [DATE], and on readmission to the facility on 9/29/21, she was referred to RNP, for upper extremity strengthening. She said the splint order dated 9/23/22 was pulled over from the resident's physician's orders prior to hospitalization. The Director of Rehab said a new therapy screening should have been done on the resident's return to the facility, but the evaluation was not done. She stated Rehab services were contracted to the facility, and they had very limited services of OT for the last couple of months. She added that OT was coming in a couple hours per week, due to limited staff. She indicated that based on the resident's history, an OT screen to evaluate for continued need for splint application should have been completed. On 11/02/22 at 11:37 AM, the Oceanside Registered Nurse/ Unit Manager (RN/UM) stated there was some talk about the resident's splints not being placed, and she was told by staff the resident had refused splint application. She said on 7/25/22 there was an order by therapy to don/doff splint daily as needed, and documentation for Special Instructions were to clarify duration and frequency when entering order. The UM stated resident #117 was hospitalized from [DATE] to 9/23/22, and on readmission, she reinstated the previous order for splint application. The resident's clinical records were reviewed by the RN/UM, and she stated that as far as she knew, there was no documentation to indicate the resident's right-hand splint was placed, or that the splint order was clarified as directed. She noted the resident should have been screened by OT, to ensure the splint was still appropriate, and if it was not, the order should have been discontinued. On 11/02/22 at 12:16 PM, the Director of Nursing (DON), stated the resident's splint order was placed by the prior OT who no longer worked at the facility, and was reactivated by the Oceanside UM on the resident's readmission to the facility. She explained no follow up was done to ensure the resident was re-screened by OT on her return from the hospital. The DON verbalized that if the OT screen was done, they would have made a referral for continued/discontinued use of her splints. She said therapy gave orders for splinting, and the UMs were responsible to check orders, and obtain clarification as needed. The DON noted resident #117 had not worn her right-hand splint since her readmission to the facility, and documentation could not be identified to indicate splints were applied on an as needed basis. She explained the order should populate on the resident's Treatment Administration Record (TAR), and verbalized the order was not a good order and should have been clarified. She stated MDS/RNP reported to her, and she was responsible to oversee the RNP. On 11/02/22 at 2:51 PM, the Director of Rehab stated OT was initiated for resident #117 on 5/04/22 for right hand weakness, and discharged from OT on 9/14/22, but a RNP was not developed for splint application. She said the resident's right-hand splint was ordered and started by OT on 5/30/22 to be donned/doffed by therapy. She confirmed that an OT screen was not completed for the resident status post her hospitalization, and verbalized that an OT screen should have been completed, and the order regarding the resident's right-hand splint should have been clarified or discontinued. 2. Record review revealed resident #143 was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, generalized anxiety disorder, aphasia, and generalized muscle weakness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105701 If continuation sheet Page 15 of 25 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 105701 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Merritt Island 500 Crockett Blvd Merritt Island, FL 32954 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 - Some A physician order dated 4/08/22 indicated the resident was referred to restorative nursing for resting hand/elbow splint to his right upper extremity 3 hours per day. Review of the resident's quarterly MDS with ARD of 9/07/22 revealed the resident's cognition was severely impaired, with a Brief Interview for mental Status (BIMS) score of 00/15. The resident was assessed to require extensive assistance for bed mobility, dressing, and personal hygiene, and was totally dependent on staff for toilet use. The assessment showed the resident had functional limitation in range of motion (ROM) to one side of his upper and lower extremities The resident's care plan ADL (Activities of Daily Living) Functional/rehabilitation Potential created on 3/03/22 indicated the resident was unable to complete activities of daily living independently due to cardiovascular accident with right sided hemiplegia and hemiparesis. Approaches listed included, 4/07/22 RNP for splint application to right upper extremity, which was noted as discontinued on 9/13/22. OT Treatment Encounter Notes dated 4/05/22 indicated discharge from OT services and splint wear schedule was discussed with the resident. OT positioned splint on RUE [right upper extremity]. Patient tolerated splint for 3 hours without s/s [signs/symptoms] of irritation or redness. The OT Discharge summary dated [DATE] revealed discharge status and recommendations were, Orthotic Management: Splint/orthotic recommendation: RUE splint for 3 hours/day without s/s of irritation or redness for contracture management RNP for contracture management including splint wear schedule. Progress note dated 9/16/22 read, decreased tolerance of PROM (passive range of motion) to RUE noted and refusing application of splint. Therapy referral placed. Progress note documented by RNP and dated 10/21/22 read, Resident is participating in the Restorative Program for PROM BLE (bilateral lower extremity), RUE . He also has a RUE splint. He is tolerating the program fair. Continue current plan. On 10/31/22 at 11:00 AM, and on 11/01/22 at 3:39 PM, resident #143 was lying in bed on his back, his right hand was contracted, and the resident was not wearing a splint. On 11/01/22 at 3:37 PM, LPN L stated the resident was admitted to the facility with contracture of his right hand, and RNP was to do splinting for 3 hours daily. On 11/01/22 at 3:46 PM, the Oceanside RN/UM stated resident #143 had physician's order for RNP to don/doff his right hand/elbow splint 3 hours daily. She stated MDS had responsibility for the RNP, and if the task was done, it would be documented in the electronic clinical record. On 11/01/22 at 4:25 PM, the MDS Coordinator, and the Assistant MDS Coordinator stated donning/doffing of splints were done by the RNP Certified Nursing Assistants (CNA). The MDS Coordinator explained that when therapy gave an order for RNP, the RNP CNA would take the order to the Assistant MDS Coordinator, who would then enter the order in the resident's clinical records, notify the resident's family/responsible person, and develop a care plan that addressed the splint. The MDS Coordinator said she would document a weekly note, and document evaluation of the splint/RNP, and both she and the Assistant MDS coordinator would discuss the resident's progress with the RNP CNAs. The resident's physician orders were reviewed with the MDS Coordinator. She confirmed an order was in place for splint application for the resident. She said, if the resident refused splints, a referral would be placed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105701 If continuation sheet Page 16 of 25 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 105701 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Merritt Island 500 Crockett Blvd Merritt Island, FL 32954 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 to Rehab for screening/reassessment. Level of Harm - Minimal harm or potential for actual harm Observations on various occasions of resident # 143 with contracted right hand, and not wearing a splint was shared with the MDS Coordinators. The Assistant MDS Coordinator stated a progress note on 9/16/22 revealed decreased tolerance and refusal of splint, but another progress note on 10/20/22 indicated the resident was tolerating splinting. Residents Affected - Some On 11/02/22 at 10:02 AM, the MDS Coordinator stated review of clinical records for the resident showed he had been refusing splinting. She recalled a couple of weeks ago the RNP CNAs, said the resident's splint was not fitting as before. She verbalized the RNP CNAs would report any concerns to the MDS Coordinator, who would then report to Rehab. The MDS Coordinator said she did not know if concerns with the resident's splint was reported to Rehab. On 11/02/22 at 10:31 AM, the Director of Rehab stated RNP would report any concerns of a splint not fitting to therapy. She stated that during the morning clinical meetings, refusal of splints would be discussed. She said she was not aware resident#143 was refusing, his right hand/elbow splint, and was told about the splint not fitting this morning (11/02/22). She said if it was reported before, the therapist would do a reassessment/screening to determine if the resident needed further therapy and if retraining of staff was required. She verbalized the resident's splint was ordered to prevent further contractures, and to increase ROM. She explained that if the splint was not being applied, the resident could have possible further contractures, and would not be able to perform tasks as he previously did. On 11/02/22 at 12:12 PM, the DON stated a referral for resident #143 was made to Therapy on 9/16/22 due to the resident's complaint of pain, and staff not being able to apply his splint. She verbalized she would have to speak to the rehab director to see what was done with the referral. The DON stated the MDS Coordinators had responsibility for the restorative program, and would be the ones to follow up with Rehab for any concerns/issues with the program. On 11/02/22 at 4:09 PM, the DON provided resident #143's Care Plan History for date range 3/03/22-11/02/22 which revealed RNP was discontinued for the resident, and an OT referral was placed on 9/13/22. The DON stated the OT screen was not done, but could not say why the screen was not done. She stated the order for splint application for the resident was not discontinued and was still active. On 11/03/22 at 10:32 AM, Restorative CNA K stated resident #143 was oriented x 2 and had a tendency to refuse splinting, stating the splint was uncomfortable for him. CNA K said she reported this to the restorative nurse in September and a request for OT screen was placed. The CNA verbalized she had not placed the resident splint since then. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105701 If continuation sheet Page 17 of 25 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 105701 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Merritt Island 500 Crockett Blvd Merritt Island, FL 32954 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to consistently provide nutritional supplements ordered for a newly admitted resident diagnosed with moderate protein malnutrition for 1 of 1 resident reviewed for nutritional status in a total sample of 62 residents, (#479). Residents Affected - Few Findings: Resident #479 was admitted to the facility from the hospital 10/25/22. His admission diagnoses included moderate protein-calorie malnutrition, stage IV lung cancer, shortness of breath, multiple sclerosis, and major depressive disorder. On 10/31/22 at 10:57 AM, resident #479 verbalized he did not receive the nutritional protein supplemental drink, Ensure that he was promised by the dietician when admitted to the facility. The resident indicated he had specifically requested the Ensure brand because it tasted better and he would drink it. He explained he needed the extra protein and calories because of his cancer diagnosis. The resident verbalized he had asked to receive the Ensure between meals and before bedtime. The resident then conveyed, . I haven't been receiving it. It's all messed up. I keep asking for it, but don't get it. One person tells me that I need a doctor's order for it, and the other says that I don't need a doctor's order. It's all very frustrating. The resident explained they gave him some drink that was not Ensure which did not taste good, and was not given at the times he requested. There was not any evidence of any type of nutritional supplemental drinks in his room at this time. Review of resident #479's initial nutritional assessment dated [DATE] indicated he was to receive a regular diet with house supplements. The assessment revealed the resident had lost over 36 pounds in the past 6 months, had a current weight of 152 pounds, and had moderate protein malnutrition. The assessment included lab values from 10/26/22 that noted his Protein Albumin was low. The assessment showed the resident's average food intake was less than 50% for most meals. The assessment indicated the resident had increased nutrient needs due to cancer and multiple sclerosis diagnoses. The nutritional interventions included house supplements 4 ounces (oz) two times a day (BID). A follow-up Registered Dietician's note dated 10/28/22 at 9:02 AM read, . House supplement initiated to assist in meeting needs The assessment did not indicate the type or name of nutritional supplement recommended or when it was ordered. Resident #479's Medication Administration Records (MARs) showed an order dated 10/26/22 for house supplement, Boost 4 ounces by mouth twice a day to be given between 9 AM to 10 AM and between 2 PM to 3 PM. The October and November 2022 MARs revealed the resident was not given the supplement Boost until 10/28/22, two days after it was ordered. The MAR noted an order was placed for a second nutritional supplement, Ensure Plus 8 oz., on 10/31/22 which was scheduled to be given twice a day, between 12 PM - 1 PM and 5 PM - 6 PM. There were not any nursing initials to reflect the resident was given the Ensure Plus until the morning of the following day, 11/1/22. Resident #479's nutritional care plan initiated 10/25/22 and revised on 10/31/22 showed the resident was at risk for altered nutritional status due to his diagnoses. Approaches dated 10/25/22 included house supplements 4 oz twice daily, and Ensure Plus 8 oz twice daily. On 11/2/22 at 12:50 PM, resident #479 was observed resting in bed. His lunch meal tray sat on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105701 If continuation sheet Page 18 of 25 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 105701 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Merritt Island 500 Crockett Blvd Merritt Island, FL 32954 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few over bed table. The resident had eaten about 1/3 of the hamburger patty and nothing else on his plate. There was not any Ensure observed on his meal tray, overbed table or anywhere in his room. At this time the resident reported that he was not given any Ensure to drink since yesterday morning. On 11/2/22 at 1 PM, the resident's Certified Nursing Assistant, (CNA) C stated she was not aware the resident was to receive Ensure. CNA C said nutritional supplements like Ensure were not stocked in the unit's pantry and it was usually sent by the kitchen on the resident's meal tray. On 11/2/22 at 1:05 PM, the resident's assigned Registered Nurse, (RN) R reviewed the MAR for 11/2/22 11 AM - 12 PM scheduled Ensure Plus administration that showed RN R documented the resident received Ensure Plus and consumed 100%. RN R stated, No, she had not given the Ensure to the resident. She said she thought the CNA C had given it to him along with his meal tray. At this time, CNA C informed RN R that Ensure was not delivered on his lunch meal tray and she was not aware the resident was supposed to receive it. RN R explained she had not checked with the CNA if the resident had received and/or drank the Ensure before documenting he consumed 100% of it. On 11/2/22 at 1:30 PM, the Director of Nursing (DON) explained nurses and not the CNAs were responsible to make sure residents' nutritional supplements were given and documented the percentage consumed. The DON acknowledged resident #479's Ensure 8 oz. was scheduled for 11 AM - 12 PM and 5 PM - 6 PM which indicated it should come on his meal tray from the kitchen. Review of resident #479's admission dietary communication sheet dated 10/25/22 with the DON did not reflect the use of nutritional supplements for the resident. At 1:45 PM, the Certified Dietary Manager (CDM) stated the kitchen had not received a dietary communication slip for Ensure Plus 8 oz. to be included on the resident's meal trays. The CDM acknowledged Ensure was not stocked in the nursing unit pantries for resident use. On 11/2/22 at 1:55 PM, the Registered Dietician (RD) stated she was informed on 10/31/22, that resident #470 was not eating well and did not like the Boost supplement. She said she obtained an order for Ensure Plus 8 oz. to be given with the resident's lunch and evening meals as he needed more calories and protein. She said she forgot to generate a dietary communication slip to inform the kitchen to send Ensure on the resident's meal trays. The RD explained the nutritional supplements required an order and it was not the facility's process to stock Ensure in the unit pantries. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105701 If continuation sheet Page 19 of 25 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 105701 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Merritt Island 500 Crockett Blvd Merritt Island, FL 32954 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 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #175 was admitted to the facility from the hospital on [DATE] with diagnosis that included acute on chronic low back pain syndrome, degenerative lumbar spondylosis without myelopathy, spinal stenosis without neurogenic claudication, and bipolar disorder. Residents Affected - Some On 10/31/22 10:25 AM, interview with resident #175 said that she was upset that she had not received the results and diagnosis from a recent second magnetic resonance imaging (MRI) test done for her right lower back pain that radiated down her leg to her foot. She stated that during hurricane [NAME] she had rammed her car into a parking space's cement stop that could not be seen because it was under water. The resident said the accident had caused her right sided pain and that she had a history of sciatic pain. She reported that she was here at the facility for short-term therapy rehabilitation. Resident #175's admission orders dated 10/3/22 included the following: PT [Physical Therapy] to evaluated and treat as indicated. OT [Occupational Therapy] to evaluate and treat as indicated. Review of therapy evaluations and progress notes for resident #175 revealed that a PT evaluation was conducted on 10/4/22. There was not any evidence that an OT evaluation was conducted. On 11/3/22 at 9:26 AM, interview with OT A said that he worked per diem for the rehabilitation department at the facility. He explained that he worked a couple times a week for 5 to 8 hours at a time and had another full-time job at a home health agency. OT A reviewed the rehabilitation records for resident #175 and acknowledged that the resident had not received an OT evaluation since her admission on [DATE]. He stated that to his knowledge, the facility's therapy department did not currently have a full-time evaluating OT. On 11/3/22 at 9:35 AM , during an interview with the Therapy Director/Certified Occupational Therapy Assistant (COTA), she acknowledged that resident #175's OT evaluation order was dated 10/3/22. She confirmed that an OT evaluation had not yet been done. The Therapy Director reported that around the first of October this year, the facility's contracted therapy company changed. When this happened, the two full time OTs who had previously worked for the old therapy company had resigned. She stated that the facility's therapy department has only one evaluating OT at this time who works on per diem basis. She indicated that because of this, resident #175 did not receive her initial OT evaluation ordered at admission. She said the resident refused many of the PT sessions while waiting on a second Magnetic Resonance Imaging Report. Review of orders revealed that the physician had held therapy orders from 10/6/22-10/10/22, but then reinstated therapy on 10/10/22 without ambulation. The Therapy Director said that the per diem OT would attempt to conduct her OT evaluation today, 11/3/22, and verbalized that she was looking to hire a full time OT. The new therapy company's policies and procedures related to therapy evaluation expectations and timeframes were requested but not readily available upon request. The Therapy Director conveyed on 11/3/22 at about 9:45 AM that the process regarding timeframes to conduct therapy evaluations was within 48 hours of the physician's order. Based on interview, and record review, the facility failed to provide Occupational Therapy as needed to address splint application and assessments for 3 of 3 residents reviewed for limited Range Of Motion (ROM) of a total sample of 62 residents, (#117, #143, #175). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105701 If continuation sheet Page 20 of 25 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 105701 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Merritt Island 500 Crockett Blvd Merritt Island, FL 32954 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 0825 Findings: Level of Harm - Minimal harm or potential for actual harm 1. Clinical record review revealed resident #117 was a [AGE] year-old female, admitted to the facility on [DATE], with a recent readmission on [DATE]. Her diagnoses included hemiplegia and hemiparesis following cerebral infraction affecting right dominant side, major depressive disorder, and stiffness of unspecified joint. Residents Affected - Some An active physician order dated 9/23/22 read right resting hand splint to be donned and doffed daily as needed. Special instructions read Clarify duration and frequency when entering order. On 11/02/22 at 10:48 AM, the Director of Rehab stated resident #117 had a stroke and had right hand splint provided by therapy to prevent contractures. She verbalized the resident was previously on Occupational Therapy (OT) caseload with start of care on 6/17/22 and was discharged from OT on 9/13/22. She explained the resident was hospitalized on [DATE], and was readmitted to the facility on [DATE], and a new Rehab screening should have been done on the resident's return to the facility, however, the screening by OT was not done. She stated Rehab services were contracted to the facility, and they had very limited services from OT for the last few months. she explained OT was coming into the facility for a couple hours per week, due to limited staff. She indicated that based on the resident's history, she should have had an OT screen to evaluate for continued need for splint application. On 11/02/22 at 11:37 AM, the Oceanside Registered Nurse/ Unit Manager (RN/UM) stated resident #117 was hospitalized from [DATE] to 9/23/22, and on readmission to the facility she reinstated the resident's previous order for splint application. She said the resident should have been screened by OT after her readmission, to ensure the splint was still appropriate. On 11/02/22 at 12:16 PM, the Director of Nursing (DON), stated no follow up was done by nursing or Rehab to ensure the resident was re-screened by OT on her return from the hospital. She noted if the OT screen was done, they would have made a referral for continued/discontinued use of the resident's right-hand splint. On 11/02/22 at 2:51 PM, the Director of Rehab explained all newly admitted or readmitted residents were screened by Rehab for all three disciplines, Physical Therapy, Speech Therapy, and Occupational Therapy. She confirmed that an OT screen was not completed for resident #117 after hospitalization. She noted an OT screen should have been completed, and order regarding the resident's right-hand splint should have been clarified or discontinued. 2. Record review revealed resident #143 was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses including, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, generalized anxiety disorder, aphasia, and generalized muscle weakness. A physician order dated 4/08/22 indicated the resident was referred to restorative nursing program for resting hand/elbow splint to his right upper extremity 3 hours per day. Progress note dated 9/16/22 read, decreased tolerance of PROM [passive range of motion] to RUE [right upper extremity] noted and refusing application of splint. Therapy referral placed. On 11/02/22 at 10:31 AM, the Director of Rehab stated Restorative Nursing Program (RNP) would report any concerns with the plan of care for the residents, and if a splint was not fitting, it should be reported to therapy. She stated she was not aware resident #143 refused his right hand/elbow (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105701 If continuation sheet Page 21 of 25 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 105701 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Merritt Island 500 Crockett Blvd Merritt Island, FL 32954 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 0825 Level of Harm - Minimal harm or potential for actual harm splint and was told about the splint not fitting this morning, on 11/02/22. She said, if it was reported before, the therapist would do a reassessment/screening to determine if the resident needed further therapy or if retraining of the RNP staff was required. She explained the resident's splint was ordered to prevent further contractures, and to increase ROM. She explained that if the splint was not being applied, the resident could have possible further contractures, and would not be able to perform tasks he previously could. Residents Affected - Some On 11/02/22 at 12:12 PM, the DON stated a referral for resident #143 was made to Rehab on 9/16/22 by RNP due to the resident's complaints of pain, and staff not being able to apply his splint. She verbalized she would have to get with the Director of Rehab to see what was done regarding the referral. On 11/02/22 at 4:09 PM, the DON provided resident #143's Care Plan History for date range 3/03/22-11/02/22 which revealed RNP was discontinued for the resident, and an OT referral was requested on 9/13/22. The DON stated the Director of Rehab was struggling to get OT staff and the resident's OT screen was not done as requested. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105701 If continuation sheet Page 22 of 25 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 105701 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Merritt Island 500 Crockett Blvd Merritt Island, FL 32954 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement appropriate transmission-based precautions (TBP) for Extended Spectrum Beta-Lactamase (ESBL) for 1 of 2 residents (#115) reviewed for Urinary Track Infection (UTI) and failed to ensure an indwelling urinary catheter drainage bag was not placed on the floor to prevent infection for 1 of 2 residents reviewed for indwelling urinary catheter (#130) out of a total sample of 62 residents. Residents Affected - Few Findings: 1. Review of resident #115's medical record revealed she was admitted to the facility on [DATE] with diagnoses including Cerebral Vascular Accident (CVA), Urinary Tract Infection (UTI), neuromuscular dysfunction of bladder and chronic kidney disease. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] documented she had moderate cognitive impairment, required total assistance with toileting and was always incontinent of bladder. Review of resident #115's plan of care dated 10/28/22 showed she had an active urine infection. The goal included that she would have no signs or symptoms of active infection related to UTI within 14 days. Approaches dated 10/31/22 included Contact Precautions due to ESBL in urine, to administer medications as ordered, observe for side effects related to antibiotic therapy (ABT) and to encourage fluids. Review of resident #115's physician orders dated 10/29/22 included the antibiotic, Augmentin 500-125 milligrams (mg) by mouth (po) twice daily (bid) for 7 days for UTI. Review of resident #115's lab urine culture with sensitivity was collected on 10/25/22. On 10/27/22 the final urine report documented greater than (>)100,000 colony-forming unit (CFU)/milliliter (ml) Escherichia Coli, ESBL. Review of resident #115's Event Report dated 10/28/22 documented UTI with acute dysuria or acute pain, culture source was urine, and Contact TBP. On 10/28/22 Enhanced Barrier Precautions and then on 10/31/22 Contact Precautions due to ESBL in urine. In the notes section revealed on 10/28/22 at 4:54 PM urinalysis results reviewed by physician and new orders received for Augmentin 500 mg BID for 7 days. Review of the Medication Administration Record (MAR) documented resident #115 received the first dose of Augmentin 500 mg po bid on 10/29/22 at 9 AM. Review of resident #115's progress notes revealed on 10/24/22 a new order received from nephrologist for urinalysis for upcoming appointment and to fax results to physician. On 10/28/22 at 4:54 PM, urinalysis results reviewed by physician and new order received for Augmentin 500 mg po BID for 7 days. On 10/31/22 at 11:29 AM, an observation of resident #115's room revealed a sign on the door for Enhanced Barrier Precautions. On 11/01/22 at 10:15 AM, Personal Protective Equipment (PPE) was observed hanging on resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105701 If continuation sheet Page 23 of 25 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 105701 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Merritt Island 500 Crockett Blvd Merritt Island, FL 32954 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 #115's room door with a sign for Contact Isolation. Two isolation bins were observed on resident Level of Harm - Minimal harm or potential for actual harm #115's side of the room. Residents Affected - Few On 11/01/22 at 10:16 AM, the 400 Unit Manager explained that resident #115's urine had been collected for culture and sensitivity on 10/25/22 and the results of UTI with ESBL were reported on 10/27/22. The 400 Unit Manager stated it was the responsibility of the nurse and the Unit Manager to review the laboratory results in a timely manner and then notify the physician for orders. On 11/02/22 at 5:14 PM, the 400 UM stated resident #115 was placed on Enhanced Barrier Precautions on 10/28/22 with no PPE or isolation bins in the room. It was not until 11/01/22 (5 days later) that the correct precautions for ESBL in urine were implemented. The Contact Isolation sign and PPE was placed on the room door and isolation bins were placed in her room. The 400 Unit Manager explained on 10/28/22 the wrong sign (Enhanced Barrier Precautions) had been placed on the room door. Resident #115 should have been placed on Contact Precautions with correct sign, PPE and bins in the room. On 11/01/22 at 10:26 AM, the Infection Control Practitioner (ICP) stated she was aware that resident #115 had a UTI with ESBL. She explained the resident should have been placed on Contact Isolation on 10/27/22 when the results of her urine indicated ESBL. It was not until 11/01/22 when the required Contact Isolation was put in place. The ICP indicated the nurse was responsible for reviewing all laboratory reports, calling the physician and implementing new orders. I don't know why the nurse did not recognize the need to set up Contact Isolation for a resident with ESBL since the nurse obtained the ABT order for Augmentin for the UTI. It was the 400 Unit Manager who realized the Contact Isolation was not set up for resident #115. On 11/01/22 at 10:54 AM, the Director of Nursing (DON) stated the Infection Tracker Form documented Contact Isolation on 10/28/22 but resident #115 was only on Enhanced Barrier Precautions. Resident #115 should have been on Contact Isolation with PPE in place. Review of the Centers for Disease Control and Prevention (CDC) Enhanced Barrier Precaution Form posted on the resident #115's room door documented Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Wear gloves and gown for the following High-Contact Resident Care Activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, Device Care or Use: central line, urinary catheter, feeding tube, tracheostomy and Wound Care: any skin opening requiring a dressing. Do not wear the same gown and gloves for the care of more that one person. Review of the Facility's Policy Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 8/16/2022. read, . This document is intended to provide guidance for Personal Protective Equipment (PPE) use and room restriction in nursing homes for preventing transmission of Multi Drug Resistant Organisms (MDROs) . Examples of MDROs Targeted by the Centers for Disease Control and Prevention (CDC) include . ESBL producing Enterobacterales . Contact Precautions are one type of Transmission-Based Precaution that are used when pathogen transmission is not completely interrupted by Standard Precautions alone. Contact Precautions are intended to prevent transmission of infectious agents, like MDROs, that are spread by direct or indirect contact with resident or resident's environment. Contact Precautions require the use of gown and gloves on every entry into a resident's room. The resident is given dedicated equipment (e.g., stethoscope and blood pressure cuff) . Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105701 If continuation sheet Page 24 of 25 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 105701 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Merritt Island 500 Crockett Blvd Merritt Island, FL 32954 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 - Few 2. Review of resident #130's medical record revealed he was admitted to the facility on [DATE] with diagnoses including bladder spasms, bladder neck obstruction, retention of urine, and urinary tract infection. The most recent MDS significant change assessment with an Assessment Reference Date of 8/23/2022 indicated the resident had an indwelling urinary catheter. The current comprehensive care plan included focus areas for prophylactic antibiotic therapy, chronic urinary tract infection (UTI), need for assistance with activities of daily living (ADL), and risk for infection due to use of a foley catheter. The interventions included enhanced barrier precautions, changing the catheter and drainage bag as needed, and proper placement. Active orders for medications and treatments included Bactrim DS 800-160 milligrams (mg), 1 tablet every 12 hours for chronic UTI, ordered 8/25/2022 with no stop date. urinary catheter care every shift, ordered 9/1/2022, indwelling catheter change as needed 16 French with 30 cc, bladder neck obstruction for anticipated blockage, thick/heavy sediment, leakage or accidental removal as needed ordered 8/12/2022, observe catheter for leakage, blockage and sediment every shift if unable to clear blockage with irrigation, change catheter as needed, document observation of urine and catheter in comments box every shift ordered 8/16/2022, and change catheter drainage bag as needed ordered 9/1/2022 On 10/31/2022 at 10:40 AM, the resident's indwelling urinary catheter drainage bag was observed on the resident's right bedside lying in direct contact with the floor. On 10/31/2022 at 4:00 PM, the resident's indwelling urinary catheter drainage bag was observed on the resident's right bedside lying in direct contact with the floor. On 10/31/2022 at 4:03 PM, Registered Nurse (RN) G explained the protocols and expectations for care of an indwelling urinary catheter included catheter checks every shift, observation for signs and symptoms of UTI, and proper placement and care of the drainage bag. She stated the CNA duties included emptying the drainage bag and reporting any issues to the nurse. She stated the drainage bag is, not be touching the floor. On 10/31/2022 at 4:10 PM, Certified Nursing Assistant (CNA) H explained the change of shift/rounding routine had been completed. She did not recall seeing resident #130's indwelling urinary catheter. She explained CNA duties included checking the bag's volume, urine color abnormalities, tangled tubing, correct height, bag placement on the bed frame, and, it must not be lying on the floor. On 11/1/2022 at 10:56 AM, RN Unit Manager I stated the expectations for nurse monitoring of an indwelling urinary catheter included cleaning, checking for leaks, color, clarity, and sediment, changing the bag and catheter, and flushing. She stated, the bag is to be placed on the bedrail where it can rest and the nurse and CNA are responsible for checking the bag placement as it should not be on the floor. The facility's Nursing Services Policy and Procedure Manual for Solaris HealthCare (revised 1/17/2018, 2/10/2019, 1/7/2020), page 9-273 titled Catheter Care, Urinary under the section Infection Control item 2b states, Be sure the catheter tubing and drainage bag are kept off the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105701 If continuation sheet Page 25 of 25