Health inspection·July 21, 2022

F 0578 Level of Harm - Minimal harm or potential for actual harm On [DATE] at 10:11 a.m., Licensed Practical Nurse (LPN) Staff B said staff find code status for a resident in several places. He said you can check the demographic sheet and see the Code Status written under the resident's picture, the physician's orders, the Medication Administration Record, or the advance directive documents. He said all should be the same and reflect the latest wishes of the resident or their Health Care Proxy. He said if someone codes, time is of the essence if you need to give the resident CPR. Residents Affected - Few On [DATE] at 12:23 p.m., in a telephone interview Resident #48's Health Care Proxy confirmed Resident #48 was a Full Code and CPR should be initiated for Resident #48 if his heart stopped beating or he stopped breathing. On [DATE] at 5:02 p.m., the Social Service Director confirmed Resident #48's Health Care Proxy was the one making health care decisions for the resident. He verified the discrepancy in the clinical record and confirmed on [DATE] the health care proxy had requested to change the code status to a full code. Review of the clinical record for Resident #55 indicated an admission date of [DATE]. Review of the clinical record revealed an incapacity letter dated [DATE] indicating Resident #55 lacked capacity to give informed consent and make medical decision. The clinical record noted on [DATE] the resident's daughter accepted the appointment as a health care proxy to give informed consent and make medical decisions on behalf of Resident #55. The clinical record contained a State of Florida Do Not Resuscitate Order form dated [DATE] signed by Resident #55's health care proxy and physician directing the withholding or withdrawing of cardiopulmonary resuscitation from the patient in the event of cardiac or respiratory arrest. The active physician's orders dated [DATE] noted Resident #55's code status to be full code (Provide CPR in the event of cardiac or respiratory arrest). The order contradicted the Healthcare Proxy's documented wishes for DNR status. On [DATE] at 11:55 a.m., Resident #55's Health Care Proxy said Resident #55 is a DNR. On [DATE] at 5:22 p.m., The Director of Nursing (DON) confirmed the clinical Record for Residents #48 and #55 contained contradicting information for Code Status. She confirmed the physician's order the residents was incorrect and would have to be corrected. On [DATE] at 1:25 p.m., the administrator said the physician orders for both residents should have been updated with the correct information when their code status changed. She said it was a problem the facility would need to correct. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105738 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 105738 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Imperial 900 Imperial Golf Course Blvd Naples, FL 34110 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 observations, record review, and staff interview the facility failed to ensure 2 (Residents #77 and #79) of 2 resident's activity programs reviewed were conducted on a continuous basis. The lack of an ongoing activity program and a lack of contact and interaction with the community could lead to a decline in the residents' self-esteem, physical, mental, and psychosocial well-being. Residents Affected - Few The findings included: 1. On 7/18/22 observed Resident #77 at 11:32 a.m., 12:45 p.m., 1:30 p.m., 2:15 p.m. and 3:00 p.m., in her room sitting in her wheelchair without the television (TV) on, not involved/engaged in an activity program. On 7/19/22 observed Resident #77 at 10:00 a.m., 11:45 a.m., and 3:00 p.m., in her room sitting in her wheelchair without the TV on, not involved/engaged in an activity program. On 7/20/22 observed Resident #77 at 9:00 a.m., in her room sitting in her wheelchair without the TV on, not involved/engaged in an activity program. On 7/20/22 review of Resident #77's medical record noted Resident #77 was admitted to the facility on [DATE]. The Activity Director wrote on 6/21/22 Resident #77 was alert with confusion but can answer some questions. She discussed activities they could provide and offer with the resident and would contact Resident #77's daughter for more information regarding Resident #77's activity needs. An activity plan of care was created on 6/21/22 stating Resident #77 preferred to stay in her room at this time, with a goal for Resident #77 to express her desire to enjoy group, individual or leisure activities as tolerated. The activity care plan noted Resident #77 enjoys music, outdoor, reading. Staff was to encourage activities, out of room socialization, provide activity agenda of all events and escort the resident to and from activities. 2. On 7/18/22 observed Resident #79 at 11:02 a.m., 1:45 p.m., 2:10 p.m. and 3:00 p.m., in his room in bed wearing a hospital gown. The TV was on, but the volume was muted. During the multiple observations, Resident #79 was not involved and/or engaged in an activity program. On 7/19/22 observed Resident #79 at 11:05 a.m., 1:47 p.m., and 3:20 p.m., in his room in bed wearing a hospital gown. The TV was on, but the volume was muted. During the multiple observations, Resident #79 was not involved and/or engaged in an activity program. On 7/20/22 observed Resident #79 at 8:22 a.m., and 9:30 a.m., in his room in bed wearing a hospital gown. The TV was on, but the volume was muted. Resident #79 was not involved and/or engaged in an activity program. On 7/20/22, review of Resident #79's medical record noted an admission date of 10/06/20. An activity progress note dated 7/12/22 stated Resident #79 was alert with confusion and under hospice care. Resident #79 ate all meals in bed, catholic services once a week and would have one-to-one room visits as tolerated. An activity plan of care, dated 4/18/22 and edited on 7/11/22 stated Resident #79 did not attend (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105738 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 105738 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Imperial 900 Imperial Golf Course Blvd Naples, FL 34110 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 group activities at this time due to decline, would do one-to-one activity as needed and as tolerated. The activity goal stated they would try to engage the resident in one-to-one, individual or group activities as tolerated. They would have the catholic channel on and in room communion as needed, they would invite Resident #79 to music, outdoors, food and holiday events as tolerated, and the facility team would transport Resident #79 to and from the activity programs as needed and as tolerated. Residents Affected - Few On 7/20/22 at 10:12 a.m., Certified Nursing Assistant (CNA) Staff H said she had been working at the facility for several years. She said she had worked with Resident #77 and Resident #79 and while they were confused at times, they were cooperative and easy to work with. She said she was unaware of any reason why Resident #77 or Resident #79 could not attend out of room activities. On 7/20/22 at 11:26 a.m., the Activity Director (AD) said she had been working at the facility for 15 to 16 years. She said when a resident was admitted to the facility, she was required do an activity assessment within 72 hours which reviewed their activity likes, dislikes, and hobbies. She obtained this information from the resident, family, and friends which she used to develop the resident's activity plan of care. She said the facility had activities in the facility and for residents who could not and/or did not leave their rooms, she developed in room one-on-one activities to meet their needs. She said a resident who was on a one-on-one in room received 3 room visits a week which lasted 10 to 20 minutes. The AD reviewed Resident #77's medical record and confirmed she was admitted to the facility on [DATE] and she had written a progress note on 6/21/22 which stated Resident #77 liked to stay in her room and she would contact Resident #77's daughter for more information regarding Resident #77's activity needs. The AD said she created an activity plan of care for Resident #77 on 6/21/22, stating Resident #77 preferred to stay in her room. She said the goal of the activity plan of care was for Resident #77 to enjoy group, individual or leisure activities in and out of her room as tolerated. The AD confirmed Resident #77's activity care plan further stated the activity department would encourage Resident #77 to attend out-of-room socialization, music, and attend outdoors activities. The AD said since Resident #77 liked to stay in her room she placed Resident #77 on their in room one-on-one activity program. The AD said after reviewing the activity tracking forms she keeps for each resident on the one-on-one program, she is unable to find documentation the activity department had invited Resident #77 to any out of room activity and/or documentation they had conducted any one-on-one activities with Resident #77 at this time. The AD said Resident #79 was admitted to the facility on [DATE] and used to attend all the facility activity programs. She said over the past several weeks Resident #79's health had declined, and he now liked watching and listening to the Catholic TV station and was on the one-on-one activity program. The AD said after reviewing the activity tracking form for residents on the one-on-one activity program she was only able to find documentation the activity department had conducted a one-on-one activity program with Resident #79 on 7/10/22 and 7/16/22. The AD said after reviewing the activity departments documentation for residents on their one-on-one activity program, she was unable to find documentation Resident #77 and Resident #79 received and engaged in an activity program on a routine basis to ensure they did not have a decline in the residents' self-esteem, physical, mental, and psychosocial well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105738 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 105738 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Imperial 900 Imperial Golf Course Blvd Naples, FL 34110 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Based on observation, record review, facility policy review, and staff interviews, the facility failed to ensure 2 (Resident #65 and #80) of 4 residents reviewed for accidents were assessed for alternative interventions prior to the use of assist rails and side rails. This had the potential to have assist rails and side rails installed when alternatives with less chance of negative consequences could be utilized. The findings included: The facility policy, Proper Use of Side Rails (revised 1/17/18) documented, The purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. General Guidelines 6. Less restrictive interventions that will be incorporated include: a. Providing restorative care to enhance abilities to stand freely and walk. b. Providing trapeze to increase bed mobility c. Placing the bed lower to the floor and surrounding the bed with a soft mat. d. Equipping the resident with a device that monitors attempts to rise. e. Providing staff monitoring at night with periodic assisted toileting for residents attempting to arise to use the bathroom. f. Furnishing visual and verbal reminders to use the call bell for residents who can comprehend this information. 7. Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails. 1. On 7/18/22 at 4:00 p.m., Resident #65 was observed in bed with a scoop mattress (mattress with raised sides used to prevent falls) and quarter upper side rails raised on both sides of the bed. A review of Resident #65's clinical record showed an admission date of 6/8/19. Diagnoses included, hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness of one side of the body) following cerebral infarction affecting left dominant side. A consent for use of side rails was signed by the resident on 6/24/19. The record contained a physician order dated 3/6/22 for two assist rails for bed mobility. An Interdisciplinary Side Rail Evaluation form dated 6/24/19 documented Evaluation of Alternatives (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105738 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 105738 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Imperial 900 Imperial Golf Course Blvd Naples, FL 34110 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Level of Harm - Minimal harm or potential for actual harm Tried: call bell in reach, scheduled or prompted toileting program, safety perimeter mattress with bolsters/safety perimeter, placement of assistive devices at bedside. The form included a section for documentation to include if the interventions were effective that was not completed prior to the use of the side rails. Residents Affected - Few On 7/20/22 at 8:50 a.m., in an interview the Director of Nursing (DON) confirmed there was no documentation to indicate if less restrictive approaches were or were not successful, prior to the use of side rails for Resident #65. 2. On 7/19/22 at 9:48 a.m., Resident #80 was observed in bed with assist rails on bed both sides of the bed in the raised position. A review of Resident #80's clinical record showed an admission date of 10/28/21. Diagnoses included dementia, anxiety, restlessness, and agitation. The clinical record showed a consent for use of side rails form signed by Resident #80 on 11/30/21. A physician order dated 3/6/22 documented two assist rails for bed mobility. The clinical record showed no documentation of alternate interventions attempted prior to the use of the assist rails. On 7/20/22 at 8:50 a.m., in an interview the DON confirmed there was no documentation to indicate if less restrictive approaches were attempted and if the interventions were successful, prior to the use of the assist rails for Resident #80. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105738 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 105738 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Imperial 900 Imperial Golf Course Blvd Naples, FL 34110 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, review of facility policy and procedures, clinical record review, resident and staff interviews, the facility failed to ensure its medication error rate remains below 5%. 25 opportunities were observed, four medication errors were identified resulting in a medication error rate of 20 %. Residents Affected - Few The findings included: The facility policy IIA2: Medication Administration - General Guidelines (revised 1/2018), documented Medications are administered in accordance with written orders of the prescriber. 1. On 7/18/22 at 9:47 a.m., Registered Nurse (RN) Staff A was observed to prepare and administer nine different medications to Resident #16, including one tablet of Multiple Vitamin with Minerals and one tablet of Sertraline (antidepressant) 100 milligrams (mg). Upon reconciliation of the observation with the physician's orders, it was revealed an order to administer a daily multiple vitamins without minerals and Sertraline 150 mg daily. 2. On 7/18/22 at 10:45 a.m., RN Staff A was observed to prepare and administer 15 different medications to Resident #29, including one tablet of Theravit Multiple Vitamin and two tablets of Acetaminophen of 325 mg each. RN Staff A handed the medication cup to the resident. Resident #29 expressed concern to RN Staff A and said two tablets appeared different from what she usually takes. RN Staff A identified the two tablets as Tylenol 325 mg. Resident #29 informed RN Staff A that she usually received Tylenol Arthritis 650 mg tablets. RN Staff A did not respond to Resident #29's concerns and the resident accepted the medications. Upon reconciliation of the observation with the physicians' orders, it was revealed an order to administer Thera M Plus (Ferrous Fumarate), a multiple vitamin and iron product used to treat vitamin and iron deficiency and a physician's order to administer two tablets of Acetaminophen Arthritis 650 mg. The Physicians orders instructed to administer Fish Oil Concentrate 1000 mg capsule daily. The Fish Oil Concentrate was not administered to Resident #29. RN Staff A documented in the electronic medication administration record she had administered the Fish Oil Concentrate capsule to Resident #29. On 7/19/22 at 1:21 p.m., the Director of Nursing (DON) said RN Staff A had informed her of the medication errors made during the medication administration observation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105738 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 105738 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Imperial 900 Imperial Golf Course Blvd Naples, FL 34110 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, review of facility policy and staff interviews, the facility failed to ensure proper labeling of medications in 1(North Unit Cart, B Hall) of 3 medication carts observed. The facility failed to ensure expired medications were not retained longer than the expiration date in 1 (South Unit) of 2 medication storage rooms observed and 1(South Unit Cart, B Hall) medication cart. This has the potential for expired medications to be administered to residents. The findings included: The facility policy Medication Storage in the Facility revised January 2018 documented, Expiration dating (beyond use dating). . Drugs dispensed in the manufacturer original container will be labeled with the manufacturer's expiration date. When the original seal of a manufacturers container or vial is initially broken, the container or vial will be dated. The nurse shall place a date opened sticker on the medication and enter the date opened . The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date . All expired medications will be removed from the active supply and destroyed in the facility, regardless of the amount remaining. 1. On 7/18/22 at 9:25 a.m., observation of the South Unit medication room's refrigerator with Registered Nurse (RN) Staff C, showed four prefilled syringes of Tuberculin PPD (purified protein derivative) testing solution with the expiration dates of 7/7/22, 7/10/22 and 7/13/22. RN Staff C confirmed the four syringes had expired and should have been discarded. Photographic evidence obtained. 2. On 7/18/22 at 10:15 a.m., observation of the North Unit, B Hall medication cart with RN Staff A showed an open box with a bottle of stock Care All eye drops. The box and the bottle were not labeled with the date it was first opened and did not specify a resident's name on the label, making it impossible to determine when to discard the medication and the resident the medication was to be used for. RN staff A confirmed the box, and the bottle were not properly labeled and should have been discarded. 3. On 7/19/22 at 9:07 a.m., observation of the South Unit, B Hall medication cart with RN Staff C, showed a bottle of Vitamin E 1000-unit capsules. The manufacturers expiration date was 6/22. RN Staff C confirmed the medication had expired and should not have been stored in the medication cart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105738 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 105738 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Imperial 900 Imperial Golf Course Blvd Naples, FL 34110 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Based on interview and record review, the facility failed to ensure collaboration of hospice services regarding medication for 1 resident (#28) of 8 hospice residents at the facility. Coordination of care between facility services and hospice services ensures the highest level of comfort and care at the end-of-life. The findings included: Review of the Nursing Facility Services Agreement - Hospice Routine Home Care Agreement: Page 2 (d) Hospice Services means (iii) physician services to the extent that these services are not provided by the attending physician, (viii) drugs and biologicals. Coordination of Care: Page 7 [c] Ensuring the facility communicates with the Hospice medical director, the hospice patient's attending physician, and other practitioners participating in the provision of care as needed to coordinate hospice care with medical care provided by other physicians. Professional Management Responsibility: Page 12 (g) Physician's Orders. Hospice shall provide appropriate orders 24 hours per day, 7 days per week for all needed services including drugs and biologicals necessary for palliation and management of pain symptoms. On 7/19/22 at 12:00 p.m., Resident #28 was observed at the facility in her room lying in bed with her daughter sitting in a chair by her side. Resident #28's daughter said the resident was admitted to hospice last week for end-of-life care. Review of the medical record revealed a Hospice admission Agreement for Resident #28 was initiated on 7/13/22. Review of the Hospice Binder revealed the Hospice admission Registered Nurse (RN) visited Resident #28 at the facility on 7/13/22. On 7/19/22 at 5:01 p.m., review of the Hospice Binder at the nurse's desk revealed one page of hand-written hospice medications were initiated for Resident #28 on 7/13/22 at 5:30 p.m. The Hospice medications included: Acetaminophen 650 milligram (mg) suppository, one suppository per rectum, every four hours, as needed for fever. Bisacodyl 10 mg suppository, one suppository, per rectum, daily as needed for constipation. Ativan 0.5 mg tablet, one tablet, oral/sublingual, every two hours, as needed for anxiety/restlessness. Atropine 1%, three drops oral/sublingual every 2 hours, as needed, for increased secretions. Roxanol 5 mg, oral/sublingual, every two hours, as needed, for pain or dyspnea (Difficulty breathing). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105738 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 105738 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Imperial 900 Imperial Golf Course Blvd Naples, FL 34110 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 0849 Oxygen 2.0 liters per minute, via nasal cannula, for dyspnea. Level of Harm - Minimal harm or potential for actual harm On 7/19/22 at 5:01 p.m., Licensed Practical Nurse (LPN) Staff G said when a resident is admitted to hospice, hospice writes new orders that include medications such as Ativan and Atropine drops. She said those medications are added to the facility medication orders as well as the Medication Administration Record (MAR). Staff G said the facility nurse gives all medications including the hospice medications. Residents Affected - Few On 7/19/22 at 5:15 p.m., review of the facility physician orders and MARs for Resident #28 revealed the hospice medication orders were not included in the medication list for Resident #28. On 7/19/22 at 5:20 p. m, review of the progress notes for Resident #28 revealed no documentation indicating the facility physician was made aware of the new hospice orders. On 7/20/22 at 05:32 p.m., the Director of Nursing (DON) said Resident #28 was admitted to Hospice on 7/13/22. She said she was working at the nurse's desk and saw the Hospice admission Nurse when he was at the facility. She said she met with the Hospice admission Nurse but was not aware of any new hospice medication orders. She opened the Hospice binder at the nurse's desk and confirmed there were hospice orders written on 7/13/22 for Resident #28. She acknowledged the orders had been in the binder for 7 days, but the medications were not available for Resident #28. She said she had not contacted the facility physician about the new orders or added them to the facility orders or MAR. She said it was her job as the desk nurse to do those things, but she did not. On 7/21/22 at 12:55 p.m., during a telephone interview with the Visiting Hospice Registered Nurse she said she was made aware of the problem with Resident #28's hospice orders this morning. She said it was a mix up with the admission Hospice Registered Nurse, and she did not know how it happened. She confirmed the facility nurses give the hospice medications to Resident #28 while she is in the facility. On 7/21/22 at 1:40 p.m., the administrator said she was made aware of the problem with Resident #28's hospice orders. She said it is a problem the facility will have to resolve with the hospice company. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105738 If continuation sheet Page 10 of 10