Inspection·December 2, 2021

N0450 should have been coded 1 Yes- Antipsychotics were received on a routine basis only. The facility's policy MDS, revised on 9/16/2019, read, It is the policy of this facility to provide a comprehensive assessment of the resident's needs . that is completed accurately . according to the Resident Assessment Instrument (RAI) guidelines. Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessment accurately reflected health conditions regarding insulin for 1 of 3 sampled residents reviewed (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 12 Event ID: 105783 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 105783 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare East Orlando 250 South Chickasaw Trail Orlando, FL 32825 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 for resident assessment (#97), and failed to accurately assess for antipsychotic medication for 1 of 5 sampled residents reviewed for unnecessary medications (#94), of a total sample of 44 residents. Findings: 1. Resident #97 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes. A physician's order read, Dulaglutide 0.75 milligrams (mg.) subcutaneous in the morning every Monday for diabetes. Dulaglutide (Trulicity) is an injectable medication used to lower blood sugar and is not considered insulin. (Retrieved from www.trulicity.com on 12/10/21). Section N, Medications of the admission MDS assessment, with assessment reference date 11/15/21, revealed resident #97 received insulin one day during the last 7 days or since admission. On 12/02/21 at 11:08 AM, the MDS Lead nurse explained she reviewed the pharmacological classification when unfamiliar with a medication. After she reviewed her pharmacological classification resource, she stated Trulicity was not considered an insulin. She indicated resident #97 was not receiving any insulin and confirmed the MDS assessment coded as insulin was inaccurate. On 12/02/21 at 11:20 AM, Registered Nurse (RN) E explained he reviewed the resident's medication orders and Medication Administration Record (MAR) to complete section N of the MDS. RN E stated he used the internet when unsure about a medication. RN E indicated there were many new medications he was unfamiliar with and confirmed he coded the MDS assessment incorrectly. RN E stated, It should not be marked as insulin and stated he knew the MDS was supposed to be accurate. RN E indicated accuracy of the MDS was very important to ensure an accurate care plan. Review of the facility policy titled, MDS revised on 9/16/19 read, Each Interdisciplinary Team member will sign and date the portion of the MDS that he/she completed to certify accuracy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105783 If continuation sheet Page 2 of 12 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 105783 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare East Orlando 250 South Chickasaw Trail Orlando, FL 32825 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** 2. Resident #68 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Parkinson's Disease, dementia, and diabetes type II. Residents Affected - Few Observations on 11/29/21 at 12:10 PM and on 12/01/21 at 4:24 PM revealed a foam dressing to the resident's right forearm. The dressing was not dated. The resident stated his arm was ripped open during transfer from his bed to his wheelchair. Review of the weekly skin evaluation dated 11/22/21 revealed the resident had a skin tear to his right forearm, and ecchymosis of his right and left forearms. A nurse's progress note, dated 11/22/21, read, observed the resident right forearm bleeding. He has a small skin tear . the resident stated he rubbed it on the arm rest of the wheelchair. This writer cleansed the right forearm with normal saline and applied a dry dressing. Provider informed and new order to apply dressing until heal. An Interdisciplinary Team review note, dated 11/23/21, read that the resident had a skin tear to right forearm . treatment initiated. On 12/01/21 at 4:27 PM, Registered Nurse (RN) A stated a skin assessment was completed for the resident on the 11 PM-7 AM shift weekly and would be documented on the weekly skin assessment evaluation. Any new skin issues would be documented as a change in condition, the physician would be notified and order for treatment obtained. RN A stated she was not sure why resident #68 had the foam dressing to his right forearm. On 12/01/21 at 4:37 PM, observation of the resident's right forearm was conducted with the wound care nurse and the Regional Nurse Consultant. The wound care nurse stated she was not aware of any wound/skin impairment for the resident. The foam dressing was removed by the wound care nurse, and the resident reported he scratched his arm on his wheelchair during transfer. On 12/01/21 at 4:43 PM, the Seashell Unit Manager (UM) stated on 11/22/21, documentation revealed the nurse noted the resident's right arm bleeding, the physician was notified, and a dry dressing was placed. She stated the protocol for any change in condition included skin assessment of the resident, notification of the physician, obtaining treatment orders, documentation of an incident report, and a progress note. A review of the resident's physician orders was conducted with the UM. She verbalized a treatment order was not entered for the resident's skin tear. The UM said the facility did not have standing orders/order for skin tears, and that a physician's order would have to be obtained for treatment. The UM stated LPN B documented in the nurse's notes but did not obtain a physician's order. On 12/02/21 at 9:28 AM, LPN B stated on 11/22/21 she identified the skin tear to the resident's right forearm. She notified the physician, cleansed the area with Normal Saline solution, and applied a foam dressing to the area. LPN B explained the facility's protocol for skin tears included notification of the physician and obtaining orders for treatment. She stated she forgot to enter the physician's order in the resident's electronic clinical record. On 12/02/21 at 11:18 AM, the Director of Nursing (DON) stated LPN B explained to her that she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105783 If continuation sheet Page 3 of 12 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 105783 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare East Orlando 250 South Chickasaw Trail Orlando, FL 32825 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few called the physician and initiated treatment for the identified skin tear. The DON stated during the morning clinical meetings, review of physician orders, facility reports and the 24-hour sheet were conducted. She said the absence of a physician's order for the resident's skin tear was missed. The DON verbalized she documented that treatment was initiated, and updated the resident's care plan, for actual skin impairment, but did not check the physician's order sheet to ensure an order was obtained. The DON stated a physician's order for treatment was required. The facility's policy Skin & Wound Care, reviewed on 3/2021, read, The staff nurse will describe and measure the wound, notify physician, obtain orders and notify resident and resident representative when a skin alteration is identified. Based on observation, interview, and record review, the facility failed to document medication administration accurately, failed to follow physician's orders for blood glucose monitoring for 1 of 10 sampled residents reviewed for medication administration (#42), and failed to obtain and document a physician order for treatment for skin tear for 1 of 3 sampled residents reviewed for skin conditions (non-pressure related) (#68), out of a total sample of 44 residents. Findings: 1. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed resident #42's Brief Interview for Mental Status (BIMS) score was 13, which indicated intact cognition. The MDS showed the resident did not reject evaluation or care needed to achieve her goals for health and well-being. Review of resident's #42's medical record revealed a physician's order, dated 11/23/21, which indicated 6 units of Humalog to be administered before meals and at bedtime for diabetes, and to hold for blood glucose less than 150. There was a second order for Humalog, dated 10/06/21, to inject per sliding scale before meals and at bedtime. Humalog mealtime insulins are used to treat people with type 1 or type 2 diabetes for the control of high blood sugar. (Retrieved from www.humalog.com on 12/10/21). Review of resident #42's care plan included diabetes and the risk for further complications, initiated on 10/04/21. The care plan listed interventions that included, Administer insulin . per MD order. Blood glucose checks and notifications per MD orders. On 12/01/21 at 8:46 AM, during observation of medication pass, resident #42 told license practical nurse (LPN) G her blood glucose needed to be checked before breakfast,but it was now too late because she had eaten. The resident said, every day was the same thing. LPN G listened to the resident and responded she needed to check her blood glucose and administer the insulin as ordered. The LPN collected the blood sample with result of 396. LPN G stepped out of the resident's room, checked the Medication Administration Record on her computer, and dialed 10 units on the pen containing Humalog. LPN G returned to resident #42's room and told her she was going to administer 10 units of insulin, to which the resident responded, 10 won't do it. However, LPN G administered insulin on the right upper posterior arm. On 12/01/21 at 9:21 AM and 11:30 AM, LPN explained she was late checking resident #42's blood glucose because 5 of her 19 assigned residents also required blood glucose monitoring. LPN G indicated the order to check insulin was at 8 AM, and breakfast usually came between 7:30 and 8 AM. LPN G (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105783 If continuation sheet Page 4 of 12 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 105783 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare East Orlando 250 South Chickasaw Trail Orlando, FL 32825 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 verified the order for insulin, stated it was before meals and at bedtime, and indicated it was not checked before the meals as ordered. LPN G indicated it was important to give insulin before meals to accurately determine how much the resident needed to better control her blood glucose level. LPN G confirmed she gave 10 units of Humalog and stated she only saw one order and documented administration of the 10 units. Residents Affected - Few On 12/01/21 at 11:05 AM, the 100-Hall Unit Manager (UM) explained if a physician's order stated to obtain blood glucose before meals it needed to be done before meals. If a resident had already eaten, the nurse could still check the blood glucose then call the physician and report the results and find out if the insulin was to be given or obtain a new order. The UM reviewed resident #42's orders and confirmed she had two orders for Humalog, one for 6 units if blood glucose results were above 150, and another where the amount to be administered was based on a sliding scale. On 12/01/21 at 12:52 PM, the Director of Nursing (DON) explained nurses were to follow physician's orders for insulin administration and blood glucose monitoring. The DON stated a nurse was to obtain blood glucose before meals if that was the physician's order. The DON explained in the event a resident had eaten, she would notify the physician with blood glucose results and get a new order. On 12/01/21 at 2:50 PM, the Advanced Practice Registered Nurse (APRN) explained her expectation would be nurses contact her or the physician if an order could not be followed. The APRN explained she saw resident #42 in the morning and when reviewing the blood glucose readings, she noted the high trends so she entered an order to increase insulin from 6 to 8 units. The APRN explained she based her decision on the review of the blood glucose results documented by the nurses. The APRN stated she wasn't contacted regarding blood glucose checked and insulin administered after the resident had eaten on that morning. The APRN indicated if blood glucose is checked inconsistently, the results will be higher and she would base her treatment on before meals results, as it was ordered. The APRN stated the changes made to insulin were based on the documentation from the nurses, and inconsistent review would result in an inaccurate treatment. Review of the facility policy Physician Orders reviewed on 1/19/18 read, Physician orders will be transcribed, noted, implemented, and followed in a timely manner. Review of the facility policy Dose Preparation and Medication Administration, revised on 1/01/13, read, Facility staff should comply with facility policy, applicable law and the State Operations Manual when administering medications. The procedure included, Administer medications within timeframes specified by facility policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105783 If continuation sheet Page 5 of 12 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 105783 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare East Orlando 250 South Chickasaw Trail Orlando, FL 32825 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 0697 Provide safe, appropriate pain management for a resident who requires such services. 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 adequately manage pain for 1 of 3 sampled residents reviewed for pain management, of a total sample of 44 residents (#959). Residents Affected - Few Findings: Resident #959 was admitted to the facility on [DATE] with diagnoses including wedge fractures of the first, third, fourth and fifth lumbar vertebrae, and the eleventh and twelfth thoracic vertebrae. Vertebrae are the 33 individual, interlocking bones that form the spinal column (retrieved on 12/03/21 from www.spinehealth.com). An admission evaluation note dated 11/23/21 at 4:40 PM revealed the resident had lower back pain that he described as a score of 4 on a 0 to 10 pain scale. The resident's chart revealed physician orders for Tylenol 650 milligrams (mg.) every 4 hours as needed for pain, and Robaxin 500 mg. every 8 hours as needed for muscle spasms. An Occupational Therapy progress note, dated 11/25/21, revealed resident #959 rated his pain as 10 during activity and 3 at rest. Resident #959's care plan for pain, initiated 11/30/21, revealed a goal that he would verbalize adequate relief of pain or the ability to cope with incompletely relieved pain . On 11/29/21 at 11:52 AM, the resident stated he received only Tylenol for his pain, and it was not effective. He explained he asked the nursing staff to get a stronger medication for his pain. He stated the Physical Therapist (PT) applied ice to his back and it helped his pain, but when he asked a nurse if she could provide ice for his back pain, she refused. Resident #959 stated the nurse told him she did not have a physician order to apply ice. On 12/01/21 at 8:52 AM, resident #959 was in bed. He stated he had been awake since 3:30 AM because he was in pain. He said, I asked for pain medication and the CNA [Certified Nursing Assistant] came back to the room and said the nurse told her I could not have any medication until 9 AM. I could not eat breakfast because I am in too much pain to sit up. Resident #959 rated his current pain level as 9 out of 10, and described it as feeling like someone was stabbing him. He stated he was not able to take a shower on Monday evening, 11/29/21, because of the pain. Two PTs entered the room at that time, and the resident told them he could not participate in therapy because of his pain. The Assistant Director of Nursing (ADON) entered the room and resident #959, informed her of how much pain he was experiencing, and explained he needed stronger pain medication. The ADON stated she thought the resident's physician ordered new pain medication for him on the previous day and offered to check the medical record. The resident's medical record revealed physician orders dated 11/30/21 for Meloxicam 5 mg. twice a day for muscle spasms and a Lidocaine 5% patch for pain. However, review of the Medication Administration Record showed resident #959 did not receive the two new pain medications until 12/01/21. On 12/01/21 at 12:30 PM, resident #959 stated no one ever asked him what an acceptable pain level would be, and he did not recall anyone asking if the Tylenol he received was effective. He said, The doctor came in yesterday and ordered additional medication for me, and so far it is working well. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105783 If continuation sheet Page 6 of 12 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 105783 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare East Orlando 250 South Chickasaw Trail Orlando, FL 32825 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 12/01/21 at 1:01 PM, CNA H stated resident #959 had complained of pain since admission. She said, I know he did not eat his breakfast this morning because he was having pain. On 12/01/21at 2 PM, Licensed Practical Nurse (LPN) G acknowledged she was assigned to care for resident #959 on Sunday, 11/28/21. She said, When the night nurse gave me report, she said she called the on-call doctor to try to get stronger pain medication for the resident, but the on-call doc [doctor] did not feel comfortable doing that, and told me to call the on-call for day shift to see if I could get something stronger for his pain. I called, but the covering doctor would not prescribe anything because he did not know the resident. On 12/02/21 at 1:39 PM, the Director of Nursing (DON) stated her expectation was that residents' reports of pain would be addressed, and if not controlled with existing medication, the physician should be notified and another order should be obtained. The policy Pain Management Program, reviewed 2/14/18, read, The effectiveness of the interventions implemented to manage the residents pain will be observed and adjustments will be made accordingly based on the resident responses and/or preference. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105783 If continuation sheet Page 7 of 12 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 105783 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare East Orlando 250 South Chickasaw Trail Orlando, FL 32825 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to accurately document medications/creams, ointments according to prescribed orders for 1 of 3 sampled residents reviewed for skin conditions (#24), failed to accurately document Physician's Orders for 1 of 3 sampled residents reviewed for pressure ulcers (#28), and for 1 of 1 resident reviewed for dialysis (#52), and failed to accurately document a partial bath instead of showers for 1 of 2 sampled residents reviewed for activities of daily living (ADLs) (#86), out of a total sample of 44 residents. Findings: 1. Resident #24 was admitted to the facility on [DATE] with the most recent readmission on [DATE]. Her diagnoses included Grover's disease. Grover's disease is a skin condition that causes the appearance of small, red spots. These spots usually develop on the chest or back, but may also form on other parts of the body that also causes itching. (https://rarediseases.info.nih.gov/diseases/6551/Grovers-disease a history of infectious and parasitic diseases and atopic dermatitis). Her Minimum Data Set quarterly assessment reference date 9/09/21, signed as complete on 9/13/21, identified the application of ointments and medications other than to feet. The plan of care for skin impairment, related to rash on back and groin, general body rashes Atopic Dermatitis to back and bilateral upper extremities, was initiated on 2/21/21 and updated most recently 10/12/21. On 11/30/21 at 9:49 AM, resident #24 had a visible reddened and bumpy rash on her exposed right lower arm. The resident said her skin itched and it kept her awake at night. On 11/23/21, the Dermatology Advanced Practice Registered Nurse prescribed Permethrin 5% cream apply head to toe. Wash off 8 hours later. Repeat application in one week. Diagnoses Grover's disease. A second prescription on 11/23/21 was for Halobetasol 0.05% cream two times a day for two weeks to itchy skin. Followed by Triamcinolone 0.1% cream two times a day for 4 weeks to itchy skin. Review of the order entries for the prescriptions were as follows: 11/23/21 Permethrin Cream 5% apply to skin topically one time a day starting on the 11/24 and ending on the last day of the month for itching until 11/30/21. Apply head to toe wash off 8 hours later. Repeat application in 1 week. 11/23/21 Halobetasol Propionate Cream 0.05% Apply to skin topically two times a day for itching until 12/09/21 to itchy skin. 11/23/21 Triamcinolone Acetonide 0.1% cream apply to skin two times a day for itching until 12/25/21 to itchy skin times 4 weeks. Proof of delivery from the Pharmacy on 11/24/21 at 8:03 AM reflected that Halobetasol Propionate Cream 0.05% and Permethrin Cream 5% was delivered to the facility. The medication administration record (MAR) for November 2021 documented that beginning on 11/24/21, Permethrin cream was given daily by three different nurses, and Triamcinolone Acetonide 0.1% cream (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105783 If continuation sheet Page 8 of 12 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 105783 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare East Orlando 250 South Chickasaw Trail Orlando, FL 32825 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 was to be given two times a day for itching until 12/25/21 to itchy skin times 4 weeks. Level of Harm - Minimal harm or potential for actual harm On 11/30/21 at 1:15 PM, the Sea Shell Unit Manager was asked about multiple doses of Permethrin given to resident #24 as well as two additional creams ordered by the dermatologist and approved by the physician on 11/23/21. She was not aware that the order for the Permethrin was incorrect. She verbalized that Permethrin was signed as given daily from 11/24 to 11/30/21 by three different nurses as well at the two creams. Residents Affected - Some On 11/30/21 at 3:20 PM, the Director of Nursing (DON) validated that there was an error on the transcription regarding the multiple medication/creams administered. The DON said the nurse faxed the order from the dermatologist to the pharmacy. The pharmacy only delivered one dose of Permethrin. Staff were signing off as given even though the resident did not receive the additional treatments. The orders for Halobetasol and Triamcinolone were also faxed to the pharmacy which only delivered the Halobetasol. Two of the three nurses signed off that Triamcinolone cream was given even though no supply was delivered. The DON contacted Licensed Practical Nurse (LPN) C by phone. LPN C explained to the DON that she gave the medications even though she did not give them. LPN C told the DON that she asked the treatment nurse if she did her treatment and LPN C assumed the treatment nurse did it the creams, so she signed off that it was done. On 12/01/21 at 9:18 AM, RN A said that she signed on the MAR that she gave Halobetasol Propionate cream 0.05% and Triamcinolone Acetonide Cream 0.1% on 11/24/21 at 9 AM and 5 PM. On 12/01/21 09:50 AM, the nurse said, I try to check the orders. I know the first day [11/24/21] I gave her the Permethrin cream and took her to the shower after 8 hours, and discarded the medication. I do not know why the next day it was signed as done. I know it should be given every 14 days. Resident #24 had three different creams for the itching plus Hydroxyzine. On 12/02/21 at 10:59 AM, LPN B said she never provided Permethrin even though she signed that she gave it. She also validated that resident #24 had a lot of skin treatment creams and powders. 2. Review of resident #28's medical record revealed she was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes, hip fracture, malnutrition and an unstageable pressure ulcer of the sacral region. Resident #28's physician's orders included to apply Collagenase ointment to the sacrum topically every day shift, cleanse with Normal Saline solution, pat dry, apply skin prep to periwound, apply Santyl, Puracol plus, foam dressing, change daily and as needed. This order was started on 10/29/21. The Wound Follow-Up forms, dated 11/23/21 and 11/30/21 and signed by the physician, showed treatment to follow included 1/4 Dakin's Solution, Skin Prep, Collagenase, Collagen, Santyl, Puracol, foam dressing and tape. Resident #28's Treatment Administration Record for November and December 2021 showed treatments were done every day with Normal Saline solution. Resident #28's care plan for pressure ulcer, revised on 7/13/21 included an intervention: Administer treatments as ordered and monitor effectiveness. On 12/02/21 at 2:59 PM, LPN J explained she followed residents with wounds in the facility. LPN J (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105783 If continuation sheet Page 9 of 12 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 105783 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare East Orlando 250 South Chickasaw Trail Orlando, FL 32825 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some indicated her responsibilities included to inspect every admission, obtaining digital pictures of any wounds, calling the physician to obtain orders for treatments, determine the best specialty mattress for the resident, perform weekly skin assessments and notify families of her findings. LPN J explained she rounded with the Wound Care Physician on Tuesdays. She explained she entered wound care orders using the physician's Wound Follow-Up form and confirmed entering resident #28's wound care order. LPN J stated the physician and herself used Dakin's Solution when providing wound care. She stated the order was transcribed incorrectly and confirmed nurses would have followed the physician's order as she entered it. Review of the facility policy Physician Orders reviewed on 1/19/18 read, Physician orders will be transcribed, noted, implemented, and followed in a timely manner. Review of the Job Description for the LPN Staff, not dated, revealed duties and responsibilities that read, Maintains accurate and complete records of nursing care provided. 3. Resident #52 was admitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease (ESRD), hemodialysis (HD), and Type 2 Diabetes. The resident's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed her Brief Interview for Mental Status (BIMS) score was 15 out of 15, which indicated an intact cognition. Resident #52's physician's orders included Dialysis on Tuesday, Thursday and Saturday, chair time at 11:40 AM, transport pick up between 10:30 and 11 AM, return between 4 and 4:30 PM. The order started on 7/13/21. Resident #52's Treatment Administration Record (TAR) for November and December 2021 showed treatments for dialysis marked complete on Tuesdays, Thursdays and Saturdays. Resident #52's care plan for renal insufficiency due to ESRD and HD, initiated on 2/07/21, had interventions that read, Dialysis . T [Tuesday], TH [Thursday], S {Saturday] . Dialysis meals to be sent on dialysis days . Tues, Thu, Sat . On 11/30/21 at 10:12 AM, resident #52 sat in a wheelchair near the door of her room and stated she was waiting for transportation to be taken to dialysis. The resident indicated her dialysis chair time was 11:40 AM and she went on Tuesdays and Saturdays. On Thursday, 12/02/21 at 1:29 PM, the resident was asleep in her bed. On 12/02/21 at 1:37 PM, the 100-Hall Unit Manager (UM) explained they have a binder for new residents on dialysis that includes information about chair and pick up times. The UM stated the binder helped the Certified Nursing Assistants (CNAs) be aware of the days and times, so they got the residents ready timely. The UM reviewed resident #52's medical record and indicated resident went to dialysis on Tuesday, Thursday, and Saturday. When asked why resident was sleeping in her room at this time as it was Thursday. The UM reviewed the Pre-Post Dialysis Evaluation forms from 11/02/21 to 11/30/21, and indicated the forms were only completed on Tuesdays and Thursdays. The UM explained the TAR check marks on Tuesday, Thursday, and Saturday during the month of November meant resident went to dialysis those days as there were no exemption code if it was not done. On 12/02/21 at 2:46 PM, the UM contacted the dialysis center to clarify resident #52's dialysis (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105783 If continuation sheet Page 10 of 12 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 105783 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare East Orlando 250 South Chickasaw Trail Orlando, FL 32825 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm days. She stated she was told resident #52's scheduled dialysis days were Tuesdays and Saturdays since 8/03/21. The UM confirmed there were no progress notes with this information or a physician order that reflected those days. The UM explained if the resident was not picked up or missed dialysis, the nurse would have called the dialysis center and entered a progress note. The UM indicated transportation would had been contacted by the dialysis center. The UM stated there were no notes documenting changes. Residents Affected - Some On 12/02/21 at 5:23 PM, the DON explained the facility coordinated with dialysis any changes of schedule and transportation. The DON indicated dialysis would have contacted the transport company about the changes for resident #52 from 3 to 2 days. The DON indicated she could not remember seeing anything regarding change of days for resident #52. The DON stated a nurse should had called the dialysis center and updated the orders. Review of the facility policy Hemodialysis, reviewed on 4/17/13, read, Orders will be obtained from the attending physician for residents receiving hemodialysis. The procedure included, Communication with be maintained between the facility and the hemodialysis service provider. 4. Resident #86 was admitted to the facility on [DATE] with diagnoses that included Wedge Compression Lumbar Fractures, Osteoarthritis, and Type 2 Diabetes. Resident #86's admission MDS assessment, dated 11/10/2,1 revealed her Brief Interview for Mental Status (BIMS) score was 15 out of 15, which indicated intact cognition. The MDS also showed the resident's functional abilities and activities of daily living as needing extensive assistance for bed mobility, transfer, toilet, and dressing. The MDS revealed resident #86 needed limited assistance for personal hygiene. The MDS indicated the resident did not reject evaluation or care needed to achieve her goals for health and well-being. Resident #86's medical record revealed shower preferred days were Monday and Thursdays during the 3-11 shift. Review of tasks showed showers were given to resident #86 on the following days: 11/08, 11/11, 11/15, 11/18, 11/22, 11/25, 11/29/21. Resident's #86 care plan included impaired vision, impaired physical mobility and ADL self-care performance deficit initiated on 11/9/21. Interventions included resident required extensive assistance with bathing/showers as scheduled and as necessary. On 11/29/21 at 5:04 PM and 11/30/21 11:44 AM, resident #86 stated she had not received any showers in the time she had been in the facility. Resident #86 explained she had received a bed bath once or twice each week and would prefer more often. On 12/01/21 at 4:35 PM, CNA I stated she usually gave showers to her assigned residents after they had dinner. CNA I explained if a resident refused showers, she informed the nurse and documented the refusal but she would offer a bath by the sink or a bed bath. CNA I explained resident #86 had been refusing showers but she had received a bed bath instead. CNA I indicated resident #86 was supposed to get showers on Mondays and Thursdays but the resident had refused, and she had documented the refusal in the computer. On 12/02/21 at 2:27 PM, the 100 Hall UM explained the DON and UMs get alerted of any residents' refusal of showers, among other things, through a dashboard in computer. The UM indicated showers for resident #86 were documented as given. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105783 If continuation sheet Page 11 of 12 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 105783 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare East Orlando 250 South Chickasaw Trail Orlando, FL 32825 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm On 12/02/21 at 4:29 PM, CNA I confirmed resident #86 refused showers and had received bed baths. CNA I explained she had the option to select partial or bed bath when documenting the task, but had been entering as showers as a mistake. The CNA I stated she sometimes notified the nurses but knew she was supposed to tell the nurse each time. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105783 If continuation sheet Page 12 of 12