Inspection·October 6, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Summary Report and verified the resident's SBP was over 160 twelve times from 9/2/23 to 10/5/23. He confirmed that on the days he worked, 10/5/23 at 7:51 AM, the resident's blood pressure (BP) was 168/81, on 9/27/23 the BP was 161/81, and on 9/26/23 the BP was 164/82. LPN A stated he did not offer or give the resident the Clonidine 0.1 as prescribed by the provider. He did not provide an answer as to why he did not administer the Clonidine as prescribed. Residents Affected - Some On 10/5/2023 at 3:25 PM, the Unit Manager (UM) on the Cypress Court unit stated that if a resident had a blood pressure medication order with parameters, the nurse should check the BP and administer the prescribed blood pressure medication as ordered. She stated the resident could experience serious complications such as a stroke, chest pain, and/or shortness of breath if the medication was not given for the high blood pressure. The UM reviewed resident #80's provider orders, Blood Pressure Summary Report, and the MAR. She stated the resident's SBP was greater than 160 twelve times from 9/22/23 to 10/5/23, and the resident should have been given the Clonidine as ordered by the physician. On 10/5/2023 at 3:55 PM, the Director of Nursing verified the resident's SBP was greater than 160 twelve times from 9/22/23 to 10/5/23. She acknowledged the resident was not given the blood pressure medication as ordered on the days the resident's SBP was greater than 160 and that the nurses should have followed the physician orders and administered the BP medication. The DON stated it is very important that nurses followed the physician orders if a resident was prescribed BP medication with parameters. The facility's Physician Services Policy noted physician orders will be followed by the center staff. If a physician order is not followed for clinical concerns or per patient's wishes, the physician should be notified and the reason for not following the order must be documented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105783 If continuation sheet Page 2 of 5 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 10/06/2023 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to verify placement of a gastric feeding tube prior to medication administration for 1 of 2 residents reviewed for Tube Feeding of a total sample of 44 residents, (#68). Findings: Review of the medical record revealed resident #68 was admitted to the facility on [DATE] and readmitted from an acute care hospital on 8/23/23 with diagnoses that included anoxic brain damage, respiratory failure, malnutrition, dependence on ventilator, and gastrostomy (feeding tube) status. The Minimum Data Set admission assessment with Assessment Reference Date of 9/12/23 noted the resident was rarely/never understood, had severely impaired cognitive skills for daily decision making, and did not have any behavioral symptoms. The resident was totally dependent, required two staff to complete Activities of Daily Living (ADLs), and he received nutrition and hydration through a feeding tube. The Comprehensive Care Plan included medication administration with crushed medications administered through a feeding tube, dependency on a feeding tube for nutrition, hydration, and medications with goals the resident would remain free of complications. The interventions instructed nurses to verify the feeding tube placement prior to its use with checks for gastric contents/residual volume. The Order Summary Report showed physician orders from 6/14/23 to 8/24/23 for Enteral (Feeding tube) Check Placement (Continuous/Intermittent and Bolus) check placement before each medication administration, and active physicians orders for nothing by mouth, continuous enteral nutrition with Nepro (Nutrition formula) at 55 ML per hour for 20 hours, and enteral flushes after medication administration. The Medication Administration Record for October 2023 showed from 10/1/23 to 10/5/23, nurses administered medications through resident #68's feeding tube that included Levothyroxine 100 Micrograms (MCG) for thyroid disorder, magnesium oxide 400 Milligrams (MG), Potassium Sodium phosphates, 280-160-250 MG, and Potassium Chloride 20 Milliequivalents (MEQ) for deficiencies, Zinc 50 MG, Juven (supplement), Vitamin C 500 MG, and House Protein 30 Milliliters (ML) for wound healing, Hydrocortisone 10 MG for itching, Keppra 250 MG for seizures, Metoprolol Tartrate 25 MG for blood pressure, Pantoprazole Sodium 40 MG for gastroesophageal reflux disease, Midodrine HCI 15 MG for blood pressure, Renal-Vite multivitamin for kidney failure, and Miralax, 17 Grams (GM), for constipation. On 10/4/23 at 11:53 AM, Registered Nurse (RN) B was observed for Medication Administration for resident #68. RN B did not check for proper feeding tube placement by residual gastric (stomach) contents with a syringe or by listening for gurgling noises with a stethoscope before she manually pushed medications followed by water flushes with a syringe, nine times. On 10/4/23 at 12:19 PM, RN B said nurses were expected to check for proper placement before they administered medications into a feeding tube. RN B acknowledged she had not confirmed proper tube placement before she administered the medications. She said, you're correct I forgot. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105783 If continuation sheet Page 3 of 5 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 10/06/2023 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 10/4/23 at 2:09 PM, the Seashell Unit Manager said the facility policy instructed nurses to check residual gastric contents prior to medication administration through a feeding tube. She said the normal process was to administer medications by gravity, and not by push. On 10/4/23 at 2:49 PM, the Director of Nursing said she expected nurses to check for proper placement prior to feeding tube use, and gravity administration was preferred. She explained the use of a syringe by manual push could rupture the balloon. Review of the facility's policy titled, 17.2 Checking Gastric Residual Volume (GRV), read, Steps in the Procedure . 4. Attach sixty (60) ml syringe to end of catheter tube. 5. If catheter is clamped, unclamp catheter. 6. Aspirate stomach contents (GRV) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105783 If continuation sheet Page 4 of 5 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 10/06/2023 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Based on interview, and record review, the facility failed to provide Corona Virus Disease 2019 (COVID-19) vaccine for 1 of 5 residents and failed to offer the COVID-19 vaccine to 2 of 5 residents out of a total sample of 44 residents reviewed for immunizations, (#33, #64). Findings: 1. Review of resident #33's medical record showed no COVID-19 consent for the year 2022. The care plan initiated 7/24/20 and revised on 1/12/23 revealed a problem for COVID-19 infection with a goal and intervention to administer the COVID-19 vaccine through the pharmacy vaccine clinic. The medical record did not reveal a COVID-19 2022 consent for resident #33. On 10/06/23 at 4:13 PM, the Assistant Director of Nursing (ADON)/Infection Preventionist stated there was no COVID medication administration record from the previous facility where the resident resided. She noted administration would be documented on resident #33's COVID card if she received the COVID-19 vaccine. Review of the COVID-19 card for resident #33 revealed no administration of the vaccine for 2022. The ADON/Infection Preventionist confirmed documentation on the COVID-19 card showed the resident received the vaccine in 2021, not 2022. On 10/06/23 at 4:41 PM, the ADON/Infection Preventionist stated there was no 2022 consent for the COVID-19 vaccine. She validated she did not know if the COVID-19 vaccine was offered to the resident or her representative in the year of 2022. Further review of the medical record revealed no physician orders and no documentation of administration of COVID-19 vaccine being administered in 2022. 2. Review of the medical record revealed resident #64's COVID 19 consent form dated 4/21/22 with comment Verbal consent via daughter . at 7:30 PM, witnessed by 2 nurses on 4/21/22. Review of the facility immunization report revealed COVID-19 vaccine was consented to be received, but there was no documentation of the vaccine being administered. The facility was unable to provide documentation of the medication administration record (MAR) showing administration of the COVID-19 vaccine in 2022. There was no documentation of a physician order to administer the COVID-19 vaccine in 2022. On 10/4/23 at 6:16 PM, the ADON/Infection Preventionist stated newly admitted residents were offered immunizations including COVID-19 vaccine at admission. She explained she kept track of the immunizations and vaccines by printing the census, and then comparing the consent to the residents that received or declined the vaccine. She stated it was her responsibility to ensure COVID-19 vaccine was administered to the residents, and the consents were current. Review of the medical records revealed no consent for the COVID-9 vaccine being offered in 2022 for resident #33. Resident #64's medical record revealed a signed consent for COVID-19 vaccine but no physician order for the vaccine to be administered in 2022. Review of the facility's policy, Vaccination of Residents revised on 8/3/23 showed all residents will be offered vaccines that aid in the preventing of infectious diseases. If vaccines are refused they shall be documented in the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105783 If continuation sheet Page 5 of 5