Health inspection·July 24, 2025

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete ensuring grievances were investigated and addressed within five days. She reported when she received a grievance, she determined whether interviews with a resident or family were needed for clarification and assigned to the appropriate department for investigation and resolution. She stated she ensured it was thoroughly investigated and resolved. She indicated all grievances were discussed in morning meetings. The SSD confirmed resident #9's grievance would have been discussed during the morning meeting on 7/11/25. The SSD stated the former DON was not present during that meeting, but the Assistant DON and the UM were. On 7/22/25 at 12:18 PM, the Social Services Assistant and the Administrator (NHA) presented resident #9's grievance form and the attached email from the resident's son. The NHA stated the SSD forwarded the email from resident #9's son to the former DON and NHA on 7/10/25. The NHA first stated both DON and NHA were on vacation at the time the email was sent, then last week, they were both separated from employment at the facility. The NHA shared that this concern was brought to her yesterday, and she contacted the son. The NHA stated the UM wanted clarification from the former DON but had received no response, when asked why the UM did not address the grievance herself in a timely manner. On 7/23/25 at 10:26 AM, during a telephone interview, Registered Nurse (RN) B stated resident #9 had dialysis on Monday, Wednesday and Friday and was usually gone by the time she came in to work those days at 7:00 AM. RN B indicated on Wednesday 7/09/25, she came in approximately 10 to 15 minutes late to work, and she did not receive a complete report from the prior shift. She shared she began her rounds and upon entering resident #9's room, her CNA informed her resident #9 was in distress. She stated she assessed resident #9 and called 911. She indicated when she called resident #9's son, his wife had more questions, but she did not know much because she had just gotten there. She shared she talked to the UM after resident #9 was sent to the hospital but no one else mentioned or asked her anything about it. On 7/23/25 at 11:37 AM, the [NAME] Wing UM stated she was responsible for oversight of nurses and Certified Nursing Assistants on her unit. The UM indicated resident #9's situation was supposed to be discussed with the DON, but she never had the opportunity. She stated she did not see the email from resident #9's son until later and reported it was not reviewed promptly due to leadership turnover. She shared she did not speak to resident #9's son during the resident's hospitalization because the event was intended to be reviewed upon the resident's return from the hospital. Review of the facility policy and procedure titled Grievances last reviewed in January 2024 revealed, Upon receipt of a grievance and/or complaint, the Grievance Officer will investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and/or complaint. The Administrator will review the findings with the person investigating the complaint to determine what corrective actions, if any, need to be taken. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. A written summary of the investigation will also be provided to the resident, and a copy will be maintained in the grievance log. Event ID: Facility ID: 106024 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 106024 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare College Park 730 Courtland Street Orlando, FL 32804 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 0610 Respond appropriately to all alleged violations. 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 report allegations of neglect to the Agency for Health Care Administration (AHCA) and conduct a thorough investigation for 2 of 3 residents, of a total sample of 12 residents, (#7 and #8).Findings:1. Review of resident #7's medical record revealed he was originally admitted to the facility on [DATE] and readmitted from an acute care hospital on 4/07/25. Resident #7's diagnoses included hemiplegia (one-sided paralysis) and hemiparesis (one-sided weakness) following a stroke affecting his left non-dominant side, contracture of the left knee, and muscle weakness. Review of the Minimum Data Set (MDS) significant change in status assessment dated [DATE] revealed resident #7's Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated moderate cognitive impairment. The assessment revealed he was dependent on staff for all Activities of Daily Living (ADLs) except for eating, and dependent on staff for mobility and transfers. The MDS indicated resident #7 had a functional range of motion impairment on one side of an upper and lower extremity. The MDS assessment showed he was always incontinent of bladder and bowel. Review of resident #7's care plan for ADL self-care performance deficit related to hemiplegia, limited mobility, wounds, left knee contracture, memory deficit, and muscle weakness was initiated on 12/09/24 and revised on 7/13/25. The care plan noted resident #7 required one-person assistance for dressing, personal hygiene, and toilet hygiene. An intervention of bed mobility indicated the resident was totally dependent on two-person assistance for repositioning and turning in bed. Review of a Change in Condition Evaluation dated 3/24/25 revealed resident #7 was observed on the floor and sent to the emergency room (ER) for treatment and evaluation. The form noted resident #7 was alert with confusion. Review of a progress noted dated 3/24/25 revealed resident #7's assigned nurse was passing medications when he heard the resident yelling that he hit his head. The note described the nurse entered the resident's room at 8:10 PM and saw resident #7 on the right side of his bed on the floor. The progress note included resident #7 was near the air conditioner unit by the window with his head underneath the chair located next to his bed. The nurse documented resident #7 stated he hit his head on the floor, the resident was not moved, he was dry, and the call light was clipped to his bed. The note included the nurse asked resident #7 how he ended up on the side of the bed and the resident responded he had a stroke six months ago and could not really think straight but the sheets made me slip. The nurse's note revealed resident #7 had an abrasion to the right side of his head and was sent to the ER. Review of resident #7's care plan for risk for falls related to deconditioning, gait/balance problems, incontinence, psychoactive drug use, and vision was initiated on 12/09/24. An intervention for a concave pressure-reducing foam mattress was added on 3/26/25. Review of a Change in Condition Evaluation dated 6/25/25 revealed resident #7 fell from his bed, was observed on the floor, and blood was noted as coming from his forehead. He was sent to the ER. Review of a progress note dated 6/25/25 revealed, Resident's CNA (Certified Nursing Assistant) stated to the writer of this note that while changing the resident he turned back on his left side and rolled off the bed. CNA was positioned on the left side of the bed close to the bed B window. While resident was noted on the R.T (right) side of the bed on the floor which is close to the room door. CNA yelled for the nurse to attend to the resident. Resident appeared to have an abrasion or cut noted on his forehead. The writer of this note went to the treatment cart and retrieved an ABD (abdominal) pad to place over the abrasion while 911 was being called. Resident was not moved until 911 arrived at the building. He was placed on the stretcher and taken to [name of hospital]. Resident is out [of] the building at this time. Review of the Five-day Nursing Home Federal Report submitted to AHCA on 6/29/25 revealed an alleged neglect incident for resident #7 on 6/25/25 at Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106024 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 106024 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare College Park 730 Courtland Street Orlando, FL 32804 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 12:40 AM. The AHCA report was completed by the Risk Manager. The report noted resident #7's assigned CNA reported that while changing the resident he turned back on his left side and rolled off the bed. CNA was positioned on the left side of the bed close to the bed B window. CNA yelled for the nurse to attend to the resident. Resident appeared to have an abrasion or cut noted on his forehead. The report included Interviews were completed with alert and oriented residents on that assignment- all of whom expressed satisfaction with the care and the facility. Skin assessments completed with the non interviewable [residents] - no new findings identified. The conclusion read, After a thorough investigation was concluded, but not limited to staff and resident interviews, chart reviews, the facility finds no physical abuse occurred. The findings were not verified. On 7/23/25 at 4:06 PM, the Risk Manager (RM) explained she was responsible for initiating investigations, gathering statements, reporting findings to superiors, contacting the Department of Children and Families (DCF), the police and AHCA. She indicated she completed the immediate and the five-day reports required for abuse and neglect allegations. She stated once the investigation was finished, it was discussed with the interdisciplinary team and the conclusion was determined as a team. She shared this was her first time in the RM's role. She indicated she learned about the neglect allegation for resident #7 on 6/25/25 by phone call received from the former Director of Nursing (DON). She stated she collected witness statements and submitted the immediate report on 6/26/25. The Risk Manager mentioned she completed a witness statement when she interviewed resident #7, but she did not have it in her file because the former DON kept it. She shared resident #7 told her it was not the CNA's fault and, it was his fault because he kept pushing backwards during care and rolled off the bed. She shared Social Services staff conducted interviews with other alert and oriented residents in the same hall CNA A worked regarding abuse and neglect and there were no concerns. When asked for evidence of the witness statements collected during the investigation, she indicated she had only one statement, from CNA A. She stated it was concluded the neglect could not be verified based on the resident's statement. She showed the one witness statement she collected during the investigation from CNA A. She added the CNA dropped off her written statement, but she did not personally interview her. She validated CNA A did not indicate whether there were two CNAs in her statement and the RM did not clarify if there was another staff assisting the CNA when moving resident #7 while providing care. After stepping out at 4:33 PM, for a few minutes to speak with the Regional Nurse Consultant (RNC), the RM returned and shared she had been under the directive of the former Administrator (NHA) and DON to stop the investigation. She indicated she was told it was based on resident #7's interview and that he required one assist for personal hygiene, so the CNA was good. She stated she did not interview anyone else after that. Review of the Witness Statement by CNA A dated 6/25/25 read, Around 12:30 I was changing [resident #7's name] when he kept pushing back and rolling. I said to him you are going to fall stop doing that. He was yelling you see she is trying to kill me. His roommate said to him be quiet don't say that. I caught him twice but when I went to the other side of the bed to put the clean sheet on, he flip himself over again. I was not able to catch him that time; he hit the floor and hit his head on the table. 2. Review of resident #8's medical record revealed she was originally admitted to the facility on [DATE] and readmitted from an acute care hospital on 2/23/25. Her diagnoses included hypokalemia (low levels of potassium on the blood), ileus (paralysis of the intestine), cirrhosis of liver, type 2 diabetes, and chronic obstructive pulmonary disease. Resident #8 was transferred to the hospital on 3/07/25. Normal levels of potassium (K) for an adult range from 3.5 to 5.2 milliequivalents per liter (mEq/L). Anything lower than 3 mEq/L may be considered severe hypokalemia. The body needs potassium for cells, muscles and nerves to function correctly. The body receives potassium through (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106024 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 106024 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare College Park 730 Courtland Street Orlando, FL 32804 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete food, (retrieved from www.clevelandclinic.org on 7/25/25). Review of the MDS quarterly assessment dated [DATE] revealed resident #8's BIMS score was 14/15 which indicated she was cognitively intact. Review of resident #8's care plan revealed a focus for history of non- compliance with her plan of care and refused medication at times, initiated on 2/27/25. Review of a Change in Condition Evaluation dated 2/18/25 revealed resident #8's laboratory results were abnormal, noting her K was 2.8 mEq/L and ileus. The Nurse Practitioner advised facility staff to send resident #8 to the ER for further evaluation and treatment. The evaluation indicated, ‘Due to ileus and potassium level of 2.5, since resident is refusing to take medications. Review of a Nutrition at Risk note dated 2/11/25, revealed through a review of CNA documentation and interview, resident #8 refused meals from lunch on 2/06/25 to dinner on 2/08/25. Nursing progress notes from 2/06/25 to 2/08/25 showed the resident was on leave of absence with her family during that time. Review of a progress note dated 2/04/25 showed she was encouraged and educated to take the K supplement to prevent heart arrythmias. She was going away for the weekend, and the physician gave orders to take a three-day supply of medications. Review of a Change in Condition Evaluation dated 3/07/25 revealed resident #8 was sent to the hospital because she was lethargic. Review of the Five-day Nursing Home Federal Report submitted to AHCA on 5/02/25 revealed an alleged neglect incident for resident #5 on 3/07/25 at 11:41 AM. The AHCA report was completed by the RM. The Analysis section which required a summary of the interviews read, Staff and residents in the same wing as former resident [resident #8's name] were interviewed with no verbalization of concerns to care being given by any staff. The report concluded, After complete and through investigation that included [but] not limited to staff and resident interviews, lab and chart reviews the facility finds that no neglect occurred. On 7/24/24 at 10:41 AM, during an interview with the new NHA, Regional Director of Operations (RDO), RM, and RNC, the RNC stated the former RM, who conducted the investigation for resident #8, had completed a full medical review, however she confirmed no witness statements could be located. The RDO recalled witness statements were collected during the investigation, but said she suspected the facility was being sabotaged. She added the RNC assisted in collecting those statements which were completed while on site. The RDO acknowledged the content of the interviews was not included in the five-day report submitted to AHCA and stated the former NHA, was not addressing the issues correctly. The RDO and RNC indicated they visited the facility the previous week and identified inadequacies in how resident fall investigations were being handled. The RNC stated the allegation of neglect was unsubstantiated based on the medical record review. Review of the facility policy and procedure titled Incident Report & Investigation Guidelines last reviewed on 12/10/24 revealed the facility would document, investigate, and record on an Incident Report & Investigation form All falls, . alleged neglect, . or other events leading to harm or injury to a visitor or resident occurring in the facility. The document included, A thorough investigation of each incident should be completed by the Facility Risk Manager and the Director of Nursing if potential for adverse the facility Administrator to be notified immediately. Interviews should be conducted with the resident and witnesses, whenever possible, with findings documented on the Risk Management Interview Record form. Event ID: Facility ID: 106024 If continuation sheet Page 5 of 5