Inspection·December 22, 2022

F 0684 day every Mon, Wed, Fri [Monday, Wednesday, Friday]. Level of Harm - Minimal harm or potential for actual harm Review of the COMS-Pre/Post Dialysis Evaluation for Resident #73 revealed missing post dialysis evaluations for the following dates: 12/14/22, 12/9/22, 12/07/22, 11/30/22, 11/28/22, 11/25/22, 11/04/22, and 11/02/22. Residents Affected - Few During an interview on 12/22/22 at 7:45 AM Staff K, Licensed Practical Nurse (LPN) stated, [Resident #73's Name] goes to dialysis on Monday, Wednesday, and Friday, is on fluid restrictions, and is sometimes noncompliant. The nursing staff do the pre-dialysis evaluation and send her [to dialysis center] with a dialysis book and a snack. When she returns, we do the post dialysis evaluation. At times, the dialysis facility will not send the required information. The nurse will try to call and get the information. The post evaluation will be done even if we do not get information from the dialysis center to assess resident and make sure blood pressure is stable. Especially since dialysis patients are sometimes not stable. During an interview on 12/22/22 at 9:30 AM the DON confirmed Resident #73 had missing pre/post dialysis evaluations on some days. Review of the facility policy titled, Documentation Standards revised 1/22/22 reads,3. Nursing staff should chart by exception, as often as necessary, in addition to scheduled charting. 3. During an observation of IV medication administration for Resident #226 on 12/21/22 at 8:04 AM Staff D, Registered Nurse (RN) removed medication from medication cart, donned PPE (personal protective equipment) and entered Resident #226's room, turned on light and put gloves on with no hand hygiene performed. Staff D doffed PPE and exited room. Staff D went to get IV tubing from medication room, returned to med cart, unlocked med cart, and retrieved medication without hand hygiene. Staff D donned PPE and grabbed gloves, enter room, and applied hand sanitizer. Placed IV medication and supplies on top of night table without cleaning table or placing a barrier. Staff D connected the medication to the IV tubing, primed IV line, and inserted tubing into the IV pump. Staff D cleaned the needleless connector with alcohol and uncapped the 10 milliliters (ml) syringe of normal saline, removed the air. Staff D administered the 10 milliliters of normal saline without checking for blood return to verify placement of the line. Staff D removed the syringe and connected the IV tubing to the PICC line needleless connector without cleaning the needless connector. During an interview on 10:08 AM Staff D, RN stated, I am not sure if I need to check for blood return. 4. During an observation of IV (intravenous) medication and oral medication administration for Resident #91 on 12/21/22 at 9:48 AM Staff G, LPN removed medication from medication cart, donned PPE, and entered Resident #91's room, performed hand hygiene, and placed on gloves. Staff G placed IV medication and supplies on top of side table without cleaning table or placing a barrier. Staff G handed oral medication to resident. Staff G removed IV fluids and supplies from resident bedside table and placed it on resident's recliner. Staff G connected the fluids to the IV tubing, primed IV line, and inserted tubing into the IV pump. Staff cleaned the needleless connector with alcohol and uncapped the 10 ml syringe of normal saline and removed the air. Staff administered the 10 ml of normal saline without checking for blood return to verify placement of the line. Staff G removed syringe and needless connector came in to contact with resident bedrail. Staff G connected the IV tubing to the midline needleless connector without cleaning the needleless connector. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106119 If continuation sheet Page 2 of 11 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 106119 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Waterman 4501 Waterman Way Tavares, FL 32778 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 During an interview on 12/21/22 at 3:50 PM Staff G stated, I did not check for blood return. I was never informed to pull back. I haven't been in a hospital setting in a long time, and not aware if the new guidelines. During an interview on 12/21/22 at 2:59 PM the DON stated that the staff are expected to draw blood to verify placement of the line. Residents Affected - Few Review of the facility policy titled Administration of an Intermittent Infusion last reviewed 1/22/22, reads: Procedure .4. Perform hand hygiene. 5. Assemble equipment and supplies on a clean work surface 16. Maintain asepsis, attach flush syringe to needleless connector. Aspirate the catheter to obtain positive blood return to verify vascular access device patency. Flush with prescribed flushing agent. Remove syringe. 17. Perform a vigorous mechanical scrub to manually disinfect the needleless connector. Allow to air dry. Attach administration set to needless connector .24. Perform hand hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106119 If continuation sheet Page 3 of 11 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 106119 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Waterman 4501 Waterman Way Tavares, FL 32778 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review , the facility failed to ensure that drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles in 3 of 8 medication carts. Findings include: During an observation of medication cart #4 with Staff A, Licensed Practical Nurse (LPN), there were two bottles of artificial tears with no date opened or expiration date. During an interview on [DATE] at 9:50 AM Staff A, LPN, stated medication should be labeled with the date that it is opened and an expiration date as well. During an observation of medication cart #5 on [DATE] at 9:56 AM with Staff B, LPN, there was a bottle of Gentamicin 0.3% eye drops and Prednisolone AC 1% eye drops with no date opened or expiration date and a bottle of B Complex Vitamins with an expiration date 11/2022. During an interview on [DATE] at 10:04 AM Staff B, LPN, stated expired medication should be thrown away and eye drops should be dated. During an observation of medication cart #6 on [DATE] at 10:07 AM with Staff C, Registered Nurse, (RN), there was a bottle of Fexofenadine with expiration date of 11/2022 and a bottle of artificial tears with no date opened or expiration date. During an interview on [DATE] at 10:12 AM with Staff C, RN stated expired medication should be removed from medication cart and all medications should be dated with an opened and expire date. During an interview on [DATE] at 10:49 AM with Director of Nursing (DON) stated all medications should be labeled upon being opened. Expired medication should be tossed. Staff are expected to check their medication carts every day. Review of the facility policy titled Storage and Expiration Dating of Medications , Biologicals last reviewed [DATE] reads: .4. Facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or return to the pharmacy or supplier. 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for open medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened 5.4 When an ophthalmic solution or suspension has a manufacturer's shortened beyond use date once opened, facility staff should record the date opened and the date to expire on the container. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106119 If continuation sheet Page 4 of 11 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 106119 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Waterman 4501 Waterman Way Tavares, FL 32778 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to ensure foods and beverages were stored in a safe and sanitary manner in the main kitchen and in 8 of 8 nourishment areas. Residents Affected - Some Findings include: A tour of the facility main kitchen was completed with the Certified Dietary Manager on 12/19/2022 beginning at 9:30 AM. There was an undated bag of French fries, an undated opened bag of chicken nuggets, an undated opened bag of onion rings, 3 undated and unlabeled bags of pizza crust and an undated bag of hash brown potatoes stored in the reach in freezer. During an interview on 12/19/2022 beginning at 9:30 AM, the Certified Dietary Manager acknowledged the open, undated, and unlabeled food items were stored in the reach in freezer. A tour of the facility nourishment rooms was completed on 12/19/2022 beginning at 9:48 AM with the Certified Dietary Manager. On 12/19/2022 at 9:48 AM in the Low 200 Hall nourishment room, there was an undated, unlabeled container of takeout food stored in the microwave oven. On 12/19/2022 at 9:51 AM in the High 200 Hall nourishment room, there were brown and red substances splattered on the interior base of the freezer. On 12/19/2022 at 9:55 AM in the Low 400 Hall nourishment room, there was a brown substance splattered in the freezer, there was no thermometer in the freezer, there was food built up on the microwave oven plate and opaque splatters on the exterior front glass of the microwave oven. On 12/19/2022 at 9:59 AM in the High 400 Hall nourishment room, there were 3 thawed nutritional supplements with no thawed-on date stored in the refrigerator, there was a brown substance splattered on the lower side shelf of the refrigerator and a yellow substance splattered on the interior base of the freezer. On 12/19/2022 at 10:04 AM in High 300 Hall nourishment room, there was a sticky substance on the interior base of the refrigerator, there were 2 undated bagged slices of pizza in the refrigerator, 1 undated and unlabeled Styrofoam container stored in the refrigerator, and there was a brown built up sticky substance on the interior base of the freezer. On 12/19/2022 at 10:07 AM in the Low 300 Hall nourishment room, there was a sticky tan and pink substance splattered in the refrigerator, there was a thawed nutritional supplement with no thawed-on date stored in the refrigerator, and there was a sticky brown substance along the groove of the freezer rubber seal. On 12/19/2022 at 10:15 AM in the Activities Bistro, there was an undated, unlabeled squeeze bottle of a brown liquid and an undated, unlabeled squeeze bottle of yellow liquid stored in the refrigerator, there was an undated, unlabeled quarter full coffee carafe and an undated, unlabeled carafe of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106119 If continuation sheet Page 5 of 11 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 106119 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Waterman 4501 Waterman Way Tavares, FL 32778 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some pink liquid stored with the open top of the carafe wedged against a shelf stored in the refrigerator and there were oyster colored flakes scattered on the base of the freezer. On 12/19/2022 at 10:17 AM in the High 100 Hall nourishment room, there were 2 thawed nutritional supplements with no thawed-on date stored in the refrigerator, there were 2 undated pocket sandwiches stored in the refrigerator and there was an opaque substance on the microwave oven glass plate. On 12/19/2022 at 10:20 AM in the Low 100 Hall nourishment room, there were 2 thawed nutritional supplements with no thawed-on date stored in the refrigerator. There was a loose plastic seal hanging from the lower edge of the refrigerator. There were 2 undated breakfast sandwiches stored in the refrigerator and there was a pooled and splattered amber substance on the interior base of the freezer. During an interview on 12/19/2022 beginning at 9:30 AM, the Certified Dietary Manager acknowledged open, undated, and unlabeled food items were stored in the nourishment room refrigerators and freezers, he confirmed the nourishment rooms were in need of cleaning and he confirmed the thawed nutritional supplements stored in the refrigerators did not have a thawed-on date. Review of the nutritional supplement use instructions displayed on the nutritional supplement carton showed the use instructions read STORE FROZEN THAW AT OR BELOW 40 [degrees Fahrenheit] USE THAWED PRODUCT WITHIN 14 DAYS. Review of the policy titled Dietary Sanitation, last reviewed 1/22/2022, read Policy: The facility will store, prepare, distribute and serve food in accordance with professional standards for food service safety and Procedure: 1. Food service staff follow procedures that reduce potential for food borne pathogens, in storing, preparing and serving food 3. All refrigerators and freezers are equipped with a thermometer and regular scheduled readings are monitored by a staff member and written on the log for the corresponding location .4. Opened food packages and left over foods stored in the refrigerators are sealed and dated Cleaning and Maintenance: 1. Cleaning schedules for all equipment and areas of the dietary department are posted with completion of cleaning recorded by the staff member assigned. Review of the policy titled Food Brought in By Others, last reviewed 1/22/2022, read Policy: It is the policy of this facility to ensure the safety of the residents and to prevent foodborne illness and contamination. PROCEDURE: .2. Food brought in by family/visitors for residents will be stored accordingly to prevent the potential for food borne illnesses. 3. The facility will provide safe handling of the food once it is brought to the staff at the facility 2. Food brought in by visitors and families will be dated and stored in refrigerators on the units or in the residents rooms that are only for resident items. Prior to placing in the refrigerators the food containers will be inspected by facility staff for any leakage or odors or signs of spoilage. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106119 If continuation sheet Page 6 of 11 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 106119 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Waterman 4501 Waterman Way Tavares, FL 32778 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 - Few 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** 2. Review of the admission record documented Resident #91 was admitted to the facility on [DATE] with diagnoses including syncope and collapse, bradycardia, chronic kidney disease, lipoprotein deficiency, type II diabetes mellitus, atherosclerotic heart disease, dehydration, chronic osteomyelitis, and infection following a procedure. Review of Resident #91's Medication Administration Record for the month of December 2022 showed Staff J, Licensed Practical Nurse (LPN) administered Sodium Chloride Solution 5% - Use 1000 milliliters (ml) intravenously every shift for hydration infused 3 liters continuously on December 16th, 2022 during the day shift. Review of Written Statement from Staff J, LPN, reads, I get another certified nurse to handle them (intravenous medications) for me. Upon the beginning of my shift on 12/16/22, there was already IV (intravenous) fluids running on my patient in room [ROOM NUMBER] (Resident #91's Room). I only monitored throughout my shift. Review of written statement from Staff E, LPN reads, I am a Nurse Supervisor at [Name of Facility] and have been hanging and flushing IV medications for [Staff J's Name] .She has not been hanging them. Review of written statement from Staff I, LPN reads, I'm the Nurse Supervisor on the 3PM to 11PM shift at [Name of Facility] and have been hanging and flushing IV medications in assistance for IV administration. I assist [Staff J's Name] with regards to IV administration and flushing. During the interview on 12/20/22 at 1:15 PM the DON confirmed Staff J, LPN, was documented as administering the IV fluids on Resident #91 Medication Administration Record. Based on interview, and record review the facility failed to maintain accurate and complete medical records for 1 of 2 residents reviewed for pressure ulcers (Resident #42) and 1 of 5 residents reviewed for IV (Intravenous) therapy (Resident #91). Findings include: 1. Review of the admission record for Resident #42 documented the resident was admitted to facility on 6/10/2022 with diagnosis that included but not limited to multiple sclerosis, essential hypertension, functional quadriplegia, dysphagia, neuromuscular dysfunction of bladder, and pressure ulcer of sacral region stage 3. Record review of the physician orders dated 11/21/2022 reads: Dakins (1/2 strength) solution 0.25 % (sodium hypochlorite) apply to sacrum topically every day shift for wound on sacrum apply Dakins wet to dry to dry to sacrum with 4x4's and cover with calcium alginate and foam dressin [sic] daily. Review of the skin and wound evaluation dated 12/20/2022 reads: A. Describe: 1. Type: 15. Pressure. 15a. Stage: 3. Stage 3: Full Thickness skin loss. Review of skin and wound evaluation dated 11/21/2022 reads: A. Describe: 1. Type: 15. Pressure. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106119 If continuation sheet Page 7 of 11 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 106119 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Waterman 4501 Waterman Way Tavares, FL 32778 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 15a. Stage: 3. Stage 3: Full Thickness skin loss. Level of Harm - Minimal harm or potential for actual harm Review of skin and wound evaluation dated 11/14/2022 reads: A. Describe: 1. Type: 15. Pressure. 15a. Stage: 3. Stage 3: Full Thickness skin loss. Residents Affected - Few Review of the specialty physician wound evaluation and management summary dated 12/15/2022 for Resident #42 reads: Chief Complaint: Patient presents with a wound on her sacrum. History of present illness: At the request of the referring provider, [providers name], a thorough wound care assessment and evaluation was performed today. She [Resident #42] has a stage 4 wound sacrum for at least 174 days duration. There is moderate serous exudate. There is no indication of pain associated with this condition. Review of the specialty physician wound evaluation and management summary dated 11/17/2022 for Resident #42 reads: Chief Complaint: Patient presents with a wound on her sacrum. History of present illness: At the request of the referring provider, [providers name], a thorough wound care assessment and evaluation was performed today. She [Resident #42] has a stage 4 wound sacrum for at least 167 days duration. There is moderate serous exudate. There is no indication of pain associated with this condition. During an interview on 12/21/2022 at 11:47 AM the Director of Nursing (DON) stated once a pressure sore is staged by [the specialty physicians] that is what we will consider the stage to be. We have meetings on Tuesday, and we review all wounds. [The specialty physicians] will have report with the wound care nurse. During an interview on 12/21/022 at 10:17 AM Staff H, Licensed Practical Nurse (LPN), stated that [Resident #42 name] has a stage 3 pressure ulcer which was staged by [the specialty physicians] and has improved. When Staff H, LPN reviewed [the specialty physicians] notes, Staff H confirmed [the specialty physicians] notes stated the wound was a stage 4. Staff H stated I do not know why I said stage 3. I got confused due to the report saying MDS 3. During an interview on 12/22/2022 at 9:25 AM the DON confirmed [Resident #42's name] pressure ulcer was documented as a stage 3 incorrectly. The DON stated [Resident #42's name] has a stage 4 pressure ulcer, not a stage 3. Review of the facility policy titled Documentation Standards last reviewed on 1/22/2022 reads: Policy: It is the policy of this facility that documentation will reflect medical presence, team approach, and clinical decision making to promote quality of care. Documentation standards will follow established professional ethics and practices Guidelines 4. Documentation content should be clinically pertinent. 5. Charting should contain specific and accurate details to inform staff, demonstrate awareness of resident's condition, and/or problems, and facilitate quality of care. Record significant changes in the resident changes in the resident's condition, response to treatment/medications follow-up with physician/allied health professionals, and notification of resident /representative. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106119 If continuation sheet Page 8 of 11 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 106119 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Waterman 4501 Waterman Way Tavares, FL 32778 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 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Potential for minimal harm Based on record review and interview the facility failed to ensure the arbitration agreements presented to 3 residents, Resident #126, Resident #127 and Resident #226, of 3 residents reviewed explicitly granted the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing the agreement and explicitly stated that neither the resident nor his or her representative was required to sign an agreement for binding arbitration as a condition of admission or as a requirement to continue to receive care at the facility. Residents Affected - Many Findings include: Review of the facility Voluntary Binding Arbitration Agreements presented to Resident #126 on 12/14/2022, presented to Resident #127 on 12/16/2022 and presented to Resident #226 on 12/16/2022 failed to explicitly grant the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing the agreement and failed to explicitly state that neither the resident nor his or her representative was required to sign an agreement for binding arbitration as a condition of admission to or as a requirement to continue to receive care at the facility. During interview on 12/21/2022 at or about 12:07 PM, the Administrator reported the facility had revised the arbitration form to include explicitly granting the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing the agreement and to explicitly state that neither the resident nor his or her representative was required to sign an agreement for binding arbitration as a condition of admission to or as a requirement to continue to receive care at the facility, but facility staff had not used the revised form. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106119 If continuation sheet Page 9 of 11 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 106119 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Waterman 4501 Waterman Way Tavares, FL 32778 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to prevent the possible spread of infection during intravenous (IV) medication administration and by not performing hand hygiene for 3 of 6 medication administration observations. Residents Affected - Some Findings include: During an observation of IV medication administration for Resident #226 on 12/21/22 at 8:04 AM, Staff D, Registered Nurse (RN), removed medication from medication cart, donned PPE (personal protective equipment) and entered Resident #226's room, turned on light and put gloves on with no hand hygiene performed. Staff D doffed PPE and exited room. Staff D went to get IV tubing from medication room, returned to med cart, unlocked med cart, and retrieved medication without hand hygiene. Staff D donned PPE and grabbed gloves, entered the room, and applied hand sanitizer. Staff D placed IV medication and supplies on top of night table without cleaning table or placing a barrier. Staff D connected the medication to the IV tubing, primed IV line, and inserted tubing into the IV pump. Staff D cleaned the needleless connector with alcohol and uncapped the 10 milliliters (ml) syringe of normal saline and removed the air. Staff D administered the 10 milliliters of normal saline without checking for blood return to verify placement of the line. Staff D removed the syringe and connected the IV tubing to the Peripherally Inserted Central Catheter (PICC) line needleless connector without cleaning the needless connector. During an interview on 12/21/22 at 8:17 AM, Staff D, RN stated, I should have done hand hygiene when returning from the medication room and cleaned the needleless connector after flushing before connecting the IV tubing. During an observation of medication administration on 12/21/22 at 8:22 AM, Staff K, Licensed Practical Nurse (LPN), exited a resident room, returned to the medication cart and without performing hand hygiene prepared medications for Resident #426. Staff K took medication with her to the medication room to retrieve medication which was missing from medication cart. No hand hygiene performed upon return. Staff K opened and labeled medication. Staff K entered the resident's room without performing hand hygiene, administered medications to Resident #426. Staff K administered nasal spray to Resident #426 without wearing gloves. During an interview on 12/21/2022 at 8:41 AM, Staff K, stated, I should have performed hand hygiene. I brought gloves inside the room with me to use them but forgot. I got nervous. During an observation of medication administration on 12/21/22 at 8:45 AM, Staff F, LPN, exited a resident room, returned to the medication cart, and prepared medications for Resident #6. Staff F entered the resident's room without performing hand hygiene and placed gloves on. Staff F exited the room with gloves on and retrieved a spoon from medication cart. Staff F entered the resident room without performing hand hygiene. Staff F administered medications to Resident #6 . During an interview on 12/21/2022 at 8:55 AM, Staff F, LPN, stated, I should have performed hand hygiene when I entered the room and removed my gloves and performed hand hygiene when exiting and re-entering residents room. During an observation of IV medication and oral medication administration for Resident #91 on 12/21/22 at 9:48 AM, Staff G, LPN, removed medication from medication cart, donned PPE, and entered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106119 If continuation sheet Page 10 of 11 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 106119 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Waterman 4501 Waterman Way Tavares, FL 32778 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #91's room, performed hand hygiene, and placed on gloves. Staff G placed IV medication and supplies on top of side table without cleaning table or placing a barrier. Staff G handed oral medication to the resident. Staff G removed IV fluids and supplies from resident bedside table and placed it on the resident's recliner. Staff G connected the fluids to the IV tubing, primed IV line, and inserted tubing into the IV pump. Staff G cleaned the needleless connector with alcohol and uncapped the 10 ml syringe of normal saline and removed the air. Staff G administered the 10 ml of normal saline without checking for blood return to verify placement of the line. Staff G removed the syringe and needless connector came in to contact with resident bedrail. Staff G connected the IV tubing to the midline needleless connector without cleaning the needleless connector. During an interview on 12/21/22 at 10:08 AM, Staff G, LPN, stated, I should have cleaned the needleless connector before connecting the tubing to the needleless connector. During an interview on 12/21/022 at 10:52 AM, the Director of Nursing stated, Staff are expected to perform hand hygiene before and after they touch the medication and in between if needed. Staff are expected to clean the needleless port before flushing. Review of the facility policy titled Hand Hygiene, last reviewed on 1/22/2022 reads: 5. Hand Hygiene shall be performed for the following situations: before preparing or handling medications .7. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare associated infections. Review of the facility policy titled Administration of an Intermittent Infusion, last reviewed on 1/22/2022 reads: Procedure: . 4. Perform hand hygiene, 5. Assemble equipment and supplies on a clean work surface . 16. Maintain asepsis, attach flush syringe to needleless connector. Aspirate the catheter to obtain positive blood return to verify vascular access device patency. Flush with prescribed flushing agent. Remove syringe. 17. Perform a vigorous mechanical scrub to manually disinfect the needleless connector. Allow to air dry. Attach administration set to needleless connector . 24. Perform hand hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106119 If continuation sheet Page 11 of 11