Health inspection·April 25, 2024

F 0641 Level of Harm - Minimal harm or potential for actual harm be made using the most recent version of the Resident Assessment Instrument. Policy Interpretation and Implementation: The assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conducts timely resident assessment and reviews according to the most recent RAI [Resident Assessment Instrument] manual specifications. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106119 If continuation sheet Page 2 of 9 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 04/25/2024 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 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure residents received medication as per physician order for 1 of 6 residents reviewed for blood pressure medication, Resident #106. Residents Affected - Few Findings include: Review of Resident #106's physician order dated 3/15/2024 read, Midodrine HCl Oral Tablet 5 MG [milligram] (Midodrine HCl) Give 1 tablet by mouth every 8 hours for hypertension hold if SBP [Systolic Blood Pressure] greater than 130. Review of Resident #106's Medication Administration Record for April 2024 showed the resident received Midodrine 5 mg on 4/1/2024 at 2:00 PM with the blood pressure of 150/91, on 4/4/2024 at 2:00 PM with the blood pressure of 164/94 and at 10:00 PM with the blood pressure of 160/90, on 4/8/2024 at 10:00 PM with the blood pressure of 150/67, on 4/13/2024 at 10:00 PM with the blood pressure of 146/93, on 4/14/2024 at 6:00 AM with the blood pressure of 146/93, and on 4/22/2024 at 2:00 PM with the blood pressure of 138/83. During an interview on 4/24/2024 at 9:21 AM, the Director of Nursing stated, It was a medication error. I spoke with the doctor and the resident. Doctor stated we need to continue with the medication and resident had no adverse effects. During an interview on 4/24/2024 at 9:35 AM, Physician #1 provided no comment on possible side effects of administration of Midodrine 5 mg to Resident #106 when the blood pressure is greater than 130. During an interview on 4/24/2024 at 11:05 AM, Physician #2, Cardiologist, stated, Midodrine 5 mg is a very low dose. In cardiology, we do not use it. It is very insufficient. I spoke to the resident [Resident #106] and she had no side effects. Extra 5 mg of Midodrine is not going to have any major impact overall. It is not a very good vasopressor, but sometimes it is all we got. Review of the facility policy and procedure titled Medication Administration- General Guidelines with the last review date of 1/16/2024 read, Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so . Procedures . B. Administration . 2) Medications are administered in accordance with written orders of the prescriber. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106119 If continuation sheet Page 3 of 9 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 04/25/2024 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure residents were not served known allergen food items for 1 of 6 residents reviewed for nutrition, Resident #419. Residents Affected - Few Findings include: During an interview on 4/22/2024 at 10:12 AM, Resident #419 stated, I have been here in the facility for a few days. The food is not good. They give chicken twice a day. If you do not like it, they give you either a peanut butter sandwich which I am allergic to or turkey sandwich. During an observation on 4/22/2024 at 12:30 PM, Resident #419 was eating lunch in her room. The tray included a ham sandwich wrapped in plastic with a piece of lettuce and tomato garnish on the plate (Photographic evidence obtained). During an interview on 4/22/2024 at 12:30 PM, Resident #419 stated, If I had tomato, I would swell up. If it would have been on the sandwich, I would not be able to eat it. The sandwich came wrapped individually from the tomato. Review of Resident #419's admission record showed the resident was allergic to to Lisinopril, sulfa antibiotics, almond oil, peanuts, and tomato. Review of Resident #419's hospital records provided from the discharging hospital documented, intolerance to tomato. Review of Resident #419's meal ticket read, Allergies: Peanuts, Tomato/Almond Oil. During an interview on 4/24/2024 at 12:28 PM, Staff C, Certified Nursing Assistant (CNA), stated, Allergies are on the meal ticket. The resident tells us what they want, and we go and get it from the kitchen. We will lift the plate lid and see that it is appropriate for the resident. During an interview on 4/24/2024 at 12:43 PM, the Regional Dietary Manager stated, It was definitely an overlook. We have a system in place. The meals get checked three times and then also checked by the CNA. If they request an alternative, the CNA goes back and checks at that point. Review of the facility policy and procedure titled Tray Identification with the last review date of 1/16/2024 read, Policy Statement: Appropriate identification/coding shall be used to identify various diets. Policy Interpretation and Implementation . 2. The Food Services Manager or designee will check trays for correct diets before the food carts or meal trays are transported to their designated areas. 3. Nursing staff shall check each food tray for the correct diet before serving the residents. Review of the facility policy and procedure titled Food Allergies and Intolerances with the last review date of 1/16/2024 read, Policy Statement: Residents with food allergies and/or intolerances will be identified upon admission and steps will be taken to prevent resident exposure to the allergens. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106119 If continuation sheet Page 4 of 9 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 04/25/2024 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 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 ensure residents received the appropriate enteral feed for 1 of 3 residents reviewed for enteral feed administration, Resident #170. Findings include: Review of Resident #170's admission record showed the resident was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis, chronic respiratory failure with hypoxia, type 2 diabetes mellitus, dementia, and gastrostomy status. During an observation on 4/23/2024 at 1:45 PM, Resident #170's enteral feed pump was running at 70 ml/hr (milliliters/hour) (Photographic evidence obtained). Review of Resident #170's physician order dated 4/18/2024 read, Enteral Feed Order two times a day Enteral Glucerna 1.5 cal/ml [calorie/ milliliter] @ [at] 80 ml/hr x 20 hours. Off at 10 am and On at 2 pm (total volume 1600 ml). Review of Resident #170's care plan dated 4/17/2024 read, Focus: Resident requires enteral tube feeding for nutrition . Interventions . Enteral feeding as ordered. During an interview on 4/23/2024 at 2:00 PM, Staff E, licensed Practical Nurse (LPN), stated, I see his pump is running at 70 ml/hr. His order reads 80 ml/hr. The rate needs to be changed. During an interview on 4/25/2024 at 10:00 AM, the Director of Nursing stated his expectation for nurses when initiating enteral feed was to verify the order and set the pump to the administration rate in the current order. Review of the facility policy and procedure titled, Enteral Tube Feeding via Continuous Pump dated 1/25/2023 and last reviewed on 1/16/24 read, Purpose: The purpose of this procedure is to provide nourishment to the resident who is unable to obtain nourishment orally. Preparation: 1. Verify that there is a physician's order for this procedure . General Guidelines . 3. Check the enteral nutrition label against the order before administration. Check the following information . g. rate of administration ml/hour. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106119 If continuation sheet Page 5 of 9 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 04/25/2024 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 1 of 4 nourishment rooms. Residents Affected - Few Findings include: During an observation while conducting a tour of the facility's nourishment rooms with the Certified Dietary Manager on 4/22/2024 beginning at 9:38 AM, there were an unlabeled and undated plastic grocery bag with 2 containers of unidentifiable food on the top shelf of the refrigerator, an unlabeled Taco Bell bag containing one Taco with the date of 4/7/2024, an unlabeled Burger King bag containing a cheese burger and French fries with the date of 4/13/2024, and an unlabeled and undated Wendy's bag containing a burger and side salad in the right side drawer of the refrigerator, and four pieces of celery wrapped in saran wrap with a date of 4/13/2024 in the butter tray of the refrigerator in the 400 hall nourishment room. During an interview on 4/22/2024 approximately at 9:40 AM, the Certified Dietary Manager acknowledged the expired and/or undated and unlabeled foods in the refrigerator and stated, Everything should be labeled with the resident's room number and the dates marked on it. I have posted the policies and there seems to be a problem with this hall only. Review of the facility policy and procedure titled Storage of Foods Brought to Residents by Family/Visitors dated 2/9/2023 and last reviewed on 1/16/24 read, Policy Interpretation and Implementation . 6. Perishable foods must be stored in a manner which minimizes risk of cross contamination in the designated resident refrigerators. These foods will be labeled with the resident's name and dated. 7. The nursing staff is responsible for discarding perishable foods within 3 days or before the use by/expiration date, whichever comes first. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106119 If continuation sheet Page 6 of 9 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 04/25/2024 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 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observation, interview, and record review, the facility failed to ensure resident records were complete and accurate for 1 of 2 residents sampled for oxygen therapy, Resident #417. Residents Affected - Few Findings include: During an observation on 4/22/2024 at 9:31 AM, Resident #417 was sitting up in a recliner in his room, receiving oxygen via nasal cannula at 2 liters per minute. During an observation on 4/23/2024 at 1:30 PM, Resident #417 was sitting up in a recliner in his room, receiving oxygen via nasal cannula at 2 liters per minute. Review of Resident #417's physician order dated 4/11/2023 read, (ACC-OXYGEN) Oxygen (Specify L/Min [liter/minute] and via device) every shift for COPD [Chronic obstructive pulmonary disease] and SOB [Shortness of breath]. During an interview on 4/23/2024 at 2:05 PM, the Director of Nursing stated, Initially we go by the 3008 form and then input orders in the system. The order is incomplete and should include the rate and the device. Review of the facility policy and procedure titled Documentation with the last reviewed date of 1/16/2024 read, Policy Statement: All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106119 If continuation sheet Page 7 of 9 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 04/25/2024 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 utilize appropriate isolation precaution signages to help prevent the possible transmission of communicable diseases and infections for Residents #19, #82, and #85 (Photographic evidence obtained), and failed to ensure the staff used appropriate PPE (Personal Protective Equipment) while providing direct care to the residents on isolation precautions for Resident #418. Residents Affected - Some Findings include: 1. Review of Resident #19's physician order dated 4/21/2024 read, COVID-19: Strict Isolation: Resident require strict isolation for positive COVID-19 every shift for COVID positive for 10 days. Review of Resident #19's care plan dated 4/22/2024 read, Focus: Resident is diagnosed with COVID-19 infection. Date Initiated: 04/22/2024 . Interventions . Droplet Isolation Precautions. During an observation on 4/22/2024 at 9:48 AM, Resident #19's door had a sign reading Enhanced Barrier Precautions on the door. Review of Resident #82's physician order dated 4/19/2024 read, COVID-19: Strict Isolation: Resident require strict isolation for positive COVID-19 every shift for COVID positive for 10 days. Review of Resident #82's care plan dated 4/20/2024 read, Focus: Resident is diagnosed with COVID-19 infection. Date Initiated: 04/20/2024 . Interventions . Droplet Isolation Precautions. During an observation on 4/22/2024 at 9:55 AM, Resident #82's door had a sign reading Enhanced Barrier Precautions on the door. During an interview on 4/22/2024 at 10:05 AM, the Infection Preventionist confirmed Residents #19 and #82 had inaccurate isolation precaution signs on their doors, and stated, They should have droplet precaution signs on their doors due to their COVID positive status. Review of the facility policy and procedure titled, Isolation- Notices of Transmission-Based Precautions revised on 10/16/2023 read, Policy Statement: Appropriate isolation notices will be used to alert staff of the implementation of Transmission-Based Precautions, while protecting the privacy of the resident. Policy Interpretation and Implementation: 1. When Transmission-Based Precautions are implemented, an appropriate sign will be placed at the entrance/doorway of the resident's room. Signs will be used to alert staff of the implementation of Transmission-Based Precautions and to alert visitors to report to the nurse's station before entering the room, while respecting the resident's privacy. 2. During an observation on 4/22/2024 at 9:40 AM, Resident #418 was sitting in a recliner in his room, receiving IV (intravenous) medication via PICC (Peripherally Inserted Central Catheter) line located on RUE (Right Upper Extremity). During an observation on 4/22/2024 at 9:41 AM, Staff A, License Practical Nurse (LPN), was disconnecting Resident #418's IV tubing. Staff A did not have a gown. During an interview on 4/22/2024 at 9:48 AM, Staff A, LPN, stated, I wear gloves because it was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106119 If continuation sheet Page 8 of 9 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 04/25/2024 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 just the removal of IV tubing. Every room will have signs and PPE depending on why you are going in the room. I am the nurse for this unit. I know every resident and what I need to wear when going into the rooms. Review of Resident #418's physician order dated 4/4/2024 read, Enhanced Barrier Precautions for picc line every shift for precautions for picc line. Residents Affected - Some During an observation on 4/22/2024 at 10:06 AM, Staff B, Occupational Therapist, was in Resident #85's room assisting with direct care. Staff B did not have a gown. There was no enhanced barrier precaution signage or personal protective equipment noted outside of room. During an interview on 4/22/2024 at 2:38 PM, Staff B, Occupational Therapist, stated, I am the Occupational Therapist for [Resident #85's name]. She was wet and I was changing her and assisting her with peri care. I did not know she was on enhanced barrier precautions. Normally, there would be a sign posted outside of the room and that is how we know what precautions to take. The room did not have any signs posted when I entered. Review of Resident #85 physician order dated 4/4/2024 read, Enhanced Barrier Precautions for MRSA Hx [Methicillin-Resistant Staphylococcus Aureus History] and wound every shift for precautions for MRSA Hx and wound. Review of Resident #85's physician order dated 4/19/2024 read, Enhanced Barrier Precautions: surgical wound every shift for foley and surgical wound. During an interview on 4/24/2024 at 1:30 PM, the Director of Nursing stated, Staff should be gowning when providing direct care. They have orders in the system as well as signage posted. During an interview on 4/25/2024 at 8:55 AM, the Infection Preventionist stated, There are orders set in the system and message will pop up. [Resident #85's name] had covid and then signs were taken down and enhance barrier was not put back up. Head of departments get a listing who is on precautions every day. Staff should 100% wear gown when in direct patient contact. Review of the facility policy and procedure titled Enhanced Barrier Precautions with the last review date of 1/16/2024 read, Policy Statement: This facility follows recommended CDC [Centers for Disease Control and Prevention] enhanced barrier precautions, to interrupt the spread of multidrug resistant organisms (MDROs) within the facility. For the purposes of this guidance, the MDROs for which the use of EBP [Enhanced Barrier Precautions] applies are based on local epidemiology. At a minimum, they should include resistant organisms targeted by CDC but can also include other epidemiologically important MDROs. Policy Interpretation and Implementation: 1. While in the building, employees are required to strictly adhere to established infection prevention and control policies, including . c. Appropriate use of PPE [Personal Protective Equipment]. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106119 If continuation sheet Page 9 of 9