Health inspection·December 2, 2021

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the General Dose Preparation and Medication Administration Policy, revision date 01/01/13, read, . 3.9 Facility staff should not leave medications or chemicals unattended . 5.4 Administer medications within time frames specified by facility policy . 5.9 Observe the resident's consumption of the medication(s) Review of the Self Administration of Medication Policy, dated 11/28/21, read, . 2. Facility, in conjunction with the Interdisciplinary Care Team, should assess and determine, with respect to each resident, whether Self-Administration of medications is safe and clinically appropriate, based on the resident's functionality and health condition . 5. Facility should ensure that orders for Self-Administration list the specific medication(s) the resident may self-administer Event ID: Facility ID: 105365 If continuation sheet Page 2 of 22 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 105365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Altamonte Springs 989 Orienta Ave Altamonte Springs, FL 32701 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide showers as per resident's preference for 1 of 4 residents reviewed for choices of a total sample of 63 residents, (#26). Findings: Resident #26 was admitted to the facility on [DATE] with diagnoses of stroke, encephalopathy, Parkinson's Disease, muscle weakness and diabetes type II. The resident's quarterly Minimum Data Set (MDS) assessment with assessment reference date 8/23/21, revealed the resident's cognition was moderately impaired, with a Brief Interview of Mental Status score of 10/15. The assessment noted the resident did not reject care, required extensive assistance from staff for bed mobility, dressing, personal hygiene, and was totally dependent on staff for toilet use and bathing. On 11/29/21 at 11 AM, resident #26 said she received bed baths and had not received showers twice per week as per her preference. Resident #26 pointed to a sign on the wall across from her bed that indicated she was to have showers on Monday and Thursday 3 PM-11 PM shift. She noted she sometimes did not get her showers weekly but instead got a bed bath or partial bed bath as staff were too busy. Review of the resident's Visual/Bedside [NAME] Report revealed the following: Safety: Assist of 2 or more with mechanical lift for all transfers Observe and report changes in usual routine .withdrawal or resistance to care Report to nurses changes Bathing/Showering: The resident requires 1 staff with showering on Tuesday and Friday evening Daily Routine: Resident to have 2 person staff assist with all care On 12/01/21 at 2:41 PM, Unit Manager (UM) C Wing stated showers were scheduled as per resident #26's preference on Tuesdays and Fridays on the 3 PM to 11 PM shift. The UM reviewed the shower sheet and noted that bed baths were documented as given by Certified Nursing Assistants (CNA) instead of showers on all but 3 shower days. The UM could only account for 4 of 9 showers given in November 2021. She said that CNAs were supposed to document refusals on the shower sheet and electronic medical record (EMR) and report refusals of care to the nurses. On 12/01/21 at 4:45 PM, resident #26 stated she really enjoyed her showers and it was more than one month since she refused a shower. The resident indicated it took 2 staff, with the use of a lift device to get her out of bed onto the shower bed. The resident could not recall the names of the CNAs that provided showers and said there were a lot of different CNAs working at the facility. On 12/01/21 at 5 PM, resident #26's assigned CNA K said she had not been involved in giving resident #26 her showers and acknowledged if a resident refused a shower, the CNA was supposed to report to the nurse. On 12/01/21 at 9:28 AM, Licensed Practical Nurse (LPN) M stated she worked the day shift and was familiar with resident #26's care. She noted the CNAs had not reported any refusal of showers by the resident. She explained that if the CNA did report any refusal of care, she would document refusal in the medical record and speak to the resident to find out why. The LPN added, the communication here (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105365 If continuation sheet Page 3 of 22 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 105365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Altamonte Springs 989 Orienta Ave Altamonte Springs, FL 32701 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 0561 is lacking and if nurses are not informed, how are we supposed to fix it. Level of Harm - Minimal harm or potential for actual harm On 12/02/21 at 1:43 PM, the Regional Nurse Consultant (RNC) said the CNAs should notify the nurse when resident refused shower and try again later. She added that if the nurses were aware, they could find out why resident refused and adjust the shower schedule. The RNC was asked to provide an interview with the resident's routinely assigned CNAs but did not provide by the end of survey. Residents Affected - Few The resident's care plan for, ADL Deficits revised on 6/01/21 included interventions to assist 1-2 with care daily, assist with grooming, dressing, bathing/showers. The facility's policy Activities of Daily Living reviewed 7/17/21 read, The resident will receive assistance as needed to complete activities of daily living [ADLs]. Any changes in ability to perform ADLs will be documented and reported to the licensed nurse The facility must provide care and services Hygiene-bathing, dressing, grooming FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105365 If continuation sheet Page 4 of 22 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 105365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Altamonte Springs 989 Orienta Ave Altamonte Springs, FL 32701 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 0584 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview and record review, the facility failed to provide a home like environment for comfortable television viewing for 2 of 5 sampled residents of a total of 63 residents, (#34 and #94). Residents Affected - Some Findings: On 11/29/21 at 11:30 AM, residents #34 and #94 were in their room watching television (TV). Both TVs were noted to have fuzzy to snow like picture on all channels. Both residents stated they were not satisfied with the picture quality on their televisions and noted the fuzzy picture quality had been like this since they came to this room in August 2021. Resident #34 recalled the maintenance staff had tried to fix the TVs and replaced lines outside which did not improve the situation to date. On 11/30/21 at 10:33 AM, residents #34 and #94 were observed in their room watching television with snowy/fuzzy picture. Resident #34 stated he liked to watch basketball and football but did not enjoy the games on his present TV. Resident #94 changed the channels on his TV that showed all channels were fuzzy and some of the higher channels were difficult to see at all. On 12/01/21 at 10:15 AM, residents #34 and #94 were watching TVs in their room with fuzzy/snow like pictures. Both residents #34 and #94 spoke about the poor picture quality and wanting to watch television with better picture. On 12/01/21 at 12:30 PM, Certified Nursing Assistant (CNA) Z was in resident #34 and #39's room and acknowledged the 2 TVs had fuzzy/snow like picture. CNA Z said this had been an ongoing problem on the entire wing and noted the televisions in this room were the worst. Resident #94 indicated to the CNA he was upset as he was not able to get a particular channel. On 12/01/21 at 5:29 PM, the Director of Maintenance (DOM) acknowledged there had been ongoing issues with poor TV quality particularly on the wing residents #34 and #94 resided. He stated the issue had not been resolved. The Director of Maintenance recalled the facility's corporate staff contracted to have fiberoptic wiring installed but did not provide invoice for work done. On 12/2/21 at 9:42 AM, the Executive Director (ED) stated the fiberoptic wiring was for the computers/internet system and not for TVs/cable service. The DOM provided log of service call visits made by cable provider that showed the last call had been made almost 3 months ago, on 9/17/21 for television with snowy picture. On 12/02/21 at 9:40 AM, the Maintenance Assistant was in resident #34 and #94's room and noted both TVs in the room were fuzzy with some channels worse than others. He pointed to a hatch in the ceiling and said he was working on the wiring and the cable company was coming out later today. On 12/02/21 at 9:42 AM, an interview was conducted with the ED and Director of Maintenance. The ED said he looked at the residents #34 and #94's TVs and acknowledged fuzzy channels. He noted the contract with the cable provider was on a month-to-month basis and if there was a problem, the cable provider was supposed to fix it. The Director of Maintenance said that when the cable provider fixed the problem, it was only resolved temporarily. The ED reviewed the work orders for residents #34 and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105365 If continuation sheet Page 5 of 22 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 105365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Altamonte Springs 989 Orienta Ave Altamonte Springs, FL 32701 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some #94's televisions from August 2021 to present and said the maintenance staff had not been specific regarding their documentation. The work requests did not show what the problem was or what was done to fix it. He noted there was no follow up to ensure the problem was fixed. The ED said the Maintenance Assistants were to report to the Director of Maintenance when they were unable to resolve the issue so the cable provider could be called for service. The Director of Maintenance spoke about the importance of television for residents and stated, for some of the residents TV is the last thing they have control of, and they should all get a good picture. On 12/02/21 at 1:05 PM, an interview was conducted with the Cable Technician (CT) after he completed service call and finished looking at the wiring issues outside the building. He explained the line going outside the building used to belong to a different cable provider and had deteriorated. He said the TVs in the building were still fuzzy and not going to be fixed today. He indicated he would need to contact the construction and maintenance department of the cable provider. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105365 If continuation sheet Page 6 of 22 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 105365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Altamonte Springs 989 Orienta Ave Altamonte Springs, FL 32701 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 provide assistance with activities of daily living (ADLs) related to hair and nail care for 2 of 7 residents reviewed for ADLs, of a total sample of 63 residents, (#121 and #14). Residents Affected - Few Findings: 1. Resident #121 was admitted to the facility on [DATE] with diagnoses including paralysis, stroke, dementia and muscle weakness. The Minimum Data Set (MDS) Significant Change in Status assessment with Assessment Reference Date (ARD) of 10/11/21 revealed resident #121 had severely impaired cognitive skills for daily decision making. The MDS assessment indicated resident #121 did not reject care that was necessary for her health and well-being. The resident had functional limitation in range of motion in all extremities, and was totally dependent on staff for personal hygiene including combing her hair. Review of resident #121's care plan for ADL deficits, initiated on 4/23/21, revealed a goal that the resident would maintain a sense of dignity by being clean and appropriately dressed. The care plan intervention directed nursing staff to provide assistance with grooming. On 11/30/21 at 1:23 PM, resident #121 was observed with untrimmed, dirty fingernails. There was black debris under all fingernails. On 12/01/21 at 9:48 AM, the resident was in bed and had a disheveled appearance. Her hair was partially braided close to her scalp but otherwise loosely and untidily spread across her pillow. The resident's fingernails remained untrimmed and there was dark material still underneath the nails. On 12/01/21 at 12:14 PM, the resident's hair remained frizzy and uncombed. Her fingernails had not been trimmed or cleaned by staff. On 12/01/21 at 2:35 PM, resident #121's ADL care was still not done. Her uncombed hair and untrimmed dirty fingernails had not been addressed by her assigned Certified Nursing Assistant (CNA). On 12/01/21 at 2:37 PM, CNA F stated she provided personal hygiene care for resident #121 at approximately 10:30 AM that morning. During observation of the resident's fingernails with CNA F, she acknowledged they were very dirty. CNA F confirmed she did not comb or brush the resident's hair. CNA F explained she did not notice these issues during provision of ADL care that morning. She confirmed CNAs were responsible for fingernail care as needed. CNA F explained residents' hair should be combed or brushed after a bath or shower, but resident #121 was not scheduled for a shower on that shift. On 12/01/21 2:41 PM, the A wing Unit Manager (UM) stood at the foot of the bed and acknowledged resident #121's fingernails were dirty enough to be seen from that distance. The UM confirmed any member of the nursing staff could provide fingernail care. She stated her expectation was assigned CNAs would perform hand hygiene throughout the shift including cleaning and trimming nails as needed. The UM stated CNAs should ensure residents' hair was neatly brushed or combed as part of daily grooming. The UM acknowledged resident 121's uncombed, unkempt hair was unacceptable, and described it as bad. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105365 If continuation sheet Page 7 of 22 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 105365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Altamonte Springs 989 Orienta Ave Altamonte Springs, FL 32701 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 12/02/21 at 11:42 AM, in a telephone interview with resident #121's son, he expressed concerns related to his mother's grooming and personal hygiene. He recalled an incident within the previous two weeks when he noticed that his mother's hair had not been brushed or combed. The resident's son stated he would like his mother to be neatly groomed at all times. Review of the Certified Nursing Aide (CNA) Job Description dated 11/10/16 revealed essential functions included assisting patients with personal grooming. The facility's policy and procedure for Activities of Daily Living (ADLs) dated 7/17/21 revealed residents would receive necessary care and services that met their goals for care. The document read, The resident will receive assistance as needed to complete activities of daily living (ADLs). The procedure included ensuring fingernails were clean and trimmed. Detailed instructions for combing and bushing a resident's hair directed staff to style hair according to the resident's preference. The document read, Consider braiding long or curly hair to help prevent it from matting in patients who must spend a lot of time in bed. The Facility Assessment Tool reviewed by the Quality Assurance and Performance Improvement committee on 12/08/20 indicated the facility would provide general resident care including activities daily living care. 2. Resident #14 was initially admitted on [DATE] then readmitted on [DATE]. Her diagnoses included multiple sclerosis, hemiplegia, hemiparesis and bilateral nuclear cataract. The quarterly Minimum Data Set (MDS) assessment with assessment reference date of 11/10/21 revealed resident #14 required extensive assistance of 1 staff person for personal hygiene but totally dependent on 1 staff for bathing. On 11/29 21 at 10:15 AM, resident #14 was in bed, alert and watching television. Her finger nails to both hands were observed to have dark, hardened debris underneath. She stated she would like to have them cleaned as she did not remember the last time they were cleaned. On 11/30/21 at 10:16 AM, resident #14 was in bed, alert and watching television. Her finger nails remained the same, with dark, hardened debris underneath. On 12/01/21 at 10:28 AM, resident #14 was in bed and asleep. Her finger nails were visible and observed to have no change in appearance. There was dark debris under the fingernails. On 12/01/21 at 1:50 PM, Certified Nursing Assistant (CNA) V stated she was assigned to care for resident #14. She recalled the resident's shower days were scheduled on Mondays and Thursdays during 7 AM to 3 PM shift. CNA V observed the resident's fingernails and stated they needed to be cleaned. She acknowledged that she was supposed to clean them as part of her morning care but she forgot to do it. On 12/01/21 at 1:57 PM, the A Wing Unit Manager stated that CNAs were supposed to clean and trim residents' finger nails when needed. A review of the resident's care plan initially created on 07/04/2019 and revised 08/16/21 revealed resident #14 had an ADL self-care deficit related to impaired mobility, impaired vision and limited range of motion due to multiple sclerosis. The interventions included to assist in grooming, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105365 If continuation sheet Page 8 of 22 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 105365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Altamonte Springs 989 Orienta Ave Altamonte Springs, FL 32701 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 0677 bathing/showers and dressing. Level of Harm - Minimal harm or potential for actual harm Policy and procedure on ADL reviewed on 07/17/21 revealed that for finger nail care ensure finger nails are clean and trimmed to avoid injury and infection . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105365 If continuation sheet Page 9 of 22 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 105365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Altamonte Springs 989 Orienta Ave Altamonte Springs, FL 32701 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** Based on observation, interview, and record review, the facility failed to provide care and services for skin rash (#30) and failed to identify and report bruises and skin tears of unknown origin Residents Affected - Few (#39) for 2 of 3 residents reviewed for non-pressure related skin conditions out of a total sample of 63 residents. Findings: 1. Review of resident #30's medical record revealed she was admitted to the facility on [DATE] with diagnoses of Diabetes Mellitus (DM), Major Depressive Disorder, Psychosis, Delusional Disorders and Anxiety. Review of the resident's annual Minimum Data Set (MDS) assessment dated [DATE] documented she was cognitively intact and needed supervision with her personal hygiene and bathing. Review of the resident's care plan dated 04/10/20 revealed she was at risk for impaired skin. Interventions included to observe skin integrity during care, report any new areas of abnormalities to nurse including but not limited to (skin tears, cuts, lacerations, rashes, redness, bruises). The Activities of Daily Living (ADL) self-care deficit care plan dated 08/26/20 documented she required one person assist with ADLs with interventions to assist with grooming, dressing and bathing/showers as needed. Review of resident #30's physician's orders dated 3/20/21 documented to keep areas under breasts dry every shift. Review of resident #30's shower schedule revealed she was scheduled to receive showers twice weekly on Wednesdays and Saturdays. Review of the resident's Weekly Skin Assessments completed on 10/30/21, 11/6/21, 11/13/21 and 11/20/21 revealed no skin issues were identified. On 11/29/21 at 4:36 PM, and on 11/30/21 at 4:54 PM, resident #30 stated she had red areas under her breasts for several weeks. She said she had notified a staff member but could not recall name. She explained the areas under her breasts were itchy and had a slight odor. On 12/01/21 at 9:09 AM, Certified Nursing Assistant (CNA) E said the resident sometimes developed red areas under her breasts. She explained that when she observed redness under the breasts, she washed the areas and then reported the skin issue to the nurse for treatment. .On 12/01/21 at 9:11 AM, Licensed Practical Nurse (LPN) D stated resident #30 had developed red areas under her breasts at times and had been treated in the past with Nystatin Powder. She said it was not a problem at this time and added, the CNA will let me know if the resident has any skin issues. On 12/01/21 at 9:27 AM, resident #30 stated she was on her way to have a shower (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105365 If continuation sheet Page 10 of 22 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 105365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Altamonte Springs 989 Orienta Ave Altamonte Springs, FL 32701 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 On 12/01/21 at 5:05 PM, the resident was observed with LPN D. The skin under both breasts was bright red. LPN D stated, This is pretty red. LPN D then explained the resident had received a shower this morning but the CNA had not informed her about any issues. The process is for the CNA to check the resident's body, to verbally inform me of any skin issues and to complete the Skin Care Alert Form. On 12/01/21 at 5:13 PM, C Wing Unit Manager (UM) stated resident #30 was scheduled for her showers on Monday and Thursday evenings. She explained that after the CNA provided a shower to a resident, the CNA then completed the Skin Care Alert Form to document any skin issues. The UM acknowledged CNA C had given resident #30 her shower on the 7 AM-3 PM shift. She stated she could not locate a Skin Care Alert Form for resident #30. On 12/02/21 at 9 AM the C Wing UM provided resident #30's Skin Care Alert Form dated 12/01/21 which documented redness under both breasts had been reported to the Team Leader. On 12/02/21 at 10:37 AM, CNA C revealed she had showered resident #30 on 12/01/21 and had observed redness under her breasts. She said, I completed the Skin Care Alert Form, turned the form in and notified CNA E who was the CNA Team Leader on the unit. On 12/02/21 at 10:43 AM, CNA E confirmed she had received resident #30's Skin Care Alert Form on 12/01/21 and filed the form in the Skin Care Alert Book. She said CNA C had informed her about the redness/rash under resident #30's breasts. She added, Resident #30's nurse was busy with another resident so I informed the UM of resident #30's skin issues. On 12/02/21 at 12:30 PM, the C Wing UM recalled she had been made aware of resident #30's rash on 12/01/21. She explained she had not informed the Nurse Practitioner (NP) so an order was not obtained for treatment of her red itchy breast rash. I did not notify the NP in a timely manner. 2. Review of resident #39's medical record revealed he was admitted to facility on 01/29/2018 with diagnoses including Alzheimer's Disease, Dementia, Convulsions, Long Term Use of Anticoagulants, and Xerosis Cutis (Dry Skin). Review of the resident's quarterly MDS assessment dated [DATE] documented he had severe cognitive impairment and required extensive assistance with bed mobility, transfers, dressing, personal hygiene and required total assistance with bathing and had received anticoagulant medication. Review of the resident's Plan of Care documented on 03/12/21 he was at risk for impaired skin integrity. Interventions included to apply skin moisturizer lotion to skin as needed, assistance of 1-2 staff with turning and repositioning when in bed, assist with bathing, grooming and activities of daily living daily, check fingernails and keep short and smooth as needed, observe skin integrity during care, and to report any new areas to nurse including but not limited to (skin tears, cuts, lacerations, rashes, redness, bruises). At risk for abnormal bruising and bleeding/hemorrhage dated 03/12/2021 with interventions to observe for unusual bruising. Review of resident #39's physician orders revealed Apixaban (anticoagulant) 2.5 milligrams orally twice daily and monitor for signs and symptoms of bleeding and bruising. Observations conducted on 11/29/21 at 2:33 PM, 11/30/21 at 4:48 PM and on 12/01/21 at 9:33 AM revealed a dressing on his left lower arm, a black scabbed skin tear approximately 3 inches long on his right mid-arm and eight multiple sized circular red/purple bruises on his right arm. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105365 If continuation sheet Page 11 of 22 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 105365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Altamonte Springs 989 Orienta Ave Altamonte Springs, FL 32701 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 Review of the resident's Weekly Skin Assessments completed on 10/09/21, 10/16/21, 10/24/21, 10/30/21, 11/06/21, 11/18/21, 11/21/21 revealed no documentation of his skin tears or bruises. On 11/27/21 documentation revealed skin tear and some discoloration on right arm. Review of resident #39's Progress Notes for November 2021 revealed no documentation of his skin tears or bruises. On 12/01/21 at 2:22 PM, the B Wing (UM) stated she was not aware of resident #39's bruises. She stated weekly skin checks were completed to monitor for resident skin issues. She said, Resident #39 is on Eliquis twice a day and the only documentation of a skin issue was on 11/27/21 which documented some discoloration and skin tear on right arm. There was no documentation of the skin tear on the resident's left arm. On 11/29/21 at 2:33 PM, and on 12/01/21 at 2:10 PM, resident #39 stated he did not know how he got the skin tears and bruises on his arms. He then stated that he was fighting with the people but was unable to identify the people. On 12/01/21 at 2:30 PM, an observation and interview with resident #39 was conducted with the B Wing UM. She confirmed the 8 red/purple bruises and skin tear on the resident's right arm. The resident again stated he did not know how he had got the bruises and then said he fought with with two guys and a couple girls two weeks ago. Several minutes later he stated staff had hit him. On 12/01/21 at 2:40 PM, CNA A said the resident required extensive assistance with his ADL care. She said she did notice the skin tear on the resident's right arm but did not see any bruises on his arms. CNA A returned to observe resident #39's arms and reported he had multiple bruises on his right arm. CNA A explained that when she observed skin tears or bruises she informs the nurse. I meant to tell the nurse but went to do something else and forgot to do it today. On 12/02/21 at 11:09 AM, the Regional Director of Clinical Services stated there are no incident reports or nurses notes for resident #39's skin tears or bruises. We should have had incident reports and/or nurse progress note for his unwitnessed skin tears and bruises. I observed resident #39's arms and he had a number of ecchymotic areas and skin tear on his right arm. Review of the Incident and Reportable Event Management Policy, dated 07/19/221, read, . Injuries of unknown source is classified when the source of the injury was not observed by any person or the source of the injury could not be explained by the resident and the injury is suspicious because of the extent of the injury or the location of the injury . Incident/Injury . 2. The licensed nurse should create an event note . 3. The licensed nurse should create a risk report in the electronic system . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105365 If continuation sheet Page 12 of 22 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 105365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Altamonte Springs 989 Orienta Ave Altamonte Springs, FL 32701 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide appropriate care and services to prevent complications related to an indwelling urinary catheter for 1 of 2 residents reviewed for urinary catheters, of a total sample of 63 residents, (#90). Findings: Resident #90 was admitted to the facility on [DATE] with diagnoses including chronic urinary retention, enlarged prostate, and need for assistance with personal care. Review of the Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 9/17/21 revealed resident #90 had a Brief Interview for Mental Status score of 8 which indicated he had moderate cognitive impairment. The resident required extensive assist for bed mobility, toilet use and personal hygiene, and did not reject evaluation and care. The MDS assessment showed he had an indwelling catheter. An indwelling urinary catheter is a tube inserted through the urethra into the bladder. Urine drains freely from the bladder through tubing attached to a urinary drainage bag. There are significant complications associated with urinary catheters including urinary tract infections (UTIs). Indwelling catheters and the attached tubing can develop a build-up of encrusted minerals and sediment that create blockages and promote UTIs (retrieved from www.cdc.gov on 12/10/21). Review of the medical record revealed resident #90 had a care plan initiated on 4/05/21 for risk for complications such as UTIs due to catheter use. The care plan goal was to minimize the risk for developing an acute UTI. The interventions included change the urinary drainage bag and provide catheter care as ordered. Resident #90's Order Summary Report included physician orders dated 10/21/21 for an indwelling catheter connected to a drainage bag, change the catheter drainage bag every 14 days, change the urinary catheter once monthly on the 28th of every month, and provide catheter care every shift. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) from October to December 2021 revealed resident #90's catheter drainage bag was changed on 10/22/21 and on 11/19/21, but not on 11/05/21 as ordered. The TAR included two blank areas for documentation related to changing resident #90's catheter on 11/06/21 and 11/28/21. A nurse's initial on 11/29/21 indicated the task was performed. On 12/02/21 at 10:25 AM, resident #90's urinary catheter tubing was coiled on his bed. The tubing had a significant amount of white sediment, clotted blood and cloudy tea-colored urine. The sides of the tubing were stained with dried blood and red, bloody urine was noted in the drainage bag. On 12/02/21 at 10:30 AM, the A Wing Unit Manager (UM) confirmed resident #90's catheter tubing and bag needed to be changed due to the presence of large amounts of dried blood, clots and sediment. She explained he suffered from frequent UTIs and his catheter should be at least changed monthly and the drainage bag with tubing should be changed at least every 2 weeks or more often if necessary. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105365 If continuation sheet Page 13 of 22 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 105365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Altamonte Springs 989 Orienta Ave Altamonte Springs, FL 32701 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 12/02/21 at 10:42 AM, the UM stated her expectation was the assigned nurse would assess the catheter every shift and complete documentation after addressing any issues. She could not explain how resident #90's catheter tubing had such a significant amount of sediment and dried blood stains if it had been changed on 11/29/21 as documented in the TAR. On 12/02/21 at 10:48 AM, Advanced Practice Registered Nurse (APRN) H stated she had treated resident #90 for frequent UTIs over the previous five months. The APRN confirmed the physician order directed nurses to change the drainage bag every 2 weeks and change the catheter monthly. She explained these interventions were necessary to prevent infection and due to the resident's condition, the catheter bag with tubing often needed to be changed more frequently than every two weeks. On 12/02/21 at 1:51 PM, Certified Nursing Assistant (CNA) I stated she was assigned to care for resident #90 on Tuesday 11/30/21. She recalled the resident's catheter bag had a large amount of bloody urine and the tubing had sediment and blood on the sides. CNA I stated she reported the concern to the assigned nurse, Licensed Practical Nurse (LPN) U on Tuesday and also informed the assigned nurse, Registered Nurse (RN) J today. 12/02/21 at 2:31 PM, RN J stated CNA I had not expressed concerns about the condition of resident #90's catheter to her. She acknowledged she noted the bloody urine, dried blood and sediment in the tubing that morning, but did not address it because she was not his regular nurse and had seen this same issue in the past. The policy and procedure Urinary Incontinence and Indwelling Urinary Catheter (Foley) Management dated 7/17/21 revealed residents would . receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. The job descriptions for RN Unit Registered Nurse and LPN Unit Licensed Practical Nurse dated 11/10/16 revealed nurses would provide . care and services to assure patient safety and attain or maintain the highest practicable physical, mental, and psychosocial well being of each patient. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105365 If continuation sheet Page 14 of 22 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 105365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Altamonte Springs 989 Orienta Ave Altamonte Springs, FL 32701 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of resident #25's medical record documented he had been admitted to the facility on [DATE] with diagnoses including Congestive Heart Failure (CHF), COPD, Pneumonia, and history of Lung Cancer. Residents Affected - Few Review of the resident's quarterly MDS assessment dated [DATE] revealed resident #25 received oxygen therapy. Review of the resident's Care Plan revealed he had a potential for acute respiratory distress related to his diagnoses of COPD, CHF, pneumonia and history of Lung Cancer. The care plan noted resident had periods of shortness of breath with exertion, fatigue with activities and low endurance with activities. The interventions included oxygen as needed (PRN). Resident #25's physician's orders dated 07/17/20 included oxygen at 2 liters per minute continuously per nasal cannula and to clean oxygen the concentrator filter with soap and water weekly on Friday. Observations conducted on 11/29/21 at 1:38 PM, 11/30/21 at 4:45 PM, 12/01/21 at 9:42 AM and 12/01/21 at 11:20 AM revealed resident #25's oxygen concentrator's external filter was covered with a layer of a gray dust type substance. On 12/01/21 at 2:22 PM, the B-Wing Unit Manager (UM) said all oxygen concentrator filters were scheduled to be cleaned on Sundays. The UM stated resident #25 a physician's order for his oxygen concentrator filter to be cleaned every Friday. She explained filters were cleaned weekly to ensure the filters were clean and free of dust. She said, if the external filter is not kept clean the concentrator would not be able to deliver the correct amount of oxygen as ordered by the physician. The UM confirmed the oxygen concentrator's external filter was covered with a layer of a gray dust and stated, There's no way this filter was cleaned last Friday. Review of the Oxygen Administration/Safety/Storage Maintenance Policy, revised 08/02/21, read, Purpose: To assure that oxygen is administered and stored safely within the healthcare centers . Infection Control: .1. Change oxygen supplies weekly and when visibly soiled . 4b External filter should be checked daily and all dust should be removed. Filters should be washed with soap and water once each week and PRN Review of the Facility Assessment Tool, dated December 2019, documented the facility provides care for residents with respiratory system conditions, COPD, Pneumonia, Chronic Lung Disease and Respiratory Failure. The Facility Assessment Tool indicated that staff are trained, educated and competent to provide oxygen administration. to residents. 2. Resident #135 was initially admitted on [DATE] then readmitted on [DATE]. Her diagnoses included COPD convulsions, diabetes mellitus, psychosis, dementia, pain, edema and anxiety disorder. The quarterly MDS assessment with assessment reference date 10/18/21 revealed the resident's cognition was intact and she received oxygen therapy. Review of the resident's clinical record revealed a physician order dated 02/10/20 for oxygen at 2 liters per minute (LPM) continuously per nasal cannula which was revised on 11/30/21 to keep oxygen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105365 If continuation sheet Page 15 of 22 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 105365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Altamonte Springs 989 Orienta Ave Altamonte Springs, FL 32701 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 0695 saturation above 92% every shift . Level of Harm - Minimal harm or potential for actual harm On 11/29/21 at 11:10 AM, resident #135 was laying in bed, with oxygen via nasal cannula attached to a concentrator located on the right side of her bed with the control knob set between 3 to 3.5 LPM. Residents Affected - Few On 11/30/21 at 10:02 AM, the resident was in bed, alert and received medication from Licensed Practical Nurse (LPN) U. Her oxygen was set at 3 LPM via nasal cannula. She stated she needed oxygen all the time. LPN U acknowledged the oxygen was set at 3 LPM. He also stated he needed to verify the physician's order for the oxygen flow rate. LPN U verified the order and reported the oxygen flow rate should be at 2 LPM. He did not provide an answer as to why it was set at 3 LPM. On 11/30/21 at 10:08 AM, the A Wing Unit Manager confirmed the physician order was to give oxygen at 2 LPM via nasal cannula. She stated the nurse should have known the order for the flow rate. Review of the care plan initiated on 08/26/19 then revised on 10/20/21 revealed resident #135 was at risk for acute respiratory distress related to COPD, anxiety and seizure disorder. Intervention was to administer respiratory therapy as ordered. Too much oxygen can be dangerous for patients with chronic obstructive pulmonary disease (COPD) with (or at risk of) hypercapnia (partial pressure of carbon dioxide in arterial blood greater than 45 mm Hg). Retrieved from <www.ncbi.nlm.nih.gov> on 12/10/21. Based on observation, interview and record review the facility failed to provide appropriate care and service for oxygen therapy for 3 of 6 residents reviewed for respiratory care out of 63 sampled residents, (#439, #135, #25). Findings: 1. Resident #439 was most recently admitted to the facility on [DATE] from an acute care hospital with diagnoses including chronic respiratory failure, Chronic Obstructive Pulmonary Disease (COPD), and dependence on supplemental oxygen. On 11/29/21 at 12:29 PM, resident #439 was in her room and wore a nasal cannula connected to a concentrator set to deliver oxygen (O2) at 2 liters per minute (L/min). On 11/29/21 at 4:35 PM, resident #439 was in her wheelchair across from the D Wing nurses' station. She wore a nasal cannula connected to a concentrator set to deliver oxygen at 2 L/min. On 11/29/21 at 4:39 PM, Registered Nurse (RN) Y stated resident #439 should be on 2 liters of oxygen. She explained nurses knew the required oxygen flow rate from the physician's orders. RN Y checked resident #439's electronic medical record and was unable to find a physician order for oxygen administration or supplies. RN Y explained admission nurses were responsible for inputting physician's orders for newly admitted residents. RN Y confirmed resident #439's hospital transfer form dated 11/11/21 showed she had COPD and was dependent on oxygen at 3 L/min. She stated it was important for all nurses to know how much oxygen the resident should receive because of her COPD diagnosis. On 11/29/21 at 5:04 PM, the D wing Unit Manager (UM) validated that absolutely a physician's order was needed to administer oxygen. He explained resident #439's attending physician verified the orders on the hospital transfer form including the order for oxygen at 3 L/min. The D wing UM confirmed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105365 If continuation sheet Page 16 of 22 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 105365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Altamonte Springs 989 Orienta Ave Altamonte Springs, FL 32701 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 0695 Level of Harm - Minimal harm or potential for actual harm there were no oxygen orders for resident #439. The D wing UM stated nurses were expected to assess residents on oxygen every shift and change the nasal cannula weekly. He confirmed there was no way to know if the nurses were doing this for resident #439 because there were no orders. He stated resident #439's diagnosis of COPD made it even more important to have an order for oxygen, to indicate the appropriate flow rate. Residents Affected - Few Review of resident #439's Minimum Data Set (MDS) admission assessment with Assessment Reference date of 11/17/21 revealed she had shortness of breath or trouble breathing with exertion and used oxygen. A care plan initiated 11/12/21 for respiratory risk and potential for acute respiratory distress revealed resident #439 needed oxygen therapy via nasal cannula. The interventions were for staff to apply oxygen as ordered by the physician, clean oxygen concentrator filter with soap and water, and change oxygen tubing as ordered. The care plan directed staff to monitor oxygen saturation rates as ordered, observe and report signs or symptoms of respiratory distress. Review of the Order Summary Report dated 11/29/21 revealed no physician orders for oxygen administration or oxygen care and monitoring. Review of the Medication Administration Record (MAR) for November 2021 revealed no documentation of oxygen use or setting for oxygen delivery, change of nasal cannula tubing or cleaning of the concentrator filter from admission until the missing order was brought to staff's attention on 11/29/21. Review of the Respiratory Symptoms Screening Tool from 11/12/21 to 11/29/21 revealed nurses charted on 5 occasions that resident #439 was on room air. Nurses documented on 10 occasions that resident #439 was receiving oxygen via nasal cannula although there were no orders. On 12/02/21 at 5:01 PM, the Regional Director of Nursing stated the expectation was for nurses to check the oxygen delivery rate at least once per shift. She indicated the admission nurse was responsible for verifying and transcribing orders at the time of admission, right away, not two weeks later. Review of the policy General dose Preparation and Medication Administration dated 12/01/07 revealed prior to administration of medication, staff should verify the correct dose, the correct rate, and confirm the MAR reflects the most recent medication order. The policy Oxygen Administration/ Safety/ Storage/ Maintenance revised on 8/2/21 directed staff to change oxygen supplies weekly and when visibly soiled. External filters should be checked daily, and all dust should be removed, filters washed with soap and water once weekly and as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105365 If continuation sheet Page 17 of 22 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 105365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Altamonte Springs 989 Orienta Ave Altamonte Springs, FL 32701 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 1 resident reviewed for pain management out of a total sample of 63 residents, (#126). Residents Affected - Few Findings: Resident #126 was admitted on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction, diabetes mellitus, major depressive disorder and generalized muscle weakness. The quarterly Minimum Data Set (MDS) assessment with assessment reference date 10/13/21 revealed resident #126 had moderately impaired cognition and received scheduled pain medication due to frequent, moderate pain. A review of the current physician's orders dated 01/14/21 read, Lidoderm Patch 5% (Lidocaine), apply to left shoulder topically in the morning for shoulder pain. The Nursing Pain Evaluation Tool dated 04/17/21 indicated resident #126 had pain level of 3 on left shoulder, making the pain worse upon movement. It also indicated pain medication or pain patch would make the pain better. On 11/29/21 at 10:10 AM, resident #126 was in bed, alert, observed to have facial grimacing. She did not have patient gown on but was covered with blanket up to the upper portion of her body which covered her right shoulder. She stated she fell at home and was having pain on left shoulder. The Lidoderm Patch on her left shoulder was only halfway attached and partly folded dated 11/28/21 with unreadable initials. On 11/30/21 at 10:20 AM, resident #126 was in bed, alert and watching television. Although she wore a patient gown, the Lidoderm Patch was visible on her left shoulder. It was the same condition as the previous day, folded halfway and dated 11/28/21. The resident stated she had pain in her left shoulder. Review of the Medication Administration Record (MAR) from 11/01/21 to 11/30 revealed that Lidoderm Patch 5% had been signed by Licensed Practical Nurse (LPN) U on 11/29/21 and 11/30/21 indicating it had been administered. On 11/30/21 at 11:05 AM, LPN Z confirmed the patch on resident #126's left shoulder was dated 2 days ago, 11/28/21. She stated it should be changed daily. She also stated resident #126 had chronic shoulder pain and needed the Lidoderm patch. On 11/30/21 at 11:15 AM, LPN U stated he would usually applied the patch during morning care. He acknowledged he signed the MAR for 11/29/21 and 11/30/21 even though he had not applied the patch. He noted nurses were supposed to apply the patch as ordered and if the patch was not applied, the nurse should notify the physician and document that it was not applied. On 12/01/21 at 10:48 AM, resident #126 was in bed, alert and watching television. Upon inspection, LPN T confirmed resident #126 did not have any patch on or near her left shoulder. After LPN T checked the order, she stated the patch was scheduled to be given at 8:00 AM. She acknowledged that it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105365 If continuation sheet Page 18 of 22 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 105365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Altamonte Springs 989 Orienta Ave Altamonte Springs, FL 32701 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 FORM CMS-2567 (02/99) Previous Versions Obsolete was given late as it should have been applied an hour before or an hour after the scheduled time. There was no documentation the physician was notified and that it was not given as ordered. On 12/02/21 at 11:03 AM, the UM stated that nurses were expected to administer medications as ordered. Upon review of the MAR with the UM, showed Lidoderm Patch 5% was administered on 12/01/21 at 9:40 AM even though it was applied at 10:48 AM. Event ID: Facility ID: 105365 If continuation sheet Page 19 of 22 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 105365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Altamonte Springs 989 Orienta Ave Altamonte Springs, FL 32701 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** Based on observation, interview and record review, the facility failed to ensure the medical record accurately reflected the resuscitation status for 1 of 1 resident reviewed for Advanced Directives of a total sample of 63 residents, (#439). Findings: Resident #439 was re-admitted to the facility on [DATE] from an acute care hospital with diagnoses including chronic lung disease, diabetes, and chronic respiratory failure. Review of resident #439's Minimum Data Set (MDS) admission assessment with Assessment Reference Date of 11/17/21 revealed she had a Brief Interview for Mental Status score of 8 which indicated moderate cognitive impairment. A care plan for Advanced Directives related to cardiopulmonary resuscitation or full code, initiated on 11/12/21 revealed resident #439 had a goal for her Advanced Directives to be honored. Interventions included a quarterly review of her code status and more often as needed. The care plan reflected a decision for full code status. Review of resident #439's medical record revealed a State of Florida Do Not Resuscitate (DNR) form signed on 11/19/21 by the physician and the resident's legal representative. Review of the Order Summary Report dated 11/29/21 indicated a physician's order dated 11/12/21 still deemed resident #439 as Full Code. On 12/01/21 at 2:18 PM, Licensed Practical Nurse (LPN) X stated Social Services was responsible for obtaining Advanced Directives when new residents were admitted . She explained Social Services ensured the physician signed the appropriate paperwork and nurses entered the appropriate order into the electronic medical record. On 12/01/21 at 4:29 PM, the Social Service Director (SSD) confirmed her department was responsible for completion of Advanced Directives. She explained they ensured newly admitted residents had physician orders to match their Advanced Directives. The SSD explained if a resident changed Advanced Directives, she would ensure the physician signed the appropriate form and place it in the medical record. She stated for a DNR order, nurses were responsible for transcription to the medical record. The SSD confirmed resident #439's medical record had an order in place for full code status rather than DNR. On 12/01/21 at 4:41 PM, the Social Services Assistant confirmed the Do Not Resuscitate form signed by the physician and the resident's legal representative in the medical record. He confirmed his handwriting on the document, but could not recall which nurse he informed of resident #439's change in Advance Directives. On 12/01/21 at 4:47 PM, the SSD acknowledged resident #439's care plan was not revised to reflect a new Advanced Directives for DNR when it was signed. The SSD stated it could definitely be a problem if the order in the electronic record did not accurately reflect a resident's wishes. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105365 If continuation sheet Page 20 of 22 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 105365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Altamonte Springs 989 Orienta Ave Altamonte Springs, FL 32701 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 acknowledged resident #439's inaccurate full code order in the electronic medical record would direct staff to initiate unwanted life saving measures. On 12/01/21 at 4:58 PM, The D wing Unit Manager (UM) said the The DNR or Advanced Directives orders were an important thing you want to take care of right away, and God forbids something happens. Residents Affected - Few On 12/02/21 at 5:02 PM, the Regional Director of Nursing stated her expectation was any change made to a resident's Advanced Directives required a matching, modified order in the medical record. She confirmed entering an Advance Directives order was a priority. The Regional Director of Nursing confirmed there was a process or system problem related to failure to communicate this important information. Review of the document Advance Directives and Advance Care Planning revised on 10/20/21 revealed, The ability of a person to control decisions about medical care . has been identified as one of the key elements of quality care at the end of life. The document directed Social Services to .verify that there is an appropriate physician's order in the medical record . and document any changes in the Advanced Directives in the medical record. It also indicated the DNR order would be incorporated into the resident's care plan and periodically reviewed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105365 If continuation sheet Page 21 of 22 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 105365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Altamonte Springs 989 Orienta Ave Altamonte Springs, FL 32701 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to prevent the potential for infection by failing to practice proper hand hygiene and donning of gloves when administering eye drops for 1 of 3 residents reviewed for medication administration, (#120). Residents Affected - Few Findings: On 11/30/21 at 9:15 AM an observation was conducted during medication administration with Registered Nurse (RN) N and resident #120. RN N prepared total of 9 by mouth (PO) and 1 eye drop medication. The nurse entered the room and identified the resident who was alert and able to take the oral medications without any difficulty. RN N then proceeded to give the eye drop medication/artificial tears 1 drop to each eye. RN N performed hand hygiene upon entry to the room but she did not don gloves between giving the oral medications and the eye drops. She used her bare hands to keep the resident's right eye open and instilled 1 drop into the right eye and then did the same on the left. On 11/30/21 at 11:01 AM, an interview was conducted with the B Wing Unit Manager (UM) and RN N post observation of medication administration. RN B stated, I just forgot to wash my hands and don gloves between giving the PO medication and eye drops. The B Wing UM verified nurses should always perform hand hygiene whenever changing routes of medication administration and wear gloves when instilling eye drops. On 12/02/21 at 11.34 AM, the Infection Preventions Control Nurse (IPC) said she had not done audits of nurses during medication administration to date and was just made aware of the nurse that did not wash her hands between giving PO medication and eye drops. The IPC Nurse said, the resident could have coughed or spit on the nurse's hands when she gave PO medications and bacteria would then be introduced into the resident's eyes. She indicated nurses should always wash hands after giving medications via PO route and don gloves as well because that was the correct procedure. The facility's policy and procedure revised on 9/21/21 for Eye Drop Instillation read, The facility will provide Eye Drop Instillation in accordance with professional standards of practice as outline by [NAME] Eyedrop administration Perform hand hygiene. Put on gloves FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105365 If continuation sheet Page 22 of 22