Health inspection·March 31, 2022

F 0686 Level of Harm - Actual harm Residents Affected - Few Resident #10 had care plans for potential impairment to skin integrity related to fragile skin and for a pressure ulcer to her sacrum. The goal was the resident would be free from injury. The care plan interventions directed staff to monitor, document, and report any changes in skin status as needed. The document listed an additional intervention to teach the resident the importance of changing positions for prevention of pressure ulcers and encourage her to make small frequent position changes. However, due to resident #10's cognitive impairment, memory problems and need for extensive assistance for movement, the interventions were not appropriate for the resident. The care plan directed staff to follow facility policies and protocols for the prevention and treatment of skin breakdown. Other approaches included staff to identify and document potential causative factors and eliminate and resolve them where possible. The care plan did not include an intervention related to frequently turning and repositioning resident #10 while she was in bed Review of the medical record revealed a physician order dated 12/02/21 for nurses to perform weekly skin sweeps every evening shift on Tuesdays. The order specified the nurse was to complete a head to toe skin sweep under the assessment tab. On 3/28/22 at 11:03 AM, resident #10 was in bed turned to her left side, and faced the door. She had a nasal cannula, dated 2/25/22, that was connected to an oxygen concentrator. Resident #10's head rested on a pillow and she had a small black scabbed area noted on the cartilage of her right, outer ear. Her hair was pulled back and she had clumps of yellowish, dried crusty substance in her hair above the right ear and also at the crease of her right ear where the tubing of the nasal cannula rested. On 3/28/22 at 12:45 PM, resident #10 remained on her left side facing the door and still wore the nasal cannula dated 2/25/22. Her face was unwashed and there was mucous that drained from her nostrils and accumulated under the nasal cannula. The nasal cannula tubing fit tightly around her neck and there were purple-colored marks on her neck, under the tubing, coming up towards her right ear. On 3/28/22 at 2:05 PM, resident #10's position was unchanged. She still lay on her left side with her head on a pillow, facing the door. The yellow crusty substance remained clumped in her hair above the right ear and the same nasal cannula,dated 2/25/22 was in place. On 3/28/22 at 3:46 PM, during an observation of resident #10 with the East Wing Unit Manager (UM), the resident was in bed and still lay on her left side. The East Wing UM acknowledged the date on the resident's nasal cannula tubing showed it had not been changed for over a month. She explained nurses were expected to change the nasal cannula tubing once weekly on Fridays. She validated there was crusted, yellowish drainage in resident #10's hair above her right ear. The East Wing UM observed the dark colored wound to the resident's outer ear and confirmed she had no previous knowledge of the area of breakdown. She carefully pulled down resident #10's right ear and removed the nasal cannula which was lying in the crease of her upper ear. A wound about the size of a small raisin where the nasal cannula had been resting was identified. The wound was open and draining, with redness noted to the surrounding tissue. The East Wing UM rolled resident #10 to her right side and removed the nasal cannula tubing from behind her left ear and found the skin underneath reddened and moist. She reported she was not aware of the wounds to resident #10's right ear. She explained the resident's last skin assessment would have been performed the past Tuesday, 3/22/22. The East Wing UM explained the wound behind the resident's right ear was at the minimum a stage 3 wound and the wound to the outside of her right ear was unstageable. On 3/28/22 at 4:10 PM, the East Wing UM stated she was unable to find any documentation of skin (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105471 If continuation sheet Page 2 of 12 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 105471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rehabilitation Center of Orlando 9311 S Orange Blossom Trl Orlando, FL 32837 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 0686 Level of Harm - Actual harm Residents Affected - Few assessments for resident #10 for the past 10 weeks, since 1/18/22. She confirmed the assigned floor nurses were supposed to perform skin sweeps weekly on the 3 PM to 11 PM shift on Tuesdays as ordered by the physician. On 3/28/22 at 4:20 PM, the Wound Care Registered Nurse (RN) assessed resident #10's wounds. She validated there were purplish marks around the resident's neck, and two wounds to her right ear. On 3/28/22 at 4:26 PM, Certified Nursing Assistant (CNA) C stated she had just completed care for resident #10. She confirmed she washed the crusty substance from the resident's hair. CNA C said checking the resident's skin was part of daily hygiene care and she was aware any skin issues should be reported to the nurse. On 3/28/22 at 5:30 PM, the Wound Care RN described taking resident #10's nasal cannula off to assess the wound to the back of her right ear. She stated she assessed the wound to the back of the right ear as a stage 3 pressure ulcer as it was open and the tissue in the wound was yellow and draining. She noted the wound to the outer ear was an unstageable pressure ulcer as it was blackened. The Wound Care RN recalled she assisted the Wound Doctor that morning during care to the resident's sacral pressure wound. She remembered the resident was turned to her left side. She added that CNAs should turn and reposition the resident to prevent worsening of the existing wound and development of new wounds. The Wound Care RN acknowledged the wounds to resident #10's ear could have been there since the past weekend. On 3/28/22 at approximately 5:35 PM, the Assistant Director of Nursing (ADON) stated CNAs were supposed to wash residents and observe for any skin issues. He explained the expectation was for CNAs to immediately report any changes in a resident's skin condition. He stated the CNAs were to let the nurse know even if the resident's skin was just pink. He indicated that treatments put into place at an early stage could prevent further damage to the skin. The ADON explained CNAs should turn the resident every two hours to prevent skin breakdown because her skin was so fragile and she was at high risk for skin breakdown. He validated the wounds to resident #10's ear should have been identified as part of her hygiene care when the CNA washed her face, including her ears. He explained the floor nurse was supposed to do a whole-body assessment during the skin sweep and confirmed that no skin sweeps were done in the past 10 weeks, since 1/18/22. He validated there was a breakdown in preventative treatment for resident #10 as the wounds were not identified. The ADON stated if the CNAs had washed resident #10's face, they should have seen the wounds to her ear and notified the nurse. The ADON agreed the wound was possibly there since Saturday. Review of the document Pressure Ulcer Wound Rounds dated 3/28/22 at 4:30 PM, revealed an unstageable, pressure type wound 0.2 centimeters (cm) by 0.3 cm by 0.1 cm to resident #10's right ear that was not present on admission. The wound bed was described as 100% dead tissue with no drainage. Review of the document Pressure Ulcer Wound Rounds dated 3/28/22 at 4:31 PM, revealed a stage 3, pressure type wound measuring 0.5 cm by 0.6 cm by 0.2 cm to the back of resident #10's right ear that was not present on admission. The wound bed was described as yellow slough with redness in the area around the wound. Review of the Medication Administration Record revealed nurses charted they performed the Weekly skin sweep that directed them to complete the head to toe skin sweep under assessment tab consistently every week of January, February and March of 2022. However, review of the medical record revealed the Weekly Skin Integrity Review was actually documented by nurses only 5 times over the 6 months (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105471 If continuation sheet Page 3 of 12 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 105471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rehabilitation Center of Orlando 9311 S Orange Blossom Trl Orlando, FL 32837 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 0686 prior to March 2022. The last skin sweep assessment for resident #10, completed on January 18, 2022, indicated her skin was intact on that date. Level of Harm - Actual harm Residents Affected - Few Review of the CNA care plan or Bedside Kardex Report for resident #10 dated 3/31/22, revealed directions for a weekly skin inspection requiring an observation of redness, open areas, scratches, cuts or bruises and to report to nurse and changes. The Kardex report detailed that resident #10 required total assistance from 2 staff for turning and repositioning for bed mobility as necessary, but it did include the required frequency for the task to meet the needs of resident #10 who was at high risk for skin breakdown. Review of the CNA task documentation report revealed no documentation of bed mobility performed on the day shift on 3/26/22, the night shifts on 3/27/22 and 3/28/22 and for the entire day of 3/29/22. On 3/29/22 at 10:15 AM, Licensed Practical Nurse (LPN) B stated she worked with resident #10 on the Friday 3/25/22 evening shift and Monday 3/28/22 day shift. LPN B stated CNAs were to provide care and wash the resident including behind the ears while the nasal cannula was moved. She confirmed the CNA did not notify her of any skin changes, and she was not aware of the wounds to resident #10's right ear. LPN B stated checking the resident's skin was part of the nurse's assessment during her shift. She stated she did not look at resident #10's nasal cannula during the day shift on Monday. She recalled she was too busy and did not look behind resident #10's ears during the shift although it was normally part of her assessment. She explained wounds from a medical device like a nasal cannula might be prevented if kept from resting on the skin by placing a cushion or gauze. She said another intervention to prevent pressure ulcers was frequent repositioning and as the nurse she was responsible to ensure CNAs turned and repositioned residents frequently. LPN B recalled resident #10 was turned toward the door during the day shift on Monday. On 3/29/22 at 12:38 PM, LPN E stated she was familiar with resident #10 as she was assigned to her on the day and evening shifts on Sunday 3/27/22. She explained resident #10 was at risk for skin breakdown and should be repositioned every two hours. She stated she did not check resident #10's skin nor was she informed by the CNA of any skin impairments for resident #10 during either shift. On 3/29/22 at 1:05 PM, CNA A stated she cared for resident #10 on Monday 3/28/22 on the 7AM to 3 PM shift. CNA A explained bed baths included washing the resident's face, body and hair and stated resident #10 needed total care from her. She said she gave resident #10 a bed bath, and combed her hair, but did not wash behind her ears or under her nose where the nasal cannula rested. She explained she thought she was not supposed to touch the nasal cannula, so she did not wash the areas where the cannula rested. CNA A did not explain how she gave the resident a bed bath but did not notice the wound to her outer right ear, the red marks on her neck, the dried drainage in her hair and her injured right ear. CNA A acknowledged resident #10 should be turned every two hours and stated she had turned her. She could not explain how resident #10 was turned every two hours if she was observed on her left side facing the door for 5 hours from approximately 11:00 AM until 4:00 PM during her shift on 3/28/22. She recalled resident #10 had a favorite side and possibly moved herself. However, CNA A then verified resident #10 was unable to move her upper body including her torso, shoulders and head on her own to change positions. CNA A confirmed resident #10's upper body was turned to her left side, towards the door during those hours. On 3/30/22 at 12:07 PM, the Hospice nurse and LPN B were at resident #10's bedside and acknowledged the resident was not able to turn herself. The Hospice nurse noted she performed a complete (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105471 If continuation sheet Page 4 of 12 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 105471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rehabilitation Center of Orlando 9311 S Orange Blossom Trl Orlando, FL 32837 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 0686 assessment and resident #10 was barely able to move. Level of Harm - Actual harm On 3/29/22 at 2:05 PM and 2:19 PM, the Director of Nursing (DON) stated the standard of care was for residents to be turned every two hours or more if needed. She identified resident #10 was at high risk for skin breakdown because she was bed bound. The DON verbalized CNAs were supposed to wash behind the ears and under the nose when they provided care to residents. She acknowledged CNA A's statement regarding not washing or looking behind resident #10's nasal cannula. The DON confirmed she assessed resident #10's wounds as unstageable and explained that she always considered anything above the neck as unstageable. The DON stated that turning and repositioning was an area of improvement for the facility. She acknowledged the issue of skin sweeps not being performed per physician orders was not identified until Monday 3/28/22, when it was brought to their attention. Residents Affected - Few On 3/30/22 at 11:34 AM, the Executive Director and DON stated a possible reason the resident was turned to her left side towards the door for approximately 5 hours, from 11:00 AM until 4:00 PM on 3/28/22, was the wound doctor asked for her to be offloaded for the debridement he performed in the morning to the pressure wound to her sacrum. Review of the Order Summary Report dated 3/28/22 at 4:04 PM, revealed no orders for nurses to leave resident #10 on her left side after her procedure that morning. On 3/31/22 at 10:55 AM, the wound physician confirmed he asked the nurse to offload resident #10 due to the debridement procedure he performed. However, he said, I did not give an order for her not be moved or to lay on one side. He stated he expected resident #10 to be turned every two hours as a standard of practice. He explained the ear is different from other parts of the body and could break down quickly because it had very little fatty tissue. The wound physician explained he felt the wound to resident #10's right outer ear was caused by shearing forces when her body was moved without lifting her head. He stated the wound to the back of her right ear was a stage 3 pressure wound. The wound physician said, The nurses should be evaluating them head to toe and looking at them everywhere, behind the ears included. He noted if a nasal cannula was in the same position for a while it needed to be offloaded from the skin to prevent breakdown. The wound physician explained, if you didn't look under something like a nasal cannula you could miss a problem. He elaborated that for most residents, the skin assessment should be done at a minimum weekly, but resident #10's skin should be checked at a minimum daily due to her poor nutrition and high risk for skin breakdown. On 3/30/22 at 1:00 PM, during a telephone interview, the Medical Director stated he assessed resident #10 via video. He stated resident #10 was at high risk for skin breakdown and explained interventions like turning and repositioning were important for prevention. He confirmed the wounds to her ear and stated the nasal canula rubbing around her skin could cause skin breakdown. He explained the nasal cannula around her neck, rubbing the skin likely caused the purplish marks to her neck. He noted the wounds to resident #10's ear would not typically appear on their own and were likely caused from the nasal cannula. The Medical Director stated he expected nurses to do skin assessments at least weekly. Review of the undated document Job Description- Clinical Nurse I, revealed the purpose of the position was to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by the nursing assistants. The document described duties and responsibilities which included the nurse conduct and document a thorough assessment of each resident's medical status throughout their course of treatment, and complete required documentation in an accurate and timely manner. Specific requirements of the Clinical Nurse I included demonstration of knowledge and skills (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105471 If continuation sheet Page 5 of 12 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 105471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rehabilitation Center of Orlando 9311 S Orange Blossom Trl Orlando, FL 32837 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 0686 necessary to provide care appropriate to the age-related needs of the residents served. Level of Harm - Actual harm Review of the Job Description - Wound Care Nurse dated 1/15/16, revealed duties and responsibilities included assistance in implementation and monitoring of compliance with policies, procedures and standards of practice consistent with corporate and external regulatory guidelines, monitoring of accurate and effective documentation, assistance with implementing an individualized treatment plan for each assigned resident. Residents Affected - Few Review of the Policies and Procedures, Clinical Guideline Skin & Wound with effective date 4/01/17 revealed an overview, To provide a system for identifying skin at risk, implementing individual interventions including evaluating and monitoring as indicated to promote skin health, healing and decrease worsening of/prevention of pressure injury. Procedures included licensed nurse to complete skin evaluations weekly and document in the medical record, CNA to complete skin observations and report changes to licensed nurse, and to develop individualized goals and interventions and document on the care plan and CNA Kardex. 2. Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including type 2 diabetes, systemic lupus erythematosus, phlebitis and thrombophlebitis of superficial vessels of the right leg. Systemic lupus erythematosus is an autoimmune disease in which the immune system attacks its own tissues, causing widespread inflammation and tissue damage in the affected organs. It can affect the joints, skin, brain, lungs, kidneys, and blood vessels (retrieved on 4/01/22 from www.cdc.gov). Thrombophlebitis is an inflammatory process that causes a blood clot to form and block one or more veins, usually in the legs. The affected vein might be near the surface of the skin or deep within a muscle (retrieved on 4/01/22 from www.mayoclinic.com). Review of the MDS admission assessment with ARD of 3/18/22 revealed resident #22 had a Brief Interview for Mental Status (BIMS) score of 9 which indicated she had moderate cognitive impairment. She required extensive to total assistance with Activities of Daily Living (ADLs). The document revealed the resident did not exhibit any behavioral symptoms including rejection of care. The assessment indicated resident #22 was at risk for developing pressure ulcers and pressure injuries and had skin conditions including pressure ulcers and pressure injuries presenting as deep tissue injury. A care plan for actual impairment of skin integrity as evidenced by pressure wound to sacrum, deep tissue injury right big toe, deep tissue injury left and right heel, pressure ulcer left ischium and excoriation to right buttocks was initiated on 3/14/22. Interventions included follow facility protocols for treatment of injury and staff to ensure bilateral boots to lower extremities are on at all times, may remove for ADL care. Review of resident #22's medical record revealed a physician order dated 3/16/22 for bilateral boots to lower extremities applied every shift. Review of the Treatment Administration Record (TAR) for March 2022 revealed nursing documentation of resident #22's bilateral boots applied as ordered. Review of Pressure Ulcer Wound Rounds form dated 3/28/22 revealed resident #22 had a suspected deep tissue injury on her right heel that measured 1.8 cm long, 2.0 cm wide and 0.1 cm deep. A Pressure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105471 If continuation sheet Page 6 of 12 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 105471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rehabilitation Center of Orlando 9311 S Orange Blossom Trl Orlando, FL 32837 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 0686 Ulcer Wound Rounds form dated 3/28/22 revealed resident also had a suspected deep tissue injury on her left heel 0.5 cm long, 1.0 cm wide and 0.1 cm deep. Level of Harm - Actual harm Residents Affected - Few On 3/28/22 at 5:12 PM, 3/29/22 at 11:01 AM and 3/30/22 at 5:01 PM, resident #22 was observed in bed without boots on her feet. She was also observed in her wheelchair on 3/28/22 at 3:55 PM, 3/29/22 at 2:40 PM and 3/30/22 at 12:29 PM without boots to both feet. On 3/31/22 at 10:06 AM, CNA F verified she was assigned to resident #22. She stated she was familiar with the resident and worked with her last week. CNA F stated she did not know if resident #22 had bilateral boots. She explained she had not seen any boots previously. CNA F searched resident #22's room but did not locate any boots. On 3/31/22 at 10:33 AM, LPN G confirmed she was the nurse assigned to resident #22. She said she saw the resident with bilateral boots last week but did not remember seeing them this week. LPN G reviewed the physician orders and noted resident #22 had an order for bilateral boots. She observed the resident and acknowledged she was not wearing any boots. LPN G searched the room but did not find the boots. She identified resident #22 was at risk for skin breakdown and needed the boots to protect her heels, promote healing and prevent further breakdown. On 3/31/22 at 1:45 PM, the DON reported resident #22 had pressure ulcers on both heels. She confirmed the resident should have bilateral boots in place to promote healing and prevent further breakdown. 3. Resident #55 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes, dementia and peripheral vascular disease. Review of the MDS Significant Change in Status assessment with ARD of 3/12/22 revealed resident #55 had a BIMS score of 0 which indicated she had severe cognitive impairment. She required extensive to total assistance with ADLs. The document revealed the resident did not exhibit any behavioral symptoms including rejection of care. The assessment indicated resident #55 was at risk for developing pressure ulcers and pressure injuries but did not have any at the time of the assessment. A care plan for actual impairment of skin integrity revised 3/24/22, indicated resident #55 had a pressure ulcer to her right heel. Interventions included Podus boot to right foot for offloading. Review of resident #55's medical record revealed a physician order dated 3/19/22 for Podus boot on right foot for offloading. Review of the TAR and MAR for March 2022 revealed no documentation to validate resident #55's podus boot was applied as ordered. Review of Pressure Ulcer Wound Rounds form dated 3/28/22 revealed resident #55 had a Stage 3 pressure ulcer on her right heel that measured 3.0 cm long, 3.0 cm wide and 0.1 cm deep. On 3/28/22 at 10:27 AM, resident #55 was observed in her reclining chair without a Podus boot on her right foot. On 3/29/22 at 12:00 PM, 3/29/22 at 2:59 PM, 3/30/22 at 9:41 AM and 3/30/22 at 5:01 PM, the resident was observed in bed without a Podus boot on her right foot. On 3/31/22 at 10:11 AM, CNA F verified she was assigned to resident #55. She stated she did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105471 If continuation sheet Page 7 of 12 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 105471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rehabilitation Center of Orlando 9311 S Orange Blossom Trl Orlando, FL 32837 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 0686 know if the resident had a boot and had not seen her with one. CNA F lifted the covers and acknowledged resident #55 was not wearing a Podus boot. She searched the resident's room but did not find the boot. Level of Harm - Actual harm Residents Affected - Few On 3/31/22 at 10:24 AM, LPN G observed resident #55's right foot and verified she had a pressure ulcer on her right heel. She acknowledged the resident did not have a Podus boot on her right foot. LPN G reviewed resident #55's physician orders and verified resident #55 had an active order for a Podus boot to right foot. LPN G stated she had never seen resident #55 with a boot. On 3/31/22 at 1:45 PM, the DON stated resident #55 was at risk for skin breakdown and had a pressure ulcer on her right heel. She acknowledged resident #55 did not have a Podus boot. She explained the reason for the Podus boot was to prevent the pressure area from getting worse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105471 If continuation sheet Page 8 of 12 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 105471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rehabilitation Center of Orlando 9311 S Orange Blossom Trl Orlando, FL 32837 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** Based on observation, interview and record review, the facility failed to provide appropriate care and services for oxygen therapy for 1 of 3 residents reviewed for respiratory care, of a total sample of 44 residents, (#10). Residents Affected - Few Findings: Resident #10 was admitted to the facility on [DATE] with diagnoses of heart disease, enlarged heart, hardening of the blood vessels in the brain, muscle weakness and chronic pain. Review of the Minimum Data Set (MDS) Quarterly assessment with Assessment Reference date 3/9/22 revealed resident #10 had severe hearing impairment and no speech. The MDS assessment indicated resident #10's cognition was severely impaired and had memory problems. The assessment showed she had a life expectancy of less than 6 months and required supplemental oxygen. The document revealed resident #10 required extensive assistance from staff for most of her care needs and she received Hospice care at the facility. A care plan initiated on 2/17/22 for risk for respiratory failure and requirement of oxygen therapy revealed a goal for the resident to have no signs or symptoms of poor oxygen absorption. The interventions included direction to provide oxygen as ordered by the physician. Review of the Order Summary Report dated 3/28/22 revealed a physician's order dated 2/16/22 for oxygen at 2 liters per minute (LPM) via nasal cannula every shift. An additional physician's order dated 2/16/22 directed staff to change tubing, mask or nasal cannula weekly and sooner if needed for hygiene on every night shift every Friday. On 3/28/22 at 11:03 AM, at 12:43 PM, and at 3:46 PM, resident #10 was lying in bed wearing a nasal cannula attached to an oxygen concentrator next to her bed set at 3 LPM. A piece of medical tape attached to the yellow tinged, nasal cannula tubing was dated 2/25/22. On 3/28/22 at approximately 4:00 PM and 4:10 PM, the East Wing Unit Manager (UM) confirmed resident #10's oxygen concentrator was set at 3 LPM. The UM acknowledged the resident's nasal cannula was dated over a month ago, on 2/25/22. She stated the nasal cannula was supposed to be changed by the nurse weekly on Fridays. The East Wing UM explained the nurse should have checked the oxygen concentrator and the nasal cannula during her shift. She indicated resident #10 was unable to change the oxygen concentrator setting herself. She said if the assigned nurse had checked the concentrator during her shift she should have adjusted it to the correct setting of 2 LPM as ordered by the physician. On 3/29/22 at 10:15 AM, Licensed Practical Nurse (LPN) B said resident #10 received Hospice care and was on oxygen therapy for comfort. She explained resident #10's oxygen level would drop without the supplemental oxygen. LPN B noted she was supposed to check the respiratory status of the resident which included checking the oxygen concentrator and nasal cannula during her shift. She acknowledged the resident's physician order was for oxygen therapy at 2 LPM. She was unsure of the facility's policy and procedure of how often the nasal cannula tubing was supposed to be changed. LPN B stated she did not check the oxygen concentrator setting or the nasal cannula during her previous shift on Monday 3/28/22 from 7AM to 3 PM. She stated if she had known the nasal cannula was last changed on 2/25/22 as the date on the tubing indicated, she would have changed it because she was sure, crusty stuff would be built up on it and it would not be sanitary. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105471 If continuation sheet Page 9 of 12 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 105471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rehabilitation Center of Orlando 9311 S Orange Blossom Trl Orlando, FL 32837 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 Residents Affected - Few On 3/29/22 at 2:05 PM, the Director of Nursing (DON) stated that oxygen was a medication and nurses should follow the physician's orders. Review of the undated document, Job Description, Clinical Nurse I revealed duties and responsibilities of the nurse included to conduct and document a thorough assessment of each resident during their stay and assist in the implementation of the individualized treatment plan for each assigned resident. The Policy Oxygen Therapy revised on 8/28/17 directed the nurse to review the physician's order, assess the resident, and label tubing with date and time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105471 If continuation sheet Page 10 of 12 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 105471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rehabilitation Center of Orlando 9311 S Orange Blossom Trl Orlando, FL 32837 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 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation, and interview, the facility failed to post the daily nurse staffing for licensed and unlicensed nursing staff directly responsible for nursing care per shift. Residents Affected - Few Findings: On 3/28/22 at 9:10 AM, the nurse staffing information form dated 3/18/22 was posted in the front lobby by the receptionist's window. On 3/28/22 at 5:50 PM, the nurse staffing information form was observed posted with the date 3/18/22 in the front lobby in the same place by the receptionist's window. On 3/29/22 at 9:30 AM, the nurse staffing information form posted in the front lobby next to the receptionist's window was still dated 3/18/22. On 3/29/22 at 1:04 PM, the nurse staffing information form dated 3/18/22 was removed, and no nurse staffing information form was posted. On 3/29/22 at 1:20 PM, the Staffing Coordinator stated she was responsible for completing the daily nurse staffing information form. She stated she removed the form earlier today to make corrections. She explained she was responsible to take down the old posting and put up the new one each day. The Staffing Coordinator acknowledged the nurse staffing form that was posted in the lobby earlier that day was dated 3/18/22. She explained she was new to her position and had forgotten to post the form since 3/18/22, and the correct form had not been posted since that day. When asked to provide a copy of the forms the Staffing Coordinator stated she had handed them over to Human Resources to review and did not provide the copies requested. On 3/31/22 at 12:10 PM, the Staffing Coordinator stated the daily nurse staffing form was posted for review in a public area because it allowed anyone who visited the facility to see how many nurses were staffed which indicated if there was enough staff to properly care for the residents in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105471 If continuation sheet Page 11 of 12 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 105471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rehabilitation Center of Orlando 9311 S Orange Blossom Trl Orlando, FL 32837 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 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow the physician laboratory orders for 1 of 5 residents reviewed for unnecessary medications of 44 sampled residents, (#147). Findings: Resident #147 was admitted to the facility on [DATE] with diagnoses of dementia, repeated falls, urinary tract infection, delusional disorder, hypokalemia (low potassium level), protein calorie malnutrition and chronic kidney disease. A medical record review revealed a physician order dated 3/19/22 for baseline labs to be done which included a CBC (complete blood count) and CMP (comprehensive metabolic panel). The facility nurse initialed the lab work was completed on 3/20/22 per the Medication Administration Record. Review of the paper and electronic medical records revealed no laboratory results. There was no documentation in the progress notes to indicate if specimen collection was not obtained by laboratory staff or resident refused lab work. A copy of the lab results was requested from the Unit Manager (UM) of the [NAME] Wing on 3/31/22 at 11:14 AM. He stated he could not locate any lab results and verified there was no documentation in the medical record of resident refusal. The UM added, they have had issues with the lab staff just leaving when resident refuses and not informing the nurse. The UM verified the physician was not notified the labs were not obtained for over 10 days after the order was written. Review of the facility policies and procedures for Laboratory, Diagnostic and X-ray revised on 6/21/21 read, Obtain a physician's order for laboratory work .Complete the required requisition form(s). Schedule laboratory work .Results of laboratory work .electronically uploaded to the resident EMR [electronic medical record] .the center to notify the ordering practitioner and resident/resident representative of results . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105471 If continuation sheet Page 12 of 12