Health inspection·August 26, 2021

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure accuracy of Minimum Data Set (MDS) assessments for 1 of 2 residents reviewed for assessment accuracy of a total sample of 41 residents, (#67). Residents Affected - Few Findings: Resident #67 was admitted to the facility on [DATE] with diagnoses of dementia without behavioral disturbances and morbid obesity. Resident #67's MDS annual assessment with assessment reference date of 7/19/21 revealed he received insulin injections on 7 of 7 days in the look-back period. Review of resident #67's medical record revealed no physician orders for insulin. Review of the Medication Administration Record (MAR) did not reflect injections administered. On 8/26/21 at 12:30 PM, the Director of Nursing (DON) stated the staff who completed the MDS assessment worked part-time and was not currently present in the facility. During review of the MDS assessment with the DON, she acknowledged the assessment was inaccurate. She stated she reached out to Registered Nurse A, the MDS coordinator, who said he made an error as the resident never received insulin injections. The DON explained the facility used the Resident Assessment Instrument (RAI) manual for instructions on coding different types of drugs. Review of the RAI version 3.0 Manual revealed section N0300: injections and N0350: insulin. These sections included directions for MDS staff to review residents' MARs for the 7-day look-back period and Count the number of days insulin injections were received The (RAI) manual revealed the results of the MDS assessment, should accurately reflect the resident's status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105706 If continuation sheet Page 2 of 7 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 105706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare West Orange 1556 Maguire Rd Ocoee, FL 34761 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide dressing changes for a Midline Catheter according to professional standards of practice for 1 of 2 residents with Intravenous (IV) catheters of a total sample of 41 residents, (#335). Residents Affected - Few Finding: Resident #335 was admitted to the facility from a specialty hospital on 8/21/21 with diagnoses of respiratory failure, chronic obstructive pulmonary disease, and lung cancer. On 8/23/21 at 11:10 AM, resident #335 was observed in bed with a Midline IV Catheter to her left upper arm. The transparent dressing that covered the IV site was dated 8/14/21, and the lower end of the dressing was lifted from her skin. Resident #335 stated the IV was inserted at the hospital, and she was unsure if she was getting medications through it. A Midline Catheter is a small tube used to give treatments and to take blood samples. It is inserted into a vein in your arm . the end of the tube does not go past the top of the armpit . it can stay in place up to 30 days(retrieved on 8/27/21 from www.drugs.com). On 8/24/21 at 9:55 AM, the A wing Unit Manager (UM) stood at resident #335's bedside and noted resident #335 had a Midline IV catheter in her left arm. She acknowledged the IV dressing was loose at the lower end and was dated 8/14/21. She said, It is a problem. She explained because the dressing was lifted off the skin it was compromised and could lead to infection. She said the dressing needed to be changed or the IV discontinued if no longer needed. She stated her expectation was all assigned nurses should assess the IV site every shift. On 8/24/21 at 10:15 AM, during review of resident #335's medical record, the A Wing UM confirmed there was a physician's order dated 8/23/21 to discontinue the Midline IV. She acknowledged the physician's order had not been followed as the IV catheter was still in the resident's left arm. She said, It should have been done. She explained Midline IV dressings should be changed every 4 days and that the nurse who admitted the resident should have assessed the IV site and obtained IV care orders from the physician at that time. The A wing UM acknowledged there was no way to confirm the Midline IV was assessed because there were no related physician's orders or nursing documentation. Review of resident #335's Nursing Comprehensive Assessment dated 8/21/21 revealed no documentation of the presence of any IV catheters. Review of resident #335's Baseline Care Plan dated 8/21/21 revealed no documentation in the Special Treatments/Procedures section under IV type, location or dressing change. Review of resident #335's Order Summary Report dated 8/24/21 revealed no orders for Midline IV dressing changes or assessment. An order dated 8/23/21 read, Flush Midline/PICC every shift for patency and D/C midline/picline one time only for IV. Review of the resident's Treatment Administration Record (TAR) and Progress Notes from 8/21/21 to 8/23/21 revealed no documentation for IV dressing changes to resident #335's Midline IV. The TAR showed the Midline IV was discontinued on 8/23/21 as ordered although a progress note that read, 20 cm Midline to R upper arm was discontinued using aseptic technique per DR. order was dated 8/24/21. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105706 If continuation sheet Page 3 of 7 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 105706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare West Orange 1556 Maguire Rd Ocoee, FL 34761 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 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Facility nurses continued documenting on resident #335's Midline IV under Check Midline placement every shift and flush Midline /PICC every shift for patency through 8/25/21, even though the line was no longer in place. On 8/26/21 at 7:35 PM, the Director of Nursing stated a Midline IV should be reported to the physician on admission for their decision regarding whether the IV catheter would be utilized, discontinued, or to obtain appropriate orders for IV care. She acknowledged the nurse who received a newly admitted resident should assess and note findings including presence of an IV catheter. She acknowledged resident #335's Order Summary Report dated 8/24/21 contained no orders for the Midline IV dressing change. She confirmed the Baseline Care Plan completed at admission, dated 8/21/21 had no documentation indicating the resident had an IV. She said, It's important to assess the resident in general and what the resident needs. The facility's Policy and Procedure, Midline Dressing Changes 005-N dated October 2019 read, Midline catheter dressings will be changed at specified intervals, or when needed, to prevent catheter- related infection associated with contaminated, loosened or soiled catheter site dressings . Change midline catheter dressing 24 hours after insertion if placed with gauze, every 7 days or if it is wet, dirty, not intact or compromised in any way. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105706 If continuation sheet Page 4 of 7 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 105706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare West Orange 1556 Maguire Rd Ocoee, FL 34761 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review, the facility failed to store medications and biologicals under proper temperature controls as indicated by manufacturer's recommendations in 1 of 2 medications rooms, (A wing). Findings: On 8/24/21 at 4:12 PM, the A wing medication room refrigerator was opened by Registered Nurse (RN) B and the thermometer inside was immediately read at 48 degrees Fahrenheit (F). The door of the refrigerator was closed at the request of State Survey Agency staff and on 8/24/21 at 4:14 PM, the Assistant Director of Nursing (ADON) opened the door and validated the temperature on the thermometer inside the refrigerator still read 48 degrees F. The ADON explained the 11:00 PM to 7:00 AM shift nurse was supposed to check the refrigerator's temperature every night. On 8/24/21 at 4:19 PM, the Director of Nursing (DON) stated if the refrigerator temperature was out of range, the nurse was expected to initiate a maintenance request. She explained the refrigerator was frozen earlier that day and the temperature was raised to defrost it. The ADON again opened the refrigerator and immediately checked the temperature of the medications with a handheld, instant-read laser thermometer gun. The thermometer temperatures read 52 to 57 degrees F when pointed at the vials and boxes of medications. The affected medications inside the A wing refrigerator included Moderna Corona Virus Disease 2019 (COVID 19) Vaccine, Tuberculin injections, Rocephin Intravenous solution, Acidophilus, Lantus insulin, Victoza, Epoetin, Levemir insulin, Humulin insulin, Novolog insulin, Phenergan suppositories, and Ativan. Review of the medication labels found in the refrigerator revealed all medications were to be stored within 36 to 46 degrees F (retrieved on 8/27/21 from accessdata.fda.gov). The US Centers for Disease Control and Prevention Temperature Monitoring Best Practices for refrigerated vaccines listed a range of 36 to 46 degrees F, with the ideal temperature of 40 degrees F (retrieved on 8/27/21 from cdc.gov). The U.S. Pharmacopeia chapter 1079 Good Storage and Shipping Practices revealed refrigerators used to store drugs were required to maintain the product temperature between the limits as defined on the product's label. The document indicated the allowable range was 36 degrees to 46 degrees F (retrieved on 8/27/21 from usp.org). On 8/25/21 at 9:42 AM, the Maintenance Director said he had not received any service requests regarding the A wing medication room refrigerator. He explained the nurse should have submitted a work order for the refrigerator when it was identified the temperature was out of range. Review of the facility's Health Care Center Refrigerator/Freezer Temperature Log Sheet from the A wing medication room refrigerator dated August 2021 revealed temperatures logged at 48 degrees F on 8/23/21 and 8/24/21. No temperatures were recorded for 8/20/21 or 8/22/21. The Recommended Temperature Guides listed at the bottom of the log revealed refrigerated storage as 36-40 degrees F, and Although 36-45 F is acceptable, 36-40 F is the ideal refrigerated range. Review of the log for August 2021 revealed all recorded temperatures above 40 degrees F. Review of the July 2021 Medication room log (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105706 If continuation sheet Page 5 of 7 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 105706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare West Orange 1556 Maguire Rd Ocoee, FL 34761 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some sheet revealed temperatures of 50 degrees F on 7/14/21, 56 degrees F on 7/20/21, and 51 degrees F on 7/29/21. On 8/25/21 at 10:27 AM, Pharmacist D confirmed that medication refrigerators were supposed to be kept under 46 degrees F. She stated the Moderna Covid-19 vaccine, and the Tuberculin syringes should be discarded if stored at 48 degrees F as shown on the facility's temperature log. On 8/26/21 at 9:45 AM, the DON reviewed the Refrigerator/Freezer log sheet and acknowledged that if no temperature was recorded on 8/22/21 there was no way to tell if the temperature was out of range on that day. On 8/26/21 at 12:23 PM, the A wing UM stated she reviewed the refrigerator log every morning, Monday through Friday, but did not realize there was no documentation on 8/20/21 and 8/22/21. She stated she was not aware the temperature in the refrigerator had to be 36-46 degrees F. The A wing UM said, I thought that 48 degrees was ok. On 8/26/21 at 12:32 PM, in a telephone interview, RN C confirmed she recorded the temperatures of the A wing medication room on 8/23/21 and 8/24/21 when the temperature log showed 48 degrees F. RN C stated she had never received information regarding acceptable temperature ranges for the medication room refrigerator. She recalled receiving a message from the UM to simply check the temperature and write it on the log. She said, It is the only thing I received from them. RN C said she was never told to report discrepancies to maintenance or anyone else if there was a problem. On 8/26/21 at 12:58 PM, Pharmacist E stated that per the temperatures of 48 degrees F recorded on the A wing medication refrigerator log on 8/23/21 and 8/24/21, the medications were not good, and should be discarded. The facility's Medication Storage in the Facility Policy and Procedure dated April 2018, read, Medications and biologicals are stored safely, securely and properly, following manufacturer's recommendations or those of the supplier. The document revealed medication storage conditions would be monitored on a monthly basis by a pharmacy designee and any problems identified would be corrected. The policy emphasized, All medications are maintained within the temperature ranges noted in the United States Pharmacopeia (USP) and by the Centers for Disease Control (CDC). Refrigerated: 36 degrees F to 46 degrees F with a thermometer to allow temperature monitoring. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105706 If continuation sheet Page 6 of 7 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 105706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare West Orange 1556 Maguire Rd Ocoee, FL 34761 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation and interview, the facility failed to provide a clean and sanitary environment to protect the health and safety of residents, staff and the public by not securing bio-medical refuse and debris in the waste containers. Finding: On Monday, 8/23/21 at 10:00 AM, the entrance/exit door of the facility's Corona Virus Disease 2019 (COVID 19) unit had large, red, bio-medical waste containers overflowing with bio-medical refuse. The containers were filled past capacity with bio-medical waste and the container lids could not be closed. On top of the container lids were several bags of bio-medical waste. Some of these bags were partially open with debris coming out of the bags. The Director of Nursing (DON) arrived in the area and stated she was not aware the waste bins were full. At 10:51 AM, the DON and the B Wing Unit Manger opened a storage shed that contained approximately 12 smaller empty bio-medical waste bins. At the opposite end of the rear parking area, near the maintenance building were 21 large, red, bio-medical waste bins which were full. On 8/23/21 at 11:24 AM, an interview was held with the Administrator, DON and Maintenance Director. They stated the staff that worked on the COVID 19 unit were responsible to put the red bio-medical waste trash bags into the red containers. The Maintenance Director said the Bio-waste company picked up the red containers every 2 weeks. He said his staff placed 3 empty bins outside of the COVID 19 Unit on Saturday and that no maintenance staff worked on Sunday. They said they had not been informed that the bins were getting full. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105706 If continuation sheet Page 7 of 7