Health inspection·July 13, 2023

F 0693 Level of Harm - Minimal harm or potential for actual harm Multivitamin with minerals 1 tablet. LPN A then proceeded to take the 8 small plastic cups containing medications and pill crusher into resident #289's room and placed them on the over bed table. Resident #289 was in bed with his eyes open and was nonverbal. LPN A proceeded to identify the resident and explained to him that she was going to be giving his medications via his G-tube and turned off the feeding pump which had been infusing Glucerna nutrition formula at 50 ml per hour. Residents Affected - Few On 7/11/23 from approximately 10:10 AM to 10:40 AM LPN A put all 8 medications in 1 small plastic bag and proceeded to crush them with the pill crusher at the bedside. When the bedside table started to buckle due to the increased pressure, she took the pill crusher to the dresser and completed crushing them. LPN A then put all crushed tablets into a medium sized plastic cup with 30 ml of water. She mixed the medications with a spoon and poured them back and forth in another plastic cup. There were large clumps of undissolved medications in the thick mixture. LPN A did not check placement of the feeding tube prior to medication administration. LPN A initially flushed the feeding tube with 30 ml of sterile water using a 60 ml piston tip syringe. She then drew up approximately 1/3 of the thick medication mixture with the same 60 ml syringe and proceeded to administer medications via the resident's G-tube. The nurse continued intermittent flushes with 5-10 ml water and 10 to 20 ml of air in the 60 ml syringe. The medication mixture would not easily administered so she continued to add more water to the mixture and went back and forth at least 4 times putting in the water and air. She then disconnected the control valve at the end of the feeding tube attached to the resident and started milking the tubing with her fingers attempting to unplug the clumps of medication. The adapter was plugged with medication particles and could not be used any more. The nurse did a final flush of the feeding tube with 60 ml of water via piston syringe directly into resident via feeding tube without the adaptor. She then connected the formula tubing directly to the resident minus the adaptor and left the pump off with the feeding formula hanging on the IV pole. LPN A stated she was instructed to give all medications together via G-tube and was not aware if there was an order to flush the tube between each medication. On 7/11/23 at 11:34 AM, the Interim Director of Nursing (DON) said it was basic nursing to give G-tube medications separately and flush in between so the tube did not get plugged. The DON said LPN A should have put each medication in their own cup and mixed them with 5-15 ml of water and given them one at a time and flushed between them as well. On 7/11/23 at 2 PM, a follow up interview was conducted with LPN A and the DON. LPN A acknowledged the 6 medication errors and acknowledged it would have been better to give medications 1 at a time because there would be less chance of clogging up the resident's G-tube. LPN A and the DON validated that it was not appropriate to instill air into the resident's G-tube. Review of the facility policy and procedures for Care and Treatment of Feeding Tubes dated Dec. 2022 read, It is a policy of this facility to utilize feeding tubes in accordance with current clinical standard of practice, with intervention to prevent complications to the extent possible .In accordance with facility protocol, licensed nurses will monitor and check that the feeding tube is in the right locations .Tube placement will be verified before beginning a feeding and before administering medications .Medication Flush Order: Give 30 ml before and after medications pass, 5 ml between meds . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105706 If continuation sheet Page 2 of 5 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 07/13/2023 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 0759 Ensure medication error rates are not 5 percent or greater. 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 medication administration error rate of 5% or greater for 1 of 3 residents sampled for medication administration, (#298). There were 6 medication errors in 29 opportunities for a medication error rate of 20.69%. Residents Affected - Few Findings: Review of resident #298's medical record revealed he was admitted to the facility on [DATE] from an acute care hospital. His diagnoses included diabetes mellitus type 2 (DM), dysphagia (difficulty swallowing), hypertension, anemia, benign prostatic hyperplasia (BPH), and gastrostomy tube. A gastrostomy tube (also called a G-tube) is a tube inserted through the belly that brings nutrition directly to the stomach (www.medlineplus.gov retrieved 08/01/23). On 7/11/23 at 9:40 AM, Licensed Practical Nurse (LPN) A prepared to administer resident #289's scheduled morning medications. LPN A placed 8 different medications into 8 small plastic cups at the medications cart that included, Vitamin C 500 milligrams (mg) 1 tablet, Acetazolamide 250 mg ½ tablet, Amlodipine 10 mg 1 tablet, Carvedilol 3.125 mg 1 tablet, Carbidopa-Levodopa 25-100 mg 1 tablet, Isosorbide Mononitrate 20 mg 1 tablet, Guaifenesin extended release 600 mg 2 tablets, and Multivitamin with minerals 1 tablet. On 7/11/23 at approximately 9:50 AM, LPN A explained she did not have the resident's antibiotic or vitamin D3 available on the medication cart and that she would retrieve them from the medication storage room and from their automated medication dispenser for administration later. LPN A was informed that she would not have medication errors for vitamin D3 or antibiotic as she informed surveyor she would give them later. LPN A did not verbalize any other medications that were scheduled that she would not be giving at this time. On 7/11/23 at approximately 10 AM, LPN A proceeded to take the 8 small plastic cups containing medications and pill crusher into resident #289's room and placed them on the over bed table. Resident #289 was noted in bed with his eyes open and was nonverbal. LPN A proceeded to identify the resident and explained to him that she was going to be giving his medications via his G-tube and turned off the feeding pump which had been infusing Glucerna nutrition formula at 50 milliliters (ml) per hour. On 7/11/23 from approximately 10:10 AM to 10:40 AM LPN A put all 8 medications in 1 small plastic bag and proceeded to crush them with the pill crusher at the bedside. When the bedside table started to buckle due to the increased pressure, she took the pill crusher to the dresser and completed crushing them. LPN A then put all crushed tablets into a medium sized plastic cup with 30 ml of water. She mixed the medications with a spoon and poured them back and forth in another plastic cup. There were large clumps of undissolved medications in the thick mixture. LPN A initially flushed the feeding tube with 30 ml of sterile water using a 60 ml piston tip syringe. She then drew up approximately 1/3 of the thick medication mixture with the same 60 ml syringe and proceeded to administer medications via the resident's G-tube. The nurse continued intermittent flushes with 5-10 ml water and 10 to 20 ml of air in the 60 ml syringe. The medication mixture would not easily administered so she continued to add more water to the mixture and went back and forth at least 4 times putting in the water and air. LPN A stated she was instructed to give all medications (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105706 If continuation sheet Page 3 of 5 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 07/13/2023 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 0759 together via G-tube and was not aware if there was an order to flush the tube between each medication. Level of Harm - Minimal harm or potential for actual harm A review of the resident #298's medical record post medication administration revealed the following 6 errors for medications scheduled at 9 AM: Residents Affected - Few 1.) 1000 mg of Vitamin C was ordered and only 500 mg was given 2.) Plain Multivitamin was ordered, and it was given with minerals 3.) Aspirin 81 mg oral chewable tablet for CVA (stroke) was error of omission 4.) Glipizide 10 mg tablet via G-tube for DM was error of omission 5.) Tamsulosin 0.4 mg capsule daily for BPH was error of omission 6.) Polyethylene Glycol 17-gram packet via G-tube for constipation was error of omission On 7/11/23 at 11:34 AM, the Interim Director of Nursing (DON) said it was basic nursing to give G-tube medications separately and flush in between so the tube did not get plugged. The DON was apprised of the 6 medications errors and concerns regarding LPN A not administering medications via G-tube safely and as per standards of practice. The DON said LPN A should have put each medication in their own cup and mixed them with 5-15 ml of water and given them one at a time and flushed between them as well. On 7/11/23 at 2 PM, a follow up interview was conducted with LPN A and the DON. LPN A acknowledged the 6 medication errors and said her computer mouse was not working properly and she did not see a page of the resident's medications to be given at 9:00 AM. The DON stated LPN A had not reported the computer issue to anyone. Review of the facility policy for Medication Administration revised January 2023 read, Medications are administered by licensed nurses .Review MAR [medication administration record] to identify medication to be administered. Compare medications source [bubble pack, vial, etc.] with MAR to verify resident name, medication name, form, dose, route, and time .Administer medications as ordered and in accordance with manufacturer specifications .Crush medications as ordered. Do not crush medications with [do not crush] instructions .Crushed meds are not to be combines and given all at once, if via tube feeding tube FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105706 If continuation sheet Page 4 of 5 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 07/13/2023 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 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee developed and implemented timely and appropriate plans of action to prevent repeat deficient practices related to medication error rates over 5%. Residents Affected - Some Findings: Review of the facility's survey history revealed repeat deficiencies concerns for medication errors over the past 5 years, and again during the current survey related to a medication error rate of 20.69%. The survey history revealed facility error rates of 6.45% on 2/10/22, 10.71% on 1/16/20 and 6.25% on 10/25/18. This will be the facility's fourth deficiency in 5 years for mediation error rate equal to or greater than 5%. On 7/13/23 at 5:18 PM, 6:23 PM, and 6:26 PM interviews were conducted with the facility's Administrator, Interim Director of Nurses (DON), and Corporate [NAME] Present (VP) of Operations regarding the facility's QAPI program. The Administrator verified they completed a plan of correction for medication errors last year but could no locate current audits for this year for medication errors except for ones done by the pharmacy nurse consultant. The DON was able to show the pharmacy consultant nurse did medication administration audits with 4 nurses in April of 2023. The VP verified that if they had ongoing PIP (Performance Improvement Plan) and audits of mediation errors that they should have documentation readily available for review but they did not. The facility could not show evidence of medication errors being discussed in QAPI meetings this year or that they had an actual PIP currently in effect for medications errors. The facility could not show evidence of current audits regarding medication errors except for routine ones that were done by the pharmacy consult nurse. The Administrator acknowledged the facility did not currently have a QAPI plan in place for Medication Errors. Review of the facility policy for Quality Assurance and Performance Improvement revised 9/1/22 read, QA is on-going, both anticipatory and retrospective in its efforts to identify how the organization is performing, including when and why facility performance is at risk or has failed to meet standards .Develop and implement appropriate plans of action to correct identified quality deficiencies .prioritizing quality deficiencies. Systematically analyzing underlying causes of systemic quality deficiencies .Monitoring and evaluations the effectiveness of corrective action/performance improvement activities and revising as needed .The facility must consider incident, prevalence, and severity of problems or potential problems identified . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105706 If continuation sheet Page 5 of 5