Inspection visit

Health inspectionMarch 8, 2024

ORLANDO HEALTH AND REHABILITATION CENTERCMS #10572833 citations on this visit

33 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 33 deficiencies, 4 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview, and record review, the facility failed to ensure 32 of 32 dependent residents on the memory care unit reviewed for dining were provided a homelike environment during mealtimes, of a total sample of 109 residents. Findings: On 3/03/24 at 1:41 PM, resident #107 was observed sitting in a chair outside her room in the hallway of the memory care unit. The resident's cognition was impaired and she was not able to answer questions appropriately. The resident stated she was hungry and asked Licensed Practical Nurse (LPN) RR when lunch was coming. The LPN responded, it will be here soon. At 1:56 PM Certified Nursing Assistants (CNAs) PP and SS were observed on the memory care unit while they distributed lunch trays to 32 residents. Resident #107 stated she didn't want to eat in her room. CNA PP told the resident she would bring her lunch tray to her room. The resident followed the CNA to her room where she remained while she ate her lunch. On 3/03/24 at 1:56 PM, CNA SS explained the memory care unit normally staffed 2 CNAs to pass meal trays to residents. She said nurses were often busy and rarely assisted. On 3/07/24 at 12:59 PM, resident #107 was observed in her room eating lunch. At 1:00 PM, CNA PP said she did not offer residents their meals in the common dining area. On 3/06/24 at 12:58 PM, CNA TT said she frequently worked on the memory care unit, and she knew the residents well. The CNA explained the mealtime routine was that 2 CNAs were responsible to pass meal trays to all 32 residents on the unit, and assisted residents to eat. She said the CNAs delivered and set up the meal trays mostly in the resident's room, and some residents ate in the hallway outside their rooms. She said she was never asked to offer residents the option of dining in the group area and the only place they ate was in their room or the hallway. She explained the residents were used to eating in their rooms or in the hallway outside their room. On 3/04/24 at 1:40 PM, resident #170 was observed sitting in a wheelchair in the hallway of the memory care unit while she ate her lunch placed on an overbed table. The Nursing Home Administrator (NHA) assisted the CNAs and distributed lunch trays to residents in their rooms. On 3/06/24 at 1:50 PM, CNA SS explained CNAs assisted residents on the memory care unit to the activities room for activities but not meals. She did not explain why residents did not eat meals in the activity room but instead ate meals in their rooms or in the hallway. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 109 Event ID: 105728 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 3/06/24 at 11:16 AM, Activities Assistant UU said the memory care unit activities room could be utilized as a common dining area. She said many of the memory care residents enjoyed eating their meals together, but it had been approximately two years since any residents were brought to the activity room for meals. She explained the activity room door was kept locked and if residents were in the room, at least one CNA was required to monitor and supervise the residents. She stated, all 32 residents who lived in the memory care unit were able and capable to participate in group dining and many of them enjoyed socializing and being out of their rooms but she could not recall the last time any resident had been there for meals. The Resident Handbook read, . Our dining services department creates appetizing meals that meet your individual needs as well as your personal preferences. We encourage you to eat your meals with other residents in the dining room; you'll find meals more enjoyable when you join your friends and acquaintances. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 2 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #284 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included chronic obstructive pulmonary disease, chronic respiratory failure, localized swelling, hyperglycemia, major depressive disorder, hypertension, and dependence on supplemental Oxygen. Residents Affected - Few The resident's quarterly MDS assessment dated [DATE], revealed the resident's cognition was intact with a BIMS score of 15 out of 15. On 3/04/24 at 1:01 PM, and on 3/05/24 at 10:35 AM, resident #284 was sitting up in bed watching a movie on his tablet. A bottle of Premium saline nasal spray was noted on the resident's tray table. Resident #284 stated he self-administer the nasal spray approximately three to four times per day. He said he was not hiding the nasal spray, and the staff knew he had it. On 3/05/24 at 10:38 AM, an observation of the resident's tray table was conducted with RN B. She acknowledged that a bottle of saline nasal spray was noted on the resident's tray table and verbalized that the resident said he bought the saline nasal spray with his own money, and the physician knew about it. A review of the resident's physician orders conducted with RN B revealed no order for the saline nasal spray found on the resident's tray table. The RN explained that for someone to self-administer medications, they must have a physician order, and a self-administration evaluation completed. RN B stated there was no order for the saline nasal spray, and a self-administration evaluation was not completed for the resident. On 3/05/24 at 10:57 AM, and at 1:20 PM, the C Wing UM and the 2nd Floor DON stated if a resident was to self-administer medications, they had to have a physician order. the facility would provide the resident with a lock box to safely store the medication, and a self-administration evaluation would be completed , and a care plan for self-administration of medication would be initiated for the resident. The C Wing UM, and 2nd floor DON acknowledged those protocols were not in place for resident #284. On 3/07/24 at 6:02 PM, a record review of the resident's clinical records conducted with the Executive DON noted a self-administration assessment for resident #284 could not be identified. This was confirmed by the Executive DON. Review of the facility's policy and procedure for Medication Administration Self-Administration by Resident, dated November 2017, revealed residents who wanted to self-administer their medications would be permitted to do so with a physician order and approval by the facility's interdisciplinary team (IDT). The procedures indicated the IDT would assess the resident's cognitive, physical, and visual abilities, then record the result of the assessment on a Medication Self-Administration Assessment form which would be kept in the medical record. The document revealed the assigned nurse would check for usage of the medication during the shift and record self-administration in the resident's medical record as indicated. 2. Review of the medical record revealed resident #586 was admitted to the facility on [DATE] with diagnoses including soft tissue disorder, peripheral vascular disease, need for assistance with personal care, abnormality of gait and mobility, and right side weakness and paralysis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 3 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The MDS admission assessment with assessment reference date of 2/24/24 revealed resident #586 had clear speech and was able to express her ideas and wants, and had clear comprehension. She had a BIMS score of 15 out of 15 which indicated she was cognitively intact. The document showed the resident received scheduled pain medication. Resident #586 had a care plan for pain or a potential for pain initiated on 2/23/24. The interventions instructed nursing staff to administer pain medication as ordered and observe for signs and symptoms of pain. Review of resident #586's Medication Review Report revealed a physician order dated 2/27/24 for Voltaren External Gel 1%, apply to right knee and right shoulder topically twice daily for pain. Voltaren Arthritis Pain gel contains Diclofenac, a nonsteroidal anti-inflammatory drug, which reduces substances in the body that cause pain and inflammation. Voltaren is used to treat joint pain caused by osteoarthritis (retrieved on 3/12/24 from www.drugs.com/voltaren-gel.html). On 3/04/24 at 1:19 PM, resident #586 sat in her wheelchair beside her bed. She rubbed her right knee and grimaced in pain. The resident asked the State Survey Agency surveyor to retrieve a tube of Voltaren ointment from her bedside table drawer and apply it to her knee or hand the tube to her and she would apply it herself. Resident #586 informed her assigned nurse, Registered Nurse (RN) GG, that she used the ointment for knee pain and her physician said there was an order for it. RN GG checked the bedside table drawer and removed two tubes of Voltaren ointment. RN GG stated resident #586 was permitted to keep the medication and he returned them to the drawer. On 3/04/24 at 1:23 PM, RN GG reviewed the resident's electronic medical record and discovered there was a physician order for the Voltaren ointment. He paused and then stated the tubes probably should not be at bedside unless the physician order indicated the resident was to apply the ointment . On 3/05/24 at 9:40 AM, resident #586 stated she still had the Voltaren ointment in her bedside table drawer. On 3/05/24 at 9:49 AM, RN D was informed resident #586 reported she had medication in her room. RN D checked the resident's bedside table drawer and retrieved one tube of Voltaren ointment and one tube of Capsaicin ointment. The resident explained when she was at home, she administered her own medication and applied the Voltaren ointment without assistance. RN D told resident #586 she was not permitted to keep medications at bedside without authorization, and she removed the tubes from the room. Capsaicin is used to help relieve shooting or burning nerve pain and to treat arthritis and muscle pain (retrieved on 3/12/24 from www.drugs.com/cons/capsaicin.html). On 3/05/24 at 9:53 AM, the B Wing UM stated RN GG should have followed the facility's policy when he discovered #586 had medication in her room and wanted to self-administer the ointment. She stated her expectation was if there was a physician order for the medication, the nurse would inform the physician of the resident's request to retain and self-administer the ointment. The B Wing UM stated the next step would be to conduct an assessment of the resident to ensure she was able to administer the medication safely, and if approved, she would be allowed to store the ointment in her room. Review of resident #586's medical record revealed as of 3/05/24 there was no physician order or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 4 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few documentation of an assessment for self-administration of medication, and no care plan revision to reflect the resident's wish to self administer the Voltaren ointment. Based on observation, interview, and record review, the facility failed to conduct medication self-administration assessment to ensure safety for 3 of 3 residents reviewed for self-administration of medications, out of a total sample of 109 residents, (#256, #284 and #586). Findings: 1. Resident #256 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes, chronic obstructive pulmonary disease, respiratory disorders, osteoarthritis, heart failure and sleep apnea. Review of the Minimum Data Set (MDS) quarterly assessment with assessment reference date (ARD) of 12/04/23 revealed resident #256 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated she was cognitively intact. On 3/04/24 at 12:50 PM, resident #256 was observed standing with her walker in the doorway to her room. She stated a nurse came in earlier and told her she was not allowed to have vitamins and supplements in her room. When asked what she had, resident #256 removed a bag from the chair in her room which contained vitamin C, turmeric, zinc, an oxide ointment, multivitamins, calcium and a menthol-based pain relief cream. Resident #256 stated the nurse told her she could not keep them and had to send them home. Resident #256 explained she had taken these supplements at home without any issues and was not aware until now that she could not have them in her room. A review of resident #256's medical record revealed she had not been assessed for self-administration of medication. The resident's plan of care did not indicate whether or not she could self-administer medications. The record did not contain any progress notes related to the conversation between the nurse and the resident or any notification to the resident's representative or the physician. On 3/05/24 at 12:57 PM, C-Wing Unit Manager (UM) stated she was unaware of any conversation with resident #256 regarding over-the-counter (OTC) medications in her room. The C-Wing UM entered the resident's room and resident #256 recounted the conversation from the previous day. She explained the nurse left the medications with her to send home. Resident #256 removed a bag from behind a chair and showed the OTC medications to the C-Wing UM. The C-Wing UM requested to take medications with the resident's permission. The C-Wing UM stated she was unaware the resident had OTC medications in her room. She acknowledged the resident had not been evaluated for self-administration of medication and the nurse should have removed them. On 3/06/24 at 2:42 PM, Licensed Practical Nurse (LPN) A confirmed she had spoken to resident #256 about the OTC medications in her room. She stated resident #256 wanted to keep the supplements and cream and send them home. LPN A explained she allowed the resident to place the items in a bag and left them in the resident's possession. She acknowledged she should have removed the supplements and creams from the resident's room as the resident was not identified as being able to self-administer medications. On 3/06/24 at 3:02 PM, the Executive Director of Nursing (DON) stated the facility did have some residents who were allowed to self-administer medications. She explained an assessment was completed to determine if the resident was capable of self-administering medications. If so, the resident would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 5 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0554 Level of Harm - Minimal harm or potential for actual harm receive a lock box for their room to secure the medications. The Executive DON reviewed resident #256's medical record and verified she had not been assessed to self-administer medications. She stated this was new for them and resident #256 would need to be assessed. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 6 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0560 Protect a residents' right to refuse some types of non-requested transfers within the nursing home. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure residents and/or their representatives had the opportunity to refuse room transfers for 1 of 11 residents identified to have concerns related to resident rights, in a total sample of 109 residents, (#122). Residents Affected - Few Findings: Resident #122 was originally admitted to the facility on [DATE] with diagnoses of Cognition Communicative Deficit, Falls, Dementia and Muscle Disorder. On 12/28/23 the resident was re-admitted to the facility to the B Wing room [ROOM NUMBER]. The re-admission Minimum Data Set assessment noted the resident's Brief Interview for Mental Status score was 7 out of 15 which indicated the resident's cognition was moderately impaired. On 3/4/24 at 2:48 PM, resident #122 was observed in her wheelchair on the B Wing in room [ROOM NUMBER]. The resident appeared upset and said she was moved from her old room to here and was not given a choice. She added, she was not given a reason why she had to move. On 3/5/24 at 12:12 PM, resident #122 stated, they still have not told me why I had to move. A progress note dated 3/4/24 indicated the following; Room Change Request By: Administration; Room change from: B109b to B128a; Person notified and time - Daughter [daughter's name] via phone. Discussed with nursing, housekeeping, dietary and administration. The progress note was written by the the Social Services Assistant (SSA) but there was no documentation as to the reason for the room change or if resident #122's daughter had agreed to the room change. On 3/8/24 at 11:23 AM, resident #122's daughter said she was the responsible party for her mother. She said the facility attempted to call her but she missed the call and when she called back, she was not able to speak to anyone about her mother's room change. She said she was not informed of her mother's room change until the next day, after her mother had moved to the new room. The daughter said she never gave the facility permission or agreed to the move prior to the room change. She said the room change was done and over with, when she finally learned her mother was moved to another room. On 3/28/24 at 12:48 PM, a meeting was conducted with Social Service Director (SSD) and the SSA. The SSD described the change of room process. He provided several reasons for resident room changes that included compatibility and choice. The SSD stated the room change was documented in the progress note and he added, We can't move them without the consent from the resident or their representative. Resident #122's room change was discussed and the SSD could not recall why the resident was moved. The Admissions Staff joined the meeting and said resident #122 was moved because the facility had a new admission and they needed to create a male room. The Admissions Staff said all of the beds in the facility were dually certified, and on 3/4/24 there were 4 beds open in the facility but they were all female rooms. Neither the SSD, SSA or the admission Staff provided an answer when asked why resident #122, who was diagnosed with dementia, had to move instead of the other resident moving to her room in 109 B. The SSA did not provide an answer as to why she failed to document in the progress note, the exact reason for the room change or the daughter's consent for her mother to be moved. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 7 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 interview, and record review, the facility failed to promote resident rights related to choice of type and frequency of baths for 1 of 17 residents reviewed for choices, out of a total sample of 109 residents, (#156). Findings: Review of the medical record revealed resident #156 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses including quadriplegia, muscle wasting, lack of coordination, and recurrent major depressive disorder. Review of the Minimum Data Set (MDS) admission assessment with assessment reference date (ARD) of 4/21/23, revealed resident #156 had a Brief Interview for Mental Status score of 15 which indicated he was cognitively intact. The document showed the resident was the primary respondent for questions in Section F - Preferences for Customary Routine and Activities, and his responses indicated he felt it was very important to be able to choose between a tub bath, shower, bed bath, or sponge bath. Review of the MDS Quarterly assessment with ARD of 1/18/24 revealed resident #156 had clear speech, was able to make his wants and needs understood, and did not have any issues with comprehension. The resident remained cognitively intact and he neither exhibited behavioral symptoms nor rejected care during the look back period. The resident had functional limitation in range of motion due to impairments of all extremities and he used a wheelchair for mobility. The MDS assessment revealed resident #156 was totally dependent on staff for mobility, bathing, dressing, and personal hygiene. Review of resident #156's medical record revealed a care plan for activities of daily living (ADL) self-care performance deficit was initiated on 4/15/23 and revised on 1/12/24. The goals included meet and anticipate the resident's needs. The interventions indicated resident #156 used a reclining shower chair and required the assistance of two staff for bathing. The document read, Shower per schedule & as needed; see shower schedule for details. Review of the A Wing Shower Schedule revealed resident #156 was to receive showers on Mondays and Thursdays during the 3:00 PM to 11:00 PM shift. On 3/03/24 at 1:35 PM, resident #156 explained he was a quadriplegic and was totally dependent on Certified Nursing Assistants (CNAs) for all ADLs. He stated he would love to have showers regularly. The resident said, I have asked CNAs and they refused. It is more work than they want to do. They don't like taking care of me because it is a lot of work. Resident #156 recalled the last time he received a shower was about six months ago when he was on the B Wing. He stated after he moved to the A Wing, CNAs only provided sponge baths and bed baths, but did not wash his entire body. Review of resident #156's medical record revealed he relocated to the A Wing on 8/30/23. Review of the resident's ADL flow sheet for the last 30 days revealed the resident received a shower on 2/12/24, refused a shower on 2/15/24, received a bed bath on 2/19/24, refused a shower on 2/22/24, received a bed bath on 2/26/24, and refused a shower on 3/04/24. On 3/06/24 at 10:39 AM, CNA F stated resident #156 was regularly on her assignment and she usually (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 8 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 provided him with bed baths. The A Wing Unit Manager (UM) stated she expected CNAs to do whatever they had to do to meet the resident's request for showers at least twice weekly according to the schedule. The A Wing UM explained there were shower chairs on the A Wing, and if necessary, CNAs had access to a shower bed and a larger shower room on another unit. On 3/06/24 at 12:08 PM, the resident emphasized he had never been offered a shower while on the A Wing, and definitely never refused one. He stated the A Wing UM just told him he would get a shower today, and said, At last! On 3/08/24 at 2:56 PM, the Staff Development Coordinator explained preferences such as type and frequency of baths were to be obtained on admission and updated throughout the resident's stay as needed. She said, We want to honor every resident's choices. Review of the facility's Resident Handbook, dated January 2017, revealed it included the Resident [NAME] of Rights. The document indicated the facility would ensure quality of life for residents through self-determination, and promote the right to receive care in a manner and environment that enhanced dignity and respect in full recognition of each resident's individuality. Review of the job description for Certified Nursing Assistant, dated 7/01/19, revealed CNAs' direct care responsibilities included ensuring .each resident's personal care needs are being met in accordance with the resident's/patient's wishes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 9 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct thorough, periodic reviews of Advance Directives to ensure resuscitation status related to Do Not Resuscitate Orders (DNROs) was appropriately documented in the medical record to effectively communicate choices regarding withholding life-sustaining measures for 3 of 4 residents reviewed for Advance Directives, out of a total sample of 109 residents, (#184, #246, and #165). Findings: 1. Review of the medical record revealed resident #184 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including cerebrovascular disease, stroke with left side weakness and paralysis, abdominal aortic aneurysm, hypertension, chronic obstructive pulmonary disease, dementia, and left carotid artery occlusion and stenosis. Review of the Minimum Data Set (MDS) Quarterly assessment with assessment reference date (ARD) of [DATE] revealed resident #184 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated she had moderate cognitive impairment. The document showed the resident exhibited weight loss although she was not on a physician-prescribed weight loss regimen. Review of the medical record revealed resident #184 had a care plan for advance directives related to a DNRO, initiated on [DATE] and revised on [DATE]. The goal was the resident's advance directives would be honored. Review of the Medication Review Report retrieved from the electronic medical record (EMR) revealed resident #184 had a physician order dated [DATE] for DNR status. Review of the paper chart on the A Wing revealed a Physician's Telephone Orders sheet with a handwritten order dated [DATE] that read Do Not Resuscitate.The paper chart did not contain the required DNRO form. A Do Not Resuscitate Order (DNRO) - Form 1896 was developed by the State of Florida Department of Health (DOH) to identify people who do not wish to be resuscitated in the event of respiratory or cardiac arrest. In order to be legally valid this form MUST be printed on yellow paper prior to being completed. [Emergency Medical Services] and medical personnel are only required to honor the form if it is printed on yellow paper (retrieved on [DATE] from www.floridahealth.gov/about/patient-rights-and-safety/do-not-resuscitate/index.html). On [DATE] at 12:18 PM, the A Wing Unit Manager (UM) reviewed resident #184's chart and validated there was no DNRO form. She confirmed the physician's telephone order sheet was not the required form. She explained the chart should have the DOH canary yellow DNRO form placed in the front for easy visibility. The A Wing UM stated she thought she saw someone from the Social Services department with the DNRO form earlier this morning. On [DATE] at 12:20 PM, the A Wing UM returned with a canary yellow DNRO form which she stated was signed by resident #184's attending physician yesterday. During review of the DNRO form with the A Wing UM, she confirmed the document was not signed by the resident or her proxy, and there was no date associated with the physician's signature. She explained the DNRO form was important as staff might perform cardiopulmonary resuscitation if the document was not available. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 10 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On [DATE] at 11:02 AM, the Social Services Director (SSD) confirmed his department was responsible for obtaining and validating advance directives, and ensuring DNRO forms were placed in the front of paper charts and the physician order for DNR was entered into the EMR. When asked about resident #184's DNRO, he explained it was not typical to have the physician sign a blank DNRO form without a signature by the resident or proxy. The SSD stated resuscitation or code status should be reviewed by Social Services staff at least every three months during care conference meetings. He stated the team would review physician orders in the EMR, but we don't always bring the physical chart to care conference. 2. Review of the medical record revealed resident #246 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including brain cancer, stroke with right side weakness and paralysis, convulsions, and adult failure to thrive. The MDS Quarterly assessment with ARD of [DATE] revealed resident #246 had severely impaired cognitive skills for daily decision making. Review of the medical record revealed resident #246 had a care plan for advance directives related to his desire for full code status, initiated on [DATE] and revised [DATE]. The goal was the resident's advance directives would be honored. Review of the Medication Review Report retrieved from EMR revealed resident #246 had a physician order dated [DATE] for DNR status. Review of the paper chart on the A Wing revealed a Physician's Telephone Orders sheet with a handwritten order dated [DATE] that read DNR. The paper chart did not contain the required canary yellow DNRO form. On [DATE] at 12:28 PM, the A Wing UM reviewed resident #246's paper chart and confirmed there was no DNRO form in the chart. She stated it was the responsibility of the Social Services department to get the form signed after a nurse obtained the order from the physician. On [DATE] at 10:55 AM, the SSD explained staff would verify advance directives on admission, during care conferences, and at the time of quarterly assessments. He acknowledged the canary yellow DNRO form should ideally be prominently placed in the front of the chart for easy accessibility. The SSD verified the absence of resident #246's DNRO was not identified during chart audits. He stated the medical record should reflect the resident's wish for DNR code status. On [DATE] at 1:18 PM, the A Wing UM emphasized that in the event either resident #184 or #246 was discovered unresponsive, nursing staff were trained to verify their code status in the chart and bring the chart to the bedside. She said, I educate my staff to check the chart, not the computer. On [DATE] at 3:49 PM, the Staff Development Coordinator stated the facility's nurses were educated to utilize the canary yellow DNRO form to verify a resident's code status. She confirmed it was essential to have the correct form in front of the chart to ensure clarity in an emergency situation. Review of the facility's policy and procedure for Advance Directives and Do Not Resuscitate (DNR), effective February 2021, revealed every resident had the right to make his/her treatment decisions. The document indicated the DNRO form must be on yellow paper and filled out completely to be valid. The policy indicated advance directives would be placed in the medical record by Social Services staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 11 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3. Review of resident #165's medical record revealed he was originally admitted to the facility on [DATE] and readmitted from an acute care hospital on [DATE]. His diagnoses included chronic obstructive pulmonary disease, hemiplegia and hemiparesis following cerebral infarction and type 2 diabetes. Review of the Minimum Data Set significant change in status with Assessment Reference Date of [DATE] revealed resident #165's Brief Interview for Mental Status score was 10 out of 15 which indicated moderate cognitive impairment. Review of the medical record revealed resident #165's granddaughter was his Power of Attorney and healthcare surrogate. Review of the Order Summary Report revealed a DNRO dated [DATE]. Review of resident #165's care plan for Advance Directives revised on [DATE] read, Resident/Authorized responsible party request DNR wish to be honored. Interventions included discussing Advance Directives with the resident and/or the appointed health care representative. Review of a Psychological History and assessment dated [DATE] showed resident #165's Advance Directives was a Full Resuscitate. Review of the Hospice Pre-Admit / In Person Visit Note dated [DATE] read, DNR was approached, but refused to sign DNR. On [DATE] at 3:40 PM, during a telephone conversation with resident #157's granddaughter, she stated she recalled signing a document for hospice services, but she did not sign a DNR. She indicated resident #165's wish was to receive cardiopulmonary resuscitation (CPR) when needed. On [DATE] at 12:48 PM, the H-Wing Unit Manager (UM) stated resident #165's code status was to resuscitate. The UM reviewed the electronic medical record for resident #165 and noted the banner and physician's orders showed he had a DNR. He confirmed he entered a physician's DNRO on [DATE] but did not recall what happened at that time. He acknowledged there was a discrepancy between the documentation in the electronic and physical medical records and reflected this could lead to an error during an emergency. On [DATE] at 1:40 PM, the SSD stated his responsibilities included obtaining new residents' advance directives on admission. He explained it was also reviewed at least quarterly during care plan meetings. He opened resident #165's physical chart and saw the first page was a written order signed by the physician on [DATE] which read, Full code. The SSD reviewed two Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer forms included in the physical chart and noted neither one indicted resident #165 was a DNR. He acknowledged the Advance Directives care plan showed the resident was a DNR. He indicated it was important the medical record showed the correct advance directives details because those represented the resident and family's wishes regarding resuscitation. He indicated the inaccurate information could result in staff abstaining from performing CPR and not honoring the resident's wishes. He said Advance Directives fall under my umbrella of responsibilities. Review of the policy and procedure titled Advance Medical Directives dated February 2021 read, . Document the Advance Directives/DNR Log upon admission, quarterly, with change in condition, and/or change in Advance Directives status. Review medical record at least quarterly and document (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 12 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0578 verification of Advance Directives in place in the progress notes. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 13 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide housekeeping and maintenance services necessary to ensure shower rooms were clean, sanitary, and homelike on 3 of 6 units (A wing, C Wing, G-Wing), failed to ensure Air Condition (AC) units were clean and in good repair in 5 rooms on the C Wing (C-09, 10, 12, 13, 25), failed to provide a comfortable interior in 2 rooms on the H-Wing, (1205, 1211) and failed to ensure return of residents clothing from the laundry for 3 of 10 residents reviewed for personal property (#4, #7, #307) of a total sample of 109 residents Findings: 1. Observations conducted on multiple units of the facility on various dates and times showed the following: On 3/04/24 at 5:38 PM, observation of the shower room on the G Wing with Certified Nursing Assistant (CNA) MM, showed towels on the floor, and on the shower chair. Three industrial mop buckets were stored against the wall in the shower room. The observation was confirmed by the CNA, and she said after each shower CNAs needed to clean up after use. On 3/04/24 at 5:46 PM, the shower room in the alcove of room [ROOM NUMBER] on A Wing showed black substance/discoloration where the wall and floor tiles joined, and standing water was observed on the floor of the shower area. On 3/04/24 at 6:11 PM, the Housekeeping Manager stated that deep cleaning of the shower rooms were done weekly, and daily cleaning was done by the assigned housekeeping staff. Observations of the shower rooms were conducted with the Housekeeping Manager. She acknowledged the findings, and stated the mop buckets in the G Wing shower room were used to remove the standing water and should not be stored in the shower room. The Housekeeping Manager could not say how long the identified concerns were present. On 3/04/24 at 6:24 PM, CNA OO stated that sometimes the water from the shower would not run out. She stated it was placed in the maintenance book, they would come and do something, and two weeks later, they would have the same problem. Observation on the C Wing in the shower room located in the alcove of room [ROOM NUMBER] on 3/05/24 at 10:01 AM, showed blackish discoloration at the corners of the shower area, where the floor tiles joined the wall, and a towel was on the floor. On 3/04/24 at 1:01 PM, in room [ROOM NUMBER], the AC vent was dusty, at 1:16 PM in room [ROOM NUMBER], the AC vent was dusty, and rusty, and the AC filter was noted on the resident's bedside table. At 2:18 PM in room [ROOM NUMBER], there was a hole to the right side of the lower door jamb inside the room, and on the lower portion of the wall close to the door jamb, next to the bathroom. The AC vent was dusty, and rusty. On 3/05/24 at 10:01 AM, in room [ROOM NUMBER], there was a towel underneath the AC unit, and resident #67's roommate stated the AC unit leaked all the time. He stated he placed the towel there, and it was soaking. The resident stated the facility was aware, but they did not care. At 10:10 AM in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 14 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 room [ROOM NUMBER], the AC unit vent was dusty, with a black substance noted to the right of the vent. A large square hole was noted above the AC unit, and a towel was underneath the AC unit. On 3/06/24 at 12:24 PM, Housekeeping Manager 2, stated there was a housekeeper on each Wing, and their responsibilities included daily room cleaning, cleaning of the shower rooms, common areas, and cleaning of the AC vents. Observations of the affected rooms and AC units were conducted with Housekeeping Manager 2, he acknowledged the findings. On 3/06/24 between 12:42 PM to 12:48 PM, observations of the above-mentioned rooms were conducted with Maintenance Assistant M, and Maintenance Assistant N, and they acknowledged the findings. Maintenance Assistant M stated he reviewed the maintenance books on the units daily, and staff should document any concern. He recalled he used to do a tour of the units to identify concerns, but stated the facility was short staffed, they did not have a Maintenance Director, and there were only two Maintenance Assistants in the building. He verbalized that he had not checked on the AC filters and stated the last time the AC units/filters were checked was probably in January 2024. However, a list to verify this could not be provided. On 3/08/24 at 9:00 AM, the Executive Administrator stated he was aware of the environmental concerns identified, and stated the facility was between Maintenance Directors. Pictures of the shower rooms on the A Wing, and G Wing were shared with the Executive Administrator. He stated the Housekeeping Manager started approximately one month ago and had been working hard to get things done. The facility's policy Physical Environment with effective date of January 1, 2020, read, A safe, clean, comfortable, and home-life environment is provided for each resident/patient . All essential mechanical, electrical, and resident/patient care equipment is maintained in safe operating condition through the facility's Preventative Maintenance Program. 3. Resident #4 was admitted to the facility on [DATE] with diagnoses to include heart failure, end stage renal disease, and hypertension. The Minimum Data Set (MDS) annual assessment noted resident #4 scored 15 on the Brief Interview for Mental Status (BIMS) evaluation which indicated intact cognition. On 3/03/24 at 3:21 PM, resident #4 and his daughter stated every time the resident sent a blanket to the laundry it never came back. The daughter stated all of them had his name on it. The daughter said she was not sure how many blankets were missing but she was sure there were several. The resident stated his wife reported it to the nurse and CNAs and they stated they would look for them but no one had ever said anything about them. On 3/06/24 at 11:16 AM, the Social Service Director (SSD) stated he was going to call the family to get a description of the blankets as there was a rack with blankets in the laundry room. On 3/8/24 at 2:00 PM, resident #4 stated no one had been to see him about the missing blankets and his wife told him no one had called her requesting information about the blankets. 4. Resident #7 was admitted to the facility on [DATE] with diagnoses to include legal blindness, dementia, anxiety, cardiac pacemaker. On 3/03/24 at 2:41 PM, resident #7's sister stated the resident had been missing clothes for a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 15 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 year. The sister said, We have reported it but they continue to keep going missing. The sister stated the facility had tried to give resident #7 some donated shirts but the family preferred she wore her own clothes. The resident's closet and drawers were observed with resident #7's sister and revealed the resident did not have any shirts. Residents Affected - Some On 3/06/24 at 12:04 PM, the SSD stated he had spoken with the family in the past and he would call to find out what was missing. He stated the facility had clothes that were donated and the residents could choose items from that bin. 5. Resident #307 was admitted to the facility on [DATE] with diagnoses to include end stage renal disease, respiratory failure, diabetes mellitus. The MDS 5-day assessment noted resident #307 scored 15 on the BIMS evaluation which indicated intact cognition. On 3/04/24 at 3:51 PM, resident # 307 stated he was missing 2 shirts, money, and a phone charger. He stated he reported it to the SSD. On 3/06/24 at 11:30 AM, the SSD stated he was aware of the missing shirts and stated the phone charger was given to resident #307 by his department. He stated he would follow up with the resident. On 3/08/24 at 9:00 AM, resident #307 stated he had not seen or spoken to anyone from social services this week. 2. On 3/03/24 at 12:48 PM, the hot water faucet in the bathroom's sink in room H-1205 was loose and not working. There was no soap in the wall mounted dispenser above the sink inside the room. Resident #267 stated the bottom drawer in the dresser next to her bed did not go all the way and she had mentioned it to staff a few times, but it had not been fixed. Observations on 3/04/24 at 11:16 AM and 3/08/24 at 9:44 AM revealed the hot water faucet was not working, there was no soap in the dispensers located in the bathroom and the room's sinks and the bottom dresser's drawer did not close completely. On 3/04/24 at 1:11 PM, a hole measuring approximately 6 inches wide by 14 inches long was observed on the wall behind the bed in room H-1211-B (photographic evidence obtained). The wall paint around the hole was peeling off with debris noted on the floor. On 3/08/24 at 9:46 AM, the Regional Physical Plant Consultant stated there was no Maintenance Director in the facility since the first week of February 2024. He stated he was not sure if work orders, or room audits were done. He stated there was a Maintenance Log in the H-Wing, but he did not know how often it was checked. He explained his role was to identify areas of improvement in the facility to keep them out of trouble. He checked the Maintenance Log located in the H-Wing's nurses station and stated there were no work orders for rooms H-1205 or H1211. He validated the concerns in rooms H-1205 and H-1211 and mentioned staff could have reported these issues because there was someone in the room every day. On 3/08/24 at 9:57 AM, the Housekeeping Manager indicated she expected housekeepers to sweep and mop their assigned rooms daily and ensure residents have soap, toilet paper and anything they need. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 16 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 She validated the concerns in rooms H-1205 and H-1211. Level of Harm - Minimal harm or potential for actual harm On 3/08/24 at 12:15 PM, the second floor's Director of Nursing stated the facility was the resident's home and things needed to be cleaned, organized, and in working order. She indicated someone should have noticed and reported the issues observed in rooms H-1205 and H-1211. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 17 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their grievance process related to homelike environment for 1 of 1 resident reviewed for grievances in a total sample of 109 residents, (#267). Findings: On 3/03/24 at 12:48 PM, resident #267 stated the bottom drawer of the dresser next to her bed did not go all the way and she had mentioned it to staff a few times, but it had not been fixed. Observations on 3/04/24 at 11:16 AM and 3/08/24 at 9:44 AM, revealed the bottom drawer did not close completely. Review of resident #267's medical record revealed she was admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy, and lack of coordination. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15 which indicated intact cognition. Review of a Grievance/Concern Report form dated 2/08/24 filed by resident #267's daughter read, daughter reports mom needs bottom drawer fixed or dresser replaced, . The Facility Follow Up section read, Job created in TELS (electronic work order log), Director of Maintenance notified. The form indicated the family member and the resident were satisfied with the resolution. The facility's Social Services Assistant, Staff NN, the Social Services Director (SSD), and the Administrator signed the Resolution of Grievance/Concern section on 2/08/24. A copy of the work order entered on 2/08/24 was attached to the Grievance/Concern Report form. The Notes section indicated the dresser needed to be replaced or the bottom drawer fixed. Review of second Grievance/Concern Report form dated 2/28/24 filed by resident #267's daughter read, Dresser drawer broken. The Facility Follow Up section noted the individual(s) designated to take action were Maintenance and SSD and read, SSD notified Maintenance of issue w/ (with) dresser drawer. Added to TELS. The action taken section read, Dresser to be repaired or replaced. The Resolution of Grievance/Concern section included a conclusion which read, Family still feels aesthetics of dresser but is functional. The form showed the grievance/concern was resolved to the resident/reporter satisfaction and read, SW (social worker) will continue to discuss options for alternate dresser/new. The SSD and Administrator signed the Resolution of Grievance/Concern section on 2/28/24. On 3/08/24 at 8:59 AM, the Social Services Director (SSD) stated he was the Grievance Officer and grievances received were logged and resolved within 72 hours. He explained grievances were discussed during daily morning meetings and he communicated with whoever filed the grievance upon resolution. He reviewed two grievances filed by resident #267's daughter on 2/8/24 and 2/28/24. He stated they addressed the drawer as functional but resident #267's daughter indicated the aesthetics of the dresser was the issue. He explained he discussed the grievance with his assistant who told him resident #267 did not like how the dresser looked with drawer sticking out. He acknowledged both grievance forms showed the concern was resolved. He stated he did not know the drawer was not replaced or repaired yet. Review of the policy and procedure titled Grievance/Concert Management dated February 2021 revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 18 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0585 the facility's intent to preserve the rights of the residents by resolving their concerns promptly. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 19 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility neglected to provide adequate oversight of staff to provide appropriate admission orders and skin assessments; and neglected to provide maintenance care and services for a peripherally inserted central line intravenous catheter (PICC) per standards of care for 1 of 1 resident reviewed for PICC lines, of a total sample of 109 residents, (#72). Resident #72 was readmitted to the facility from the hospital on 1/10/24 with a peripherally inserted central line catheter in his left upper arm. The 3008 Agency for Healthcare Administration Transfer and Discharge form dated 1/10/24 detailed the double lumen PICC, but the form did not give the date it was inserted, the date the dressing was last changed or the location. The admitting nurse at the facility documented the presence of a double lumen device under the skin assessment portion of the readmission documentation, but failed to mention it was a PICC. She documented the wrong location and did not obtain orders for discontinuance or maintenance/care of the intravenous central line. Resident #72 went for a short stay to the emergency room on 2/26/24, but otherwise remained at the facility for 7 weeks and 4 days without receiving care and services to maintain the PICC line or prevent infection. On 3/03/24 the PICC was brought to the attention of facility staff by the surveyor and was ordered removed on 3/04/24. Resident #72 required an ultrasound, an X-ray of his left arm and blood work to ensure he had no complications from the facility's neglect of the PICC line. The facility's failure to identify and provide necessary care and services for maintenance and use of a peripherally inserted central line catheter placed resident #72 and all residents who were admitted /readmitted with medical devices including PICCs at risk for serious injury/impairment/death. Without appropriate central line catheter care, there was high likelihood resident #72 could have developed severe infection, blood clots, vascular damage or even death. This failure resulted in Immediate Jeopardy (IJ) starting on 1/10/24. The IJ was removed on 3/06/24. Findings: Cross reference F684 and F726. Resident #72, a [AGE] year-old was admitted to the facility on [DATE] with diagnoses of pneumonia, acute respiratory failure with low oxygen, chronic lung disease, feeding tube to the stomach, low white blood count, heart failure, skin cancer, lung cancer and tongue cancer. Review of Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 1/10/24 revealed resident #72 was readmitted to the facility on [DATE] for vomiting blood. The Treatment Devices section of the form indicated under type, a double lumen PICC. The form did not indicate when it was inserted, when the device dressing was last changed or where it was located. The time sensitive medications section of the document did not list any antibiotics. A PICC line is a thin, flexible tube inserted into an upper arm vein and guided into the large vein on the right side of the heart. It is used for intravenous delivery of antibiotics or chemotherapy drugs. Delayed complications such as infection and device dysfunction are more gradual in onset and occur over weeks or sometimes months. The most common complication is infection which can lead to sepsis, shock, and death. The reported patient mortality rate was between 12% and 25% for central line (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 20 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few related blood stream infections. Device dysfunctions occurred more often in central lines that have been in place for extended times and include catheter fracture and venous clots. Furthermore, cancer patients have amongst the highest risk of thrombosis at 41%. Current research showed no difference between PICCs and standard central lines for rates of complications (retrieved from www.ncbi.nlm.nih.gov on 3/11/24). Review of the Admission/readmit: Data Collection and Baseline Care Plan with effective date 1/10/24 at 3:45 PM, revealed Licensed Practical Nurse (LPN) BB documented on section 41 Skin Integrity resident #72 was admitted with the following skin issues, right arm- multiple bruises and she incorrectly documented right double lumen instead of left. The box for subsection i3 to Obtain physician orders for care instructions and monitoring, was checked. Section E, Drug Regimen Review detailed the drug regimen was reviewed by the practitioner on admission completed to include medication reconciliation completed upon admission/readmission, order entry warnings and any applicable pharmacy recommendations and found, No clinically significant findings. The subsections for date and time of follow up and follow up information/see new orders were left blank. On 3/03/24 at 2:25 PM, resident #72 was awake and alert, seated upright in bed. On his left upper arm, the double lumens of a PICC line were seen hanging down from his sleeve. Resident #72 stated he received the intravenous line (IV) in the hospital, but he could not recall how long he had it, nor why it was still there. Resident #72 lifted his sleeve to reveal a piece of worn, white tube-type gauze covering most of the IV site. He moved the gauze over to reveal the PICC dressing underneath was undated, unlabeled, and gaping open at the bottom where the double lumens hung out. He stated he could not recall receiving care for the PICC line while at the facility. On 3/03/24 at 2:34 PM, LPN Z stood at resident #72's bedside, and acknowledged she was aware of the IV in his arm. LPN Z verified the PICC catheter dressing was unlabeled with no date or initials on it and was loose at the bottom where the lumens emerged. She stated she did not know how long he had the line and was unable to say by looking at the unlabeled IV dressing. LPN Z explained she was not IV certified and would have to notify the supervisor if it needed to be assessed or needed care. She stated she was supposed to look at the dressing to check if it was intact, clean and for the date of the last dressing, but said she was at the end of her shift and had not done that. She stated she had not noticed there was no date on the dressing at all. LPN Z stated she did not know when the last time resident #72's PICC dressing had been changed. A few minutes later, LPN Z left resident #72's room and looked in the electronic health record to check the physician's orders. She said she could not find any orders for resident #72's PICC line. She said she had never noticed there were no physician orders for resident #72's PICC. LPN Z stated care and maintenance of a PICC line was important because it was a central line and could get infected without proper care. Review of the Abuse Prevention Program policy with most recent date of August 2020 revealed the facility designated and implemented processes which strived to reduce the risk of abuse and neglect. The document described those policies would assist the facility to reduce the risk of abuse and neglect including staff burnout which might increase the likelihood of such events. The definition of neglect was described as the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. In interviews on 3/03/24 at 2:53 PM and 3/04/24 at 10:47 AM, the C wing Unit Manager (UM) said she was told by LPN Z of resident #72's PICC line having no orders. She was unable to say how long he had had the IV, when it was inserted, why he had had it or why it was still in place. She stated she thought resident #72's IV was a midline he received at the hospital but was not sure when. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 21 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few verified there were no orders to care for the IV, no care plan for it, nor was it on the Medication Administration or Treatment Administration record for February 2024. The C wing UM explained the line needed to be flushed every shift, before and after any medications going into it along with dressing changes and assessment. She described the admission process for the assigned nurse who should do a full body head to toe assessment of the resident and note any devices or skin impairments on the resident. The C wing UM explained the nurse looked at all of the hospital paperwork including the hospital transfer form in order to transcribe the orders needed for the resident at the facility to determine if there were any changes, new medications or devices when a resident returned to the facility from the hospital. She stated it was important for the nurse to read all of the hospital papers to determine if there were any changes that happened since the resident went to the hospital. The C wing UM indicated the assigned nurse would call the physician to verify the orders. She stated the next day the UM would perform a chart audit using the admission checklist on all newly admitted or readmitted residents along with performing a second head to toe skin assessment. She described the chart audit would include the UM again checking the paperwork from the hospital for anything pertinent related to the care of the resident including skin, devices like an IV or catheter or even follow up appointments. The C wing UM detailed that on the skin assessment they were to document anything that was not normally found on the skin or going into the skin/body. She stated there were batch orders for IVs and other things that allowed the nurse to place all the needed orders to care and maintain an IV including a PICC. The C wing UM detailed the UMs would hand the audits to the DON and said she assumed they were checking it as well. The C wing UM explained the UMs would then summarize information about the newly admitted or readmitted resident during the clinical meeting every morning. The C wing UM explained the nurse should call the doctor for orders if a resident had a PICC line to determine if the line should be discontinued or implement orders for its care and maintenance. She acknowledged the second skin assessment she documented for resident #72 was inaccurate and stated she did not recall seeing his PICC line on his left arm when she did the second head to toe skin assessment. The C wing UM stated the LPN BB should have called the physician about resident #72's PICC line when she did the admission. She admitted she should have documented the PICC on the second skin assessment she performed and must have overlooked it. She stated she also did not catch it when she reviewed the hospital transfer form and therefore did not call the physician for the necessary orders. The C wing UM explained she was aware of resident #72's PICC and had even spoken to the physician about the PICC the previous week in regard to some labs that were needed but could not explain why she did not ask for orders for its care and maintenance at that time. She admitted she notified the on-call physician on 3/03/24 after being made aware by the State Surveyor there was a resident with an IV that she needed orders for. She acknowledged she did not inform the on-call physician of the details that resident #72 had a PICC that had not received care and services since January. The C wing UM instead received approval to put in the batch orders for resident #72's PICC without the physician knowing all of the circumstances concerning his PICC not receiving care. The C wing UM acknowledged she was aware that resident neglect meant not receiving care and services that were required for a resident's health and wellbeing. She reiterated a PICC needed to be kept clean, with an intact dressing, needed dressing changes and care because it could cause infections like sepsis or an infection in your heart. Review of the medical record revealed resident #72 had 7 weekly skin assessments from 1/13/24 to 2/28/24. None of the assessments documented the PICC line on his left upper arm nor any actions taken regarding the PICC. The assessments indicated there were no new areas of skin impairment and no mention of the PICC line. One assessment documented a refusal by resident #72. Revi (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 22 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few ew of the Treatment Administration Record dated January 2024, revealed a physician's order to monitor bruise to left inner forearm and notify the physician of any changes every shift that started on 1/11/24. During the month of January, 23 different nurses documented they had looked at resident #72's left arm and did not notify the physician about his undated/unlabeled PICC line. Review of the Treatment Administration Record dated February 2024, revealed the same physician's order to monitor the bruise to resident #72's left inner forearm and notify the physician of any changes every shift. For February 2024, 22 different nurses documented they had looked at resident #72's left arm and did not notify the physician about his undated/unlabeled PICC line. Review of the Treatment Administration Record for March 2024 revealed 6 nurses documented they had looked at resident #72's left arm per the physician order to monitor the bruise to his left forearm and failed to notify the physician about his undated/unlabeled PICC line that had no orders for care or maintenance. In total, 33 different nurses including three UM's and the first floor Director of Nursing (DON) documented they had looked at resident #72's left arm and failed to notice the PICC line and notify the physician for orders. On 3/03/24 at 3:06 PM, LPN AA stated she had cared for resident #72 since January when he was readmitted to the facility with the PICC line. She could not recall how long he had the PICC line or why he had it but said it had been awhile. LPN AA explained if a resident came to the facility with a PICC line, the nurse needed to obtain orders from the doctor to care for it. She stated she never realized he didn't have orders to care or maintain his PICC. She described a PICC line as needing to be flushed and the site assessed every shift, yet she did not know why she never questioned the lack of physician orders for care of resident #72's PICC line. On 3/04/24 at 12:28 PM, the admitting nurse, LPN BB in a telephone interview stated she was IV certified and recalled caring for resident #72 over the past several months. She stated when she admitted or readmitted a resident she did a head-to-toe skin assessment and often the supervisor or UM submitted the orders for medications and other care needs. LPN BB described the hospital transfer form was sometimes incorrect, so it was important to do your own assessment of the resident. She explained if she saw a wound or other skin impairment she would let the physician know, and she would document it in the skin assessment. LPN BB stated she could not recall resident #72's PICC, could not recall notifying the physician, nor could she recall assessing resident #72 at all. She explained a PICC line needed orders for care like flushes and if there were no medications ordered for it, the physician would often discontinue the line. LPN BB stated if she saw that a new or readmitted resident had a PICC line, she would notify the supervisor as they would call the physician for orders. She explained she would also look at a resident from head to toe during weekly skin checks and document if there was an IV and notify the physician. LPN BB could not recall ever discussing the PICC line with his primary physician or Advanced Practice Registered Nurse (APRN) CC and could not say why she had not notified them herself. On 3/04/24 at 1:13 PM, the Staff Development Coordinator (SDC) stated on admission the admitting nurse should put in the required batch orders for the PICC line. These orders included flushes every shift and as needed, change of the administration set every 4 days for any IV medications, documentation of site appearance every shift, dressing changes every 7 days and as needed, change the cap every 7 days, change the dressing within 24 hours of admit/insertion, flush each lumen with 10 milliliters of normal saline after each intermittent infusion, for blood draws flush with 10 milliliters of normal saline and to measure the arm circumference. She stated nurses had received education on what they were expected to do on admission and there was a class in their electronic learning modules they would take during onboarding. She described the admitting nurse was supposed to admit the resident in the electronic health record, observe the resident, do a hands-on head to toe assessment, then (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 23 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few verify the medications with the physician including any batch orders as needed. The SDC explained the UM also did a second skin assessment on each resident on admission/readmission and documented any skin impairment in the health record. She acknowledged the C wing UM documented bruises to resident #72's upper left arm and left and right hands but failed to document the PICC line to his upper left arm upon admission or obtain orders. The SDC acknowledged subsequent assigned nurses failed to document the PICC line in the skin assessments including the first skin assessment on 1/13/24. She stated nurses were aware of the batch orders for PICCs and should have called the physician. On 3/08/24 at 11:52 AM, the Regional Clinical Reimbursement Specialist stated the facility Clinical Reimbursement Specialists participated in clinical meeting and discussed care plans for new admissions, readmissions and any other residents with changes in their plan of care. She described the Clinical Reimbursement Specialists did an order listing review every morning, and looked at the physician orders. The Regional Clinical Reimbursement Specialist stated when they did the Minimum Data Set Assessment they were supposed to look at the resident for their assessment. She said they should have physically assessed resident #72 and noted he had a PICC line and documented it on the Annual MDS assessment on 1/13/24. The Regional Clinical Reimbursement Specialist explained the facility Clinical Reimbursement Specialist would have looked at him on 1/10/24 and he should have had a care plan for the PICC. The Regional Clinical Reimbursement Specialist said there was obviously some kind of a problem. On 3/08/24 at 8:49 AM, the Risk Manager (RM) stated she was told about the concerns regarding resident #72's PICC line on Monday, 3/04/24. She explained staff usually gave her a call, before they did a risk report. The RM said a risk report was done for any falls, treatment or medication variance, skin impairments, abuse/neglect allegations, unexpected hospitalizations, or deaths. She described the concerns for resident #72 having not received care or services for his PICC as the risk for infection. The RM stated the PICC line should have been removed due to risk it lead to infection or damage to major vessel in the heart. She stated her expectation was the nurse would notify the physician of the PICC not getting treatment when it was discovered and document this in the medical record. On 3/04/24 at 10:24 AM, in a telephone interview APRN CC stated she saw resident #72 frequently at the facility and described herself as the primary provider besides his attending physician. APRN CC stated she had not known resident #72 had a PICC line, nor had she known he had not had any orders for care or maintenance of the line since he arrived at the facility on 1/10/24. She described having seen resident #72 just a few days previously for some concerns about constipation. She stated she was not aware resident #72 had the PICC line and was surprised as he had no reason to have it as he did not have antibiotics or any other medication that needed a PICC. APRN CC described the physician ZZ having seen resident #72 on the previous Thursday as well and was adamant she was unaware of the PICC in his left upper arm as well. She explained they had not ordered any antibiotics and stated there was no justification for resident #72 to still have the PICC. She stated 7 weeks and 4 days was a very long time for resident #72 to not have any care for the PICC. She explained the nurses should have called to obtain orders to either discontinue the line or orders for care and maintenance. She stated no one from the facility had notified her or physician WW about resident #72's PICC not having any care or orders since the facility was made aware the day before on 3/03/24. APRN CC then called physician ZZ to clarify what she knew about resident #72's PICC. APRN CC continued the telephone interview and stated she spoke with physician WW, who told her she also did not know about resident #72's PICC. APRN CC stated if they had known, they would have discontinued the PICC line. APRN CC indicated nurses should have observed the PICC line during their weekly skin checks and noticed there were no orders for care and notified her or the physician. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 24 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of resident #72's medical record revealed resident #72 was assessed 9 times by the APRN between his admission on [DATE] and 3/03/24. The progress notes on 1/12/24, 1/13/24, 1/23/24, 1/24/24, 1/26/24, 1/30/24, 2/02/24, 2/07/24, and 2/20/24 did not mention resident #72's PICC line even though cardiac, skin and extremities were documented as assessed. On 3/04/24 at 12:50 PM, in a telephone interview, physician WW stated when APRN CC first called her she did not recall resident #72 having the PICC line, but now she remembered he had one. She stated she had spoken with the nurse about the line needing to be changed but wanted to deal with resident #72's abdominal pain first. Physician WW was asked if she knew resident #72 had gone for 7 weeks without any care for his PICC and she said she was not aware he didn't have any orders for the PICC since he came to the facility with it in January. Physician WW explained APRN CC saw resident #72 frequently, confirmed APRN CC was supposed to perform and document a complete hands-on assessment of the resident. She stated none of the facility staff had called to inform her or ask for orders for the PICC. Physician WW stated she did not know how it happened that resident #72 went for that long without anyone knowing he did not have any orders to care for the PICC. She said she had looked at the on call list and there was nothing that showed there were any issues with resident #72's PICC from 3/03/24 when the facility was made aware of the concerns about lack of care. She stated it was important for the PICC to get care because it could cause serious complications. On 3/08/24 at 2:21 PM, the Medical Director stated he was made aware of the issue with resident #72's PICC not having care since his readmission on [DATE]. He stated he expected facility nurses to obtain orders for care and notify the physician. The Medical Director stated PICCs were associated with complications like infections and said it was very lucky that resident #72 did not get a Central line associated infection or other complication due to this lack of care or maintenance for his PICC. The undated job description Unit Manager summary of position detailed the UM was responsible for overseeing direct nursing care to assigned residents by assuming responsibility and accountability for the nursing care and services provided on the unit. The UM was responsible for and adhered to the standards of care for the assigned residents and assisted with monitoring and implementation of physician orders based on individual resident needs. The UM was also responsible to supervise the resident care activity performance by licensed nurses. Essential duties and responsibilities included ensuring proper nursing care was provided, overseeing the assessments of the resident admission process and participation in the clinical admission process. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: * A registered nurse removed the PICC line from resident #72 on 3/04/24. The site was assessed by the RN and no signs of infection were present upon removal. Resident #72 remained in the facility with no change in condition or signs of distress. *The DON, Assistant DON (ADON) and UMs assessed all 381 residents for intravenous lines including central lines on 3/05/24. There were 6 residents with intravenous lines, including central lines with appropriate orders in place, proper fluids running as ordered and dressings appropriately dated. Each intravenous linesite was assessed by an RN with no signs of symptoms of infection present. * The Nurse Consultant educated the DON on the proper assessment of intravenous lines, including central lines on 3/05/24. The DON educated RNs who participated in the resident assessment referenced in bullet point #2 on the proper assessment of intravenous lines, including central lines. The DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 25 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0600 Level of Harm - Immediate jeopardy to resident health or safety or designee-initiated education on notification of physicians related to obtaining orders for care, maintenance or discontinuance of intravenous lines, including central lines. Education was initiated with licensed nurses related to neglect with obtaining and following physician orders related to intravenous lines including central lines. As of 3/05/24 24 of 114 licensed nurses had received education related to abuse and neglect training. They had a goal to complete an additional 25 nurses by 3/06/24 with the remaining nurses to be completed prior to starting their next work shift. Residents Affected - Few * The DON or designee will compare the admission data collection to the physician order to validate notification to the physician occurred and orders for maintenance or discontinuance of the line were obtained. The DON or designee will visually inspect every resident with an intravenous line including central lines to validate care, maintenance or discontinuance orders were followed. Review of in-service education sign in sheets and reconciliation with staff roster validated education was completed according to the facility's plan. 98 of the total 102 nurses at the facility were educated on neglect; assessment, documentation, and monitoring of IV site and dressing; midline/central line dressing change and flushing of vascular device. Additionally, 76 RNs were educated on PICC catheter removal. Interview with the Nursing Home Administrator on 3/08/24 at 12:32 PM, revealed he was the abuse coordinator and reported the allegation of neglect on 3/05/24 to the State Agency, Department of Children and Families and to local law enforcement. An ad hoc Quality Assurance Performance Improvement (QAPI) was held on 3/06/24 that included the Medical Director. On 3/05/24 a venous doppler of resident #72's left upper arm, an Xray of the left arm and labs were ordered by the physician to ensure no complications such as retained objects or infection after the removal of the PICC. Per interview with the Executive DON these tests resulted as within normal limits. On 3/06/24, 3/07/24 and 3/08/24 interviews were conducted with 30 of the nursing staff, including 24 RNs and 6 LPNs, including 6 second shift nurses. All verbalized understanding of the education provided by the facility including neglect, assessment, documentation, and monitoring of IV site and dressing; midline/central line dressing change and flushing a vascular device. The sample was expanded to include 4 other residents identified with IV lines. No concerns were found regarding these residents including resident #354 who had a tunneled central line in his right chest. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 26 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the medical record revealed resident #155 was originally admitted to the facility on [DATE] with soft tissue disorder, diabetes mellitus type 2, bipolar disorder, end stage renal disease, dependent on Dialysis, colitis, heart disease, and hypertension. The resident was emergently transferred to the hospital 3 times, on 07/03/23, 12/27/23, and 3/01/2024. A progress note on 7/03/23 indicated resident #155 was taken to hospital from dialysis due to clogged dialysis catheter. The note indicated a change in condition was reported to the physician and resident's family. Review of a progress note dated 12/27/23 revealed resident #155 was hospitalized due to missed dialysis treatments. A progress note dated 3/01/24 indicated resident #155 refused dialysis twice and the physician ordered her to be sent to hospital. Review of resident #155 medical chart revealed no written notice of transfer or discharge form for the hospitalizations on 7/03/23, 12/27/23, and 3/01/24. The notices were requested from the facility and they were provided by the Executive Director of Nursing, (EDON). Review of the notice of transfer and discharge forms for these 3 dates did not include the reason for transfer nor did they include a signature from the resident, or representative. Additionally, none of the forms indicated a notice was given to the local State Long Term Care Ombudsman. On 3/07/24 at 9:52 AM, staff RN V stated the UM was responsible for the notice of transfer or discharge form when a resident went to the hospital. On 3/07/24 at 10:05 AM, the C wing UM reported the resident's assigned nurse was responsible for completing the notice of transfer or discharge form when a resident went to the hospital. She stated the nurse would put the completed form in the medical records box to be sent to the local Ombudsman. On 3/07/24 at 3:25 PM, the D wing UM stated when residents were transferred, he would assist the nurse with the paperwork including the notice of transfer and discharge form. The next day he would give Risk Management a copy of the notice of the transfer and discharge form. He explained the resident representative was called and telephone consent was obtained if not present or if the resident was not able to sign it themselves. On 3/07/24 at 3:51 PM, medical records representative AA explained the nurse filled out the notice of transfer and discharge form and it was kept in the resident's chart. She reported her department did not handle this form until after the resident was discharged from the facility and the permanent medical record was compiled. On 3/07 /24 at 3:43 PM, the SSD provided a copy of the Discharge Log he emailed to the Ombudsman for December 2023. Resident #155's transfer to the hospital on [DATE] was not included in this log. When brought to his attention, the SSD explained he had not realized all residents whose bed had been held during their discharge were not included on the monthly discharge notification list he sent to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 27 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0623 the Ombudsman. Level of Harm - Minimal harm or potential for actual harm On 3/08/24 at 09:12 AM, the H wing UM stated he sent a copy of the notice of transfer and discharge form to the hospital with the resident. He explained the original went into the resident's chart. He stated he also kept a copy of the notice of transfer and discharge form in a binder in his office. He explained he was unaware a written copy was required to be provided to the resident or their representative. He stated he did not know who was supposed to get the copy to the resident or their representative. Residents Affected - Some On 3/08/24 at 9:31 AM, the H wing UM presented the binder with the notice of transfer and discharge forms that were identical to the incomplete ones previously provided. The 2nd floor Director of Nursing (2nd floor DON) showed the H wing UM, the notice of transfer and discharge forms were not filled out correctly including where they were being transferred to, the reason for transfer, and signatures. She explained if the resident was unable to sign, then the representative gets contacted and the UM writes on the form, the family was contacted. The UM and 2nd floor DON looked for the original notice of transfer and discharge forms that were expected to be put in this resident's chart but could not locate them. The 2nd floor DON and H wing UM acknowledged resident #155's cognition was intact and could have signed the form herself. The 2nd floor DON and H wing UM were in agreement that it was important for the resident or their representative and Ombudsman to receive the written notification as it explains the process and information needed to appeal the decision of transfer if they disagreed with the facility's decision to transfer them. On 3/08/24 at 10:52 AM, the Executive Administrator stated the facilities procedure for notice of transfer or discharge form was the social service department sent the form to the family the next day after they were transferred to the hospital. He explained a packet was typically sent with the resident when they go to the hospital and if an emergency, then it may have to be sent the next day. When the Executive Administrator was informed that the Social Service Department had not been providing a written copy of the form to the resident or their representative or the Ombudsman, he did not have a response. 6. Resident #61 was admitted to the facility on [DATE] with diagnoses including asthma, chronic obstructive pulmonary disease, nontoxic goiter, hypertension and acute kidney failure. Review of resident #61's medical record revealed she was hospitalized on [DATE] due to shortness of breath and difficulty breathing, on 11/17/23 due to altered mental status and on 11/22/23 due to rapid respirations and labored breathing. The medical record contained Notification of Transfer or Discharge forms for each hospitalization. The forms were incomplete and were not signed by facility staff or by the resident or their representative. On 3/07/24 at 3:39 PM, the SSD stated he was responsible for sending the log of transfers and discharges to the Ombudsman. He explained the log was sent on the first of each month for the previous month. On 3/07/24 at 4:15 PM, the SSD acknowledged he was unable to locate the log sent to the Ombudsman for November 2023 transfers and discharges. He also acknowledged he did not send any notices to residents or resident representatives for residents who transferred to the hospital. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 28 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 3/08/24 at 10:52 AM, the Administrator stated social services was responsible for issuing the Notification of Transfer or Discharge form and send to the resident representative. He stated nurses could initiate the form but social services should follow and ensure the process was completed. The Discharge Documentation-Florida Policy and Procedure, with an effective date October 2023 reads the facility would provide required documents to discharged residents based on the type of discharge or transfer. The procedure described for any facility-initiated discharges other than those while the resident was still hospitalized , the facility would provide notice of discharge to the resident and resident representative along with a copy of the notice to the office of the state Ombudsman at least 30 days prior to discharge or as soon as possible. For emergency transfer the procedures indicated the notice of transfer was to be provided to the resident and resident representative as soon as practicable, but within 24 hours of the transfer and copies of the transfer form were to be sent to the Ombudsman as soon as practicable, such as every month in a list. The Discharge Documentation-Florida section of the policy and procedure included for emergency transfer the written transfer and discharge form was required documentation. For Involuntary commitments the transfer and discharge from copy should be sent to the state Ombudsman office. Based on interview, and record review, the facility failed to provide written Notification of Transfer or Discharge forms to the residents or their representative, and the state Ombudsman for 6 of 7 residents reviewed for hospitalizations out of a total sample of 109 residents, (#58, #198, #727, #155, #3, and #61). Findings: 1. Resident #58 was admitted to the facility on [DATE] with diagnoses that included traumatic brain injury, epilepsy, heart failure, and alcohol abuse. A progress note dated 2/13/24 revealed resident #58 had escalating behavior and aggressiveness and auditory hallucinations and was placed on one to one observation. Further review of resident #58's medical record revealed the Clinical Psychologist ordered he be sent to the hospital for an involuntary examination on 2/13/24 for auditory hallucinations, and homicidal statements. A transfer note indicated resident #58 was sent to a higher level of care by emergency medical services (EMS) at 10:28 AM on 2/23/24. Review of resident #58's medical record revealed a written Notification of Transfer or Discharge form for the hospitalization dated 2/13/24 signed only by the Nursing Home Administrator/Designee. The notice was not signed as received by the resident or representative nor was there indication of notification to the state Ombudsman. The Social Service Director was unable to provide documentation of the notice to the Ombudsman. The facility was unable to provide documentation the resident or resident representative was given a copy of the Notification of Transfer or Discharge form nor of written notice made to the state Ombudsman. 2. Resident #198 was admitted to the facility on [DATE] with diagnoses that included adjustment disorder with disturbance of conduct, major depressive disorder, vascular dementia, hypertension and encephalopathy. A progress note dated 7/28/23 revealed resident #198 repeatedly had verbalized aggressiveness, and homicidal intentions. Later that day, resident #198 was ordered to be sent to the hospital for an involuntary mental health examination by the clinical psychologist because she was a danger to herself (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 29 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0623 and others. She was placed on one-to-one observation and sent to the hospital in 7/28/23 at 10:36 AM. Level of Harm - Minimal harm or potential for actual harm Review of the medical record revealed a Notification of Transfer and Discharge form dated 7/28/23. The form was not signed by the resident or resident representative and the section for the date notice was given and effective date was left blank. On the second page of the notice the section for notice given to the resident, legal guardian or representative, and for the state Ombudsman was also left blank. There was no indication or documentation that the resident, resident representative, or the state Ombudsman were notified in writing of the emergent discharge to the hospital. The Social Service Director was unable to provide documentation of the notice to the state Ombudsman of resident #198's emergent transfer to the hospital for involuntary examination. Residents Affected - Some 3. Resident #727 was admitted to the facility on [DATE] with diagnoses that included chronic lung disease, depression, lung cancer, hypertension and stroke. A change in condition note on 12/16/23 revealed resident #727 had an altercation with another resident and displayed behaviors of agitation and psychosis. A Certificate of Professional Initiating Involuntary Examination dated 12/16/23 by the Clinical Psychologist detailed resident #727's behavior as having auditory hallucinations, aggressiveness and unable to de-escalate behaviors or redirection. Resident #727 was ordered to be hospitalized emergently at 1:25 PM on 12/16/23. The facility was unable to provide the Notification of Transfer and Discharge form for resident #727's hospitalization on 12/16/23. The Social Service Director was also unable to provide documentation of notice to the state Ombudsman of resident #727's emergent transfer to the hospital for involuntary examination. 5. Resident #3 was admitted to the facility on [DATE] with diagnoses to include schizophrenia, depression, anxiety, heart failure, and hypertension. The Minimum Data Set (MDS) admission assessment noted resident #3 scored 11 on the Brief Interview for Mental Status (BIMS) evaluation which indicated the resident's cognition was moderately impaired. The MDS assessment did not identify any mood or behavior problems. Review of the record revealed resident #3 went to the hospital from [DATE] to 1/10/24. On 3/07/24 at 12:00 PM, the Social Service Director (SSD) stated he did not have resident # 3 on his list for notification to the Ombudsman. He stated he generated a list from their electronic system and she was not on the list. The SSD stated he did not complete the Transfer/Discharge form, and thought it was a nursing responsibility. On 3/08/24 at 10:52 AM, the Executive Administrator stated social services would issue the Notice of Transfer the next day and sent it to the family. He explained there was a packet that the nurse completed when a resident was transferred to the hospital. He said it contained a form that the nurse initiated, however in an emergency situation the nurse may not be able to fill out the form. On 3/07/24 at 3:25 PM, the D Wing Unit Manager (UM) stated when a resident was transferred to the hospital, he would print the face sheet, get the Transfer/Discharge form, and the resident's medication list. The next day he would give the Risk Management Department a copy of the paperwork. The UM explained the process should be the resident signs the transfer form and if unable to sign, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 30 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0623 Level of Harm - Minimal harm or potential for actual harm responsible party would be called and telephone consent obtained. The responsible party would need to sign the form and return a copy to the facility. The facility was unable to provide a signed copy of the Transfer and Discharge form for resident #3. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 31 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASARR) for a newly diagnosed Serious Mental Illness (SMI) for 1 of 10 residents reviewed for PASARR from a total sample of 109 residents, (#138). Findings: Review of resident #138's medical record revealed she was originally admitted to the facility on [DATE] with diagnoses including type 2 diabetes, heart failure and chronic kidney disease. Diagnoses of schizoaffective disorder, bipolar type, anxiety, and major depressive disorder were added to the resident's plan of care after she was admitted . Review of resident #138's quarterly Minimum Data Set (MDS) with Assessment Reference Date 1/30/24 revealed she had a Brief Interview for Mental Status score of 10 out of 15 which indicated moderate cognitive impairment. The MDS assessment showed resident #138 required assistance from staff for activities of daily living. The assessment revealed a Mood Interview was conducted and no symptoms were identified. The assessment noted no rejection of care necessary to obtain goals for her health and well-being. The assessment showed other behavioral symptoms not directed toward others (e.g., verbal/vocal symptoms like screaming, disruptive sounds) occurred 1 to 3 days in the lookback period. Review of resident #138's medical record revealed a State of Florida Agency for Health Care Administration Preadmission Screening and Resident Review (PASRR) Level I Screen form dated 10/18/17. Section I. A, Mental Illness (MI) or suspected MI, (check all that apply), was left blank. Section IV: PASARR Screen Completion showed No diagnosis or suspicion of SMI or ID (Intellectual Disability) indicated. Level II PASRR evaluation not required was checked. There was no evidence in the medical record a new Level I was completed. Review of a Progress Note dated 9/15/23 revealed an Interdisciplinary Team (IDT) meeting was held to discuss behavior issues. The note indicated resident #138 exhibited behaviors including anxiety, agitation and screaming. The note mentioned a psych consult was obtained and the care plan was updated. A Progress Note dated 9/29/23 revealed an IDT meeting was held to discuss behavior management. The note mentioned change of diagnosis for the use of Seroquel (new diagnosis not listed) and new medication Depakote 125 milligrams (mg) twice a day for mood disorder. A Progress Note dated 10/26/23 revealed an IDT meeting was held to discuss behavior management. The note indicated resident #138 exhibited behaviors including anxiety, agitation and screaming. The note mentioned a psych consult was obtained and the care plan was updated. Review of a care plan for mood related to periods of mood symptoms such as sadness, anxiety or restlessness was initiated on 5/03/18. The care plan was revised on 1/30/24. Review of a behavioral care plan initiated on 11/18/22 and revised on 1/30/24 revealed resident #138 showed behaviors such as getting upset with schedules, spitting out food and refused meals, combativeness toward staff and yelling out during care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 32 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of a psychotropic medication care plan initiated on 10/27/17 and revised on 1/31/24 revealed resident #138 used antidepressants to manage depression/insomnia, antipsychotic to manage schizoaffective disorder, bipolar, and anticonvulsant to manage mood. Review of a Progress Note dated 6/05/23 revealed an initial evaluation for a psychiatric evaluation and medication management for schizoaffective disorder. The note included, Patient has a documented history of schizoaffective disorder and cognitive communication deficit and listed a diagnosis of schizoaffective disorder, bipolar type. Review of a Progress Note dated 10/24/23 revealed resident #138 reported poor sleep over the past several weeks. The recommendations included to continue working with the psychologist and start Trazadone 50 mg at bedtime for insomnia. Review of a Progress Note dated 3/1/24 read, patient presents with klazomania (compulsive shouting) and confusion, not redirectable at this time. Staff reports patient's behavior has been persistent and includes sleep disruptions. The Review of Systems section included elevated/expansive/irritable mood . restlessness . disruptive/repetitive behaviors/vocalizations . agitation . The Assessment and Plan included to stop quetiapine 25 mg twice daily, continue dextromethorphan-quinidine 20-10 mg twice daily and start clonazepam 0.5 mg twice daily. On 3/06/24 at 2:10 PM, the Social Services Director (SSD) explained the PASARR form was received on admission. He stated the form was reviewed and if a discrepancy was found or a new one was required, he would complete and resubmit. He indicated when a new SMI was diagnosed, he collaborated with psych and nursing team to determine if the SMI impaired the resident's daily function in some way, then he would submit a review of a Level I. Later, on 3/07/24 at 11:17 AM, the SSD stated the only PASARR completed for resident #138 was in 2017. He indicated resident #238 had behaviors of hollering out and there was a behavior care plan. He stated that had been her behavior since working with her and she received psych services. He indicated they had addressed her needs and noted the PASARR had not been discussed during their interdisciplinary team meetings. On 3/08/24 at 7:57 AM, the Executive Director of Nursing stated she was responsible for the oversight of the nursing department clinical programs. She indicated the PASARR Level I was required for all residents admitted to the facility. She explained the form was required to identify residents with SMI to determine the level of care required for them. She noted the PASARR was completed and submitted to the appropriate organization by the SSD, and the Level I was good for life unless a change in condition required a new one. On 3/08/24 at 12:47 PM, the second floor Director of Nursing (DON) stated she noted changes in resident #138's behaviors since she fell years ago. She indicated resident #138 had increased behaviors and was under psych treatment. She mentioned resident #138 suffered from bipolar disorder, anxiety, and dementia. She stated they had a monthly meeting with the psych team to discuss behaviors and changes of psych medications if required. She stated the Clinical Reimbursement Specialist (CRS) added new diagnoses to the medical record. On 3/08/24 at 2:00 PM, CRS R stated she did not attend behavior / psych meetings. She indicated new psych diagnoses were obtained by looking at the psychiatrist's progress notes. She explained a newly diagnosed SMI with psychotropic medications would require a care plan with the appropriate interventions. She stated the PASARR process was done by the SSD. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 33 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 3/08/24 at approximately 2:15 PM, the Regional CRS stated the schizoaffective diagnoses was added on 12/18/23 to be effective on 10/24/23. She stated the CRS who added that would have looked at the psych note from 10/24/23 to confirm the diagnoses. She explained there were lots of corrections done after an audit for schizophrenia diagnoses was completed last summer. She explained resident #138's medical record showed she had a diagnoses of schizoaffective disorder unspecified which was added on 10/4/22. She indicated the unspecified disorder was resolved on 10/24/23 and the new specific diagnosis of schizoaffective disorder, bipolar type was added on 10/24/23. She stated the CRS would look for supportive documentation to make those changes. Review of the facility's policy and procedure titled PASRR Requirements Level I & Level II dated February 2021 only addressed the preadmission screening process. Review of the facility's policy and procedure titled Behavior Management Program Overview dated October 2021 read, The facility promotes the utilization of a behavior management program based on individual resident needs. The form did not address how the facility identified residents with newly evident or possible SMI, ID or a related condition and services for such residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 34 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 request a Preadmission Screening and Resident Review (PASARR) level 1 and level II evaluations for 1 of 10 residents reviewed for PASARR from a total sample of 109 residents, (#12). Residents Affected - Few Findings: Review of the medical record revealed resident #12 was admitted to the facility on [DATE] from the hospital. His diagnosis included vascular dementia, antisocial personality disorder, paranoid schizophrenia, major depressive disorder, and unspecified psychosis. Resident #12's admission Minimum Data Set (MDS) with an assessment reference date of 10/19/2018 revealed the resident was admitted to the facility with psychotic disorder, schizophrenia, and dementia. The assessment noted the resident's high-risk medications included antipsychotics that were administered on a routine basis. The admission assessment noted the resident was not considered for a level II PASAAR. Resident #12's Annual MDS with an assessment reference date of 12/6/23 revealed the resident had severely impaired cognitive skills for daily decision making. The annual MDS assessment noted the resident had behaviors present that fluctuated and changed in severity such as difficulty focusing and disorganized thinking. The assessment also noted he was diagnosed with psychotic disorder, schizophrenia, and dementia and received antipsychotics on a routine basis. The annual MDS revealed that the resident was not considered for a level II PASARR. Review of the change in condition behavior evaluation dated 2/10/24 revealed resident #12 exhibited verbal aggression and other behavior symptoms. Review of resident #12's medical record revealed a psychotropic care plan was initiated on 10/25/2018 that indicated the resident was at risk for complications related to receiving psychotropic medications for diagnosis of paranoid schizophrenia. A behavior care plan was initiated on 2/15/2019 that indicated the resident had episodes of being socially inappropriate such as yelling violently loud, throwing items in the dining room, being intimidating when yelling, and became angry if someone stayed in his path. A mood care plan initiated on 2/15/2019 noted the resident had episodes of mood swings such as mad, sad, angry, anxious, crying, mania, and hyperactive. It also noted the resident had episodes of screaming at staff members at times. Interventions included psychological services and to intervene as necessary to protect the rights and safety of others. The resident's psychiatry note dated 6/27/2019 revealed the resident was diagnosed with recurrent paranoid schizophrenia and major depressive disorder. On 3/05/24 at 11:15 AM, the H Wing Unit Manager (UM) stated he could not find resident #12's level I or level II PASARR in the resident's chart or in the electronic medical record. On 3/6/24 at 2:30 PM, the Social Service Director (SSD) stated he had been working at the facility since September 2022 and that a level I PASARR screen was to be completed prior to admission to the facility. He verified resident #12 was admitted to the facility on [DATE] with a diagnosis of schizophrenia and vascular dementia, but he could not find the resident's level I or level II PASARR. The SSD stated the resident should have had a level I and a level II submitted in 2018 prior to admission. He explained he submitted a level I PASARR yesterday, 3/5/24, when it was brought to his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 35 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0645 attention by the State Agency Surveyor and that it triggered for a level II to be completed as well. Level of Harm - Minimal harm or potential for actual harm On 3/8/24 at 1:00 PM, the Executive Director of Nursing stated a PASARR level I was completed prior to admission to the facility. She acknowledged that resident #12 should have had a level I PASARR completed prior to admission and a level II if it was triggered by the level I submission. Residents Affected - Few The facility's Preadmission Screening and Resident Review Policy and Procedure read, preadmission screening for mental illness and intellectual disability is required to be completed prior to admission to a Nursing Home. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 36 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the opportunity to participate in the development, implementation, and evaluation of their care plan was provided to 1 of 3 residents reviewed for care planning, of a total sample of 109 residents, (#29). Findings: Resident #29 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included malignant neoplasm of cerebrum, legal blindness, cardiomyopathy, and encephalopathy. Review of the resident's annual Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's vision was severely impaired, and the resident's cognition was intact with a Brief Interview For Mental Status (BIMS) score of 14 out of 15. On 3/04/24 at 2:19 PM, resident #29 stated he had not been to a care plan meeting did not have any family to attend the care plan meetings. On 03/07/24 at 10:16 AM, Licensed Practical Nurse/Clinical Reimbursement Specialist (LPN /CRS) S, stated resident #29 had a responsible party whom the invitation letter was sent. She stated the Unit Manager (UM), and Activities Director also reminded residents about their care plan meeting. The LPN/CRS stated staff would inform resident #29 since he was blind, and he would have to be escorted to the meeting. Review of the Invitation to Care Plan Meeting letters for care plan meetings held on 10/02/23, and on 12/25/23, revealed the invitation letters were addressed to the resident's Responsible Party. There was no documentation to indicate the resident was notified or invited to his care plan meetings which was confirmed by the LPN/CRS. On 3/07/24 at 10:34 AM, the Director of Nursing (DON) stated a list of residents with their scheduled care plan meeting was provided to her and the Unit Managers during the facility's Risk and Clinical meetings. She confirmed resident #29 had a responsible party, and stated the resident's cognition was intact, and he could participate in his care plan meeting. The DON reviewed the resident's clinical records and acknowledged documentation to indicate the resident was invited to his care plan meeting, and allowed to participate could not be identified. On 3/07/24 at 11:20 AM, resident #29 reiterated, no, he was never asked or invited to attend his care plan meetings. On 3/08/24 at 9:09 AM, the Regional CRS stated she was aware of the concern regarding the resident not being invited to participate in his care plan meeting. She said there was room for change in how the process was done. The Regional CRS acknowledged there was no documentation to indicate the resident was invited or participated in his care plan meetings. She stated that even if residents had a Guardian, they had the right to participate in their care plan meetings. The policy Care Plan-Interdisciplinary Plan of Care from Interim to Meeting, effective February 2024 read, the overall care plan should be oriented towards .Involving the resident to have a role in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 37 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0657 Level of Harm - Minimal harm or potential for actual harm care planning even if adjudged incompetent .as appropriate to participate in the development and implementation of his or her person- centered plan of care . The facility assists residents .to participate in and understand the assessment and care planning process holding care planning meetings at the time of day when a resident is functioning best . Call or visit is recorded on copy of letter. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 38 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 Activities of Daily Living (ADL) care with respect to oral care, bathing, grooming, nail care and change of clothing for 9 of 18 residents identified to have concerns with lack of ADL care in a total sample of 109 residents, (#300, #246, #110, #87, #435, #29, #434, #238, #137). Residents Affected - Some Findings: 1. Resident #434 was initially admitted to the facility on [DATE]. The resident was transferred to the hospital on 2/18/24 and readmitted to the facility on [DATE]. Resident #434's diagnoses included cerebral infarction, muscle wasting and neuromuscular dysfunction of bladder. On Monday, 3/04/21, at 12:55 PM resident #434 was observed in bed, dressed in a gown. There was a tube feeding pump to his right and his mouth and lips were dry. The resident complained his mouth was dry and sticky strings of saliva were observed on the right side of his mouth as he spoke. The resident requested a cup of water from staff who were present in the room. The resident stated he was nothing by mouth (NPO) in the hospital, but they gave him a sponge mouth swab that was wet and provided relief to keep his mouth and lips from being dried out. He said he had not been given mouth swabs since he had been at the nursing home. The resident's hair was matted, greasy and unkempt. He had facial hair with several days worth of growth. The resident explained he had a stroke, and that he had difficulty moving his left arm/hand. Review of the Occupational Therapy notes starting on 2/29/24 noted resident currently was dependent upon staff for hygiene, showers, dressing and oral care. On 3/04/24 at 5:53 PM, the resident was lying in bed and said the last time his mouth was swabbed was several days ago. Registered Nurse (RN) E was at her medication cart that was located just outside the resident's door. Resident #434 said the swabs were to moisten his mouth and he recalled the staff saying he was getting too much water. Resident #434 sarcastically said, You don't get too much water from a swab. The resident pointed out that if the staff left the swabs on his over the bed table, he could swab his mouth himself when he needed to. Resident #434 indicated he did not have good range-of-motion with his left arm/hand because of the stroke, but he could use his right hand to swab his mouth. He looked at his fingernails and said he wanted his nails to be shorter but he had not asked the staff. A few minutes later at 6:07 PM, RN E came into the room with mouth swabs and a small amount of mouthwash in a plastic cup. The resident dipped the swabs into the mouthwash and swabbed his mouth without the assistance of RN E. He added that it felt good to get some relief from his dry mouth. On Tuesday, 3/05/24 at 11:27 AM, resident #434 was in his bed on his right side. There were 2 mouth swabs on the over-the-bed table, but there was no mouthwash. He said staff swabbed his mouth earlier this morning, but his mouth was again dry now. He explained he had asked a Certified Nursing Assistant (CNA) for mouthwash this morning, but he was told to wait until she had finished passing out the breakfast trays. Resident #434 stated he had not shaved for 3 weeks since his brother had been to visit . He explained he did not like having a beard or mustache because it made him itch. The resident began scratching the hair that was on his neck. He said if he had his electric razor, he could shave himself, but believed his brother had taken the electric razor when his things were packed up. Resident #434 said today was supposed to be a shower day, but the staff came in with towels and they, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 39 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 - Some Wiped him down, instead. He stated, You feel cleaner, with a shower. Resident #434 said when he was at home he used to shower every morning. On Wednesday, 3/06/24 at 11:40 AM, resident #434 sat in a high back wheelchair with the over-the bed table in front of him. The resident did not have any mouth swabs. He said his mouth was swabbed earlier this morning, but his mouth was dry now. On 3/08/24 at 11:45 PM, the B Wing Unit Manager (UM) said resident #434's scheduled shower days were Tuesday and Friday on the 7AM to 3PM shift. The Kardex was reviewed, and the B Wing UM said resident #434 refused showers on Monday, 3/04/24, had a shower on Wednesday, 3/06/24 and refused a shower yesterday Thursday, 3/07/24. The B Wing UM could not explain why staff would document a shower refusal for Monday 3/04/24 and Thursday 3/07/24, since it was not his scheduled shower day. Approximately 15 minutes later, at 12:00 PM, the B Wing UM went to resident #434's room. When the B wing UM asked if he had refused a shower, resident #434 turned his head to the right and scoffed. He then looked at the B Wing UM and said he did not refuse any showers. Resident #434 still had a beard and he told the B Wing UM that he liked to be clean shaven. He added that after he got his shower on 3/06/24 the CNA did not offer to shave him. As the resident spoke to the B Wing UM thick, dry saliva strands were seen on both sides of his mouth. The resident said that he had mouth swabs and mouthwash previously, but had not had anything for his dry mouth in the past 2 days. 2. Resident #435 was admitted to the facility on [DATE] with diagnoses that included cirrhosis of the liver, metabolic encephalopathy, type II diabetes and bacteria in the urine. On Monday, 3/04/24 at 6:09 PM, resident #435 was in bed and stated he felt better since the nurse inserted a new urinary catheter so he was getting some relief. The resident was wearing a hospital gown, and had a beard. The Occupational Therapy Plan of Care noted resident #435 required assistance from staff for bathing and hygiene. On Tuesday, 3/05/24 at 2:47 PM, resident #435 stated he had not had a shower since he had been here. He indicated he was prideful and would prefer to walk to the shower room but agreed to be taken to the shower room in a wheelchair. The resident was wearing a hospital gown and still had a beard. He stated he has not shaven in the past week because facility staff had not offered to shave him. On Wednesday, 3/06/24 at 11:30 AM, resident #435 was observed wearing a tee-shirt and pants. He sat on a chair on the left side of the bed. He remarked that his roommate, had showered this morning and he said he was next to get a shower, most likely this afternoon. The resident still had not been shaved. On 3/08/24 at 11:33 AM, the B Wing UM reviewed the shower schedule and said resident #435 was scheduled to have showers on Wednesdays and Saturdays on the 3 PM to 11 PM shift. She reviewed the Kardex and said there were not any showers documented on the Kardex, for resident #435. Several minutes later at 12:00 PM, the B Wing UM spoke to resident #435 in his room. Resident #435 told the UM that he had not yet had a shower but was promised one by staff. When asked if he liked to be clean shaven, he responded, Absolutely. Resident #435 said his daughter was visiting today and he would like to be showered and shaved when she arrived to the facility. 4. Resident #29 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 40 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 - Some that included malignant neoplasm of the cerebrum, legal blindness, cardiomyopathy, major depressive disorder, encephalopathy, and diabetes type II. Review of the resident's annual MDS assessment dated [DATE], revealed the resident's vision was severely impaired, and the resident's cognition was intact with a Brief Interview For Mental Status (BIMS) score of 14 out of 15. The assessment revealed the resident required partial/moderate assistance with personal hygiene. Observations on 3/04/24 at 2:27 PM, and on 3/06/24 at 5:17 PM, showed resident #29 resting in bed. The fingernails on his right and left hands were long and untrimmed, and the resident stated he wanted his fingernails trimmed. Review of the POC (Point of Care) History for nail care for the period 2/10/24 to 2/29/24 showed an entry on 2/23/24 that read, No nail care resident refused. There was no other documentation to indicate nail care was provided, or that the resident refused nail care, and there was no documentation for March 2024 in the POC Response History regarding nail care for resident #29. A care plan for ADL self- care performance deficit related to impaired cognition, impaired balance, history of a brain tumor, and blindness was created on 1/08/22, with revision on 1/29/24. Interventions included, check nail length and trim and clean on bath day and as necessary. 5. Resident #87 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included diabetes type II, polymyositis, muscle wasting and atrophy, atrial fibrillation, and hemiplegia/hemiparesis following cerebral infarction affecting left non-dominant side. Review of the resident's quarterly MDS assessment dated [DATE], revealed the resident's cognition was intact, with a BIMS score of 13 out of 15. The assessment noted the resident had functional limitation in range of motion (ROM) to his upper left extremity and required supervision or touching assistance with personal hygiene. On 3/04/24 at 12:54 PM, resident # 87's fingernails of his right hand were noted to be long and untrimmed. The resident said he asked for his fingernails to be trimmed, but nothing had been done about it. He said the fingernails on his left hand broke off. On 3/05/24 at 1:38 PM, CNA Q stated fingernail care was done during ADLs, and said resident #87 did not say anything to her about his fingernails. On 3/05/24 at 1:44 PM, observation of the resident's fingernails was conducted with CNA Q. The fingernails on the resident's right hand were long, and untrimmed, and the fingernail of the resident's left thumb was long, and untrimmed. Resident #87 repeated that the fingernails on his left hand broke off, and said his nails needed to be cut. CNA Q acknowledged the findings. Review of the POC History for nail care for the period 2/08/24 to 3/05/24 revealed that documentation on 2/11/24 indicated that no nail care was provided, and on 2/23/24 read, resident refused. The column for not applicable was checked nine out of eleven times. Review of the Kardex, (a nursing worksheet that includes a summary of patient information such as daily care schedules) as of 3/06/24 revealed there was no task for nail care, but indicated the resident was dependent on staff for personal hygiene. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 41 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 - Some A care plan for ADL self -care performance deficit related to his medical condition was initiated 9/26/23, with revision 10/02/23. Interventions noted the resident had total dependence on staff for ADLs. 6. Resident # 110 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic respiratory failure, aphasia, hemiplegia/hemiparesis following cerebral infarction affecting the right dominant side, heart disease, diabetes type II, and dementia. Review of the resident's significant change MDS assessment dated [DATE], revealed the resident was rarely/never understood. The assessment noted the resident had functional limitation in ROM to one side of his upper and lower extremities and was dependent on staff for personal hygiene. On 3/04/24 at 12:42 PM, resident #110 was sitting up in bed, his fingernails on his bilateral hands were untrimmed, and discolored. On 3/06/24 at 5:08 PM, the resident was sitting up in bed, he was shouting out, and was pantomiming that he wanted something to eat. The fingernails of his bilateral hands were untrimmed, and discolored. On 3/06/24 at 5:10 PM, CNA P confirmed that resident #110 was part of her assignment. She stated she worked the 7 AM to 3 PM shift and was now working on the 3 PM to 11 PM shift. CNA P said nail care was provided for residents during ADL care. The resident's fingernails were observed with the CNA. She acknowledged the resident's fingernails were long, untrimmed, with a dark substance underneath the nails. The CNA verbalized that she did not provide fingernail care for the resident. She then asked the resident if he wanted his nails trimmed, and he said yes. Review of the POC Response History for nail care for thirty days look back period, revealed documentation of two dates 2/11/24, and 2/27/24, and the column for no nail care and not applicable was checked. Review of a care plan for ADL self- care performance deficit related to resident cannot complete ADL tasks independently and requires individualized interventions to improve function because of weakness, fatigue, recent hospitalization and decline in function was initiated 9/10/20, with revision 9/21/23. Interventions included checking nail length and trim and clean on bath day and as necessary. 7. Resident #238 was admitted to the facility 3/08/23 with diagnoses that included diabetes type II, generalized muscle weakness, transient cerebral ischemic attack, muscle wasting and atrophy, acute cerebrovascular insufficiency, dysphagia following cerebral infarction, and gastrostomy. Review of the quarterly MDS assessment dated [DATE], revealed resident #238 was rarely/never understood, and was dependent on staff for all her ADLs. On 3/04/24 at 12:33 PM, and on 3/05/24 at 10:08 AM, observations showed resident #238 was lying in bed on her back, she had chin, and facial hair, her left hand was contracted with no splint noted, and her fingernails on both hands were long and untrimmed. On 3/05/24 at 1:29 PM, CNA T stated she provided nail care and shaving for residents every two to three days and confirmed that she had the resident in her assignment. Observation of the resident's fingernails, chin, and facial hair was conducted with the CNA. She acknowledged the findings and said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 42 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 ADL care would be provided. Level of Harm - Minimal harm or potential for actual harm Review of the POC Response History for nail care for the period 2/10/24 to 2/29/24 revealed one entry on 2/23/24 which indicated that nail care was not provided. Residents Affected - Some A care plan for ADL self -care performance deficit related to her medical diagnosis was initiated 3/08/23 with revision 12/18/23. Interventions directed CNAs to check nail length and trim and clean on bath days and as necessary. On 3/06/24 at 5:33 PM, observations of the fingernails of residents #29, #87, #110, and #238 were conducted with the C Wing UM. She acknowledged the findings and explained that for residents with a diagnosis of diabetes, nurses were responsible to trim their nails. The fingernails for all other residents should be cleaned and trimmed by the residents' assigned CNA during ADL care. On 3/06/24 at 6:07 PM, the Executive DON stated fingernail care was provided to the residents with ADLs Care. The Executive DON explained that the facility had a concierge from Monday to Friday, who did daily rounds in all resident's rooms, and the UMs were supposed to round on residents, to ensure required care was provided. Review of the Kardex(es) for resident #29, #110, and #238 as of 3/06/24 directed CNAs to check nail length and trim and clean on bath day and as necessary. The facility did not have a policy pertaining to nail care, the Executive DON stated nail care was addressed in the CNAs Job description. 3. Review of the medical record revealed resident #246 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including stroke with right side weakness and paralysis, failure to thrive, expressive language disorder, and left eye vision loss. Review of the Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 1/20/24 revealed resident #246 had severely impaired skills for daily decision making. The document indicated the resident did not exhibit behavioral symptoms or reject evaluation or care that was necessary to achieve his goals for health and well-being. The MDS assessment revealed resident #246 was always incontinent of bowel and bladder and had functional limitation in range of motion due to impairment of upper and lower extremities on one side. Resident #246 was totally dependent on staff for assistance with oral hygiene, toileting hygiene, bathing or showering, dressing, and personal hygiene. The document indicated the resident was totally dependent on staff for transfers, but transfers to the shower were not attempted during the look back period. Resident #246 had a care plan for activities of daily living ADL self-care performance deficit, initiated on 4/22/22 and revised on 1/23/24. The goal was the resident's ADL needs would be anticipated and met. The interventions included provide showers as scheduled and as needed, offer a sponge bath when not a scheduled bath day, check nail length and trim and clean on bath days and as necessary, and lubricate skin with routine care. On 3/04/24 at 2:41 PM, resident #246 was in bed lying on his back and he wore a hospital-type gown. The fingernails on his left hand were long with sharp edges, and there was a dark brown substance under all fingernails. The resident had an unkempt appearance, greasy hair, and an unpleasant body odor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 43 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 - Some On 3/05/24 at 10:18 AM, resident was in bed, lying on his back, and again wore a hospital-type gown. His fingernails remained long and dirty, and his hair was still greasy. There was a white substance noted in the inner corner of the resident's left eye. On 3/05/24 at 11:53 AM, resident #246's ADL status was unchanged. He wore the same gown and his face had not been washed. The resident showed the fingernails on his left hand and nodded when asked if he would like them trimmed. On 3/06/24 at 9:53 AM, CNA G showed the A Wing shower schedule which indicated resident #246 was to receive showers on Tuesdays and Fridays during the 7:00 AM to 3:00 PM shift. She stated CNAs were responsible for nail care and should always clean and file fingernails even if they were not permitted to cut them. During observation of resident #246's hands, she confirmed his fingernails were dirty and too long. She acknowledged she had not yet provided the resident with personal hygiene care. On 3/06/24 at 10:02 AM, the A Wing Unit Manager UM explained CNAs should provide nail care at least twice weekly on shower days, and whenever necessary. She inspected resident #246's fingernails and confirmed they were too long, sharp, dirty, and needed to be cleaned and trimmed. The A Wing UM stated if residents refused ADL care, CNAs should inform the assigned nurse. She verified all CNAs assigned to care for resident #246 and all nurses who completed weekly skin checks should have observed and addressed concerns with his fingernails and general ADL status. The A Wing UM validated the resident had white drainage in the corner of his eye. On 3/06/24 at 6:02 PM, the Executive Director of Nursing (DON) stated all residents should receive showers and nail care at a minimum of twice weekly and more often if requested or necessary. The Executive DON stated she expected UMs to do regular rounds and identify any issues with resident care and hygiene. On 3/07/24 at 1:22 PM, CNA I confirmed she was assigned to care for resident #246 on Tuesday, 3/05/24. She stated she gave the resident a shower that day, and also cut and cleaned his fingernails. When informed there were concerns identified with the resident's hygiene and fingernails on 3/06/24, CNA I was not able explain the conflicting findings. On 3/07/24 at 1:28 PM, the A Wing UM validated resident #246 definitely did not look like he had a recent shower or nail care when she observed him on 3/06/24. Review of the job description for Certified Nursing Assistant, dated 7/01/19, revealed direct care responsibilities included ensuring each resident's personal care needs were met. The document indicated CNAs would bathe and shave residents, and provide oral hygiene, nail, and hair care. 8. Resident # 300 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, type 2 diabetes, hypertension, and depression. The MDS Quarterly assessment noted resident #300 scored 14 on the BIMS evaluation which indicated he was cognitively intact. The assessment revealed the resident had no mood or behavior problems. On 3/05/24 at 12:38 PM, resident #300's fingernails were observed to be about one inch long. When asked if he wanted his nails that long, he said no and said he had requested for staff to have them trimmed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 44 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 On 3/06/24 at 08:45 AM, resident #300 was in bed finishing breakfast, his nails were still long. Level of Harm - Minimal harm or potential for actual harm On 3/06/24 at 12:45 PM, RN W confirmed the residents nails were very long. Resident #300 told the nurse he wanted to have his fingernails trimmed. She said, He is diabetic and a CNA cannot cut nails if the resident is a diabetic, they can only be trimmed by a nurse. Residents Affected - Some On 3/07/24 at 9:19 AM, resident #300 was sitting up in bed eating breakfast. He stated the UM came into the room this morning and asked to see his nails. His nails were still long. On 3/08/24 at 9:13 AM, observed resident #300 in bed watching television, nails still not trimmed. On 3/7/24 at 6:15 PM, The D Wing UM said he checked with his Director of Nursing because he was not sure if he could cut resident #300's fingernails. The UM said, I am allowed to cut his nails and I will get it done. CNAs trim the nails on shower days but they are not allowed to trim if the resident is diabetic. 3/08/24 at 3:45 PM, The Executive DON stated her expectation was for the residents to have their nails cleaned and trimmed on shower days or as requested. 9. Resident #137 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included traumatic brain injury, acute respiratory failure, subdural hemorrhage. The MDS significant change in status assessment noted resident #137 scored rarely or never understood on the Brief Interview for Mental Status (BIMS) evaluation which indicated the resident had severe cognitive impairment. The MDS assessment did not identify any mood or behavior problems. On 3/07/24 at 9:11 AM, resident #137 was lying in bed, lips dry and cracked, his tongue coated with white substance. A short time later RN W acknowledged the resident needed mouth care. The RN stated mouth care needed to be done, at a minimum every shift. RN W called CNA VV to perform mouth care for the resident. The CNA stated mouth care needed to be done every shift and as needed. On 3/08/34 at 3:45 PM, the Executive DON stated her expectation was that mouth care be provided every shift and more often if needed. Review of the CNA Job Description dated 7/01/19 read gives oral hygiene. Provides nail and hair care. Review of the undated. Job Description Unit Manager revealed the UM was responsible for overseeing direct nursing care to assigned residents and was accountable for the nursing care and services provided including supervision of resident care activity performance by licensed nurses and CNAs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 45 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0679 Provide activities to meet all resident's needs. 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 a resident centered activities program which met the individual interests and needs of the resident, which encouraged both independent and group interactions for 11 out 17 residents identified not to have any meaningful activities of a total sample of 109 residents, (#246, #107, #309, #202, #137, #435, #434, #47, #238, #285 and #7). Residents Affected - Some Findings: 1. Resident #309 admitted to the facility on [DATE]. Her diagnoses included type II diabetes, degenerative disease of the nervous system and dementia. The admission Minimum Data Set assessment dated [DATE] noted in Section F that it was very important to the resident to do her favorite activities and it was very important for her to participate in religious services or activities. The quarterly activity assessment dated [DATE] indicated the resident required physical assistance with activities and that she enjoyed reading, watching television, socializing, puzzles, music and outdoors. The staff noted were no changes in resident #309's recreational needs. The activity assessment made no mention of attending church services on any other religious activities. The resident's activity care plan dated 2/13/24 noted the resident required physical assistance to & from activities. The care plan did not list attending church service or participation in religious activities as the resident's favorite activities. The care plan noted the resident's predominate activities such as reading, television, word puzzles, and music. The activities described in the care plan the resident could do alone in her room and did not require much physical assistance from staff to move her from her room. On 3/05/24 at 1:03 PM, the resident was observed lying in bed awake but she was not engaged in any meaningful activity. The resident was polite, but confused and attempted to answer questions to the best of her ability and understanding would allow. On 3/05/24 at 1:41 PM, the resident's niece, who was the resident's responsible party, complained that facility staff did not bring her to activities. She said her sister who lived in the area visited and checked up on their aunt. The resident's niece said staff don't take resident #309 to church services as she would like to. The niece stated her aunt was a Church-going woman, and she was previously active at her church. On 3/06/24 at 3:34 PM, the Activity Director indicated that resident #309 got room visits from the activity staff with the last activity visit on 1/29/24. The activity director said that on 1/29/24 the resident was invited to church-bible study but was not able to attend. No reason was documented as to why the resident did not attend the religious activity on 1/29/24. The Activity Director said that her assistant was assigned to resident #122's unit and she was the person who did the room visit on 1/29/24. The activity director did not provide any information that the resident had attended church services. On 3/07/24 at 11:20 AM, a bible study group activity was assembled in the facility's chapel. Approximately 1-2 minutes later resident #309 was observed lying in bed wearing only a teal blouse and an incontinence brief. The resident was awake but confused. At 11:26 AM, the Activity Assistant came in the room and resident #309 requested a beverage. As the Activity Assistant walked out of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 46 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resident's room, she was asked why resident #122 was not at the bible study activity. The assistant said bible study started at 10:30 AM and ended at 11:30 AM. She said resident #309 did not attend bible study. The assistant said church service was on Sundays at 2 PM. She said that resident #309 could attend church services if she was available. The assistant explained available meant that the resident was out of bed, dressed and groomed, which meant activities of daily living (ADLs). However, the assistant stated she did not provide ADLs. 2. Resident #434 was admitted to the facility on [DATE]. His diagnoses included cerebral infarction, muscle wasting and neuromuscular dysfunction of the bladder. The 2/16/24 activity assessment indicated resident #434 preferred morning activities and needed visual adaptation. The assessment indicated the activities resident #434 enjoyed were reading, watching television (TV), socializing with people, sports, animals, and word puzzles. On 3/04/24 at 5:56 PM, resident #434 said he did not get any activities except when therapy staff came to the room. He stated he did not even have a wheelchair so he could leave the room. He explained he watched television all day but he would rather be doing other activities such as bingo, art or maybe puzzles. On 3/05/24 at 11:41 AM, the resident was again in his room, in bed, watching TV. He said he did not have any glasses and if there were any words on the TV, he Can't make them out. There was no indication the facility was working on a solution for him to see better to enjoy the TV programs. The activity assessment dated [DATE] noted there had been no changes in resident #434's recreation preferences since the last review. The resident's care plan initiated on 2/16/24 and last reviewed on 3/05/24 indicated the resident could pursue his own activities without facility intervention. The care plan also noted that the resident required physical assistance, To & from activities. On 3/06/24 at 11:40 AM, the resident sat in a high back wheelchair in his room. He said he received the wheelchair today. He was reading the activity calendar but said it was difficult to read without glasses. He said his brother must have taken his glasses when his brother packed up all his things, which were brought to another state. On 3/06/24 at 3:46 PM, the Activity Director verified the resident required assistance to and from activities per his care plan. She said resident #434 got room visits and the last one was on 2/29/24. The activity director did not provide any documentation that showed resident #434 participated in any of his preferred activities and only was able to show the dates of room visits but was unable to show documentation of the length of the room visit. Review of the facility's activity calendar revealed bingo had been scheduled on 3/03/24 and 3/04/24 and was an available activity. 3. Resident #435 was admitted to the facility on [DATE] and his diagnoses included cirrhosis of the liver, cardiomyopathy, type II diabetes, sepsis and a bacterial infection. He was on contact isolation for an infectious bacteria in the urine, but he had a foley catheter. On 3/05/24 at 2:51 PM, resident #435 expressed that at times he felt isolated because no one spent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 47 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some time with him. He said he did not want to do anything specific like a puzzle or a game, he just wanted someone to have a conversation with. The resident's activity care plan dated 2/29/24 noted his preferred activities were television, socializing, sports, animals, music, sitting outside, cooking, and the cell phone. There were no indications on the resident's care plan that he would receive room visits. On 3/06/24 at 3:42 PM, the Activity Director said the resident had been on isolation for an infection and indicated therefore room visits were appropriate. She did not provide any documentation to show room visits from facility staff had occurred during the time he was on isolation. The Activity Director stated she would consider a friendly room visit which would be about 5 minutes in duration. 9. Resident #238 was admitted to the facility on [DATE] with diagnoses that included diabetes type II, generalized muscle weakness, transient cerebral ischemic attack, muscle wasting and atrophy, acute cerebrovascular insufficiency, dysphagia following cerebral infarction, and gastrostomy. Review of the admission MDS assessment dated [DATE], revealed resident #238 was rarely/never understood. Section F-Preferences for Customary Routine and Activities noted it was very important for the resident to listen to music, go outside for fresh air when the weather is good, and participate in religious services or practices. An Activity assessment dated [DATE] read, Resident states she enjoys reading, watching television .listening to Caribbean music, sitting outside for fresh air there has been no change in her recreational need since last review. Continues to require 1:1 intervention, remains passive throughout visits. Review of the Documentation Survey Report for activity for January to March 2024, showed documentation that indicated that Individual Activity was provided for the resident on 1/15, 1/22, 1/24, 1/29, 1/31, 2/01, 2/05, 2/09, 2/14, 2/26, and on 3/05, a total of eleven days. Observations on 3/04/24 at 12:33 PM, 3/05/24 at 10:08 AM, and 3/05/24 at 1:03 PM, resident #238 was lying in bed on her back, she was able to verbalize her name, but could not answer any additional questions. No activities were noted, the television was not on, and there was no music playing. On 3/06/24 at 12:38 PM, Registered Nurse (RN) B stated the facility had activity staff that provided room to room visits to residents. On 3/06/24 at 2:11 PM, the Activities Director stated the facility had a specific Activity Assistant for each unit, and one to one, and friendly visit was provided for residents documented as dependent, who stayed in their room, or was low functioning. She stated resident #238 was on one-to-one visits for sensory stimulation and was scheduled for one to two visits per week. The Activities Director reviewed the Documentation Survey Report and verbalized that in February 2024, there was a ten-day gap between visits, but she could not say what happened to cause the gap. She stated the last Activity evaluation conducted for the resident was on 12/11/23, and the resident remained passive throughout the visit, and the plan was to continue one-on-one and different interventions. She verbalized the resident only had one-on-one visit in March on 3/05/24. A care plan for Activities initiated 3/10/23, with revision on 12/13/23 noted the resident required staff assistance with pursuing activities of past interest, and indicated she enjoyed watching (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 48 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0679 Level of Harm - Minimal harm or potential for actual harm television, socializing with people, and sitting outside for fresh air. The goal was that the resident would receive staff visits 1-2 times per week to offer assistance with active and passive leisure pursuits. Interventions included, would benefit from In room (reading, television, socializing, word puzzles, music), preferred activities are (reading, television, socializing, animals, word puzzles, music, sitting outside, bingo), prefers the following radio stations (Caribbean music), TV stations (All). Residents Affected - Some 7. Review of the medical record revealed resident #202 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including right above knee amputation, chest pain, heart failure, brain bleed due to trauma, and major depressive disorder. The MDS Annual assessment with assessment reference date (ARD) of 8/01/23 revealed Section F Preferences for Customary Routines and Activities indicated resident #202 felt it was very important to listen to music she liked. The resident indicated it was somewhat important to have reading material, keep up with the news, do her favorite activities, and participate in religious services or practices. The document revealed it was not very important to the resident to be around animals, and not at all important to go outside or do group activities. The MDS Quarterly assessment with ARD of 1/30/24 revealed resident #202 had adequate hearing, vision and clear speech. She was able to express her wants and needs and had clear comprehension. The MDS assessment showed the resident's BIMS score was 9 which indicated she had moderate cognitive impairment. The document revealed the resident had functional limitation in range of motion related to impairments of both legs, was totally dependent on staff for transfers, and used a wheelchair for mobility. Review of the medical record revealed resident #202 had a care plan for impaired cognitive function related to difficulty making decisions, initiated on 2/03/21 and revised on 1/30/24. The interventions instructed staff to invite, encourage, remind, and escort the resident to activity programs consistent with her interests. A care plan for activities, initiated on 2/02/21 and revised on 1/29/24, revealed the resident required physical assistance to and from activities, and could pursue her own activities with facility intervention. The goal was resident #202 would accept friendly visits from activity staff one to two times weekly. The interventions indicated the resident would benefit from the general activities program which included musical entertainment and social events; in-room activities such as visits from family, puzzles, and television; small group activities such as sitting outside and playing cards; and large group activities which included crafts and bingo. The document revealed Activity department staff would provide a monthly calendar for the resident. Review of the Certified Nursing Assistant (CNA) care plan or Kardex revealed care directives related to activities. The document listed resident #202's preferred activities and noted she required assistance to and from activities. On 3/03/24 at 2:02 PM, resident #202 said, I don't know what activities they have here. I stay in my room. She recalled she participated in a bingo group activity once and enjoyed it. The resident explained CNAs were always rushed whenever they came into her room and did not assist her to activities. Observation of the resident's room revealed an activities calendar posted on the closet door across the room. The calendar was approximately eight feet away from the resident and the print was illegible from that distance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 49 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 3/05/24 at 11:56 AM, resident #202's mother explained her daughter had one leg amputated and required assistance to get out of bed. She stated she frequently expressed concern to facility staff regarding her daughter spending most of her days in bed. Resident #202 stated CNAs occasionally transferred her to a wheelchair, but they left her in the room facing the television. On 3/06/24 at 2:55 PM, the Activities Director stated Activities Assistants did in-room friendly visits with resident #202 one to two times weekly. She provided the Documentation Survey Report forms for January to March 2024 and confirmed the resident received four visits in January, six visits in February, and one visit in the first week of March. The Activities Director verified the resident's activities care plan listed different types of activities she would benefit from and enjoy, and she acknowledged none of those activities occurred during the period reviewed. She stated CNAs were aware of the activities calendar and Activities Assistants should communicate with CNAs and encourage them to bring residents out of their rooms if possible. The Activities Director explained participation in activities was important to enhance resident #202's quality of life. 8. Review of the medical record revealed resident #246 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including stroke with right side weakness and paralysis, failure to thrive, expressive language disorder, and left eye vision loss. Review of the MDS Annual assessment with ARD of 4/23/23 revealed Section F - Preferences for Customary Routines and Activities indicated resident #246 was not able to participate in the interview so a staff assessment of activity preferences was completed. The document revealed resident #246's preferences included listening to music, keeping up with the news, doing things with groups of people, participating in his favorite activities, spending time outdoors, and participating in religious activities or practices. The MDS Quarterly assessment with ARD of 1/20/24 revealed resident #246 had adequate hearing, highly impaired vision, did not speak, and had severely impaired skills for daily decision making. The document indicated the resident had impairments of upper and lower extremities on one side, was totally dependent on staff for transfers, and used a wheelchair for mobility. Resident #246 had a care plan for activities initiated on 5/04/22 and revised on 1/22/24. the document indicated the resident required staff assistance related to his cognitive deficits and physical assistance to and from activities. The goal was he would receive one to two visits weekly for participation in activities of interest and sensory stimulation. The interventions included encourage the resident to participate in activities of choice which were television, sports, music, and sitting outside. The care plan revealed resident #246 would benefit from the general activities program and in-room activities. Review of the Kardex revealed the document listed resident #246's preferred activities and noted his preferred activity time of day was the afternoon. Review of the Quarterly Activity assessment dated [DATE] revealed resident #246 required assistance with activity pursuits and activities staff visited him in his room. The document indicated he liked watching movies, cartoons, his favorite football team, and sports, and listening to classic rock music. The assessment showed the resident enjoyed spending time outdoors. On 3/04/24 at 2:41 PM, resident #246 was in bed in a darkened room with the privacy curtain drawn. The curtain blocked the light from the window and the overhead light was off. The resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 50 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0679 television was off and there was no evidence of activities in the room. Level of Harm - Minimal harm or potential for actual harm On 3/04/24 at 6:21 PM, resident #246's room remained dark with the privacy curtain drawn. The television was still off and there was no radio in the room. Residents Affected - Some On 3/05/24 at 10:18 AM and 11:53 AM, resident #246 was in bed with his eyes closed. His room was dark, the privacy curtain was drawn, and the overhead light was off. On 3/06/24 at 3:35 PM, resident #246 was in bed with his eyes closed. The television was off and the room was still dark as the privacy curtain blocked the daylight from the window. On 3/06/24 at 2:10 PM, the Activities Director reviewed resident #246's Documentation Survey Report forms which indicated the resident had in-room visits on six days in January 2024, five visits in February 2024, and none during the first week of March 2024. She confirmed his last friendly visit was on 2/27/24. The Activities Director acknowledged resident #246's preferences included spending time outdoors and she would love to see him get out of bed for increased stimulation. She explained she only had six staff members so it would require coordination with the nursing department to ensure resident #246 attended activity programs. When informed the resident was observed for three days in a darkened room with no television or music, the Activities Director stated if staff were available they would go room to room and ensure residents had some form of stimulation. On 3/06/24 at 3:44 PM, the A Wing Unit Manager verified resident #246 was able to attend activities if staff got him out of bed and into his wheelchair. She explained the resident's roommate liked the curtain between beds drawn and frequently turned the resident's television off. 4. Resident #7 was admitted to the facility on [DATE] with diagnoses that included legal blindness, dementia, anxiety, and a cardiac pacemaker. The Minimum Data Set (MDS) annual assessment noted resident #7 scored rarely or never understood on the Brief Interview for Mental Status (BIMS) evaluation which indicated severely impaired cognition. The assessment indicated the resident was dependent for all activities of daily living care. On 3/06/24 at 5:41 PM, resident #7 was observed lying in bed with her eyes closed. On 3/08/24 at 3:31 PM, resident # 7 was observed sitting in bed with her eyes closed. Review of the activity care plan indicated resident #7's preferred activities were television, socializing, music, and sitting outside. Review of the Activity Documentation Survey for January 2024 revealed the resident had in room visits 5 times out of 31 days for the month which included television, aromatherapy, mail, and current events. The documentation for February 2024 revealed the resident had in room visits 6 times for the 29 days of the month which included television, music, current events, and aromatherapy. There was no documentation that indicated he recieved social activities, or outside activities. On 3/06/24 at 3:16 PM, the Activity Director stated resident #7 was designated for one-to-one visits. The Activity Director confirmed that resident #7 had no one-to-one visits in March. 5. Resident #47 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 51 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0679 included legal blindness, kidney transplant, hypertension, cerebral infarction. Level of Harm - Minimal harm or potential for actual harm The Minimum Data Set annual assessment noted resident #47 scored 06 on the Brief Interview for Mental Status evaluation which indicated severely impaired cognition. The assessment indicated the resident required substantial/maximum assistance for all activities of daily living care. Residents Affected - Some On 3/03/24 at 2:49 PM, resident #47 was observed lying in bed, and stated he is doing okay. On 3/04/24 at 3:51 PM, resident #47 was observed lying in bed with his eyes closed. On 3/05/24 at 12:55 PM, resident #47 was observed lying in bed with his eyes closed. On 3/06/24 at 8:52 AM, resident #47 was observed lying in bed with his eyes closed. Review of the Activity Assessment revealed resident #47 enjoyed listening to music and the television. His current enjoyment included conversations about past relationships, talking about food, going to the beach and he enjoyed laughing. Review of the activity care plan revealed resident #47 preferred to stay in his room listening to music and television, required staff visits for socialization and conversations. Review of the Activities Documentation Survey Report resident # 47 had 7 total in room visits out of 29 days in February and none in March. 6. Resident #137 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included traumatic brain injury, acute respiratory failure, subdural hemorrhage. The MDS significant change in status assessment noted resident #137 scored rarely or never understood on the Brief Interview for Mental Status (BIMS) evaluation which indicated the resident had severe cognitive impairment. The MDS assessment did not identify any mood or behavior problems. On 3/04/24 at 6:11 PM, resident #137 was observed lying in his bed, the television was not on. On 3/06/24 at 5:44 PM, resident #137 was observed lying in bed with his eyes closed. Review of resident #137's activity care plan revealed past interests included watching television, music, reading magazines, and playing the drums. He currently required a one-to-one intervention for sensory stimulation. Review of the Activity Documentation Survey Report for January resident # 137 had 4 in room visits over 31 days of the month, in February he had 7 in room visits over 29 days, and in March he had 1 in room visit. On 3/06/24 at 3:20 PM, the Activity Director stated resident #137 preferred instrumental music. She stated he used to play drums and only showed positive reaction to music. On 3/06/24 at 3:16 PM, the Activites Director said, Over the last month or two I have shifted the activity program to involve the younger population, because she said she had 101 residents under the age of 60. She stated the activities had been moved from upstairs to the downstair's dining room. The Activites Director said all residents were invited to attend activites. She said, We are stretched and we are doing the best we can. On 3/07/24 at 6:35 PM, the D Wing Unit Manager (UM) stated the residents had activities every day. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 52 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0679 If they did not leave their room someone from activities should come to their room to do activities with them Level of Harm - Minimal harm or potential for actual harm 3/08/24 at 3:45 PM, the Executive Director of Nursing (DON) stated her expectation was that all residents should be involved in the activities of their choice. Residents Affected - Some 10. Review of the medical record revealed resident #107, an [AGE] year old female was admitted to the facility on [DATE] from an acute care hospital with diagnoses of Alzheimer's Disease, schizoaffective disorder, cognitive communication deficit, malnutrition, pulmonary (lung) disease, gout, stage 3 kidney disease, weakness, and reduced mobility. The MDS admission assessment with ARD of 12/18/23 identified a BIMS score of 5 out of 15 that indicated the resident was severely, cognitively impaired and had no behaviors or rejections of evaluation or care. The resident's Functional Abilities and Goals of everyday activities showed she required supervision and assistance from staff to complete ADLs and mobility functions, and she was frequently incontinent of bladder and bowel functions. Her Preferences for Customary Routine and Activities noted it was very important for the resident to listen to music she liked, be around pets, do her favorite activities, and it was somewhat important for her to go outside for fresh air in good weather. The comprehensive care plan, activities focus noted the resident required reminders to events of interest that included television, word puzzles, and crafts with interventions for discussions of her prior interests in gardening and family, incorporated benefits that included musical entertainment, social events, reading, television, music, crafts, socials, outside activities, animals, and cooking. On 3/03/24 at 1:50 PM, 3/04/24 at 1:04 PM, and 3/06/24 at 12:17 PM, resident #107 was observed sitting in a wheelchair outside her room in the hallway on the memory care unit. At 12:31 PM, the resident was observed in a restless state while she rose from her chair several times. Review of resident #107's Documentation Survey Reports noted in January 2024, the resident did not have group activities for 23 out of 31 days or individualized activities 29 out of 31 days. In February 2024, she did not have group activities 22 out of 29 days, self-directed activities for 16 out of 29 days, or any individualized activities. The Kardex noted resident #107 preferred opera, music, reading, television, socializing, animals, word puzzles, crafts, cooking, and sitting outside. The CNA tasks included invitations to morning, afternoon, and evening activities, and individual materials provided. 11. A review of the medical record revealed resident #285, a [AGE] year old male was admitted to the facility on [DATE] and re-admitted from an acute care hospital on 2/22/24 with diagnoses of encephalopathy (brain disorder), Parkinson's Disease, dementia, malnutrition, need for personal care assistance, liver disease, pulmonary (lung) edema (swelling), right hip fracture, rhabdomyolysis (skeletal muscle damage), dysphagia (difficulty swallowing), colitis (inflammation of the colon), gait and mobility abnormalities, depression, and anxiety. The MDS Significant Change assessment with ARD 12/18/23 identified a BIMS score of 4 out of 15 that indicated the resident was severely, cognitively impaired. The resident had inattention that fluctuated, and no behaviors or rejections of evaluation or care. Functional Abilities and Goals noted he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 53 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some required substantial assistance, was dependent on staff to complete ADLs and mobility functions, and he was always incontinent of bladder and bowel functions. The Staff Assessment of Daily and Activity Preferences noted he preferred music, doing things with groups of people, participating in favorite activities, spending time outdoors, and religious activities and practices. On 3/03/24 at 1:33 PM, resident #285 was observed sitting in a chair by the window in his room at the end of the memory care unit hallway, approximately 25 yards from the nurse's station. He was heard yelling out, I need help. On 3/05/24 at 11:25 AM, the resident was in his room lying in bed and was heard as he spoke to himself nonsensically. The Activity assessment dated [DATE] documented resident #285's life's work was building cars, he was a veteran, preferred or benefitted from small and large groups, in room activities, general programs, sitting outside, television, movies, nature watches, word puzzles, music, pet interactions, and gardening. The assessment included a description of the resident's favorite activities that read, Resident states he enjoys watching Sci-Fi on television, socializing with people, animals (dogs), doing word puzzles, listening to Rock-n-Roll music, sitting outside for fresh air, gardening, and at times playing games. In the past he enjoyed playing sports and playing dominoes. He has past interest of enjoyment in coloring, walking, and sitting outside. At this time requires staff assistance for redirection. Review of resident #285's Documentation Survey Reports showed in January 2024, there were no group activities for 23 out of 31 days, self-directed activities 23 out of 31 days, or individualized activities 20 out of 21 days. In February 2024, no group activities for 27 out of 29 days, self-directed activities for 23 out of 29 days, and no individualized activities were noted. The Kardex for CNAs showed resident #285's preferred activities were television, socializing, animals, word puzzles, music, sitting outside, gardening, and games. It was noted that the resident required assistance and was to be escorted to and from activity functions. The March 2024 Activity Calendar listed various daily indoor group activities. There were no outdoor activities noted on the schedule. On 3/06/24 at 1:50 PM, CNA SS explained CNAs were expected to assist residents on the memory care unit to the activities room, and many enjoyed eating there together. She said, Somebody has to be in the room with them. On 3/06/24 at 11:16 AM, Activities Assistant UU was observed with seven residents in the memory care activities room. She said the residents had varied interests and she utilized the activities calendar as a daily schedule along with individual activities for residents who refused the group. She stated the Electronic Health Record (EHR) was where activity invitations, resident participations, and any refusals were documented. She explained she was always solely responsible for the unit's programs, that all 32 residents required staff supervision, and it was not possible to conduct both indoor and outdoor activities at the same time on her own. She said many of the residents enjoyed being outdoors for fresh air and gardening as weather permitted. In a joint observation of the outdoor activities area, she showed there were a few lifeless potted plants on a table that residents could water if they liked to garden and stated, They're dying right now. Review of the facility's weather during March 2024 revealed from 3/01/24 to 3/08/24, temperatures reached 81 to 87 degrees Fahrenheit, (retrieved on 3/14/24 from weather.com). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 54 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0679 Level of Harm - Minimal harm or potential for actual harm On 3/06/24 at 1:27 PM, the Activities Director said she was responsible for the facilities activities program, and she supervised the Activities Assistants. She explained, residents' interests were documented for staff in the EHR, the monthly calendar was utilized for structure, and she expected staff to cater to the resident's individual needs to provide one-on-one activities. She stated activities included outdoors enjoyment and that all were, Important for their mental health; residents are dependent on us to set up anything for them. Residents Affected - Some The facility's Standard Individual; 1:1 or in Room Programs with effective date of October 2021 read, Person Centered Activity Programming will be provided to residents who cannot effectively plan their own activity pursuits .Support activities are provided for residents who may be severely impaired .one on one activities are FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 55 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate care and services in accordance with accepted professional standards to identify, obtain and implement physician orders for a peripherally inserted intravenous central line catheter (PICC) for 1 of 1 resident reviewed for PICC lines, (#72), failed to change intravenous line dressings as per orders for 1 of 6 residents reviewed for medication administration (#435), and failed to monitor blood glucose levels as per physician orders for 1 of 3 residents reviewed for (#584) insulin use out of a total sample of 109 residents, (#72). Residents Affected - Few Resident #72 was readmitted to the facility from the hospital on 1/10/24 with a peripherally inserted central line catheter in his left upper arm. The 3008 Agency for Healthcare Administration Transfer and Discharge form dated 1/10/24 detailed the double lumen PICC, but the form did not give the date it was inserted, the date the dressing was last changed or the location. The admitting nurse at the facility documented the presence of a double lumen device under the skin assessment portion of the readmission documentation, but failed to mention it was a PICC. She documented the wrong location and did not obtain orders for discontinuance or maintenance/care of the intravenous central line. Resident #72 went for a short stay to the emergency room on 2/26/24, but otherwise remained at the facility for 7 weeks and 4 days without receiving care and services to maintain the PICC line or prevent infection. On 3/03/24 the PICC was brought to the attention of facility staff by the surveyor and was ordered removed on 3/04/24. Resident #72 required an ultrasound, an X-ray of his left arm and blood work to ensure he had no complications from the facility's neglect of the PICC line The facility's failure to identify and provide necessary care and services for maintenance and use of a peripherally inserted central line catheter placed resident #72 and all residents who were admitted /readmitted with medical devices including PICCs at risk for serious injury/impairment/death. Without appropriate central line catheter care, there was high likelihood resident #72 could have developed severe infection, blood clots, vascular damage or even death. This failure resulted in Immediate Jeopardy (IJ) starting on 1/10/24. The IJ was removed on 3/06/24. Findings: Cross reference to F600 and F726 1. Resident #72, a [AGE] year-old was admitted to the facility on [DATE] with diagnoses of pneumonia of unknown origin, acute respiratory failure with low oxygen, chronic lung disease, feeding tube to his stomach, low white blood cell count, heart failure, skin cancer, lung cancer and tongue cancer. Review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed resident #72 was cognitively intact, had clear speech, adequate vision, and had clear comprehension of others. The assessment indicated resident #72 required moderate assistance with most transfers and required supervision for bed mobility. The assessment also revealed resident #72 had no refusal of care, no intravenous medications, nor did it indicate any IV access including central lines during the look back period. On 3/03/24 at 2:25 PM, resident #72 was awake and alert, seated upright in bed. On his left upper arm, the double lumens of a PICC catheter were seen hanging down from his sleeve. Resident #72 stated he received the intravenous line (IV) in the hospital, but he could not recall how long he had it, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 56 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 - Immediate jeopardy to resident health or safety Residents Affected - Few nor why it was still there. Resident #72 lifted his sleeve to reveal a piece of worn white, tube-type gauze covering most of the IV site. He moved the gauze over to reveal the PICC dressing underneath was undated, unlabeled, and gaping open at the bottom where the double lumens hung out. He stated he could not recall receiving care for the PICC line while at the facility. Review of Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 1/10/24 revealed resident #72 was readmitted to the facility on [DATE] for vomiting blood. The Treatment Devices section of the form indicated for type, a double lumen PICC. The form did not indicate when it was inserted, when the device was last changed or where it was located. There were no antibiotics or IV medications listed on the form. A PICC line is a thin, flexible tube inserted into an upper arm vein and guided into the large vein on the right side of the heart. It is used for intravenous delivery of antibiotics or chemotherapy drugs. Delayed complications such as infection and device dysfunction are more gradual in onset and occur over weeks or sometimes months. The most common complication is infection which can lead to sepsis, shock, and death. The reported patient mortality rate was between 12% and 25% for central line related blood stream infections. Device dysfunctions occurred more often in central lines that have been in place for extended times and include catheter fracture and venous clots. Furthermore, cancer patients have amongst the highest risk of thrombosis at 41%. Current research showed no difference between PICCs and standard central lines for rates of complications (retrieved from www.ncbi.nlm.nih.gov on 3/11/24). On 3/03/24 at 2:34 PM, Licensed Practical Nurse (LPN) Z was at resident #72's bedside, and acknowledged she was aware of the PICC IV in his arm. LPN Z verified the PICC dressing had no date or initials on it and was loose at the bottom where the lumens emerged. She stated she did not know how long he had the line and was unable to say by looking at the unlabeled IV dressing. LPN Z explained she was not IV certified and would have to notify the supervisor if it needed to be assessed or needed care. She stated she was supposed to look at the dressing to check if it was intact, clean and for the date of the last dressing change, but said she was at the end of her shift and had not done that. LPN Z stated she did not know when the last time resident #72's PICC dressing had been changed. She reviewed the resident's medical record and stated she could not find any physician orders for resident #72's PICC line. She said she was not aware there were no physician orders for resident #72's PICC. LPN Z stated care and maintenance of a PICC line was important because it was a central line and could get infected without proper care. On 3/03/24 at 2:53 PM, the C wing Unit Manager (UM) said she was told by LPN Z of resident #72's PICC line having no orders. The C wing UM stated she was not aware of the PICC line. She verified there were no orders to care for the IV, no care plan, nor was it on the Medication Administration or Treatment Administration record for February 2024. The C wing UM explained the line needed to be flushed every shift, before and after any medications going into it along with regular dressing changes and assessments. On 3/03/24 at 3:06 PM, LPN AA stated she had cared for resident #72 since January when he was readmitted to the facility with the PICC line. She could not recall how long he had the PICC line or why he had it but said it had been awhile. LPN AA explained if a resident came to the facility with a PICC line, the nurse needed to obtain orders from the doctor to care for it. She stated she never realized he didn't have orders to care or maintain his PICC. She described a PICC line as needing to be flushed and the site assessed every shift, yet she did not know why she never questioned the lack of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 57 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 physician orders for care of resident #72's PICC line. Level of Harm - Immediate jeopardy to resident health or safety Review of the Admission/readmit: Data Collection and Baseline Care Plan dated 1/10/24 at 3:45 PM, revealed LPN BB documented resident #72 was admitted with skin issues of right arm- multiple bruises and incorrectly documented right double lumen instead of left. The box for subsection i3 to Obtain physician orders for care instructions and monitoring, was checked by LPN BB. Section E, Drug Regimen Review detailed the drug regimen was reviewed by the practitioner on admission completed to include medication reconciliation completed upon admission/readmission, PCC order entry warnings and any applicable pharmacy recommendations and found, No clinically significant findings. The subsections for date and time of follow up and follow up information/see new orders were left blank. Residents Affected - Few Review of the Medication Review Report dated 3/03/24 at 3:12 PM, revealed no physician orders for IV medications nor for care or maintenance of resident #72's PICC line. Review of resident #72's medical record revealed no care plan was ever created for his PICC line until 3/04/24, when it was brought to the facility's attention by the State Agency Surveyor. The facility had a policy and procedure for weekly skin check to document the skin condition throughout the resident's stay in the facility. The policy with effective date October 2021 described the nurse would conduct a weekly skin check to identify impairment or suspected impairment timely to reduce the risk for further decline in skin integrity. The policy further described the nurse should document on the weekly skin check and on the appropriate corresponding skin grid any new areas of impairment weekly, as needed and on admission or readmission to the facility. The procedure section described the nurse to document actions taken based on the skin check, to update the care plan as appropriate and to make a notation on the 24-hour report so the Interdisciplinary Team (IDT) would be informed. Review of the medical record revealed resident #72 had 7 weekly skin assessments completed during the 8-week period from 1/13/24 to 2/28/24, none of which documented the PICC line on his left upper arm nor were any actions taken documented on the assessments. Seven different nurses checked resident #72's skin each week and all of the assessments indicated there were no new areas of skin impairment and had no mention of the PICC. Review of the Treatment Administration Record dated January 2024, revealed a physician's order to monitor bruise to left inner forearm and notify the physician of any changes every shift that started on 1/11/24. Twenty three different nurses documented they had looked at resident #72's left arm and did not notify the physician about his undated/unlabeled PICC line in January 2024. Review of the Treatment Administration Record dated February 2024, revealed the same physician's order to monitor the bruise to resident #72's left inner forearm and notify the physician of any changes every shift. For February 2024, 22 different nurses documented they had looked at resident #72's left arm and did not notify the physician about the PICC line. Review of the Treatment Administration Record for March 2024 revealed 6 nurses documented they had looked at resident #72's left arm per the physician order to monitor the bruise to his left forearm and failed to notify the physician about his PICC line that had no orders for care or maintenance. In total 33 different nurses including three UM's and the first floor Director of Nursing (DON) documented they had looked at resident #72's left arm and all of them failed to notice the PICC line and notify the physician for orders. On 3/04/24 at 10:03 AM, the B wing UM stated a clinical meeting was held every weekday morning to discuss all new admissions and readmissions. She stated the UMs discussed the admissions and readmissions to their unit using the information from the hospital paperwork, baseline care plan and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 58 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 - Immediate jeopardy to resident health or safety admission audit. She explained the admission audit was completed by the nurse managers after the admission was completed by the assigned nurse. The B wing UM described the process included checks to verify physician orders were in place for devices such as IV lines. She explained this was a check to ensure orders were complete on admission. If orders were incomplete, the UM would contact the physician to obtain the orders. The B wing UM was unsure if the DON or anyone else looked at the audits once they were completed by the managers. Residents Affected - Few On 3/04/24 at 10:47 AM, the C wing UM described the admission process for the assigned nurse. She stated the nurse should do a full body head to toe assessment of the resident and note any devices or skin impairments. She explained the nurse looked at all the hospital paperwork including the hospital transfer form in order to transcribe the orders needed for the resident at the facility to determine if there were any changes, new medications or devices when a resident returned to the facility from the hospital. She stated it was important for the nurse to read all of the hospital forms to determine if there were any changes in the resident's care. She explained the assigned nurse would then call the physician to verify the orders. The C wing UM stated the next day, the UM would perform a chart audit using the admission checklist on all newly admitted and readmitted residents along with performing a second head to toe skin assessment. She described the chart audit would include the UM checking the paperwork from the hospital for anything pertinent relating to the care of the resident including skin, devices like an IV or catheter or even follow up appointments. The C wing UM detailed that on the skin assessment they were to document anything that was not normally found on the skin or going into the skin/body. She stated there were batch orders for IVs that allowed the nurse to place all the needed orders to care and maintain an IV including a PICC. The C wing UM detailed the UMs then handed the audits to the DON. The C wing UM explained the UMs would then summarize information about the newly admitted or readmitted resident during the clinical meeting every morning. The C wing UM explained the nurse should call the doctor for orders if a resident had a PICC line to determine whether the line should be discontinued or obtain care orders for maintenance. She acknowledged she documented the second skin assessment for resident #72 which was inaccurate and stated she did not recall seeing the PICC line on his left arm when she did the second head to toe skin assessment. The C wing UM stated LPN BB should have called the physician about resident #72's PICC line when she did the admission. She admitted she should have documented the PICC on the second skin assessment she performed and must have overlooked it. The C wing UM stated she also did not catch it on the hospital transfer form therefore she did not call the physician for the necessary orders. The C wing UM explained she was aware of resident #72's PICC and had even spoken to the physician about the PICC the previous week in regard to some labs that were needed but could not explain why she did not ask for orders for its care and maintenance, nor did she document the conversation. She reiterated a PICC needed to be kept clean, with an intact dressing, needed dressing changes and care because it could cause infections like sepsis or an infection in your heart. Review of the admission Checklist (Clinical Leadership) updated December 2023, revealed the hospital transfer form was checked to verify physician orders were complete, confirmed with the physician and matched the orders in the electronic medical record. Another section of the audit detailed for the manager to review the admission nurse chart audit and to read the admission Data Collection to verify its accuracy. Further in the document a section described a second skin check was completed and compared to the initial skin check along with notification to the physician, documentation and appropriate orders in place. Another section of the audit form detailed IV fluids/meds, dressing (check date), pump, to be checked with the care plan, physician orders, computer and at bedside. On 3/04/24 at 11:23 PM, the Executive DON stated the UMs turned the audits in to either the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 59 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 - Immediate jeopardy to resident health or safety Residents Affected - Few 1st floor or 2nd floor DON. She explained the DONs only ensured the audits were completed but did not check the information on the audits for accuracy. She stated they discussed the new admissions and readmissions at the clinical meeting by talking about the diagnoses and the plan. She then explained they did not review the audits in the meeting. The Executive DON stated it was her expectation the nurse would call the physician about the PICC line and document the conversation. On 3/04/24 at 12:28 PM, the admitting nurse, LPN BB in a telephone interview stated she was IV certified and recalled caring for resident #72 in the past several months. She stated when she admitted or readmitted a resident she did a head-to-toe skin assessment and often the supervisor or UM submitted the orders for medications, and other care needs. LPN BB described the hospital transfer form was sometimes incorrect, so it was important to do an assessment of the resident. She explained if she saw a wound or other skin impairment she would inform the physician, and document the skin assessment. LPN BB stated she could not recall resident #72's PICC, could not recall notifying the physician, nor could she recall assessing resident #72 at all. She explained a PICC needed orders for care like flushes and if there were no medications ordered for it, the physician would often discontinue the line. LPN BB stated if she saw that a new or readmitted resident had a PICC, she would notify the supervisor since they would be the one to call the physician for orders. LPN BB could not recall ever discussing the PICC with the resident's primary physician or Advanced Practice Registered Nurse (APRN) CC and could not say why she had not notified them. On 3/04/24 at 10:24 AM, in a telephone interview, APRN CC stated she saw resident #72 frequently at the facility and described herself as the primary provider besides the resident's attending physician. APRN CC stated she had not known resident #72 had a PICC line, nor had she known he had not had any orders for care or maintenance of the line since he arrived at the facility on 1/10/24. She described having seen resident #72 just a few days previously for some concerns about constipation. She stated she was not aware resident #72 had the PICC line and was surprised as he had no reason to have it as he did not have antibiotics or any other medication that needed a PICC. APRN CC described the physician ZZ having seen resident #72 on the previous Thursday as well and was adamant she was unaware of the PICC in his left upper arm as well. She explained they had not ordered any antibiotics and stated there was no justification for resident #72 to still have the PICC. She stated 7 weeks and 4 days was a very long time for resident #72 to not have any care for the PICC. She explained the nurses should have called to obtain orders to either discontinue the line or orders for care and maintenance. She stated no one from the facility had notified her or physician WW about resident #72's PICC not having any care or orders since the facility was made aware the day before on 3/03/24. APRN CC then called physician ZZ to clarify what she knew about resident #72's PICC. APRN CC continued the telephone interview and stated she spoke with physician WW, who told her she also did not know about resident #72's PICC. APRN CC stated if they had known, they would have discontinued the PICC line. APRN CC indicated nurses should have observed the PICC line during their weekly skin checks and noticed there were no orders for care and notified her or the physician. On 3/04/24 at 12:50 PM, in a telephone interview, physician WW stated when APRN CC first called her she did not recall resident #72 having the PICC line, but now she remembered he had one. She stated she had spoken with the nurse about the line needing to be changed but wanted to deal with resident #72's abdominal pain first. Physician WW was asked if she knew resident #72 had gone for 7 weeks without any care for his PICC and she said she was not aware he didn't have any orders for the PICC since he came to the facility with it in January. Physician WW explained APRN CC saw resident #72 frequently, confirmed APRN CC was supposed to perform and document a complete hands-on assessment of the resident. She stated none of the facility staff had called to inform her or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 60 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 - Immediate jeopardy to resident health or safety Residents Affected - Few ask for orders for the PICC. Physician WW stated she did not know how it happened that resident #72 went for that long without anyone knowing he did not have any orders to care for the PICC. She said she had looked at the on call list and there was nothing that showed there were any issues with resident #72's PICC from 3/03/24 when the facility was made aware of the concerns about lack of care. She stated it was important for the PICC to get care because it could cause serious complications. Further review of resident #72's medical record revealed resident #72 was assessed 9 times by APRN CC between his admission on [DATE] and 3/03/24. These progress notes on 1/12/24, 1/13/24, 1/23/24, 1/24/24, 1/26/24, 1/30/24, 2/02/24, 2/07/24, and 2/20/24 had no mention of resident #72's PICC even though cardiac, skin and extremities were documented as assessed. On 3/04/24 at 1:13 PM, the Staff Development Coordinator (SDC) stated on admission the admitting nurse should put in the required batch orders for the PICC line. These orders included flushes every shift and as needed, change of the administration set every 4 days for any IV medications, documentation of site appearance every shift, dressing changes every 7 days and as needed, change the cap every 7 days, change the dressing within 24 hours of admit/insertion, flush each lumen with 10 milliliters of normal saline after each intermittent infusion, for blood draws flush with 10 milliliters of normal saline and to measure the arm circumference. She stated nurses had received education on what they were expected to do on admission and there was a class in their electronic learning modules they would take during onboarding. She described the admitting nurse was supposed to admit the resident in the electronic health record, observe the resident, do a hands-on head to toe assessment, then verify the medications with the physician including any batch orders as needed. The SDC explained the UM also did a second skin assessment on each resident on admission/readmission and documented any skin impairment in the health record. She acknowledged the C wing UM documented bruises to resident #72's upper left arm and left and right hands but failed to document the PICC line to his upper left arm upon admission or obtain orders. The SDC acknowledged subsequent assigned nurses failed to document the PICC line in the skin assessments including the first skin assessment on 1/13/24. She stated nurses were aware of the batch orders for PICCs and should have called the physician. On 3/06/24 at 5:32 PM, Registered Nurse (RN) E recalled seeing resident #72 with the PICC in his arm. She described that a PICC line would usually have an order to flush it and to change the dressing. She acknowledged she had documented resident #72's left arm per the physician orders and could only say it slipped her mind to check if the PICC line had any orders for care or maintenance. On 3/06/24 at 5:45 PM, RN B also recalled caring for resident #72 since January. She remembered seeing the PICC in his arm and said in the evenings with two nurses on the unit it was very busy. She explained if she saw an order to do something she would do it but might not notice if there was no order for something. RN B said if the PICC dressing did not have a date on the dressing the nurse should look at the orders and call the physician if there weren't any orders. She was unable to say why she did not notice resident #72 did not have a date on his PICC dressing. On 3/08/24 at 2:21 PM, the Medical Director stated he was made aware of the issue with resident #72's PICC line with no care orders since his readmission on [DATE]. He stated he expected nurses to obtain orders for care and to notify the physician. The Medical Director stated PICCs were associated with complications like infections and said it was very lucky resident #72 did not get a central line associated infection or other complication due to the lack of care or maintenance for his PICC. Review of the Clinical Guidelines Manual- admission Orders presented by the facility with effective date of October 2021 revealed the policy admission orders would be obtained/approved through the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 61 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 - Immediate jeopardy to resident health or safety Residents Affected - Few attending physician following or prior to the resident's admission to the facility. The procedure section described the procedure if returned from the hospital to contact the attending physician if the order read to resume all previous orders, and to assure at minimum the orders contained diet, medication, routine care to maintain or improve functional ability, and code status. The return from the hospital procedure did not give direction specifically to review the orders that came with the transfer. The admitted from the hospital/ER section detailed the procedure to review the transfer orders, contact the attending physician immediately upon admission to review the transfer orders and obtain approval and to obtain further orders as appropriate. Review of both the undated job descriptions, Licensed Practical Nurse and Registered Nurse revealed both the LPN and RN were responsible for delivering care to residents using the nursing process of assessment, planning, intervention, implementation, and evaluation to maintain standards of professional nursing. The document further described the responsibilities of the LPN and RN which included assess, plan, direct, and evaluate total nursing care as determined by the resident's needs in accordance with established standards, policies, and procedures. Another responsibility was to monitor, record and report changes in resident's condition in a timely manner, and to perform physical exams to determine the resident's status and develop a treatment plan. Also to complete and review the admission Data record and to assess the needs of residents to identify potential health or safety problems. The undated job description Unit Manager summary of position detailed the UM was responsible for overseeing direct nursing care to assigned residents by assuming responsibility and accountability for the nursing care and services provided on the unit. The UM was responsible for and adhered to the standards of care for the assigned residents and assisted with monitoring and implementation of physician orders based on individual resident needs. The UM was also responsible to supervise the resident care activity performance by licensed nurses. Essential duties and responsibilities included ensuring proper nursing care was provided, overseeing the assessments of the resident admission process and participation in the clinical admission process. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: * A registered nurse removed the PICC line from resident #72 on 3/04/24. The site was assessed by the RN and no signs of infection were present upon removal. Resident #72 remained in the facility with no change in condition or signs of distress. *The DON, Assistant DON (ADON) and UMs assessed all 381 residents for intravenous lines including central lines on 3/05/24. There were 6 residents with intravenous lines, including central lines with appropriate orders in place, proper fluids running as ordered and dressings appropriately dated. Each intravenous linesite was assessed by an RN with no signs of symptoms of infection present. * The Nurse Consultant educated the DON on the proper assessment of intravenous lines, including central lines on 3/05/24. The DON educated RNs who participated in the resident assessment referenced in bullet point #2 on the proper assessment of intravenous lines, including central lines. The DON or designee-initiated education on notification of physicians related to obtaining orders for care, maintenance or discontinuance of intravenous lines, including central lines. Education was initiated with licensed nurses related to neglect with obtaining and following physician orders related to intravenous lines including central lines. As of 3/05/24 24 of 114 licensed nurses had received education related to abuse and neglect training. They had a goal to complete an additional 25 nurses by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 62 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 3/06/24 with the remaining nurses to be completed prior to starting their next work shift. Level of Harm - Immediate jeopardy to resident health or safety * The DON or designee will compare the admission data collection to the physician order to validate notification to the physician occurred and orders for maintenance or discontinuance of the line were obtained. The DON or designee will visually inspect every resident with an intravenous line including central lines to validate care, maintenance or discontinuance orders were followed. Residents Affected - Few Review of in-service education sign in sheets and reconciliation with staff roster validated education was completed according to the facility's plan. 98 of the total 102 nurses at the facility were educated on neglect; assessment, documentation, and monitoring of IV site and dressing; midline/central line dressing change and flushing of vascular device. Additionally, 76 RNs were educated on PICC catheter removal. Interview with the Nursing Home Administrator on 3/08/24 at 12:32 PM, revealed he was the abuse coordinator and reported the allegation of neglect on 3/05/24 to the State Agency, Department of Children and Families and to local law enforcement. An ad hoc Quality Assurance Performance Improvement (QAPI) was held on 3/06/24 that included the Medical Director. On 3/05/24 a venous doppler of resident #72's left upper arm, an Xray of the left arm and labs were ordered by the physician to ensure no complications such as retained objects or infection after the removal of the PICC. Per interview with the Executive DON these tests resulted as within normal limits. On 3/06/24, 3/07/24 and 3/08/24 interviews were conducted with 30 of the nursing staff, including 24 RNs and 6 LPNs, including 6 second shift nurses. All verbalized understanding of the education provided by the facility including neglect, assessment, documentation, and monitoring of IV site and dressing; midline/central line dressing change and flushing a vascular device. The sample was expanded to include 4 other residents identified with IV lines. No concerns were found regarding these residents including resident #354 who had a tunneled central line in his right chest. 2. Review of resident #435's medical record revealed he was admitted to the facility on [DATE] from an acute care hospital with diagnoses that included sepsis (infection of the blood stream), methicillin-resistant Staphylococcus aureus (a bacteria resistant to certain antibiotics), and extended spectrum beta-lactamase (enzymes that break down and destroy some commonly used antibiotics). Review of the Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form signed by the hospital's physician on 2/28/24 revealed resident #435 had a Midline IV line inserted on 2/21/24 for administration of IV antibiotics. A midline catheter is a small, thin tube that is inserted into a vein in the upper arm or at the bend in the elbow. A midline catheter is a type of IV access.may be used to: . give medicines. (Retrieved from www.elsevier.com on 3/13/24). Review of resident #435's care plan for IV medications initiated on 2/29/24 included an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 63 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 intervention to check dressing at site daily. Change per facility policy/MD (physician) orders. Level of Harm - Immediate jeopardy to resident health or safety Review of resident #435's physician orders revealed he received Meropenem (IV antibiotic) three times a day for sepsis until 3/05/24. He had additional orders dated 2/29/24 for nurses to change the IV dressing every 7 days or as needed (PRN) for soiling and/or disl[TRUNCATED] Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 64 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 treatment to promote healing of a pressure ulcer for 1 of 1 resident reviewed for pressure ulcers of a total sample of 109 residents, (#295). Residents Affected - Few Findings: Review of resident #295's medical record revealed he was readmitted to the facility on [DATE] from an acute care hospital with diagnoses of pressure ulcer of left hip, stage 4, pressure ulcer of sacral region, stage 3 and paraplegia. Review of the Minimum Data Set 5-day assessment with Assessment Reference Date (ARD) of 12/09/23 revealed resident #295's Brief Interview for Mental Status score was 14 out of 15 which indicated intact cognition. The assessment showed resident #295 had one Stage 3 and one Stage 4 pressure ulcers. A Stage 3 pressure ulcer is a Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. (Retrieved from the CMS Appendix PP Manual) A Stage 4 pressure ulcer is a Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole (rolled edges), undermining and/or tunneling often occur. (Retrieved from the CMS Appendix PP Manual) Review of the Physician's Orders revealed an order dated 1/11/24 which read, Negative pressure wound therapy (NPWT): set at 125 mm/Hg (millimeter mercury) of continuous negative pressure therapy. An order dated 1/11/24 read, Wound Vac: dressing change three times per week on T (Tuesday), TH (Thursday), SA (Saturday). Cleanse left hip with wound cleanser, pat dry, apply skin prep to peri wound. Cut black granufoam to size and gently place in wound bed. Attach wound vac at wound site. Cover with transparent dressing. No hissing should be heard when wound vac is initiated. Every night shift every Tue, Thu, Sat for wound healing. An additional order dated 1/11/24 instructed nurses to change the wound vac dressing on T, Th, Sa and as needed (PRN) if negative pressure was not restored. NPWT applies controlled suction to a wound using a suction pump that delivers intermittent, continuous, or variable negative pressure evenly through a wound filler (foam or gauze). Drainage tubing adheres to an occlusive transparent dressing; drainage is removed through the tubing into a collection canister. NPWT increases local vascularity and oxygenation of the wound bed and reduces edema by removing wound fluid, exudate, and bacteria. (Retrieved from www.woundcareadvisor.com on 3/13/24). Negative pressure therapy stabilizes the wound environment, reduces wound edema/bacterial load, improves tissue perfusion, and stimulates granulation tissue and angiogenesis. negative pressure of 125 mm Hg is considered optimal pressure. (Retrieved from www.ncbi.nlm.nih.gov on 3/13/24). On 3/05/24 at 12:51 PM, resident #295 stated he was recently hospitalized due to wound infection and overheard the physician mentioning to the nurse he may need to be referred to a Wound Care Center. Resident #295 had a portable wound vac on his lap and the setting read 120 mm/Hg. Additional (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 65 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 - Minimal harm or potential for actual harm Residents Affected - Few observations on 3/06/24 at 5:13 PM, and 3/08/24 at 1:54 PM, revealed the wound vac setting read 120 mm/Hg. On 3/06/24 at 11:37 AM, the H-Wing Unit Manager (UM) stated the facility did not have a designated wound care nurse and wound care was provided by the nurse assigned to the resident. He indicated he conducted wound rounds with the Director of Nursing (DON) every Tuesday and orders were obtained from the physician for changes to the current treatment when necessary. On 3/08/24 at 12:21 PM, Registered Nurse (RN) HH stated she had been working at the facility for a couple of weeks and she was not familiar with wound vacs. She explained she had observed the UM change the dressing and the setting was done by the UM. She indicated she had observed changes to the wound vac dressing two times on 2/29/24 and 3/06/24 because the dressing was dislodged. She stated she documented it in the electronic medical record. Review of the Treatment Administration Record (TAR) and Progress Notes for the months of February and March 2024 did not reveal wound vac dressing was changed PRN by RN HH. On 3/08/24 at 12:35 PM, the second floor Director of Nursing (DON) reviewed resident #295's medical record and noted no documentation of the wound vac dressing was found in the TAR or progress notes. At 4:23 PM, she confirmed the wound vac was set at 120 mm/Hg and the physician's order read 125 mm/Hg. She indicated she expected nurses to document treatments when done, follow the physician's orders and clarify any discrepancies with the physicians. On 3/08/24 at 4:34 PM, the UM stated when resident #295's dressing became dislodged and was changed, RN HH was new to the facility and he was in the process of training her. He stated she did not know how to document the PRN dressing change. He said, some wound vac machines are pre-set and can only go to 120 and he was not familiar with this machine. At 6:07 PM, he stated he called the wound vac's manufacturer and just learned how to establish the correct setting. Review of the policy and procedure titled Wound Prevention & Treatment Overview read, A Resident with ulcers will receive continued preventive interventions & necessary treatment & services to promote healing & prevent infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 66 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0688 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Resident #85 was admitted to the facility on [DATE], with diagnoses that included multiple sclerosis, schizoaffective disorder, bipolar disorder, delusional disorders, foot drop right/left foot, and chronic pain. Review of the MDS quarterly assessment with Assessment Reference Date (ARD) of 12/08/23, revealed the resident's cognition was intact, with BIMS score of 14 out of 15. The assessment noted the resident had impairment in functional limitation in ROM on both sides of her upper and lower extremities and was dependent on staff assistance for transfer and personal hygiene. A physician order dated 4/18/22 noted left resting hand splint for 2 hours with skin integrity daily. On 3/04/24 at 10:07 AM, and on 3/05/24 at 9:56 AM, resident #85 was sitting up in bed watching television. Her left hand was contracted, and no splint was noted. The resident said she could not recall when the splint was last placed, and staff forgot to apply the splint. Resident #85 stated therapy told her she should wear the splint daily. On 3/06/24 at 12:19 PM, Licensed Practical Nurse (LPN) A stated the resident used to wear a splint to her left hand, but it had been a while since she saw the splint. LPN A stated the resident had a physician order for left hand splint, and it was usually placed by therapy. On 3/06/24 at 4:04 PM, the Rehab Program Manager stated resident #85 was previously on OT caseload for orthotic management. On 2/02/22 the goal was for the resident to wear a left resting hand splint for approximately 2 hours a day, and the resident was discharged from OT with a left-hand resting splint. On 4/05/22 she was discharged from Physical Therapy and a Functional Maintenance Program for splinting was established. The Rehab Program Manager stated the expectation was for nursing to reach out to therapy if they had any questions or concerns regarding the splint. She stated Therapy had not received any referral from nursing regarding the resident's splinting program until 3/06/24. The Director said, if a resident refused splinting, the assumption was that nursing would send a referral to Therapy to see if the resident's splinting program was still appropriate. The Rehab Program Manager stated splints were worn to increase tone, maintain joint integrity, and decrease contractures. Review of the Therapy Recommendations for Restorative/Functional Maintenance Program revealed the resident's discharge from therapy was 3/31/2022, and the splinting program form directed staff to apply left resting hand splint daily for 2 hours as tolerated. Review of the POC (Point of Care) Response History for the period 2/06/24 to 3/07/24 revealed directions for left resting hand splint daily for up to 2 hours or per patient tolerance. Documentation indicated the resident's left hand resting splint was applied for four days in February, on 2/09/24, 2/10/24, 2/11/24, 2/17/24, and one day in March on 3/02/24. There was no documentation to indicate the resident refused splint application. On 3/06/24 at 5:00 PM, LPN A stated the facility usually had CNAs in the Restorative Nursing Program (RNP), but she did not know how they operated. She said the resident refused to have her splint applied when she offered to place it today, and she placed a referral for her to be screened by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 67 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0688 therapy. Level of Harm - Actual harm On 3/06/24 at 5:33 PM, the C Wing UM stated the facility used to have an RNP, but no longer had one. She could not recall when the RNP was discontinued. The UM explained that when a resident was discharged from therapy with orthotics, therapy would teach the floor CNAs and nurses to don and doff the orthotic. The UM reviewed the resident's physician orders and acknowledged an order was in place for application of a resting left-hand splint daily. Residents Affected - Few On 3/06/24 at 5:49 PM, the 2nd Floor DON stated the splinting process started with therapy, and after discharge from therapy, nurses followed up on the splinting process. Observation of the resident's contracted left hand without a splint in place was shared with the 2nd Floor DON. She stated resident #85 had a BIMs score of 14 out of 15 and had a care plan in place for refusal of care, and skin checks at times. Review of the ADL care plan initiated 4/23/25 with revision on 3/16/23 revealed no reference to splint application. A care plan for splint application was not identified. On 3/06/24 at 6:07 PM, the Executive DON stated the facility had a RNP, but did not have any specific Restorative CNA. She stated all CNAs performed the task the Restorative CNA would, UMs monitored their units, and the Executive DON had ultimate oversight of the RNP. On 3/08/24 at 10:17 AM, the Rehab Program Manager stated that due to referral from nursing on 3/06/24 regarding refusal of orthotics by resident #85, a therapy screen was conducted on 3/07/24. She stated the left-hand resting splint for the resident was still appropriate, and Therapy had picked her up again. She explained if splint application was not being done, therapy needed to do education of resident and staff. The Rehab Program Manager stated there was no documentation regarding the resident's refusal of splint application when the screen/evaluation was conducted on 3/07/24. 6. Resident #238 was admitted to the facility on [DATE] with diagnoses that included diabetes type II, generalized muscle weakness, transient cerebral ischemic attack, muscle wasting and atrophy, acute cerebrovascular insufficiency, dysphagia following cerebral infarction, and gastrostomy. Review of the MDS quarterly assessment with ARD of 12/11/23 revealed the resident was rarely/never understood. The assessment noted the resident had impairment in functional limitation in ROM to one side of her upper extremity and had dependence on staff assistance for all her activities of daily living. On 3/04/24 at 12:33 PM, 3/05/24 at 10:08 AM, 3/05/24 at 1:00 PM, 3/06/24 at 12:31 PM, and on 3/06/24 at 5:06 PM, resident #238 was observed in her bed. The resident verbalized her name, but was unable to answer any other questions. Her left hand was contracted, and the resident did not have a splint. On 3/06/24 at 12:38 PM, RN B stated resident #238's left hand was contracted, and sometimes her splint was applied by therapy. The RN could not recall the last time she saw the resident with her splint on. On 3/06/24 at 3:39 PM, the Rehab Program Manager stated resident #238 was previously on OT caseload from 6/23/23 and was discharged on 11/29/23 to wear a left orthotic splint for 5 to 6 hours. The Rehab Program Manager explained that when a resident had a splint, and was no longer on therapy caseload, the resident would be referred to the RNP. She stated that a Restorative program would be given to the Restorative nurse, the Restorative CNA would be educated about donning and doffing the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 68 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0688 Level of Harm - Actual harm Residents Affected - Few splint/orthotic, and would sign off indicating the education was received, and then nursing would be responsible for the splinting program. The Rehab Program Manager stated she was not aware the resident's splint was discontinued, and therapy had not received any referral from nursing requesting a therapy screen. The Rehab Program Manager verbalized that a review of the resident's therapy documentation, for the last six months, revealed there was no request from nursing for a therapy screen for the resident. She said, if therapy did not receive a referral from nursing, regarding any concerns or issues with the resident's splint, the expectation was the splinting program was ongoing. On 3/07/24 at 11:14 AM, the resident was lying in her bed positioned to her left side. Her left hand was contracted, and a splint was not noted. Review of the OT Progress and Discharge Summary revealed start of care 6/23/23, and end of care 11/29/23. The short-term goal was, patient will wear left palmar guard or appropriate orthotic for 7 hours .to maintain joint integrity and improve ROM. Based on observation, interview, and record review, the facility failed to provide ongoing evaluation to monitor for decreased range of motion and ensure treatment was provided in a timely manner to prevent complications associated with limited mobility, (#246); and failed to provide care and services related to management and application of orthotic devices to prevent worsening of contractures and promote skin integrity, (#124, #137, #268, #238, #85, and #222), for 7 of 12 residents reviewed for limited range of motion and reduced mobility, out of a total sample of 109 residents. The facility's failure to identify and report a change in joint mobility delayed the initiation of appropriate services and interventions to prevent complications and worsening of the condition, and caused actual harm related to pain and reduced range of motion for resident #246, that was inconsistent with the goals of the resident and his representative. Findings: 1. Review of the medical record revealed resident #246 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including stroke with right side weakness and paralysis, failure to thrive, brain cancer, expressive language disorder, and left eye vision loss. Review of the Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 1/20/24 revealed resident #246 had short and long-term memory problems and severely impaired skills for daily decision making. The document indicated the resident did not exhibit behavioral symptoms or reject evaluation or care that was necessary to achieve his goals for health and well-being. The MDS assessment revealed resident #246 had functional limitation in range of motion due to impairment of upper and lower extremities on one side. Resident #246 was totally dependent on staff for assistance with oral hygiene, toileting hygiene, bathing, dressing, and personal hygiene. The document indicated the resident was totally dependent on staff for transfers and required substantial to maximal assistance for rolling from side to side. The MDS assessment revealed the resident did not receive range of motion services or assistance with splints or braces. Review of the medical record revealed resident #246 had a care plan, initiated on 4/22/22 and revised on 1/23/24, for activities of daily living (ADL) self-care performance deficit related to decreased mobility, weakness, and paralysis. The goals were the resident would have his ADL needs anticipated and met by staff and Occupational Therapy was ordered with goals established according to the Occupational Therapy plan of care. The interventions included assist with ADL as indicated, lubricate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 69 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0688 Level of Harm - Actual harm Residents Affected - Few skin with routine care, check nail length and trim and clean on bath day and as necessary, offer a sponge bath when not scheduled bath day, and Occupational Therapy evaluation and treatment per physician orders. Review of the Medication Review Report revealed resident #246 had physician orders dated 9/21/23 for Physical Therapy, Occupational Therapy, and Speech Therapy to evaluate and treat as needed, and Restorative Nursing Program (RNP) services as needed. On 3/06/24 at 9:53 AM, Certified Nursing Assistant (CNA) G stated CNAs were responsible for residents' personal hygiene including bathing and nail care. During observation of resident #246's ADL status, the resident's right arm was at his side, elevated on a pillow. When asked to show the fingernails on the right hand, resident #246 shook his head from side to side and used his left hand to lift the right arm a few inches off the pillow. He demonstrated that his right arm was flaccid. Closer observation revealed the resident's right hand was in a cupped position and his fingers were curved towards his palm. CNA G attempted to open the resident's right hand to inspect his fingernails but she was unable to extend his fingers. The resident grimaced and waved his left hand to signal her to stop. CNA G stated she had never seen the resident with a splint and she did not find any orthotic devices when she searched his bedside table and closet. On 3/06/24 at 10:02 AM, the A Wing Unit Manager (UM) stated nurses inspected or assessed residents at least once weekly when whole body skin checks were completed. She explained CNAs provided care every shift and were assigned to give residents at least two showers or baths weekly. The A Wing UM verified nurses and CNAs were responsible for noting and reporting any concerns related to ADL status and changes in condition. On 3/06/24 at 5:12 PM, the Rehab Program Manager stated resident #246 received Occupational Therapy services from 6/05/23 to 7/04/23. She explained while on caseload, his goals were related to wheelchair positioning, and on discharge from therapy, he received an arm support tray for his wheelchair as his right arm was flaccid. The Rehab Manager reviewed the medical record and stated resident #246 did not have discharge recommendations for RNP services or a splint. She was informed of the resident's cupped right hand and pain during an attempt to open his hand. On 3/06/24 at 5:22 PM, the Rehab Program Manager assessed resident #246's range of motion. She described findings of increased tone rather than contractures. The Rehab Program Manager stated the resident had increased tone when she attempted extension of his fingers. She confirmed the resident expressed discomfort and grimaced at approximately 160 degrees of flexion of his shoulder. The Rehab Program Manager explained increased tone could lead to a contracture and skin integrity issues. She said, At this point, he needs to be evaluated right away, before he gets to the point where he can't move it. We need to preserve the joint integrity. This is a significant change over eight months and we need to get in there to make sure he retains full movement. The Rehab Program Manager stated the Therapy department did not conduct periodic screenings of all residents in the facility. She explained the process was the Nursing department would refer residents who exhibited any type of decline in ADLs, mobility, or range of motion via an electronic referral form. She said, We are very heavily reliant on the nursing staff.It would have been appropriate for nursing to refer him when there was a change in tone. The Rehab Program Manager explained based on her assessment of resident #246, she would begin with gentle range of motion and set a goal for use of a resting hand splint. On 3/06/24 at 5:40 PM, Occupational Therapist H stated she was resident #246's therapist when he was last on caseload in July 2023. She stated she ordered a trough for his wheelchair as his arm was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 70 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0688 Level of Harm - Actual harm Residents Affected - Few so flaccid. She emphasized the resident was able to lay his hand flat in the trough when he was discharged from Occupational Therapy caseload and said, If he had tone at the time we would have ordered a resting hand splint. On 3/06/24 at 6:02 PM, the Executive Director of Nursing (DON) stated her expectation was nursing staff would report any changes or declines appropriately. She explained any staff member could initiate a therapy referral, but nurses and UMs were usually the ones who did so. She validated any assigned staff member should have noticed changes in resident #246's right hand and arm during provision of care. On 3/07/24 at 3:12 PM, Occupational Therapist H explained resident #246's right arm is flaccid and not functional. She stated he could develop contractures over time, but if he received daily range of motion exercises, they might be prevented. Occupational Therapist H said, I would have expected staff to realize he was getting tighter. She confirmed she assessed resident #246 today and developed a plan of care based on her findings. She stated the proximal joints of all digits on the right hand were fixed contractures, but most of the other joints could be stretched, and he had mild pain with the wrist. Occupational Therapist H stated she already ordered a hand roll splint. She stated she was not able to fully open the resident's hand and said, I was not going to push him to fully open as he was in pain, signified by him telling me to stop. Review of an Occupational Therapy Plan of Care dated 3/07/24 revealed Occupational Therapist H noted resident #246 was referred to skilled therapy due to increased tone and developing deformities of the right hand digits. The document indicated the resident had right proximal interphalangeal joint flexion contractures. She determined Skilled [Occupational Therapy] is medically indicated to maximize joint integrity and provide orthotic management. Without immediate intervention, patient is at risk for development of joint deformities. Occupational Therapist H developed short term goals to include wearing a right hand roll and long term goals included functional maintenance program for range of motion and use of a right grip hand splint. On 3/07/24 at 2:57 PM and 3:21 PM, the Executive DON reviewed resident #246's Occupational Therapy Plan of Care and noted the document referred to deformities, increased tone, and contractures, which she acknowledged were negative outcomes that were not identified by nursing staff. The Executive DON stated her expectation was all CNAs would do range of motion exercises during resident care. She explained the facility did not currently have a RNP with designated restorative CNAs. She stated it was concerning that staff had not noted or reported the changes in the resident's right hand and arm. On 3/08/24 at 3:52 PM, the Executive DON provided a copy of the Occupational Therapy Plan of Care dated 3/07/24, with additional documentation by the attending physician to validate the patient has change in tone to right hand and an instruction to remove the word deformities from the document. The Executive DON verbalized understanding that regardless of terminology, resident #246 experienced a decline in range of motion, a change of condition that was not identified and treated by the facility, until discovered by the State Survey Agency surveyor and brought to the facility's attention. 2. Resident #124 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include nontraumatic intracranial hemorrhage, respiratory failure, and other specified disorders of muscle. The quarterly MDS assessment noted resident #124 scored 15 out of 15 on the Brief Interview for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 71 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0688 Mental Status (BIMS) evaluation which indicated the resident was cognitively intact. The MDS assessment did not identify any mood or behavior problems. Level of Harm - Actual harm Residents Affected - Few On 3/05/24 at 10:37 AM, resident #124 was observed lying in bed watching television and his left hand was contracted with no splint. The resident stated he used to have a splint but did not know what happened to it. Review of the resident's care plan for Range of Motion (ROM), dated 5/22/20 and revised 3/19/22 revealed an intervention for Splint type: resting orthotic hand brace. Apply to left hand after breakfast and remove after lunch. Observe and report decline in ROM. On 3/06/24 at 6:09 PM, the Director of Rehab stated resident #124 was on caseload from 10/19/23 to 10/30/23 for Occupational Therapy (OT). She stated his discharge summary included he would have palm guard for 8 hours. When she was informed the resident no longer had his palm guard, the Rehab Director stated the resident would be screened the next day. Review of the Occupational Therapy Screening Form dated 3/07/24 indicated the following: Joint Contracture(s) or is at High Risk for Developing such. Patient has flexor tone in elbow and digits. Occupational Therapy evaluation is recommended. Patient has potential to benefit from orthotic management program to prevent skin breakdown and address hypertonicity. 3. Resident #137 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include traumatic brain injury, acute respiratory failure, and subdural hemorrhage. The MDS Significant Change in Status Assessment noted resident #137 scored rarely or never understood on the BIMS evaluation which indicated the resident had severe cognitive impairment. The MDS assessment did not identify any mood or behavior problems. On 3/04/24 at 6:21 PM, resident #137 was observed lying in bed with both hands contracted with no splints. On 3/06/24 at 5:56 PM, the Director of Rehab stated resident #137 was on physical therapy (PT) caseload from 12/06/23-1/06/24. She stated he had not been on OT caseload since 2021. The Director of Rehab said when he was discharged from OT he was supposed to wear a right-hand resting splint for 2 hours each day and the CNA was educated on the application of the right-hand splint. Resident #137 was screened by OT on 3/07/24 and received the following recommendation: Skilled OT is medically indicated to improve impaired range of motion, tone, cognition, coordination orthotic management. Without immediate intervention, the patient is at risk for further decline in function. 4. Resident #268 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include acute kidney failure, anemia, and other specified muscle disorders. The MDS quarterly assessment noted resident #268 scored 15 out of 15 on the BIMS evaluation which indicated the resident was cognitively intact. The MDS assessment did not identify any mood or behavior problems. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 72 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0688 On 3/05/24 at 9:39 AM, resident #268 was observed sitting in bed. His left hand was contracted with no splint. The resident stated he did not have a splint and did not receive OT. Level of Harm - Actual harm Residents Affected - Few On 3/06/24 at 6:03 PM, the Director of Rehab stated resident #268 was last on OT caseload from 3/2/23-5/20/23. She explained the discharge summary read for left hand, 4th and 5th finger contracture, resident will wear left resting hand splint for 95 minutes with no signs or symptoms of hand skin breakdown. The Director said, the resident is on the board to be screened because a therapist noticed his hand. She stated he would be screened tomorrow. On 3/07/24 at 6:30 PM, The D Wing Unit Manager stated his expectation was the CNA would apply the splint if it was not done by the therapist. He stated the facility did not have restorative CNAs. On 3/08/24 at approximately 11:00AM, the OT discharge summary and screening were requested for resident #268 but was not received by the end of the survey. On 3/08/24 at 3:45 PM, the Executive DON stated the facility did not have restorative CNA's at this time. She explained the floor CNA's were taught to apply and remove the splints for the residents. She stated her expectation was that residents would get the care that was ordered for them. The Certified Nursing Assistant (CNA) job description dated 7/01/2019 read: Performs restorative and rehabilitative procedures as instructed. and provides range of motion exercises according to the care plan. 7. Review of the medical record revealed resident #222 was admitted to the facility on [DATE] from the hospital. Her diagnosis included cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, muscle wasting and atrophy, and anxiety disorder. The significant change in status MDS with an assessment reference date of 1/24/24 revealed resident #222 had severely impaired cognitive skills for daily decision making. The MDS assessment also indicated resident #222 had OT from 1/5/24 to 1/18/24 and PT from 1/5/24 to 1/17/24. Review of the Occupational Therapy Discharge and Summary revealed resident #222 was discharged on 1/18/24 with a splinting functional maintenance program and a left upper extremity palm guard. Resident #222's medical record revealed the restorative task dated 2/9/24-3/8/24 was to perform skin checks before and after application of Orthosis but was documented by the nursing staff as not applicable. On 3/3/24 at 1:27 PM, 3/6/24 at 9:57 AM, and on 3/7/24 at 10:12 AM, observation revealed resident #222 had a left-hand contracture with no palm guard or splint in place. On 3/7/24 at 11:44 AM, the OT Rehab Program Manager stated the resident had OT from 1/5/24 to 1/18/24 with a long-term goal that consisted of a range of motion and splinting functional maintenance program. She confirmed the resident had been discharged from OT on 1/18/24, with directions to wear a left palm guard for 60 minutes each day, intended to prevent further contracture and preserve skin integrity. The OT Rehab Program Manager acknowledged the nursing staff had the responsibility to ensure the resident had a palm guard in place and to notify OT if the palm guard was missing, so a replacement could be arranged. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 73 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0688 Level of Harm - Actual harm Residents Affected - Few On 3/7/24 at 11:45 AM, OT H verified the resident previously had a palm guard with restorative care to address the orthotic when last discharged from OT on 1/18/24 and the palm guard was currently missing from the resident's room. On 3/7/24 at 12:35 PM, RN U stated she had been working at the facility for 14 years. She acknowledged the resident had a left-hand contracture with no palm guard. She did not recall ever seeing a palm guard for the resident. On 3/7/24 at 12:35 PM, RN W stated she was familiar with the resident and could not recall ever observing the resident with a palm guard. On 3/7/24 at 12:34 PM, CNA Y stated she had worked at the facility for 1 year and was familiar with the resident. CNA Y conveyed she had never seen the resident with a palm guard. On 3/8/24 at 11:34 AM, RN X stated she was familiar with the resident. RN X said she was aware resident #222 had a left-hand contracture and she had not seen the resident with an orthotic device or palm guard. She conveyed if she noticed a resident with a contracture, she would notify therapy. She could not give a reason why she did not notify therapy of the resident's contracture. On 3/8/24 at 12:25 PM, the Executive DON explained they did not have a stand-alone restorative program. She said that when OT discharged a resident to restorative nursing services, it was the Unit Manager's responsibility to place the task in the electronic medical record to ensure CNAs were trained appropriately, and the orthotics were applied. On 3/8/24 at 1:32 PM, the D Wing UM accessed the resident's active restorative task and noted resident #222 was to have an orthotic applied and nursing staff were to observe for skin breakdown. He confirmed the restorative task was placed on 1/4/24 and showed it had been documented not applicable for the past 30 days. The UM explained there was not a system in place for him to monitor whether restorative nursing was being carried out and whether the residents had their orthotics applied as ordered. On 3/08/24 4:40 PM the Executive DON said the facility did not have a splint policy. The facility's policy Restorative Nursing Programs and Guidelines with revision date of October 2017 read, The facility provides Restorative Nursing Programs that involve interventions to improve or maintain the optimal physical, mental and psychological functioning . The programs include Contracture Management and Prevention-This program includes the provision of active and, or passive range of motion exercises/movements to maintain or improve joint flexibility as well as strength .also involves splint/brace assistance to protect joint and skin integrity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 74 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident's environment was free of accident hazards related to an unsecured oxygen cylinder for 1 of 10 residents reviewed for accidents, out of a total sample of 109 residents, (#71). Findings: Resident #71 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, acute respiratory failure, shortness of breath, chronic respiratory failure and anxiety disorder. Review of the Minimum Data Set quarterly assessment with assessment reference date 2/23/24 revealed resident #71 had a Brief Interview for Mental Status (BIMs) score of 15 out of 15 which indicated he was cognitively intact. A care plan initiated 6/09/23, revised 3/05/24 indicated resident #71 was on oxygen therapy as needed related to shortness of breath. Interventions included administer oxygen as ordered and report changes in respiratory status to the physician. Review of resident #71's medical record revealed a physician order dated 2/12/24 for oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath. On 3/04/24 at 1:05 PM, resident #71 was observed resting in bed. A free-standing oxygen cylinder was observed upright against the wall approximately 3 feet from the resident. Oxygen tubing was connected to the cylinder along to the resident's bed. The oxygen cylinder was not secured to prevent it from falling over. On 3/04/24 at 1:14 PM, Certified Nursing Assistant (CNA C) entered the room and explained the unsecured oxygen cylinder was placed in a carrier when resident #71 used a wheelchair but when he was in his room, the cylinder stood upright position on the floor against the wall. CNA C stated she always placed the cylinder against the wall and was not aware the oxygen cylinder needed to be secured in a carrier in the resident's room. On 3/04/24 at 1:23 PM, Registered Nurse (RN) B stated the oxygen cylinder should be secured in a carrier. She explained the container was combustible and could be a danger if it fell over. On 3/06/24 at 3:12 PM, the Executive Director of Nursing (DON) stated oxygen cylinders were to be secured in a rolling carrier. She explained the cylinder could be secured in a carrier bag if a resident used a wheelchair. The Executive DON acknowledged the contents were combustible and could explode if the tank fell over. She stated the oxygen cylinder should not have been left in the room unsecured. The facility's policy and procedure for Oxygen Therapy dated November 2023 indicated oxygen was a flammable gas that supports combustion. The document noted oxygen tank cylinders must be secured at all times to prevent the cylinder from falling over. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 75 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 - Some 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 obtain a physician's order for removal and care of an indwelling urinary catheter for 1 of 2 residents observed for indwelling catheters of a total sample of 109 residents, (#136). Findings: Review of the medical record revealed resident #136 was admitted to the facility on [DATE] and readmitted on [DATE] from the hospital. Her diagnosis included dementia, cerebral infarction, transient cerebral ischemic attack, Alzheimer's Disease, major depressive disorder, and other specified disorders of the bladder. Resident #136's Quarterly Minimum Data Set (MDS) with an assessment reference date of 1/17/24 revealed the resident scored 09 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated she had moderate cognitive impairment. The assessment noted resident #136 was totally dependent on staff for toileting and was incontinent of bowel and bladder. Review of resident #136's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (3008) dated 1/26/24 noted an indwelling urinary catheter was inserted at the hospital on 1/18/24 and was not removed at the hospital prior to discharge. Resident #136's medical record revealed there was no physician's order for the resident's indwelling urinary catheter since her readmission to the facility on 1/26/24. On 3/7/24 at 12:37 PM, Registered Nurse (RN) U stated resident #136 was readmitted to the facility on [DATE] with an indwelling urinary catheter. She reviewed the hospital transfer form and explained the catheter was inserted on 1/18/24 at the hospital and it was not removed prior to discharge. RN U confirmed there was no physician's order for the indwelling catheter since the resident's readmission. On 3/8/24 at 11:34 AM, RN X said she was familiar with the resident's care. She indicated a few months ago, during shift change, it was reported to her the resident returned from the hospital with an indwelling urinary catheter. She stated she did not obtain physician orders for the indwelling catheter. On 3/8/24 at 12:25 PM, the Executive Director of Nursing (EDON) stated when a resident was readmitted with an indwelling urinary catheter, the resident's primary nurse was expected to notify the provider about the catheter and obtain the necessary routine orders including catheter care. She verified resident #136 should have had a physician order in place for the indwelling catheter upon readmission on [DATE]. On 3/8/24 at 10:15 AM, the EDON stated the facility did not have an indwelling urinary catheter policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 76 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide appropriate care and services as per physician orders for 1 of 1 resident reviewed for gastric tube feeding out of a total sample of 109 residents, (#222). Findings: Review of the medical record revealed resident #222 was admitted to the facility on [DATE] from the hospital. Her diagnosis included stroke, hemiplegia and hemiparesis, aphasia, dysphagia, gastrostomy tube, moderate protein-calorie malnutrition, type II diabetes, obesity, and anxiety disorder. The significant change in status Minimum Data Set (MDS) with an assessment reference date of 1/24/24 revealed resident #222 had severely impaired cognitive skills for daily decision making. The assessment also indicated resident #222 had a feeding tube that provided 51 percent or more of her total caloric intake and 501 cubic centimeters (cc) or more of her fluid intake per day. Review of resident #222's medical record revealed a care plan was initiated on 3/22/21 that indicated the resident required enteral feeding as her sole source of nutrition with interventions that included administer enteral nutrition as ordered. The nutritional risk evaluation dated 2/24/24 indicated resident #222 was to remain nothing by mouth (NPO) related to dysphagia. It also noted the resident had significant weight gain over the span of two months with a Body Mass Index (BMI) of 29.5, which was within the overweight range. The resident's Glucerna 1.2 calorie tube feed order was reduced from an infusion rate of 80 milliliters (ml) per hour to 72 ml per hour. Resident #222's Medication Review Report and the Medication Administration Record (MAR) showed the enteral feed formula, with an infusion rate of 80 milliliters per hour, was discontinued on 2/24/24. A new order was placed for Glucerna 1.2 calorie formula to be administered at a rate of 72 ml per hour. On 3/03/24 at 1:27 PM observation of resident #222 revealed Glucerna 1.2 calorie tube feed infused via pump at 85 milliliters per hour. On 3/04/24 at 1:00 PM, the D Wing Unit Manager (UM) accessed resident #222's enteral feed physician order and stated the resident was to receive Glucerna 1.2 calorie at a rate of 72 ml per hour. The D Wing UM turned on the resident's tube feed pump and verified the infusion rate was set at 85 ml per hour. He acknowledged the tube feed pump should have been set at 72 ml per hour. The D Wing UM explained nurses were expected to validate tube feed orders at the beginning of every shift to confirm tube feed administration rate was as per physician orders. On 3/04/24 at 1:14 PM, Registered Nurse (RN) W reviewed resident #222's enteral tube feed physician order and said the resident was to receive Glucerna 1.2 calorie at a rate of 72 ml per hour. She stated when she began her shift, the resident's tube feed was running at 85 ml per hour, which was not the correct rate as prescribed. She stated she did not validate the physician order at the start of her shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 77 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm On 3/8/24 at 12:25 PM, the Executive Director of Nursing (EDON) stated nurses assigned to the residents were responsible to program the tube feed pump. She said she expected nurses to verify physician orders each shift and before adjusting the tube feed pump setting. On 3/8/24 at 10:15 am, the EDON stated the facility did not have a tube feed policy. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 78 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 maintain oxygen flow rate as ordered by the physician for 2 of 5 residents reviewed for respiratory care from a total sample of 109 residents, (#137 and #157). Residents Affected - Few Findings: 1. Resident #137 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include traumatic brain injury, acute respiratory failure, and subdural hemorrhage. The Minimum Data Set (MDS) significant change in status assessment noted resident #137 scored rarely or never understood on the Brief Interview for Mental Status (BIMS) evaluation which indicated the resident had severe cognitive impairment. On 3/03/24 at 2:45 PM, resident #137 was observed lying in bed with oxygen by concentrator at rate of 3.5 liters per minute (LPM). On 3/04/24 at 12:25 PM, the resident # 137 was in bed and received oxygen by concentrator at 3.5 LPM. On 03/04/24 at 12:36 PM, Registered Nurse (RN) FF reviewed the physician order and stated the resident's oxygen should be at 2 LPM. She acknowledged the resident's oxygen was set at 3.5 LPM. RN FF said, I always check the oxygen settings at the start of my shift. I don't know why I did not check it this morning. Review of the Medication Review Report revealed a physician order for Humidified Oxygen per trach continuously. Oxygen saturation to maintain saturations greater than 90% at 2 liters, every shift dated 4/20/23. Review of resident #137's care plan for Oxygen dated 5/05/21 and revised on 7/26/22 revealed an intervention to, Administer Oxygen as ordered. (Refer to current Physicians Order Sheet/Medication Administration Record for current order). 03/04/24 at 1:01 PM, the D Wing Unit Manager (UM) stated his expectation was the nurses would check the liter flow at the start of the shift and as needed. The UM stated it was important to give oxygen at the rate it was ordered to avoid serious consequences. On 3/08/24 at 3:45 PM, the Executive Director of Nursing (DON) stated her expectation was that nurses would check the liter flow of oxygen at the beginning of their shift and with each medication pass. 2. Review of the medical record revealed resident #157 was admitted to the facility on [DATE] from the hospital. His diagnosis included nontraumatic intracranial hemorrhage, chronic obstructive pulmonary disease (COPD), acute respiratory failure with hypoxia, acute pulmonary edema, and heart failure. Resident #157's Annual MDS with assessment reference date of 12/10/23 revealed the resident scored (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 79 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 15 out of 15 on the BIMS that indicated he did not have any cognitive impairment. The assessment noted the resident relied on a manual wheelchair for mobility and received oxygen therapy. Review of resident #157's medical record revealed a care plan initiated on 5/25/2020 and revised on 6/14/23 that indicated the resident had oxygen therapy related to COPD and was at risk for complications. The interventions included administering oxygen therapy as ordered. Resident #157's Medication Review Report showed an active physician's order for oxygen at 2 LPM via nasal cannula (NC) continuously for COPD. On 3/05/24 at 11:09 AM, resident #157 was observed sitting in his wheelchair with oxygen administered through NC. The portable oxygen concentrator's liter flow was set at 3 LPM. On 3/05/24 at 12:02 PM, the 2nd floor DON reviewed the resident's oxygen order and stated the current order was for 2 liters per minute of oxygen continuously. She verified the resident's oxygen setting and confirmed that it was set at 3 liters instead of the prescribed 2 liters. The 2nd floor DON acknowledged it was imperative that residents received the prescribed oxygen to prevent serious complications from occurring. She reiterated that nurses were expected to validate oxygen orders and ensure liter flow rates were set as per physician orders. On 3/6/24 at 3:23 PM, RN V stated it was the RNs responsibility to set the resident's oxygen flow rate according to the physician's order and to routinely monitor the oxygen settings to ensure they matched the physician's order. The facility's Oxygen Therapy Policy and Procedure noted when oxygen was provided to residents, physician's orders were to be verified and the device be applied to the resident with the appropriate liter flow. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 80 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0698 Provide safe, appropriate dialysis care/services 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** 3. Review of the medical record revealed resident #109 was admitted to the facility on [DATE] with diagnoses including end stage renal disease with dependence on dialysis, heart disease, and type 2 diabetes. Residents Affected - Few The MDS admission assessment with assessment reference date of 2/13/24 revealed resident #109 had a Brief Interview for Mental Status of 14 out of 15 which indicated she was cognitively intact. The document showed the resident exhibited no behavioral symptoms and did not reject evaluation or care that was necessary to achieve her goals for health and well-being. The MDS assessment showed resident #109 received dialysis treatments. Review of the medical record revealed resident #109 had a care plan for dialysis, initiated on 2/08/24. The goal was the resident would experience minimal to no complications related to fluid volume disturbance. The interventions included monitor her right upper arm dialysis catheter site for signs and symptoms of infection every shift, dialysis on Tuesdays, Thursdays, and Saturdays, observe for bleeding and injury, and a renal consult as needed. On 3/05/24 at 3:47 PM, resident #109 stated she neither saw her nurse this morning prior to leaving for dialysis nor received her morning medications. The resident explained she had been in her room since she returned from dialysis but the nurse had not come in to assess her yet. On 3/05/24 at 3:52 PM, Registered Nurse (RN) D was at the nurses' station and was not aware resident #109 was back from dialysis. When asked about the communication sheet that was to be sent with the resident, RN D stated the forms were kept in a binder. She searched resident #109's room, bag, and wheelchair and did not find the binder. On 3/05/24 at 4:02 PM, RN D was informed the resident stated she was not assessed and did not receive her medications before dialysis. RN D explained she saw the resident in the common area when she arrived at the start of the 7:00 AM shift. She acknowledged she never gave the morning medications and did not know when resident #109 left the facility. RN D verified the pre-dialysis procedures included assessing the dialysis site, obtaining and documenting vital signs and medications administered on the communication form. She validated she did not do any of these required tasks and the resident went to the dialysis center without a communication form. On 3/05/24 at 4:07 PM, the B Wing Unit Manager (UM) stated the communication forms had sections to be completed by the facility nurse before and after dialysis, and a section to be completed by the dialysis center. She explained when the post-dialysis section of the form was completed by the facility nurse, the document should be placed in the resident's chart. The B Wing UM reviewed resident #109's chart and did not find any dialysis communication forms. She confirmed the dialysis center did not send information by email or fax after each treatment. On 3/06/24 at 11:52 AM, the Executive Director of Nursing stated it was important for nurses to conduct assessments before and after dialysis and complete the communication form. She explained nurses placed the form in the chart and also entered an associated progress note in the electronic medical record. On 3/06/24 at 12:13 PM, the B Wing UM stated she located a manila envelope with a few communication forms for resident #109. She provided Dialysis Communication Tool forms dated 2/10/24, 2/17/24, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 81 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0698 Level of Harm - Minimal harm or potential for actual harm 2/24/24, which represented 3 of the 12 days the resident was scheduled for dialysis since admission. The forms contained only pre-dialysis information, and no documentation by the dialysis center or the facility nurse who received the resident on return to the facility. The B Wing UM validated, It is not good communication. It is not acceptable that [the] nurse did not conduct an assessment prior to receiving a treatment. Residents Affected - Few Review of the electronic medical record revealed one Dialysis Progress Note dated 2/29/24 at 3:35 PM, which indicated the nurse assessed resident #109's access site and checked her vital signs on return to the facility from dialysis. Review of the facility's policy and procedure for Dialysis Management, dated October 2021 revealed the facility would coordinate care and services for dialysis residents and contractual agreements would include the interchange of information that was useful and necessary for the care of the resident. The guidelines instructed nurses to complete the Dialysis Communication Tool before and after dialysis and following up on any special instructions from the dialysis center. Instructions for frequency of completion of the communication form indicated it should be utilized each time the resident went to dialysis and was a permanent part of the medical record. The Nursing Home Dialysis Transfer Agreement, dated 1/14/13, between the facility and resident #109's dialysis center read, The facility shall ensure that all appropriate medical, social, administrative, and other information accompany all Designated residents at the time of transfer to the center. The document indicated the information would include appropriate medical records, the history of the illness, labs, x-ray findings, current treatments such as medications, any changes in condition, medication changes, and .any other information that will facilitate the adequate coordination of care as reasonably determined by [the dialysis] center. Based on observation, interview, and record review, the facility failed to maintain adequate communication with the dialysis center, follow the comprehensive person-centered care plan and ensure post-dialysis assessments were completed for 3 of 4 resident reviewed for dialysis of a total sample of 109 residents, (#109, #220, and #313). Findings: 1. Review of the medical record revealed resident #220 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. His diagnoses included end-stage renal disease (ESRD) with dependence on dialysis, type 2 diabetes, and hypertension. Review of the Minimum Data Set (MDS) Quarterly assessment with Assessment Reference Date (ARD) of 12/15/23 revealed resident #220's Brief Interview for Mental Status (BIMS) score was 15 out of 15 which indicated intact cognition. The assessment showed the resident had no behavioral symptoms and did not reject evaluation or care that was necessary to achieve his goals for health and well-being. The assessment revealed resident #220 required dialysis. Review of resident #220's physician orders revealed an order dated 1/01/24 to document vital signs (VS) upon resident returning from dialysis every Tuesday, Thursday, and Saturday. Active physician orders also included, No blood pressure or blood draws in left arm dated 12/30/23 and 1/01/24. An additional order dated 1/01/24 read, No blood pressure or blood draws in right arm. An order dated 1/01/24 indicated there was an arteriovenous (AV) fistula on the left upper arm (LUA). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 82 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0698 Level of Harm - Minimal harm or potential for actual harm An AV fistula is a type of access used for hemodialysis. An AV fistula is a connection between an artery and a vein creating a ready source with a rapid flow of blood. The fistula is located under the skin and is used during dialysis to access the bloodstream. When having blood pressure taken or blood drawn, use the non-fistula arm to avoid any restriction of blood flow which can cause clotting. (Retrieved from www.davita.com on 3/14/24) Residents Affected - Few Review of resident #220's care plan for Hemodialysis was revised on 8/01/23. The care plan interventions included the catheter site located on the left arm and monitoring every shift for signs and symptoms of infection. The intervention to not take blood pressure or blood draws was noted for both the right and left arm. Review of Weights and Vitals Summary report from February to March 2024 revealed blood pressure was documented on the left arm 72 times. Review of the Dialysis Communication Tool showed 3 sections, the first and third were to be completed by the facility's nurses and the middle section was to be completed by the dialysis center. There were 7 forms missing from January to March 2024 on, 1/16, 1/30, 2/06, 2/17, 2/20, 2/24, and 3/07/24. Review of the 22 forms provided showed none contained documentation from the dialysis center. Review of the progress notes did not reveal any contact made with the dialysis center. There were 16 out of 22 forms that did not have post-dialysis VS or details of assessment. On 3/08/24 at 8:05 AM, the Executive Director of Nursing (EDON) explained when the resident returned from dialysis treatment, nurses needed to assess the resident and enter a post-dialysis progress note. She noted when entering the VS in the electronic medical record, specifically the blood pressure, the system prompted the nurse to identify the site it was taken from. The EDON checked resident #220's physician orders and VS records. She stated the order to obtain blood pressure needed to be clarified. She indicated nurses took the blood pressure from the right arm, because he had a fistula on the LUA. She said the documentation was inaccurate. On 3/08/24 at 1:37 PM, Registered Nurse (RN) HH stated she took resident #220's blood pressure on the right arm because she knew he had a fistula on the LUA. She indicated she took his vital signs when he returned from dialysis but did not check the form and did not complete the last section with the post-dialysis assessment. She stated she did not enter a progress note and said she did not receive orientation about completing dialysis forms. 2. Review of the medical record revealed resident #313 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included ESRD with dependence on dialysis, type 1 diabetes, amputation of both legs below the knees, and heart failure. Review of the MDS significant change in status assessment with ARD of 1/26/24 revealed resident #313's BIMS score was 15 out of 15 which indicated intact cognition. The assessment showed she had no behavioral symptoms and did not reject evaluation or care that was necessary to achieve her goals for health and well-being. The assessment revealed resident #313 required dialysis. Review of resident #313's physician orders revealed an order dated 2/23/24 to document VS upon resident's return from dialysis every Monday, Wednesday, and Friday. Additional orders dated 2/23/24 indicated she had an AV fistula on the LUA and not to take blood pressure or have blood drawn from her left arm. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 83 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Weights and Vitals Summary report from February to March 2024 revealed blood pressure was documented on her left arm 23 times. Review of resident #313's care plan for Hemodialysis was revised on 10/23/23 and interventions included Protect shunt (hole or small passage) from injury: No constriction or BP (blood pressure) to affected limb. The care plan listed resident #313 had an AV fistula in the LUA and the right arm. An intervention dated 12/01/23 directed nursing staff to communicate and coordinate with the dialysis center regarding care plan goals. Review of Dialysis Progress Notes from January to March 2024 revealed 3 post-dialysis notes were entered. On 3/08/24 at 8:18 AM, the EDON stated VS needed to be documented accurately and acknowledged documentation in residents #220 and #313's medical records reflected the blood pressure was taken from the left and right arm multiple times. On 3/08/24 at 1:20 PM, the second floor Director of Nursing (DON) stated the Dialysis Communication Tool forms for resident #313 were not available because she was at dialysis. The DON explained when a resident returned from dialysis the form needed to be reviewed and the last section needed to be completed, with the VS and assessment documented and a progress note entered in the electronic medical record. She indicated if the dialysis center did not complete the second section of the form, the facility nurse needed to contact the dialysis center to find out the missing information. She acknowledged the Dialysis Communication Tool forms for resident #220 were not completed as required and there was no evidence of communication with the dialysis center. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 84 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure licensed nurses were knowledgeable and demonstrated competency to provide care and services per standards of care for a peripherally inserted intravenous central line catheter (PICC) for 1 of 1 resident reviewed for PICC lines, out of a total sample of 109 residents (#72) and failed to ensure licensed nurses were competent to follow physician orders for medication parameters, topical ointments and diabetes management for 4 of 102 licensed nurses, (Registered Nurses D, K, E and GG). Resident #72 was readmitted to the facility from the hospital on 1/10/24 with a peripherally inserted central line catheter in his left upper arm. The 3008 Agency for Healthcare Administration Transfer and Discharge form dated 1/10/24 detailed the double lumen PICC, but the form did not give the date it was inserted, the date the dressing was last changed or the location. The admitting nurse at the facility documented the presence of a double lumen device under the skin assessment portion of the readmission documentation, but failed to mention it was a PICC. She documented the wrong location and did not obtain orders for discontinuance or maintenance/care of the intravenous central line. Resident #72 went for a short stay to the emergency room on 2/26/24, but otherwise remained at the facility for 7 weeks and 4 days without receiving care and services to maintain the PICC line or prevent infection. On 3/03/24 the PICC was brought to the attention of facility staff by the surveyor and was ordered removed on 3/04/24. Resident #72 required an ultrasound, an X-ray of his left arm and blood work to ensure he had no complications from the facility's neglect of the PICC line. The facility's failure to ensure licensed nurses were knowledgeable and competent to assess central line catheters including PICCs, obtain appropriate admission orders, and provide care and services for peripherally inserted central line catheters placed resident #72 and all residents admitted to the facility with a central line catheter or other intravenous (IV) catheter device at risk. Without appropriate central line catheter care, there was high likelihood resident #72 could have developed severe infection, blood clots, vascular damage or even death. These failures resulted in Immediate Jeopardy starting on 1/10/24. The Immediate Jeopardy was removed on 3/06/24. Findings: Cross reference F600 and F684 1. Resident #72, was admitted to the facility on [DATE] with diagnoses of pneumonia, acute respiratory failure with low oxygen, chronic lung disease, feeding tube to his stomach, low white blood cell count, heart failure, skin cancer, lung cancer and tongue cancer. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 1/10/24 revealed resident #72 was readmitted to the facility on [DATE] with a double lumen PICC line. The form did not indicate when it was inserted, when the device was last changed or where it was located. The Admission/readmit: Data Collection and Baseline Care Plan with effective date 1/10/24 at 3:45 PM, indicated Licensed Practical Nurse (LPN) BB documented resident #72 was admitted with the following skin issues, right arm- multiple bruises and she incorrectly documented and failed to identify the type of line. She recorded only, right double lumen instead of indicating the PICC in his left upper arm. LPN BB checked the box which directed the nurse to, Obtain physician orders for care instructions and monitoring, and she later (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 85 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few documented the drug regimen was reviewed by the practitioner on admission. She indicated on the form there were no clinically significant findings. Review of the Medication Review Report dated 3/03/24 at 3:12 PM, revealed no current physician orders for IV medications nor for care or maintenance of resident #72's PICC line. Review of resident #72's Medication and Treatment Administration Records for January 2024, February 2024 and March 2024 revealed no physician orders for care, maintenance, or assessment of resident #72's PICC line. Further review of resident #72's medical record revealed no care plan was created for his PICC line until 3/04/24, when concerns about the PICC were brought to the facility's attention by the State Agency Surveyor. On 3/03/24 at 2:25 PM, resident #72 was awake and alert, seated upright in bed. On his left upper arm, the double lumens of a PICC catheter were hanging down from his sleeve. Resident #72 stated he received the intravenous line (IV) in the hospital, but he could not recall how long he had it, nor why it was still there. Resident #72 lifted his sleeve to reveal a piece of worn white, tube-type gauze covering most of the IV site. He moved the gauze over to reveal the PICC dressing underneath was undated, unlabeled, and gaping open at the bottom where the double lumens hung down. He stated he could not recall receiving care for the PICC line while at the facility. On 3/03/24 at 2:34 PM, Licensed Practical Nurse (LPN) Z was at resident #72's bedside, and acknowledged she was aware of the PICC IV in his arm. LPN Z verified the PICC dressing had no date or initials on it and was loose at the bottom where the lumens emerged. She stated she did not know how long he had the line and was unable to say by looking at the unlabeled IV dressing. LPN Z explained she was not IV certified and would have to notify the supervisor if it needed to be assessed or needed care. She stated she was supposed to look at the dressing to check if it was intact, clean and for the date of the last dressing change, but said she was at the end of her shift and had not done that. LPN Z stated she did not know when the last time resident #72's PICC dressing had been changed. She reviewed the resident's medical record and stated she could not find any physician orders for resident #72's PICC line. She said she was not aware there were no physician orders for resident #72's PICC. LPN Z stated care and maintenance of a PICC line was important because it was a central line and could get infected without proper care. During interviews on 3/03/24 at 2:53 PM and 3/04/24 at 10:47 AM, the C wing Unit Manager (UM) said she was told by LPN Z of resident #72's PICC line having no orders. She was unable to say how long he had had the IV, when it was inserted, why he had had it or why it was still in place. She stated she thought resident #72's IV was a midline he received at the hospital but was not sure when. She verified there were no orders to care for the IV, no care plan for it, nor was it on the Medication Administration or Treatment Administration record for February 2024. The C wing UM explained the line needed to be flushed every shift, before and after any medications going into it along with dressing changes and assessment. She described the admission process for the assigned nurse who should do a full body head to toe assessment of the resident and note any devices or skin impairments on the resident. The C wing UM explained the nurse looked at all of the hospital paperwork including the hospital transfer form in order to transcribe the orders needed for the resident at the facility to determine if there were any changes, new medications or devices when a resident returned to the facility from the hospital. She stated it was important for the nurse to read all of the hospital papers to determine if there were any changes that happened since the resident went to the hospital. The C wing UM indicated the assigned nurse would call the physician to verify the orders. She stated the next day the UM would perform a chart audit using the admission checklist on all newly admitted or readmitted residents along with performing a second head to toe skin assessment. She described the chart (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 86 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few audit would include the UM again checking the paperwork from the hospital for anything pertinent related to the care of the resident including skin, devices like an IV or catheter or even follow up appointments. The C wing UM detailed that on the skin assessment they were to document anything that was not normally found on the skin or going into the skin/body. She stated there were batch orders for IVs and other things that allowed the nurse to place all the needed orders to care and maintain an IV including a PICC. The C wing UM detailed the UMs would hand the audits to the DON and said she assumed they were checking it as well. The C wing UM explained the UMs would then summarize information about the newly admitted or readmitted resident during the clinical meeting every morning. The C wing UM explained the nurse should call the doctor for orders if a resident had a PICC line to determine if the line should be discontinued or implement orders for its care and maintenance. She acknowledged the second skin assessment she documented for resident #72 was inaccurate and stated she did not recall seeing his PICC line on his left arm when she did the second head to toe skin assessment. The C wing UM stated the LPN BB should have called the physician about resident #72's PICC line when she did the admission. She admitted she should have documented the PICC on the second skin assessment she performed and must have overlooked it. She stated she also did not catch it when she reviewed the hospital transfer form and therefore did not call the physician for the necessary orders. The C wing UM explained she was aware of resident #72's PICC and had even spoken to the physician about the PICC the previous week in regard to some labs that were needed but could not explain why she did not ask for orders for its care and maintenance at that time. She admitted she notified the on-call physician on 3/03/24 after being made aware by the State Surveyor there was a resident with an IV that she needed orders for. She acknowledged she did not inform the on-call physician of the details that resident #72 had a PICC that had not received care and services since January. The C wing UM instead received approval to put in the batch orders for resident #72's PICC without the physician knowing all of the circumstances concerning his PICC not receiving care. The C wing UM acknowledged she was aware that resident neglect meant not receiving care and services that were required for a resident's health and wellbeing. She reiterated a PICC needed to be kept clean, with an intact dressing, needed dressing changes and care because it could cause infections like sepsis or an infection in your heart. Review of the Job Description- Unit Manager-RN undated, revealed the UM was responsible for overseeing direct nursing care to assigned residents. The UM assumed responsibility and accountability for the nursing care and services provided on the assigned unit. The UM was also responsible for and adhered to the standards of care for assigned residents and assisted with data collection, monitoring and implementation of physician orders based on individual resident needs. The UM was also responsible for supervising the resident care activity performance by licensed nurses. Essential duties and responsibilities included observing staff and visiting residents to ensure proper nursing care was provided and oversaw the assessments of the resident admission process. On 3/04/24 at 10:03 AM, the B wing UM stated a clinical meeting was held every weekday morning to discuss all new admissions and readmissions. She stated the UMs reviewed the admissions and readmissions to their unit using the information from the hospital paperwork, baseline care plan and the admission audit. She explained the admission audit was completed by the nurse managers after the admission was completed by the assigned nurse. The B wing UM described she checked to verify the physician orders for devices such as IV lines were in place. She explained this was to ensure orders were complete on admission and if they were not she would call the physician to obtain the orders. The B wing UM was unsure if the DON or anyone else looked at the audits once they were completed by the managers. In interviews on 3/04/23 at 11:23 AM and 4:55 PM, the Executive DON stated the UMs submitted the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 87 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0726 Level of Harm - Immediate jeopardy to resident health or safety audits to either the 1st floor or 2nd floor DON. She explained the DONs only ensured the audits were completed but did not check the information on the audits for accuracy. She stated they discussed the new admissions and readmissions at the clinical meeting by reviewing their diagnoses and the plan of care. The Executive DON stated the facility did not have a policy and procedure for PICC lines and stated only an RN could draw blood by PICC line but acknowledged a physician order was needed. She noted it was her expectation the nurse would call the physician about the PICC line and document the conversation. Residents Affected - Few Review of the Clinical Guidelines Manual- admission Orders presented by the facility with effective date of October 2021 revealed the policy admission orders would be obtained/approved through the attending physician following or prior to the resident's admission to the facility. The procedure section described the procedure if returned from the hospital to contact the attending physician if the order read to resume all previous orders, and to assure at minimum the orders contained diet, medication, routine care to maintain or improve functional ability, and code status. The return from the hospital procedure did not give direction specifically to review the orders that came with the transfer. The admitted from the hospital/ER section detailed the procedure to review the transfer orders, contact the attending physician immediately upon admission to review the transfer orders and obtain approval and to obtain further orders as appropriate. In a telephone interview on 3/04/24 at 12:28 PM, the admitting nurse, LPN BB stated she was previously certified to care for intravenous lines and recalled caring for resident #72 in the past several months. She stated when she admitted or readmitted a resident she did a head-to-toe skin assessment and often the supervisor or UM submitted the orders for medications and other treatments. LPN BB described the hospital transfer form was sometimes incorrect, so it was important to do your own assessment of the resident. She explained if you saw a wound or other skin impairment you would let the physician know, and you would document it in the skin assessment. LPN BB acknowledged she had documented the double lumen was present on resident #72 when she completed the Admission/readmit: Data Collection and Baseline Care Plan on 1/10/24 but documented incorrectly the location of the line and failed to document what type of line it was. Although she documented the presence of resident #72's IV she also acknowledged she did not obtain orders from the physician per the batch orders available for the PICC. She stated she could not recall resident #72's PICC, could not recall notifying the physician, nor could she recall assessing resident #72 at all. LPN BB explained a PICC needed orders for care like flushes and if there were no medications ordered for it, the physician would often discontinue the line. LPN BB stated if the nurse saw that a new or readmitted resident had a PICC they were supposed to notify the supervisor since they would be the one to call the physician for orders. LPN BB could not recall ever discussing the PICC with his primary physician or Advanced Practice Registered Nurse (APRN) CC and could not say why she had not notified them herself as she was aware of what type of care the IV required. LPN BB next explained weekly skin checks were completed by the assigned nurse as it was scheduled. She described the process was to look at the resident head to toe and note any new impairments or anything that did not normally belong on their skin. LPN BB stated the nurse should document what they found and complete an incident report for any newly found impairments. On 3/06/24 at 5:32 PM, Registered Nurse (RN) E recalled seeing resident #72 with the PICC in his arm and she acknowledged she had documented having looked at resident #72's left arm per the physician orders. She described that a PICC line should at the minimum have orders to flush it and to change the dressing but could only say it may have slipped her mind that the PICC did not have any orders for care or maintenance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 88 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On 3/06/24 at 5:45 PM, RN B also recalled caring for resident #72 since January. She remembered seeing the PICC in his arm and said in the evenings with two nurses on the unit it was very busy. She explained if she saw an order to do something she would do it but said she might not notice if there was no order for something. RN B said if the PICC dressing did not have a date on the dressing you should look at the orders and call the physician if there weren't any orders. She was unable to say why she did not notice resident #72 did not have a date on his PICC dressing. RN B stated care for the PICC line was important because you would want to treat the resident like you would want someone to care for yourself. Review of the Treatment Administration Record dated January 2024, revealed a physician's order to monitor bruise to left inner forearm and notify the physician of any changes every shift that started on 1/11/24. During the month of January, 23 different nurses documented they had looked at resident #72's left arm and did not notify the physician about his undated/unlabeled PICC line. Review of the Treatment Administration Record dated February 2024, revealed the same physician's order to monitor the bruise to resident #72's left inner forearm and notify the physician of any changes every shift. For February 2024, 22 different nurses documented they had looked at resident #72's left arm and did not notify the physician about his undated/unlabeled PICC line. Review of the Treatment Administration Record for March 2024 revealed 6 nurses documented they had looked at resident #72's left arm per the physician order to monitor the bruise to his left forearm and failed to notify the physician about his undated/unlabeled PICC line that had no orders for care or maintenance. In total 33 different nurses including three UM's and the first floor Director of Nursing (DON) documented they had looked at resident #72's left arm and failed to notice the unlabeled PICC line and notify the physician for orders. On 3/08/24 at 11:52 AM, the Regional Clinical Reimbursement Specialist stated that the facility Clinical Reimbursement Specialists go to the clinical meeting and participate in it to discuss the care plans for new admissions, readmissions, and any other residents with changes in their plan of care. She described that the Clinical Reimbursement Specialists did an order listing review every morning, and they should look at the orders. The Regional Clinical Reimbursement Specialist stated when they did the Minimum Data Set Assessment they were supposed to go and look at the resident for their assessment. She said they should have also assessed resident #72 and it should have been on his Annual MDS on 1/13/24 that he had the PICC. The Regional Clinical Reimbursement Specialist explained the facility Clinical Reimbursement Specialist would have looked at him on 1/10/24 and he should have had a care plan for the PICC. She said they should have seen it then and made a care plan for it. Absolutely, she said. The Regional Clinical Reimbursement Specialist said there was obviously some kind of a problem. In interviews on 3/04/24 at 12:23PM and 1:13 PM, the Staff Development Coordinator (SDC) stated on admission the admitting nurse should put in batch orders for the PICC line. These orders would include flushes every shift and as needed, change of the administration set every 4 days for any IV medications, documentation of site appearance every shift, dressing changes every 7 days and as needed, change the cap every 7 days, change the dressing within 24 hours of admit/insertion, flush each lumen with 10 milliliters of normal saline after each intermittent infusion, for blood draws flush with 10 milliliters of normal saline and to measure the arm circumference. She stated nurses got education on what they were expected to do on admission and there was a class in their electronic learning modules. She described the admitting nurse was supposed to admit the resident in the computer, look at the resident as they meet them, do a hands-on head to toe assessment, then verify the medications with the physician including any batch orders as needed. The SDC explained the UM also did a second skin assessment on each resident on admission/readmission and documented any skin impairment in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 89 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few computer. She acknowledged the C wing UM documented bruises to resident #72's upper left arm and left and right hands but failed to document the PICC in his upper left arm. The SDC acknowledged nurses had said they had drawn labs from the PICC line without any physician orders. She explained, IV certified nurses could draw blood from a PICC line but confirmed they needed a physician order to do so. The SDC also acknowledged subsequent assigned nurses failed to document the PICC in the skin assessments including the first skin assessment on 1/13/24. She stated nurses were aware of the batch orders for PICCs and should have called the physician. On 3/04/24 at 10:24 AM, in a telephone interview APRN CC stated she saw resident #72 frequently at the facility and described herself as the primary provider besides his attending physician. APRN CC stated she had not known resident #72 had a PICC line, nor had she known he had not had any orders for care or maintenance of the line since he arrived at the facility with it on 1/10/24. She described having seen resident #72 just a few days previously for some concerns about constipation. She stated she was not aware resident #72 had the PICC line and was surprised as he had no reason to have it because he did not have antibiotics or any other medication that needed to go through a PICC. APRN CC described the physician ZZ having seen resident #72 on the previous Thursday as well and was adamant she was unaware of the PICC in his left upper arm as well. She explained they had not ordered any antibiotics and stated there was no justification for resident #72 to still have the PICC. She stated 7 weeks and 4 days was a very long time for resident #72 to not have had any care for his PICC, and commented facility staff should have called and gotten orders to either discontinue or care for it. She then explained her, and the physician WW were the primary point of contact for the facility staff and said they primarily called her but could text her as well. She stated no one from the facility had notified her or physician WW about resident #72's PICC not having any care or orders since the facility was made aware the day before on 3/03/24. The APRN CC then asked to stop the conversation and call back later until after she could call physician ZZ to clarify what she knew about resident #72's PICC. A few minutes later APRN CC continued the telephone interview and stated she spoke with physician WW, who told her she also did not know about resident #72's PICC. APRN CC stated if they had known he had a PICC they would have discontinued it. She stated they were going to discontinue it now. APRN CC explained normally she expected facility nurses to notify the physician of the PICC line. APRN CC stated the nurses also did weekly skin checks and should have noticed the PICC and noticed there were no orders for care and notified her or the physician. Further review of resident #72's medical record revealed resident #72 was assessed 9 times by the APRN between his admission on [DATE] and 3/03/24. These progress notes on 1/12/24, 1/13/24, 1/23/24, 1/24/24, 1/26/24, 1/30/24, 2/02/24, 2/07/24, and 2/20/24 had no mention of resident #72's PICC even though cardiac, skin and extremities were documented as assessed. On 3/04/24 at 12:50 PM, in a telephone interview physician WW stated when APRN CC first called her she did not recall resident #72 having the PICC line, but now she remembered he had one. She stated she had talked with the nurse about the line needing to be changed but wanted to deal with resident #72's abdominal pain first. Physician WW was asked if she knew resident #72 had gone for 7 weeks without any care for his PICC and she said she was not aware he didn't have any orders for the PICC since he came into the facility with it in January. Physician WW explained APRN CC saw resident #72 frequently, confirmed APRN CC was supposed to perform and document a complete hands-on assessment of the residents. She stated none of the facility staff had called to inform her or ask for orders for the PICC and also confirmed a physician order was needed for IV certified nurses to use the PICC for blood draws. Physician WW stated she did not know how it happened that resident #72 went for that long without anyone knowing he did not have any orders to care for the PICC. Physician WW said she had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 90 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few looked at the on-call list and there was nothing that showed there were any issues with resident #72's PICC from 3/03/24 when the facility was made aware of the concerns about lack of care. She stated it was important for the PICC to get care because it could cause serious complications. On 3/08/24 at 2:21 PM, the Medical Director stated he was made aware of the issue with resident #72's PICC not having care since his readmission on [DATE]. He stated he expected nurses to obtain orders for care and to notify the physician. The Medical Director stated PICCs were associated with complications like infections and said it was very lucky that resident #72 did not get a central line associated infection or other complication due to this lack of care or maintenance for his PICC. Review of both the undated job descriptions, Licensed Practical Nurse and Registered Nurse revealed both the LPN and RN were responsible for delivering care to residents using the nursing process of assessment, planning, intervention, implementation, and evaluation to maintain standards of professional nursing. The document further described the responsibilities of the LPN and RN which included assess, plan direct, and evaluate total nursing care as determined by the resident's needs in accordance with established standards, policies, and procedures. Another responsibility was to monitor, record and report changes in resident's condition in a timely manner, and to perform physical exams to determine the resident's status and develop a treatment plan. Also to complete and review the admission Data record and to assess the needs of residents to identify potential health or safety problems. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: * A registered nurse removed the PICC from resident #72 on 3/04/24. The site was assessed by the RN and no signs of infection were present upon removal. Resident #72 remained in the facility with no change in condition or signs of distress. *The DON, Assistant DON (ADON) and UMs assessed all 381 residents for intravenous lines including central lines on 3/05/24. There were 6 residents with intravenous lines, including central lines with appropriate orders in place, proper fluids running as ordered and dressings appropriately dated. Each intravenous line site was assessed by an RN with no signs of symptoms of infection present. * The Nurse Consultant educated the DON on 1) clinical care related to intravenous line, including central line, 2) accurately documenting site location, 3) notification to the physician to clarify and obtain orders for the care, maintenance or discontinuance of the line, and 4) initiating the care plan. As of 3/05/24, the DON or designee has provided education to 24 of 114 nurses on 1) clinical care related to intravenous line, including central line, 2) accurately documenting site location, 3) notification to the physician to clarify and obtain orders for the care, maintenance or discontinuance of the line, and 4) initiating the care plan. As of 3/05/24 24 out of 104 registered nurses and LPNs with IV certification have completed competencies related to 1) PICC Catheter removal, 2) Flushing of Vascular Access Device, and 3) Midline/Central Line Dressing Changes. We have a goal of completing education and competencies on an additional 25 nurses by 3/05/24, with the remaining nurses being completed prior to the start of their next shift worked. * The DON or designee will observe each patient with an intravenous line including central line to validate that care, maintenance, or discontinuance has occurred. Any variance identified will result in the immediate reeducation of the licensed nurse. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 91 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Review of in-service education sign in sheets and reconciliation with staff roster validated education was completed according to the facility's plan. 98 of the total 102 nurses at the facility were educated on neglect; assessment, documentation, and monitoring of IV site and dressing; midline/central line dressing change and flushing a vascular device. Additionally, 76 RNs were educated on PICC catheter removal. An ad hoc QAPI was held on 3/06/24 that included the Medical Director. Residents Affected - Few On 3/05/24 a venous doppler to resident #72's left upper arm, an Xray to the left arm and labs were ordered by the physician to ensure no complications such as retained objects or infection after the removal of the PICC. Per interview with the Executive DON these tests resulted as within normal limits. On 3/05/24 through 3/08/24 interviews were conducted with 30 of the nursing staff, including 24 RNs and 6 LPNs, including 6 second shift nurses. All verbalized understanding of the education provided by the facility including neglect; assessment, documentation, and monitoring of IV site and dressing; midline/central line dressing change and flushing a vascular device. The sample was expanded to include all 4 other residents identified with IV lines. No concerns were found regarding these residents including resident #354 who had a tunneled central line in his right chest. 2. On 3/03/24 at 5:34 PM and 3/05/24 at 10:05 AM, RN K stated there were residents on her assignment who had physician orders for blood glucose checks and insulin administration scheduled at 4:00 PM. She confirmed she had not done the task and she did not always do so before dinner as the residents left the unit to eat in the dining room. RN K stated she checked some residents' blood glucose levels after they returned from dinner in the dining room. On 3/04/24 at 1:07 PM, RN GG confirmed he had not checked scheduled pre-lunch blood glucose levels for his assigned diabetic residents and explained he was busy doing other things. RN GG acknowledged blood glucose monitoring and insulin administration were to be completed prior to meals. When asked if he reported he was running late to the Unit Manager, RN GG stated the manager was aware. On 3/06/24 at 11:01 AM, RN E acknowledged she performed blood glucose monitoring after her assigned resident consumed breakfast. She explained blood glucose could be checked and insulin administered either 20 minutes before or after meals. When asked if there would be a difference in the readings, RN E said, .the after meal reading would be higher, but not a really big difference. She was asked to review the physician order for insulin that read, with meals. RN E confirmed the order meant insulin should be given while eating but she reiterated, I know I can do it 20 minutes before or after meals. I have had him before. On 3/06/24 at 12:31 PM, the B Wing UM stated she expected all nurses to know blood glucose monitoring was to be done before mealtime. She stated if residents ate in the dining room, it was the nurse's responsibility to ensure blood glucose was checked before they left the unit. The B Wing UM explained the nurse could remind the resident to see her before going to the dining room. She stated her off[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 92 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #284 was admitted to the facility on [DATE], with his most recent readmission on [DATE]. His diagnoses included chronic obstructive pulmonary disease, chronic respiratory failure, localized swelling, hyperglycemia, major depressive disorder, hypertension, and dependence on supplemental oxygen. On 3/05/24 at 10:35 AM, resident #284 was sitting up in bed watching television. A plastic cup with seven tablets was on his tray table. The resident's assigned nurse, RN B was at the medication cart, outside of the resident's room. RN B came into the resident's room and stated she went out of the room to retrieve something and left the container with medications on the resident's tray table. RN B stated she should have remained with the resident, until he had taken his medications, and acknowledged medications should not be left at the resident's bedside. Review of the resident's Medication Administration Record for 3/05/24 revealed medications included in the resident's 9 AM medication administration and signed off by RN B Included, Duloxetine 30 milligram (mg) for depression, Finasteride 5 mg for enlargement for prostate, Gabapentin 300 mg for neuropathy, Metoprolol 25 mg for high blood pressure, Vitamin C 500 mg for wound healing, Multi-vitamin-minerals for nutritional supplementation, Plavix 75 mg for recent stent, Potassium 20 milliequivalents for low potassium, Eliquis 5 mg, Bumex 2 mg for edema, Ferrous Sulfate 325 mg, Metformin 500 mg for diabetes, Isosorbide Dinitrate 10 mg for angina, and Methocarbamol 500 mg for spasms. On 3/07/24 at 10:55 AM, the 2nd floor DON stated when RN B left the resident's room, she should have taken the container with medications with her. She stated nurses were not supposed to leave medications at the residents' bedside. The facility's policy Medication Administration General Guidelines dated 09/18 read, Medications are administered as prescribed in accordance with manufacturers specification, good nursing principles and practices . The resident is always observed after administration to ensure that the dose was completely ingested. Based on observation, interview, and record review, the facility failed to provide pharmaceutical services related to accurate interpretation of a physician order, (#437); proper acquisition, storage, and administration of medication, (#586); appropriate storage of medications at bedside, (#256); and safe administration of medication according to professional standards, (#284), for 4 of 109 sampled residents. Findings: 1. Review of the medical record revealed resident #437 was admitted to the facility on [DATE] with diagnoses including heart attack, chronic ischemic heart disease, palpitations, and a heart murmur. Review of the Medication Review Report revealed resident #437 had a physician order dated 3/01/24 for Midodrine HCl 5 milligrams (mg) oral tablet, give one tablet by mouth three times daily for hypotension or low blood pressure. The order included a parameter to hold the drug if the resident's systolic blood pressure was greater than 130 millimeters of mercury (mm Hg). The American Heart Association indicates blood pressure is recorded as two numbers, and the first (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 93 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some or upper number, the systolic blood pressure (SBP), measures how much pressure blood exerts against artery walls when the heart contracts (retrieved on 3/11/24 from www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings). Midodrine is a cardiovascular drug that works by constricting blood vessels and increasing blood pressure. It is prescribed to treat low blood pressure which causes severe dizziness or light-headedness that affects daily life (retrieved on 3/11/24 from www.drugs.com/mtm/midodrine.html). Review of resident #437's Medication Administration Record (MAR) for March 2024 revealed Midodrine HCl was scheduled three times daily, at 9:00 AM, 1:00 PM, and 5:00 PM. The document indicated 8 of the 15 doses of Midodrine HCl scheduled between 3/01/24 at 5:00 PM and 3/06/24 at 1:00 PM were either held or administered outside of the parameter provided by the physician. The MAR showed the following: On 3/01/24 at 5:00 PM, the medication was administered despite the resident's SBP of 131 mm Hg. On 3/03/24 at 9:00 AM and 1:00 PM, the medication was held although the resident's SBPs were 120 mm Hg. On 3/03/24 at 5:00 PM, the medication was held for a SBP of 122 mm Hg. On 3/04/24 at 9:00 AM and 1:00 PM, the medication was given although the resident's SBP was 131 mm Hg. On 3/05/24 at 9:00 AM and 1:00 PM, the medication was held despite SBP readings of 120 mm Hg. On 3/06/24 at 11:45 AM, the Executive Director of Nursing reviewed resident #437's medical record and compared the physician order for Midodrine HCl with the MAR. She validated the findings the medication was either incorrectly held for SBPs less than 130 mm Hg or given when SBPs were greater than 130 mg Hg. 2. Review of the medical record revealed resident #586 was admitted to the facility on [DATE] with diagnoses including soft tissue disorder, peripheral vascular disease, need for assistance with personal care, abnormality of gait and mobility, and right side weakness and paralysis. Review of resident #586's Medication Review Report revealed a physician order dated 2/27/24 for Voltaren External Gel 1%, apply to right knee and right shoulder topically twice daily for pain. The physician order did not include dosage or instructions regarding the quantity of the drug to be applied to the areas. Voltaren Arthritis Pain gel contains Diclofenac, a nonsteroidal anti-inflammatory drug, which reduces substances in the body that cause pain and inflammation. Voltaren is used to treat joint pain caused by osteoarthritis. The manufacturer's instructions included use of the enclosed dosing card to measure the correct dose, either 2 or 4 grams depending on the affected area of the body (retrieved on 3/12/24 from www.drugs.com/voltaren-gel.html). On 3/04/24 at 1:19 PM, resident #586 stated she kept Voltaren ointment in her bedside table drawer and applied it to her right knee for pain. The resident's assigned nurse, Registered Nurse (RN) GG checked the resident's bedside table and confirmed there were two tubes of Voltaren in the drawer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 94 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0755 Level of Harm - Minimal harm or potential for actual harm On 3/04/24 at 1:23 PM, RN GG reviewed the medical record and verified resident #586 had a physician order for Voltaren ointment to be applied to her right knee and right shoulder twice daily. He stated he was not aware of the physician order and did not apply the ointment as scheduled at 10:00 AM this morning. RN GG checked the treatment cart and discovered there was no Voltaren ointment for resident #586. He confirmed the resident did not have a physician order related to keeping the ointment at the bedside. Residents Affected - Some On 3/05/24 at 9:40 AM, resident #586 stated she still had her Voltaren ointment in the bedside table drawer, but when she complained of pain this morning, her nurse brought an ointment into her room from the hallway. On 3/05/24 at 9:43 AM, RN D stated earlier in the shift, resident #589 requested Voltaren ointment cream that her doctor ordered for neuropathy in her feet. RN D explained there was no physician order for the medication but the resident complained of pain and numbness in her feet. RN D said, So I applied a little to her bilateral feet and I will call the doctor and get an order. It is a stock med, but needs a prescription. When asked to open the treatment cart and show resident #586's Voltaren, RN G removed the only tube of Voltaren ointment and confirmed she utilized it for the resident. Observation of the label revealed the medication was not labeled with resident #586's name. On 3/05/24 at 9:53 AM, RN D reviewed the medical record and verified the current physician order had instructions to apply the medication to the resident's right knee and right shoulder, not to her feet. On 3/06/24 at 11:09 AM, RN E applied resident #589's scheduled Voltaren ointment at 9:00 AM this morning per revised orders. RN E explained the resident's medication had not yet come in from pharmacy so she borrowed from another resident's supply. She confirmed she did not contact the pharmacy regarding the missing medication. On 03/06/24 at 11:29 AM, the Executive Director of Nursing (DON) was informed despite discussions on 3/04/24 with RN GG and on 3/05/24 with RN D, resident #586 was permitted to continue storing Voltaren ointment at bedside without physician authorization, and the nurses neither made arrangements for the pharmacy to deliver the drug nor contacted the physician for clarification of the missing dosage. The Executive DON was told that on 3/05/24 and 3/06/24, RNs D and E respectively administered Voltaren ointment prescribed for another resident to resident #589. She stated her expectation was nurses would obtain, clarify, and follow physician orders, and ensure medications were requested and obtained from the pharmacy in timely manner. On 3/06/24 at 12:25 PM, the B Wing Unit Manager (UM) stated nurses should obtain and administer medications as ordered and never borrow from one resident for another. She explained it was important to ensure orders were reviewed by the pharmacy to ensure appropriate dosage and frequency of medications, and to prevent harmful interactions and side effects. Review of the facility's policy and procedure for Medication Administration General Guidelines, dated September 2018, revealed medications would be administered according to manufacturer's specifications, good nursing practices, and written orders of the prescriber. The policy indicated if necessary, the nurse would seek clarification from the physician and/or the pharmacy. The document read, Medications supplied for one resident are never administered to another resident. 3. Resident #256 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 95 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0755 chronic obstructive pulmonary disease, respiratory disorders, osteoarthritis, heart failure and sleep apnea. Level of Harm - Minimal harm or potential for actual harm On 3/04/24 at 12:50 PM, resident #256 was observed standing with her walker in the doorway to her room. She stated a nurse came in earlier and told her she was not allowed to have vitamins and supplements in her room. When asked what she had, resident #256 removed a bag from the chair in her room which contained vitamin C, turmeric, zinc, an oxide ointment, multivitamins, calcium and a menthol-based pain relief cream. Resident #256 stated the nurse told her she had to send them home and the facility could provide them for her. Residents Affected - Some Resident #256's medical record did not contain any documentation of the conversation with the resident, resident's representative or the physician. On 3/05/24 at 12:57 PM, the C-Wing UM met with resident #256 who confirmed she had spoken with Licensed Practical Nurse (LPN) A the previous day. Resident #256 reported she still had the supplements in her room and showed them to the C-Wing UM who made a list of them and then removed them from the resident's room. The C-Wing UM stated LPN A should not have left them in the resident's possession. On 3/06/24 at 2:42 PM, LPN A confirmed she was the nurse who had spoken to resident #256 on 3/04/24. She stated resident #256 wanted to keep the supplements and cream and send them home. LPN A explained she allowed the resident to place the items in a bag and left them in the resident's possession. She acknowledged she should have removed the supplements and creams from the resident's room until someone came to pick them up. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 96 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 ensure medications were administered according to physician orders to prevent medication errors for 2 of 6 residents observed during the medication administration task, out of a total sample of 109 residents, (#437 and #584). There were 2 errors in 25 opportunities for a medication error rate of 8%. Residents Affected - Few Findings: 1. Review of the medical record revealed resident #437 was admitted to the facility on [DATE] with diagnoses including heart attack, chronic ischemic heart disease, palpitations, and a heart murmur. On 3/03/24 at 5:31 PM, Registered Nurse (RN) K checked resident #437's blood pressure with an electronic wrist cuff and showed the reading of 122/77. She checked the electronic medical record and explained she would not administer the resident's scheduled 5:00 PM due to parameters given by the physician. RN K said, The blood pressure was okay. Review of the Medication Review Report revealed resident #437 had a physician order dated 3/01/24 for Midodrine HCl 5 milligrams (mg) oral tablet, give one tablet by mouth three times daily for hypotension or low blood pressure. The order included a parameter to hold the drug if the resident's systolic blood pressure was greater than 130 millimeters of mercury (mm Hg). The American Heart Association indicates blood pressure is recorded as two numbers, and the first or upper number, the systolic blood pressure (SBP), measures how much pressure blood exerts against artery walls when the heart contracts (retrieved on 3/11/24 from www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings). Midodrine is a cardiovascular drug that works by constricting blood vessels and increasing blood pressure. It is prescribed to treat low blood pressure which causes severe dizziness or light-headedness that affects daily life (retrieved on 3/11/24 from www.drugs.com/mtm/midodrine.html). Review of resident #437's medical record revealed a care plan for cardiovascular problems was initiated on 3/01/24. The goal was for the resident to have reduced cardiac symptoms, and the interventions included administer medications as ordered and observe for signs and symptoms of hypotension. On 3/06/24 at 11:45 AM, the Executive Director of Nursing (DON) confirmed resident #437's SBP of 122 was below the parameter of 130 mm Hg set by her physician. The Executive DON acknowledged the physician order indicated the resident should have received the scheduled dose of Midodrine as the order indicated it should be held only if the SBP was greater than 130 mm Hg. She stated she expected nurses to administer medications as ordered by the physician. On 3/06/24 at 12:44 PM, RN K acknowledged she should have given resident #437's scheduled 5:00 PM dose of Midodrine on 3/03/24 based on the SBP of less than 130 mm Hg. RN K explained she did not read the instructions carefully. 2. Review of the medical record revealed resident #584 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes with neuropathy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 97 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 3/04/24 at 1:12 PM, RN GG checked resident #584's blood glucose level and obtained a reading of 183 milligrams per deciliter. The resident explained his lunch tray arrived approximately 45 minutes before. On 3/04/24 at 1:15 PM, RN GG administered resident #584's scheduled 12:00 PM dose of Humalog insulin 5 mg. He acknowledged the medication was late and should have been given prior to or on arrival of the resident's meal. Review of the Medication Review Report revealed resident #584 had a physician order dated 2/22/24 for Humalog insulin 5 units subcutaneous with meals for diabetes. Review of the Medication Administration Record for March 2024 revealed the drug was scheduled at 8:00 AM, 12:00 PM, and 5:00 PM. Review of the delivery schedule for meal carts revealed lunch carts were scheduled to arrive on the B Wing, resident #584's unit, between 11:10 AM and 11:20 AM. A care plan for risk for complications of diabetes, initiated on 2/23/24 and revised 3/01/24, revealed the goal to minimize the effects of low or high blood glucose levels. The interventions instructed nurses to administer routine insulin as ordered. On 3/06/24 at 11:36 AM, the executive DON stated her expectation was RN GG would check blood glucose levels and administer insulin with meals as ordered, and within the required timeframe. Review of the facility's policy and procedure for Medication Administration General Guidelines, dated September 2018, revealed medications would be administered as prescribed, in accordance with manufacturers' specifications, and only after nurses familiarize themselves with the medication. The procedures indicated medications would be administered per written physician orders and nurses would contact the prescriber if they needed clarification of orders. The document read, Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 98 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide meals and alternatives that met nutritional needs and food preferences for 1 of 4 residents reviewed for dialysis, (#109); and failed to provide fortified foods to meet nutritional adequacy according to the plan of care for 1 of 10 residents reviewed for food and nutrition services, (#238), out of a total sample of 109 residents. Findings: 1. Review of the medical record revealed resident #109 was admitted to the facility on [DATE] with diagnoses including end stage renal disease with dependence on dialysis, muscle wasting and atrophy, anemia, type 2 diabetes, and severe protein-calorie malnutrition. The Minimum Data Set (MDS) admission assessment with assessment reference date of 2/13/24 revealed resident #109 had adequate hearing, clear speech, and was able to make her ideas and wants understood. The resident had a Brief Interview for Mental Status of 14 which indicated she was cognitively intact. The MDS assessment revealed resident #109 received dialysis treatments and had a therapeutic diet order. A therapeutic diet is ordered by a health care practitioner as part of the treatment for a disease or clinical condition (retrieved on 3/14/24 from www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R36SOMA.pdf). Review of the medical record revealed resident #109 had a care plan initiated on 2/08/24 and revised on 2/11/24, for a nutritional problem or potential nutritional problem related to requiring a therapeutic diet, diagnosis of end stage renal disease, and varied intake. The goal was for the resident to maintain her nutritional intake and current body weight. The interventions included provide diet and fluids as ordered, offer substitutes for refusals, Registered Dietitian to consult and follow as needed, supplements as ordered, obtain and review labs as ordered, observe and document meal consumption and diet tolerance. Review of the Order Summary Report revealed resident #109 had a physician order dated 2/07/24 for meal or snack to be sent with her to dialysis treatments on Tuesdays, Thursdays, and Saturdays. A physician order dated 2/11/24 indicated the resident required a renal therapeutic diet with daily fluid restriction of 1200 milliliters. On 3/04/24 at 1:34 PM, resident #109 stated she went to the dialysis center three days weekly and returned to the facility at about 2:30 PM. She explained on dialysis days, the facility provided a lunch bag with a sandwich and a small container of juice. The resident stated she was usually very hungry when she returned from dialysis as her breakfast tray consisted of only one slice of bread and if she wanted coffee, she had to ask for it. Resident #109 stated staff did not provide a lunch tray or snack when she returned from dialysis, so she remained hungry until her dinner tray arrived. On 3/05/24 at 3:47 PM, resident #109 was seated on the side of her bed. She stated she again received only one piece of toast this morning before she left for dialysis. She confirmed she got a ham and cheese sandwich and a container of apple juice in her lunch bag. The resident pointed to crackers she purchased and the container of juice she saved from her lunch bag and explained she would again (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 99 of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few have to wait for dinner to have a full meal as staff did not save her lunch. When asked about her food preferences, resident #109 confirmed she did not like some breakfast foods like eggs or oatmeal, but she would eat a slice of ham and cold cereal. The resident provided the meal ticket from her breakfast tray that morning. The document was dated 3/05/24 and indicated the resident received one slice of wheat toast, one packet each of jelly, margarine, salt, and pepper, and an 8-ounce cup of coffee. The meal ticket read, Do not send eggs. Review of the Food Preferences form dated 2/08/24 revealed the resident's beverage preferences were coffee for breakfast and apple juice for lunch and dinner. The document listed other preferences as No turkey, fish, chicken. No type of cereal or milk, no eggs. Offer yogurt or cottage cheese for protein. Review of the Comprehensive Nutrition Evaluation dated 2/09/24 revealed the Registered Dietitian (RD) discussed resident #109's food preferences with her and noted the resident did not care for fish, chicken, and turkey for dialysis lunch bag meal. The document indicated resident #109 had increased protein needs and required 83 to 97 total grams of protein per day. On 3/08/24 at 9:13 AM, RD J confirmed she conducted resident #109's comprehensive nutritional assessment on admission and ordered a renal therapeutic diet to meet her needs. RD J stated on 3/05/24, after discussion with the RD at the dialysis center regarding the resident's lab results, she recommended a change from a renal diet to a liberalized diet with large portions of protein. RD J was informed resident #1 only received a slice of toast for breakfast with no protein, and did not get lunch on return to the facility on dialysis days. She stated she was not aware, and if she had been informed, she would have met with the resident to explore other food options. RD J acknowledged resident #109 was not provided with an adequate amount of food and protein based on the requirements identified in her nutritional assessment. On 3/08/24 at 9:33 AM, the Assistant Administrator confirmed it was not appropriate to provide resident #109 with only a slice of toast for the breakfast meal. He stated the kitchen had the capability of reheating her lunch meal on dialysis days, and there were always alternatives available such as grilled cheese sandwiches, deli meat, and chef salads. On 3/08/24 at 9:57 AM, the Food Services Manager stated she was not aware resident #109 received only toast for breakfast or that she was hungry and wanted lunch on return from dialysis. She acknowledged a slice of toast for breakfast every day was unacceptable The Food Services Manager stated if a resident required a renal diet but disliked eggs, the dietitian should be informed. On 3/08/24 at 10:44 AM, the Assistant Food Services Manager acknowledged resident #109 should have been offered alternatives based on her diet order. He confirmed the RD should have been notified that she was not receiving eggs so the resident's meal preferences could have been updated. The Assistant Food Services Manager stated possible alternatives included breakfast meats, deli meats, yogurt, cottage cheese, and vegetarian patties. The facility's policy and procedure for Food Preferences, effective January 2023, revealed food preferences would be obtained on admission and periodically thereafter to promote the provision of .preferred foods to enhance/maintain quality of life and nutritional status. The procedure indicated the Food Services Manager or her designee would obtain communicate with new residents regarding diet order, food preferences, food intolerances, menus and alternate items. The document revealed instructions to notify the RD of any concerns identified during the discussion. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page100of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Review of resident #238's medical record revealed the resident was initially admitted to the facility on [DATE] with systemic involvement of connective tissue, type II diabetes mellitus, pulmonary disease, muscle wasting, and encephalopathy. Review of the quarterly MDS assessment dated [DATE] indicated the resident's cognition skills for memory and decision making were severely impaired and the resident required full assistance with meals. It also noted the resident had a weight loss of 5% or more in the last month or 10% or more in the last 6 months. The quarterly nutrition evaluation dated 12/13/23 indicated the resident's therapeutic diet order included fortified foods and supplements to overcome nutritional deficiencies. On 3/03/24 at 2:07 PM, the resident's meal tray was noted with with no fortified mashed potatoes per the meal ticket. The Certified Nursing Assistant (CNA) T, who was assisted the resident with her meal confirmed the fortified food item was missing. She stated if a food item was missing, she would inform the dietary staff. She explained she did not inform the dietary staff as the dietary manager was not in the facility today but would let her know tomorrow. On 3/04/24 at 2:00 PM, CNA JJ brought the lunch meal tray to resident #238. The tray did not have the fortified mashed potatoes or the health shake per the meal ticket. The CNA acknowledged the items were missing on the meal tray. On 3/04/24 at 2:06 PM, the Food Service Manager stated the Registered Dietitian had previously instructed dietary staff to provide fortified pudding as the fortified menu item for lunch meals instead of fortified mashed potatoes. The Food Service Manager acknowledged the tray did not include any fortified food, neither the pudding nor mashed potatoes. She verified the tray was also missing the health shake and said the dietary department was currently out of health shakes. The Food Service Manager stated fortified foods were needed for residents as they may be at risk for weight loss. On 3/08/24 at 2:13 PM, RD EE, stated dietary staff were trained on the importance of following meal tickets when assembling meals and periodic checks for tray accuracy were completed. She reported there was no written policy regarding the procedure for meal tray accuracy. On 3/08/24 at 2:16 PM, the Executive Director of Nursing (EDON), stated the nurse on duty was to check all trays to ensure the trays had the correct diet before staff delivered the meal trays to the residents' rooms. She explained the staff were expected to compare the tray contents with the items listed on the meal ticket to ensure the residents received what was ordered. She added, if something was missing from the tray, the staff were expected to go to the kitchen to get the missing food item. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page101of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview, the facility failed to ensure food was stored, prepared, and served in a safe and sanitary manner to prevent foodborne illness in the main kitchen and 4 out of 6 pantries. Residents Affected - Many Findings: 1. On 3/03/24 at 11:30 AM, during the initial kitchen inspection the following were observed: A pan of jelly was found partially covered and without a label or date in the walk-in refrigerator #2. A large rack that held 5 sheet pans contained a variety of wrapped sandwiches that were not labeled or dated. The Assistant Food Service Manager KK acknowledged the findings and explained the food items were supposed to be labeled and dated. The Food Service Manager stated the Assistant Food Service Manager KK, was responsible to ensure all stored food items were covered, labeled and dated. The internal thermometer in the walk in refrigerator #3 indicated a temperature of 48 degrees Fahrenheit (F). A carton of half and half cream was not cold to the touch. The Food Service Manager took the temperature of the half and half cream and reported it was 47 degrees F. In the freezer, a melted case of ice cream and a package of unsealed, unlabeled, and undated muffins were noted. A rewrapped package of shredded mozzarella cheese that had melted was also noted. The Food Service Manager acknowledged the cheese had thawed and melted. A dark substance was noted along the upper seam of the interior wall and above the exterior door along with the pipes running into it. The Food Service Manager verified the dark substance and stated an employee was told to clean these areas last Thursday, but it had not been done. Another case of melted ice cream that had refroze was identified. The lids of the ice cream cups were sunk-in, and their exteriors were covered with sticky ice cream. The pipe of the coffee maker in the kitchen was leaking into a pan placed on the shelf underneath the coffee maker. The pipe was covered with a dark substance. The Food Service Manager acknowledged this finding. In the dry storage room, a box containing graham crackers, cookies, and saltine packets contained loose saltine crackers. A plastic storage container held individually packaged salad dressing which had spilled and congealed to the bottom of the container. The scoop for the flour bin had flour caked around its handle and was sitting in the flour at the bottom of the bin. The Food Service Manager acknowledged this finding. The large can racks had a buildup of thick, dark, sticky, substance on them. There was a large piece of brown paper on the floor underneath the racks with an approximate 12 X 15 spill of dried substance with several dead roaches and roach parts on it. The Food Service Manager said the room was cleaned monthly but acknowledged the build-up on the can racks was older than one month. Outside the facility, several used worn medical gloves, plastic bags, dirty food containers, and a dirty towel were on the ground around the compactor. A spray bottle of an unknown cleaning substance without a label was noted which was verified by the Food Service Manager. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page102of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm 2. On 3/07/24 at 11:45 AM, a follow-up kitchen observation revealed several temperatures out of compliance during the tray line: The temperature of the chicken salad ranged between 42-52 degrees F depending on how deep the thermometer was inserted. Residents Affected - Many The milk temperature was 43.4 degrees. The fortified pudding was 48 degrees. The temperature of the plantains was 111 degrees. The Food Service Consultant stated temperatures were taken, but only records of temperatures taken when tray line started were found, not during the tray line. The Food Service Manager stated temperatures were not taken during tray line on routine basis, but only if staff felt like something was not at the required temperature. The Food Service Consultant stated the Food Service Manager was responsible for foods being in a safe temperature range during tray line even though she was working on the tray line and would not be able to take temperatures while assembling trays. 3. On 3/08/24, the H-wing unit pantry/nourishment room was observed at 12:20 PM and contained a tray of dirty breakfast dishes. The H wing Unit Manager (UM) stated when staff brought a meal tray back late after a meal, they were supposed to take it directly to the kitchen and not put it in the unit's pantry. 4. On 03/08/24 at 2:30 PM, the C wing pantry had a damp cloth covering the pipes underneath the sink which was dirty and had a hole. The C wing UM and the Assistant Administrator verified this finding. 5. On 3/08/24 at 4:08 PM, the B-wing refrigerator had an unlabeled and undated thermos in the refrigerator. The ice machine was observed with dirt and stains. There was a hole in the wall behind the baseboard. The B wing UM stated she assumed the thermos belonged to a resident. She acknowledged the disrepair of the wall and baseboards and stated she reported the dirty ice machine to the Food Service Manager a while ago. 6. On 3/08/24 at 4:20 PM, the A wing UM verified there was black substance on the platform of the cabinet under the sink. She stated it was obvious to her it had been like that for a while. She stated she thought the pantry cabinets should not be screwed shut, especially when under a sink or plumbing so their condition could be checked periodically. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page103of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 interview and record review, the facility failed to ensure the medical record reflected actual medication administration time for 1 of 4 residents reviewed for dialysis, (#109), and accurate blood glucose level and insulin administration time for 1 of 6 residents reviewed during the medication administration task, (#584), out of a total sample of 109 residents. Findings: 1. Review of the medical record revealed resident #109 was admitted to the facility on [DATE] with diagnoses including end stage renal disease with dependence on dialysis, heart disease, type 2 diabetes, and gastroesophageal reflux disease. Review of the Order Summary Report revealed resident #109's physician orders included Apixaban 2.5 milligrams (mg) once daily for atrial fibrillation (2/08/24), Loperamide 2 mg once daily for diarrhea (2/14/24), Losartan Potassium 25 mg once daily for high blood pressure (2/07/24), Novasource renal supplement 237 milliliters once daily and record the percentage consumed (2/11/24), Pantoprazole Sodium Delayed Release 40 mg once daily for heartburn (2/07/24), Renal Vitamin 0.8 mg once daily for nutritional supplement (2/11/24), and Zyrtec 10 mg once daily for congestion (3/01/24). Review of the Medication Administration Record (MAR) for March 2024 revealed the above mentioned medications were scheduled to be given at 9:00 AM. The document was initialed on 3/05/24 by Registered Nurse (RN) D to verify she administered all 9:00 AM medications as ordered, except Loperamide which resident #109 refused. RN D's documentation on the MAR showed the resident also consumed 100% of her Novasource supplement at 9:00 AM that morning. On 3/05/24 at 3:47 PM, resident #109 stated she did not get her scheduled morning medications before she left for dialysis. The resident confirmed she had been in her room since she returned from dialysis and still had not seen a nurse. On 3/05/24 at 4:02 PM, resident #109 was in her wheelchair in the hallway beside a medication cart. The resident held a cup in her hand and stated she just received her medications from the nurse. RN D was asked to show resident #109's electronic MAR for the current shift. Review of the computer screen revealed all medications scheduled for 9:00 AM were displayed in green to indicate they were administered. RN D admitted she did not administer the medications at 9:00 AM as ordered and said, I won't lie, I just gave them a while ago. Review of the Administration History Report for 3/05/24 revealed RN D documented she administered resident #109's scheduled 9:00 AM medications at 8:40 AM, and not at 4:00 PM when the task was completed. On 3/06/24 at 11:52 AM, the Executive Director of Nursing (DON) confirmed resident #109's medical record was inaccurate if the nurse documented medication administration times that were not the actual times the tasks were completed. 2. Review of the medical record revealed resident #584 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes with neuropathy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page104of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 Review of the Medication Review Report revealed resident #584 had a physician order dated 2/22/24 for Humalog insulin 5 units subcutaneous with meals for diabetes. Review of the MAR for March 2024 revealed the the resident's Humalog insulin was scheduled at 8:00 AM, 12:00 PM, and 5:00 PM. The document showed on 3/04/24, RN GG documented resident #584's blood glucose level was 216 milligrams per deciliter (mg/dL) at the three times it was monitored throughout the day. On 3/04/24 at 1:12 PM, RN GG checked resident #584's blood glucose level and obtained a reading of 183 mg/dL. On 3/04/24 at 1:15 PM, RN GG administered resident #584's scheduled 12:00 PM dose of Humalog insulin 5 mg. He acknowledged the medication was late as he was busy doing other tasks. Review of the Administration Details for resident #584's Humalog insulin dose revealed on 3/04/24, RN GG's documentation indicated he administered the resident's 12:00 PM dose at 11:02 AM, over two hours before the drug was actually given. On 3/06/24 at 11:36 AM, the Executive DON reviewed resident #584's medical record and verified RN GG's documentation of insulin administration on 3/04/24 at 11:02 AM for a blood glucose level of 216 mg/dL did not accurately reflect observations during the task. She acknowledged it was unlikely the resident had the same blood glucose level on three separate occasions during the shift. On 3/08/24 at 2:26 PM, the B Wing Unit Manager (UM) stated RN GG informed her he documented that he checked resident #584's blood glucose level and administered his schedule insulin although he had not done the task. The B Wing UM explained RN GG did it because he was running behind. Review of the facility's policy and procedure for Medication Administration General Guidelines, dated September 2018, revealed the nurse who administered a medication dose should record the administration on the resident's MAR immediately following the task. The document indicated if a regularly scheduled dose was not administered at the scheduled time, or given at another time, the nurse would note the missed dose and attach a progress note with an explanation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page105of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview, and review of facility documentation, the facility failed to ensure implementation of policies to the extent of including thorough monitoring of previously identified areas of concern and adequately tracking performance to ensure prior improvement measures were realized and sustained. Findings: Review of the facility's policy, Quality Assessment and Assurance (QA&A) Compliance revealed the following: Department Heads/disciplines are required to develop department specific audit plans and report activities and audit findings to the Committee at intervals determined by department specific risk analysis, and at the direction of the Nursing Home Administrator. Audit findings that identify opportunities for improvement are addressed through education, development of a Quality Assurance and Performance Improvement Plan (QAPI) or Performance Improvement Plan (PIP), or other means as indicated. Systems failures and/or in-depth analysis of processes are addressed through development of a QAPI. QAPI requires a systematic review of data, identification of the root cause(s) of the systems failure, and implementation of corrective actions through the use of Plan, Do, Study. Therefore, the facility requires audits at designated time intervals and system failures are addressed within QAPI. Any cited violation of 42 CFR part 483 and 488, requirements for Long Term Care Facilities would constitute a systems failure. The facility had deficiencies of F623, F755 and F812 in the last recertification survey of 5/5/22. In the course of this survey, the following deficiencies were again identified, F812, F623 and F755. As a result of these repeat citations, it was identified there was insufficient auditing and oversight of the mentioned citations During an interview of the Executive Director on 3/8/24 at approximately 1:23 PM, he stated in their facility QAPI reviews, they had not been aware of the discrepancies found concerning transfer forms (F623). He stated they performed consistent monitoring of food sanitation, food storage, kitchen equipment and other dietary concerns but he could not explain how they missed the concerns identified in F812. He stated they performed consistent audits of medication related concerns and they had not identified any recent trends of medication variances. He stated they would have identified any unattended medications at a resident's bedside but noted they had not caught it with the current citation of F755. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page106of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 adhere to proper infection control practices related to hand hygiene during lunch meal service on 1 of 6 units, (B Wing). Residents Affected - Few Findings: On 3/03/24 at 12:23 PM, the lunch meal cart arrived on the B Wing and staff pushed it towards the first hallway to be served. On 3/03/24 at 12:27 PM, Certified Nursing Assistants (CNAs) G and L opened the door of the meal cart and removed trays without performing hand hygiene. They entered room [ROOM NUMBER] and placed the trays on both residents' tables. While in the room, they removed the plate covers, opened containers, and used the residents' utensils during set-up of the meal. Both CNAs left the room and returned to the meal cart, but neither CNA G nor CNA L performed hand hygiene before removing the next trays, although there were containers of hand sanitizer located on the walls nearby. On 3/03/24 at approximately 12:30 PM, CNA L entered room [ROOM NUMBER] with a lunch tray and performed meal set up while CNA G entered room [ROOM NUMBER] and stayed to assist a resident with the meal. On 3/03/24 at approximately 12:33 PM, CNA L exited the room, walked past the hand sanitizer dispenser in hallway, and retrieved another tray from the cart without performing hand hygiene. She then crossed the hallway, knocked on a door, and looked into the room, but did not enter. She returned the lunch tray to the meal cart and selected another tray which she took to room [ROOM NUMBER]. CNA L placed the tray on the overbed table for bed B and opened containers and cut the food with the resident's utensils as she set up the meal. On 3/03/24 at approximately 12:35 PM, CNA L returned to the meal cart after she again passed a hand sanitizer dispenser without performing hand hygiene. She retrieved another lunch tray and took it into room [ROOM NUMBER]. CNA L continued distributing lunch trays to residents in room [ROOM NUMBER] bed A and room [ROOM NUMBER]. On 3/03/24 at approximately 12:39 PM, CNA L was prompted to pause delivery of lunch trays and informed she had not sanitized her hands at any time during the task. CNA L acknowledged she did not wash or sanitize her hands before starting meal distribution or between providing trays for residents. When asked if hand hygiene was necessary during this task, CNA L said, No. I was not really touching anything. On 3/03/24 at approximately 12:40 PM, CNA G was informed she did not perform hand hygiene prior to or between handling meal trays. She verified staff were supposed to perform hand hygiene during distribution of trays. On 3/03/24 at 12:49 PM, the Staff Development Coordinator (SDC) validated staff were expected to perform hand hygiene between distributing trays, either by washing hands with soap and water or using hand sanitizer, for infection prevention and control purposes. The SDC explained it was essential for staff to perform hand hygiene before and after delivering trays or assisting with meal set up as there was the possibility for cross-contamination related to touching the meal cart, room doors, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page107of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 residents, and items on overbed tables or the tray. Level of Harm - Minimal harm or potential for actual harm Review of the job description for a Certified Nursing Assistant, dated 7/01/19, revealed essential duties and responsibilities included passes food trays using safe and sanitary measures (following infection control guidelines). Residents Affected - Few Review of the facility's policy and procedure for Hand Hygiene, effective October 2021 read, The facility considers hand hygiene the primary means to prevent the spread of infections. The procedure revealed Employees must perform hand hygiene before and after handling food or assisting a resident with meals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page108of109 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 105728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, and interview, the facility failed to maintain mechanical, and electrical equipment in the kitchen in safe operating condition. Residents Affected - Some Findings: On 3/03/24 at 12:30 PM, dietary staff on the tray line assembling meal trays stood in a large, approximately 6 feet wide by 12 feet long, pool of water on the floor. The Food Service Manager stated there had been 2 leaks in the tray line but one was fixed a few weeks ago and she was waiting for their equipment contractor to fix the second leak. On 3/07/24 at 11:45 AM, the dietary staff were observed on tray line assembling trays while again, standing in a pool of water approximately 6 feet wide by 12 feet long due to the leak from the steam table well. The Food Service Manager explained the repair company came to the facility on 3/04/24 but could not repair the steam table as a part was needed. She stated the first repair to the steam table was 3 months ago and the repair company did not have time to repair the second leak during that visit. She stated she had been trying to get the leak repaired since then. She noted when the repair company came on 3/04/24, they did a different repair, but did not have time to fix the steam table leak. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page109of109

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Citations

33 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0550GeneralS&S Epotential for harm
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
0554GeneralS&S Dpotential for harm
F554 - The right to self-administer medications if the interdisciplinary team, as
Allow residents to self-administer drugs if determined clinically appropriate.
0560GeneralS&S Dpotential for harm
F560 - The right to refuse to transfer to another room in the facility, if the purpose
Protect a residents' right to refuse some types of non-requested transfers within the nursing home.
0561GeneralS&S Dpotential for harm
F561 - Self-determination
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
0578GeneralS&S Dpotential for harm
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
0584GeneralS&S Epotential for harm
F584 - Safe Environment
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.
0585GeneralS&S Dpotential for harm
F585 - Grievances
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
0600SeriousS&S Jimmediate jeopardy
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
0609GeneralS&S Dpotential for harm
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
0610GeneralS&S Dpotential for harm
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
0623GeneralS&S Epotential for harm
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
0644GeneralS&S Dpotential for harm
F644 - Coordination
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
0645GeneralS&S Dpotential for harm
F645 - Preadmission Screening for individuals with a mental disorder and individuals
PASARR screening for Mental disorders or Intellectual Disabilities
0657GeneralS&S Dpotential for harm
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
0677GeneralS&S Epotential for harm
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
0679GeneralS&S Epotential for harm
F679 - Activities
Provide activities to meet all resident's needs.
0684SeriousS&S Jimmediate jeopardy
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0686GeneralS&S Dpotential for harm
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
0688SeriousS&S Gactual harm
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
0689GeneralS&S Dpotential for harm
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
0690GeneralS&S Epotential for harm
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
0693GeneralS&S Dpotential for harm
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
0695GeneralS&S Dpotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0698GeneralS&S Dpotential for harm
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
0726SeriousS&S Jimmediate jeopardy
F726 - Nursing Services
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
0755GeneralS&S Epotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0759GeneralS&S Dpotential for harm
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
0803GeneralS&S Dpotential for harm
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
0812GeneralS&S Fpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0842GeneralS&S Dpotential for harm
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
0867GeneralS&S Epotential for harm
F867 - Program feedback, data systems and monitoring
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
0880GeneralS&S Dpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0908GeneralS&S Epotential for harm
F908 - Maintain all mechanical, electrical, and patient care equipment in safe
Keep all essential equipment working safely.

FAQ · About this visit

Common questions about this visit

What happened during the March 8, 2024 survey of ORLANDO HEALTH AND REHABILITATION CENTER?

This was a inspection survey of ORLANDO HEALTH AND REHABILITATION CENTER on March 8, 2024. The surveyor cited 33 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at ORLANDO HEALTH AND REHABILITATION CENTER on March 8, 2024?

Yes, 33 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

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Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Health inspection·March 8, 2024