Inspection·October 15, 2025

F 0600 Level of Harm - Actual harm Residents Affected - Few plexiglass partition. Nurse notified Supervisors, Physicians, family and 911 was called. The resident was transferred to the hospital for evaluation.*10/05/25 at 8:13 PM - Resident returned to the facility. Hospital records showed bilateral hand x-rays were negative for fractures; a right-hand laceration required no sutures. Resident was restless and reported pain in the right hand. Tramadol was administered. A Transfer Form dated 10/05/25 revealed the reason for transfer to the hospital was behavioral symptoms (e.g. agitation, psychosis). Review of ED (Emergency Department) Provider Notes dated 10/05/25 revealed resident #6 presented to the ED by EMS (Emergency Medical Services) from [facility's name] after they reported he was punching plexiglass and sustained lacerations to both of his hands. The document included, On initial evaluation of the patient he stated that he was locked up and was not allowed to go to the bathroom for an hour and a half. Patient stated that this frustrated him and he hit his hands on the door. He is unable to provide any other meaningful history. Review of the psych provider note dated 10/06/25 read, Patient is a [AGE] year old male . able to make needs known. He is unable to answer some questions during assessment due to cognitive impairment secondary to dementia. Patient was transferred to ER (Emergency Room) last night, returned to facility after a few hours, no change in psychotropics. Patient is unable to recall event, and when prompted denies any negative mental or emotional effect from event. Nursing reports agitation, combativeness, restlessness, and physically aggressive behavior worse at night. Nursing reports frequent attempts to get up independently to urinate at night, agitation with redirection attempts. On 10/13/25 at 8:54 AM, during a telephone interview, Registered Nurse (RN) J stated resident #6 was combative at times but said staff generally managed with redirection and calm communication. She indicated he had been on 1:1 due to falls. She recalled when she started her shift at 7:00 PM on 10/05/25, resident #6 was in the hospital. She stated the day shift nurse reported resident #6 was agitated, broke the plexiglass partition by the nurses station and was sent to the ER. She stated resident #6 returned from the hospital around 8:00 PM and CNA A continued the 1:1 with him until 11:00 PM. RN J stated the hospital paperwork showed resident #6 sustained no fractures and no stitches were required. RN J mentioned when she returned to work the following night, she learned the video footage showed CNA A smashed resident #6's hand with the door and staff in the unit did not intervene. On 10/13/25 at 9:25 AM, during a telephone interview, resident #6's responsible party and Power of Attorney (POA) stated he was informed on Sunday 10/05/25 resident #6 got hurt, was bleeding profusely and was sent to the ER for evaluation. He indicated there were minimal details of how he got hurt during the initial report. He stated he received another call from the facility the following day, when the true story emerged. The POA stated he was asked to press charges against CNA A because the act was deliberate. He said he was hesitant to press charges but was reassured the video footage of the incident was watched several times, including by law enforcement. The POA noted resident #6's hands were swollen with a cut on four fingers of his right hand. On 10/13/25 at 12:10 PM, during a telephone interview, CNA D stated she worked 3:00 to 11:00 PM on 10/05/25 providing 1:1 for a resident in room [ROOM NUMBER]. She reported she observed CNA A close the door to resident #6's room while the resident struggled trying to open it. She indicated she heard the resident yell and later saw the resident exit his room holding a bloody brief. She recalled the nurse telling her it was the assigned 1:1 staff responsibility to deal with the behaviors. She stated the resident she was assigned to care for asked her to close the door because it was too noisy outside. The CNA explained she received a call from the facility the following day asking for details about what happened that Sunday. She stated she received another call on Tuesday when she was informed she was suspended and last night she learned she was terminated. She stated she could not understand their reason as she was not supposed to leave her assigned (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 2 of 9 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 10/15/2025 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 - Actual harm Residents Affected - Few 1:1 resident and she reported what she saw to the floor nurse. CNA D indicated the Executive Administrator (ENHA) and Executive Director of Nursing (EDON) told her she was supposed to report the incident to them, but she claimed she did not know this was the process. On 10/13/25 at 12:35 PM, RN G confirmed she was one of the weekend supervisors on duty on 10/05/25. She explained she responded to a page for supervisor assistance after the other weekend supervisors had arrived in the unit. She recalled entering resident #6's room and observing two nurses dressing resident's hands. She stated resident #6 was agitated. She explained she was told resident #6 became aggressive and broke the plexiglass partition by the nurses station. She stated she ensured documents were ready for EMS and contacted the weekend's DON. She indicated she gave blank witness statements to the staff in the unit and instructed them to complete them. She stated CNA A was reassigned to sit by the nurses station and monitor the broken plexiglass until maintenance arrived. On 10/13/25 at 12:51 PM, during a telephone interview, RN H validated he was one of the weekend supervisors on duty on 10/05/25. He reported being paged to the unit after the incident and observing the resident anxiously standing in front of the nurse' station with blood on his hand. He was not aware of earlier behavioral escalation or that the resident had been confined in his room. He recalled handing blank witness statements for staff to complete. On 10/13/25 at 1:06 PM, CNA K stated he worked as 1:1 for resident #6 from 7:00 AM to 3:00 PM on 10/05/25. He shared resident #6 needed assistance with most ADLs but could verbalize his needs. He indicated resident #6 became easily frustrated and required patience. CNA K said, Most of his (resident #6) frustrations come in the afternoon. He stated he returned to work two days later and learned CNA A supposedly closed the door on his fingers intentionally, which was caught in camera. CNA K shared he asked resident #6 what happened on his knuckles and the resident told him someone closed the door on him. On 10/14/25 at 10:04 AM, during a telephone interview, resident #11's daughter confirmed she visited her mother on 10/05/25. She stated while looking for her mom, she noticed resident #6 was agitated and bleeding on his hand. She shared resident #6 was trying to open and close a door while repeatedly saying he was bleeding. She shared she walked to the nurses station and told the nurses the resident was bleeding, but the nurses did not react, they are always looking down, like looking at a cell phone. She said that made her angry, and she thought what could have happened. She shared she was nervous. She stated she saw a female employee holding a door and the nurses at the desk ignored the situation. She shared she had to tell them look at him! She shared later that day she noticed the plexiglass was missing at the nurses station. She stated she was asked about her observations during the incident the following day. On 10/14/25 at 5:20 PM, the first floor Administrator (NHA) stated she received a text from RN G a few minutes before 5:00 PM on 10/05/25 asking for maintenance to repair the plexiglass in the secured unit because of an incident. The NHA indicated when she read the message, she called RN G who informed her resident #6 was combative, broke the plexiglass partition, his hand was bleeding, and he was going to the ER for further evaluation. She explained a Maintenance Assistant took care of the broken plexiglass before resident #6 returned to the facility. She explained she was off the Monday after the incident, but the ENHA called her and informed her what they had uncovered in the video. On 10/14/25 at 5:46 PM, during a telephone interview, RN M stated she responded to a page for supervisor assistance in the secure unit. She recalled observing pieces of plexiglass on the floor and at the desk by the nurses station. She indicated resident #6 was sitting in a wheelchair screaming. She stated CNA A told her he was very aggressive. She shared other residents around the nurses station were getting anxious so they [NAME] resident #6 to his room, where he was bleeding profusely, and she performed wound care. RN M mentioned she was confused when she noticed blood in resident #6's room but none on the plexiglass. She stated he had a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 3 of 9 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 10/15/2025 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 - Actual harm Residents Affected - Few cut on three fingers of his right hand and a cut on his left forearm. She recalled CNA A standing next to her and resident #6 pointed at them and said, you hit me, you hit me. She stated she told resident #6 she just got there. She noticed everyone in the unit was scared, and resident #6 was anxious and upset. She indicated Licensed Practical Nurse (LPN) B told her he did not know what happened because he was passing medications and she noticed his medication cart down the hallway. On 10/15/25 at 12:44 PM, the Medical Director stated he learned about the incident involving resident #6 on Sunday 10/05/25. He indicated resident #6 was sent to the ER to ensure there was no additional trauma besides the laceration to his bilateral hand and forearm. He shared he evaluated resident #6 the next day and found him at his baseline, severe cognitively impaired. He indicated the ENHA and EDON informed him they were reviewing the video footage because of discrepancies in the staff's statements. He mentioned he asked about the training CNA A had received and was told her education included dementia, redirection, and what to do when a patient was agitated. He stated training was not an issue. He said, this building has it challenges and they were trying to implement a culture of reporting, if you see something say something. He mentioned the culture of not speaking up was one of the missing pieces in this incident as no one who witnessed the incident shared anything. He stated they learned what happened through the cameras. He indicated resident #6 sustained soft tissue trauma but could have sustained fractures. On 10/13/25 at 3:07 PM, during an interview with Risk Manager O and the ENHA, Risk Manager O stated she was reviewing the video to determine how the plexiglass partition broke, when she saw CNA A holding the door of resident #6's room and his hand stuck on the door. She indicated when resident #6 exited his room, he was holding a brief and was bleeding. ENHA stated CNA A had expressed fear of the resident and claimed to close the door for self-protection. The ENHA indicated after reviewing the video, staff actions were inconsistent with facility policy and all staff on the unit that day were first suspended then terminated for failure to intervene. The ENHA added the facility nor the police thought CNA A's life was in danger, hence why she was arrested. Later on 10/15/25 at 1:25 PM, the ENHA stated they recognized how severe this incident was and treated it as such. Review of the facility's security system by the survey team showed the following:*On 10/05/25 at 3:44 PM, resident #6's room door was closed from the inside, unable to see who closed it.*On 10/05/25 at 3:45 PM, LPN B went into the resident's room and exited within 20 seconds. *On 10/05/25 at 3:46 PM, CNA A exited resident #6's room and immediately held the door shut. Resident #6 struggled to get door open. CNA A faced camera, smiling. LPN B went into the nurses' station, across resident #6's room.*On 10/05/25 at 3:47 PM, LPN B returned and stood by the medication cart while CNA A continued to hold the door closed.*On 10/05/25 at 3:47 PM, resident #6's fingers were caught on door while CNA A continued holding the door shut. *On 10/05/25 at 3:47 PM, CNA C walked from the activity room with a bag of linen in her hands toward where CNA A was holding the door handle. CNA C stopped by CNA A who was holding the door handle. CNA C appeared to say something to CNA A.*On 10/05/25 at 3:49 PM, CNA A let go of the door handle, resident #6 opened the door, spots of blood could be seen on the privacy curtain and the door frame. Resident #6 stood by door holding a brief on his bleeding right hand. LPN B brought wheelchair and positioned it in front of resident #6. Resident #6 placed hands on the wheelchair and grabbed Styrofoam cup with water in the wheelchair and threw it on the floor. LPN E and Registered Nurse (RN) F were sitting at the nurses station eating, did not get up to respond or assist.*On 10/05/25 at 3:49 PM, resident #6 walked toward another room without assistive device, unsteadily gait observed.*On 10/05/25 at 3:50 PM, a visitor alerted LPN E and RN F who were still sitting at the nurses' station. RN F stood up from her chair, remained in nurses' station. *On 10/05/25 at 3:51 PM, resident #6 approached nurses station, held on to plexiglass which broke and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 4 of 9 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 10/15/2025 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 - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete after a few seconds resident #6 let it drop to the floor. Resident #6 threw brief he was holding onto the nurses station.*On 10/05/25 at 3:52 PM, RN F on the phone while LPN B placed his hands on resident #6's shoulders. CNA L stood by resident #6 and LPN B. *On 10/05/25 at 3:55 PM, resident #6 was assisted to wheelchair by CNA L and LPN B. On 10/05/25 at 3:55 PM, RN M arrived at the unit. A few seconds later, RN H (weekend supervisor) and the Manager on Duty (MOD) arrived at the unit.*On 10/05/25 at 3:56 PM, RN F on the phone. Resident #6 taken wheeled to his room.*On 10/05/25 at 3:56 PM, LPN B entered room with dressing supplies; MOD also entered resident's room. Blood observed on the floor by nurses station.*On 10/05/25 at 3:58 PM, RN G (weekend supervisor) arrived. *On 10/05/25 at 4:05 PM, EMS (paramedics) arrived in the unit.*On 10/05/25 at 4:10 PM, resident #6 was wheeled out of his room, transferred to stretcher by EMS, dressing noted on his right hand and on his left hand extending to the forearm. A few minutes later, resident #6 left the unit with EMS. Review of the job description for the Certified Nursing Assistant (CNA) dated 7/1/19 showed the CNA was responsible for assisting residents with direct care under the supervision and guidance of licensed nurses (RN or LPN). The Essential Duties and Responsibilities included to report all observed or reported incidents of potential abuse, neglect or accidents immediately to their direct supervisor, manage combative residents while maintaining self-esteem and avoid injury to self and residents., respect the rights of each resident according to the Resident [NAME] of Rights, foster and support a culture of compliance and did not engage in abuse or neglect. Review of the job description for the Licensed Practical Nurse (LPN) not dated showed the LPN reported to Unit Manager (RN). The Essential Duties and Responsibilities included to supervise CNA staff, monitor all aspects of residents care, report all observed or reported incidents of potential abuse, neglect or accidents immediately to the direct supervisor, and manage combative residents while maintaining self-esteem and avoiding injury to self and residents. The form revealed LPN had the authority to suspend individuals from work for rule violations. Review of the job description for the Registered Nurse (RN) not dated showed the RN reported to the Unit Manager (RN/DON). The Essential Duties and Responsibilities included to monitor all aspects of residents care, observe the residents and surroundings; identify changes in resident's behavior or conditions, report all observed or reported incidents of potential abuse, neglect or accidents immediately to the direct supervisor, and manage combative residents while maintaining self-esteem and avoiding injury to self and residents. The form revealed the RN supervised LPNs and CNAs, enforced facility policies with authority to issue Disciplinary Action Reports as needed and the authority to suspend individuals from work for rule violations. Review of the Facility assessment dated [DATE] revealed over 30% of residents had cognitive disabilities, including dementia. The form showed 47% residents had psychiatric disorders, and 7% exhibited aggressive behaviors. Review of the Abuse Prevention Program policy and procedure reviewed in September 2025 revealed physical abuse included controlling behavior through corporal punishment or a restraint not required to treat the resident's symptoms. The document showed staff was instructed to report concerns, incidents, and grievances and how to provide protection for residents. Event ID: Facility ID: 105728 If continuation sheet Page 5 of 9 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 10/15/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to report an allegation of physical abuse to the Agency for Health Care Administration (AHCA) in a timely manner for 1 of 5 residents reviewed for abuse, of a total sample of 12 residents, (#6). The failure to immediately report prevented prompt protective measures to residents and delayed the reporting to state authorities.Findings: Cross Reference F600 Review of resident #6's medical record revealed he was originally admitted to the facility on [DATE] and readmitted on [DATE] after hospitalization. His diagnoses included dementia with behavioral disturbances, mood disorder, history of urinary tract infections, weakness, reduced mobility, anxiety, repeated falls, and stroke. Review of the Minimum Data Set (MDS) significant change in status assessment with Assessment Reference Date of 8/02/25 revealed a Brief Interview for Mental Status score was not obtained because resident #6 was rarely or never understood. The MDS assessment noted behavioral symptoms not directed toward others which did not interfere with his care or participation of activities. The MDS assessment showed this behavior did not put others at risk and did not intrude on the privacy of others. The MDS assessment noted resident #6 needed substantial assistance from staff for eating and oral hygiene and was dependent on staff for transfers, toileting hygiene, shower/bath, upper & lower body dressing, put on/off footwear, and personal hygiene. Resident #6 had functional limitation in range of motion on his bilateral upper and lower extremities. Review of resident #6's medical record revealed a care plan for impaired cognitive function/dementia, revised on 8/06/25. Another care plan for behaviors, revised on 10/07/25 revealed resident #6 was on one to one (1:1) supervision, combative with staff, impulsive and refused care and medications at times. The interventions directed staff to speak softly and clearly when communicating and allow time to communicate effectively. Review of resident #6's Kardex (care plan used by Certified Nursing Assistants (CNAs)) revealed interventions such as to observe and report changes including resistance to care. Review of Progress Notes in resident #6's medical record showed the following entries:*10/05/25 at 6:29 AM - Resident combative during the care, attempting to hit staff, and refusing hydration.*10/05/25 at 5:16 PM - At approximately 3:30 PM, resident was observed screaming at other residents and staff, then struck the nursing station plexiglass partition. Nurse notified Supervisors, Physicians, family and 911 was called. The resident was transferred to the hospital for evaluation.*10/05/25 at 8:13 PM - Resident returned to the facility. Hospital records showed bilateral hand x-rays were negative for fractures; a right-hand laceration required no sutures. Resident was restless and reported pain in the right hand. Tramadol was administered. Review of ED (Emergency Department) Provider Notes dated 10/05/25 revealed resident #6 presented to the ED by EMS (Emergency Medical Services) from [facility's name] after they reported he was punching plexiglass and sustained lacerations to both of his hands. The document included, On initial evaluation of the patient he stated that he was locked up and was not allowed to go to the bathroom for an hour and a half. Patient stated that this frustrated him and he hit his hands on the door. He is unable to provide any other meaningful history. On 10/13/25 at 8:54 AM, during a telephone interview, Registered Nurse (RN) J stated resident #6 returned from the hospital around 8:00 PM and CNA A continued the 1:1 with him until 11:00 PM. She stated the hospital paperwork showed resident #6 sustained no fractures and no stitches were required. She mentioned when she returned to work the following night, she learned the video footage reviewed by management showed CNA A smashed resident #6's hand with the door, staff in the unit did not intervene, and someone was arrested. On 10/13/25 at 12:10 PM, during a telephone interview, CNA D confirmed she saw CNA A trying to close the door for resident #6's room from the outside and when she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 6 of 9 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 10/15/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some released the door, he came out holding a brief. She recalled the nurse told CNA D to close the door and it was the assigned 1:1 staff to deal with whatever. She stated the resident she was assigned to care for asked her to close the door too because it was too noisy. She explained she received a call from the facility the following day asking for details of what happened on Sunday. She shared on Tuesday she received another call and was informed she was suspended and last night she learned she was terminated. She stated she could not understand their reason as she was not supposed to leave her assigned 1:1 resident and she reported what she saw to the nurse. CNA D indicated the Executive Administrator (ENHA) and Executive Director of Nursing (EDON) told her she was supposed to report what she saw to them, but she claimed she did not know. On 10/13/25 at 12:35 PM, RN G confirmed she was one of the weekend supervisors on duty on 10/05/25. She recalled entering resident #6's room and observing two nurses dressing resident's hands. She stated resident #6 was agitated. She explained she was told resident #6 became aggressive and broke the plexiglass partition by the nurses station. She indicated she gave blank witness statements to the staff in the unit and instructed them to complete them. She stated CNA A was reassigned to sit by the nurses station and monitor the broken plexiglass until maintenance arrived. On 10/13/25 at 12:51 PM, during a telephone interview, RN H validated he was one of the weekend supervisors on duty on 10/05/25. He reported being paged to the unit after the incident and observing the resident anxiously standing in front of the nurse' station with blood on his hand. He was not aware of earlier behavioral escalation or that the resident had been confined in his room. He recalled handing blank witness statements for staff to complete. On 10/14/25 at 10:04 AM, during a telephone interview, resident #11's daughter confirmed she visited her mother on 10/05/25. She stated she noticed resident #6 was agitated and bleeding on his hand. She shared resident #6 was trying to open and close a door while repeatedly saying he was bleeding. She shared she walked to the nurses station and told the nurses the resident was bleeding, but the nurses did not react, they are always looking down, like looking at a cell phone. She said that made her angry, and she thought what could have happened. She shared she was nervous. She stated she saw a female employee holding a door and the nurses at the desk ignored the situation. She shared she had to tell them look at him! On 10/14/25 at 5:46 PM, during a telephone interview, RN M recalled observing pieces of plexiglass on the floor and at the desk by the nurses station when she arrived at the secure unit. She indicated resident #6 was sitting in a wheelchair screaming. She stated CNA A reported resident #6 was very aggressive. RN M mentioned she was confused when she noticed blood in resident #6's room but none on the plexiglass. She recalled CNA A standing next to her and resident #6 pointed at them and said, you hit me, you hit me. She stated she told resident #6 she just got there. She noticed everyone in the unit was scared, and resident #6 was anxious and upset. She indicated Licensed Practical Nurse (LPN) B told her he did not know what happened because he was passing medications and she noticed his medication cart down the hallway. On 10/13/25 at 3:07 PM, during an interview with Risk Manager O and the ENHA, Risk Manager O stated she was reviewing the video to determine how the plexiglass partition broke when she saw CNA A holding the door of resident #6's room and his hand stuck on the door. She indicated when resident #6 exited his room, he was holding a brief and was bleeding. ENHA stated CNA A had expressed fear of the resident and claimed to close the door for self-protection. The ENHA indicated after reviewing the video, staff actions were inconsistent with facility policy and all staff on the unit that day were first suspended then terminated for failure to intervene. The ENHA added the facility, nor the police thought CNA A's life was in danger, hence why she was arrested. The ENHA explained they contacted each employee by telephone and offered the opportunity to make an addendum to their statements, and each was informed the facility had reviewed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 7 of 9 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 10/15/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some video, and all but one declined. Later on 10/15/25 at 1:25 PM, the ENHA stated they recognized how severe this incident was and treated it as such. Review of the facility's investigation revealed the following Witness Statements were collected: *Interview of resident #6 by Risk Manager O on 10/06/25 - She locked me in my room. She did not let me out. She closed the door on my fingers. *CNA A - she did not receive report and did not know what to expect when I went into the room . Resident #6 seemed very anxious and very combative. Resident #6 noticed a resident passing by and walked quickly to say something to her. Once he got up, I knew he was trying to leave the room so I tried to intervene by stopping him. Resident #6 became verbally aggressive toward me, he began hitting me repeatedly and I became afraid for my life. I called for help and ran out of the room to protect myself . tried to open the door and his hand caught in the door he began to bleed. He managed to get out of the room and started yelling. I could not calm him down. resident #6 broke the glass by the nursing station with his bare hands. She included resident #6 was calmed down, his nurse arrived at the scene to stabilize his wound and 911 was contacted while resident was escorted back into his room. *CNA I wrote she was doing a one-on-one (1:1) supervision, was inside a resident's room when she heard a lot of noises. She stepped out of the room and saw a resident standing up by the nursing station and she said call the supervisor. He was agitated. *CNA C wrote she saw CNA A holding resident #6's door. She told CNA A to stop, to open the door, and call for help. CNA C statement read, And I remember I called the nurse for her because she still hold the door. CNA C went into a room and continued providing personal care to one of her assigned residents. Another statement by CNA C, collected on 10/06/25 via phone call by Risk Manager O, read, I was assigned to G Wing back area. As I was passing, I saw [CNA A's name] holding the door, I said, If he's agitated why don't you ask for help. I then went to assist another resident that needed to be changed. *Resident #11's visitor statement, obtained by Risk Manager O on 10/6/25 read, I came in to see my mother and she was not in her room. The nurse stated she was in the dining/activity area. As I was walking toward the dining/activity area, I noticed a resident bleeding and I stated to the nurses in the nurses' station he's bleeding. They did not respond. *LPN B wrote that on 10/05/25 at approximately 3:30 PM, resident #6 was screaming at other residents and staff. The resident punched the plastic protector at the nursing station. Supervisors, physicians, and family were notified, 911 was called, and the resident was to the hospital for evaluation. *RN F wrote that at approximately around 4:00 PM while she was at the desk, it was brought her attention when resident #6 was trying to run out of his room to attack another resident and his CNA, he jammed his fingers in the doorway of his room. She added she went to assess the scene, and resident #6 had quickly ran out of his room and was yelling. Trying to calm him down seemed impossible as he seemed very anxious, was violent and verbally aggressive. I noticed patient was bleeding as he was belligerently hitting the glass at the nursing station until he broke it completely with his bare hands. I called for back up and did my best to calm him but he would not and he did not even notice he was bleeding profusely. I placed a call to 911. By the time I got off the phone with the 911 operator I grabbed dressing supplies to go reinforce the effort being made by the nursing staff to stop [resident #6's name] bleeding and to dress his injured hands. [Resident #6's name] calmed down and was safely transferred to the hospital. *LPN E wrote she was at the nursing station when resident stormed out of his bedroom with bloody hands, and broke the glass at the nursing station and tried to grab (whatever) he could. Supervisor came, restrained him took him back to his room, and took care of the injury. *The EDON interviewed CNA D via phone call on 10/06/25 and wrote, On 10-5-25 I was assigned 1:1 with 1109 I saw the CNA holding the door of 1101 and I told the nurse to go help the CNA. He refused and told me That is why the patient is on one to one. The EDON wrote another (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105728 If continuation sheet Page 8 of 9 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 10/15/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete statement of her phone conversation with CNA D which read, While speaking with [CNA D's name] I asked her what did she do when she saw the CNA holding the door She stated she told the nurse the CNA needed help and he (the nurse) told me, That is why the patient is on one to one. She also stated that the nurse [LPN B's name] told her to close the door of the resident (1106) because he was making too much noise and she then went into the room with the resident and closed the door. Review of the facility's security system did not show CNA A frightened or resident #6 running or punching the plexiglass partition by the nurses station. The video showed LPN B and CNA C saw CNA A holding resident #6's door closed with resident #6 inside his room, while he was trying to open it and get out. LPN E and RN F were sitting at the nurses station, across resident #6's room, and did not respond or intervene until a visitor alerted them to look at the resident. Review of resident #6's Observation Sheet dated 10/05/25 showed CNAs assigned for 1:1 observation were required to initial and document resident behaviors using codes every 15 minutes. CNA A initialed the form at 3:45 and 4:00 PM and used codes 4 (aggressive toward residents) and 12 (combative). CNA A documented hospital from 4:15 to 7:45 PM. She initialed and documented codes 1 (in room lying in bed) and 2 (calm) from 8:00 to 10:45 PM. Review of the Immediate Nursing Home Federal Report submitted by Risk Manager (RM) O to AHCA on 10/06/25 at 3:02 PM revealed an allegation of physical abuse for resident #6. The report showed the incident occurred on 10/05/25 at 3:46 PM and the ENHA, EDON and RM became aware of the incident on 10/06/25 at 11:33 AM while performing a camera review of the incident. The report read, As I was reviewing, I saw CNA [CNA A's name] holding the door to 1101B closed, I saw the door close on resident's fingers and when he came out of the room, he was bleeding holding a towel. He then walked to the nurse's station and was holding onto the plexiglass to maintain his balance and it came loose. The report mentioned resident #6 sustained no fractures of his hand or fingers but had scratches on his right four fingers from the door and scratches on his forearms from the plexiglass. Review of CNA A's timecard revealed she worked on Sunday 10/05/25 until 11:34 PM. She returned to work on Monday 10/06/25 from 6:57 AM until 1:00 PM. Review of her assignment showed she cared for 10 residents until approximately 11:15 AM when the video footage was reviewed by management and she was removed from the unit. On 10/15/25 at 12:44 PM, the Medical Director stated he questioned who CNA A was and the kind of training she received. He stated he learned she had received required education, so training was not an issue. He mentioned the culture of not speaking up was one of the missing pieces in this incident as none of the staff working in the secured unit that day reported anything. He stated they learned what happened through the cameras. Review of the job descriptions for CNA, LPN, and RN staff revealed each was required to report potential abuse immediately to their supervisor. Review of the Abuse Prevention Program policy and procedure reviewed in September 2025 revealed physical abuse included controlling behavior through corporal punishment or a restraint not required to treat the resident's symptoms. The document showed staff was instructed to report concerns, incidents, and grievances and how to provide protection for residents. Event ID: Facility ID: 105728 If continuation sheet Page 9 of 9