Inspection·April 21, 2022

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide care and services for midline Intravenous (IV) catheters according to standards of practice and plan of care for 2 of 3 residents reviewed for IV catheters of a total sample of 46 residents, (#59 and #67). Residents Affected - Some Findings: 1. Resident #59 was admitted to the facility on [DATE], and most recently re-admitted on [DATE] from an acute care hospital. His diagnoses included acquired end stage renal disease, lymphedema, history of Methicillin Resistant Staphylococcus Aureus infection, diabetes mellitus and diabetic peripheral angiopathy. Review of the Minimum Data Set Five-day assessment with assessment reference date [DATE] revealed resident #59 had a Brief Interview for Mental Status score of 14 which indicated he was cognitively intact. Additionally, the assessment revealed the resident did not reject care from staff and received dialysis. On [DATE] at 10:05 AM, resident #59 was seated in his wheelchair waiting for transportation to dialysis. A midline IV catheter was visible to his right upper arm. The clear adhesive dressing was not dated and unlabeled, with a piece of clear tape across the bottom holding the dressing down. The resident stated he had not received any medications in the IV for about a week and he didn't know why he still had the midline. His right hand was swollen, and the resident explained it had been like that for about a week. A midline catheter is put into a vein by the bend in your elbow or your upper arm . The midline tube ends in a vein below your armpit .midline catheter may allow you to receive long-term IV medicine or treatments .(retrieved [DATE] www.drugs.com). On [DATE] at 4:37 PM, resident #59 was awake and alert, sitting up in bed. He had the midline IV in his right upper arm with the clear dressing that was undated and unlabeled with clear tape on the bottom edge of the dressing. There was dark brown blood in the tubing. He explained the doctor told him the IV should be removed since it was not being used, and said, No one has done it. On [DATE] at 12:11 PM, resident #59's wife was at the bedside. He had the same midline IV catheter in his right arm with the clear dressing undated and dried blood still in the tubing. The resident reported the nurse hadn't looked at his IV at all today, and no one had changed the dressing for a while. Resident #59's wife stated she asked staff last week why he still had the IV, but they never gave her an answer. On [DATE] at 12:16 PM, the Assistant Director of Nursing (ADON) acknowledged the resident's unlabeled and undated midline IV catheter with the dark brown blood in the tubing underneath the dressing. She indicated the dressing should have been dated and initialed by the nurse and that nurses were responsible to assess the IV catheter site every shift. The ADON reviewed resident's physician orders and stated there were no active orders for midline IV. She conveyed there were no orders for flushes, dressing changes, or assessments. She noted resident #59's midline IV catheter was inserted at the beginning of April and the nurse who entered the order for the midline did not enter any orders for the care of the midline IV. The ADON explained orders to assess the midline catheter and IV site (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105731 If continuation sheet Page 2 of 8 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 105731 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Commons at Orlando Lutheran Towers 210 Lake Avenue Orlando, FL 32801 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and dressing changes would normally be a part of the care nurses provided for a midline IV. She said the resident had orders for IV antibiotics and flushes but those orders expired after antibiotic therapy was completed. The ADON indicated the protocol was for the nurse to ask the physician for orders to discontinue the IV when the IV antibiotic medications were completed. She said if the IV was to be left in place, orders would be given for flushes, dressing changes and assessments. The ADON acknowledged midline IV catheters were an infection risk, especially for someone who received hemodialysis. They ADON confirmed there was no documentation in the resident's medical record to indicate the midline catheter dressing was changed or assessed since it was inserted on [DATE]. Review of resident'#59's Medication Administration Record (MAR) revealed an order completed for Have midline inserted every evening shift until [DATE] 23:59 which started on [DATE] at 3:00 PM. The MAR showed orders for antibiotic and flushes which the resident received via midline IV catheter on [DATE] through [DATE]. There were no other orders documented by nurses in April for midline IV catheter care including dressing changes, or for nurses to assess the midline catheter for infection or complications. Resident #59 had a care plan for intravenous lines, Receiving IV therapy and at risk for complications,the type of IV access was left blank. The goal was for resident #59's IV line to remain patent and have no complications. Interventions for resident #59's IV line were for staff to administer fluids as ordered, educate resident and family about central line associated bloodstream infection prevention, explain purpose of IV and procedure prior to start, observe for complications, dislodgment of IV catheter, swelling, redness, pain, separation of IV lines, shortness of breath, drainage or soiled IV dressing, phlebitis, infiltration, or bleeding. Further interventions included Provide IV site care as ordered. Review of the Nurse Progress Notes revealed no documentation of midline IV catheter dressing changes or assessments from the date the midline catheter was inserted on [DATE] until the line was discontinued on [DATE]. On [DATE] at 11:37 AM, Licensed Practical Nurse, (LPN) C said she had cared for resident #59 on the previous Monday and Tuesday shifts. She stated she knew to check the IV catheter based on the report she received from the previous nurse or based on the orders in the computer. She confirmed standard orders for midline IV catheters included flushes, and assessment of the IV catheter site usually every shift. LPN C explained when the IV medications were complete, she knew to call the physician and ask if midline was to be discontinued. She indicated she did not get report on the previous Monday or Tuesday about the IV catheter from the previous shift and there were no orders in the electronic record for the care of the IV. She that if the resident had an IV, that should be communicated by the nurses in the shift change report. She stated, That is something you would tell the next nurse, part of the information you would give and expect to get. On [DATE] at 12:04 PM, LPN D said she usually cared for resident #59 on her assignment. She reported he had the midline catheter inserted at the beginning of April to receive IV antibiotics for a urinary tract infection. LPN D explained she thought midline IV catheter dressings should be changed every seven days and the dressing needed to be labeled with a date and initialed. LPN D recalled the past Sunday that resident #59 still had the IV so she told the night nurse during report to call the doctor and get order to discontinue the IV but did not explain why she did not call the physician herself. LPN D noted the night nurse did not do it. LPN D stated the nurse should know to call the physician and get the IV discontinued when the IV medication order was completed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105731 If continuation sheet Page 3 of 8 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 105731 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Commons at Orlando Lutheran Towers 210 Lake Avenue Orlando, FL 32801 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On [DATE] at 10:50 AM, the Director of Nursing (DON) stated the nurse should put in the orders for care of the midline IV catheter when it was inserted. She said for a clear dressing on a midline IV catheter such as resident #59's, the standard of care was to change the dressing every five to seven days or more often as needed. She conveyed a midline catheter was supposed to be flushed at least daily if no meds were going through it, and nurses should assess the site every shift for problems with the IV or the dressing. The DON explained if the nurse found a problem with the midline IV catheter such as patency, they would call the contracted IV team to come in and assess the line. She explained nurses should not use tape to hold down the IV dressing, instead the dressing should be changed, dated, initialed and documented in the medical record. She acknowledged that while the IV was not being used for medications, it would still need care from nurses such as flushing the line, changing the dressing, and assessing the IV for signs and symptoms of infection or other complications. She explained the IV team came on the evening of [DATE] to see resident #59's midline IV catheter once it had been brought to their attention by the surveyor. She stated the IV team was not able to salvage resident #5''s midline IV catheter because of dried blood in the line. Review of the Insertion of Peripheral IV Catheter dated 4/17 revealed general guidelines to, change dressing and perform site care if dressing becomes soiled, is no longer intact. The guidelines indicated the label on the dressing should include the date and time of dressing placement, initials, gauge size and length of catheter. The document directed that the IV catheter should be removed when there is suspected contamination, complication or when therapy is discontinued. Review of the document, Flushing Midline and Central Line IV Catheters dated 4/17 revealed the general guideline that midline IV catheters will be flushed at regular intervals to maintain patency. Review of the document Midline Dressing Changes dated 4/17 revealed general guidelines to change midline catheter dressing every five to seven days or more often it is wet, dirty, not intact or compromised in any way using sterile technique. The document also instructed staff to record the date and time the dressing was changed in the resident's medical record along with the signature and title of the person recording the data. 2. Resident #67 was admitted to the facility on [DATE] from an acute care hospital with diagnoses including recent sepsis, acute stress reaction and brain abscess. She had a Midline IV line inserted [DATE] in the right arm for administration of IV antibiotics and the line was re-inserted in the same location on [DATE] as it was not functioning properly. She received Merrem (IV antibiotic) every 6 hours for brain abscess through [DATE]. There was a prior order dated [DATE] to discontinue PICC (peripherally inserted central catheter) line but no new orders were entered post Midline IV insertion [DATE] or [DATE] regarding new IV type and care. There were prior orders in effect dated [DATE] for catheter site dressing changes every week and as needed that were not specific to the type of IV present nor the location. On [DATE] at 10:35 AM, resident #67 was observed sitting up in wheelchair at the bedside. She had a gauze dressing with transparent dressing over the right upper arm midline IV site. There was no visible date noted on the IV dressing. The resident was alert and oriented to person and place. She said, I was receiving IV antibiotics for brain infection. On [DATE] at 9:35 AM, resident #67 was observed sitting up in wheelchair and the midline IV in her right upper arm appeared same as yesterday's observation. There was no date on gauze dressing and the IV insertion site could not be visualized due to the presence of gauze. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105731 If continuation sheet Page 4 of 8 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 105731 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Commons at Orlando Lutheran Towers 210 Lake Avenue Orlando, FL 32801 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On [DATE] at 10:15 AM, Registered Nurse (RN) B was in the resident's room and observed the residents's midline dressing on right upper arm without a date. RN B validated observation of gauze dressing present without date and stated, when gauze is present dressing should be changed at minimum every 2 days. On [DATE] at 10:25 AM, the Unit Manager (UM) stated the resident had a midline inserted in her right arm on [DATE] and due to complications, she had another visit by the IV team on [DATE]. The UM added, the IV team would have applied new dressing on [DATE]. The UM indicated she could not find any evidence in the medical record to show the nurses changed IV site since [DATE]. The UM said she thought that if gauze was present then the IV site dressing needed to be changed every 2-3 days. On [DATE] at 10:45 AM the UM provided the facility policy for Midline Dressing Changes and validated the policy was to change dressing every 2 days/48 hours if gauze present. The UM added, the reason an IV site should be changed at least every 2 days as there was increased risk of infection due to moisture when gauze was present On [DATE] at 10:57 AM, the DON said the standard of practice was for nurses was to change gauze dressing every 48 hours and transparent film dressing every 5-7 days. The DON added, the nurses should have changed it 24 hours after the initial insertion and re-insertion of IV because there could be blood on the gauze which could lead to increased risk infection if not removed. According to the facility Midline Dressing Changes policy dated [DATE], Change midline catheter dressing 24 hours after insertion if placed with gauze .Use a sterile, transparent, semi-permeable membrane (TSM) or gauze dressing. If gauze dressing is used cover with a TSM dressing and change the dressing every 48 hours . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105731 If continuation sheet Page 5 of 8 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 105731 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Commons at Orlando Lutheran Towers 210 Lake Avenue Orlando, FL 32801 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 ensure respiratory therapy was administered as per physician orders for 1 of 3 residents reviewed for oxygen (O2) therapy of a total sample of 46 residents, (#29). Residents Affected - Few Findings: Resident #29 was admitted to the facility on [DATE] with diagnoses to include dementia, Parkinson's disease, morbid obesity, and dependence on supplemental oxygen. Review of the resident's physician orders revealed an active order dated 2/28/22 for oxygen via nasal canula (n/c) at 2 liters/minute. On 4/19/22 at 1:43 PM, resident #29 was observed lying in bed without oxygen nasal canula nor any oxygen at the bedside. On 4/19/22 at 3:15, the Unit Manager (UM) acknowledged resident #29 was not receiving oxygen and the oxygen concentrator was across the room against the wall. She stated the oxygen was ordered as needed (PRN) and the concentrator was in the room in case the resident needed it. The UM reviewed the physician orders and acknowledged resident #29 should have been on oxygen at 2 liters via n/c continuously. She stated the resident was on hospice and continued to review the chart for a hospice order for prn oxygen . The UM was only able to find documentation in the hospice care plans and comprehensive assessment which indicated the resident was on 2 liters of oxygen prn. She stated, no, these are not orders. On 4/19/22 at 3:50 PM, the Director of Nursing (DON) reviewed resident #29's physician orders and reported an order dated 2/28/22 for oxygen at 2 liters n/c continuous. The DON stated the nurse probably forgot to add the continuous when the oxygen orders were ordered. Review of resident #29's care plans revealed a care plan for altered respiratory status/difficulty breathing related to shortness of breath. The goal noted the resident would not experience complication related to shortness of breath with an intervention to administer oxygen at 2 liters as ordered. Review of the Treatment Administration Record for April 2022, revealed an order for Oxygen via n/c at 2 liters/min every shift. The start date was 2/28/22, which the nurses signed every shift as being administered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105731 If continuation sheet Page 6 of 8 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 105731 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Commons at Orlando Lutheran Towers 210 Lake Avenue Orlando, FL 32801 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to prevent medication administration error rate of 5% or greater for 2 of 8 residents sampled for medication administration, (#279 and #84). There were 2 medication errors in 27 opportunities for a medication error rate of 7.41%. Residents Affected - Few Findings: 1. On 4/18/22 at 9:17 AM, Licensed Practical Nurse (LPN) A prepared resident #279's scheduled medications. He removed 1 tablet Multivitamin (MTV) with Mineral from the cart stock medication bottle and placed it in a pill cup with the resident's other oral medications. He then proceeded to administer the medications to the resident who was in her room. Review of the medical record for resident #279 revealed she was admitted to the facility on [DATE]. A current physician order dated 4/14/22 was for MTV give 1 tablet by mouth one time a day for supplement. The order did not include Mineral to be given with MTV. On 4/18/22 at 11 AM, LPN A in the presence of the 7th floor Unit Manager (UM) showed his medication cart drawer only contained MTV with Mineral and no plain MTV. The UM acknowledged LPN A made a mediation error by giving the cart stock MTV that also contained mineral as the order was for plain MTV. LPN A indicated he was not aware there was difference between plain MTV and MTV with Mineral. 2. On 4/18/22 at 11:25 AM, Registered Nurse (RN) B was observed checking resident #84's blood sugar which was 312. RN B stated, since the resident's blood sugar is over 100 he can have insulin. RN B proceeded to prepare the insulin pen Admelog SoloStar 100 units/milliliter (ml) and dialed the dose to 10 units. RN B then administered 10 units of insulin subcutaneous (SQ) into the resident's left abdomen. Admelog is a fast-acting mealtime insulin that works to control blood sugar when you eat. (https://www.admelog.com) Review of the medical record for resident #84 revealed he was re-admitted to the facility on [DATE] with diagnosis including diabetes mellitus (DM) type 1. A current physician order dated 2/11/22 was for Admelog SoloStar Solution Pen-Injector 100 units/ml SQ one time a day at 1 PM for DM without complications. On 4/18/22 at 1:04 PM, the 7th floor UM reviewed resident #84's physician orders and stated, I do not know why the nurse gave 10 units prior to lunch as he is supposed to get 14 units of insulin after lunch at 1 PM. The UM validated the nurse gave the wrong dose of insulin at the wrong time. On 4/18/22 at 1:46 PM, RN B stated, I got confused because they just recently changed his insulin orders and we usually give insulin prior to meals not after. The UM added, the nurses should check the orders in the electronic medical record (EMR) and if not clear then double check the paper chart. On 4/21/22 at 10:50 AM, the Director of Nursing acknowledged the 2 medication errors regarding resident #279 and #84. She indicated the facility had plain MTV and MTV with Minerals on hand for medication cart stock and that nurses needed to triple check their medications to avoid errors. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105731 If continuation sheet Page 7 of 8 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 105731 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Commons at Orlando Lutheran Towers 210 Lake Avenue Orlando, FL 32801 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility's policy and procedures for Medication Administration General Guidelines revised April 2018 read, Medications are administered as prescribed in accordance with good nursing principles and practice Five Rights- Right resident, right drug, right dose, right route and right time Medications are administered in accordance with written orders of the prescriber Medications are administered within 60 minutes of scheduled time, except before, with or after meals orders, which are administered based on mealtimes Event ID: Facility ID: 105731 If continuation sheet Page 8 of 8