Inspection·March 28, 2024

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident #84 had contracture of his right hand and verbalized that the assessment was inaccurate. The LPN MDS Coordinator said she coded for limitation in ROM for the resident's lower extremity but did not accurately assess/code ROM to the resident's upper extremity. The facility did not have a policy pertaining to accuracy of assessment, but stated they followed the directives of the Resident Assessment Instrument (RAI) Manual. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 dated October 2023 GG0115 read The intent of GG0115 is to determine whether functional limitation in range of motion (ROM) interferes with the resident's activities of daily living or places them at risk of injury. The RAI defined functional limitation in range of motion as Limited ability to move a joint that interferes with daily functioning (particularly with activities of daily living) or places the resident at risk of injury. Coding instructions were, Code 0, no impairment, if resident has full functional range of motion on the right and left side of upper/lower extremities. Code 1, impairment on one side: if resident has an upper-and/or lower extremity impairment on one side that interferes with daily functioning or places the resident at risk of injury. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105731 If continuation sheet Page 2 of 12 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 03/28/2024 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 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** 2. Resident #82, a [AGE] year-old female was admitted to the facility on [DATE], with her most recent readmission on [DATE]. Her diagnoses included end stage renal disease (ESRD), peripheral vascular disease, cardiomyopathy, hypertensive heart, chronic kidney disease with heart failure with stage 5 chronic kidney disease, chronic systolic (congestive) heart failure, and venous thrombosis and embolism. Hemodialysis is a procedure that uses a machine to do the job of your kidneys. The machine pumps your blood through a dialyzer, or artificial kidney. The dialyzer filters fluid, salts, and waste from your blood. Once they are removed, clean blood from the dialyzer returns to your body through a vein. (retrieved on 4/08/24 from drugs. com). Review of the quarterly MDS assessment dated [DATE], revealed the resident's cognition was moderately impaired with a Brief Interview For Mental Status score of 9 out of 15, and the assessment noted the resident received dialysis. The resident's physician's orders dated 7/01/23, directed staff to give all medications at least 6 hours prior to hemodialysis (HD) or after returning, and on 8/04/23, revealed the resident's dialysis days were Monday/Wednesday/Friday, and chair time was 11:30 AM. Review of the resident's Medication Admin Audit Report for her dialysis days in March 2024, revealed the following medications were administered between 7:56 AM and 10:00 AM, approximately one to three hours prior to dialysis on March 1st, 4th, 6th, 8th, 11th, 13th, 15th, 18th, 20th, 22nd, 25th, and 27th. Liquid protein 30 milliliters, Sevelamer carbonate 800 milligram (mg) 2 tablets for chronic kidney disease, Carvedilol 12.5 mg, Losartan Potassium 25 mg for high blood pressure, and Levothyroxine 112 microgram (mcg) for hypothyroidism. The medications were not given at least 6 hours prior to dialysis as per the physician's order. On 3/27/24 at 2:40 PM, RN E stated the resident went out to dialysis three days per week, Monday, Wednesday, and Friday. RN E stated the resident received her medications between 8 AM to 9 AM, and her dialysis chair time was at 11:30 AM. The resident's physician orders were reviewed with RN E, and she acknowledged physician order dated 7/01/23 directed staff to give all medications at least 6 hours prior to Hemodialysis or after returning. RN E stated the order was a standard order, and she did not know what the facility's protocol was if the order was not carried out. On 3/27/24 at 2:58 PM, LPN B stated the physician order for medication to be given at least 6 hours prior to dialysis was a standing order for residents on dialysis, and the order populated to the resident(s) MAR. She said the order should be carried out, and if staff was unable to do so, the physician should be notified, so adjustments in the medication administration schedule could be made. On 3/28/24 at 11:04 AM, the resident's physician orders, and the Medication Admin Audit Report for the period 3/01/2024 through 3/27/2024 were reviewed with the DON. She acknowledged that the resident's medications were not administered as per physician order on the days the resident had dialysis. A care plan for ESRD with dialysis was created on 10/19/22 with revision on 8/02/23. An intervention initiated on 11/26/22 was give all medications at least 6 hours prior to HD or after returning. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105731 If continuation sheet Page 3 of 12 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 03/28/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The policy Medication Administration -General Guidelines dated April 2018 read, Medications are administered in accordance with written orders of the prescriber. Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to assure accurate receiving and dispensing of a high-risk antipsychotic medication for 1 of 8 residents observed for medication administration, (#8) and failed to ensure medications were administered per physician's order prior to hemodialysis for 1 of 1 resident reviewed for dialysis, (#82), of a total sample of 48 residents. Findings: 1. Review of the medical record revealed resident #8 was admitted to the facility on [DATE] from the hospital. His diagnosis included schizoaffective disorder, bipolar, Alzheimer's disease, dementia, type II diabetes, and stage 4 kidney disease. Resident #8's admission Minimum Data Set (MDS) with an assessment reference date of 2/26/24 revealed the resident scored 13 out of 15 on the Brief Interview for Mental Status which indicated he did not have any cognitive impairment. The MDS assessment indicated resident #8 required moderate assistance from the staff with transfers. The admission MDS also noted the resident did not exhibit behavioral symptoms or rejection of care that is necessary to achieve the resident's goals for health and well-being. Resident #8's admission MDS assessment revealed the resident received high risk medications that included antipsychotic and antidepressant medications. Review of resident #8's medical record revealed that a care plan was initiated on 2/21/24 which indicated the resident used psychotic medications related to schizophrenia and bipolar disorder and the interventions included to administer psychotropic medications as ordered by a physician. On 3/26/24 at 9:41 AM, Registered Nurse (RN) A administered aripiprazole 20 milligrams (mg) tablet along with Vraylar 4.5 mg capsule to resident #8 during the medication administration observation. The pharmaceutical strip pack noted the resident's name, aripiprazole 20 mg and Vraylar 4.5 mg, to be administered on Tuesday, 3/26/24. A record review post medication administration observation of resident #8's order summary report and the medication administration record (MAR) revealed the provider ordered aripiprazole 20 milligrams (mg) by mouth once a day for antipsychotic to be discontinued on 2/26/24 and the provider then prescribed Vraylar 4.5 mg by mouth once a day for antipsychotic to start on 2/27/24. Aripiprazole and Vraylar are antipsychotic medications that are used to treat schizophrenia. There are moderate interactions with using aripiprazole and Vraylar together. Using aripiprazole with Vraylar together may increase side effects such as drowsiness, blurred vision, dry mouth, heat intolerance, flushing, decreased sweating, difficulty urinating, abdominal cramping, constipation, irregular heartbeat, confusion, and memory problems. Side effects are more likely to occur in the elderly .The recommended maximum number of medicines in the 'antipsychotics' category to be taken concurrently is usually one, (Retrieved on 4/05/24 from www.Drugs.com). On 3/26/24 at 10:28 AM, RN A checked resident #8's MAR and discovered that aripiprazole had been discontinued on 2/26/24. She acknowledged that she administered aripiprazole during the medication administration observation at 9:41 AM and she also indicated that she administered it the day before. She confirmed that she should not have administered aripiprazole to the resident since it was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105731 If continuation sheet Page 4 of 12 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 03/28/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm discontinued. RN A conveyed she should have checked the MAR to ensure that the medication matched the physician order before administering it. RN A observed that aripiprazole was also in the medication cart and was included in the resident's medication regimen for the next day. She reiterated that aripiprazole should not be included in the pharmacy strip pack for the resident since it had been discontinued on 2/26/24. Residents Affected - Some On 3/26/24 at 11:00 AM, the Licensed Practical Nurse (LPN) Supervisor on the 200 unit accessed resident #8's electronic medical record and stated that aripiprazole was discontinued on 2/26/24. She indicated that the pharmacy delivered strip packs for resident #8 on Mondays, Wednesdays, and Fridays, each containing a two-day supply of medications. She stated that the most recent medication strip pack delivered by the pharmacy was on Monday 3/25/24 that contained aripiprazole and Vraylar among others. She confirmed that aripiprazole should not have been administered by RN A on 3/26/24 and that it should not have been included in the pharmacy strip pack that was scheduled to be administered on Tuesday, 3/26/24 and Wednesday, 3/27/24. She emphasized that nurses are required to verify the resident's medications in the medication cart against the physician's orders on the MAR before administering them. On 3/27/24 at 8:50 AM, the Director of Nursing (DON) confirmed that aripiprazole 20 mg was discontinued on 2/26/24 and should not have been given to the resident. The DON acknowledged that RN A should have checked the MAR before giving the medication. She conveyed that prefilled medication strip packs are delivered in trays from the pharmacy on Mondays, Wednesdays, and Fridays that contain a two-day supply of medications and were placed in the medication cart by the pharmacy and the nurse on duty. She confirmed when a medication was discontinued, it would automatically interface with the pharmacy informing them of the discontinued medication. She stated that aripiprazole should not have been delivered by the pharmacy. She also reiterated when a nurse verifies a medication, the nurse was expected to ensure the medications align with the physician orders on the MAR before administering them. She mentioned if there was not a physician order for a medication that was included in the strip pack, the nurse must not administer the medication, should remove the medication from the strip pack, and notify the supervisor and the provider. On 3/27/24 at 2:13 PM, the Pharmacy Operations Manager stated that on 2/26/24 they received an order from the facility to discontinue aripiprazole and on 2/27/24 received an order to start Vraylar. She conveyed that orders are entered into the operating system by a tech and then reviewed and verified by the pharmacist for accuracy. She also conveyed if a medication is discontinued, the pharmacy is to discontinue it from the resident's profile. She confirmed that aripiprazole continued to be delivered on Mondays, Wednesdays, and Fridays for a month after it was discontinued and that it should not have been sent out after the discontinued date of 2/26/24. She acknowledged that the discontinued aripiprazole remained on resident #8's profile until 3/27/24 and that both aripiprazole and Vraylar were delivered to the resident in the pharmacy strip packs until 3/27/24. The Pharmacy Operations Manager acknowledged the potential adverse reactions for aripiprazole would be drowsiness, leukopenia, neutropenia, hyperglycemia, and extrapyramidal systems such as Parkinsonism, dystonia, and tardive dyskinesia. The Pharmacy and Facility's Medication Orders policy read, Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe .Any dose or order that that appears inappropriate .is verified by nursing with the attending physician. The Pharmacy and Facility's Preparation and General Guidelines policy read, The medication administration record (MAR) is always employed during medication administration. Prior to administration of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105731 If continuation sheet Page 5 of 12 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 03/28/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm any medication, the medication and dosage schedule on the resident's medication administration record are compared with the medication label. If the label and MAR are different and the container has not already been flagged indicating a change in directions, or if there is any other reason to question the dosage of directions, the physician's orders are checked for the correct dosage schedule. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105731 If continuation sheet Page 6 of 12 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 03/28/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure pharmacy recommendations were acted upon in a timely manner for 1 of 5 residents reviewed for unnecessary medications, of a total sample of 48 residents, (#82). Findings: Resident #82, a [AGE] year-old female was admitted to the facility on [DATE], with her most recent readmission on [DATE]. Her diagnoses included end stage renal disease, peripheral vascular disease, cardiomyopathy, hypertensive heart and chronic kidney disease with heart failure with stage 5 chronic kidney disease, chronic systolic (congestive) heart failure, venous thrombosis and embolism. A pharmacy recommendation dated 10/17/23 indicated the resident received levothyroxine at 9:00 AM, and the recommendation was to administer 112 micrograms (mcg) as a single dose on an empty stomach, and read, Consider dosing at 6 am. Levothyroxine is used in adults and children to treat hypothyroidism (underactive thyroid-a condition where the thyroid gland does not produce enough thyroid hormone). Directions included, Take levothyroxine tablets and capsules on an empty stomach, at least 30 to 60 minutes before breakfast with a full glass of water. Take the medicine at the same time each day. (retrieved on 4/08/24 from drugs.com). Review of the resident's physician's orders revealed an order dated 10/09/23 for levothyroxine 112 mg daily for hypothyroidism. Review of the resident's Medication Administration records for the period October 2023 through March 2024 revealed the medication levothyroxine was scheduled for administration at 9:00 AM. On 3/27/24 at 9:07 AM, the Director of Nursing (DON) stated the Consultant Pharmacist reviewed residents' medications, made recommendations, and sent a report via email to her. The DON stated that the recommendations were distributed to the Physician/Providers for review and response, and the expectation was that recommendations would be addressed within thirty (30) days of receipt. On 3/28/24 at 12:25 PM, resident #82's pharmacy recommendation dated 10/17/23, the resident's physician order and MARs were reviewed with the DON. She acknowledged the findings and said the recommendation should have been addressed within 30 days of receipt. The DON said that specific recommendation was a nursing task, and nurses could change the time of administration of the medication in the resident's electronic medical record. The policy Medication Regimen Review dated April 2018 read, Recommendations are acted upon and documented by the facility staff and/or prescriber .The Director of Nursing or designated licensed nurse address and document recommendations that do not require a physician intervention. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105731 If continuation sheet Page 7 of 12 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 03/28/2024 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 a medication administration error rate of 5% or greater for 1 out of 8 residents observed for medication administration, of a total sample of 48 residents, (#8). There were 3 medication errors in 25 opportunities for a medication error rate of 12%. Residents Affected - Few Findings: Review of the medical record revealed resident #8 was admitted to the facility on [DATE] from the hospital. His diagnosis included schizoaffective disorder, bipolar, Alzheimer's disease, dementia, type II diabetes, and stage 4 kidney disease, benign prostatic hyperplasia (BPH) with lower urinary tract symptoms, and anemia in chronic kidney disease. Resident #8's admission Minimum Data Set (MDS) with an assessment reference date of 2/26/24 revealed the resident scored 13 out of 15 on the Brief Interview for Mental Status which indicated he did not have any cognitive impairment. The MDS assessment indicated resident #8 required moderate assistance from the staff with transfers. The admission MDS also noted that the resident did not exhibit behavioral symptoms or rejection of care that is necessary to achieve the resident's goals for health and well-being. Resident #8's admission MDS assessment revealed the resident received high risk medications that included antipsychotic and antidepressant medications. Review of resident #8's medical record revealed a care plan initiated on 2/21/24 that indicated the resident used psychotic medications related to schizophrenia and bipolar disorder. Interventions included staff to administer psychotropic medications as ordered by a physician. On 3/26/24 at 9:41 AM, Registered Nurse (RN) A prepared the scheduled medications for resident #8 and placed the pills into the medicine cup, totaling 14 pills. RN A then verified the count of pills in the cup, ensuring there were 14 pills present. She administered the medications to resident #8, who was in his room. A record review post medication administration observation of resident #8's order summary report and the medication administration record (MAR) revealed the provider ordered Aripiprazole 20 milligrams (mg) by mouth once a day for antipsychotic to be discontinued on 2/26/24. It also showed active orders for ferrous sulfate 325 milligrams (mg) by mouth one time a day for anemia and Proscar 5 mg by mouth one time a day for BPH. Ferrous sulfate and Proscar were scheduled to be administered daily at 9:00 AM. On 3/26/24 at 10:28 AM, RN A checked resident #8's medication administration record and discovered that Aripiprazole had been previously discontinued on 2/26/24. She acknowledged that she administered Aripiprazole during the medication administration observation at 9:41 AM. She stated she should not have administered Aripiprazole to the resident since it was discontinued. She also stated there were active orders on the MAR for Proscar and ferrous sulfate that she failed to administer as prescribed. RN A recalled there were 14 pills in the medication cup and confirmed that neither Proscar nor ferrous sulfate were included in the pills she administered to the resident. RN A conveyed she should have checked the MAR to ensure that resident #8's medications matched the physician orders before administering them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105731 If continuation sheet Page 8 of 12 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 03/28/2024 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 On 3/26/24 at 11:00 AM, The Licensed Practical Nurse (LPN) Supervisor on the 200 unit accessed resident #8's electronic medical record and stated that Aripiprazole was discontinued on 2/26/24. She confirmed that Aripiprazole should not have been administered by RN A. She emphasized that nurses were required to verify the resident's medications in the medication cart against the physician's orders on the MAR before administering them. Residents Affected - Few On 3/27/24 at 8:50 AM, the Director of Nursing (DON) confirmed that Aripiprazole 20 mg was discontinued on 2/26/24 and should not have been given to the resident. The DON acknowledged that RN A should have checked the MAR before giving the medication. She also reiterated when a nurse verified medications, the nurse was expected to ensure the medications aligned with the physician orders on the MAR before administering them. The facility's medication orders policy read, Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe .Any dose or order that that appears inappropriate .is verified by nursing with the attending physician. The facility's preparation and general guidelines policy read, Medications are administered as prescribed in accordance with good nursing principles .The mediation administration record (MAR) is always employed during medication administration. Prior to administration of any medication, the medication and dosage schedule on the resident's medication administration record (MAR) are compared with the medication label. If the label and MAR are different and the container has not already been flagged indicating a change in directions, or if there is any other reason to question the dosage of directions, the physician's orders are checked for the correct dosage schedule. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105731 If continuation sheet Page 9 of 12 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 03/28/2024 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 0760 Ensure that residents are free from significant medication errors. 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 that a resident was free of a significant medication error regarding administration of a discontinued high risk antipsychotic medication for 1 out of 8 residents observed for medication administration, of a total sample of 48 residents, (#8). Residents Affected - Few Findings: Review of the medical record revealed resident #8 was admitted to the facility on [DATE] from the hospital. His diagnosis included schizoaffective disorder, bipolar, Alzheimer's disease, dementia, type II diabetes, and stage 4 kidney disease. Resident #8's admission Minimum Data Set (MDS) with an assessment reference date of 2/26/24 revealed the resident scored 13 out of 15 on the Brief Interview for Mental Status that indicated he did not have any cognitive impairment. The MDS assessment indicated resident #8 required moderate assistance from the staff with transfers. The admission MDS also noted that the resident did not exhibit behavior symptoms or rejection of care that is necessary to achieve the resident's goals for health and well-being. Resident #8's admission MDS assessment revealed that the resident received high risk medications that included antipsychotic and antidepressant medications. Review of resident #8's medical record revealed that a care plan was initiated on 2/21/24 that indicated the resident used psychotic medications related to schizophrenia and bipolar disorder and the interventions included to administer psychotropic medications as ordered by a physician. On 3/26/24 at 9:41 AM Registered Nurse (RN) A administered Aripiprazole 20 milligrams (mg) tablet along with Vraylar 4.5 mg capsule to resident #8 during the medication administration observation. The pharmaceutical strip pack noted the resident's name, Aripiprazole 20 mg, Vraylar 4.5 mg, and the directions for administration on Tuesday, 3/26/24. A record review post medication administration observation of resident #8's order summary report and the medication administration record (MAR) revealed the provider ordered Aripiprazole 20 milligrams (mg) by mouth once a day for antipsychotic to be discontinued on 2/26/24 and the provider also prescribed Vraylar 4.5 mg by mouth once a day for antipsychotic to start on 2/27/24. Aripiprazole and Vraylar are antipsychotic medications that are used to treat schizophrenia. There are moderate interactions with using Aripiprazole and Vraylar together. Using Aripiprazole with Vraylar together may increase side effects such as drowsiness, blurred vision, dry mouth, heat intolerance, flushing, decreased sweating, difficulty urinating, abdominal cramping, constipation, irregular heartbeat, confusion, and memory problems. Side effects are more likely to occur in the elderly .The recommended maximum number of medicines in the 'antipsychotics' category to be taken concurrently is usually one, (Retrieved on 4/5/24 from www.Drugs.com.) On 3/26/24 at 10:28 AM, RN A checked resident #8's medication administration record and discovered that Aripiprazole had been discontinued on 2/26/24. She acknowledged she administered Aripiprazole during the medication administration observation at 9:41 AM and she also indicated she administered it the day before. She confirmed she should not have administered Aripiprazole to the resident since it was discontinued. RN A conveyed she should have checked the MAR to ensure the medication matched the physician order before administering it. RN A observed that Aripiprazole was also in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105731 If continuation sheet Page 10 of 12 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 03/28/2024 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medication cart and was included in the resident's medication regimen for the next day. She reiterated that Aripiprazole should not be included in the pharmacy strip pack for the resident since it had been discontinued on 2/26/24. On 3/26/24 at 11:00 AM, the Licensed Practical Nurse (LPN) Supervisor on the 200 unit accessed resident #8's electronic medical record and stated that Aripiprazole was discontinued on 2/26/24. She indicated the pharmacy delivered strip packs for resident #8 on Mondays, Wednesdays, and Fridays, each contained a two-day supply of medications. She stated that the most recent medication strip pack delivered by the pharmacy was on Monday 3/25/24 that contained Aripiprazole and Vraylar among others. She confirmed that aripiprazole should not have been administered by RN A on 3/26/24 and it should not have been included in the pharmacy strip pack that was scheduled to be administered on Tuesday, 3/26/24 and Wednesday, 3/27/24. She emphasized that nurses were required to verify the resident's medications in the medication cart against the physician's orders on the MAR before administering them. On 3/27/24 at 8:50 AM, the Director of Nursing (DON) confirmed that Aripiprazole 20 mg was discontinued on 2/26/24 and should not have been given to the resident after that date. The DON acknowledged that RN A should have checked the MAR before giving the medication. She conveyed that prefilled medication strip packs were delivered in trays from the pharmacy on Mondays, Wednesdays, and Fridays that contain a two-day supply of medications and were placed in the medication cart by the pharmacy and the nurse on duty. She confirmed when a medication is discontinued, it would automatically interface with the pharmacy informing them of the discontinued medication. She stated that Aripiprazole should not have been delivered by the pharmacy. She also reiterated when a nurse verified a medication, the nurse was expected to ensure the medications align with the physician orders on the MAR before administering them. She mentioned if there was not a physician order for a medication that was included in the strip pack, the nurse must not administer the medication, should remove the medication from the strip pack, then notify the supervisor and the provider. On 3/27/24 at 2:13 PM, the Pharmacy Operations Manager stated that on 2/26/24 they received an order from the facility to discontinue Aripiprazole and on 2/27/24 received an order to start Vraylar. She conveyed that orders were entered into the operating system by a tech, then reviewed and verified by the pharmacist for accuracy. She also conveyed if a medication was discontinued, the pharmacy was to discontinue it from the resident's profile. She confirmed that Aripiprazole continued to be delivered on Mondays, Wednesdays, and Fridays for a month after it was discontinued and that it should not have been sent out after the discontinued date of 2/26/24. She acknowledged the discontinued Aripiprazole remained on resident #8's profile until 3/27/24 and both Aripiprazole and Vraylar were delivered to the resident in the pharmacy strip packs until 3/27/24. The Pharmacy Operations Manager acknowledged the potential adverse reactions for Aripiprazole would be drowsiness, leukopenia, neutropenia, hyperglycemia, and extrapyramidal symptoms such as Parkinsonism, dystonia, tardive dyskinesia. The pharmacy and facility's Medication orders policy read, Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe .Any dose or order that that appears inappropriate .is verified by nursing with the attending physician. The pharmacy and facility's Preparation and General guidelines policy read, The medication administration record (MAR) is always employed during medication administration. Prior to administration of any medication, the medication and dosage schedule on the resident's medication administration record (MAR) are compared with the medication label. If the label and MAR are different and the container has not already been flagged indicating a change in directions, or if there is any other reason to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105731 If continuation sheet Page 11 of 12 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 03/28/2024 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 0760 question the dosage of directions, the physician's orders are checked for the correct dosage schedule. Level of Harm - Minimal harm or potential for actual harm Isolated Class III Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105731 If continuation sheet Page 12 of 12