Health inspection·May 9, 2025

F 0695 nurses were supposed to follow physician's orders. Level of Harm - Minimal harm or potential for actual harm A review of the facility's Oxygen Therapy policy and procedure dated November 2023 read, Oxygen is provided to residents based on physician's orders to supplement oxygen as needed per disease process. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105791 If continuation sheet Page 2 of 4 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 105791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Delaney Park Health and Rehabilitation Center 215 Annie Street Orlando, FL 32806 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure oxygen concentrators were maintained in safe, functional condition for 5 of 8 sampled residents who were oxygen-dependent, of a total sample of 12 residents, (#2, #8, #9, #10, and #11). The facility also failed to ensure that failed or potentially compromised concentrator units were promptly removed from use to avoid placing residents at risk of receiving inadequate oxygen support. Residents Affected - Some Findings: On 5/08/25 at 11:30 AM, resident #2's son reported his mother used oxygen continuously. He identified an oxygen concentrator in her room that displayed a yellow light, and a sticker labeled, FAILED. He stated the equipment should have been working properly and expressed concern that families were left to identify malfunctioning equipment. On 5/08/25 at 1:36 PM, during a telephone interview, resident #1's spouse reported when the resident returned to the facility from a hospital stay in March 2025, the transport company driver informed her the oxygen concentrator was beeping and displaying a yellow light. Resident #1's spouse stated she reported the malfunction at that time to staff. She indicated she returned the next day and observed the same unit continued to beep intermittently. She stated after multiple reports, she was later informed the unit had been replaced. On 5/08/25 at 4:18 PM, the Central Supply Coordinator stated the facility had approximately twenty oxygen concentrators. She explained the oxygen concentrators were inspected and serviced monthly by an outside provider. She indicated when she was told an oxygen concentrator was not working, the Maintenance Director would inspect it and called the outside provider if needed. She validated resident #2's oxygen concentrator had a yellow light, and stated it was replaced that morning. She explained the oxygen concentrator was placed in the central supply room with a note that indicated it needed to be repaired. During a tour of rooms with oxygen concentrators conducted with the Central Supply Coordinator on 5/08/25 at 4:30 PM, she validated 4 of 14 units seen on the tour displayed yellow indicator lights; for residents #8, #9, #10, and #11. One unit had a sticker labeled, FAILED. The Central Supply Coordinator was unable to explain the meaning of the yellow light and stated she did not know who placed the sticker or when it was applied. She stated even if the green light was not illuminated, it did not necessarily mean oxygen was not being delivered. On 5/09/25 at 9:20 AM, the Nursing Home Administrator (NHA) reported that yellow lights could appear for several reasons, including poor placement. He stated nursing staff checked concentrators weekly, and maintenance responded to issues. He confirmed the vendor performed annual inspections. He provided evidence of the most recent inspection dated 9/23/2024 which showed 8 out of 15 concentrators failed and required repair or replacement. A purchase requisition dated 10/04/2024 documented the purchase of 5 new concentrators. The NHA was unable to confirm which units had been replaced or whether failed units remained in use. On 5/09/25 at 10:16 AM, during a telephone interview, the oxygen concentrator services' Account Manager explained a yellow light indicated caution and could signal a failure in oxygen purity. He described if the unit did not reach the required purity within 15 minutes, it was considered to have failed and should be removed from service. He emphasized failed units could not be relied on to meet residents' prescribed oxygen needs and should not remain in use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105791 If continuation sheet Page 3 of 4 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 105791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Delaney Park Health and Rehabilitation Center 215 Annie Street Orlando, FL 32806 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Level of Harm - Minimal harm or potential for actual harm Review of the undated [NAME] 2 Series User Manual revealed features which included Oxygen Purity Indicator Lights/Fault and Power Indicator Lights. The manual indicated, the SensO2 feature monitors the purity of oxygen generated by the oxygen concentrator. If purity falls below factory preset standards, indicator lights on the control panel will illuminate. The Oxygen Purity indicator included a caution visual image and yellow light that illuminated and a telephone image, which instructed the user to call the supplier. Residents Affected - Some A review of the Physical Environment policy and procedure dated August 2024 indicated, All essential mechanical, electrical, and resident care equipment is maintained in safe operating condition through the facility's Preventative Maintenance Program. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105791 If continuation sheet Page 4 of 4