Inspection·February 17, 2022

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment accurately reflected resident status related to location prior to re-entry for 1 of 4 residents reviewed for accidents, out of a total sample of 31 residents, (#38). Residents Affected - Few Findings: The Center for Medicare & Medicaid Services Resident Assessment Instrument [RAI] Version 3.0 Manual dated October 2019 revealed the results of the MDS assessment should accurately reflect the resident's status. Review of resident #38's medical record revealed she was admitted to the facility on [DATE] and readmitted from acute care hospital on [DATE] with diagnoses including Alzheimer's disease, displace fracture of left femur, abnormality of gait and incomplete quadriplegia. On 11/22/21 resident #38 was sent to the hospital for fracture of the left femur. She was then readmitted to the facility on [DATE]. Review of the MDS Significant Change in Status assessment dated [DATE], revealed Section A: Identification Information question A1800 titled Entered From was coded with the number 2. This code inaccurately indicated resident #38 returned to the facility from another nursing home or swing bed rather than from the acute care hospital. The number 3 should have been selected since the resident was in an acute care hospital prior to reentering the facility. On 2/17/21 at 4:00 PM, MDS Coordinator C validated resident #38's MDS Significant Change in Status assessment dated [DATE] was inaccurate. She said, The assessment should have reflected that she returned to us from the hospital and not another nursing home. Review of the RAI version 3.0 Manual revealed instructions for completing Section A 1800: Entered From. The document indicated the rationale for understanding the setting that the individual was in immediately prior to facility admission, entry or reentry could inform care planning and discharge planning discussion. The steps for assessment read, Review transfer and admission records [and] Ask the resident and/or family or significant others. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105797 If continuation sheet Page 2 of 6 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 105797 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Guardian Care Nursing & Rehabilitation Center 350 South John Young Parkway 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 0692 Provide enough food/fluids to maintain a resident's health. 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 re-assess significant weight loss of 1 of 2 residents identified at nutritional risk, of a total sample of 31 residents, (#25). Residents Affected - Few Findings: Resident #25 was admitted to the facility on [DATE] with diagnoses that included diabetes, hypertension, dementia, and altered mental status. Review of the medical record revealed a physician diet order dated 11/26/21 for No Concentrated Sweets, No Added Salt, and a regular texture. The resident's nutritional care plan dated 12/07/21, read, Residents Weight Will REMAIN STABLE THROUGH THE NEXT REVIEW. On 2/16/22 at 12:51 PM, the resident ate lunch in the main dining room. His meal consisted of macaroni beef bake, breadstick, side salad, mashed potatoes, pears, and beverages. At that time the resident was had eaten only 40% of his meal. Review of the resident's meal percentage log from 1/01/21 to 2/17/22 revealed the resident usually ate 75% to 100% of all meals, with an occasional meal 50% consumed. The Consultant Registered Dietician (RD) assessed resident #25's nutritional risk status on 12/01/21. She noted the resident's height was 68 inches and his weight was 142 pounds. The RD noted the resident's goal weight was between 139 and 169 pounds. The documented indicated the RD recommended a nutritional supplement, Suplena, was to be resumed. Review of the medical record revealed on 11/08/21, the resident weighed 141.6 pounds. On 12/03/21, the resident showed a weight gain and was 142.2 pounds. Over the next two weeks, the resident's weight fluctuated, and he weighed 140.8 pounds and 141.2 pounds on 12/10/21 and 12/17/21, respectively. On 12/24/21, resident #25's weight decreased to 132.6 pounds. This was a significant weight loss as it was 6.09% in 1 week. Centers for Medicare and Medicaid Services . parameters for evaluating significance of unplanned and undesired weight loss indicated a 5% weight loss in 30 days was significant, and greater than 5% was categorized as severe weight loss. On 1/26/22 the resident weighed 132.8 pounds, which was still less than the RD's recommended goal weight. Further record review revealed neither the RD nor the Interdisciplinary Team (IDT) had re-assessed resident #25 to determine if his weight loss was a self-limiting condition that would normally resolve itself, or a significant decline that required intervention. On 2/17/22 at 3:19 PM, the Certified Dietary Manager (CDM) was not able to explain why resident #25's weight loss was not re-assessed by the RD or any other member of the IDT. The CDM added that the RD was only at the facility once weekly, on Wednesdays. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105797 If continuation sheet Page 3 of 6 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 105797 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Guardian Care Nursing & Rehabilitation Center 350 South John Young Parkway Orlando, FL 32805 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide appropriate care and services related to following physician orders for 1 of 1 resident sampled for gastric tube (GT) feedings out of a total sample of 31 residents, (#389). Findings: Resident #389 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease, atherosclerotic heart disease, diabetes, and gastrostomy status. A gastric tube (G-tube) is a flexible feeding tube that is placed directly into the stomach through a surgical incision in the abdominal wall. The G-tube allows nutrition, fluids, and medications to be put directly into the stomach, bypassing the mouth and esophagus (retrieved on 3/01/22 from www.medlineplus.gov). Review of resident #389's medical record revealed physician orders dated 2/13/22 for tube feeding, Glucerna 1.5 calorie at 60 cubic centimeters per hours (cc/hr) to start at 6:00 AM and stop at 12:00 AM, with water flushes of 500 cc every eight hours. On 2/14/22 at 12:13 PM, observation of resident #389 revealed Glucerna 1.5 calorie tube feeding infused via pump at 75 cc/hr. Additional observations on 2/14/22 at 2:50 PM and 2/15/22 at 11:30 AM, revealed the tube feeding continued to infuse at 75 cc/hr. On 2/15/22 at 2:23 PM, Licensed Practical Nurse (LPN) B confirmed resident #389's tube feeding was infusing at 75 cc/hr. She validated that was not the rate prescribed by the physician, and there was no physician order on the 7:00 AM to 3:00 PM Medication Administration Record (MAR) for tube feeding or enteral feed. LPN B said, Usually we ensure accuracy of the right tube feeding rate by verifying it with the physician order. On 2/15/22 at 3:10 PM, the interim Director of Nursing (DON) explained nurses on the 7:00 AM to 3:00 PM shift should be aware of a resident's tube feeding infusion rate as they received report from the off-going nurse and could access the physician orders in the computer. She stated the expectation was nurses would follow the physician orders. During review of resident #389's physician orders, and the February 2022 MAR and Treatment Administration Record (TAR) with the interim DON, no physician order for tube feeding was noted on the MAR for the 7:00 AM to 3:00 PM shift. The interim DON said, You're right. It is not there. She explained accuracy of the medical record and tube feeding rate was the responsibility of the clinical team which consisted of herself, the Supervisor, and Minimum Data Set (MDS) staff. She explained the clinical team reviewed new physician orders and checked charts to ensure orders were in the computer. On 2/17/22 at 10:21 AM, the interim dietitian stated it was important for residents to have the correct tube feeding formulas based on their needs to ensure adequate caloric intake. She stated the infusion rate was ordered by the physician and had to be followed. The interim dietitian explained tube feeding infusion rates were adjusted as needed. On 2/17/22 at 11:34 AM, the physician stated resident #389 was becoming congested, and the tube (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105797 If continuation sheet Page 4 of 6 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 105797 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Guardian Care Nursing & Rehabilitation Center 350 South John Young Parkway Orlando, FL 32805 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 feeding rate was decreased from 75 cc/hr to 60cc/hr to address the situation. Level of Harm - Minimal harm or potential for actual harm Review of the facility's in-service education for Physician Orders and Follow Up dated 10/22/21 revealed nurses were educated on topics including red-lining or reconciling orders, utilization of the 24-hour report and electronic communication, and clinical management team's consistent use of the order review report for daily monitoring. Residents Affected - Few The facility's policy Physician Orders read, . Once orders are clarified and confirmed do the following: b. Transfer all orders to the MAR/TARS, whether paper or electronic. Review of the facility's policy for Administering Medications revised 2012 read, Medication shall be administered in a safe and timely manner, and as prescribed . The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105797 If continuation sheet Page 5 of 6 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 105797 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Guardian Care Nursing & Rehabilitation Center 350 South John Young Parkway Orlando, FL 32805 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain a physician order for oxygen therapy for 1 of 1 resident sampled for respiratory care out of a total sample of 31 residents, (#389). Residents Affected - Few Findings: Resident #389 was admitted to the facility on [DATE] with diagnoses including sepsis, atherosclerotic heart disease, peripheral vascular disease, and diabetes. On 2/14/22 at 12:13 PM, resident #389 was observed with oxygen infusing at 3 liters per minute (L/min) via nasal cannula. Additional observations on 2/14/22 at 2:50 PM and 2/15/22 at 11:30 AM, revealed resident #389 remained on oxygen at 3 L/min via nasal cannula. Review of the Medication Administration Record (MAR), Treatment Administration Record (TAR) and Physician Order Sheet for February 2022 revealed resident #389 had no physician order for oxygen therapy. However, review of the resident's medical record revealed an oxygen saturation summary report with documentation of oxygen administration via nasal cannula since 2/09/22 at 9:03 PM. On 2/15/22 at 1:41 PM, Licensed Practical Nurse (LPN) B confirmed resident #389 received oxygen at 3 L/min via nasal cannula. LPN B stated residents definitely needed to have a physician order for oxygen administration and all nurses were responsible for ensuring a physician's order for oxygen was in the computer. During review of the medical record, LPN B confirmed resident #389 did not have a physician order for oxygen therapy. On 2/15/22 at 1:54 PM, the interim Director of Nursing (DON) stated physician orders were to be reconciled on admission. She explained the nurses were responsible for verifying and confirming oxygen orders. She stated after morning meetings the clinical team, which consisted of herself, the Supervisor, and Minimum Data Set (MDS) staff, reviewed new physician orders, and checked charts. The interim DON confirmed resident #389 did not have a physician order for oxygen therapy. On 2/17/22 at 10:37 AM, the interim DON stated resident #389's Situation, Background, Appearance, Review and Notify (SBAR) report dated 2/08/22 revealed an order for oxygen at 2 L/min via nasal cannula. She explained the nurse who completed the document checked the recommendation for oxygen but did not enter the physician's order into the electronic medical record. The interim DON was informed the resident was observed with oxygen at 3 L/min via nasal cannula. During medical record review, the interim DON noted a baseline care plan with admission date of 2/5/22 that did not include any documentation or revisions for oxygen listed under Special Treatments / Procedures. Review of the facility's in-service education for Physician Orders and Follow Up dated 10/22/21 revealed nurses were educated on topics including red-lining or reconciling orders, utilization of the 24-hour report and electronic communication, and clinical management team's consistent use of the order review report for daily monitoring. Review of the facility's policy for Oxygen Administration undated read, The purpose of this procedure is to provide guidelines for safe oxygen administration. 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105797 If continuation sheet Page 6 of 6