Inspection·August 1, 2019

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 7/30/19 at 10:04 AM, the resident was in bed with the head of the bed elevated. She spoke in Spanish with facial grimace and pointed to her back. Bilingual housekeeper E interpreted that resident complained of back pain. The resident tried to use the call light to call the nurse but could not reach it. The call light was on the floor between both beds. On 7/31/19 at 11:11 AM, CNA F stated, I know the resident gets pain medicine because she has arthritis. She sometimes says her back hurts but helping her to change position helps her. The resident's call light should always be within her reach. At 11:40 AM, licensed practical nurse (LPN) G stated the resident gets routine pain medication, Tramadol. She is followed by the rheumatologist who gives her injections every 6 months. The resident can use her call light. The expectation is that she should always have access to the call light. Resident #36's quarterly MDS assessment dated [DATE], reflected a BIMS score of 9/15 indicating moderate cognitive impairment. The section for health condition reflected that the resident had been on scheduled pain medication. Resident #36's care plan, dated 5/23/19 read, Incontinent episodes of bowel and or bladder relating to impaired cognition, communication and mobility related to dementia. Interventions included encourage resident to request assistance with toileting task. The care plan for at risk for falls related to a syncope/collapse episode in the shower without injury reflected interventions to remind resident to call for assistance with transfer/mobility and reinforce safety awareness. This could not be done by the resident if her call light was not in her reach. 3. Resident #67 was admitted to the facility on [DATE] with diagnoses including difficulty walking, muscle weakness, urinary tract infection, osteoarthritis, and chronic congestive heart failure. On 7/31/19 at 9:38 AM, resident #67 sat in a wheelchair on the opposite side of the call light. The call light was attached to the left side of the bed. The resident sat on the right side of her bed. The resident stated she was waiting for the CNA to make her bed because she wanted to get back in the bed. At 9:40 AM, CNA B stated that whenever the resident would like to call me for help, she used the call light. Right now, the call light is on the opposite side wrapped around the side rail of the bed, closer to her roommate. The resident was in her wheelchair between her bed and the bathroom and she cannot get to the call light. She said, I should always make sure the call light is within the resident's reach. At 10:08 AM, LPN C stated that CNAs are expected to ensure that the call light is always within resident's reach. Resident's #67's 30-day MDS assessment dated [DATE] documented a BIMS score of 13/15 indicating she was cognitively intact. The functional status listed the resident as needed physical assist for bed mobility, and transfer. Resident #67's care plan, dated 6/05/19, reflected that the resident experienced incontinent episodes of bowel and or bladder related to impaired mobility and weakness. Intervention included to encourage resident to request assistance with toileting needs. Resident #67's care plan, dated 6/04/19 reflected that the resident was at risk for falls related to deconditioning, gait/balance problems, incontinence, psychoactive drug use and unaware of safety needs. Interventions included that the call light be within reach. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105974 If continuation sheet Page 2 of 10 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 105974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Orlando 3211 Rouse Road Orlando, FL 32817 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to honor resident's food preference for 1 of 3 resident reviewed for choices, (#106). Finding: Resident #106 was admitted to the facility on [DATE], with her most recent readmission on [DATE]. Her diagnoses included pleural effusion, end stage renal disease, diabetes type II, atherosclerotic heart disease and chronic obstructive pulmonary disease. The Medicare 5-day minimum data set (MDS), with assessment reference date 7/21/19, showed resident #106's cognition was intact, with a brief interview of mental status of 12/15. The resident required extensive assistance of one person for bed mobility, transfers, dressing, toilet use, and personal hygiene, and supervision for eating. The food and beverage preference list for resident #106 was obtained on 3/27/18, and showed that her dislikes included pork chops, pork roast, ham, sausages, and bacon. On 7/30/19 at 10:09 AM, resident #106 said she did not eat pork, and was served pork for supper on 7/29/19, on her return from dialysis. Resident #106 said she told staff she did not eat pork, and asked for something else, but was told the kitchen was closed. The resident said she had to eat walnuts and bread she had in her room. Resident #106's daughter visited the resident at this time, and confirmed the resident's report. On 7/31/19 at 2:30 PM, assistant certified dietary manager (ACDM) I said food preferences were obtained from residents on the day of admission or the following day. Review of the resident's food and beverage preference list provided by the ACDM showed the resident's dislikes included pork. On 7/31/19 at 2:46 PM, the resident's food and beverage preference list was also reviewed with registered dietician (RD) J. She verified that dislikes checked included pork chops, and pork roast. The RD said she was not sure why resident #106 was served pork on Monday 7/29/19. On 7/31/19 at 4:19 PM, certified nursing assistant (CNA) K said on Monday 7/29/19, when he served resident # 106 her meal tray, she told him to open the lid. The resident then asked what kind of meat was on her tray. CNA K said he told her he would verify by reviewing the menu. When he checked, it was pork. CNA K said that he commented to resident # 106, I know you are not going to eat it. She said that's right, I am Muslim. CNA K said the resident asked him to get some food from the refrigerator that her daughter had brought in for her, but the food had been thrown out. The CNA K said resident #106 asked him to go to the kitchen, and ask for chicken tenders. He stated that chicken tenders were not available. He got a fruit plate, crackers, and hot tea for the resident. A second interview was conducted with the RD and ACDM on 8/01/19 at 10:06 AM. They said the worker on the tray line might not have placed the correct item on the resident's tray. The staff checking the trays also did not catch the error. Both the RD and ACDM said the food preferences for resident #106 should have been honored, and the resident should not have been given pork. The ACDM said it was a mistake. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105974 If continuation sheet Page 3 of 10 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 105974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Orlando 3211 Rouse Road Orlando, FL 32817 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 0561 Level of Harm - Minimal harm or potential for actual harm A care plan for at risk for nutritional compromise related to endocrine/cardiac/renal dysfunction and fluid shifts as evidenced by diagnoses of diabetes, congestive heart failure, end stage renal disease requiring hemo dialysis was initiated on 5/31/19. An intervention was to honor food preferences as available. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105974 If continuation sheet Page 4 of 10 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 105974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Orlando 3211 Rouse Road Orlando, FL 32817 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 0623 Level of Harm - Potential for minimal harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #106's medical record reflected an admission date to the facility on 3/23/18, with her most recent readmission on [DATE]. Her diagnoses included pleural effusion, end stage renal disease, dependence on renal dialysis, diabetes type II, atherosclerotic heart disease and chronic obstructive pulmonary disease. The discharge minimum data set assessments, dated 5/22/19, 6/17/19 and 7/10/19, showed the resident was discharged to an acute care hospital, and return was anticipated. Nursing progress notes, dated 5/22/19, 6/17/19 and 7/15/19, showed the resident was transferred to an acute care hospital due to changes in her medical condition. The resident's electronic and physical chart revealed the Ombudsman Notification attached to the transfer documents for transfer of 7/10/19 had missing documentation, including the reason for transfer, the effective date of the transfer, and the location to which the resident was transferred. This was verified by the assistant director of nursing (ADON). Notification to the Ombudsman for transfers on 5/22/19, and 6/17/19 could not be identified. On 8/01/19 at 2:49 PM, the Social Services Director (SSD) said that previously, notification of transfers/hospitalizations were sent to the Ombudsman on a monthly basis, but now notification was sent on a weekly basis. Notification to the Ombudsman was not identified for resident #106 for transfers on 5/22/19 and 6/17/19. On 8/01/19 at 3:45 PM, the director of nursing (DON) said that with any change in condition of a resident, the physician and family should be notified, and the bed hold acknowledgement/reservation policy, and Ombudsman notification was required. On 8/01/19 at 4:45 PM, the DON and ADON said after review, documentation could not be identified regarding the Ombudsman notification for transfers of 5/22/19 and 6/17/19. The DON said the expectation is that the Ombudsman notification should be completed for all residents transfers/hospitalizations. She verbalized that this was not done for resident #106. The facility policy for Transfers and Discharges, effective 5/6/19, read, As members of the interdisciplinary team, Social Services and Nursing staff participate in all transfers and discharges .to ensure proper notification .facility must send a copy of the notice to a representative of the office of the State Long-Term Care Ombudsman Based on observation, interview and record review, the facility failed to notify the State Long Term Care Ombudsman in writing when a transfer to the hospital occurred for 2 of 4 residents reviewed for hospitalization, (#216 & 106). Findings: 1. Resident #216 was admitted to the facility on [DATE] and re-admitted on [DATE] from an acute care hospital with diagnoses of urinary tract infection (UTI), sepsis, heart failure, respiratory failure, unsteadiness on feet, muscle weakness and diabetes. On 7/29/19 at 10:45 AM, resident #216 sat up in bed. She was alert and oriented to person, place, and time. She was talkative, pleasant, and indicated that she had a recent hospitalization due to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105974 If continuation sheet Page 5 of 10 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 105974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Orlando 3211 Rouse Road Orlando, FL 32817 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 0623 UTI. Level of Harm - Potential for minimal harm Resident #216's medical record revealed that she was transferred to the hospital on 7/07/19 due to shortness of breath. The medical record did not contain any evidence that the State Long Term Care Ombudsman was notified of the transfer to hospital. Residents Affected - Some On 8/01/19 at 2:49 PM, an interview was conducted with the Social Services Director (SSD) regarding notification to the Ombudsman of resident #216's transfer to hospital on 7/07/19. The SSD said it was her responsibility to notify the Ombudsman when a resident is transferred to the hospital and this one just got missed. The SSD indicated that she is now sending the notifications to the Ombudsman weekly and started doing this a couple of weeks ago. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105974 If continuation sheet Page 6 of 10 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 105974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Orlando 3211 Rouse Road Orlando, FL 32817 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #106's medical record reflected an admission to the facility on 3/23/18, with her most recent readmission on [DATE]. Her diagnoses included pleural effusion, end stage renal disease, dependence on renal dialysis, diabetes type II, atherosclerotic heart disease and chronic obstructive pulmonary disease. The discharge minimum data set assessments dated 5/22/19, 6/17/19 and 7/10/19 showed the resident was discharged to an acute care hospital, and return was anticipated. Nursing progress notes dated 5/22/19, 6/17/19 and 7/15/19 showed the resident was transferred to an acute care hospital due to changes in her medical condition. The resident's electronic and physical chart did not contain the notice of bed-hold policy issued to resident #106/or resident representative. On 8/01/19 at 3:45 PM, the DON said that with any change in condition of a resident, the physician and family should be notified, and the bed hold acknowledgement/reservation policy, was required. On 8/01/19 at 4:45 PM, the DON and assistant DON (ADON) said after review, documentation could not be identified regarding the bed hold acknowledgement/reservation policy for hospitalization of 5/22/19 and 6/17/19. This was verified by the DON. The facility's policy and procedure Bed Hold Acknowledgement/Reservation Policy, read, At the time the resident is to leave the Facility for a temporary stay in a hospital .The resident/legal representative will be given a written copy of the Bed Hold Policy. Based on record review and interview, the facility failed to provide a bed-hold notice upon transfer for 2 of 4 residents reviewed for hospitalization, (#216 & 106). Findings: 1. Resident #216 was admitted to the facility on [DATE] and transferred to the hospital on 7/07/19 for shortness of breath. Resident #216's medical record did not contain any documentation to indicate that the resident or the responsible party were provided with the bed-hold notice within 24 hours of transfer. On 8/01/19 at 3:48 PM, the Director of Nursing (DON) stated that it was the responsibility of the floor nurse to provide the bed hold notification to the resident or responsible party upon transfer to hospital. The DON confirmed that the facility did not have any evidence to indicate the resident or resident representative had been provided the bed hold information at the time of the transfer or within 24 hours of the transfer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105974 If continuation sheet Page 7 of 10 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 105974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Orlando 3211 Rouse Road Orlando, FL 32817 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to follow physician's order for weekly weights for 1 of 1 resident reviewed for edema out of 41 total sampled residents, (#21). Residents Affected - Some Findings: Resident #21's medical record reflected an admission date of 10/26/18. Her diagnosis included atherosclerotic heart disease, atrial fibrillation, diabetes type II, hypertension, and cardiac pacemaker. The quarterly minimum data set (MDS) assessment with assessment reference date (ARD) 1/31/19 showed the resident required extensive assistance for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. The Significant Change MDS with ARD 5/02/19 showed improvement in the resident's functional ability. She now required limited assistance for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. The Physician's order, dated 6/27/19, was for weekly weight every night shift every Tuesday for edema, start date 7/02/19. Resident #21's medications included Bumex 0.5 milligrams (mg.) twice daily. Bumex is a diuretic that helps to rid the body of salt and water (Mayo Clinic). Record review showed the following entries for the resident's weight: 6/09/19: 155.6 pounds (lb.) and 7/02/19: 148.5 lb, for a total weight loss of 7.1 lb. Three weeks of weights were not documented in the resident's chart after 7/02/19. On 7/31/19 at 9:34 AM, licensed practical nurse (LPN) G said if a resident was on weekly weights, the weight would be obtained on the night shift. Weights should then be entered in the computer. Weights were reviewed with LPN G, who verified that the last documented weight for resident #21 was on 7/02/19. No other weight could be identified by LPN G for resident #21. On 7/31/19 at 11:32 AM, the unit manager (UM) said weekly weights were usually done by the 11 PM-7 AM staff. If staff were busy, the restorative certified nursing assistant would obtain the weights. The UM verified that resident #21 had a physician's order for weekly weights, and the last documented weight was on 7/02/19. The UM said she could not say why the resident's weight was not done. She said in reviewing the treatment administration record (TAR) for July 2019, it showed that resident #21 refused the weekly weights on 7/09/19, and 7/23/19. The UM said the facility's protocol, if a resident refused treatment, was for staff to notify the physician. Documentation could not be identified to indicate the physician was notified of the resident's refusal of her weekly weights. This was verified by the UM. On 8/01/19 at 1:10 PM, the director of nursing (DON) said if treatment was refused by the resident, the expectation is that the physician would be notified. The resident's TAR for July 2019 was reviewed with the DON, and assistant DON. The TAR indicated that the resident's weight was obtained on 7/02/19; she refused on 7/09/19 and on 7/23/19. The TAR also indicated the resident's weight was obtained on 7/16/19, but review of the Weights and Vitals Summary showed no weight documented corresponding with this date. Documented weights were 7/02/19 148.5 lb., and the next entry was on 7/29/19 146.3 lb. This was verified by the DON. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105974 If continuation sheet Page 8 of 10 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 105974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Orlando 3211 Rouse Road Orlando, FL 32817 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 0684 A care plan for at risk for weight fluctuation related to use of diuretic as evidenced by edema to lower extremities was initiated on 6/27/19. The goal read, will not have greater than 3 lb. weigh gain in a week. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105974 If continuation sheet Page 9 of 10 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 105974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Orlando 3211 Rouse Road Orlando, FL 32817 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure a nourishment room was kept in a clean/sanitary manner and failed to ensure food items in the nourishment room refrigerator were labeled and dated in 1 of 2 nourishment rooms. Findings On 8/01/19 at 8:31 AM, the 300 and 400 unit nourishment room had dirty dessert cups, spoons and small plate. At this time, license practical nurse (LPN) A stated that the soiled dishes should not be in the nourishment room. LPN A then opened the refrigerator door and a white styrofoam box was observed on the second shelf. The box contained left over food brought into the facility from an outside source. On another shelf inside the refrigerator was a resealable zipper storage bag with sandwiches. The bag was not labeled or dated. LPN A stated, I must throw this out as it is not labeled and has no date. Review of the facility policy and procedure for Nourishment Storage Areas read, The areas where nourishments and snacks are stored for the residents outside of the food and nutrition services department are maintained according to the local/state and federal regulations and facility guidelines. The facility designates which department is responsible for the cleanliness and sanitation of the areas where resident snacks and supplements are stored. Food is covered, labeled and dated appropriately. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105974 If continuation sheet Page 10 of 10