Inspection·February 25, 2021

F 0582 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Reviewed Facility SNF/ABN 2018 guideline for practice page 1-29. Showed page 2 The purpose is to inform the resident when their services will no longer be covered/Paid by Part A.page 5 To be considered timely, the SNF ABN form should be issued: ON or BEFORE the date Medicare coverage is ending .page 8 SNF ABN Body Complete the following fields: Beginning on blank .Page 9 Care .page 10 Reason Medicare May Not Pay .page 16 Estimated Cost .and page 17 SNF ABN Option Boxes he beneficiary must choose one of the options if there is a drop in level of care Event ID: Facility ID: 105974 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 105974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/25/2021 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 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 ensure that recommendations from the Dietitian were implemented for nutritional status related to dialysis (#65) and failed to re-evaluate a resident readmitted from the hospital with significant weight loss, (#59) for 2 of 10 residents reviewed for nutritional status out of 42 total sampled residents, (#65 & 59). Residents Affected - Few Findings: 1. Resident #65 was admitted to the facility on [DATE] and then re-admitted from an acute care hospital on 2/10/21 with diagnoses of end stage renal disease, dependent on dialysis, infected left below the knee amputation (BKA) stump, wound dehiscence with infection, protein, calorie malnutrition and diabetes. Review of the medical record revealed the Registered Dietitian's (RD) progress note dated 1/25/21 that read, his albumin level per dialysis was low at 2.9 (normal 3.2 to 5.5). Review of the 5 Day Minimum Date Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact with Brief Interview for Mental Status of 15. The assessment noted the resident received a therapeutic diet, was on dialysis and received intravenous (IV) antibiotics. An RD note dated 2/11/21 read, Recommend: double protein portions and sugar free Prosource (protein supplement) 30 milliliters (ml.) BID (twice per day) for dialysis support and support surgical wound healing . Resident #65's care plan revised on 2/11/21 noted the Resident at Risk for Weight Fluctuations and goal was to maintain adequate nutritional status. The interventions included, RD to evaluate and make diet change recommendations as needed. Review of the physician orders dated 2/10/21 included, Prosource sugar free 30 ml. 3 times per day for weight support and Liberal Renal Diet, Regular Texture. On 2/25/21 at 10 AM, the RD said she communicated monthly with the dialysis Dietitian regarding resident # 65's diet, labs, supplements and meal intake. She said the last labs she reviewed were from January 2021 and his albumin (protein) was low at 2.9. She then evaluated him again on 2/11/21 after he returned from the hospital and recommended double protein portions and sugar free ProSource twice per day. She said the process for making new recommendations included documenting in the progress notes, completing form titled Nutrition Assessment Recommendations which are placed in the mailboxes of the Unit manager (UM), Assistant Director of Nurses (ADON), and Director of Nursing (DON). She said the facility nurse then obtains physician orders for the new recommendations which can usually be implemented with the next meal. The RD was not able to find a copy of the Nutrition Assessment Recommendations form for 2/11/21 for resident #65. The RD was not aware until it was pointed out to her by the surveyor that the double protein portions for resident #65 had not been initiated now for 14 days. On 2/25/21 at 10:30 AM, the Certified Dietary Manager (CDM) joined the interview with the RD. The CDM validated the RD recommendations for double protein portions had not been initiated for resident #65. He said he did not have the Nutrition Assessment Recommendations form for 2/11/21 with the RD (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105974 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 105974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/25/2021 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few recommendations for resident #65. His process involved making a list of the orders not yet entered in the electronic system and then providing the list to the UM who follows up with the physician to obtain the needed orders. The RD said I want resident #65 to have double protein portions because he is a dialysis resident, he eats well and giving him double protein makes sense for him because he likes food. The added protein could benefit him because he loses protein in his dialysis treatments and needs it to help with healing the amputation wound. On 2/25/21 at 11 AM, the ADON said that she was covering for the UM on the 200/300/400 halls. She said that she did not remember getting any recommendations on 2/11/21 from the RD regarding increasing resident #65's protein portions. She stated that if she had received the recommendations, she would have obtained physician orders immediately, entered the order into the electronic medical record and the resident could have started the new orders with his next meal. The ADON noted she checked her mailbox daily and did not receive any recommendations from the RD for resident #65 dated 2/11/21. On 2/25/21 at 12:20 PM, resident #65's lunch tray was checked with assigned Registered Nurse (RN) A. The meal ticket read, Regular texture, liberal renal, CCH. The meal tray did not contain double protein portions and the ticket did not indicate double protein portions. On 2/25/21 at 12:40 PM, resident #65 was observed sitting up in bed eating his lunch. He was alert and oriented. He said he liked his lunch and was noted to have already consumed approximately 75% of his food and was still eating. The resident said he thought the facility staff had said something to him in the past regarding getting double protein portions. He said he would like double protein portions as he frequently refused the protein supplement as he did not like the taste. Review of the medication administration record (MAR) revealed that resident #65 was ordered Sugar free Prosource 30 milliliters 3 times per day. He refused it 7 times from 2/11 to 2/24/21 and did not receive it 9 times due to being absent from the facility. The facility Nutrition/History Assessment and the Resident Assessment effective 10/4/19 policy read, Each resident receives a comprehensive nutritional assessment to determine nutritional needs on admission, annually and when resident becomes at risk for compromised nutritional status .RD or designed completes the Nutrition Data Collection section .RD assesses the resident to determine nutritional needs by reviewing information and completing RD portion of nutrition assessment .A systematic approach will be used to optimize a resident's nutritional status. The process includes identifying and assessing each resident's nutritional status and risk factor, evaluating/analyzing the assessment information, developing and consistently implementing pertinent approaches and monitoring the effectiveness of interventions and revising them as necessary. 2. Review of resident #59's medical record revealed he was initially admitted to the facility on [DATE] and re-admitted back to the facility on 1/09/2021 with diagnosis of Alzheimer's disease, dysphagia, and newly diagnosed congestive heart failure. Review of the Minimum Data Set (MDS) dated [DATE] documented resident #59 had a Brief Interview for Mental Status (BIMS) score of 03 out of 15, which indicated severe cognitive impairment. He required one person extensive assist for eating and had 5% weight loss in the last month and a loss of 10% of weight in the last six months and was not on a prescribed weight loss regimen. Review of resident #59's care plans with a completion date of 12/16/2020 documented he had a care plan for being at risk for weight fluctuations related to polypharmacy with goals to maintain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105974 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 105974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/25/2021 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 0692 adequate nutritional status as evidenced by no sign of weight change in 1, 3 and 6 months. Level of Harm - Minimal harm or potential for actual harm Review of resident #59's medical record revealed he had a nutrition assessment completed upon his initial admission, dated and signed by the Registered Dietitian on 11/23/2021. There was no evidence of a nutritional assessment completed after his re-admission on [DATE]. Residents Affected - Few Review of physician's orders revealed an active order dated 1/09/2021 for regular diet, with regular texture and thin consistency with fortified foods. A review of the resident's weights showed he weighed 209.6 pounds at admission and one month later on 12/28/2020, he weighed 187.6 lbs., a 10.5 % weight loss. Three months post admission, on 2/20/2021, the resident weighed 164.4 lbs. which was a 21.56% loss. On 02/23/21 at 12:23 PM, resident #59 was resting in bed with his lunch tray at his bedside. Certified Nursing Assistant (CNA) I came in to assist the resident to with his lunch. He ate 25% of his lunch. On 02/24/21 at 12:28 PM, resident #59 consumed 50% of his meal. On 02/23/21 at 5:19 PM, resident #59 stated he was not hungry and did not have an appetite. He said the loss of appetite had been going on for one week or so. He said he was not thirsty either. Review of resident #59's medical record revealed on 02/14/2021, he had a recently identified, facility acquired, unstageable pressure ulcer to his sacrum and heels. On 2/24/21 at 5:42 PM, the Registered Dietitian (RD) stated on 1/18/2021 resident #59 triggered for weight loss and she recommended fortified foods for weight stabilization. She stated at that time, the resident's sister was bringing in snacks. She noted she did not recommend any supplements. The RD acknowledged that there is a system in place to identify residents with weight loss but due to staff shortages I am not getting consistent weights. In the beginning, we did that, I had to learn to back off because of the lack of communication with staff. There is not enough staff to feed or get weights. Review of the Supplemental Nutrition policy, last revised on 01/01/2007, documented, supplemental nutrition is provided to the residents per physician's order. Supplemental nutrition may be provided for weight maintenance, weight loss, poor intake, low albumin level and/or pressure ulcers .Guidelines: residents with weight/intake concerns are evaluated weekly . Review of Residents with weight/intake concerns policy, last revised on 01/02/2007 documents, residents who have a significant weight variance are evaluated, and approaches are implemented per resident as needed . Review of the Residents with Pressure Ulcers policy, last revised on 11/11/2016, documents, the food and nutrition services department provides proper nutritional support when a resident is identified to be at risk for pressure ulcer/skin breakdown or has an identified pressure ulcer(s) . Review of the Nutrition/History Assessment and the Resident Assessment Instrument (RAI), last revised on 1/1/2007, documents, each resident receives a comprehensive nutrition assessment to determine nutritional needs .The nutrition data collection/assessment is completed on admission, annually and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105974 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 105974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/25/2021 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 0692 whenever the comprehensive minimum data set (MDS) is completed . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105974 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 105974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/25/2021 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 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 dressing changes for a midline intravenous (IV) catheter according to current professional standards of practice for 1 of 2 residents reviewed for IV care out of 42 sampled residents, (#209). Residents Affected - Few Findings: Resident #209 was admitted to the facility on [DATE] with diagnoses of cellulitis to lower limbs. He had a Midline IV line insertion order dated 2/15/21 for administration of IV antibiotics (Zosyn) for wound infection through 2/22/21. He had additional nursing orders in effect dated 2/17/21 for IV Midline Catheter-Measure upper arm circumference 10 centimeters above antecubital every 2 days with gauze dressing present, and flushing IV with normal saline every shift (3 times per day). On 2/22/21 at 12:50 PM, resident #209 was observed in his room sitting up in chair eating lunch. He had a gauze dressing covering his right upper arm midline IV site dated 2/21/21. Due to the presence of gauze over IV site, visualization for any signs of symptoms of infection was not possible. There was an IV pole next to resident #209's bed with empty bag of IV antibiotics hanging from the pole. On 2/22/21 at 12:55 PM, the Assistant Director of Nursing (ADON) acknowledged resident #209 had IV right upper arm with gauze under transparent dressing and over IV site dated 2/21/21. The ADON said the nurses should not have placed gauze over IV site as the insertion site could not be visualized with gauze present. On 2/24/21 at 9:32 AM, resident #209 was observed sitting up in chair. He still had the same gauze dressing with date of 2/21/21 covering the IV site right upper arm. The dressing was now over 48 hours or greater than 2 days duration and per standard of nursing practice should have been changed yesterday 2/23/21. The Infusion Nurses Society specifies that the site care frequency is based on type of dressing: Transparent semipermeable dressings should be changed every 5-7 days and gauze dressings should be changed every 2 days (www.sciencedirect.com). On 2/24/21 at 9:45 AM, Registered Nurse (RN) B verified she was assigned to resident #209 yesterday on the day shift 7 AM to 3 PM. She said that she flushed the IV but did not look at the site as it did not prompt on electronic medical record (EMR) for a dressing change on her shift. RN B observed the resident's dressing on his right upper arm IV site and acknowledged the gauze in place dated 2/21/21 was changed by RN A this past Sunday. RN B said the IV dressing should have been changed yesterday. She added that as per standards of practice it should be changed every 48 hours for gauze dressing and every 7 days for clear transparent dressing. On 2/24/21 at 9:53 AM, RN A said she changed resident #209's IV dressing on his right upper arm IV on Sunday 2/21/21. She said she used gauze as the facility did not have antibiotic disks to put over the site. On 2/24/21 at 11:30 AM, the Director of Nursing (DON) said, she did not know why the orders in the computer were put in for gauze dressing every 2 days and the nurses should have used transparent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105974 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 105974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/25/2021 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 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete dressing. Gauze can harbor bacteria if not changed every 2 days. The DON reviewed the Medication Administration Record (MAR) which showed the nurses had documented gauze dressing change every 2 days which was not accurate since the nurse did change dressing with gauze on 2/21/21 and it was not on MAR. The nurse also documented on 2/22/21 that the dressing was changed, and we know that it was not. According to the facility Midline Catheter Dressing Change policy and procedure revised 7/1/12, The catheter insertion site is a potential entry site for bacteria that may cause a catheter related infection. A transparent dressing is the preferred dressing .When a transparent dressing is applied over a sterile gauze dressing it is considered and gauze dressing and is changed .Every two days . Event ID: Facility ID: 105974 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 105974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/25/2021 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 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 follow physician's orders for oxygen therapy for 1 of 5 residents reviewed for respiratory care, out of 42 total sampled residents (#100). Residents Affected - Few Findings: Resident #100 was re-admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease, pneumonia, obstructive sleep apnea, dependence on supplemental oxygen (O2) and cognitive deficit disorder. Review of the Minimum Data Set (MDS) dated [DATE] revealed resident #100 received oxygen (O2) therapy. Resident #100 had a physician's orders dated 1/15/2021 for O2 at 2.5 liters/minute (LPM) continuously per nasal cannula (NC) every shift and keep the pulse oxygen levels >89%. Review of the care plan for resident #100, documented she had diagnosis of pneumonia with a goal to be free of symptoms of respiratory distress. There was no care plan for oxygen therapy nor any interventions to administer oxygen per physician's orders. On 02/25/2021 at 12:05 PM, the MDS Coordinator stated the process for care planning included reviewing new orders, faxing them to the to pharmacy, then transcribing them onto the Medication Administration Record (MAR) or the Treatment Administrator Record (TAR) and then initiating a care plan. It is ultimately MDS's job to develop care plans. If it does not get done, then it is definitely MDS's responsibility. Review of resident #100's MAR and TAR revealed no evidence of monitoring to ensure oxygen was being administered at 2.5 LPM via NC. Review of the medical record of resident #100, revealed on 2/10/2021 at 12:49 AM, her O2 saturation rate dropped to 88%. Observations conducted on 02/22/2021 at 11:59 AM, 02/22/21 2:05 PM, 02/22/21 4:30 PM, 02/23/21 5:08 PM, 02/24/21 12:45 PM revealed resident #100's oxygen concentrator was set at 2 LPM via NC. On 02/24/2021 at 2:33 PM, Registered Nurse (RN) A stated resident #100 received O2 at 2 LPM via NC. RN A stated her process was to check resident #100's oxygen every time she went in the room and she checked it approximately three or four times today. She could not remember what the oxygen was set at. On 2/24/2021 at 2:37 PM, RN A checked the resident's oxygen. RN A stood looking down at the oxygen concentrator flow meter and said, it's on 2.5 L. When RN A observed the oxygen flow rate at eye level, she said, oh, it's at 2 LPM, not 2.5. She acknowledged the oxygen flow rate should have been set at 2.5 LPM. Review of the Procedure checklist for oxygen administration, dated 2/25/2021 documented, .Oxygen administrator objective: to administer oxygen according to the standard of care . verify the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105974 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 105974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/25/2021 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 0695 practitioner's order. Level of Harm - Minimal harm or potential for actual harm Review of the Oxygen Administration policy, reviewed November 20, 2020 documented, .all respiratory devices should be checked every shift by the licensed nurse . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105974 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 105974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/25/2021 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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** Based on observation, interview and record review, the facility failed to ensure medications were administered as prescribed for 2 of 42 sampled residents, (#85, #87). Findings: Resident #85 was admitted to the facility on [DATE]. Her diagnoses included Gastro-Esophageal Reflux Disease, and compression fracture of vertebrae. On 02/22/21 at 2:56 PM, resident #85's roommate, resident #87 had medications in two stacked cups on his bedside table. The top cup contained a cream and the bottom cup had 2 pills. One pill was oval and the other round. Registered Nurse (RN) B came into the room and said she did not see the medications on resident #87's bedside table this morning. She took the medications, reviewed the Medication Administration Record for both residents. She determined the medications were for resident #85. She said the two medications were Synthroid, for hypothyroidism and Protonix for esophageal reflux. She added that resident #85 should have received these medications at 6 AM. A telephone interview was conducted on 02/24/21 at 9:49 AM with RN H, who was the residents' assigned nurse at 6 AM. She said she was giving medications to resident #85 at the end of her shift when she was called to another room for water leak. I set the medications for #85 on the roommate's bedside table. I totally forgot that I misplaced the medication for resident #85 on resident #87's bedside. RN H was not aware she did not give resident #85 her medications. A review of the Medication Administration Record showed RN H had signed the medication as given. On 02/25/21 at 2:10 PM, the Assistant Director of Nursing acknowledged that resident #85 had not received her 6 AM medications. Review of the Clinical Services Manual for Administration of Medication (Revised 5/06/20) Standard: All medications are administered safely and appropriately per physican order to address residents' diagnoses and signs and symptoms. The Policy noted :Medication administration is the responsibility of the nursing professional. Only licensed personnel administer medications. Review of the Pharmacy Med Pass Checklist under medication administration noted Nurse is with resident until meds are swallowed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105974 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 105974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/25/2021 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure the appropriate rinse water temperature was maintained and rinse water pressure was monitored for the high temperature dish machine to ensure proper sanitation of dishes, silverware and glassware used by the residents. Residents Affected - Some Findings: On 2/22/21 at 2:24 PM, the kitchen staff were in the dish room washing lunch dishware in the mechanical dishwashing machine. The wash temperature was 165-170° Fahrenheit (F). The rinse temperature was 195-200° F. Observation of the pressure gauge used to monitor the water pressure during the rinse cycle revealed the pressure was greater than 40 pound per square inch (PSI). Interview with the dietary aide who monitored the machine for temperature and functioning was not aware he had to monitor the PSI. During the observation, the Food Service Director also said he was not aware to monitor PSI. When questioned what the dial should register during the rinse cycle, he was not able to explain what the pressure should read during the rinse cycle. He confirmed they were not monitoring the rinse cycle PSI. Review of the Dishwashing temperature logs from 12/01/20 to 2/22/21 did not include monitoring of the PSI. Review of the operating manual for the high temperature dishwashing machine noted the incoming water temperature should be 180°F and the rinse cycle flow pressure required was 15-25 PSI. Review of Centers for disease Control (CDC) environmental health operations manual chapter 13.7, Warewashing evaluation pressure gauge for the in line hot water injection point pressure should be 15-25 PSI. (HTTPS://www.cdc.gov/nceh/vsp/operationsmanual/opsmanual2000.pdf) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105974 If continuation sheet Page 12 of 12