Health inspection·June 29, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that if the platelet levels dropped again to 30 K/uL or less, the resident required hospitalization for a platelet transfusion. On 6/29/2023 at 11:26 AM, the Unit Manager said the Psychiatric Advanced Practice Registered Nurse provided nurses with orders by progress notes, entering into the medical record software, or verbalized, and sometimes handwrote them. She said nurses transcribed any verbal or handwritten physician's orders into the medical record to implement. She reviewed resident #87's medical record and acknowledged there were orders to complete laboratory testing for Depakote levels on 6/01/2023 and 6/08/2023. She said the lab work was missed, and she could not explain why it had not been done. On 6/29/2023 at 11:39 AM, the Director of Nursing (DON) explained nurses transcribed physicians' orders and monitored residents for adverse effects of medications included in their plan of care. She reviewed resident #87's medical record and acknowledged there were labs ordered for Depakote levels included in the Psychiatry notes on 6/01/2023 and 6/08/2023. She stated the resident should have had lab tests done 3 weeks prior to monitor for toxicity. On 6/29/2023 at 4:21 PM, the DON explained nurses were expected to transcribe orders as part of their routine duties and responsibilities. She said nurses were provided education, training, and job expectations during new hire orientation, annually, and as needed. She said resident #87's medical record clearly showed the plan of care included interventions for lab orders that were not implemented and she concluded it happened due to, human error. The facility policy and procedures titled, Procedural Guidelines for Physician Orders SHCEDU0001.21 read, Authorized center staff should enter new Physician orders in the electronic ordering system as soon as they are received. The Facility Assessment Tool dated 10/31/2022 read, 3.4 . Registered Nurse/Licensed Practical Nurse On Hire and Annual . Transcribe Physician's Orders and administer medication according to facility policy and procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105987 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 105987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hunters Creek Nursing and Rehab Center 14155 Town Loop Blvd Orlando, FL 32837 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 0880 Provide and implement an infection prevention and control program. 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 maintain proper infection control practices to prevent contamination during wound care for 1 of 3 residents observed for wound care out of a total sample of 38 residents, (#1). Residents Affected - Few Findings: Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cerebrovascular disease, sepsis, urinary tract infection, bacterial disease, diabetes mellitus type 2, peripheral vascular disease, non-pressure wound left lower lateral back and pressure wounds sacrum and right lower lateral back. Review of resident #1's medical record revealed a care plan for actual skin breakdown revised on 6/19/23. The care plan indicated the resident had non pressure wound on left lateral lower back and pressure wounds right lower lateral back and sacrum. The care goal read, Resident will show signs of healing and remain free from complications .Wounds will be free from infection . Interventions included a wound care specialist for weekly wound evaluation/treatment. The physician's order for wound care dated 6/23/23 directed nurses to cleanse the lateral back wounds with normal saline, apply gauze wet with Dakins (bleach) solution and secure with gauze island border dressing daily. The wound treatment order dated 6/19/23 for the sacrum was to apply collagen powder and hydrogel with silver, secure with border with silver every day shift and as needed. On 6/28/23 at 2:25 PM, an observation was conducted of wound care for resident #1's right and left lower lateral back and sacral wounds. Licensed Practical Nurse (LPN) A assisted with positioning the resident and the Director of Nursing (DON) was present during care as well. The Wound Care Nurse performed hand hygiene, gathered wound care dressing supplies, and established a clean working area on the resident's overbed table. LPN A positioned the resident who was in bed onto her left side. The Wound Nurse removed the soiled dressing from the resident's right lower lateral back wound that had moderate amount of blood and yellowish drainage. The Wound Nurse, with the DON's prompting then washed her hands with soap and water, donned new gloves and applied new clean dressing per physician orders. LPN A then positioned the resident onto her right side and the Wound Nurse proceeded to remove the soiled dressing from the resident's left lower back wound. The dressing had moderate amount of bloody drainage. The Wound Nurse proceeded to clean the wound with normal saline and applied Dakins moist gauze and secured it with a border dressing. The Wound Nurse did not perform hand hygiene or change her gloves after she removed the soiled dressing and applied the clean dressing. Prior to doing wound care for the resident's sacral wound, the Wound Nurse removed her soiled gloves, washed her hands in the bathroom, donned new gloves and proceeded to remove the soiled dressing. The dressing had small amount of bloody drainage. The Wound Nurse proceeded to clean the sacral wound with normal saline, applied collagen powder and hydrogel with silver to wound bed using tongue blade and secured it with border dressing. The Wound Nurse did not perform hand hygiene or change gloves after removing the soiled dressing from the sacrum or application of new dressing. For 2 of 3 wounds the wound nurse did not perform hand hygiene and change gloves between dirty and clean procedures. On 6/28/23 at 2:55 PM, an interview was conducted with the Wound Nurse, DON, and Regional Nurse. The Regional Nurse assisted with the interview as the Wound Nurse's primary language was Spanish. They were informed the Wound Nurse did not perform hand hygiene or change gloves while observed doing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105987 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 105987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hunters Creek Nursing and Rehab Center 14155 Town Loop Blvd Orlando, FL 32837 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 0880 Level of Harm - Minimal harm or potential for actual harm resident #1's wound care of her sacral and left lower back wounds. The DON and Wound Nurse validated the findings. The DON acknowledged the Wound Nurse did the wound care to resident #1's right lower back wound correctly with her prompting but did not use appropriate technique for the sacral and left lower back wounds. The DON noted it was an infection control concern when a nurse did not remove soiled gloves and perform hand hygiene after removing soiled dressings. Residents Affected - Few A facility policy and procedure for Dressings, Dry/Clean revised September 2013 read, The purpose of this procedure is to provide guidelines for application of dry, clean dressings .Steps in the Procedure .6. Put on clean gloves. Loosen tape and remove soiled dressing. 7. Pull glove over dressing and discard into plastic biohazard bag. 8. Wash and dry your hands thoroughly. 9. Open dry, clean dressings(s) by pulling corners of the exterior wrapping outward, touching only the exterior surface .1. Using clean technique The facilities' policy for Hand Washing/Hygiene revised 6/5/19 read, The facility considers hand hygiene the primary means to prevent the spread of infections .Soap and water is required for hand hygiene when: a. Hands are visible soiled .c. After potential exposure to body fluid FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105987 If continuation sheet Page 4 of 4