Inspection·November 16, 2023

F 0561 Level of Harm - Minimal harm or potential for actual harm preference was to wear the condom catheter at night to avoid waking up frequently to use the urinal and/or waiting for staff to assist him with the urinal. On 11/14/23 at 9:43 AM, Certified Nursing Assistant A stated resident #101 used a urinal. She confirmed he used to wear a condom catheter at night, but it was discontinued as it caused redness on his penis. Residents Affected - Few On 11/14/23 at 2:32 PM, resident #101's wife stated he was admitted to the facility with a condom catheter and he definitely wanted to continue using one at night. She explained her husband drank a lot of water during the day and without the condom catheter, he woke up several times during the night either to use the urinal, get assistance to empty it or change the bedding if he spilled it. Resident #101's wife confirmed nurses had not applied the condom catheter for almost a month. On 11/14/23 at 5:09 PM, Licensed Practical Nurse (LPN) B recalled resident #101 had an order for a condom catheter on admission to the facility from his home. She confirmed he did not want to use the urinal at night. LPN B acknowledged although the order was listed on the TAR she had not provided the condom catheter during the past two weeks. On 11/15/23 at 9:01 AM, LPN C acknowledged resident #101 had not worn his condom catheter for a while and she usually documented that the device was not in place at the start of the day shift. She recalled she recently spoke to the Advanced Practice Registered Nurse who verified the resident's skin issue was resolved and he could resume using the condom catheter at night. LPN C said, We need to honor choices as [residents] have a right. On 11/15/23 at 9:38 AM, the Director of Nursing (DON) confirmed she discussed use of the condom catheter with resident #101 and his family on several occasions. She said, He absolutely wants to use the condom catheter.There is no reason the resident should not have it if his skin is intact. The DON reiterated resident #101 had the right to choose to use the condom catheter at night if he wanted to do so. Review of the facility's Standards & Guidelines for Exercise of Rights by Resident or Surrogate, effective 3/01/23, revealed an objective to protect and promote the rights of each resident to a dignified existence and self-determination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106153 If continuation sheet Page 2 of 15 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 106153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy Pointe at Ucf 2120 Hestia Loop Oviedo, FL 32765 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatments as ordered to promote wound healing for 1 of 2 residents reviewed for non-pressure skin conditions, out of a total sample of 13 residents, (#101). Residents Affected - Few Findings: Review of the medical record revealed resident #101 was admitted to the facility on [DATE] with diagnoses including right side weakness and paralysis and a communication disorder following a stroke, and chronic pain. Resident #101 had a care plan initiated on 5/15/23 for risk for pressure and non-pressure skin alterations related to reduced mobility, weakness, and use of antiplatelet drugs. The care plan was revised to show the resident sustained a skin tear on his right hand on 11/08/23. The interventions included administer treatments as ordered and monitor for effectiveness. Review of the Order Listing Report revealed a physician order dated 11/09/23 to cleanse the outer aspect of resident #101's right hand with normal saline, pat dry, apply the dressing, and change daily every day shift. On 11/13/23 at 10:15 AM, resident #101 had a tan-colored dressing on the back of his hand dated 11/12/23. On 11/14/23 at 10:26 AM, the dressing was unchanged on the dorsal surface of resident #101's hand. The resident's assigned nurse, Licensed Practical Nurse (LPN) D, was at the bedside and she validated the dressing was dated 11/12/23. On 11/14/23 at 2:32 PM, the resident still had the right hand dressing dated 11/12/23. On 11/14/23 at approximately 3:15 PM, resident #101's medical record was reviewed. The Treatment Administration Record (TAR) was initialed by LPN C on 11/13/23 and by LPN D on 11/14/23 to indicate the resident's right hand dressing had been changed as ordered. On 11/14/23 at 3:37 PM, during observation of resident #101's right hand dressing with LPN D, she confirmed it was the same dressing, dated 11/12/23. She acknowledged she documented that she did the dressing change during the 7:00 AM to 3:00 PM day shift although the date on the dressing showed it had not been changed since 11/12/23. LPN D said, I was going to do it before I left. On 11/14/23 at 3:57 PM, the Director of Nursing (DON) was informed resident #101's dressing had not been changed for two days despite documentation in the medical record by two nurses to show it had been done. The DON verified nurses should never document that a task was done until it was completed. She stated her expectation was nurses would administer treatments according to the physician's order. The DON explained the purpose of regular wound care and application of treatments was to enable nurses to monitor wound status, evaluate for and avoid complications, and promote wound healing. On 11/15/23 at 9:01 AM, LPN C confirmed she was resident #101's assigned nurse on Monday, 11/13/23. She acknowledged she documented that his right hand dressing change was done, although she did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106153 If continuation sheet Page 3 of 15 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 106153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy Pointe at Ucf 2120 Hestia Loop Oviedo, FL 32765 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 do it. She said, It was an accident. I know I should not document before doing something. Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy and procedure for Clean Dressing Change revealed a purpose to protect the wound, prevent irritation and infection, and promote healing. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106153 If continuation sheet Page 4 of 15 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 106153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy Pointe at Ucf 2120 Hestia Loop Oviedo, FL 32765 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 appropriate care and services according to accepted professional standards related to conducting a pressure wound assessment on admission and applying wound treatment as ordered to promote healing and prevent worsening of a pressure ulcer for 1 of 2 residents reviewed for pressure ulcers, out of a total sample of 13 residents, (#104). Residents Affected - Few Findings: Review of the medical record revealed resident #104 was admitted to the facility on [DATE] with diagnoses including stroke with right side weakness and paralysis, traumatic brain injury, and gastrointestinal hemorrhage. Review of resident #104's Clinical admission form dated 11/13/23 revealed the nurse found the resident's skin was warm and dry, and her skin color and turgor or elasticity were normal. The document indicated there was a new skin issue, a dressing on coccyx (back of body above buttocks). The admission evaluation revealed the wound had tunneling. The National Pressure Injury Advisory Panel defines a pressure injury as localized damage to the skin and underlying soft tissue usually over a bony prominence.The injury can present as intact skin or an open ulcer and may be painful. (Retrieved on 11/27/23 from www.npiap.com). Tunneling wounds are channels which extend from the wound, into or through subcutaneous tissue or muscle. Tunneling can be the result of infection or trauma to the wound or surrounding tissue. Tunneling wounds need careful wound assessment and management. (Retrieved on 11/27/23 from www.woundsource.com). Resident #104 had a care plan for a documented pressure ulcer, initiated on 11/13/23. The goals were to prevent future pressure ulcers, manage the pressure ulcer, and the wound would show signs of improvement. The interventions included evaluate the characteristics of the pressure ulcer, monitor the pressure ulcer for signs of progression or decline, provide wound care according to treatment orders, and refer the resident to a specialized wound management practitioner. A care plan for wound management, initiated on 11/13/23, included the goal that the resident's wound would show signs of improvement. The interventions included measure the pressure ulcer at regular intervals and provide wound care as ordered. Review of Progress Notes revealed a note by Licensed Practical Nurse (LPN) B regarding resident #104's Skin Only Evaluation. The document included the same information documented on the Clinical admission form and indicated the resident's skin issue needs review. The sections of the progress note designated for Completed Clinical Suggestions and Comments were left blank. Review of resident #104's medical record revealed no documentation to show her pressure ulcer was assessed during the 48 hour period since her admission to the facility. The medical record had no information on the number, type, or stage of the wound(s) and no physician order for appropriate pressure pressure-reliving devices. There was no description of the wound's characteristics including signs and symptoms of infection, presence of drainage, or the type of treatment and dressing in place. On 11/13/23 at 10:13 AM, resident #104 stated she was newly admitted to the facility this morning, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106153 If continuation sheet Page 5 of 15 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 106153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy Pointe at Ucf 2120 Hestia Loop Oviedo, FL 32765 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 0686 Level of Harm - Minimal harm or potential for actual harm within the last two hours. She explained she would be receiving wound care services for a wound on her tailbone. On 11/14/23 at 9:23 AM, resident #104 stated a nurse changed her dressing last night. She could not recall the nurse's name or the time the task was completed. Residents Affected - Few On 11/14/23 at 10:02 AM, LPN D stated to her knowledge resident #104 did not have wound care scheduled during the day shift. On 11/15/23 at 9:10 AM, LPN C stated she was the nurse on duty when resident #104 was admitted on the morning of 11/13/23. She explained she did not finish the resident's admission assessment during the day shift nor lift the dressing on her coccyx to assess the wound. LPN C stated resident #104's admission orders included a wound treatment order and she felt the resident should be seen by a wound care physician. She stated the wound care physician was in the facility on 11/13/23 but he did not assess resident #104's wound as she had existing orders from another physician and he had not been consulted. LPN C recalled the wound physician instructed her to follow the current treatment orders as written, until a new order was received. She stated she would do the treatment today as it was scheduled for the day shift. On 11/15/23 at 12:11 PM. LPN C checked resident #104's coccyx and confirmed there was a tan-colored foam dressing dated 11/14/23 in place. She explained she would not be able do the resident's wound care as scheduled as she did not have the necessary supplies. LPN C explained on the day resident #104 was admitted , she noted there was an order for Dakin's solution to cleanse the wound. She said, I was unsure if we had it in-house at that time. Today I checked, and [there was] none in treatment cart. LPN C stated she called the pharmacy and was told the Dakin's solution was scheduled for delivery today. Observation of all treatment cart drawers with LPN C revealed no Dakin's solution. When asked how wound care was done on 11/14/23, as indicated by the date on resident #104's dressing, if the Dakin's solution was not available, LPN C stated she was not sure what the nurse used. Dakin's solution is used to prevent and treat skin and tissue infections that could result from cuts, scrapes and pressure sores. Dakin's solution is a type of hypochlorite solution. It is made from bleach that has been diluted and treated to decrease irritation. Chlorine, the active ingredient in Dakin's solution, is a strong antiseptic that kills most forms of bacteria and viruses. (Retrieved on 11/27/23 from www.webmd.com/drugs/2/drug-62261/dakins-solution/details). Review of the Medication Administration Record (MAR) revealed resident #104 had an admission physician order to flush the sacral wound with full strength Dakin's solution, pack with calcium alginate silver rope, and cover with an absorbent dressing. The wound care with dressing change was scheduled once daily, on the day shift, and as needed. The document was initialed by LPN C on 11/13/23 to show the task was not done as the medication was not available. The MAR was initialed by LPN D on 11/14/23 to indicate she completed resident #104's wound care as ordered. On 11/15/23 at 12:31 PM, the Director of Nursing (DON) stated her expectation was nurses would follow facility processes to obtain medication and/or supplies that were not available. She explained the pharmacy did not stock full strength Dakin's solution and the physician should have been notified. The DON was informed there was no documentation of an admission wound assessment for resident #104. She confirmed the admission nurse was responsible for removing the dressing and evaluating the wound. She acknowledged an LPN's scope of practice did not allow staging of wounds; however, she verified an LPN could measure and describe wounds, and either herself or the wound physician would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106153 If continuation sheet Page 6 of 15 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 106153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy Pointe at Ucf 2120 Hestia Loop Oviedo, FL 32765 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few determine the stage. The DON explained it was essential to obtain initial wound measurements and description on admission for comparison with weekly assessment findings. She confirmed her expectation was nurses would follow accepted standards of practice related to providing wound care as ordered. On 11/15/23 at 1:58 PM, after he assessed resident #104's wound, the attending physician explained her pressure ulcer had a dusky, ischemic appearance. He verified there was no calcium alginate packed into the wound as ordered. He stated his recommendation was a consultation with a wound specialist physician for assessment and possibly a change in wound treatment. The attending physician stated the resident would also require a specialty air mattress for her bed. Review of the facility's policy and procedure for Prevention of Pressure Ulcer/Injury (undated) revealed the purpose to prevent skin breakdown and development of pressure ulcers/injuries. The document indicated if a pressure ulcer was present the licensed nurse would .record condition of the skin, including stage, size, site, depth, color, drainage, and odor as well as treatment provided. The policy instructed nurses to inspect every resident's skin upon admission and once a shift, particularly over bony prominences such as heels and the sacrum. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106153 If continuation sheet Page 7 of 15 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 106153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy Pointe at Ucf 2120 Hestia Loop Oviedo, FL 32765 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 0726 Level of Harm - Minimal harm or potential for actual harm Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on interview and record review, the facility failed to ensure nursing staff had the appropriate competencies and skill sets required to meet residents' needs as indicated by the plans of care. Residents Affected - Some Findings: Review of the Facility Assessment, effective March 2023, revealed with a census of eight residents, the facility would be staffed with a Director of Nursing (DON) and an Assistant DON (ADON). The document indicated the facility provided care for residents with short-term and long-term rehabilitative needs, physical and cognitive impairments, respiratory conditions, infectious conditions, and diabetes. The Facility Assessment revealed it would admit residents with common diagnoses such as skin ulcers and injuries, urinary incontinence, anemia, and heart disease. Staff competencies required to provide the level and scope of care needed would be evaluated at least annually, and competencies for all nursing staff would address common diagnoses. The document indicated all staff would receive training on Resident Rights and Infection Control and Prevention. Licensed nurses were required to complete additional training on topics that included admission assessment, skin assessment, pressure injury assessment, specialized care such as wound care and dressings, and medication administration. Certified Nursing Assistants (CNAs) were required to complete in-service training on activities of daily living including transfers, use of a gait belt, safe resident handling, and prevention of skin breakdown. The Facility Assessment revealed the job descriptions for nurses and CNAs outlined their job requirements and essential functions, and nursing staff from staffing agencies were expected to meet the same standards as facility personnel. On 11/14/23 at 10:13 AM, Licensed Practical Nurse (LPN) D stated she was hired by the facility about two weeks ago. She stated she had two days of general orientation in the classroom setting and then she worked alongside a nurse for three days. LPN D explained she shadowed the nurse for two days and on the third day, the nurse watched as she completed all tasks for the residents. LPN D stated there was a checklist of skills and the nurse signed off to verify she completed all requirements. She explained today was her first day on her own, and she felt comfortable with her assignment. On 11/14/23 at 9:35 AM, during medication administration, LPN D omitted a resident's medication as it was not available in the medication cart. She did not call the pharmacy or attempt to retrieve the drug from the medication room. On 11/14/23 at 11:13 AM, as she continued medication administration, LPN D failed to read pharmacy instructions written on blister packs of prescribed medication for another resident. She crushed a tablet and opened a capsule, both of which were to be swallowed whole. On 11/14/23 at 11:39 AM, the DON was informed of medication errors made by LPN D. She stated all nurses were expected to read medication instructions and recognize the types and forms of drugs that should be taken whole. The DON stated there was an emergency kit in the medication room, and nurses should check the kit and facility stock to ensure residents received ordered medication. The DON escorted LPN D to the medication room and educated her on retrieval of medication from the emergency kit as the nurse was not knowledgeable of the procedure. Review of the facility's incident log and incident investigation findings revealed on 10/03/23 at approximately 7:45 PM, an agency CNA reported that one of his assigned residents sustained a skin (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106153 If continuation sheet Page 8 of 15 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 106153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy Pointe at Ucf 2120 Hestia Loop Oviedo, FL 32765 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some tear when he transferred her from the wheelchair to the shower chair. The investigative report, completed by the DON on 10/04/23, revealed the agency CNA failed to follow the resident's care plan which included the directive to transfer her with assistance of two staff. On 11/14/23 at 12:13 PM, the DON explained the facility worked with a contracted staffing agency that provided a core team of nursing staff. The DON stated the facility attempted to utilize the same agency staff if possible, and if someone did not perform satisfactorily, he/she would not be permitted to return to the facility. The DON confirmed she fulfilled the role of the facility's staff educator, but when asked about how she ensured agency staff were aware of the facility's policies, procedures, and protocols she said, We do not do competencies with agency staff. On 11/15/23 at 4:15 PM, the facility's Administrator confirmed the facility used a contracted staffing agency. He said, There is no competency check done by the facility. We rely on the agency to send us competent nursing staff. On 11/14/23 at 3:57 PM, the DON was informed of a concern related to documentation by two nurses, LPNs C and D, that reflected dressing changes were done on 11/13/23 and 11/14/23 although the task had not been done since 11/12/23. The DON confirmed her expectation was nurses would do treatments according to physician orders and not sign off a task as completed until it was done. On 11/15/23 at 12:31 PM, the DON was informed of concerns regarding a newly admitted resident with a pressure ulcer whose wound had not yet been assessed although she had been in the facility for over 48 hours. She was informed of additional concerns related to staff not informing the physician that the required wound cleansing solution was not available, and not doing wound care as ordered but documenting in the medical record that it was done. The DON confirmed the admission nurse should have evaluated the wound on admission and reviewed treatment options with the physician if there was a problem obtaining supplies. She stated she typically assessed residents with pressure ulcers within 24 hours of admission or discovery of a wound, and she would measure the area and determine the stage of the wound at that time. The DON acknowledged she did not assess the resident's pressure ulcer. On 11/15/23 at 2:15 PM, the DON was informed of infection control concerns noted during a clean dressing change procedure by LPN C. She acknowledged it was concerning that LPN C did not perform hand hygiene and wound cleansing according to professional standards. The DON stated it was disappointing that LPNs C and D did not reach out to her for additional training and/or assistance. When asked about how the facility ensured nursing staff had the necessary skills to care for the residents, the DON said, The nurses are not required to perform these skills for me before they go out onto the floor. They come to us as licensed nurses with the expectation that they have the basic skills of a nurse. I have not had them do return [demonstrations] or skills. The DON stated the facility did not have a skills lab for nurses to practice or perform clinical procedures. She verified there was mandatory online training but nobody looks at staff for competency at this time. The DON stated as the facility census grew, the plan was to hire an ADON who would fulfill the role of Staff Educator. Review of the Nurse Unit Orientation Checklist form revealed the document would be maintained and managed by the DON after completion. The form indicated a nurse mentor would be assigned to a nurse orientee, and both nurses would initial designated areas to verify the topic was completed. The mentor was to note whether the orientee's performance was satisfactory. Unit orientation topics included use of the electronic medical record, reporting and communicating incidents and events, chart reviews such as recording vital signs and weights, completing incident reports and hospital transfers, new admission assessments, and Infection Control which included handwashing and infection prevention. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106153 If continuation sheet Page 9 of 15 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 106153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy Pointe at Ucf 2120 Hestia Loop Oviedo, FL 32765 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The Nurse Unit Orientation Checklist did not include clinical nursing skills and competencies such as observation of medication administration and wound care. On 11/15/23 at 3:49 PM, the DON stated she was unable to locate the checklist to show LPN D completed required tasks during her orientation to the unit. The DON stated she contacted LPN D's nurse mentor by phone and he informed her the checklist form was in his locker. On 11/16/23 at 9:01 AM, the Human Resources Manager confirmed he was not able to locate competency or orientation checklists for the nurse who was assigned to mentor LPN D. On 11/16/23 at 10:15 AM, the Administrator explained LPN D's orientation checklist was not in her nurse mentor's locker as previously stated by the DON. He provided a photograph he obtained from LPN D who had the checklist her possession. The 3-page document was blank in the areas designated for the mentor's initials and signature and none of the tasks had documentation to show whether LPN D's performance was satisfactory or not. On 11/16/23 at 10:33 AM, the DON reviewed LPN D's orientation checklist and confirmed it was incomplete. She explained she spoke with the nurse mentor and he informed her that LPN D did well. She confirmed she did not ask the mentor for the completed checklist and acknowledged LPN D was permitted to work independently on 11/14/23 without evidence her orientation was completed satisfactorily. The DON explained the Human Resources staff was unable to locate competencies for any member of nursing staff. She stated every nurse, although licensed, should be evaluated for competency. She acknowledged mentor qualifications were not defined and she selected mentors based on their seniority. She said, At this point there is no list of basic required competencies. Review of the job description for Licensed Practical Nurse, revised in January 2021, revealed the LPN cared for residents under the direction of the DON. Essential duties and responsibilities included clinical evaluations and admission process. The document read, To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Review of the job description for the Director of Nursing, revised in July 2015, revealed she would plan, organize and direct the overall operation of nursing services in accordance with applicable regulations, policies,and guidelines to foster the highest degree of quality care. The DON's essential duties included providing and promoting staff education programs, training direct care staff, supervising all members of the Nursing department and conducting performance evaluations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106153 If continuation sheet Page 10 of 15 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 106153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy Pointe at Ucf 2120 Hestia Loop Oviedo, FL 32765 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview, and record review, the facility failed to post required nurse staffing information daily to ensure accurate and comprehensive data was accessible to residents and/or visitors. Residents Affected - Many Findings: On 11/13/23 at 8:44 AM, observation of the first floor main entrance lobby revealed no staffing information posting for the skilled nursing facility. On 11/13/23 at 9:35 AM, observation of the second floor foyer and entrance to the skilled nursing unit revealed nurse staffing information was not posted as required. A document titled Nursing Staff on Duty was noted on the wall outside the common dining area but it did not include the resident census and the actual hours worked by specific categories of licensed and unlicensed nursing staff. On 11/14/23 at 9:18 AM, the Nursing Staff on Duty form showed the name of the facility, the date, and first names of nursing staff scheduled for each shift. The document did not provide the census or actual hours for each category of nursing staff to include Registered Nurses, Licensed Practical Nurses, and Certified Nursing Assistants. On 11/14/23 at 12:01 PM, the Healthcare Scheduler confirmed her responsibilities included posting nurse staffing information for the facility every morning. She validated the documents posted on 11/13/23 and 11/14/23 did not include the facility's census or the total actual hours worked by each category of nursing staff per shift each day. The Healthcare Scheduler explained her process was to complete the forms after the postings were taken down. She stated she calculated and entered the actual number of hours worked by each member of nursing staff on the previous day. The Healthcare Scheduler acknowledged she was not aware the number of hours needed to be posted prior to the start of each shift. She stated she had been on staff for about two months and the facility's Administrator and Director of Nursing trained her. However, the Healthcare Scheduler stated she had not yet reviewed the Federal regulations for staffing for skilled nursing facilities, including nurse staffing posting requirements, but she learned things as they came up. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106153 If continuation sheet Page 11 of 15 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 106153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy Pointe at Ucf 2120 Hestia Loop Oviedo, FL 32765 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 0759 Ensure medication error rates are not 5 percent or greater. 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 prevent medication errors for 2 of 6 residents reviewed during the Medication Administration task, out of a total sample of 13 residents, (#101 and #102). There were 3 errors in 31 opportunities for a medication error rate of 9%. Residents Affected - Few Findings: 1. Review of the medical record revealed resident #101 was admitted to the facility on [DATE] with diagnoses including right side weakness and paralysis and a communication disorder following a stroke, and chronic pain. Review of a Health Status Note dated 11/14/23 at 6:40 AM revealed resident #101 had an intermittent, non-productive cough. The Order Listing Report included a physician order dated 11/14/23 for Mucinex Extended Release tablets, give one 600 milligram (mg) tablet every 12 hours for seven days, to treat cough and congestion. On 11/14/23 at 9:35 AM, Licensed Practical Nurse (LPN) D prepared to administer resident #101's scheduled morning medication. She withdrew two tablets Vitamin D 25 micrograms, one tablet Clopidogrel 75 mg, one tablet Escitalopram 20 mg, one capsule Tamsulosin 0.4 mg, and one tablet Rexulti 1 mg. LPN D reviewed the Medication Administration Record (MAR) and stated the resident's Prednisone 20 mg tablets were not available in the medication cart but she would immediately submit a request for the drug to the pharmacy. Reconciliation of the medications administered by LPN D with physician orders and the MAR revealed resident #101 did not receive his scheduled morning dose of Mucinex 600 mg. On 11/14/23 at 11:43 AM, the Director of Nursing (DON) was informed LPN D did not administer resident #101's Mucinex tablet, and she did not verbalize a rationale for holding the medication. The DON stated the Mucinex was an over-the-counter drug that was stocked in the facility by central supply staff. She explained LPN D should have retrieved the medication and administered it ordered. On 11/14/23 at approximately 11:46 AM, when asked why she did not administer resident #101's Mucinex tablet, LPN D stated she did not see it in the medication cart. 2. Review of the medical record revealed resident #102 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes with neuropathy or nerve damage and severe protein-calorie malnutrition. On 11/14/23 at 10:34 AM, LPN D prepared to administer resident #102's scheduled morning medication. She retrieved blister packs and bottles from the medication cart and placed the resident's five pills in individual plastic cups. The medications included Ferrous Sulfate enteric-coated 325 mg tablet and Gabapentin 300 mg capsule, both with prominently placed instructions on the blister packs that read, Swallow Whole. Do Not Chew Or Crush. LPN D explained resident #102's medication had to be crushed as she could not swallow them whole. She crushed all tablets individually including the Ferrous Sulfate enteric-coated tablet and labeled each plastic cup to identify the contents. LPN D then opened the Gabapentin capsule and emptied the powder into a labeled plastic cup. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106153 If continuation sheet Page 12 of 15 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 106153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy Pointe at Ucf 2120 Hestia Loop Oviedo, FL 32765 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Enteric-coated Ferrous Sulfate tablets should be swallowed whole and never crushed or chewed as doing so can release all of the drug at once, increasing the risk of side effects (retrieved on 11/28/23 from www.webmd.com/drugs/2/drug-4127/ferrous-sulfate-oral/details). The manufacturer's prescribing information for Gabapentin capsules revealed the drug should be swallowed whole with water (retrieved on 11/28/23 from www.drugs.com/pro/gabapentin-capsules.html). On 11/14/23 at 11:13 AM, LPN D began administration of resident #102's medication. She added a spoonful of chocolate pudding to each plastic cup as she gave the tablets. She was prompted to stop the medication administration task before she gave resident #102 the Ferrous Sulfate and Gabapentin tablets and review the blister packs for those medications. She confirmed the blister packs indicated the Ferrous Sulfate and Gabapentin tablets were not to be crushed or chewed. LPN D acknowledged she did not read the instructions when she took the tablets from the blister packs. On 11/14/23 at 11:39 AM, the Director of Nursing (DON) stated her expectation was all nurses would read medication labels carefully and also recognize that enteric-coated tablets and capsules should not usually be altered, opened, or crushed. The DON explained nurses should follow pharmacy instructions as written, and if they had concerns related to a resident's ability to swallow or take medication in the form provided, they should notify the physician. Review of the facility's policy and procedure for General Medication Administration (undated) revealed a purpose to safely and accurately administer physician-ordered medication to each resident. The document listed general guidelines including timely administration as occurring between one hour before and one hour after the scheduled time, following physician orders regarding holding medication, and only crush medications as ordered.Consult a pharmacist before crushing medications if unsure. Some medications that are never to be crushed include: enteric-coated medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106153 If continuation sheet Page 13 of 15 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 106153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy Pointe at Ucf 2120 Hestia Loop Oviedo, FL 32765 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 ensure its policy and procedures for clean dressing changes reflected accepted Infection Control standards of practice; and failed to adhere to proper Infection Control practices during wound care to prevent cross-contamination for 1 of 2 residents reviewed for pressure ulcers, out of a total sample of 13 residents, (#104). Residents Affected - Few Findings: Review of the medical record revealed resident #104 was admitted to the facility on [DATE] with diagnoses including stroke with right side weakness and paralysis, traumatic brain injury, and gastrointestinal hemorrhage. Review of resident #104's Clinical admission form dated 11/13/23 revealed she had a dressing on coccyx (back of body above buttocks). The resident's medical record revealed a care plan for wound management, initiated on 11/13/23. The goal was her wound would show signs of improvement. The interventions included provide wound care as ordered. Review of the Medication Administration Record revealed resident #104 had a physician order dated 11/15/23 to flush the sacral wound with quarter strength Dakin's solution, pack with calcium alginate, and cover with an absorbent dressing. The Journal of Wound, Ostomy and Continence Nursing describes clean technique for wound care as including strategies to reduce the overall number of microorganisms or to prevent or reduce the risk of transmission of microorganisms. Clean technique involves meticulous handwashing, maintaining a clean environment by preparing a clean field, using clean gloves.and preventing direct contamination of materials and supplies (retrieved on 11/28/23 from www.nursingcenter.com/journalarticle?Article_ID=1320693). The facility's policy and procedure for Clean Dressing Change (undated) revealed the purpose to protect the wound, prevent irritation, promote healing and prevent infection and the spread of infection. The policy listed necessary equipment that included dressings or dressing tray, appropriate container for soiled dressing, two pairs of clean gloves, paper towels or towelette drape, and a waterproof pad. The procedure directed nurses to place a plastic bag near to the foot of the bed for soiled dressing materials, create a clean field with paper towels or towelette drape, open the dressing pack, don clean gloves, remove the soiled dressing, and place it in the plastic bag. The document indicated the nurse would then apply the second pair of clean gloves, pour the ordered solution onto gauze, cleanse the wound, and apply the dressing. The facility's policy and procedure did not reflect current accepted standards of practice for infection prevention and control, as noted by the Centers for Disease Control and Prevention (CDC) in educational material titled, Hand Hygiene in Healthcare Settings. The CDC indicated multiple opportunities for hand hygiene may occur during a single care episode and occasions for hand hygiene included immediately before touching a patient, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with body fluids or contaminated surfaces, and immediately after glove removal. According to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106153 If continuation sheet Page 14 of 15 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 106153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy Pointe at Ucf 2120 Hestia Loop Oviedo, FL 32765 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 Residents Affected - Few the CDC, the use of Alcohol Based Hand Rub is appropriate for the previously listed circumstances, but if handwashing with soap and water was the selected method, it should done by rubbing hands together vigorously for 15 to 20 seconds (retrieved on 11/28/23 from www.cdc.gov/handhygiene/providers/index.html). On 11/15/23 at 1:33 PM, Licensed Practical Nurse (LPN) C prepared to provide wound care for resident #104. She retrieved packages of gauze and absorbent dressings, a bottle of Dakin's quarter strength solution, a small plastic cup, and a package of calcium alginate from the treatment cart. LPN C entered the resident's room and approached the tray table beside the bed. She pushed the resident's personal belongings to the left side of the tray table and placed the treatment supplies on the right side. She then used her foot to push a trash can closer to the head of the bed. Resident #104 was positioned on her left side in bed with a dressing on her coccyx. LPN C placed a folded washcloth on the bedspread beneath the resident's left hip and donned clean gloves. She removed the soiled dressing, dropped it on the washcloth, and removed her gloves. She dropped the gloves in the trash can and donned two pairs of gloves. Next, LPN C opened a package, removed a gauze pad, and poured Dakin's solution into a small plastic cup. LPN C folded the gauze in half, held it against the lower edge of resident #104's open wound, and poured the solution onto the gauze. She wiped around the edges of the wound and folded, re-moistened, and re-used the same gauze four additional times to cleanse the wound bed and peri-wound areas. LPN C dropped the soiled gauze onto the folded washcloth on bed. She removed the outer pair of gloves, added them to the other soiled items on the washcloth beneath the wound, and opened another package of gauze. LPN C used the gauze to pat the area dry. She realized she did not have a cotton-tipped applicator to pack the calcium alginate into the wound, so she removed her gloves and walked to the treatment cart, without performing hand hygiene, and retrieved the cotton-tipped applicator. LPN C entered the bathroom to wash her hands, and the water ran for approximately seven seconds. She used a paper towel to dry her hands, donned gloves, and completed the wound treatment by packing the wound and applying an absorbent dressing. LPN C collected the soiled items on the bed, threw them in the trash can, and then removed the washcloth. Lastly, she retrieved a pen from her pocket to date and initial the dressing on the resident's coccyx. On 11/15/23 at 1:58 PM, LPN C was informed of concerns related to breaks in infection control during observation of resident #104's wound care. She acknowledged she neither cleaned the tray table nor placed a barrier to create a clean field on which to place the treatment supplies. When asked why she did not change gloves between clean and dirty tasks and perform hand hygiene during the procedure, LPN C said, I double-gloved and took it off. She explained she was not aware that wearing two pairs of gloves was unacceptable or that she had to perform hand hygiene after removal of gloves. LPN C confirmed she did not perform hand hygiene prior to retrieving items from the treatment cart during the procedure. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106153 If continuation sheet Page 15 of 15