Health inspection·February 24, 2022

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On February 23, 2022 at 9:00 AM, Residents #26 and #17 (roommates) were observed in their room, each sitting up in bed, awake. Call light for each resident observed to be on the floor, out of each resident's reach. Resident #17 was asked if she could reach her call light. She stated No. Resident #26 was asked if she could reach her call light. She looked at the call light on the floor, and stated No. On February 23, 2022 at 9:05 AM, Resident #27 was observed lying in bed with head of bed elevated and her eyes open. Call light was observed to be hanging over the back of her bed headboard, out of her reach. She was asked if she could reach her call light. She shook her head and did not answer verbally. (Photographic evidence obtained). On February 23, 2022 at 9:20 AM, Resident #14 was observed lying in bed, awake. She was calling out please help me touch pad call light was observed on her bedside table behind a bag of personal items (resident was unable to reach call light). Employee C, Certified Nursing Assistant (CNA) and Employee A, Licensed Practical Nurse (LPN) were asked to come to Resident #14's room. Employee C, CNA was asked where resident's call light was. Employee C, CNA and Employee A, LPN proceeded to search for the call light. Employee A, CNA located the touch pad call light behind the bag of personal items on bedside table, outside of resident's reach. Employee A, CNA checked the call light to ensure it was operational. Employee C, LPN was asked if she ensures call lights are in reach for her residents. Employee C, LPN repeated the question in Spanish, and stated, She doesn't speak English well, so I'm interpreting for her. Employee C, LPN answered in English, stating Yes, I do, I check the call lights. They were both sleeping, so I haven't been in here yet, I was taking care of residents on the other side. She was asked if the call light should be within the resident's reach. She said, Yes. On February 23, 2022 at 4:30 PM, Resident #26 was observed lying in bed, eyes open. Her call light was observed on the floor, out of resident's reach. During an interview with Employee B, CNA on February 23, 2022, at 4:37 PM, she was asked who was responsible for answering the call lights. She replied, We all do, everyone. If someone walks by a call light, they are expected to at least answer it, and get someone else if needed, depending on what the resident needs. She was asked how often resident call lights are checked to ensure they can reach them. She replied, I check my rooms every 15 minutes, so I make sure the call light is in reach of the resident. On February 24, 2022 9:50 AM, Resident #27 was observed lying in bed, awake. The call light was observed hanging over headboard, behind resident, out of her reach. On February 24, 2022 at 10:20 AM, Employee A, LPN was observed in Resident #27's room, administrating medications. When Employee A, LPN was done administrating medications, she was asked if she knew why the residents call light was hanging behind her bed board, out of her reach. She stated No, I do not. But we can put it where it goes. Employee A, LPN proceeded to place the call light across the resident's chest and stated, Here is your call light. You squeeze this if you need us for anything and we'll come help you. Employee A, LPN was asked if she regularly checks call light placement when she exits a resident room. She replied, I usually do. A review of the facility's policy titled Bedrooms (revised May 2017) stated: Policy Statement: All residents are provided with clean, comfortable, and safe bedrooms that meet federal and state requirements. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105262 If continuation sheet Page 2 of 24 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 105262 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Lake Post Acute 991 E New York Ave Deland, FL 32724 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 0558 Level of Harm - Minimal harm or potential for actual harm 6. All residents rooms are equipped with a resident call system that allows the residents to call for staff assistance. . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105262 If continuation sheet Page 3 of 24 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 105262 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Lake Post Acute 991 E New York Ave Deland, FL 32724 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview with the Maintenance Director, the facility failed to maintain a safe, clean, comfortable, and homelike environment for residents in four (Rooms 210, 209, 104 and 110) of four rooms identified with environmental concerns from a total of 21 rooms. The findings include: On 2/21/22 at 10:45 AM, room [ROOM NUMBER] was observed with foam insulation coming out of the framing on both sides of the air conditioner. (Photographic evidence) On 2/21/22 at 11:00 AM, room [ROOM NUMBER] was observed with yellow foam insulation exposed around the air conditioner unit, which was not framed. (Photographic evidence obtained) On 2/21/22 at 11:36 AM, room [ROOM NUMBER] was observed with an air conditioner attached to wall with duct tape covering the top and bottom of surface. (Photographic evidence obtained) On 2/21/22 at 11:45 AM, room [ROOM NUMBER] was observed with foam insulation exposed around the air conditioner without any casing or frame. (Photographic evidence obtained) On 2/24/22 at 10:50 AM, an interview was conducted with the Maintenance Director. He was shown the pictures taken for the rooms with the air conditioners documented above. He looked at the pictures of the air conditioner units with foam exposed and leaking through the casing. He confirmed the air conditioners should have framing around them or duct tape around them. A review of the facility's policy titled, Maintenance Service revised 12/2009, noted the Maintenance Department is responsible for maintaining the buildings, ground, and equipment in a safe and operable manner at all times. One of the functions listed for maintenance personnel included: maintaining the heat/cooling system in good working order. (Photographic evidence obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105262 If continuation sheet Page 4 of 24 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 105262 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Lake Post Acute 991 E New York Ave Deland, FL 32724 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 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to complete a comprehensive assessment within 14 days after a significant change for one (Resident #144) of two residents sampled for significant change, from a total sample of 24 residents. Residents Affected - Few The findings include: A clinical record review for Resident #144 revealed an admission date of 9/10/19. His diagnoses included malignant neoplasm of bronchus lung, and dementia. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required supervision with bed mobility and transfers, independent with eating and limited assistance with toileting. A review of Resident #144's Certified Nursing Assistant (CNA) documentation for toileting for the last 14 days revealed he required extensive to total assist. A review of the resident's weights revealed he weighed 104.5 pounds on 2/21/22 and weighed 129 pounds on 12/10/21 for a weight loss of 18.99%. On 2/22/22 at 12:15 PM, Resident #144 was observed lying in his bed asleep in his room. An interview with Employee G, CNA was conducted at time of observation. She reported that the resident had refused his lunch. On 2/23/22 at 8:30 AM, Resident #144 was observed in his room. He had refused his breakfast but drank a milkshake and juice. On 2/23/22 at 12:15 PM, Resident #144 was observed in his room. He was not eating his lunch. Employee K, CNA entered his room and attempted to assist resident with eating. The resident refused the meal and did not want a substitute. Employee K, CNA encouraged him to drink his fluids, but he refused. On 2/24/22 at 8:30 AM, Resident #144 was observed in his room, lying in the bed with an untouched breakfast tray at bedside. When he was asked if he wanted to eat his breakfast, he shook his head no. An interview was conducted with Employee G, Registered Nurse (RN) on 2/24/22 at 10:29 AM. She reported that Resident #144 refuses to eat, refuses to get out of bed, and needs total assist with activities of daily living (ADL's). The RN stated the resident has declined and there was a hospice consult ordered. During an interview with Employee F, CNA on 2/24/22 at 10:48 AM, she stated that she cares for Resident #144, and he requires two staff members to assist him with ADL's and requires total assistance. An interview was conducted with the Social Services Director on 2/24/22 at 10:56 AM. She reported that Resident #114 is weak and smaller than a month ago. An interview was conducted with Employee D, RN MDS Coordinator on 2/24/22 at 11:13 AM. She reported working from home and coming to the facility on Monday, Wednesday, and Friday for half a day due to having lung cancer. She stated that Resident #114's hospice consult was discontinued and confirmed a significant change of condition had not been started for the resident. The RN explained that if a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105262 If continuation sheet Page 5 of 24 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 105262 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Lake Post Acute 991 E New York Ave Deland, FL 32724 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 0637 Level of Harm - Minimal harm or potential for actual harm resident comes back from the hospital and had a decline in change of condition, a significant change assessment would be completed or if starting or ending hospice services. She stated the residents should be observed for two weeks to see if there are any acute or chronic changes. She acknowledged that if Resident #114's ADL's have changed, and he has had weight loss, a significant change should be done. She stated a significant change would be done today. Residents Affected - Few During an interview with the Director of Nurses (DON) on 2/24/22 at 2:02 PM, she confirmed that Resident #114 did not have any registered dietician notes for his weight loss. The DON also confirmed that the resident required two staff members for his ADL's and is total care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105262 If continuation sheet Page 6 of 24 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 105262 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Lake Post Acute 991 E New York Ave Deland, FL 32724 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 0642 Ensure a qualified health professional conducts resident assessments. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and facility policy and procedure review, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for four (Residents #10, #31, #22, and #144) out of a total sample of 24 residents. The information recorded within the MDS assessment concerning anticoagulant medications did not reflect the resident's status at the time of the Assessment Reference Date (ARD). Residents Affected - Some The findings include: A review of the clinical record for Resident #10 revealed she was admitted on [DATE] and readmitted on [DATE]. Her diagnoses included major depressive disorder, muscular dystrophy, COPD, bipolar disorder, and type 2 diabetes mellitus. A review of Resident #10's Minimum Data Set (MDS) assessments dated 11/19/21 and 2/18/22, Section N (Drug Regimen Review), revealed Medications received in the past seven days: Anticoagulants 7 days out of 7. A review of Resident #10's physician's orders revealed no orders for anticoagulant medications. A review of the care plan for Resident #10 revealed no focus area related to anticoagulant medications. A phone interview was conducted with Employee D, MDS Coordinator Nurse on 2/24/22 at 11:10 AM. She confirmed that she had completed Resident #10's MDS assessments dated 11/19/21 and 2/18/22. She was asked to identify the anticoagulation medications that triggered Section N to indicate that Resident #10 had received anticoagulation medication (seven out of seven of the past days) on each of those two assessments. She stated, She's on Plavix. She was asked if she considered Plavix to be an anticoagulant medication. She stated, Yes. She was asked if she coded all residents who receive Plavix as receiving an anticoagulation medication on the MDS assessments. She replied Yes, I guess I have. I have looked and I see Plavix is a blood thinner. She was asked how she determined that Plavix is a blood thinner. She stated I goggled it. It says it's used to reduce the risk of blood clots, that's why I put it as an anticoagulant. A list of all residents currently prescribed Plavix and a copy of their most recent MDS, Section N0410-E, was requested from Administrator. A list of four residents currently receiving Plavix was received and reviewed, which revealed the following information: Resident #10: orders reviewed, no anticoagulant medications ordered currently or discontinued. Resident #31: orders reviewed, no anticoagulant medications ordered currently or discontinued. Resident #22: orders reviewed, no anticoagulant medications ordered currently or discontinued. Resident #144: orders reviewed, no anticoagulant medications ordered currently or discontinued. A review of the MDS assessments, section N0410-E, concerning anticoagulation medications received (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105262 If continuation sheet Page 7 of 24 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 105262 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Lake Post Acute 991 E New York Ave Deland, FL 32724 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 0642 in the past 7 days from date of MDS assessment: Level of Harm - Minimal harm or potential for actual harm Resident #10: MDS assessment dated [DATE] reveals coding for anticoagulation medications received 7 days out of the past 7 days. Residents Affected - Some Resident #31: MDS assessment dated [DATE] reveals coding for anticoagulation medications received 7 days out of the past 7 days. Resident #22: MDS assessment dated [DATE] reveals coding for anticoagulation medications received 7 days out of the past 7 days. Resident #144: MDS assessment dated [DATE] reveals coding for anticoagulation medications received 7 days out of the past 7 days. A review of the Centers for Medicare and Medicaid Service website (CMS.gov) dated April 2012, revealed Section N0410-E stated Anticoagulants: do not code antiplatelet medications such as aspirin/extended release, dipyridamole, or clopidogrel (Plavix) here. Review of the facility policy titled Electronic Transmission of the MDS (revised September 2010) stated under Policy Interpretation and Implementation 6. The MDS Coordinator is responsible for ensuring that appropriate edits are made prior to transmitting MDS data and that feedback and validation reports from each transmission are maintained for historical purposes and for tracking. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105262 If continuation sheet Page 8 of 24 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 105262 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Lake Post Acute 991 E New York Ave Deland, FL 32724 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure a Level 2 Preadmission Screening and Resident Review (PASRR) was completed to determine appropriateness of placement in a nursing facility for two (Residents #19 and #31) of two residents identified with serious mental disorders, out of a total of 24 residents in the sample. Residents Affected - Few The findings include: 1. A clinical record review for Resident #19 revealed she was admitted on [DATE]. She remained in the facility at the time of survey. Her diagnoses included schizophrenia, personality disorder, unspecified dementia with behavioral disturbances and major depressive disorder. Resident documented as having moderately impaired cognitive skills and short-term memory problems. Further record review for Resident #19 revealed she had a Level I PASRR dated 6/4/21. The screening tool indicated under section I.A. Mental Illness (MI), or Suspected MI that Resident #19 had a diagnosis of schizophrenia and had previously received services for MI. Section II asked if the individual had at least one of 3 characteristics on a continuing or intermittent basis. Question 2.A. under this section was marked Yes, that Resident #19 experienced interpersonal functioning difficulties on a continuing or intermittent basis, including serious difficulty interacting appropriately and communicating effectively with other persons; had a possible history of altercations or evictions; had a fear of strangers; demonstrated avoidance of interpersonal relationships or social isolation; or had been dismissed from employment. The form instructed a Level II PASRR screening was required to be completed prior to admission to the nursing facility if any box in section I.A or 1.B. was checked, and there was a Yes checked in Section II.1, II.2 or II.3 unless the individual met the definition of a provisional admission or a hospital discharge exemption. Section III, PASRR Screen Provisional Determination, noted Resident #19 was being admitted under the 30-day hospital discharge exemption. Instructions were should the resident be admitted under the 30-day exemption, and the stay in the nursing facility (NF) was anticipated to exceed 30 days, the NF must notify the Level I screener on the 25th day of stay and the Level II evaluation completed no later than the 40th day of admission . The discharge exemption statement was signed by the attending physician on 6/4/21. Further clinical record review for Resident #19 found no evidence a Level 2 screening was completed within 40 days of her admission, as required. 2. A clinical record review for Resident #31 revealed he was admitted to the facility on [DATE]. He remained in the facility at the time of survey. His diagnoses included unspecified dementia with behavioral disturbances, non-Alzheimer's dementia, Parkinson's disease, traumatic brain injury (TBI). anxiety, depression, and schizophrenia. Further record review for Resident #31 revealed he had a Level I PASRR dated 3/24/17 that noted under section I.A. he had diagnoses of anxiety disorder, depressive disorder and schizophrenia based on a documented history and medications. Section II question 2.A. was marked Yes indicating Resident #31 experienced interpersonal functioning difficulties on a continuing or intermittent basis, including serious difficulty interacting appropriately and communicating effectively with other persons, had a possible history of altercations or evictions, had a fear of strangers, or demonstrated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105262 If continuation sheet Page 9 of 24 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 105262 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Lake Post Acute 991 E New York Ave Deland, FL 32724 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 0645 avoidance of interpersonal relationships, was socially isolated, or had been dismissed from employment. Level of Harm - Minimal harm or potential for actual harm Section 2.C. was also marked Yes when asked if the individual had serious difficulty adapting to typical changes in circumstances, manifested agitation, had exacerbated signs and symptoms associated with the illness or withdrawal from the situation, or required intervention by the mental health or judicial system. Residents Affected - Few Section 3.A. was marked Yes when asked if the resident has had psychiatric treatment more intensive than outpatient care more than once in the past two years, had experienced episode of significant disruption to normal living situation for which supportive services were required in a residential treatment environment, or required intervention by housing or law enforcement. Section 4. was marked Yes when asked if the individual exhibited actions or behaviors that may make them a danger to themselves or others. The form instructed that a Level II PASRR must be completed prior to admission if any box in section I.A. or I.B. was checked, and there was a yes checked in Section II.1, II.2 or II.3. Further clinical record review for Resident #19 revealed no evidence that a Level II screening was completed within 40 days of her admission, as required. During an interview with the Director of Nursing (DON) and the Social Services Director (SSD) on 02/22/22 at 03:07 PM, they asked for clarification as to why a Level II screen was required for Residents #19 and #31. The SSD also asked why the hospital did not initiate the Level II screening while the residents were in the hospital. The requirements for the Level II screening were explained to the SSD. She expressed understanding of the requirements and acknowledged Level II screenings were required for both residents. She stated she would contact Kepro to initiate the Level II screenings. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105262 If continuation sheet Page 10 of 24 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 105262 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Lake Post Acute 991 E New York Ave Deland, FL 32724 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure the environment remained free of accident hazards and failed to monitor the effectiveness and function for a position change alarm for one (Resident #27 in room [ROOM NUMBER]) of one resident reviewed for accident hazards, from a total sample of 24 residents. The findings include: A medical record review for Resident #27 revealed she was admitted on [DATE] and readmitted on [DATE]. Her diagnoses include dementia without behavioral disturbance, major depressive disorder, generalized anxiety disorder, and insomnia. A review of the 5-day Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. A review of physician's order for Resident #27, dated 12/2/20, read: Bed alarm while resident is in bed. Check every shift (q shift) and as needed (PRN) for functioning. On 2/21/22 at 1:48 PM, Resident #27's call light cord was observed to be frayed at the end of the cord. It was not attached to anything and was lying on the floor. (Photographic evidence obtained) On 2/21/22 at 3:10 PM, Resident #27 was observed lying in bed with the head of bed flat. A bed position change alarm was attached to the left side of bed on the side rail with a frayed cord not attached to anything. The frayed end of the cord was lying on the floor. On 2/22/22 at 9:30 AM, Resident #27 was observed lying in bed with the head of bed flat. A bed position change alarm was attached to the left side of bed on the side rail with a frayed cord not attached to anything. The frayed end of the cord was lying on the floor. On 2/22/22 at 10:35 AM, Resident #27 was observed lying in bed with the head of bed elevated. A bed position change alarm was attached to the left side of bed on the side rail with a frayed cord not attached to anything. The frayed end of the cord was lying on the floor. On 2/23/22 at 9:05 AM, Resident #27 was observed lying in bed awake with the head of bed slightly elevated. A bed position change alarm was observed attached to the left side of bed on the side rail with a frayed cord not attached to anything. The frayed end of the cord was lying on the floor. A review of the February 2022 Medication Administration Record (MAR) for Resident #27 revealed the bed alarm was signed off and checked as functioning by staff each day (up to February 23rd) three times a day (day, evening, and night). A review of the person-centered care plan for Resident #27 with revised date on 2/2/21 revealed resident was at risk for falls related to confusion, gait/balance problems, incontinence, psychoactive drug use, and unaware of safety needs. Interventions included be sure resident's call light is within reach and encourage to use it for assistance as needed; bed alarm on bed; on when resident is in bed and off when out of bed; and check every shift and as needed for functioning. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105262 If continuation sheet Page 11 of 24 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 105262 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Lake Post Acute 991 E New York Ave Deland, FL 32724 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 2/23/22 at 9:05 AM, an interview was conducted with Employee A, LPN who was the nurse caring for Resident #27. She was asked if the resident uses a bed alarm. She replied, I'm not sure and proceeded to look it up on the computer. She replied, Yes, she has a bed alarm. She was asked if she was responsible to check the bed alarm each shift for functioning. She stated, Yes. She was asked if she documents the MAR during her shift that the bed alarm for Resident #27 is in place and functioning. She said, Yes. She was asked to observe the bed alarm unit for Resident #27. She looked at bed alarm unit and held up the unattached frayed cord. She said, It's not supposed to be like this. There should be a pad under the resident, and this would be connected to the pad, but the cord is broken. If she sits up, the pad alarms from the shift in her weight. She was asked if the resident had a pad under her at this time. She asked the resident if she could check for a pad. Upon checking, she stated, No, she doesn't. I'll go get a new unit and pad. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105262 If continuation sheet Page 12 of 24 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 105262 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Lake Post Acute 991 E New York Ave Deland, FL 32724 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 observations, record reviews, interviews, and policy and procedure review, the facility failed to ensure acceptable parameters of nutritional status and nutritional assessments were completed for four (Residents #144, #15, #25, and #8) of four residents reviewed for nutrition, out of a total sample of 24 residents. Residents Affected - Some The findings include: 1. A clinical record review for Resident #144 revealed an admission date of 9/10/19. His diagnoses included malignant neoplasm of bronchus lung, Alzheimer's disease, major depressive disorder, and dementia. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident was independent with eating. A review of the resident's weights revealed the resident weighed 104.5 pounds on 2/4/22 and weighed 129 pounds on 12/10/21 for a weight loss of 18.99%. Resident #114 was documented as refusing multiple meals over the past 14 days. Further record review for Resident #144 revealed no evidence of nutritional assessments by the Registered Dietician. On 2/22/22 at 12:15 PM, Resident #144 was observed lying in his bed asleep. An interview with Employee G, CNA was conducted at time of observation. She reported that the resident had refused his lunch. On 2/23/22 at 8:30 AM, Resident #144 was observed resident in his room. He had refused his breakfast but drank a milkshake and juice. On 2/23/22 at 12:15 PM, Resident #144 was observed in his room. He was not eating his lunch. Employee K, CNA entered his room and attempted to assist resident with eating. The resident refused the meal and did not want a substitute. Employee K, CNA encouraged him to drink his fluids, but he refused. On 2/24/22 at 8:30 AM, Resident #144 was observed in his room, lying in the bed with an untouched breakfast tray at bedside. When he was asked if he wanted to eat his breakfast, he shook his head no. An interview was conducted with Employee G, Registered Nurse (RN) on 2/24/22 at 10:29 AM. She reported that Resident #144 refuses to eat, refuses to get out of bed, and needs total assist with activities of daily living (ADL's). The RN stated the resident has declined and there was a hospice consult ordered. During an interview with Employee F, CNA on 2/24/22 at 10:48 AM, she stated that she cares for Resident #144, and he requires two staff members to assist him with ADL's and requires total assistance. An interview was conducted with the Social Services Director on 2/24/22 at 10:56 AM. She reported that Resident #114 is weak and smaller than a month ago. During an interview with the Director of Nurses (DON) on 2/24/22 at 2:02 PM, she confirmed that Resident #114 did not have any registered dietician notes for his weight loss. The DON also confirmed that the resident required two staff members for his ADL's and is total care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105262 If continuation sheet Page 13 of 24 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 105262 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Lake Post Acute 991 E New York Ave Deland, FL 32724 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 - Some 2. A review of the clinical record for Resident #15 revealed he was admitted to the facility on [DATE]. His diagnosis included osteomyelitis, orthopedic aftercare following surgical amputation, peripheral vascular disease (PVD), type 2 diabetes, bipolar disorder, anxiety disorder and an unstageable pressure ulcer. The Discharge Return Anticipated Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental (BIMS) score of 14 out of 15, indicating cognitively intact. He required no assistance with eating. Resident #15 was 67 inches () tall and weighed 123 pounds (lbs.) The assessment reported significant weight loss without being on a prescribed weight loss regimen. An observation and interview were conducted with Resident #15 on 02/23/22 at 9:54 AM. He stated he had lost weight and did not have much of an appetite. Resident #15 explained, he usually consumed approximately 50% of his meal, then felt full. He started receiving shakes yesterday and he thinks he sometimes received a supplement from the nurse. On 02/23/22 at 2:05 PM, an interview was conducted with Employee K, Certified Nursing Assistant (CNA) who cares for Resident #15. She stated that the resident was a very good eater and usually ate up to 100% of his meal. Employee G, CNA, who was standing nearby, chimed in, and agreed with Employee K, CNA that his meal intake was very good. A review of the care plan for Resident #15 dated 12/15/21 revealed the resident has a potential nutritional problem. The goal was to maintain adequate nutritional status through the review date. Interventions included, but were not limited to: Medications as ordered, discuss feeling about weight, monitor and report changes, labs as ordered, diet as ordered and Registered Dietician (RD) to evaluate and make diet change recommendations. (Photographic evidence obtained) A review of Resident #15's weight record revealed on 09/17/2021, he weighed 140.5 lbs. and on 02/04/2022, he weighed 113 lbs. This reflected a -19.57 % loss over a 5-month period. A review of physician's orders for Resident #15 revealed an order for Med Pass (a nutritional supplement) 120 cubic centimeters (cc's, the equivalent of milliliters [ml]) three times a day. (Photographic evidence was obtained) Further review of the clinical record for Resident #15 revealed no evidence of nutritional assessments by the Registered Dietician. There was no evidence the RD had assessed the resident since his significant weight loss to determine what additional nutritional interventions might be warranted. 3. A clinical record review for Resident #25 revealed an admission date of 10/8/21. His diagnoses included non-Alzheimer's dementia, Parkinson's disease, anxiety, depression, bipolar disorder, psychotic disorder, post-traumatic stress disorder (PTSD) and obesity. The Quarterly MDS assessment dated [DATE] revealed Resident #25 had a BIMS score of 13 out of 15 points, indicating cognitively intact. Resident #15 was independent with eating. He was noted to have had a 5% or more weight loss in the last month and a 10% or more loss in the last 6 months but was not on a prescribed weight loss regimen. Resident #15 received a therapeutic diet. Resident #25 was interviewed on 02/21/22 at 11:50 AM. He reported he had lost about 50 pounds since his admission to the facility 4 months ago. In a second interview on 02/23/22 at 10:04 AM, Resident #25 reported he did not eat his breakfast today. He did not know if he ate his dinner last night. He thought he was getting a little cup full of a nutritional supplement once a day from the nurse. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105262 If continuation sheet Page 14 of 24 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 105262 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Lake Post Acute 991 E New York Ave Deland, FL 32724 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 - Some On 02/23/22 at 12:26 PM, Resident #25 was observed in bed. His lunch was on the over bed table but was untouched. Resident #25 reported, he was nauseous and would not be eating lunch today. On 02/23/22 at 1:48 PM, Resident #25's family member and representative was interviewed. She said, she brought him a sandwich for lunch today. He only ate half. She said Resident #25 won't eat here. He was a very picky eater and had lost 50 pounds. On 02/24/22 at 9:47 AM, Employee G, CNA, was interviewed. She reported that Resident #25 refused breakfast today and typically only ate up to 50% of his lunch. He did eat snacks. Resident #25 wanted fast food and for his representative to bring his food in. Employee G, CNA thought there used to be a dietician who came in to review charts and make diet changes. She came about twice a month but Employee G, CNA had not seen anyone in a while. The CNA explained Resident #25 took a lot of medications but won't eat, so he complains of stomach pain. She regularly reminded him, he needed to put something in his stomach before taking his pills. A review of the care plan for Resident #25 dated 1/10/22 revealed the resident had the potential for a nutritional problem related to therapeutic diet and obesity. The goal was to maintain adequate nutritional status through the next review date. Interventions included medications as ordered, diet as ordered, discuss feelings about weight and his commitment to weight loss/gain, and monitor /record/report to signs and symptoms of malnutrition or emaciation (cachexia, muscle wasting, significant weight loss) to the physician. Registered Dietician to evaluate and make diet change recommendations as needed. (Photographic evidence was obtained) A review of Resident #25's weight history revealed he weighed 248 lbs. on 10/19/2021 and weighed 222 pounds on 02/04/2022, which was a -10.48 % loss in 3 1/2 months. A review of the CNA Task sheets for the past 30 days revealed Resident #25 only consumed 0-25% of his meal on 24 occasions, and 26% to 50% on 8 meals. There was one meal refusal noted. (Photographic evidence was obtained) A History and Physical examination dated 12/15/21 noted abnormal weight loss and instructed to monitor Resident #25's weight. Further review of the clinical record found there was no evaluation of his nutritional status or caloric and hydration needs by an RD since his admission. A review of the physician order for Resident #25 dated 11/16/21 revealed Give 120 ml three times a day for weight loss. The order did not specify what liquid was to be given. Review of the electronic medication administration record (eMAR) found it also failed to specify what the nurse was to give three times daily. (Photographic evidence was obtained) On 02/24/22 at 10:48 AM, Employee E, the Registered Nurse (RN) assigned to Residents #15 and #25, was interviewed. She was asked if either resident received a nutritional supplement. She reviewed the eMAR for Resident #25 which instructed Give 120 cc three times a day. Realizing the order did not specify what to give, she said, Hmmmm . Employee E, RN then checked Resident #25's physician's order and confirmed it did not specify what should be given. She said it should be for Med Pass, as that was the only supplement that would be given in the amount of 120 ml. Employee E, RN reviewed the physician's orders and eMAR for Resident #15 and confirmed an order for 120 milliliters (ml) of Med Pass three times daily. She was asked if Residents #15 and #25 received their Med Pass this morning. Without providing a direct answer, she explained health shakes were sent out this morning. Employee E, RN retrieved an empty carton from the trash bin to show what was sent out. Inspection of the carton (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105262 If continuation sheet Page 15 of 24 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 105262 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Lake Post Acute 991 E New York Ave Deland, FL 32724 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 - Some found it was a 118 ml chocolate Mighty Shake. When asked again if Resident #15 received his Med Pass, Employee E, RN looked at the eMAR. The corresponding signature box for the morning dose of Med Pass was illuminated green, indicating the supplement was signed off as provided. Employee A replied Yes, explaining that the eMAR was green, reflecting its administration. She then corrected herself and said, He got the shake. Employee E, RN was asked if Resident #25 received his Med Pass this morning. She hesitated, then perused his electronic record. She then acknowledged that Resident #25 also received a shake instead of Med Pass. Employee E was asked if the eMAR was signed off for Residents #15 and #25 indicating they received Med Pass, but instead actually received Mighty Shakes. She confirmed they were. (Photographic evidence obtained) A review of the Med Pass container in Resident #15 and #25's medication cart revealed the following information: 120 ml serving provided 10 grams of protein and approximately 199 calories. A review of the nutritional value of the Mighty Shakes found there was 6 grams of protein and 220 calories per 120 ml serving. (Photographic evidence was obtained) An interview was conducted with the Administrator on 02/24/22 at 12:48 PM. She stated the facility just hired a Registered Dietician, but she did not know when the former RD was in the facility last. She stated the Dietary Manager should be completing some nutritional reviews on the residents. When advised that Residents #15, #25, #144, and #8 did not have any dietary evaluations since admission, she stated, she was not aware. The Director of Nursing (DON) was interviewed on 02/24/22 at 2:07 PM. She reported Resident #15 had triggered for a 180-day weight loss in December, which was above 10%. Resident #15 had multiple hospital transfers and returns. He received liquid protein and, she believed, Med Pass. When asked to locate a nutritional evaluation for Resident #15 or Resident #25, she could not. The DON had no explanation how the residents' nutritional needs could be monitored if they had never been calculated by the RD. She was advised of the findings in the eMAR related to the shake being provided in lieu of Med Pass. The DON confirmed the Mighty Shake was not an appropriate substitute for Med pass. 4. A record review for Resident #8 revealed an admission date of 11/10/21 with diagnosis that included Type 2 diabetes mellitus, major depressive disorder, paroxysmal atrial fibrillation; sepsis; dementia without behavioral disturbance; unspecified psychosis not due to a substance or known physiological condition; acute kidney failure. A review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed resident had a BIMS score of 9 out of 15, indicating moderately impaired. The assessment identified weight loss with no prescribed weight loss regimen. Resident is on a therapeutic diet. A review of the care plan for Resident #8 with start date 2/21/22 revealed resident has a potential for nutritional problem due to therapeutic diet and his prescribed diet was carbohydrate control diet. A review of resident's weight revealed he weighed 171.5 lbs. on 11/22/2021 and weighted 158 lbs. on 02/04/2022, which is a -7.87 % loss. A review of resident # 8's medical record showed no nutrition assessments done since admission and no dietician consults were observed since weight loss had been identified. On 2/24/22 at 12:30 PM, Resident #8 was observed eating in the dining room. The resident was observed needing redirection at lunch. During an interview with DON on 02/24/22 at 2:51 PM, she reported that the only intervention the facility has for Resident #8's weight loss is weekly weights. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105262 If continuation sheet Page 16 of 24 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 105262 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Lake Post Acute 991 E New York Ave Deland, FL 32724 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 A review of the facility's policy and procedure, Nutritional Assessment Policy dated October 2017, read: As part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition shall be conducted for each resident. The dietician in conjunction with the nursing staff and healthcare practitioner will conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that places the resident at risk for impaired nutrition. Residents Affected - Some . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105262 If continuation sheet Page 17 of 24 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 105262 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Lake Post Acute 991 E New York Ave Deland, FL 32724 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, record review, and facility policy and procedure review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. These practices could have a potential to cause foodborne illness for all of the 40 residents in the facility. The findings include: On 2/21/22 at 1:53 PM, during a kitchen tour the following items were observed: 1. The refrigerator was observed with two partially opened milk cartoons. 2. An open container of chicken salad with no dates on them. 3. The dry storage area had bags of bread with no dates on them. (Photographic evidence obtained) On 2/21/22 at 2:05 PM, the dishwashing machine was observed with the Certified Dietary Manager (CDM), who reported it was a high temperature machine. The temperature of the dishwasher did not go past 110 °F. The dishwasher log was reviewed and revealed no staff initials or temperatures taken. (Photographic evidence obtained). At this time, the CDM was asked what the temperature of the dishwasher should be. He stated, he would have to check on that. On 2/21/22 at 2:30 PM, the CDM reported that the dishwasher was a low temperature machine not a high temperature one. On 2/21/22 at 2:50 PM, the dishwashing machine was observed with the CDM for a second time. The CDM reported he could not get the water temperature over 100 °F. The CDM was asked what he was going to do about the dishwasher issue. He reported, they would use the 3-compartment sink to wash. The CDM was asked if he thought there was enough time to wash all the dishes before dinner, he stated, he would use disposable items. On 2/22/22 at 1:15 PM, Employee N, Dietary Aide, was observed washing dishes with dishwashing machine, her hairnet was not covering her bangs. She was asked what temperature the dishwasher should be, she stated, I don't know exactly. On 2/22/22 at 1:18 PM, an interview was conducted with Employee L, Cook. She was asked to explain the dishwasher procedure, she stated, We wash the dishes before we put them in dishwasher. On 2/22/22 at 1:20 PM, the dishwashing machine was observed at 110 °F after 5 cycles of washing which revealed the dishwashing machine was not reaching appropriate temperature for sanitation of dishes. During the observation, Employee N, continued to wash dishes even after being aware of the dishwasher being below proper temperature. After they were sent through the machine the dishes were immediately put in plate stacker next to tray line. Employee L was asked about drying them, she stated, they leave them in the rack for a minute before putting them away. The dishes were observed wet nesting, with no time given to air dry. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105262 If continuation sheet Page 18 of 24 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 105262 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Lake Post Acute 991 E New York Ave Deland, FL 32724 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm During an interview with Director of Nursing (DON) on 2/22/22 at 2:00 PM, she was asked about the dishwashing machine. She reported that it needed to be primed and run a few times before it can get to temperature. She said, she was not sure what the temperature should be and reported a repair guy came today after breakfast and checked the machine. The DON was asked if CDM was at the facility. The DON stated she hadn't seen him today and that he is the full time CDM at two facilities. Residents Affected - Many On 2/22/22 at 2:18 PM, the DON entered the kitchen and reviewed the dishwasher machines manufacturer's instructions which read a temperature of 125°F. The DON primed the machine many times, but it never reached 120 °F. (Photographic evidence obtained) On 2/22/22 at 2:20 PM, the DON and Administrator were told of the dishwashing machine issues by the survey team. The DON and Administrator stated, they would use disposable items until they could get someone out again to check the dish machine. On 2/23/22 at 10:05 AM, an interview was conducted with the CDM, he was not wearing a hairnet. The CDM reported at this time that the maintenance director reset the hot water heater. He also stated that all dishes had been rewashed since yesterday and the dishwasher was reaching a temperature of 125 °F. The CDM was asked about the 3-compartment sink sanitizer log, he stated, They don't use 3 compartment every day. He was also asked, Why the log for the dishwasher temperatures was not being done? The CDM stated, Staff don't care. On 2/23/22 at 11:20 AM, the February food temperature book was reviewed in the kitchen. The book revealed meal temperatures were not being recorded on a regular basis. (Photographic evidence obtained) On 2/23/22 at 12:15 PM, a second observation of the dry storage revealed the following: 1. No dates on bread. 2. Open peanut butter container with no date on it. 3. Open container of powdered mash potatoes no date on it. A review of the refrigerator/freezer temperature log was revealed no month or year marked on the form with several dates missing which included: 2/3, 2/8, 2/12, 2/13, 2/14, 2/16, 2/17 and 2/18. (Photographic evidence obtained) On 2/23/22 at 12:05 PM, a second observation was of the kitchen refrigerator revealed the following: 1. Water was observed dripping from fan in refrigerator on to the floor. 2 An open container of chicken salad, with no date was still in refrigerator. 3. Expired milks dated 2/22/22. (Photographic evidence obtained) On 2/24/22 at 9:56 PM, the nourishment room refrigerator was observed and revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105262 If continuation sheet Page 19 of 24 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 105262 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Lake Post Acute 991 E New York Ave Deland, FL 32724 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 1. Jar of pickles without date. Level of Harm - Minimal harm or potential for actual harm 2. Bowl of yellow substance in facility's plastic bowl without date. 3. Two sandwich halves without date. Residents Affected - Many 4. Two plastic bags with food items in them. 5. Mighty Shake dated December 2022. (Photographic evidence obtained) A review of facility's policy and procedure titled, Food Brought by Family and Visitors revised October 2017, read #5. All personnel involved in preparing, handling, serving, or assisting the resident with meals or snacks will be trained in safe food handling practices. #7 b. All Perishable foods must be stored in refrigerator and labeled with the resident' name, item and the use by date. (Photographic evidence obtained) A review of the facility's policy and procedure titled, Sanitization dated October 2008, read #8. Low-Temperature Dishwasher (Chemical Sanitization) a. Wash temperature (120°F) and b. Final rinse with 50 parts per million (ppm) hypochlorite for at least 10 seconds. (Photographic evidence obtained) A review of the facility's policy and procedure titled Dishwashing Machine Use Policy read the supervisor will check the dishwashing machine for proper concentration of sanitizer solution after filling the dishwashing machine and one a week thereafter. Concentration will be recorded in the facility approved log. The operator will check the temperatures using the machine gauge with each dishwashing machine cycle and will record the results in a facility approved log. The operator will monitor the gauge frequently during dishwashing machine cycle. Inadequate temperatures will be reported to the supervisor and corrected immediately. If hot water temperatures or chemical sanitation concentrations do not meet requirement, cease use of dishwashing machine immediately until temperatures or PPM are adjusted. (Photographic evidence obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105262 If continuation sheet Page 20 of 24 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 105262 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Lake Post Acute 991 E New York Ave Deland, FL 32724 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a record reviews and interviews, the facility failed to ensure medication administration records (MARs) were accurately documented in accordance with professional standards of practice for two (Residents #15 and #25) of five residents reviewed for unnecessary medications, out of a total of 24 residents in the sample. The findings include: 1. A review of the clinical record for Resident #15 revealed he was admitted to the facility on [DATE]. His diagnosis included osteomyelitis, orthopedic aftercare following surgical amputation, peripheral vascular disease (PVD), type 2 diabetes, bipolar disorder, anxiety disorder and an unstageable pressure ulcer. The Discharge Return Anticipated Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental (BIMS) score of 14 out of 15, indicating cognitively intact. He required no assistance with eating. The assessment reported significant weight loss without being on a prescribed weight loss regimen. A review of the physician's orders for Resident #15 revealed an order for Med Pass (a nutritional supplement) 120 cubic centimeters (cc's, the equivalent of milliliters [ml]) three times a day. (Photographic evidence was obtained) 2. A clinical record review for Resident #25 revealed an admission date of 10/8/21. His diagnoses included non-Alzheimer's dementia, Parkinson's disease, anxiety, depression, bipolar disorder, psychotic disorder, post-traumatic stress disorder (PTSD) and obesity. The Quarterly MDS assessment dated [DATE] revealed Resident #25 had a BIMS score of 13 out of 15 points, indicating cognitively intact. Resident #15 was independent with eating. He was noted to have had a 5% or more weight loss in the last month and a 10% or more loss in the last 6 months but was not on a prescribed weight loss regimen. A review of the physician order for Resident #25 dated 11/16/21 revealed Give 120 ml three times a day for weight loss. The order did not specify what liquid was to be given. Review of the MAR found it also failed to specify what the nurse was to give three times daily. (Photographic evidence was obtained) On 02/24/22 at 10:48 AM, Employee E, the Registered Nurse (RN) assigned to Residents #15 and #25, was interviewed. She was asked if either resident received a nutritional supplement. She reviewed the electronic MAR (eMAR) for Resident #25 which instructed Give 120 cc three times a day. Realizing the order did not specify what to give, she said, Hmmmm . Employee E, RN then checked Resident #25's physician's order and confirmed it did not specify what should be given. She said it should be for Med Pass, as that was the only supplement that would be given in the amount of 120 ml. Employee E, RN reviewed the physician's orders and eMAR for Resident #15 and confirmed an order for 120 milliliters (ml) of Med Pass three times daily. She was asked if Residents #15 and #25 received their Med Pass this morning. Without providing a direct answer, she explained health shakes were sent out this morning. Employee E, RN retrieved an empty carton from the trash bin to show what was sent out. Inspection of the carton found it was a 118 ml chocolate Mighty Shake. When asked again if Resident #15 received his Med Pass, Employee E, RN looked at the eMAR. The corresponding signature box for the morning dose of Med Pass was illuminated green, indicating the supplement was signed off as provided. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105262 If continuation sheet Page 21 of 24 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 105262 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Lake Post Acute 991 E New York Ave Deland, FL 32724 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Employee A replied Yes, explaining that the eMAR was green, reflecting its administration. She then corrected herself and said, He got the shake. Employee E, RN was asked if Resident #25 received his Med Pass this morning. She hesitated, then perused his electronic record. She then acknowledged that Resident #25 also received a shake instead of Med Pass. Employee E was asked if the eMAR was signed off for Residents #15 and #25 indicating they received Med Pass, but instead actually received Mighty Shakes. She confirmed they were. (Photographic evidence obtained) The Director of Nursing (DON) was interviewed on 02/24/22 at 2:07 PM. She was advised that Resident #15's and #25's Med Pass had been signed for this morning, but a Mighty Shake was provided instead. The DON confirmed the Mighty Shake was not an appropriate substitute for Med pass. She said the nurses should not be signing off Med Pass if it was not given. She acknowledged the order for Resident #25's supplement needed clarification to specify what should be given. The DON had no explanation why nurses were signing off at each administration time without knowing what was supposed to be given. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105262 If continuation sheet Page 22 of 24 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 105262 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Lake Post Acute 991 E New York Ave Deland, FL 32724 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record reviews, and facility policy and procedure review, the facility failed to maintain a functioning resident call system when two call lights were found not to light up or make an audible sound in one resident room (room [ROOM NUMBER]) affecting two (Residents #12 and #43) from a total sample of 24 residents, out of a total of 21 rooms. Residents Affected - Few The findings include: During an interview with Resident #12 on 2/21/22 at 12:28 PM in room [ROOM NUMBER], he reported his call light did not work. The call light was tested and found to not light up or make any sound at the wall or in the hallway. Resident #12 said, If I need help, I yell but sometimes, they don't hear me because my roommate's radio and television is playing. He also reported that the call light system has not worked for a year. Resident #12 also reported that his roommate's call light did not work. The call light for Resident #43 was tested and found to not light up or make any sound at the wall or in the hallway. A bell was observed on the over bed table for Resident #43. The bell was out of his reach. During an interview with Employee Z, Certified Nursing Assistant (CNA) on 2/21/22 at 4:25 PM, she stated she had worked at the facility for 5 months. When she was asked about the call light function in room [ROOM NUMBER], she stated, she thought they all worked. She explained, she had no special instructions regarding the call lights for room [ROOM NUMBER]. On 02/23/22 at 4:40 PM, a second interview was conducted with Resident #12 in room [ROOM NUMBER]. He confirmed that his call light was still not working. The call lights were tested and found to not light up or make any sound at the wall or in the hallway. An observation of the nurses' station revealed no lights or alarms on the switch board for room [ROOM NUMBER], and no one came to the room after it was pressed. A review of the January 2022 maintenance repair book revealed five issues were reported regarding call lights. (Photographic evidence obtained) On 2/24/22 at 10:50 AM, an interview was conducted with the maintenance director. He reported that he is normally at another facility and is trying to get a maintenance person at this facility. He explained that if the building needs maintenance, they call him. He is usually at the facility on Mondays to run the generator. When he was asked about the call light system, he reported that he doesn't know it very well because it is older, but previous issues have been reported to corporate. He stated that the company that installed the system have to come fix it. He stated that at his other facility, if the call light doesn't work, we give them bells to use, he is not sure about what they do in this facility. He was questioned about the current intercom system and stated he did not know why some rooms have intercom systems but not all of them. He reported, they haven't said anything to him about call lights not working lately. On 02/24/22 at 11:08 AM, the maintenance director tested the call lights in room [ROOM NUMBER]. He confirmed that the call lights were not functioning. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105262 If continuation sheet Page 23 of 24 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 105262 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Lake Post Acute 991 E New York Ave Deland, FL 32724 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 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 02/24/22 at 11:36 AM, the maintenance director communicated that the residents in room [ROOM NUMBER] (Residents #12 and #43) now had a wireless call light on them. The maintenance director stated he had an intercom system unit invoice that were ordered in 11/2021, but he could not verify if these units were going to be installed in this facility. On 02/24/22 at 2:54 PM, an interview was conducted with Director of Nursing (DON). She stated that if she had any issues with call lights, she would call the maintenance director. When she was asked if she was aware of call light issues in room [ROOM NUMBER], she stated, Yes, the resident told me about it a while ago. A review of facility's policy and procedure titled, Maintenance Service, last revised December 2009 read Maintenance service shall be provided to all areas of the building, grounds, and equipment and noted that the functions of maintenance include but are not limited to maintaining the paging system in good working order. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105262 If continuation sheet Page 24 of 24