Inspection·August 18, 2022

F 0758 Level of Harm - Minimal harm or potential for actual harm stated the resident was being monitored until he went out to the hospital and came back. Behavior monitoring was documented on the MAR or on a behavior monitoring sheet. The DON confirmed that behavior monitoring was not restarted when the resident returned from the hospital. She said depakote levels were monitored and ordered every three months. She further stated, I will restart the behavior monitoring for Zyprexa, Lexapro and Depakote today. [Resident #40] is due for a depakote level now. Residents Affected - Few An interview was conducted with the DON on 8/18/22 at 9:45 a.m. She stated Resident #40's depakote level should be monitored every three months. There was no order for a depakote level, and the last one was conducted in September 2019. It was low. He had one in August 2019 and it was low also. She provided documentation of the two laboratory tests for 8/7/19 and 9/21/19. An interview was conducted with the Medical Director via telephone on 8/18/22 at 12:50 p.m. He stated depakote levels for seizures should be checked every three months, and if there are no symptoms of side effects, then he would check the depakote level annually if it was prescribed for mood. A review of the Behavioral Assessment, Intervention and Monitoring Policy and Procedure (revised February 2019), noted: Behavioral symptoms will be identified using facility-approved behavioral screening tools. The facility will comply with regulatory requirements related to the use of medications to manage behavioral changes. The nursing staff will identify, document and inform the physician about specific details regarding changes in an individual's mental status, behavior and cognition including: onset, duration, intensity and frequency of behavioral symptoms, and new onset or changes in behaviors will be documented regardless of the degree of risk to resident or others. Interventions will be adjusted based on the impact on behavior and other symptoms, including any adverse consequences related to treatment. If antipsychotic medications are used to treat behavioral symptoms, the Interdisciplinary Team (IDT) will monitor for side effects and complications related to to psychoactive medications for example: lethargy, abnormal involuntary movements, anorexia or recurrent falling. 2. A medical record review was conducted for Resident #17, revealing an admission date of 6/8/22 with diagnoses including Alzheimer's disease, unspecified psychosis not due to a substance or known physiological condition, anxiety disorder, and major depressive disorder. Physician's orders included Lorazepam Intensol concentrate, 2 mg/ml (milligrams per milliliter) for anxiety disorder every six hours, started on 6/28/22; Risperdal Consta suspension, 50 mg injected intramuscularly one time a day every 21 days for behavioral disturbances related to unspecified psychosis not due to a substance or known physiological condition, and Lexapro started on 8/14/22 for depression. The resident's Minimum Data Set (MDS) assessment, dated 6/14/22, revealed a brief interview for mental status (BIMS) score of 00 out of a possible 15 points, indicating severe cognitive impairment. Also noted was one-to-one supervision for behaviors. A review of Resident #17's care plan (last revised on 6/15/22) read: The resident uses psychotropic medication related to a diagnosis of psychosis and anxiety. Interventions included: Administer psychotropic medications as ordered; monitor for side effects and effectiveness every shift; and monitor/document/report as needed any adverse reactions of psychotropic medications. Resident also care planned for having behavior problem of choosing to refuse medications, rejection of care, and exit-seeking behavior. Additionally, the resident's care plan read, impaired cognitive function/dementia or impaired thought processes related to dementia with interventions that included: Administer medications as ordered and monitor for side effects and effectiveness. A level II Preadmission Screening and Resident Review (PASSAR) was conducted and the resident was suspected of serious mental illness with a plan for redirection, psychiatric services and medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105262 If continuation sheet Page 2 of 3 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 08/18/2022 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 0758 management. Level of Harm - Minimal harm or potential for actual harm A review of the medication administration record (MAR) was conducted for the month of August 2022. No behavior monitoring was documented for medications Lexapro, Risperdal, or Lorazepam. Residents Affected - Few An interview was conducted with Certified Nursing Assistant (CNA) B on 8/17/22 at 3:30 p.m. She stated Resident #17 was receiving one-to-one supervision due to her behaviors of exit seeking as well as She likes to mess with door wires. CNA B stated the resident had a Wanderguard (alarm worn as a bracelet or anklet) and sometimes refused care. An interview was conducted with Registered Nurse (RN) C on 8/18/22 at 11:33 a.m. She stated the licensed practical nurses and registered nurses monitored residents for behaviors. She stated medications for which a resident was monitored for behaviors included narcotics, depakote, lorazepam, antipsychotics and Alzheimer's disease medications. When asked if she was monitoring behaviors for Resident #17, she reported yes. At this time, she was asked to provide documentation of the behavior monitoring being done for Resident #17. RN C stated there was no documentation. She was unable to produce documented evidence of behavior monitoring. An interview was conducted with Unit Manager D on 8/18/22 at 11:44 p.m. She confirmed that the behaviors/behavior monitoring for Resident #17 should have been in her orders and they were not. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105262 If continuation sheet Page 3 of 3