Health inspection·February 27, 2025

F 0623 of Care (undated), revealed the following: Level of Harm - Minimal harm or potential for actual harm Purpose: Pre-Discharge Planning will be coordinated by the Case Management Social Service Department for the development of post-discharge plan of care. Residents Affected - Few 7. Contact those service agencies determined to be needed to support resident's needs, resources, and services upon discharge. These may include such services as: home health, durable medical equipment, therapy services, meals on wheels, transportation, etc. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105349 If continuation sheet Page 2 of 4 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105349 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alliance Health and Rehabilitation Center 130 W Armstrong Avenue Deland, FL 32720 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, medical record review, and facility policy and procedure review, the facility failed to ensure the implementation of the comprehensive person-centered care plan for one (Resident #7) of four residents reviewed for falls, out of six residents identified for falls with major injuries, from a total survey sample of 31 residents. Failure to implement the necessary fall interventions on a resident's care plan places them at risk for additional falls and associated injury/pain. The findings include: Resident #7 was observed and interviewed on 02/27/2025 at 9:40 AM. She was lying in bed covered with a blanket up to her chin. No fall mats were observed on the floor on either side of the bed. (Photographic evidence obtained) Resident #7 stated she had been educated on and was encouraged to use her call light prior to trying to get up and walk or transfer. Resident #7 was observed a second time on 02/27/2025 at 9:55 AM. She was lying in bed with her eyes closed. No fall mats were on the floor. A review of the resident's face sheet revealed she was admitted to the facility on [DATE] and then readmitted on [DATE]. Her diagnoses included osteoporosis, atrial fibrillation, cognitive communication deficit, heart failure, unspecified dementia without behavioral disturbance, hypothyroidism, hyperlipidemia, major depressive disorder, chronic pain, chronic obstructive pulmonary disease (COPD), anemia, nondisplaced fracture of proximal phalanx of left great toe, moderate protein calorie malnutrition, and presence of automatic cardiac defibrillator. (Copy obtained) A review of the quarterly [NAME] Data Set (MDS) assessment, dated 01/29/2025, revealed that Resident #7 was assessed with a Brief Interview for Mental Status (BIMS) score of 10 out of 15 possible points, indicating moderate cognitive impairment. No signs or symptoms of mood disorder or impairment in upper or lower extremities were documented. A wheelchair was used for mobility. The resident required set-up or supervision only for activities of daily living (ADLs), and had two or more falls since the last assessment. (Copy obtained) A review of the Care Plan, dated 02/11/2025, revealed the following focus areas: The resident is at risk for falls related to impaired balance/gait, use of psychotropic medications, urinary incontinence. Initiated 03/15/2022. Revised 01/14/2025. Goal: Potential for falls/fall-related injuries will be minimized through next review date. Interventions included fall mats while in bed. Initiated 01/12/2025. The resident has alteration in behavior as evidenced by refusing care at times, has impulsive behaviors, poor safety awareness, will spontaneously get up without calling for assistance and refuses to wear non-skid socks. Falls were documented on 08/27/2024, 9/06/2024, 10/12/2024, 10/28/2024, 12/26/2024, 12/28/2024, and 01/12/2025 x 2. (Copy obtained) During an interview with Certified Nursing Assistant (CNA) A on 02/27/2025 at 10:53 AM, she looked around Resident #7's room and confirmed that there were no fall mats in the room. She did not get (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105349 If continuation sheet Page 3 of 4 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105349 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alliance Health and Rehabilitation Center 130 W Armstrong Avenue Deland, FL 32720 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 0656 Level of Harm - Minimal harm or potential for actual harm the resident up this morning; therapy got her up and helped her dress. She stated the resident usually has fall mats. The resident went to breakfast, came back, got into bed, and then got up just a few minutes ago and left her room. She did not assist the resident to get up this last time either. She stated Resident #7 liked to get up and go back to bed throughout the day. She would prefer to be in bed all day but they encouraged her to get up. Residents Affected - Few During an interview with Physical Therapist B on 02/27/2025 at 11:03 AM, he stated he thought there was a fall mat on the floor on the side of the bed nearest the window, but not one under her wheelchair. He stated he helped the resident get dressed and go to the restroom. He then stated he recalled that there were no fall mats down at all but there should have been. He confirmed that the resident could propel her wheelchair independently. He did not take her to breakfast; she wheeled herself down to the main dining room. He stated the CNAs were responsible for ensuring that the floor mats were in place. During an interview with Resident #7 on 02/27/2025 at 12:49 PM, she was observed in bed under the covers. Fall mats were observed on either side of the bed that looked clean and new. The resident stated the fall mats on the floor were put down this afternoon, and it was the first time they had ever put mats down in her room. She was asked again if they had ever placed fall mats next to her bed on the floor. She chuckled and said, No, not ever. She stated she needed them so she would not get hurt if she fell out of bed. She had never fallen out of bed, but she had fallen on the floor in her room. During an interview with CNA A on 02/27/2025 at 12:53 PM, she stated she put the mats down in the resident's room. She found them in the resident's closet next to her clothes. CNA A stated she had not put the mats in the closet and confirmed that the mats did not belong in the closet with the resident's clean clothing. During an interview with the Director of Nursing (DON) on 02/27/2025 at 1:04 PM, she stated she was unaware that the fall mats were not down on the floor this morning when the resident was in bed. She stated, Well, we will do better. She confirmed that the CNAs were responsible for placing the fall mats down for the resident's safety. A review of the facility's policy and procedure titled Nursing admission At Risk - Post Fall and Quarterly Evaluation (Copyright 2010, otherwise undated) revealed: Purpose: To evaluate and monitor risk for falls and status for implementation of interventions. To prevent or reduce risk of fall and any associated injury. 5. The licensed nurse will evaluate resident for appropriate fall interventions per responses obtained in effort to minimize residents fall and/or injury. 6. The licensed nurse will inform the resident's physician of fall risk and obtain approval for application of safety devices, if applicable, will complete order for the same and transcribe to the Treatment Administration Record (TAR) for continuity of care. 7. The licensed nurse will ensure the application of safety equipment/interventions and notify staff of resident's risk for fall and related injury. (Copy obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105349 If continuation sheet Page 4 of 4