Inspection visit

InspectionJuly 22, 2021

WEST VOLUSIA HEALTHCARE AND REHABILITATION CENTERCMS #1054476 citations on this visit

6 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to provide the necessary care and services for one resident (#28), dependent for all activities of daily living, from a sample of 33 residents. Residents Affected - Few The findings include: A record review for Resident #28 revealed an [AGE] year-old female admitted on [DATE] with diagnoses including metastatic breast cancer and dementia. She was totally dependent for all activities of daily living. She was bedbound, verbally non-responsive, and receiving hospice services. Her record revealed the cancer to her left breast had erupted through the skin on the left side of her chest. During an observation of Resident #28 on 7/20/21 at 10:05 am, she was seen lying in bed in a hospital gown. The gown was stained with a large amount of dried blood at the area of her left chest. There was a large dressing to the left chest area dated 7/20/21. Resident #28 was non-verbal and unable to answer questions. Further observation of the dressing found there was serosanquinous drainage seeping out from the bottom edge of the dressing onto her skin and hospital gown. An interview was conducted with the Licensed Practical Nurse (Employee D) at 10:15 am. She was asked when Resident #28's dressing was last changed. She said the wound nurse had just been in the room to change the chest dressing. She was asked to observe the dressing and the hospital gown. She said the dressing was dated 7/20/21, indicating it had been changed, however there was drainage seeping out and the hospital gown was wet and stained with old bloody drainage. She said the wound nurse should have changed her gown when she changed the dressing. She stated she would have the Certified Nursing Assistant (CNA) come and change her gown. An interview was conducted with the wound nurse on 7/20/21 at 10:20 am. She was asked if she had changed the dressing for Resident #28, and she said she had just been in her room and changed the dressing. She was asked if she had changed her hospital gown, and she said no. When asked if there was drainage on the wound when changed, she confirmed that there was. When asked how often the dressing was changed she said twice a day, she changed it in the morning and then was changed by evening nurse. On 7/21/21 at 9:20 am, Resident #28 was observed lying in bed. The left side of her hospital gown was saturated with serous drainage. Also, the sheet under her upper left side was observed with a large stained area that was dry and brown in color. The dressing to the left chest wall, dated 7/20/21, was observed with serous drainage seeping out of the edges of the dressing onto the surrounding skin and hospital gown. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 12 Event ID: 105447 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 105447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Volusia Healthcare and Rehabilitation Center 1851 Elkcam Blvd Deltona, FL 32725 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete An interview was conducted with Employee D, LPN, on 7/21/21 at 9:25 am. She was asked how often the dressing was changed for Resident #28, and she replied Twice a day. The wound nurse changes it in the morning and she changes the dressing in the evening before she leaves at 7:00 pm. She was asked about wound drainage. She said the protruding mass on the chest wall was large and did have serosanguineous drainage often. When asked if the amount of drainage had increased, she said no, it had been draining for awhile. When asked if the dressings applied were able to absorb enough drainage to keep the skin and clothing dry, she said usually and the CNA would tell her if the dressing was leaking. She was asked if she had seen Resident #28 this morning, and she replied not yet. She was asked to observe Resident #28. Employee A stated the hospital gown was wet from drainage and the sheet under her had a ring of old, dried drainage. She said she would notify the wound nurse the dressing needed to be changed and have the CNA change the resident's gown and sheet. Event ID: Facility ID: 105447 If continuation sheet Page 2 of 12 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 105447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Volusia Healthcare and Rehabilitation Center 1851 Elkcam Blvd Deltona, FL 32725 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on observations, staff and resident interviews, admission packet review and medical record review, the facility failed to ensure one resident (Resident #70), from a sample of 33 residents, received assistance with making appointments to receive proper treatment and an assistive device to maintain hearing ability. Residents Affected - Few The findings include: On June 19, 2021 at 8:51 am, Resident #70 was observed in his room, sitting up in his wheelchair, dressed in his day clothes and eating breakfast. Resident #70 asked this writer to speak louder while speaking with him. When asked if he had hearing aids, he stated, No, but I need them. I need two of them. He was asked if he had ever had hearing aides. He stated, No, never. I wish I could get them. When asked if he had ever let staff know that he wanted hearing aides since his admission to the facility, he stated, Yeah, I don't know who I told, but I know I asked. On June 20, 2021 at 9:40 am, Resident #70 was observed watching television in his room with the volume excessively loud. On June 21, 2021 at 10:20 am, Resident #70 was observed working with therapy in his room. His television was on and the volume was excessively loud. On June 21, 2021 at 10:25 am, Employee B, Licensed Practical Nurse (LPN), was interviewed. She was asked if she was caring for Resident #70 on her assignment today. She replied Yes. Employee B was asked if the resident was hard of hearing and she replied, Yes, he's very hard of hearing. I have to get right up to him and talk on his right side so he can here me, and talk loud. When asked if he had hearing aides, Employee B replied No. When asked if he had had an audiology evaluation since his admission, she replied, No, not yet. We have requested a hearing evaluation but with COVID, we're not sure about him going out or having someone come in to do an evaluation. On June 21, 2021 at 1:10 pm, the Administrator was interviewed. She had been asked for a facility policy for audiology consults and hearing aids. She stated I looked, and we don't have a policy for audiology appointments. If a resident needs something like ear drops, the doctor will order them. If they need an audiology consult for hearing aides, they go out to an audiologist for an appointment. She was asked if the facility had an audiology company that came to the facility to see residents. She stated No. A review of Resident #70's medical record revealed the following: His MDS (Minimum Data Set) assessment, dated June 16, 2021, revealed he had a BIMS (brief interview for mental status) score of 9 out of a possible 15 points, indicating moderate cognitive impairment. His hearing was listed as moderate difficulty. The question asking whether the resident had hearing aids was answered No. Further review of his MDS assessments dated November 11, 2020 and February 10, 2021, revealed his hearing ability was listed as moderate difficulty. The question asking whether the resident had hearing aids was answered No on both dates. A review of Resident #70's current orders revealed an order entered on November 5, 2020 (his date of admission) which read, Audiology as needed. A review of the current care plan for Resident #70 showed the following focus/goals/interventions (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105447 If continuation sheet Page 3 of 12 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 105447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Volusia Healthcare and Rehabilitation Center 1851 Elkcam Blvd Deltona, FL 32725 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 0685 under Communication: Level of Harm - Minimal harm or potential for actual harm Focus: The resident has a communication problem related to hearing deficit (updated 6/16/2021) Residents Affected - Few Goals: The resident will be able to make basic needs known on a daily basis through the next review date. The resident will develop communication abilities by the next review date. Interventions: Anticipate and meet needs. Be conscious of resident position when in groups, activities, dining room to promote proper communication with others. Communication: allow adequate time to respond, repeat as necessary. Do not rush. Request clarification from the resident to ensure understanding. Face when speaking, make eye contact. Turn off the TV, radio to reduce environmental noise. Ask yes/no questions when appropriate. Use simple, brief consistent words/cues. Use alternative communication tools as needed. A review of progress notes in the social services section of Resident #70's medical record did not reveal any progress notes pertaining to audiology or hearing concerns. On June 22, 2021 at 9:30 am, in an interview with the Social Services Director, she was asked how the long-term care residents were referred to audiology. She replied, We have an outside company. They can come on-site to evaluate residents for hearing aides and audiology issues. We fill out a referral form and send it to them, then they send someone out to see the resident, and they take it from there. When asked how she would know if a resident needed an audiology evaluation she replied, Well, sometimes a resident will tell me themselves, whether they come to me or maybe when I am just speaking to them in their room on other matters. Other times, a nurse or other staff member might tell me, and then I'll initiate the evaluation. Then there will be another conversation that will happen for Medicaid to determine if there is any family cost. The Social Services Director was asked if Resident #70 had been referred to audiology or set up for an audiology appointment since he was admitted in November 2020. She replied No, he hasn't. . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105447 If continuation sheet Page 4 of 12 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 105447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Volusia Healthcare and Rehabilitation Center 1851 Elkcam Blvd Deltona, FL 32725 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. A record review for Resident # 29, revealed a [AGE] year-old female with diagnoses including lymphedema, morbid obesity, congestive heart failure and diabetes. She was alert and oriented and needed total assistance with all activities of daily living except for eating. Residents Affected - Some During an observation of Resident #29 on 7/20/21 at 1:30 pm, she had a nasal cannula in place. Observation of the oxygen concentrator found the flow rate was at 4.5 LPM. During an interview with Resident # 29 at 1:35 pm, she was asked what rate of oxygen was she ordered and she stated, Three liters. During an observation of Resident # 29 on 7/21/21 at 9:30 am, the oxygen concentrator flow rate was set at 4.5 LPM. Also, the humidifier bottle was on the floor attached to the concentrator. The humidifier bottle did not have a date indicating when it was opened and connected to the concentrator. An interview as conducted with Employee D, LPN, on 7/21/21 at 9:35 am. She was asked what oxygen rate was ordered for Resident #29. She reviewed the Medication Administration Record (MAR) and said no oxygen order were found, but she thought the order was for 2-3 LPM. She said she would check the order when she finished the medication pass. When asked if she had observed the concentrator for flow rate, she said she had not been in the room yet. She was asked when the humidifier bottle for the concentrator last changed, and she said the date should be on the bottle. After observation of the humidifier, she said there was no date found. A review of the record found no orders for oxygen. A review of the care plan addressed Oxygen Therapy at 3-4 LPM, dated March 2021. Further review of the record found that a new order was obtained on 7/21/21 at 9:40 am for oxygen at 3-4 liters, keep oxygen saturation levels above 92%. A review of the facility's Policy and Procedure for Oxygen Therapy (revised 8/28/17), revealed the following: Physician's order for oxygen therapy shall include administration modality, FiO2 of liter flow, continuous or PRN (as needed), and PRN orders must include specific guidelines as to when the resident is to use oxygen. (Photocopy obtained) Based on observations, record review and interviews, the facility failed to provide respiratory care as needed and ordered for four (Residents #38, #57, #65 and #29) of 13 residents receiving oxygen therapy, from a total of 33 residents in the sample. Three residents (#38, #57, #29) were receiving oxygen without physician's orders, and one resident (#65) was receiving the wrong amount of oxygen. The findings include: 1. An observation was made of Resident #38 in his room on 7/19/21 at 8:43 AM. He was in a vegetative state, had a tracheostomy and was receiving oxygen at 5 liters per minute (LPM). A second observation on 7/20/21 at 9:41 AM, revealed oxygen infusing through the trachea at 5 LPM. Resident #38 was lying in bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105447 If continuation sheet Page 5 of 12 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 105447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Volusia Healthcare and Rehabilitation Center 1851 Elkcam Blvd Deltona, FL 32725 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A third observation made on 7/21/21 at 9:33 AM, revealed the oxygen was still infusing via the trachea at 5 LPM. A review of the medical record for Resident #38 revealed an admission date of 6/8/21 with diagnoses including quadriplegia, contractures, and chronic respiratory failure with tracheostomy. The Minimum Data Set (MDS) admission Assessment, dated 6/15/21, reported the resident in a vegetative state, requiring total care for all activities of daily living, receiving oxygen, and tracheostomy care. The care plan, updated 6/24/21, noted a tracheostomy for chronic respiratory failure with oxygen as ordered. A review of the current physician's orders revealed no order for the oxygen the resident was receiving at 5 LPM. An interview was conducted with Employee A, Licensed Practical Nurse (LPN), at 11:40 AM on 7/21/21 at the nurses' station. Employee A reviewed the current Medication Administration Record (MAR) and physician's orders. She confirmed there was no oxygen order for oxygen at a flow rate of 5 LPM through the tracheostomy, but she said she would take care of that now. An interview was conducted with the Director of Nursing (DON) at 2:00 PM on 7/21/21. She confirmed a physician's order was needed for oxygen, and Resident #38 had no such order for the oxygen he was receiving. 2. An observation was made of Resident #57 in her room on 7/19/21 at 10:31 AM, with oxygen infusing at 3 LPM via nasal cannula. A second observation Resident #57 was made on 7/20/21 at 10:00 AM. She was in her room receiving oxygen at 2 LPM via nasal cannula. On 7/21/21 at 2:00 PM, the resident was observed receiving oxygen at 2 LPM via nasal cannula. A record review was conducted for Resident #57, which noted an admission date of 6/19/21 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). A review of the current physician's orders revealed no order for the oxygen. An interview was conducted with the DON at 9:05 AM on 7/22/21 concerning the oxygen for Resident # 57. The DON confirmed that Resident #57 had no physician's order for the oxygen and it was entered yesterday by staff (7/21/21). She reported conducting a Quality Assurance improvement plan with education of staff that was started yesterday (7/21/21), and a audit of all residents receiving oxygen for orders and following physician's orders for the accurate liters of oxygen to be infusing. 3. On July 19, 2021 at 9:00 am, Resident #65 was observed in her room with her oxygen concentrator set at between 3.5 and 4 LPM. She was receiving her oxygen via nasal cannula. On July 19, 2021 at 12:19 pm, a medical record review for Resident #65 revealed an active physician's order that stated, Respiratory: Oxygen-Continuous 2 liters with an order date of 5/26/2021. On July 19, 2021 at 1:20 pm, Resident #65 was observed sitting up in her bed with her oxygen concentrator set at between 3.5 and 4LPM. Oxygen was being delivered via nasal cannula. She was asked if she ever adjusted the setting on her oxygen concentrator, and she replied, Oh no, I don't touch that. That's for the nurses to do. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105447 If continuation sheet Page 6 of 12 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 105447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Volusia Healthcare and Rehabilitation Center 1851 Elkcam Blvd Deltona, FL 32725 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On July 20, 2021 at 10:15 am, Resident #65 was observed lying on her bed with her oxygen being delivered via nasal cannula. Her oxygen concentrator was set at between 3.5 and 4 LPM. On July 21, 2021 at 10:20 am, Employee B, Registered Nurse (RN), was interviewed. She was asked if she was the nurse caring for Resident #65 today. She stated Yes. She was asked for the resident's current oxygen order, adn she stated, Three liters per minute. She was asked if the order was for continuous oxygen or as needed oxygen, and she replied, Her order is continuous. On July 21, 2021 at 10:30 am, Resident #65 was observed lying on her bed, awake, with her head at the foot of the bed. Her oxygen was being delivered via nasal cannula. Her oxygen concentrator was set at between 3.5 and 4 LPM. She was asked how her breathing was. She gave an ok sign with her fingers and smiled. On July 22, 2021 at 9:15 am, Resident #65 was observed lying in her bed, awake, with her head at the foot of the bed. Her oxygen was being delivered via nasal cannula. Her oxygen concentrator was set at between 3.5 and 4 LPM. On July 22, 2021 at 10:00 am, Employee C, LPN, was interviewed. She was asked if she was caring for Resident #65 today. She stated Yes. She was asked how often she checked the oxygen concentrators to ensure they were set on the prescribed rate of oxygen for the residents. She stated I'm not sure what you mean. She was then asked, Do you check the oxygen concentrators for your residents who are receiving oxygen to see whether they are receiving the physician-ordered flow rate? She replied, Yes, obviously I check it when I check their pulse-ox rate. She was asked how often she checked her residents' pulse-ox rates. She stated, It depends, some are once a shift and some are more often. She was asked what the physician's order for Resident #65's oxygen stated. She replied, 2 liters. On July 22, 2021 at 10:15 am, Resident #65 was observed standing in her room. Her oxygen was being delivered via nasal cannula. Her oxygen concentrator was observed to be set between 3.5 and 4 LPM. On July 22, 2021 at 10:30 am, further medical review for Resident #65 revealed a care plan with the following focus/goal/intervention, dated 12/23/2020, and last revised on 6/7/2021: Focus: The resident has COPD Goal: The resident will be free of s/sx (signs and symptoms) of respiratory infections through the review date. Interventions: Give aerosols or bronchodilators as ordered. Monitor/document any side effects and effectiveness. Monitor for difficulty breathing on exertion. Remind resident not to push beyond endurance. Monitor for s/sx acute respiratory insufficiency: anxiety, confusion, restlessness, SOB (shortness of breath) at rest, cyanosis, somnolence. Monitor/document for anxiety. Offer support, encouragement. Give PRN medications for anxiety as ordered. Oxygen settings: 02 via nasal prongs as ordered. Further review of Resident #65's progress notes revealed three recent notes which addressed the resident's oxygen orders as follows: 6/13/2021 15:29: if using oxygen, describe liters per minute. 3L. Comments: Pt is on 3L via NC continuous at her baseline. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105447 If continuation sheet Page 7 of 12 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 105447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Volusia Healthcare and Rehabilitation Center 1851 Elkcam Blvd Deltona, FL 32725 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 0695 6/14/2021 09:19: if using oxygen, describe liters per minute. 3Lts Level of Harm - Minimal harm or potential for actual harm 6/17/2021 18:40: if using oxygen, describe liters per minute. 3L. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105447 If continuation sheet Page 8 of 12 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 105447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Volusia Healthcare and Rehabilitation Center 1851 Elkcam Blvd Deltona, FL 32725 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and observations, the facility failed to ensure behavior monitoring was conducted for one (Resident #77) of five residents receiving psychotropic medications from a total sample of 33 residents. The findings include: A record review for Resident #77, revealed an [AGE] year-old female admitted on [DATE] with diagnoses including schizophrenia, anxiety, delusions, dementia and falls. Her medications included: Xanax 0.5 mg (milligrams) 3 times a day (anxiety), ABH gel 3 times a day for severe insomnia and anxiety, remeron 7.5 mg daily (depression), depakote sprinkles 125 mg 2 times a day( anxiety), and seroquel 25 mg 2 times a day (antipsychotic). Documentation indicated she was alert with confusion, very anxious, restless, wandering in her wheelchair and looking for her children. She needed assistance with activities of daily living, was incontinent of bowel and bladder, and required assistance with ambulation. A review of the Medication Administration Record (MAR) for June and July 2021, found no behavior monitoring for the use of psychotropic and antipsychotic medications. An interview was conducted with the Licensed Practical Nurse (Employee A) on 7/21/21 at 2:30 pm. She was asked where the nurses documented behavior monitoring for Resident #77, and she replied on the MAR. She was asked to locate the documentation in electronic medical record after a review of the MAR, and she stated there was no documentation of behavior moniotring in the electronic record either. An interview was conducted with Licensed Practical Nurse (Employee G) on 7/21/21 at 2:40 pm. She was asked where behavior monitoring documentation was located. She reviewed the computer and was able to locate documentation for another resident and demonstrated how to click on boxes to answer questions related to behavior. When asked if she could locate behavior monitoring for Resident #77, she stated there was none, but would add nehavior monitoring to the resident's record today. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105447 If continuation sheet Page 9 of 12 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 105447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Volusia Healthcare and Rehabilitation Center 1851 Elkcam Blvd Deltona, FL 32725 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 and an interview with the Director of Dietary Services (DDS), the facility failed to store ice in a clean and sanitary manner, and refrigerated food and nutritional supplements at safe and proper temperatures and in accordance with professional standards in one (East Wing pantry) of two pantries in the facility. The findings include: An observation of the East Wing pantry ice machine on 7/21/21 at 12:06 PM, found significant biological growth, brownish in color and slimy in appearance, running along the length of the top interior of the machine. There was condensation covering the area and multiple droplets that were poised to drip into the clean ice. The thermometer in the refrigerator, which held containers of juice, applesauce and nutritional supplements, read 44 degrees Fahrenheit (f). (Photographic evidence obtained) In a second visit to the East Wing pantry with the DDS on 7/22/21 at 4:00 PM, the ice machine was observed in the same condition. The concern was shown to the DDS. Using his cell phone flashlight, he looked in the ice machine and said, That's disgusting. When asked what the ice was used for, he said it was for the residents' hydration carts on a daily basis. He looked at the refrigerator thermometer, which now read 50 degrees f. He stated the refrigerator had just been fixed. The DDS was asked to take the temperature of the applesauce that was in the refrigerator. He did, and the digital food thermometer registered 46 degrees f. He retrieved one of two cartons of vanilla-flavored Med Plus (a high calorie nutritional supplement) from the refrigerator, poured a cup and took the temperature. The thermometer registered 47.6 degrees f. The DDS confirmed the refrigerator was not holding at the proper temperature and would need to be repaired again. He also stated he would immediately address the ice machine. The Regional Director of Clinical Services reported on 7/22/21 at 4:39 PM, that the facility would immediately address the ice machine by emptying and cleaning it. She added that someone had turned the involved refrigerator's freezer all the way down, which sometimes froze up the unit. It would be emptied, turned off, cleaned and checked again. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105447 If continuation sheet Page 10 of 12 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 105447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Volusia Healthcare and Rehabilitation Center 1851 Elkcam Blvd Deltona, FL 32725 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. Based on a review of resident and facility records, and interviews with residents and staff, the facility failed to maintain complete medical records in accordance with professional standards of practice and the facility's policies and procedures for one (Resident #18) of one resident who received hemodialysis treatments, out of a total of 33 residents in the sample. The findings include: In an interview with Resident #18 on 7/19/21 at 9:45 AM, he stated he received hemodialysis treatments at a local center. The dialysis center sent written information home with him after each visit and dressed (bandaged) his dialysis access site at the center. He exposed the access site, which was on his right upper chest. It was covered with a clean gauze bandage. Resident #18 stated they were going to relocate the access site to his right forearm soon. Employee F, Licensed Practical Nurse (LPN), was interviewed on 7/19/21 at approximately 10:00 AM. She confirmed Resident #18 received dialysis treatments. Employee F explained that she took his vital signs pre- and post-dialysis, and documented it on a communication sheet. The dialysis access site was checked every shift for bleeding or infection. It was not necessary to check for bruit and thrill (the sound and feel associated with turbulent blood flow) due to the site's location on the chest. No medications were required to be held prior to dialysis. A record review for Resident #18 found an admission 5-day Minimum Data Set (MDS) assessment with an assessment reference date of 5/14/21. Resident #18 had a brief interview for mental status (BIMS) score of 15/15, indicating intact cognition, and required supervision with activities of daily living. His diagnoses included medically complex conditions and renal insufficiency/failure/end-stage renal disease (ESRD). Resident #18 received dialysis while a resident and before residing in the facility. Resident #18 was care planned on 5/17/21 for his multiple medical conditions including hemodialysis related to ESRD. The approaches included dialysis treatments on Tuesdays (T), Thursdays (TH) and Saturdays (SAT). Additional guidance instructed, may hold medications, monitor right chest port and report problems. Resident #18 had a physician's order for no medications prior to dialysis, and treatment every T, TH and SAT. A review of Resident #18's dialysis communication forms for July 2021 revealed missing pre- and post-dialysis information on the following dates: On 7/3/21, the nurse responsible for Resident #18, initiated a Dialysis Communication Record for him to take to his dialysis provider. The sending nurse did not sign, date or time stamp the form. Each of those sections were left blank. The section that was to be completed by the facility upon his return from his treatment also had missing information. The sections asking for Resident #18's blood pressure, pulse, respirations, temperature, pain level, access site location, bruit and thrill and the presence of bleeding were blank. The author, Employee H, Registered Nurse (RN), did not sign/date the form. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105447 If continuation sheet Page 11 of 12 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 105447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Volusia Healthcare and Rehabilitation Center 1851 Elkcam Blvd Deltona, FL 32725 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 The Dialysis Communication Record for Resident #18's 7/8/21 treatment was void of a sending nurses' signature, date or time. There was no notation upon his return related to the access site location, bruit or thrill by Employee H. On 7/14/21, Employee H did not note Resident #18's access site, bruit, thrill or presence of bleeding upon his return from treatment. On 7/17/21, the sending nurse did not sign, date or time-stamp the form. Upon return, the section asking for the access site location, and for the presence of bruit and thrill, bleeding or pain was left blank by Employee H. A review of the facility's policy and procedure titled Coordination of Hemodialysis Services (#N1359 revised 7/2/19) noted, The dialysis communication form will be initiated by the facility for any resident going to an ESRD center for hemodialysis. Nursing will collect and complete the information regarding the resident to send to the ESRD nurse. Upon return to the facility, nursing will . .5. Complete the post-dialysis information on the dialysis communication form and file in the resident's clinical record. (photocopy obtained) An interview was conducted with the Director of Nursing on 7/22/21 at 5:15 PM. She reviewed the forms and confirmed the missing information. She stated the nurses should be filling out the forms as that information was important. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105447 If continuation sheet Page 12 of 12

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Citations

6 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0677GeneralS&S Dpotential for harm
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
0685GeneralS&S Dpotential for harm
F685 - Vision and hearing
Assist a resident in gaining access to vision and hearing services.
0758GeneralS&S Dpotential for harm
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
0812GeneralS&S Fpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0842GeneralS&S Dpotential for harm
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
0695GeneralS&S Epotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.

FAQ · About this visit

Common questions about this visit

What happened during the July 22, 2021 survey of WEST VOLUSIA HEALTHCARE AND REHABILITATION CENTER?

This was a inspection survey of WEST VOLUSIA HEALTHCARE AND REHABILITATION CENTER on July 22, 2021. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at WEST VOLUSIA HEALTHCARE AND REHABILITATION CENTER on July 22, 2021?

Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide care and assistance to perform activities of daily living for any resident who is unable."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

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Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Inspection·July 22, 2021