Inspection·February 23, 2023

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few problems, incontinence, psychoactive drug use and fall. The goal was to minimize the risk for minor injury through the next review date. The care plan included the following interventions: Anticipate the needs of the resident; Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed; bed in low position; educate the resident/resident's representative/caregivers about safety reminders and what to do if a fall occurs; ensure that the resident is wearing appropriate footwear/non-skid socks when ambulating or mobilizing in wheelchair; patient evaluate and treat as ordered or as needed. Further review of the care plan revealed that there was no evidence that the care plan was revised or reviewed by the interdisciplinary team after the resident fell on [DATE] or on 12/23/2022. (Photographic evidence obtained) During an interview with Employee K, Licensed Practical Nurse (LPN) on 2/23/2023 at 4:43 PM, she stated that she was the nurse that responded to Resident #42's fall on 12/23/2022. She stated, she saw it happen. She was approximately 20 feet away and could not get to him fast enough to prevent him from hitting his head. He fell forward out of the front of the wheelchair and hit his head on the double panic bolt bar on the fire door. She stated, Oh I remember it like it just happened. It was like a dolphin dive! She stated that he had fallen before. An interview was conducted with the Director of Nursing (DON) on 2/23/2023 at 5:27 PM about the falls. The DON confirmed that the care plan was not updated to reflect the falls on 10/13/2022 and 12/23/2022 and did not contain any updated interventions to prevent future falls or protections from injury. A review of the facility's policy and procedure entitled, Fall Management (effective date 11/30/2014, revised 7/29/2019) read: Residents are evaluated for fall risk. Patient centered interventions are initiated, based on resident risk. Purpose: Is to identify residents at risk for falls and establish/modify interventions to decrease the risk of further fall(s) and minimize the potential for a resulting injury. B. Fall Mitigation Strategies: 1. Develop resident centered interventions based on resident risk factors. 2. Update the resident's care plan and the Nurse Aide Kardex with interventions. C. Post Fall Strategies: 5. Update care plan and Nurse Aide Kardex with interventions. 8. Update plan of care with new interventions as appropriate. (Photographic evidence obtained) 2. On 2/21/2023 at 11:29 AM, Resident #54 stated that she wished to go home, and no one was assisting her with discharge. She added that she was capable of taking care of herself and would get home health services if needed. The resident added that she does not know who made the decision for her to stay at the facility because she had her own home. She said, Institutional living is not for me. Resident could not recall attending any care plan meeting. A review of Resident #54's medical record revealed she was admitted to the facility on [DATE] with a re-entry on 6/19/2022 with admitting diagnoses of muscle wasting and atrophy, cognitive deficit, and need for assistance with personal care. A review of the quarterly minimum data set assessment dated [DATE] indicated Resident #54 had a brief interview for mental status (BIMS) score of 9 out of 15 possible points, indicating moderate cognitive impairment. She required extensive assistance for bed mobility, transfer, and toilet use. She was independent with eating. According to the assessment, Resident's return to the community was uncertain. Resident #54's care plan dated 2/3/2022 indicated she wished to be discharged home. The care plan was updated on 3/10/22 and indicated the resident wished to remain in the facility for long term (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105447 If continuation sheet Page 2 of 18 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 02/23/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few care. Interventions included to encourage the resident to discuss concerns. The care plan also indicated that resident is an elopement risk/wanderer related history of attempts to leave facility unattended. In an interview with the Social Services Director (SSD) on 2/22/2023 at 2:57 PM, she stated that the discharge plan is initiated upon admission. She added that she also visited the resident if there covered days were almost expiring before initiating a notice of medicate non coverage (NOMNC) to review their discharge plan. When asked about residents that were long term at the facility, but would wish to return to the community, she said, Residents who are long term can request discharge and time. The interdisciplinary team (IDT) also discuss discharge plan during care plan meeting, but I have to make sure that residents who wish to discharge have a plan on discharge location. She added that she had received requests for discharge from three long term care residents and Resident #54 was not among them. When asked if Resident #54 attended her care plan meetings, she stated that the MDS department would have a list of the attendees for each care plan. In an interview on 2/23/2023 at 12:52 PM, Employee D, Licensed Practical Nurse (LPN MDS) stated that when residents are admitted the care plan is done based on the hospital documentation and resident/ family interview. She added the care plan was updated quarterly. When asked about the process of care planning, she said, Resident family/representative are sent a letter a week prior to invite them to the care plan meeting. During the care planning meeting the staff and the families who are present sign the Care conference Card. She added that the resident should always be present and if resident does not participate in the care plan, a documentation should be included that attempts were made along with resident response. When asked if Resident #54 participates in her care plan, she stated that she would obtain the care conference cards to verify. After she obtained the care conference cards for 2022, she confirmed that Resident #54 did not attend in any of the meetings in 2022. There was no documentation proving any attempts were made to have resident attend the meeting. Review of the care conference dated 3/10/2022, 6/7/2022 and 11/29/2022 revealed that Resident #54 did not attend any of the care plan meetings. (Copies obtained) A review of facility's policy and procedures title, Care Plan Invitation (revised on 09/25/2017) read: The resident and/or the resident representatives shall be invited to attend each of the interdisciplinary care planning conference for the specific resident. The procedure included: -Deliver care plan invitation to the resident 7-14 days prior to the date of the conference. Place a copy of the invitation in the medical record. - If the resident has capacity, ask if they wish to have the resident representative at the care conference. Per resident choice or determination of capacity, mail care planning invitation to the resident representative 7-14 days prior to the date of the conference. Place a copy of the invitation in the medical record - Have all attendees to the Care Planning Conference, including resident and resident representatives sign the Care Plan Conference Record to verify their attendance. (Copy obtained) A review of the facility's policy and procedure titled, Plans of Care (revised on 09/25/2017) read: An individualized person- centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with the state and federal regulatory requirements. The procedure read, Develop and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105447 If continuation sheet Page 3 of 18 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 02/23/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete implement and individualized person- centered comprehensive plan of care by the interdisciplinary Team that include but not limited to the attending physician, a registered nurse with registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of food and nutrition service staff, and other appropriate staff of professionals in the disciplines as determined by the resident's needs or as requested by the resident, and to the extent practicable the participation of the resident and the resident's representative(s). (Copy obtained) Event ID: Facility ID: 105447 If continuation sheet Page 4 of 18 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 02/23/2023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and facility policy and procedure review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #6) out of 63 sampled residents. Residents Affected - Few The findings include: On 2/20/2023, Resident #6 was observed lying in bed under the covers. There were no physical signs of abuse or neglect. When an interview was attempted, the resident responded nonsensically to many of the questions that were asked. The resident appeared to be pleasantly confused, and the interview was ended. A record review for Resident #6 revealed she was admitted on [DATE] and was readmitted on [DATE], after being transferred out for acute care. Diagnoses included urinary tract infection (UTI); muscle weakness; unspecified atrial fibrillation; dysphagia; muscle wasting & atrophy; acute embolism and thrombosis of deep veins; long term use of anticoagulant and essential hypertension. A review of Resident #6's admissions minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 14 out of 15, indicating cognitively intact. Resident required extensive assistance with all activities of daily living. Pain assessment was completed. There was no pain or falls reported during the look back period. A review of the current physician's orders for Resident #6 revealed Eliquis 5mg by mouth twice a day; monitoring for anticoagulant usage each shift; pain monitoring each shift; complete blood count (CBC) and basic metabolic panel (BMP) each Friday; vital signs each shift; regular no added sodium (NAS) diet, dysphagia puree texture and regular thin liquids consistency A review of nursing progress note dated 1/23/2023, read: Resident found on floor next to bed 1cm X 1cm abrasion on left side forehead appeared resident hit head on bedside table. Further record review revealed Resident #6 was enrolled in hospice services on 1/27/2023. A review of the resident's most recent care plan addressed falls as: Focus: the resident is at risk for falls related to gait/balance problems, incontinence, history of fall date initiate 11/30/2022; Goal: Minimize the risk of falls through next review date Target date 4/10/2023; Interventions: Frequent toileting, anticipate and meet the resident's needs; be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed; ensure the resident is wearing appropriate footwear/non-skid socks when mobilizing in wheelchair; physical therapy evaluate and treat as ordered or as needed dated initiated 11/30/2023. During an interview on 2/22/2023 at 12:59 PM with Employee E, Advance Registered Nurse Practitioner (ARNP), she acknowledged she was familiar with Resident #6. She confirmed the resident is currently receiving Hospice services. She was not sure how often these services were provided in the facility. She stated the facility nurse coordinates with hospice. She confirmed the resident sustained a fall with injury in the facility on 1/23/2023. She stated, she sees the resident every 30 days and/or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105447 If continuation sheet Page 5 of 18 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 02/23/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm in the event of an acute situation. When asked, she stated the fall would have been considered an acute situation, however, she did not see the resident until 1/25/2023, two days after the fall with injury, then again on 1/26/2023 and 1/30/2023. On 2/2/2023, she documented the bruise the resident sustained during the fall as it was more prominent at that time. She stated there was no x-ray nor was Resident #6 sent out for evaluation and/or treatment. Residents Affected - Few During an interview with the Director of Nursing (DON) on 2/22/23 at 4:17 PM, she reviewed the details of Resident #6's fall on 1/23/2023. She confirmed the date of the fall and stated it occurred at 1:15 AM. The resident was observed next to her bed and sustained a laceration to the forehead 1 cm x 1 cm in size. The laceration was treated in house by the facility staff and the resident's physician was notified. When asked about post fall interventions, she stated the resident was re-educated to ask for assistance when getting out of bed. The DON was asked about the facility's fall process. She stated a facility wide code green is called when there is a fall. Nursing does the assessment and the doctor is called. She stated there is no physical documentation. She stated if a fall is unwitnessed neurochecks are performed. She confirmed the fall sustained by Resident #6 was unwitnessed and the resident would have needed neurochecks. She stated some of the neurochecks are done on paper as well as electronically. She stated the neurochecks are done within the first 15 minutes then every hour then every four hours after a resident sustains a fall. She was asked to provide the neurochecks done for Resident #6. She stated, they should be located in the resident's electronic chart. At this time, she was also asked to confirm the order for hospice services. She stated the facility was still verifying the order for hospice. She stated the order was put in by an agency nurse and was being investigated by the facility. She stated the facility needed to determine if the family or the doctor requested hospice services. During an interview with the DON on 2/22/2023 at 4:47 PM, she was advised the neurochecks for Resident #6 were not found in the electronic chart. She was given the physical chart retrieved from the nurses' station on the East Wing of the facility. In the presence of Administrator, the DON sorted through the resident's physical chart looking for the neurochecks that should have been done after resident sustained the fall on 1/23/2023. After several minutes, the DON confirmed there were no neurochecks in the resident's physical chart. During an interview with Employee E, the ARNP on 2/23/2023 at 11:52 AM, she confirmed she put in the consult for hospice service. She stated the diagnosis was failure to thrive. She stated the Power of Attorney for Resident #6 spoke to Hospice and the services were optional. She again stated the reason for her consult was the resident's failure to thrive. She was provided a copy of the hospice documentation showing atherosclerotic heart disease listed as admitting diagnosis. The ARNP was asked if this information was accurate. She stated, she can't prove a resident's primary diagnosis. She stated she puts in the consult, but she can't pick the resident's diagnosis. When asked about collaboration between herself, hospice, and the physician, she stated they meet in the facility. She stated the on-call team was notified after Resident #6 sustained the fall on 1/23/2023. She confirmed the resident sustained an injury as a result of the fall but stated she was fine and confirmed there were no post fall interventions put in place. She was asked in her professional opinion about residents who take anticoagulants who had falls and sustained a head injury with bleeding. She stated she would probably send the resident out, but Hospice would have to be called since this resident is on Hospice. During a phone interview with the Medical Director on 2/23/2023 at 12:01PM, he acknowledged being the Medical Director for the facility and member of the facility's Quality Assurance and Performance Improvement (QAPI) team. He stated he was aware of the fall Resident #6 sustained on 1/23/2023. He (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105447 If continuation sheet Page 6 of 18 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 02/23/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated his on-call service took the report for the fall. He stated the specific person who took the report was currently out of the country and unavailable for interview. He stated the facility advised there was head injury and provided the resident's vitals. He stated the facility was advised to perform neurochecks for Resident #6 after the fall. He stated, When a resident is on a anticoagulant there is a low threshold there so we send them out to the hospital to make sure there is no cranial bleeding. When asked about the order for Hospice, he stated the ARNP spoke with the resident's Power of Attorney (POA). He stated there was a phone call with the POA for Resident #6 to discuss Hospice as an option. When asked how he collaborates with Hospice, he specifically replied, That's a great question. I've been trying to open the lines of communication. I've asked that we be involved when residents and their families make that decision. It's getting better. A review of the facility's policy and procedure titled, Fall Management (Effective Date: 11/30/2014 Revision Date 7/29/2019) read: C. Post Fall Strategies 2. Initiate Neurological checks as per policy or directed by physician order 6. Initiate post fall documentation every shift for 72 hours 9. Review resident weekly x 4. (Photographic evidence obtained) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105447 If continuation sheet Page 7 of 18 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 02/23/2023 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 Based on observations, interviews, record review, and facility policy and procedure review, the facility failed to ensure that one (Resident #21) of 10 residents receiving respiratory care, received oxygen as ordered, from a total sample of 63 residents. Residents Affected - Few The findings include: On 2/20/2023 at 10:57 AM, Resident #21 was observed lying in bed wearing a nasal cannula. The oxygen concentrator located at bedside revealed an oxygen flow of 1.5 Liters per minute (L/min). A bag attached to the oxygen concentrator was dated 2/7/2023. (Photographic evidence obtained) A record review of Resident #21's physician's order revealed no current oxygen order. Respiratory oxygen at 2 L/min via nasal cannula as needed for shortness of breath was discontinued 8/22/2021 at 4:15 PM. (Photographic evidence obtained) On 2/21/2023 at 10:15 AM, a second observation of Resident #21 was conducted with Employee B, Unit Manager. The resident's oxygen concentrator was set at 1.5 L/min with a bag attached to the oxygen concentrator dated 2/7/2023. (Photographic evidence obtained) Employee B confirmed Resident #21's oxygen order was discontinued on 8/22/2021. A record review for Resident #21 revealed an initial admission date of 2/19/2021 and readmit date of 1/12/2023. Diagnoses included hemiplegia unspecified affecting left nondominant, weakness; unspecified lack of coordination; cognitive communication deficit; anxiety disorder, unspecified; other schizoaffective disorders; major depressive disorder, recurrent, unspecified; long term (current) use of anticoagulants; and muscle weakness. A review of the quarterly minimum data set (MDS) assessment, dated 1/16/2023, revealed Resident #21 had no interview for mental status, resident was rarely/never understood. The assessment also documented she was receiving oxygen therapy. A review of the January 2022 Medication Administration Record (MAR) for Resident #21 identified no monitoring of oxygen therapy. A review of Resident #21 care plan dated 12/1/2022 revealed she had oxygen therapy as needed via nasal prongs as ordered. Progress notes dated 2/6, 2/7, 2/10, 2/11, 2/12, and 2/13 revealed oxygen administered at 2 L/min via nasal cannula. During an interview with the Director of Nursing (DON) 2/22/2023 at 3:25 PM, the DON confirmed that nursing was responsible for providing ongoing monitoring of oxygen therapy and tube changes. She stated, the physician provides orders, and nursing follow the physician orders. Each nurse had access to the electronic medical record to identify oxygen settings. A review of the facility's policy and procedure titled, Oxygen Therapy (revision date 8/28/2017) read: Physician's order for oxygen therapy shall include Administration modality, FiO2 or liter flow, Continuous or (as needed) PRN, PRN orders must include specific guidelines as to when the resident is to use oxygen. (Photographic evidence obtained) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105447 If continuation sheet Page 8 of 18 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 02/23/2023 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on observations, interviews, and record review, the facility failed to provide adequate staffing to respond timely to call lights for 2 (Residents #103 and #262) of 2 residents requiring assistance with activities of daily living. The facility also failed to ensure sufficient nursing staff to provide a timely medication pass for 7 (Residents #102, #215, #214, #71, #31, #14, and #212) of 12 residents observed for medication. The findings include: Cross reference F759 and F760 Upon entrance to the facility on 2/19/2023 at 11:00 AM, the Director of Nursing (DON) was observed passing medication on the East wing. During an interview with the DON on 2/19/2023 at 11:05 AM, she confirmed, she was the assigned nurse for that section. She added that her shift was 7 AM - 7 PM. On 2/19/2023 at 12:35 PM, Resident #103 was interviewed. He stated that the care was terrible. He added, Sometimes I have to wait an hour for staff to answer my call light and sometimes an aide will come in, turn off the call light and say they will return, and never come back. Not to mention the weekends are the worst. He went onto say, The DON is on a med cart even today, and sometimes they have one nurse on two med carts. On 2/20/2023 at 9:30 AM, the call light for Resident #262 was observed to be on. During this time, staff were walking past the light, but no one answered it. At 10:30 AM, the call light was still on and staff were observed walking right past the light. On 2/2/2023 at 10:30 AM, Resident #262 was interviewed. He stated that he had the call light on because he needed to be changed. He added that the certified nursing assistant (CNA) assigned to him came in and stated she would be back, but it had been almost an hour and she never came back. In an interview with Employee C, LPN/Unit Manager on 2/20/2023 at 9:45 AM, she stated, all staff have the responsibility to answer the call lights. When asked who was assigned to Resident #262, she was not sure as she was working on a different unit. When she asked the other staff members, she was told the assigned CNA was providing a shower to another resident. She then asked another staff member to attend to the resident's light. On 2/20/2023 at 11:24 AM, Employee A, Licensed Practical Nurse (LPN) was observed passing medication on the [NAME] Wing front hall. The nurse was asked if she had any residents that were due for blood sugar checks, she said, I don't know yet because I'm still not done with the 9:00 o'clock medications, I still have 4 more residents (Residents #102, #215, #214, and #71) to give medications to. When asked what the time frame was for administering medications, she stated that she had one hour before and one hour after the scheduled time. She confirmed that the medications were late. When asked what the facility protocol was if medications are administered late, she said, I need to contact the Director of Nursing (DON) to come and help. Employee A confirmed she had not notified anyone that she was running behind schedule and walked away from the cart to the DON's office. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105447 If continuation sheet Page 9 of 18 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 02/23/2023 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 0725 On 2/20/2023 at 12:15 PM, Employee B, LPN was observed preparing medication for Resident #31. Level of Harm - Minimal harm or potential for actual harm During an interview with Employee B on 2/20/2023 at 12:30 PM, she confirmed that Resident #31's medications were due at 9:00 AM. When asked if there were any other residents that had not received medications, she reviewed the electronic medication administration record (eMAR) and stated that two more residents (Residents #14 and #212) other than Resident #31 had not received their 9:00 AM medications. She added that she started the medication administration late because there was a staffing issue, and she started her med pass at 10:00 AM. Residents Affected - Some In an interview with the DON on 2/20/23 at 02:49 PM, she confirmed that medications were administered late. She mentioned that there was a hick up with staffing and hence the late medication administration. During an interview with the Administrator and the DON on 2/23/2023 at 4:54 PM, they both confirmed that staffing has been a challenge, but they always try to get agency staff to cover. The DON confirmed that she worked on the cart on a rotating basis with other supervisors. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105447 If continuation sheet Page 10 of 18 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 02/23/2023 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 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observations and interview, the facility failed to post the nurse staffing data specified in paragraph (g)(1) of this section [ (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (C) Certified nurse aides. (iv) Resident census.] on a daily basis at the beginning of each shift for 2 of 2 days observed. Residents Affected - Many The findings include: On 2/20/2023 at 10:10 AM, the daily nurse staffing data had not been updated for the current date. The data posted reflected the census and nurse staffing data for 2/16/2023. (Photographic evidence obtained) On 2/21/2023 at 8:45 AM, the daily nurse staffing data had not been updated for the current date. The data posted reflected the census and nurse staffing data for 2/16/2023. (Photographic evidence obtained) On 2/21/2023 at 1:24 PM, the daily nurse staffing data had not been updated for the current date. The data posted reflected the census and nurse staffing data for 2/16/2023. (Photographic evidence obtained) During an interview with the Administrator on 2/21/2023 at 4:54 PM, she was asked about the nurse staffing information posted at the entrance of the facility. Upon seeing the information posted dated 2/16/2023, she stated, Oh that's not correct. That needs to be changed. She acknowledged the nurse staffing information posted had not been updated and was out of date. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105447 If continuation sheet Page 11 of 18 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 02/23/2023 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, record reviews, staff interviews, and facility policy and procedure review, the facility failed to ensure a medication error rate of less than 5%, based on 14 errors with 33 opportunities for errors, resulting in an error rate of 42.42%. Residents Affected - Some The findings include: Cross reference F760. On 2/20/2023 at 11:24 AM, Employee A, Licensed Practical Nurse (LPN) was observed passing medication on the [NAME] Wing front hall. The nurse was asked if she had any residents that were due for blood sugar checks, she said, I don't know yet because I'm still not done with the 9:00 o'clock medications, I still have 4 more residents to give medications to. When asked what the time frame was for administering medications, she stated that she had one hour before and one hour after the scheduled time. She confirmed that the medications were late. When asked what the facility protocol was if medications are administered late, she said, I need to contact the Director of Nursing (DON) to come and help. Employee A confirmed she had not notified anyone that she was running behind schedule and walked away from the cart to the DON's office. During an interview with the DON on 2/20/2023 at 11:30 AM, she confirmed that the medications were late for 4 residents (Residents #102, #215, #214, and #71). She added that late medications are considered as med errors and the physician should be notified of the medication errors. (Copies of the physician orders obtained for the four residents). During a medication administration observation on 2/20/2023 at 11:23 AM, Employee P Registered Nurse (RN) was observed preparing to obtain blood sugar for Resident #262. After gathering all the supplies, nurse donned gloves and walked into the resident room. He cleaned the resident's middle finger of the left hand and obtained a drop of blood to the testing strip. He stated that the blood sugar was 327. He walked out of the resident room, discarded the lancet in the sharps container. In the same gloves he obtained a sani wipe for cleaning the glucometer. After scrubbing the glucometer for about 30 seconds, he wrapped it in a clean sani wipe and left it on a barrier placed on the cart. He doffed gloves, (no hand hygiene was performed); obtained a Humalog insulin pen, reviewed the orders and stated that resident required 16 units of insulin. He went to the resident room, donned gloves and injected 16 units to the left upper arm. He walked out of the resident room, doffed gloves (no hand hygiene was performed) and checked the electronic medication record as administered. He then took the glucometer and placed in the cart and walked way to pick up a phone call form the facility phone. On 2/20/2023 at 12:15 PM, Employee B, LPN was observed preparing medication for Resident #31. While preparing the medications, Resident #31 walked up to her and stated she had a headache. She described the pain level at level 8 out 10 (10 being most severe) and requested that Employee B give her Tylenol. The nurse obtained all other mediation, but did not get the Tylenol. she stated that she did not have the 500 milligrams (mg) per orders and she would have to call the physician to request another medication or a different dosage. She explained the same to the resident. Resident #31 expressed disappointment for the medication being so late. She added, I have severe acid reflux and it bothers me if I don't get my medications on time. During an interview with Employee B on 2/20/2023 at 12:30 PM, she confirmed that Resident #31's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105447 If continuation sheet Page 12 of 18 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 02/23/2023 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 0759 Level of Harm - Minimal harm or potential for actual harm medications were due at 9:00 AM. When asked if there were any other residents that had not received medications, she reviewed the electronic medication administration record (eMAR) and stated that three residents (Residents #31, #14, and #212) had not received their 9:00 AM medications. She added that she started the medication administration late because there was a staffing issue, and she started her med pass at 10:00 AM. Residents Affected - Some During a follow up interview with the DON on 2/20/2023 at 2:49 PM, she confirmed that the medications were administered late. She added that the nurse should have called the physician to see if the dose or the time could be adjusted. She mentioned that there was a hick up with staffing and hence the late medication administration. On 2/20/2023 at 2:51 PM, Resident #31 stated she still had headache and was not sure if Employee B had given her the Tylenol medication. She added that the ice pack helps and she would ask the staff to give it to her. On 2/20/2023 at 3:20 PM, Employee B confirmed that she had not administered the Tylenol to Resident #31 and had not provided any non-pharmacological interventions. When asked if she had notified the physician that the dosage require was not available, she said, No , I did not call the physician because the central supplies stated that they would get the medication and I forgot to follow up to get the medication. On 2/22/2023 at 9:43 PM, an observation of medication administration was conducted for Resident #41 with Employee C, LPN (Agency). The nurse obtained one tablet for Entresto 24 mg- 26 mg, and metoprolol 25 mg one-half tablet. He then went to the resident's room and gave the medication to the resident. A review of the medication orders for Resident #41 revealed Entresto 24 mg- 26 give one tablet two times a day hold for Blood pressure (BP) less than 110/60 and Metoprolol 25 mg give 1 tablet daily and hold for BP less than 110/60. (Photographic evidence obtained) On 2/22/2023 at 9:45 PM, Employee C was asked what the blood pressure was for Resident #41. He confirmed that he did not obtain it. He added that the nursing assistants were supposed to obtain the blood pressure and he was not sure what the readings were. During an interview with the DON on 2/23/2023 at 12:07 PM, she stated that hand hygiene should be performed before donning gloves and after doffing off gloves including while administering medication. She added that if medication is not available in the cart, the nurse should try and check if its available in the pyxis system, if it's still not available the physician should be notified to see if the dose or a different medication should be given. When asked about obtaining blood pressure medication for medications with parameters, she stated that the blood pressure should be obtained by the nurse before giving the medication. A review of the facility's policy and procedure titled: Administering Medication (revised April 2019) read: Medications are administered in a safe and timely manner, and as prescribed. The policy interpretation and implementation revealed the following: 2. The Director of Nursing Services supervises and directs all personnel who administer medication and have related functions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105447 If continuation sheet Page 13 of 18 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 02/23/2023 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 0759 Level of Harm - Minimal harm or potential for actual harm 3. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. 4. Medications are administered in accordance with the prescribers orders, including any required time frames. Residents Affected - Some 5. Medications administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. Enhancing optimal therapeutic effect of the medication b. Preventing potential medication of food interactions; and c. Honoring resident choices and preferences, consistent with his or her plan of care. 6. Medication errors are documented, reported and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. 7. Medications are administered within one (1) hour of their prescribed time unless otherwise specified (for example before and after meal orders). 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage right time and right method (route) of administration before giving the medication. 11. The following information is checked/ verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary. 25. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic techniques, gloves, isolation precautions, etc.) for administration of medication, as applicable. (Photographic evidence obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105447 If continuation sheet Page 14 of 18 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 02/23/2023 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, record review, and facility policy and procedure review, the facility failed to 1) ensure that 7 (Residents #102, #215, #214, #71, #31, #14, and #212) of 12 residents observed for medication administration, remained free of significant medications errors, by failing to administer their 9:00 am medications within one (1) hour of prescribed time and failing to notify the physician of the medication errors, and 2) failed to administer blood pressure medication as ordered, following parameters set by the physician for 1 (Resident #41) of 12 residents reviewed for medication administration, by failing to obtain blood pressure readings prior to giving the medication. Residents Affected - Some The findings include: 1. On 2/20/2023 at 11:24 AM, Employee A, Licensed Practical Nurse (LPN) was observed passing medication on the [NAME] Wing front hall. The nurse was asked if she had any residents that were due for blood sugar checks, she said, I don't know yet because I'm still not done with the 9:00 o'clock medications, I still have 4 more residents to give medications to. When asked what the time frame was for administering medications, she stated that she had one hour before and one hour after the scheduled time. She confirmed that the medications were late. When asked what the facility protocol was if medications are administered late, she said, I need to contact the Director of Nursing (DON) to come and help. Employee A confirmed she had not notified anyone that she was running behind schedule and walked away from the cart to the DON's office. During an interview with the DON on 2/20/2023 at 11:30 AM, she confirmed that the medications were late for 4 residents (Residents #102, #215, #214, and #71). She added that late medications are considered as med errors and the physician should be notified of the medication errors. (Copies of the physician orders obtained for the four residents). A review of the current physician's orders for the four residents revealed the following orders for critical medications: Resident #102 had orders for Baclofen 20 mg every 6 hours for muscle spasms, Gabapentin 600 mg three times a day for polyneuropathy, Levetiracetam (Keppra) 750 mg 2 times a day for convulsions, Oxycontin 10 mg every 12 hours for pain and Oxcarbazepine 150 mg (give 450 mg) two times a day for spasms and neuropathy. (Photographic evidence obtained) Resident #215 had orders for Apixaban (Eliquis) 5 mg every morning and at bedtime. Insulin lispro sliding scale before meals, midodrine 5mg give three tablets three times a day for hypotension. (Photographic evidence obtained) Resident #214 had orders for Apixaban (Eliquis) 5 mg in the morning and at bedtime. Metoprolol 25 mg every morning and at bedtime. Levemir insulin 25 units one time a day for diabetes. (Photographic evidence obtained) Resident #71 had orders for Quetiapine (Seroquel) 25 mg and 50 mg two times a day for anxiety. (Photographic evidence obtained) On 2/20/2023 at 12:15 PM, Employee B, LPN was observed preparing medication for Resident #31. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105447 If continuation sheet Page 15 of 18 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 02/23/2023 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with Employee B on 2/20/2023 at 12:30 PM, she confirmed that Resident #31's medications were due at 9:00 AM. When asked if there were any other residents that had not received medications, she reviewed the electronic medication administration record (eMAR) and stated that two more residents (Residents #14 and #212) other than Resident #31 had not received their 9:00 AM medications. She added that she started the medication administration late because there was a staffing issue, and she started her med pass at 10:00 AM. A review of the current physician's order for Resident #31 and other two residents revealed all three had orders for critical medications: (Photographic evidence obtained) Resident #31 had orders for Clonidine HCI 0.1 mg two times a day for hypertension and Gabapentin 300 mg two times a day for pain. Resident #14 had orders for Apixaban (Eliquis) 5 mg two times a day of thrombosis, insulin apart per sliding scale before meals and at bedtime. (Photographic evidence obtained) Resident #212 had orders for Apixaban 5 mg two times a day for blood thinner. Humalog 5 units before meals for diabetes, Lantus 10 units two times a day for diabetes. (Photographic evidence obtained) During a follow up interview with the DON on 2/20/2023 at 2:49 PM, she confirmed that the medications were administered late. She added that the nurse should have called the physician to see if the dose or the time could be adjusted. She mentioned that there was a hick up with staffing and hence the late medication administration. 2. On 2/22/2023 at 9:43 PM, an observation of medication administration was conducted for Resident #41 with Employee C, LPN (Agency). The nurse obtained one tablet for Entresto 24 mg- 26 mg, and metoprolol 25 mg one-half tablet. He then went to the resident's room and gave the medication to the resident. A review of the medication orders for Resident #41 revealed Entresto 24 mg- 26 give one tablet two times a day hold for Blood pressure (BP) less than 110/60 and Metoprolol 25 mg give 1 tablet daily and hold for BP less than 110/60. (Photographic evidence obtained) On 2/22/2023 at 9:45 PM, Employee C was asked what the blood pressure was for Resident #41. He confirmed that he did not obtain it. He added that the nursing assistants were supposed to obtain the blood pressure and he was not sure what the readings were. During an interview with the DON on 2/23/2023 at 12:07 PM, she stated that while administering blood pressure medications with parameters, the blood pressure should be obtained by the nurse before giving the medication. A review of the facility's policy and procedure titled: Administering Medication (revised April 2019) read: Medications are administered in a safe and timely manner, and as prescribed. The policy interpretation and implementation revealed the following: 2. The Director of Nursing Services supervises and directs all personnel who administer medication and have related functions. 3. Staffing schedules are arranged to ensure that medications are administered without unnecessary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105447 If continuation sheet Page 16 of 18 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 02/23/2023 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 0760 interruptions. Level of Harm - Minimal harm or potential for actual harm 4. Medications are administered in accordance with the prescribers orders, including any required time frames. Residents Affected - Some 5. Medications administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. Enhancing optimal therapeutic effect of the medication b. Preventing potential medication of food interactions; and c. Honoring resident choices and preferences, consistent with his or her plan of care. 6. Medication errors are documented, reported and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. 7. Medications are administered within one (1) hour of their prescribed time unless otherwise specified (for example before and after meal orders). 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage right time and right method (route) of administration before giving the medication. 11. The following information is checked/ verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary. 25. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic techniques, gloves, isolation precautions, etc.) for administration of medication, as applicable. (Photographic evidence obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105447 If continuation sheet Page 17 of 18 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 02/23/2023 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 kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility's kitchen, by failing to date mark numerous open food packages in the refrigerator and the freezer. Food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: A tour of the kitchen was conducted on 2/19/2023 at 11:45 AM. During the tour, no date markings were observed on and open container of mayonnaise, an open box filled with tomatoes, an open bag of cabbage, another open box filled with lettuce, a bag of cream wrapped in plastic, and another open bag of shredded cheese on the shelf in the walk-in refrigerator. There was no date marking observed on one open package of buns sitting on a shelf in the walk-in freezer. (Photographic evidence obtained) Another tour of the kitchen was conducted on 2/20/2023 at 9:45 AM. No date markings were observed on an open box filled with tomatoes, an open bag of cabbage, an open box filled with lettuce, and another open bag of shredded cheese on the shelf in the walk-in refrigerator on the shelf in the walk-in refrigerator. There was no date marking observed on one open package of buns sitting on a shelf in the walk-in freezer. (Photographic evidence obtained) An interview was conducted with Dietary Aide H on 2/23/2023 10:44 AM, who confirmed that the facility's policy for date marking was to ensure open food was covered, labeled, and dated. An interview was conducted with the Certified Dietary Manager (CDM) on 2/23/2023 at 10:53 AM. The CDM stated it was a collective responsibility of all staff to maintain food storage standards. She confirmed that the facility policy for food storage and date marking was that opened foods should be zipped locked or saran wrapped, labeled, and dated. A review of the facility's policy and procedure entitled Food Storage: Cold Foods (dated 9/2017), revealed: All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code. Procedures: #5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. (Copy obtained) Reference: FDA Food Code 2022 Annex 5. Conducting Risk-Based Inspections Annex 5 - C. Intervention Strategies for Achieving Long-term Compliance. 4. Establish First-In-First-Out (FIFO) Procedures. Page 31. https://www.fda.gov/media/164194/download (Accessed on 1/23/2023): Product rotation is important for both quality and safety reasons. First-In-First Out (FIFO) means that the first batch of product prepared and placed in storage should be the first one sold or used. Date marking foods as required by the Food Code facilitates the use of a FIFO procedure in refrigerated, ready-to-eat, TCS foods. The FIFO concept limits the potential for pathogen growth, encourages product rotation, and documents compliance with time/temperature requirements. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105447 If continuation sheet Page 18 of 18