Inspection·August 10, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents had a comfortable and homelike environment, by failing to utilize maintenance services to maintain baseboards, bedframes, ceiling tile framework, toilets, paint, walls, and tile, affecting rooms 110, 115, 200, 201, 203, 204, 206, 208, 210, 211, 218, 224, 301 and 304, fourteen of 68 rooms in the facility. A failure to maintain the facility's interior can result in water damage, mold, accidents, pests, and other environmental hazards which could place residents, staff, and visitors at risk. The findings include: On 08/09/2023, the facility, including all 68 resident rooms, was toured beginning at 9:55 AM. The building integrity appeared intact without any observations of pests. The lobby was clean and free of debris with adequate lighting, a comfortable temperature, and no malodor. Hallways appeared clean and were free of debris/tripping hazards. The ceiling tiles, baseboards and floors were worn. The facility is [AGE] years old. Housekeeping staff were observed cleaning resident rooms and common areas. No malodor was noted in the facility or on residents' persons during the survey. Staff/resident interactions were friendly, courteous, and professional. On the facility's central hall, the baseboard located between the Employee Lounge and the 200 hall was damaged and pulled away from the wall, leaving enough space between the baseboards and walls to harbor pests, soil/debris and/or mold. Flaking paint and plaster were observed, however, no mold or pests were observed, even when the baseboard was disturbed. The Janitor's Room located on the same hall and adjacent to the Employee Lounge had broken tile at the corner of the doorway. (Photographic evidence obtained) On 08/09/2023, beginning at 10:00 AM, observations of multiple resident rooms revealed damaged baseboards with enough space between the baseboards and walls to harbor pests, soil/debris and/or mold. Flaking paint and plaster were observed, however, no mold or pests were observed during the survey. The rooms observed with baseboard damage were rooms 200, 201, 203, 204, 206, 208, 210, 211, 218, 301, and 304. (Photographic evidence obtained) room [ROOM NUMBER], Bed A, was observed with surface rust on the front, right leg of the bed, however, the bed was secure and functional. No other beds in the facility were observed with rust damage. room [ROOM NUMBER] was observed with surface rust on the metal ceiling tile frames and air vents. No water damage was observed. Ceiling tiles were not discolored. room [ROOM NUMBER] was observed with a slightly warped wall/sheet panel. room [ROOM NUMBER] was observed with a cracked windowsill. room [ROOM NUMBER]'s toilet was off-center and had a broken caulk seal at its base, however, the toilet was secured to the floor and did not move when pressure was applied. There was no leakage at the base of the toilet; the floor was dry, and the toilet was functional. There was some surface rust on the metal fixtures securing the toilet to the floor and at the water inlet valve. (Photographic evidence obtained) room [ROOM NUMBER]'s wall, adjacent to the (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 10 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 08/10/2023 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)