Inspection·February 14, 2024

F 0880 where the sign is. She is droplet precautions for Covid. Level of Harm - Minimal harm or potential for actual harm A review of Resident #2's medical record indicated the resident was admitted to the facility on [DATE] with a primary diagnosis of Covid 19. The resident's physician's order, dated 2/8/24, revealed the resident was to be on contact/droplet isolation. (Photographic evidence obtained) Residents Affected - Few 3. The Infection Preventionist identified Resident #4 as being on contact precautions for herpes zoster. A PPE hanger was observed stocked with gloves, gowns, face masks, and face shields. There was no sign observed on the door. She was asked if there should be a sign on the door identifying the precaution type and PPE required to enter the room. She stated, Yes, there should be a sign for contact precautions. A review of Resident #4's medical record indicated she was admitted to the facility on [DATE] with diagnoses that included weakness and Covid 19 (2/5/24 per hospital record review). The resident's physician order, dated 2/13/24, revealed Covid 19/UR (Upper Respiratory) Symptom Monitoring: Monitor for Covid 19 and UR symptoms every shift. Her physician's order, dated 2/14/24, revealed she was to be on Isolation Precautions: Contact Isolation- provide isolation set up with cart, barrels, red bags, stop sign and PPE. (Photographic evidence obtained) During a second tour of the facility on 2/14/24 at 1:50 PM, Employee A, CNA was observed entering Resident #3's room, without donning any PPE. Employee A was observed exiting the same room without any PPE on or doffing PPE. When Employee A was asked if she had entered Resident #2's room without donning PPE. She stated, Yes. When asked if she was trained to don PPE, per the contact precaution sign posted on the door of the room, prior to entering the room. She stated, Yes, if I am going to care for the resident in the B bed, because he has a urine infection. But if I am only caring for the resident in the A bed, then no, I don't need to use the PPE. She was asked if she knew which resident was ringing the call bell before she entered the room. She stated, The B bed rang the light for the A bed, because the A bed can't ring the light because he is confused, and the B bed thought that the A bed needed some help to get out of bed. A second interview was conducted with the Infection Preventionist on 2/14/24 at 2:50 PM. She was asked to review what Resident #4 was on precautions for, and what type of precautions she is on. She stated, She just got here last night, she has herpes in her oral cavity and is on Acyclovir. She was then asked to review her chart to determine if the resident's precautions were also related to Covid 19. After reviewing the chart, the Infection Preventionist stated, Yes, she is Covid; you are correct, she is both. When asked if Resident #3 should be on both droplet and contact precautions. She stated, Yes, she should be on both precautions. When asked if the staff were trained to don required PPE for precaution every time they enter the room? She replied, Absolutely. When she was asked if staff should don the required PPE per signage on the door regardless of which resident they think they are going to provide care to once they enter the room. She stated, The staff is aware of which resident in the room is on precautions. I would expect them to always don and doff the PPE when they enter the room. My rationale is they may have to do something for either resident while they are in the room. A review of the facility's policy titled Infection Control Program Overview (Published 12/4/23) revealed the following: Purpose: The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105447 If continuation sheet Page 2 of 3 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 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 0880 transmission of communicable diseases and infections. Level of Harm - Minimal harm or potential for actual harm Scope of the Infection Control Program: The infection Control Program is comprehensive in that it addresses detection, prevention, and control of infections among residents, staff, volunteers, visitors, and others. Residents Affected - Few Staff and resident education are done to focus on risk infection and practices to decrease risk. Policies, procedures, and aseptic practices are followed by personnel in performing procedures. (Photographic evidence obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105447 If continuation sheet Page 3 of 3