Inspection·January 23, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of a behavior note for Resident #2 dated 1/10/25, indicated that he remained in a wheelchair all night long. He was encouraged to go to bed but would not. Behavior notes from 1/12/25- 1/22/25 noted residents behaviors of resisting care and hitting staff during care. Review of a social service note for Resident #2 dated 1/15/25, noted that he had multiple episodes of resisting care. Review of the care plan for Resident #2 initiated on 1/8/25 revealed resident is resistive to care related to adjustment to nursing home. Dementia does not allow staff to change him, hits and kicks and punches at staff - holds on to other residents wheelchair and does not understand interactions. Resident #2 was also care planned for potential to be physically aggressive related to anger and poor impulse control. On 1/23/25 at 1:45 pm, an interview was conducted with CNA F who was familiar with Resident #2. She stated that she had assisted other staff caring for Resident #2. She explained that he was combative, and required total care for activities of daily living, but can feed himself with supervision. She added resident is confused and cannot make needs know. She mentioned that when she was assisting Resident #2 yesterday, he held her hand and would not let go. She calmly got the resident to release her hand without incident. She stated the resident needs redirection and reapproaching to get care done and at times it takes several attempts. She added that staff should not force him to get the care. When asked if she had received training on dealing with combative residents. She said, I have been her for 24 years and I have received a lot of education, but I cannot remember specific training. During an interview with Licensed Practical Nurse (LPN B) on 1/23/25 at 2:15 pm, she stated that on 1/10/25, she heard yelling from the shower room. Shortly thereafter, Patient Care Attendant (PCA C) came to the nursing station and asked if she was the assigned nurse to Resident #2 because the resident was on the floor in the shower room. Upon entering the shower room, the resident was seated on the floor next to the shower chair. Some bruises were noted on the assessment. Resident #2 could not explain what happen and was still anxious and agitated. She asked CNA A (Assigned CNA) to get a Hoyer lift to assist getting the resident back on the chair. During this time, she asked PCA C what happened. The CNA told her that the resident became combative and punched CNA A in the stomach. PCA C reported that she witnessed CNA, A react and made contact with Resident #2 with an open hand on the ear. PCA C stated that she had asked CNA A to stop giving him a shower as the resident was combative, but she did not listen. When CNA A returned and asked what happened, she stated the resident was combative, but she wanted to clean him up because he was soiled. She added that as she was bending down to clean the resident, he punched her in the stomach and out of reflect, she hit him on the side of his ear. She reported the incident to the abuse coordinator. 2. Review of the medical record for Resident #4 revealed an admission date of 9/17/24. His diagnoses included metabolic encephalopathy, muscle wasting and atrophy, depression, gout, need for assistance with personal care, gastroparesis, type II diabetes mellitus, diverticulosis of large intestine and inflammatory liver disease. Review of the quarterly MDS with ARD of 12/20/24, revealed Resident #4 had a BIMS score of 15, indicating cognitively intact, with no behaviors noted. He required partial/moderate assistance with showering and personal hygiene and was totally dependent with toileting and transfer. The assessment indicated that he was frequently incontinent of urine and bowel. On 1/23/25 at 2:45 pm, an interview was conducted with Resident #4. When he was asked about the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105447 If continuation sheet Page 2 of 4 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few incident that happened in the shower room. He explained that the CNA E had an attitude from the time she was beginning his shower. He said that it was around 11:00 am and lunch time is around 11:30 am (his shower takes 30-45 minutes). CNA E came to get him to the shower and she said, it's almost time for lunch and I won't be dealing with you stupid cracker shitting in here because I'm not going to be cleaning it up. CNA E walked out of the shower obtained a plastic bag and placed it under the shower chair. CNA E then told him that she was an agency staff and there was nothing he could do as she would find a job somewhere else. Resident #4 stated that he felt bad and defeated and did not tell anyone at the time. The next day when he saw a familiar face (did not recall who) he told her what happened and she asked him to report it, and that's when he went to front office to report it. He continued to state that the agency staff did not seem to care and were always in hurry while providing care Review of the physician orders for Resident #4 dated 9/18/24 revealed furosemide (Lasix) 40 mg daily for fluid retention, duloxetine 60 mg daily for depression, and trazadone 50 mg at bedtime for depression. On 1/23/25 at 2:56 pm, an interview was conducted with the Social Services Assistant (SSA). She stated that on 1/21/25, Resident #4 came to the front office and stated that the CNA who was assigned to him the previous day was rude. He told her that the CNA said , You cannot Shit here cracker. She stated she helped the resident write the report and handed it to the Social Service Director (SSD). She confirmed that Resident #4 was alert and oriented x4 and was able to make needs know. On 1/23/25 at 3:00 pm, an interview was conducted with the Administrator. She explained that she was new to the facility and the investigation for Resident #2 was ongoing at the time of her hire. She went on to say the resident was combative during care. However, CNA A who was assigned to Resident #2 confirmed that she forced resident to the shower to clean him up as he was soiled. In the shower Resident #2 hit the CNA on the stomach and out of reflex the CNA grazed Resident #2 on the side of the face near his ear. She stated that the CNA was suspended after the allegation and abuse training initiated related to resident rights - Right to refuse care. The allegation of abuse was substantiated. When asked about Resident #4's abuse concerns. The administrator explained that CNA E was providing a shower. When the resident was in the shower, he had a tendency of having the bowel movement during shower. CNA E told him that he was not going to shit there and called him a cracker. She continued to state that the CNA was an agency CNA and would not be returning to the facility. When asked for the agency staff training and competency, she confirmed that the training could not be obtained. When asked about the training for Dementia and Alzheimer's training/behavior management training for CNA A prior to the incident. She confirmed that the training could not be found. She also confirmed that the facility had not conducted any training or in-service on Dementia and Alzheimer's training/behavior management after the incident with Resident #2. Review of the facility's policy titled, Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, Injury Of Unknown Source And Investigations, effective 04/01/2022 and no revision date revealed the following: PURPOSE: It will be the policy of this facility honor residents' rights and to address with employees the seven (7) components regarding mistreatment, abuse, neglect, misconduct, injuries of unknown source, involuntary seclusion, corporal punishment, misappropriation of resident property or funds, or use of physical or chemical restraint not required to treat the resident's symptoms in accordance with Federal Law. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105447 If continuation sheet Page 3 of 4 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2025 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 0600 DEFINITIONS: Level of Harm - Minimal harm or potential for actual harm Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology (mental abuse including, but not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate a resident). Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Residents Affected - Few TRAINING: a. Training of employees will be through the following: i. Orientation program ii. Ongoing in-service training iii. Annually and more often if needed iv. One-to-one counseling when identified v. Indicators to identify staff burnout b. Training will focus on the following topics: i. Recognizing abuse, neglect, and misappropriation of resident property ii. Steps on how to report including to whom and when. iii. How to protect residents, staff, and others from immediate danger iv. Signs of and intervention techniques to be used with residents having aggressive behavior or catastrophic reaction. v. How to recognize the signs of burnout, frustration, and stress in self and co-workers. vi. Employees' responsibility upon witnessing neglect, or misappropriation of property. vii. Federal standards on resident protection, reporting, and investigation of ANEMMI. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105447 If continuation sheet Page 4 of 4