Health inspection·February 10, 2022

F 0610 Level of Harm - Minimal harm or potential for actual harm On 2/10/2022 at approximately 12:30 p.m., the Social Services Director (SSD) provided a typed statement dated 2/9/2022 at 6:50 p.m. The statement was regarding an interview conducted by the SSD with Resident #35's son. The interview indicated Resident #35 was lethargic and was unable to answer questions. The resident's son mentioned his mother told him that the male hospice aide wanted to rub lotion on her during one of his visits. She did not think it was okay for him to do this, so she declined the offer. (Copy obtained) Residents Affected - Few On 2/9/2022 at 11:15 a.m., an interview was attempted with Resident #35. She was lying in her bed with her son at the bedside. Her eyes were open and she was able to smile but was unable to answer any questions. On 2/9/2022 at 5:50 p.m., an interview was conducted with the Social Services Director (SSD), Administrator in Training (AIT), and Director of Nursing (DON). The SSD explained that all residents receiving hospice care by the alleged perpetrator were interviewed on 12/15/2021. A list of the residents interviewed by the facility and their responses was reviewed. The list did not contain Resident #35's name. During the interview, the SSD was asked whether Resident #35 had been interviewed. The SSD explained that neither Resident #35 nor her Resident Representative had been interviewed as part of the facility's investigation on 12/15/2021. When asked why Resident #35 had not been interviewed, the SSD explained that Resident #35 had enrolled in hospice care a couple of weeks before the CNA (hospice CNA) was arrested, and added that when the facility developed the list of potential victims, Resident#35 was overlooked. The facility's abuse prevention policy titled Abuse Prevention Program (no effective date, no facility review date) was reviewed. The policy statement read, As part of the resident abuse prevention, the facility's administration will identify and assess all possible incidents of abuse; investigate and report any allegations of abuse within timeframes as required by federal and state requirements; The policy outlined the role of the person conducting the abuse investigation to include interviewing other residents to who the accused employee provides care or services. (Copy obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105514 If continuation sheet Page 2 of 8 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 105514 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Debary Health and Rehabilitation Center 60 N Hwy 17/92 Debary, FL 32713 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to effectively manage a resident's pain, by failing to identify and respond to non-verbal indicators of pain for one resident (Resident #7) reviewed for pain management from a total sample of 35 residents. Residents Affected - Few The findings include: A review of Resident #7's medical record, revealed an admission date of 6/6/2014. Her medical diagnoses included vascular dementia and cerebral infarction (stroke). Resident #7 also had a contracture of her left arm. A quarterly Minimum Data Set (MDS) assessment, dated 2/1/2022, revealed a Brief Interview for Mental Status (BIMS) score of 02 from a total 15 possible points, indicating severely impaired cognition. Resident #7 required extensive to total assistance with activities of daily living (ADLs) and received hospice services for end-of-life care. On 2/7/2022 at 12:13 p.m., Resident #7 was observed sitting in a reclining geri-chair in her room. The chair was reclined. She was grimacing, her brow was furrowed, and she was repeatedly whimpering. Resident #7 was not able to answer any questions. On 2/8/2022 at 2:05 a.m., an off-hours visit was made to the facility. Resident #7 was observed lying in her bed. Her eyes were open, her brow was furrowed, she was frowning, and she was repetitively whimpering. Resident #7 was not able to answer any questions. A review of the resident's physician's orders, revealed an order for acetaminophen 650 mg (milligrams) to be given by mouth every four hours as needed for general discomfort. An order dated 8/17/2021, was identified for hospice services. (Copies obtained) On 2/8/2022 at 2:15 a.m., an interview was conducted with Licensed Practical Nurse (LPN) A. She confirmed that she was assigned to Resident #7. She was notified that the resident was lying awake in bed and was displaying non-verbal indicators of pain. The nurse stated, Oh, she makes those noises all the time. The nurse was asked whether she had conducted a pain assessment on the resident during the current shift. The nurse stated she had not. The nurse was then asked how she assessed the resident for pain. The nurse stated, She doesn't complain of pain and then explained that the resident was non-verbal. When asked whether the nurse had received any recent education regarding effective management of a resident's pain, she stated, I think so, but I can't say for sure. When asked whether the resident had any medications available for pain, LPN A stated she wasn't sure. LPN A was then asked to review Resident #7's physician's orders. LPN A reviewed the orders and stated the resident had an order for Tylenol (acetaminophen) that could be given every four hours as needed. LPN A was asked to evaluate Resident #7 for pain, as she appeared very uncomfortable. As of 2/8/2022 at 2:30 a.m., LPN A had still not evaluated Resident #7 for pain. A review of the medication administration records (MARs) for February 2022, revealed one administration of acetaminophen on 2/8/2022 at 4:55 a.m. (Copy obtained) A review of the MARs for January 2022, revealed no documented administration of the acetaminophen for the entire month. (Copy obtained) A review of an Addendum Plan of Care Review by the hospice provider, dated 1/13/2022, revealed no entries for the pain levels section and included a handwritten statement which read, Tylenol (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105514 If continuation sheet Page 3 of 8 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 105514 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Debary Health and Rehabilitation Center 60 N Hwy 17/92 Debary, FL 32713 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 0697 effective. (Copy obtained) Level of Harm - Minimal harm or potential for actual harm A review of the resident's comprehensive care plans revealed a focus area for Alteration in Comfort related to Cognitive Impairment and Muscle Spasms (may not be able to express pain). Interventions included the administration of pain medication as ordered, assistance to reposition for comfort, observation for any verbal or non-verbal indicators of pain or discomfort, and to notify the physician/hospice if current pain medications were not effective. (Copy obtained) Residents Affected - Few Resident #7's Pain Level Summaries for February 2022 were reviewed. Of the 25 pain assessments documented in February 2022 for this non-verbal resident, 17 were documented as verbal pain assessments. (Copies obtained) On 2/10/2022 at 11:58 a.m., Resident #7 was observed lying in bed. The head of the bed was elevated. A positioning wedge had been placed next to her right leg. The resident was frowning and was attempting to extend her right leg repeatedly. When asked whether she was in pain, she continued to frown and look around the room. She was not able to answer any questions. On 2/10/2022 at 2:24 p.m., Resident #7 was observed lying in bed. The head of the bed was elevated. The positioning wedge had been removed from the resident's right side. The resident was frowning and repeatedly whimpering. Resident #7 was again unable to answer any questions, but did eventually state, Ow while looking at her right leg. On 2/10/2022 at 3:20 p.m., an interview was conducted with Certified Nursing Assistant (CNA) B. She confirmed that she was assigned to Resident #7 and that she was familiar with the resident's care. She was asked whether Resident #7 ever complained of pain. CNA B stated, No. She doesn't say much. Not that I'm aware of. CNA B was then asked whether she was familiar with non-verbal indicators of pain. She responded, I guess if they have like a scrunched up face or something like that. CNA B was asked whether she had received any recent training in identifying indicators of pain in non-verbal residents. She stated she did not believe she had. On 2/10/2022 at 3:25 p.m., an interview was conducted with Registered Nurse (RN) C. The nurse confirmed that she was assigned to Resident #7 and that she was familiar with the resident. She was asked whether the resident ever complained of or showed signs of pain. She stated, She doesn't talk. She kind of does that sound thing, which we think could be pain but who knows. Other than that, I'm not sure. RN C was asked to review Resident #7's medical record for pain medications. She explained that Resident #7 had acetaminophen available every four hours as needed. She added that there was no documented administration of acetaminophen on the previous shift. RN C was asked whether she had assessed Resident #7 for pain during the current shift. She stated she had just come on duty, but she had not received any concerns about Resident #7 in report from the off-going nurse or CNA. RN C was notified that Resident #7 appeared to be uncomfortable and was asked to assess Resident #7 for pain. She stated, Well, I can't start her medications until 4:00 p.m. RN C was reminded that Resident #7's acetaminophen could be administered every four hours as needed. She stated, Oh that's right. It's as needed. I'll go down and see her. The nurse left the medication cart and went into Resident #7's room. She returned to the medication cart approximately two minutes later and stated, Yea, she's probably in pain. I'll go ahead and get her the Tylenol. The facility's policy for pain management, titled Pain Assessment and Management (Version 1.3 (H5MAPR0208), Revised March 2015) was reviewed. The purpose of the policy read, The purpose of this procedure is to help the staff identify pain in the resident, to develop interventions that are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105514 If continuation sheet Page 4 of 8 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 105514 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Debary Health and Rehabilitation Center 60 N Hwy 17/92 Debary, FL 32713 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few consistent with the resident's goals and needs, and that address the underlying causes of pain. The policy continued, Pain management is a multidisciplinary process that includes the following: Assessing the potential for pain; effectively recognizing the presence of pain; developing and implementing approaches to pain management . The policy directed staff to observe possible behavioral signs of pain which included, verbal expressions such as groaning, crying, screaming; facial expressions such as grimacing, frowning, clenching of the jaw, etc; guarding, rubbing, or favoring a particular part of the body; insomnia; (Copy obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105514 If continuation sheet Page 5 of 8 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 105514 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Debary Health and Rehabilitation Center 60 N Hwy 17/92 Debary, FL 32713 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. Specifically, the facility failed to ensure that the dietary staff were trained and knowledgeable about proper sanitation practices in the kitchen. Specific instruction on hand hygiene, food handling and sanitation is important in health care settings serving nursing home residents, due to the risk of serious complications from foodborne illness as a result of their compromised health status. Unsafe food handling practices represent a potential source of pathogen exposure. This failure potentially impacted every resident consuming food from the facility's kitchen. The findings include: A tour of the kitchen with the Certified Dietary Manager (CDM) on 02/07/22 at 2:13 PM revealed: -On the refrigerator across from the tray line, the door handles were soiled and sticky with food debris, and the inner door of the refrigerator had dried debris afixed to the surface of the door. -Inside the refrigerator was an opened 46-ounce container of nectar consistency water dated with a use by date of 11/08/21, without an opened date. There was another 46-ounce container of thickened orange juice dated 02/03/22. There was an unlabeled container of a reddish/orange liquid dated 02/04, with the year not indicated. (Photographic evidence obtained) -In the food pantry, 24 single-serve bowls of cereal were observed to be unlabeled and undated, with two large brown boxes stacked on top of them. -Multiple containers of 46-ounce lemon-flavored nectar-thickened water were observed on the shelves with use by dates of 11/08/21. (Photographic evidence obtained) -The 3-compartment sink across from the food line was observed with the first wash compartment containing mixing bowls and utensils soiled with food products, the second rinse compartment #2 had a colander of cooked bowtie pasta in it, and the third sanitized compartment was observed plugged up and ¾ filled with cloudy water. -The large floor storage bins for flour and rice were not sealed. (Photographic evidence obtained) -The walk-in refrigerator was observed with a multi-serving bag of ketchup opened in the cardboard box. The silver ketchup dispensing bag was soiled with residual ketchup and the cap was encrusted with dried ketchup. A large tray of undated food was on the refrigerator shelf not completely wrapped to prevent contamination. Unidentified contents were observed with illegible writing. A red, sticky substance was found on the shelves and floor. (Photographic evidence obtained) -In the walk-in freezer, there was a 17-pound box of opened frozen pie dough sheets with a plastic storage bag that was open to air and undated. Frozen sweet potatoes were poorly wrapped in plastic wrap with a use by date of 02/02 and were exposed to the air. A kitchen observation on 02/09/2022 from 2:30-3:50PM revealed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105514 If continuation sheet Page 6 of 8 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 105514 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Debary Health and Rehabilitation Center 60 N Hwy 17/92 Debary, FL 32713 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 -A dietary aid was observed working on the dish line with shoulder-length hair. Her hairnet only partially covered her head. -The refrigerator exterior doors had been cleaned, but the interior door remained soiled with dry debris. -Cook G was observed making macaroni salad, not wearing gloves. His mask was positioned on his chin and he adjusted his eyeglasses numerous times. He walked to the refrigerator, returned with salad dressing, then proceeded to break down cardboard. He then returned to continue making the macaroni salad without wearing gloves or washing his hands. -Three containers of peanut butter were found on the can rack with a use by date of 01/22/22, and an additional container was observed in the food prep area with the same use by date. An interview was conducted with [NAME] G regarding the facility's policy/practice regarding foods use by dates, and he stated they discarded these items before the use by date. He added that it was something everyone in the kitchen kept an eye on; this was not one person's responsibility. -A kitchen blue light was observed with debris inside the fixture and on the bulb. Clean soup containers/warmers were located directly four feet from the light. -There were large 18x12 cooking sheets improperly stored with the edges of the cooking sheets resting on the floor. Ceiling vents over the tray line were soiled with dust and debris hanging from them. (Photographic evidence obtained) -There were two detached hoses from juice concentrate dispensers observed lying on shelves unbagged. The cranberry juice multi-serving dispenser was resting on the counter with the dispenser nozzle in direct contact with the countertop. -At 3:03PM, the walk-in refrigerator was checked and a tray of brownies and a tray of yellow sheet cake, both dated 02/07/2022, were observed partially exposed, loosely covered with white paper. (Photographic evidence obtained) Loosely wrapped cheese was observed on the shelf with a use by date of 12/03/21 and a received date of 12/29, no year indicated. Dinner service was observed on 02/09/2022 from 4:10 PM to 5:15 PM. On the service line, [NAME] G was observed taking food temperatures correctly, but failing to record them in the meal temperature log. He stated he usually filled them in later. A review of the meal temperature log showed that the temperatures were not recorded for lunch or dinner on 02/09/2022. The Regional Dietary Director was interviewed on 02/10/2022 at 9:00 AM. Information regarding the cleaning of the kitchen vents by an outside vendor was provided. The last date of service was 10/18/2021 with documentation that the hood should be cleaned every 90 days. Documentation was provided stating that the ice machines were cleaned monthly and filters were changed every 6 months as per manufacturer recommendation, with a last changed date of on 10/21/21. A kitchen tour was conducted on 02/10/2022 from 11:50 AM to 12:45 PM with the Regional CDM during the lunch service. The facility CDM was observed in the kitchen on three of the four survey days, wearing a dark-colored beanie on her head with braided hair exposed in the back about 3 inches below the rim of the hat. The regional CDM stated the dietary staff should have their hair completely contained in a hair net, and that they were permitted to wear hats, but the hair must be contained. In the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105514 If continuation sheet Page 7 of 8 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 105514 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Debary Health and Rehabilitation Center 60 N Hwy 17/92 Debary, FL 32713 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 walk-in freezer there were numerous torn bags of opened and undated bags of pizza dough and potato wedges. These food items were stored in cardboard boxes with unclosed lids, not properly resealed/or wrapped up. The Regional CDM stated the items that had been opened should have been dated and properly resealed, but they should not be exposed to the air. [NAME] G was observed touching his glasses with and without gloves, touching papers in the kitchen and grabbing utensils for meal service numerous times during this kitchen visit. In the walk-in refrigerator, a full-sheet cake approximately 12x18 and a same-sized tray of brownies were observed with white paper lying on top of them dated 02/08/22. An interview was conducted with the Regional CDM and Registered Dietitian (RD) on 02/10/2022 at 1:38 PM. The RD stated she mainly communicated with the Regional CDM, and he would notify her if there was something he needed her to follow up with. She stated her main communication was with facility management. She said when she came to the facility, the CDM would let her know if she needed her to follow up on a resident need, or if a nurse wanted to talk to her. That was the kind of things she worked on. She said she reviewed new admissions and addressed changes in weights and anything that was brought up by the Interdisciplinary Team (IDT). She provided support for the dietary department, but she did not do education for the dietary department. Corporate did that. When she walked through the kitchen, it was the same as the Regional CDM, or corporate staff. They had a checklist, but it was done by the dietary department. She only reviewed the checklist, but she did not complete it. It was something she submitted to the corporate office. An interview was conducted with the Regional CDM on 02/10/2022 at 1:45 PM. He stated he had been here for a little over two weeks, and that this was a new building for him. Going forward he said he would be a part of education, working with the CDM training the management team and deciding what mandatory in-services would be done, what was expected to be done on a monthly basis and would conduct monthly audits in addition to ongoing education and audits. At 1:52 PM, the findings were reviewed with the Regional CDM, who stated he understood and acknowledged the concerns. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105514 If continuation sheet Page 8 of 8