Inspection·January 19, 2024

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few possible points, indicating severe cognitive impairment. A review of section GG for self-care revealed he was dependent on staff for bed mobility, transfers, toilet hygiene, and personal hygiene. A review of sections E for behaviors revealed that there were no indications of refusal of care behaviors. A medical record review for Resident #8 revealed diagnoses including diabetes mellitus, type 2 and dementia. A review of Resident #8's most current person-centered care plan revealed: FOCUS: Activities of Daily Living (ADL) Deficits related to functional mobility deficits, weakness, cerebral vascular accident (CVA). Goals: Resident will be clean, dressed, and well-groomed with no contractures through next review. Interventions: Set up and supervise simple grooming tasks, Set- up for ADL tasks daily, allow time to do as much on own as able. A review of December 2023 and January 2024 nursing progress notes revealed no documentation of Resident #8's refusal of nail care or preference to wear his fingernails long. A facility policy review for Activities of Daily Living (ADLs) (Revised January 2012) revealed the following: Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and Implementation. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: Hygiene (bathing, dressing, nail care and oral care). 4. A resident's ability to perform ADLs will be measured using clinical tools, including Minimum Data Set (MDS). . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105514 If continuation sheet Page 2 of 9 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 01/19/2024 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 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, and record review, the facility failed to ensure that one (Resident #96) of 35 sampled residents received treatment and care in accordance with professional standards of practice, the resident's plan of care and resident choices, based on the resident's and resident representative's desire to have bilateral compression stockings placed on lower extremities daily as ordered. Residents Affected - Few The findings include: On 1/16/24 at 12:18 PM, Resident #96 was observed seated in his wheelchair. He was dressed in a long-sleeved shirt, long dark pants, and dark-colored crew socks. When greeted, he smiled and said hello. He was accompanied by his niece, who reported that she visited every day. When asked how the care at the facility had been, she stated He's ordered to wear compression stockings daily, but they never place them on him. I even purchased multiple pairs. The resident's niece pulled up Resident #96's pant legs to expose his lower extremities showing that he was not wearing bilateral compression stockings. Resident #96 was observed on 1/19/24 at 9:05 AM. He was seated in his wheelchair dressed in a long-sleeved shirt, dark-colored pants and dark crewcut socks. A blanket covered his face. When greeted, he smiled and shook his head up and down. When asked to see his socks, he pulled up both pant legs revealing that no compression stockings were in place. Resident #96 was observed again on 1/19/24 at 12:15 PM, in the main dining room, eating lunch with his niece. When asked if his compression socks were on, his niece stated No and pulled up the resident's pant legs showing his dark-colored crew socks. No compression socks were in place. A review of Resident # 96's medical record revealed he was admitted on [DATE] from an acute-care hospital. His diagnoses included traumatic subdural hemorrhage, traumatic brain dysfunction, sequela, type 2 diabetes, hypertension, and anxiety. A review of the 5-day, admission Minimum Data Set (MDS) assessment, dated 11/10/23, revealed the resident had adequate hearing and vision; was understood, was able to understand others and had a Brief Interview for Mental Status (BIMS) score of 00 out of 15 possible points, indicating severe cognitive impairment. He required partial moderate assistance from staff with lower body dressing, and partial moderate assistance from staff for putting on and taking off footwear. A review of the active physician's orders revealed an order dated 12/7/23: Encourage use of compression stocking to bilateral lower extremities. On AM and remove at HS every day for apply and at bedtime for remove. A review of the electronic treatment administration record (eTAR) found that Resident # 96's placement of compression stockings to bilateral lower extremities on in AM and remove at bedtime, had been signed off as Administered on 1/16/2024 and 1/19/2024, despite the observations and interview with the resident's family member verifying that they had not been placed. (Copies obtained) During an interview with Certified Nursing Assistant (CNA) F on 01/19/24 at 10:24 AM, who reported being assigned to a floating position around the facility to assist with residents, she stated she was not too familiar with Resident #96 but could locate treatments a resident required to include (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105514 If continuation sheet Page 3 of 9 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 01/19/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few compression stockings through the [NAME] system located in the electronic medical record. She confirmed that the CNAs were responsible for placing compression stockings if there was a physician's order. She further stated if a resident refused, the nurse was notified and the refusal was documented. On 1/19/24 at 12:02 PM, an interview was conducted with CNA G, who reported he had been assigned to Resident #96, but not this week. He was aware that Resident #96 had orders for compression stockings and stated he would place them on in the morning and the assigned CNA at night should be removing them. When asked if there would be a reason the compression stockings weren't placed, he stated, No, not unless the staff taking care of him wasn't aware of the order. On 1/19/24 at 12:05 PM, an interview was conducted with Registered Nurse (RN) E, who confirmed that there would be no reason why compression stockings weren't placed on Resident #96 unless there was an updated order from the physician placing the current one on hold, for which there would be a new physician's order and documentation in a progress note. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105514 If continuation sheet Page 4 of 9 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 01/19/2024 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observations, medical record review, interviews, and review of the policy and procedure for Following Physicians' Orders (revised 1/2024), the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote healing for one (Resident #111) of two residents selected for pressure ulcer review, from a total sample of 35 residents. Resident #111 suffered deterioration of a sacral pressure wound which was facility-acquired. Residents Affected - Few The findings include: An interview was conducted with Resident #111 and her son on 1/16/24 at 11:53 a.m. in her room. The resident was speaking with her son and was observed on a low air loss mattress with pillows on the bed and booties on both her feet. She reported having wounds on her sacrum and lower legs. The son reported the wound care nurse was great, but when she was off on weekends, no one completed the wound care. Both reported that the wound care physician was overseeing and caring for the wounds. On 1/17/24 at 9:00 a.m., Resident #111 was observed lying in bed and stated the wound care physician came by and reported the wound on her sacrum was not improving. He stated he was going to change the treatment. The wound care physician provided the treatment to the resident's sacrum today. A review of Resident #111's record revealed an admission date of 11/25/23. Diagnoses included: paraplegia, cord compression, diabetes mellitus stage III, sacral pressure ulcer, peripheral vascular disease, osteoporosis, and vascular wounds of the lower extremities. A review of the current physician order, dated 1/18/24, revealed a treatment order for the sacrum which instructed clinical staff to cleanse the sacrum with normal saline or wound cleanser, pack with calcium alginate ropes, apply a sheet of calcium alginate, and cover with a silicone foam dressing every day and as needed. A review of the January 2024 Treatment Administration Record (TAR), revealed treatments to the sacrum were not signed off as having been provided on 1/3 morning and evening, 1/6 morning, 1/12 morning and evening, or 1/16 evening. The December 2023 TAR was reviewed and revealed that on multiple days the sacral treaments, which were scheduled twice a day, were not signed off as having been provided on the following days: 12/8, 12/9, 12/10, 12/16, 12/23, 12/24, 12/28 and 12/29/23. An interview was conducted with the Director of Nursing (DON) at 2:30 p.m. on 1/18/24. She reviewed the TARs for December and January and confirmed that there were multiple blanks where staff did not sign off as having completed the wound care. She reported staff should be signing off on the TAR when wound care is completed. The DON reported that on 1/3/24, she completed the morning dressing change to the sacrum and forgot to sign that TAR. An interview was conducted with Registered Nurse (RN) E/Wound Care Nurse on 1/18/24 at 3:10 p.m. She reported completing wound care on the long-term care side of the facility from Monday through Friday each week. The nurses assigned to the residents completed the wound care on the weekends and when she was not there. On the rehabilitation unit, the desk nurse completed the wound treatments, and if she was absent, the unit manager completed the wound care/dressing changes. Wound care was documented on the TAR and signed off after completion. Residents who had pressure ulcers, and those followed by wound care, had weekly UDAs (User Designed Assessments). Site, wound type, measurements, date identified, reviews, tunneling or undermining, drainage, pain, tissue types, wound color etc were documented in the UDA. The RN reviewed the December and January 2024 TARs. She stated Resident #111's wound was identified on 12/4/23. It was facility-acquired and treatments began on 12/5/23. After reviewing the TARs, the RN confirmed that the treatments for wound care were not signed out on 12/8, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105514 If continuation sheet Page 5 of 9 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 01/19/2024 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 12/9, 12/10, 12/16, 12/23, 12/24, 12/28, or 12/29/23. The January 2024 TAR was reviewed and she confirmed that the 1/3 evening, and the 1/6, 1/12, and 1/16 wound care treatments to the sacrum were not signed out by the nursing staff as having been done. A wound care consult was conducted on 12/6/23 and Resident #111 was evaluated for an initial wound assessment of the sacral wound. The Stage III sacral pressure wound measured 3.5 x 5.5 x 0.1 cm (centimeters). No tunneling was noted. There was a moderate amount of drainage with no odor. The wound was noted with 90% granulation and 10% slough (dead tissue). An order was written to cleanse the wound with wound cleanser, pat dry, apply honey gel silicone border foam dressing and avoid direct pressure to the wound site. A wound consultation note, dated 1/10/24, noted an X-Ray to the sacrum and coccyx with no osseous (bone) abnormalities. There was a plan for a bone scan to rule out osteomyelitis and an infectious disease consultation for evaluation of possible pyoderma gangrenosum (condition that causes large, painful sores (ulcers) to develop on your skin, most often on your legs). The sacral wound continues to demonstrate deterioration. Debridement to sacrum performed today. Sacral Stage III pressure ulcer not healed with measurements 10 x 8 x 5.2 with undermining noted at 1:00 and ends at 3:00. There is a moderate amount of drainage noted with a strong odor. The wound has 40% granulation, 60% slough and is deteriorating. A new treatment order was written. A 1/17/24 UDA wound evaluation note was reviewed and revealed a Stage III to sacrum with measurements 10 x 8 x 5.2 with undermining, moderate drainage, and the treatment order was changed. On 1/18/24, the physician order notes to cleanse sacrum with normal saline or wound cleanser, pack with calcium alginate ropes, apply sheet of calcium alginate and cover with silicone foam dressing every day and as needed. An interview was conducted with Advanced Registered Nurse Practitioner (ARNP) H on 1/19/24 at 9:30 a.m. He reported being notified the wound was deteriorating on the sacrum. A bone scan, X-Ray and labs were ordered along with making an appointment with the Infectious Disease Physician. The ARNP reported the wound was being treated by the wound care physician and he was following. There was a question of pyoderma gangresom, possible osteomylelitis and noncompliance of the resident with turning and positioning. The ARNP stated if wound care treatment/dressings were not being completed, the wound could be compromised. He was not aware that wound care was not being completed. On 1/19/24 at 9:45 a.m., Resident #111's sacral wound was observed with RN I. The wound was the size of a fist and a half with slough and red and black color around the wound. The RN stated signing off on the TAR was expected when completing wound care. The RN noted the wound had deteriorated and the wound care physician was seeing the resident. A review of the facility's policy and procedure for Following Physicians' Orders (revised 1/2024) revealed that physicians' orders should be followed as prescribed and if not followed, the reason should be recorded on the resident's medical record during that shift. The physician should be notified along with responsible party if indicated. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105514 If continuation sheet Page 6 of 9 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 01/19/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observations, staff and resident interviews, medical record review, and a review of facility policy, the facility failed to ensure that two (Resident #56 and #94) of 35 residents in the total sample, were provided an environment as free of accident hazards as was possible. The findings include: On 01/16/24 at 11:44 AM, razors were observed at the sink in Resident #56's room. On 01/17/24 at 9:12 AM, four razors were observed rubberbanded together in a cup on the sink in Resident #56's room. (Photographic Evidence Obtained) On 01/19/24 at 8:57 AM, three razors were observed in an open cabinet at the sink in Resident #94's room. (Photographic Evidence Obtained) Resident #94 was asked if the razors belonged to him and he stated, yes. He was asked if the razors were usually stored in the cabinet at the sink and he replied, Yes. On 01/19/24 at 9:12 AM, an interview was conducted with Registered Nurse (RN) J. She was asked how sharps were managed at this facility and she replied, We dispose of sharps in the sharps container after use. She was asked to describe some examples of sharps. She stated, needles, razors, lancets. On 01/19/24 at 9:13 AM, an interview was conducted with Certified Nursing Assistant (CNA) K. She was asked to provide some examples of a sharps item. She replied, needles and razors. She was asked if razors were kept out in the open in the residents' rooms. She stated, No, we are not supposed to keep razors in the room. Sometimes the family bring things and we may not be aware, but if I find it, I take it out of the room and store it for the resident, but it's not supposed to be left out in the room. On 01/19/24 at 9:20 AM, an interview was conducted with Licensed Practical Nurse (LPN) C, who was acoompanied to Resident #56's room. She was asked what was in the cup that was located at the sink and why were the items located there. LPN C replied, Those are razors and I don't know why they're here, I'd have to ask the CNA. She was asked how razors were usually stored and disposed of. She replied, Razors should not be kept in the resident's room, and they should be disposed of into the sharps after use. She was asked if she was familiar with the medications that Resident #56 received and she replied, Yes, I think he gets an anticoagulant but let me be sure. She used her computer to look up Resident #54's medication list, then she replied, Yes, he takes Eliquis. She was asked to describe some pertinent side effects or adverse reactions to Eliquis. LPN C stated, Bleeding is a side effect or adverse reaction for taking Eliquis. She was asked if the accepted practice of the facility was to leave razors out in the open in the resident's room and she said, No, we usually get the razors from supply and then dispose of them after use, but I will immediately remove those razors. When she was asked whether the resident could shave himself, LPN C stated, No, his CNA shaves him. A review of the facility's policy and procedure for Sharps Disposal (Revised January 2012), revealed the following: The facility shall discard contaminated sharps into designated containers. Policy Interpretation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105514 If continuation sheet Page 7 of 9 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 01/19/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm and Implementation. 1. Whoever uses contaminated sharps will discard them immediately or as soon as feasible into designated containers. 7. Whoever observes incorrect disposal or handling of contaminated sharps should report the information to the Infection Preventionist (or designee). . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105514 If continuation sheet Page 8 of 9 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 01/19/2024 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, staff interviews, medical record review, and facility policy review, the facility failed to ensure a medication error rate of less than 5 percent. Three errors were identified out of 26 opportunities for error, resulting in a medication error rate of 11%, involving two (Residents #50 and #99) of four residents observed during medication administration, from a total of 35 residents in the sample. Residents Affected - Few The findings include: On 1/17/24 at 8:00 a.m., Nurse A was observed preparing medications for Resident #50. She pulled each medication according to the electronic Medication Administration Record (eMAR) and signed off each as she prepared the medications. She administered the medications, which were being given by mouth, to the resident. Upon returning to the medication cart, Nurse A was asked if she had completed this medication pass for Resident #50. She stated yes. She was asked if she had signed off all the medications on the eMAR for this resident. She stated yes. She was asked if she was going to prepare medications for the next resident at this time. She stated yes. She was asked to open the eMAR for Resident #50 and review it. After her review, Lubricant Eye Drop Solution 0.4-0.3% was observed to have been signed off as having been administered. The nurse was asked if she had administered this eye drop to the resident. She stated, Oh, no I didn't. On 1/18/24 at 8:20 a.m., Nurse B was observed preparing medications for Resident #99. Nurse B prepared and poured one Folic Acid tablet 1 mg (milligram) into a medication cup. After completing the medication preparation and pouring for all medications, she locked the eMAR screen and the medication cart. She was asked if the medications she had poured were what she was going to bring into the room to administer to Resident #99. She stated yes. She was asked to review the order for Folic Acid prior to entering the resident's room. Upon reviewing the order in the eMAR, she stated, Oh, Folic Acid 1 mg tablets, give 5 tablets. I need to add 4 more tablets to make the 5 tablets. Nurse B was then observed administering the medications to Resident #99. She administered 2 sprays of Flonase Nasal Spray 50 micrograms (mcg) per spray into each nostril. After Nurse B administered one spray in each nostril, she stated, I'm going to wait a minute or two to do the second spray. She administered a second spray into each nostril. While reviewing Resident #99's medications in the eMAR to sign them off after administration, Nurse B stated, Oh, it was only one spray for each nostril. A review of the facility's policy titled Medication Administration (revised 1/2024) revealed: Standard: Medications are ordered and administered safely and as prescribed. Procedure: 3. Medications are administered in accordance with presciber orders; 9. The individual adminstering the medication checks the label to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105514 If continuation sheet Page 9 of 9