Inspection·April 13, 2023

F 0582 Level of Harm - Minimal harm or potential for actual harm None of the options were marked in response. In addition, the notice was signed by the resident on 3/9/23; the same day the services ended. 2. A record review for Resident #63 revealed that she was admitted to the facility on [DATE]. Her diagnoses included, but were not limited to, COVID-19, heart failure and aftercare following hip joint prosthesis. Residents Affected - Few Further review found that Resident #63 had a physician's order dated 1/4/23 for occupational therapy five times a week for four weeks as per the plan of care (POC) for ADLs (activities of daily living), re-education, therapeutic activities, and therapeutic exercises as appropriate. A NOMNC was issued on 2/10/23 to Resident #63 related to her skilled nursing services starting on 1/2/23. The last day of Part A services was 2/10/23. The facility initiated the discharge when Resident #63's skilled benefit days were not exhausted. The NOMNC was signed by the resident on 2/10/23, the day services ended. An ABN was also issued on 2/10/23 for PT and OT ending on 2/10/23, due to Resident #63 meeting her therapy goals. Estimated costs were listed and Resident #36 selected Option 3: I do not want the therapy listed above. She signed the form the same day, 2/10/23. An interview was conducted with the facility Social Worker (SW) on 4/13/23 at 5:14 p.m. She stated as soon as insurance sent an e-mail notification indicating that skilled services were terminating, the resident was notified in writing that same day. Sometimes insurance notified two days in advance but that was not always the case. The Admissions Coordinator (AC) was interviewed on 4/13/23 at 5:19 p.m. When asked about Resident #36's and Resident #63's termination of benefits, she explained both were long-term care residents. She stated each had skilled nursing services open back up in-house. The determination was made in advance that services would terminate when the in-house benefits ended. The facility always knew the termination date a couple of days in advance. When shown the forms and asked about Resident #36's and Resident #63's same-day notification, the AC shook her head no. She said, Unfortunately, there was always a couple days notice. The termination is discussed by the management team during the Utilization Review meetings on Wednesdays. [Residents #36 and #63] should have been given advanced notice. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105570 If continuation sheet Page 2 of 35 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 105570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indigo Manor 595 N Williamson Blvd Daytona Beach, FL 32114 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observations, staff interviews, and facility document and policy review, the facility failed to protect the residents' right to personal privacy and confidentiality of his or her personal/medical records for three (Residents # 26, 31, and 28) out of a total sample of 52 residents. Residents Affected - Few The findings include: On 4/11/23 at 9:04 a.m., an observation was made on the 2600 hallway. Licensed Practical Nurse (LPN) B, assigned to the medication cart on this hallway, was not observed anywhere in the vicinity. Her medication cart was halfway down the residential hallway. The laptop computer on the cart was open, unlocked, and displaying Resident #26's personal health information. (Photographic evidence obtained) LPN B returned to the cart at 9:07 a.m. and began preparing medications. On 4/12/23 at 8:20 a.m. during a medication administration observation with LPN B, she left her medication cart to deliver medications to Resident #31. The medication cart laptop screen was left open with Resident #31's personal medication information visible. When LPN B returned to her medication cart five minutes later, she was asked if she had left the medication screen open with resident medical information visible. She replied, Oh, I did. I didn't mean to do that. The hallway was observed to have various staff and residents walking past the medication cart during this time who could have seen Resident #31's personal medical information. On 4/13/23 at 9:15 a.m., an observation on the 2600 hallway revealed a medication cart left unattended with the laptop computer screen open and displaying the personal medical information for Resident #28. No nurse was observed in the area. LPN E returned to the medication cart at 9:18 a.m. She was asked if she realized she had left the computer screen open and unattended with resident medical information visible. She stated, I know. I had to go get his blood pressure and I left it up. I didn't mean to. A review of Resident Rights contained in the facility's admission Agreement (dated 9/1/22) revealed: (h) Privacy and confidentiality: The resident has a right to personal privacy and confidentiality of his or her personal and medical records. A review of the facility's policy titled Administration Procedures for All Medications (effective date 9/2018) revealed: Procedures: II. Privacy: 2. Secure (cover) records containing protected health information, such as Medication Administration Records (MARs). . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105570 If continuation sheet Page 3 of 35 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 105570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indigo Manor 595 N Williamson Blvd Daytona Beach, FL 32114 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, a review of resident records and facility policies, and interviews with staff, the facility failed to ensure residents were free from neglect, by failing to provide supervision and interventions to maintain safety, prevent elopement (leaving the premises without supervision or permission) and minimize the risk of injury or death for one (Resident #92) of three residents reviewed for elopement risk, from a total of 52 residents in the sample. The facility's neglect to provide appropriate services and interventions to prevent elopement after identifying the resident as at risk, permitted Resident #92 to exit the facility and wander to a busy intersection without staff supervision, placing him at risk for serious bodily harm or death. On 2/27/23, Resident #92 was admitted to the facility's first floor. The same day, at 2:15 p.m., he was assessed as an elopement risk and a Wanderguard (alarm bracelet) was to have been applied. On 2/28/23 at 6:29 a.m., the resident was noted as wandering the unit checking exit doors. An order and placement of a Wanderguard was to be obtained this AM. On 2/28/23 between 2:20 p.m. and 2:30 p.m., Resident #92 left the facility and was located wandering down a busy boulevard at approximately 2:31 p.m. He was brought back to the facility, moved to a more secure floor, and a Wanderguard was placed. The resident was identified by the facility as an elopement risk upon admission. Due to the failure of three nurses to adequately supervise Resident #92 and put safety interventions in place, the resident was able to elope and was found wandering down the busy boulevard. The resident likely could have fallen, been hit by a car, and/or have gotten lost. The facility census was 152 and there were nine residents identified as at risk for elopement as of 4/12/23. The Immediate Jeopardy (IJ) began on 2/28/2023 at 2:30 p.m. and was identified on 4/12/2023 at 11:30 a.m. The Administrator was notified of the IJ determination at 2:30 p.m. on 4/13/23, and the Immediate Jeopardy was ongoing as of the survey exit on 4/13/23. The findings include: Cross reference to F689. A record review for Resident #92 found he was admitted to the facility on [DATE]. A Clinical admission Evaluation and corresponding nursing progress note was completed by Registered Nurse (RN) A on 2/27/23 at 2:15 p.m. She indicated Resident #92 was not alert and oriented to person, place or time. He ambulated with a steady gait and was described as confused, with disorganized thought and moderate cognitive impairment (memory loss). Resident #92 was verbal but incoherent. Narrative notes reported him wandering about the floor and that the previous nurse was to obtain a Wanderguard. Staff were to monitor him closely for wandering. (Photographic evidence was obtained.) An Elopement Evaluation completed 2/27/23 at 3:43 p.m. by RN A indicated Resident #92 had verbally expressed a desire to go home, packed his belongings to go home, or stayed near an exit door. Both goal-directed and aimless wandering were observed. Resident #92 was assessed as being recently (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105570 If continuation sheet Page 4 of 35 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 105570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indigo Manor 595 N Williamson Blvd Daytona Beach, FL 32114 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 - Immediate jeopardy to resident health or safety Residents Affected - Few admitted and had not accepted the situation. Wandering was likely to affect the privacy of others. Resident #92 scored a 5 and was identified as At Risk. (Photographic evidence obtained) Licensed Practical Nurse (LPN) C wrote a progress note on 2/28/23 at 6:29 a.m., indicating that Resident #92 was non-compliant with COVID-19 isolation, was wandering the unit, and was checking exit doors. Every hour checks were initiated. Resident #92 was to be checked on frequently by staff. Order and placement for Wanderguard to be obtained this morning. (Photographic evidence obtained) A 2/28/23 progress note written at 4:00 p.m. by LPN D, revealed that Resident #92 was found walking down the boulevard by staff members. He was escorted back to the facility. His room was changed to [the second floor], and a Wanderguard was placed on his left ankle to ensure his safety. (Photographic evidence obtained) Observations of the facility and surrounding areas were conducted during the survey between 4/10/23 and 4/13/23. The facility is situated on the northeast intersection of a busy four to six lane boulevard (turn lanes considered) with a speed limit of 45 miles per hour (mph). The boulevard intersects with a three lane road (speed limit 30 mph) at the northwest end of the property. The facility's front glass sliding doors face [NAME] and are approximately 200 feet from the boulevard. The doors open to a covered portico then a two-lane parking lot. Between the lot and the boulevard is a grassy treed area. The terrain is uneven, with dips and rises in its surface. A sidewalk runs parallel to the boulevard just beyond the grass. Using a step counter application and timer, the distance from the front door, across the grass to the sidewalk was calculated at 135 steps. Traversing that distance took one minute 16 seconds. The diagonal distance from the front door to the corner intersection is approximately the same distance. On admission, Resident #92's room was on the first floor on the north wing. He would have had to walk approximately 200 feet to get from his room, past the nurses' station, down another hallway, turn and pass administrative offices and the reception desk to reach the front door. (Photographic evidence was obtained of all areas described.) A review of a facility report dated 2/28/23, revealed that Resident #92 was seen walking in the hallway on the Certified unit (1st floor, 1 North) on 2/28/23. He was ambulating up and down the hallways. At approximately 2:20 p.m., staff saw him walking in the hallway on the Certified unit. At approximately 2:30 p.m., staff were unable to locate him. A possible elopement alarm was initiated and approximately one minute later, at 2:31 p.m., Resident #92 was found on the front lawn of the facility. He willingly got into a staff member's car and was transported back to the facility. He was too confused to explain what he was trying to do, but he did tell the nurse who was in the car that he was looking for a woman. The facility's report revealed that on 2/28/23, between 2:20 p.m. and 2:30 p.m., Resident #92 walked out the front lobby doors to take a walk. He was found by staff at approximately 2:31 p.m. He was too confused to provide an explanation about what he was trying to do other than he was looking for a woman. Resident #92 was identified as an elopement risk on admission and triggered At Risk on his elopement assessment. Staff statements revealed he was walking on the sidewalk in non-skid socks. Despite nurses documenting wandering and exit-seeking behavior, no Wanderguard was placed. Nursing notes on 2/28/23 at 6:29 a.m. indicated that Resident #92 was wandering the unit and checking exit doors. Every hour and frequent checks were initiated. Order and placement for Wanderguard to be obtained this a.m. This same day at 2:31 p.m., Resident #92 was found walking down the boulevard and escorted back to the facility. His room was relocated and a Wanderguard was applied. The report concluded that Resident #92 had been recognized as an elopement risk but not moved to a more secure location on the second floor. As a result, three nurses received warnings for failing to provide Resident #92 with a Wanderguard which may have prevented this elopement. The report stated staff were re-educated on elopement. (Photographic evidence obtained) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105570 If continuation sheet Page 5 of 35 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 105570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indigo Manor 595 N Williamson Blvd Daytona Beach, FL 32114 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 - Immediate jeopardy to resident health or safety Residents Affected - Few An interview was conducted with LPN B on 4/12/23 at 9:13 a.m. She explained that on admission, the assigned nurse was to obtain a brief history of the resident, conduct a skin assessment, and must complete multiple additional assessments and consents. She reported it was a little much on the nurses at times. When a resident exhibited wandering behavior, staff redirected them to another location. If the behavior persisted, she presumed a Wanderguard would be placed. The devices were stored on site in central storage. The nurse was to notify the Nurse Practitioner if a patient was wandering or exit-seeking. Nurses instructed Certified Nursing Assistants (CNAs) to keep an eye on residents who wandered. An interview was conducted with Certified Nursing Assistant (CNA) G on 4/12/23 at 9:29 a.m. She explained the standard for supervision was to check on residents every two hours. For residents who wandered, checks would be every 45 minutes to an hour. If a resident was exit-seeking, she redirected them away from the door and told the nurse. The doctor decided which resident got a personal alarm, which went on the resident's ankle or wrist. There were alarms on all facility doors. In an interview with LPN E on 4/12/23 at 9:37 a.m., she explained that if a resident was observed wandering, she would notify the supervisor and get a Wanderguard. They were stored in the facility and could be obtained right away. Residents were assessed on admission using an elopement risk assessment. If a resident still tried to leave after being oriented to the facility and provided with reassurance they could call their family, they were reassessed for cognition and elopement risk. If a resident was confused, staff would place the Wanderguard. Sometimes residents who wandered or were exit-seeking could be moved upstairs, especially when there was a risk. The elevator was code-operated and only alert and oriented residents had the code. Supervision would be increased from the standard every two to three hours to hourly for more confused residents. If the need for a Wanderguard was identified, it could be placed immediately, then the nurse could contact the physician and write a telephone order for its use. LPN E stated there was an elopement book at the nurses' station for identifying residents at risk. She reviewed the book at this time and confirmed Resident #92's information was not included. An interview was conducted with the front desk receptionist on 4/12/23 at 10:02 a.m. She reported she worked Mondays through Fridays from 8:00 a.m. to 5:30 p.m. Another staff member relieved her when she went to lunch. The facility was not a locked facility. The receptionist was asked how she knew which residents were at risk for elopement and who could sign out and leave independently. She said she knew residents who wandered had the alarm (Wanderguard). The sensor is right here on the side of the wall. (She gestured to the wall flanking the reception desk.) If they went past it by themselves, she knew that was not good. When the alarm went off, staff came running. She said she kind of knows which residents could come and go, but she just started here mid-March, so was still learning. There was an elopement risk book in the drawer. She was not sure if it was up to date, but she had access to the electronic medical records. She retrieved the elopement book from the drawer and confirmed upon review that Resident #92's information was not included. LPN F was interviewed on 4/12/23 at 10:22 a.m. She was assigned to the second floor south unit where Resident #92 now resided. LPN F said all residents were assessed on admission, and if they were identified as at-risk for elopement, or if they exhibited wandering behaviors, the family and physician were called and a Wanderguard was placed. Normally, the Wanderguards were kept downstairs on the Certified unit or in central storage. When the need was identified, the device could be placed within five to ten minutes. LPN F explained that she would not want to put that off since residents could be quick on their feet when they wanted to be. It only takes a split second when you take your eye off of them. LPN F again reinforced that she wouldn't wait to place a device when needed. The other (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105570 If continuation sheet Page 6 of 35 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 105570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indigo Manor 595 N Williamson Blvd Daytona Beach, FL 32114 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 - Immediate jeopardy to resident health or safety Residents Affected - Few option would be to get a physician's order and put the resident on one-on-one supervision. More frequent checks would also be a suggestion, but she would check more frequently than every hour. A lot can happen in one hour. LPN F produced the elopement book for unit 2 south, and Resident #92's information was included. The second floor north wing elopement book was reviewed and found Resident #92 was on the list of residents who wore a Wanderguard, however, further review found no photograph or demographic information for him. LPN K looked through the book on 4/12/23 at 10:38 a.m. She confirmed that Resident 92's information was not in the book. Certified Nursing Assistant (CNA) I was interviewed on 4/13/23 at 10:17 a.m. She explained that she was one of the staff who found Resident #92 after his elopement. On the day of the event after the Code Indigo (elopement) was announced, she and the Assisted Living Facility (ALF) Administrator immediately drove off-campus and located Resident #92 at the north end of the property at the intersection. Resident #92 willingly got into the car and was returned to the facility. An interview was conducted with the Administrator at 12:40 p.m. on 4/13/23. When asked if the elopement book was what the receptionists used for identifying residents at risk, she confirmed it was. The facility's records were reviewed. A written statement from the Assisted Living Facility (ALF) Administrator was included, which verified on the day of the event, she and CNA I went to search for Resident #92. They rode down [boulevard name] boulevard and found Resident #92 walking along the sidewalk in non-skid socks. He stated he was looking for a woman and was unaware he had eloped. The statement was signed by the ALF Administrator on 3/3/23. The file contained the meeting sign-in sheet for the elopement training that the facility report said was provided in response. The training was conducted on 3/1/23 with 14 staff members in attendance. Only three of the staff were floor nurses; two LPNs and one registered nurse (RN). The remainder of the staff were all department heads, including but not limited to, the Maintenance Director, the Human Resources Director, Admissions Coordinator, ALF Administrator and Dietician. A review of the employee roster at the time of the survey revealed there were 211 staff members. Thirty-two (32) were licensed nurses (RNs and/or LPNs). There was no evidence any of the floor nurses had received any re-training on elopement risk identification or prevention. One elopement response drill was conducted on 2/28/23 with 24 staff members signing as having been in attendance. A review of the facility's policy on Abuse/Neglect/Exploitation (not dated) revealed: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation . Neglect is defined as failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Under the section Prevention of Abuse, Neglect and Exploitation it read: The facility will implement its policies to prevent and prohibit neglect that achieves: D. The identification, ongoing assessment, care planning for appropriate interventions and monitoring of resident with needs and behaviors which might lead to conflict or neglect. (Photographic evidence obtained) A review of the facility's policy titled Elopement (undated) read: The facility ensures residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105570 If continuation sheet Page 7 of 35 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 105570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indigo Manor 595 N Williamson Blvd Daytona Beach, FL 32114 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 prevent accidents and receive care in accordance with their person-centered-plan addressing the unique factors contributing to wandering or elopement risk. Level of Harm - Immediate jeopardy to resident health or safety Policy Explanation and Compliance Guidelines: Residents Affected - Few 1. Wandering is random or repetitive locomotion that may be goal-directed (e.g., The person appears to be searching for something such as an exit) or non-goal directed or aimless. 2. Elopement occurs when a resident leaves the premises of a safe area without authorization (e.g., an order for discharge or leave of absence) and/or any necessary supervision to do so. 3. The facility is equipped with door locks/alarms to help avoid elopements. 4. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 5. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks and monitoring for effectiveness and modifying interventions when necessary. 6. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering: a. Resident will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan meeting. b. The ID (Interdisciplinary) Team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior or minimize risks associated with hazard will be added to the care plan and communicated with appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopement. e. Charge nurses and UMs will monitor the implementation of interventions, response to interventions and document accordingly. f. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff. The section titled Tips for Prevention of Elopement included, but were not limited to: -Involve family in the prevention strategy by supervising resident during key risk times. -Room placement for easy observation . -. Involve the activities department in the prevention strategy; involve resident in small groups and activities that engage resident's attention at key risk times . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105570 If continuation sheet Page 8 of 35 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 105570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indigo Manor 595 N Williamson Blvd Daytona Beach, FL 32114 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 - Immediate jeopardy to resident health or safety -Never assume everyone knows the resident is a wanderer; make it clear to dining room aides, new staff and whoever is involved in the resident's care . -Consider color coded wristbands as an alert to staff. -Consider the use of a personal alarm for the resident . (Photographic evidence obtained) Residents Affected - Few On 4/13/23 at approximately 1:00 p.m., after being advised of concerns about Resident #92's elopement and the facility's lack of response, the Administrator and Director of Nursing (DON) entered the conference room. They asked why relocating Resident #92 to a secure floor and placing a Wanderguard was not a sufficient response to his elopement. They were advised of the following investigative findings and resulting concerns: 1. Three different floor nurses failed to act appropriately and provide needed services and interventions to protect Resident #92. None placed a Wanderguard, implemented sufficient supervision, or relocated Resident #92 to a secure unit. The in-service training the facility provided in response to the incident only included three of 32 licensed floor nurses. Most training attendees did not work the floor and were not responsible for assessing risk or implementing interventions. Due to the lack of training, there was a likelihood other residents could be affected. 2. Three of four of the facility's elopement books had not been updated to contain Resident #92's information after he was assessed as at risk or since the event. 3. The facility's policy for elopement was vague and allowed for subjective decision-making by nurses related to the implementation of safeguards; and 4. Only one drill had been conducted in response to the incident with only three of 32 floor nurses in attendance. When advised that the lack of urgency and appropriate response to correct the problem contributed to a likelihood of recurrence, the Administrator and DON acknowledged the concern. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105570 If continuation sheet Page 9 of 35 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 105570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indigo Manor 595 N Williamson Blvd Daytona Beach, FL 32114 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of resident records, facility policies, and interviews with staff, the facility failed to coordinate with the state pre-admission screening and resident review (PASARR) program under Medicaid to determine whether a Level II screening was indicated after one (Resident #25) of two residents reviewed for PASARR, from a total of 52 residents in the sample, received a post-admission diagnosis of serious mental illness (SMI). The findings include: A record review for Resident #25 found she was admitted to the facility on [DATE]. She had a Level 1 PASARR screening, dated 1/24/22, that indicated she had no SMI or intellectual disability (ID) and did not require a Level II screening (an evaluation that determines the appropriate setting and recommends specialized services needed for individuals with SMI or ID). (Photographic evidence obtained) Further review revealed that Resident #25's cumulative diagnoses list reflected that on 7/19/22, a diagnosis of schizoaffective disorder, bipolar type (a mental illness that results in symptoms of schizophrenia, such as hallucinations, delusions and psychosis, and bi-polar disorder, marked by episodes of alternating mania and depression) was added. Based on the newly diagnosed mental illness, the facility was required to contact the entity/administrator of the PASARR program to determine whether a Level II assessment was indicated. The facility's policy titled Resident Assessment-Coordination with PASARR Program (implemented on 1/1/23) read: This facility coordinates assessments with the PASARR program under Medicaid to ensure individuals with a mental disorder, intellectual disability (ID), or related condition receives care and services in the most integrated setting appropriate to their needs. Under the Policy Explanation and Compliance Guidelines it read: 1. All applicants to this facility will be screened for serious mental disorders or ID and related conditions in accordance with the state's Medicaid rules for screening . . 9. Any resident who exhibits a newly evident or possible SMI, ID, or related condition, will be referred promptly to the state mental health or ID authority for a level II review. (Photographic evidence obtained) An interview was conducted with the Social Worker (SW) on 4/13/23 at 2:52 p.m. She reviewed Resident #25's record, the post-admission SMI diagnosis, and confirmed a redetermination by the state authority was required. The SW stated she would send Resident #25's information to the state authority. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105570 If continuation sheet Page 10 of 35 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 105570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indigo Manor 595 N Williamson Blvd Daytona Beach, FL 32114 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, a review of resident records and facility policies, and interviews with staff, the facility failed to provide supervision and implement interventions to maintain resident safety, prevent elopement (leaving the premises without supervision or permission) and minimize the risk of injury or death for one (Resident #92) of three residents reviewed for elopement risk, from a total of 52 residents in the sample. The facility's failure to provide appropriate supervision and implement identified and/or available interventions, allowed Resident #92 to exit the facility and wander to a busy intersection without staff supervision, placing him at risk for serious bodily harm or death. On 2/27/23, Resident #92 was admitted to the facility's first floor. The same day, at 2:15 p.m., he was assessed as an elopement risk and a Wanderguard (alarm bracelet) was to have been applied. On 2/28/23 at 6:29 a.m., the resident was noted as wandering the unit checking exit doors. An order and placement of a Wanderguard was to be obtained this AM. On 2/28/23 between 2:20 p.m. and 2:30 p.m., Resident #92 was located wandering down a busy boulevard. He was brought back to the facility, moved to a more secure floor, and a Wanderguard was placed. The resident was identified by the facility as an elopement risk upon admission. Due to the failure of three nurses to adequately supervise Resident #92 and put safety interventions in place, the resident was able to elope and was found wandering down the busy boulevard. The resident likely could have fallen, been hit by a car, and/or have gotten lost. The facility census was 152 and there were nine residents identified as at risk for elopement as of 4/12/23. The Immediate Jeopardy (IJ) began on 2/28/2023 at 2:30 p.m. and was identified on 4/12/2023 at 11:30 a.m. The Administrator was notified of the IJ determination at 2:30 p.m. on 4/13/23, and the Immediate Jeopardy was ongoing as of the survey exit on 4/13/23. On 4/26/23, a revisit determined that Immediate Jeopardy was removed on 4/13/23, and scope and severity were reduced to a D. The findings include: Cross reference to F600. A record review for Resident #92 found he was admitted to the facility on [DATE]. A Clinical admission Evaluation and corresponding nursing progress note was completed by Registered Nurse (RN) A on 2/27/23 at 2:15 p.m. She indicated Resident #92 was not alert and oriented to person, place or time. He ambulated with a steady gait and was described as confused, with disorganized thought and moderate cognitive impairment (memory loss). Resident #92 was verbal but incoherent. Narrative notes reported him wandering about the floor and that the previous nurse was to obtain a Wanderguard. Staff were to monitor him closely for wandering. (Photographic evidence obtained) An Elopement Evaluation completed 2/27/23 at 3:43 p.m. by RN A indicated Resident #92 had verbally expressed a desire to go home, packed his belongings to go home, or stayed near an exit door. Both goal-directed and aimless wandering were observed. Resident #92 was assessed as being recently (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105570 If continuation sheet Page 11 of 35 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 105570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indigo Manor 595 N Williamson Blvd Daytona Beach, FL 32114 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 admitted and had not accepted the situation. Wandering was likely to affect the privacy of others. Resident #92 scored a 5 and was identified as At Risk. (Photographic evidence obtained) Licensed Practical Nurse (LPN) C wrote a progress note on 2/28/23 at 6:29 a.m., indicating that Resident #92 was non-compliant with COVID-19 isolation, was wandering the unit, and was checking exit doors. Every hour checks were initiated. Resident #92 was to be checked on frequently by staff. Order and placement for Wanderguard to be obtained this morning. (Photographic evidence obtained) A 2/28/23 progress note written at 4:00 p.m. by LPN D, revealed that Resident #92 was found walking down the boulevard by staff members. He was escorted back to the facility. His room was changed to [the second floor], and a Wanderguard was placed on his left ankle to ensure his safety. (Photographic evidence obtained) Observations of the facility and surrounding areas were conducted during the survey between 4/10/23 and 4/13/23. The facility is situated on the northeast intersection of a busy four to six lane boulevard (turn lanes considered) with a speed limit of 45 miles per hour (mph). The boulevard intersects with a three lane road (speed limit 30 mph) at the northwest end of the property. The facility's front glass sliding doors face [NAME] and are approximately 200 feet from the boulevard. The doors open to a covered portico then a two-lane parking lot. Between the lot and the boulevard is a grassy treed area. The terrain is uneven, with dips and rises in its surface. A sidewalk runs parallel to the boulevard just beyond the grass. Using a step counter application and timer, the distance from the front door, across the grass to the sidewalk was calculated at 135 steps. Traversing that distance took one minute 16 seconds. The diagonal distance from the front door to the corner intersection is approximately the same distance. On admission, Resident #92's room was on the first floor on the north wing. He would have had to walk approximately 200 feet to get from his room, past the nurses' station, down another hallway, turn and pass administrative offices and the reception desk to reach the front door. (Photographic evidence was obtained of all areas described.) A review of a facility report dated 2/28/23, revealed that Resident #92 was seen walking in the hallway on the Certified unit (1st floor, 1 North) on 2/28/23. He was ambulating up and down the hallways. At approximately 2:20 p.m., staff saw him walking in the hallway on the Certified unit. At approximately 2:30 p.m., staff were unable to locate him. A possible elopement alarm was initiated and approximately one minute later, at 2:31 p.m., Resident #92 was found on the front lawn of the facility. He willingly got into a staff member's car and was transported back to the facility. He was too confused to explain what he was trying to do, but he did tell the nurse who was in the car that he was looking for a woman. The facility's report revealed that on 2/28/23, between 2:20 p.m. and 2:30 p.m., Resident #92 walked out the front lobby doors to take a walk. He was found by staff at approximately 2:31 p.m. He was too confused to provide an explanation about what he was trying to do other than he was looking for a woman. Resident #92 was identified as an elopement risk on admission and triggered At Risk on his elopement assessment. Staff statements revealed he was walking on the sidewalk in non-skid socks. Despite nurses documenting wandering and exit-seeking behavior, no Wanderguard was placed. Nursing notes on 2/28/23 at 6:29 a.m. indicated that Resident #92 was wandering the unit and checking exit doors. Every hour and frequent checks were initiated. Order and placement for Wanderguard to be obtained this a.m. This same day at 2:31 p.m., Resident #92 was found walking down the boulevard and escorted back to the facility. His room was relocated and a Wanderguard was applied. The report concluded that Resident #92 had been recognized as an elopement risk but not moved to a more secure location on the second floor. As a result, three nurses received warnings for failing to provide Resident #92 with a Wanderguard which may have prevented this elopement. The report stated staff were re-educated on elopement. (Photographic evidence obtained) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105570 If continuation sheet Page 12 of 35 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 105570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indigo Manor 595 N Williamson Blvd Daytona Beach, FL 32114 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 On 4/12/23 at 9:00 a.m., the Director of Nursing (DON) was asked if this was the only elopement incident since the last survey. He stated yes, but that Resident #92 had been admitted from an assisted living facility (ALF) and simply didn't know he couldn't just go outside. He was asked for the elopement policy and procedures, Wanderguard guidelines, and anything related to elopement prevention at this time. An interview was conducted with LPN B on 4/12/23 at 9:13 a.m. She explained that on admission, the assigned nurse obtained a brief history of the resident and conducted a skin assessment. Multiple additional assessments had to be completed and consents had to be signed. LPN B said she wished the process was smoother; it was a little much on the nurses at times. Depending on the time of admission, the paperwork was expected to be completed during the same shift. If it could not be completed, the oncoming nurse had to finish it. She tried to leave as many cues as possible regarding outstanding tasks. When a resident exhibited wandering behavior, staff redirected them to another location. If the behavior persisted, she presumed a Wanderguard would be placed or the Unit Manager (UM) would be asked if a Wanderguard was appropriate. The devices were stored on site in central storage. Nurses instructed Certified Nursing Assistants (CNAs) to keep an eye on residents who wandered. Fifteen-minute checks were only used for neuros (neurological checks, implemented after a fall with potential head injury), but she would note any increased supervision for wandering in a progress note. The nurse notified the Nurse Practitioner if a patient was wandering or exit-seeking. LPN B said she had worked in the facility since November 2022 but had not participated in an elopement drill. When asked if she received training on elopement prevention and response, she said no, but she just knows what the signs are. An interview was conducted with CNA G on 4/12/23 at 9:29 a.m. She explained the standard for supervision was to check on residents every two hours. For residents who wandered, checks would be every 45 minutes to an hour. If a resident was exit-seeking, she redirected them away from the door and told the nurse. The doctor decided which residents got a personal alarm, which went on the resident's ankle or wrist. There were alarms on all facility doors. CNA G said she had elopement training when hired in October 2022, but none since. She had not participated in any elopement drills. In an interview with LPN E on 4/12/23 at 9:37 a.m., she explained that there was an elopement book at the nurses' station, and everyone had access to it. It included the names and pictures of residents at risk for elopement. If a resident was observed wandering, she would notify the supervisor and get a Wanderguard. They were stored in the facility and could be obtained right away. Residents were assessed on admission using an elopement risk assessment. If a resident still tried to leave after being oriented to the facility and provided with reassurance that they could call their family, they were reassessed for cognition and elopement risk. If a resident was confused, staff would place the Wanderguard. Sometimes residents who wandered or exit-seeked could be moved upstairs, especially when there was a risk. The elevator was code-operated and only alert and oriented residents had the code. Supervision would also be increased. Staff usually checked on residents every two to three hours but for more confused residents, they checked hourly. These frequent checks were communicated verbally but not documented except maybe in a nurse's note. The nurse's note would explain hourly rounding was being conducted due to the resident's increased confusion. It could be recorded on the medication or treatment administration records (MARs or TARs), but it would be a lot of checking off. If the need for a Wanderguard was identified, it could be placed immediately, then the nurse could contact the physician and write a telephone order for its use. Elopement training was provided quarterly, and the elopement books were updated at that time by the UM, but the nurse could do it too. The book on the certified unit was reviewed at this time but contained no photograph or identifying information for Resident #92. LPN E reviewed the book on request and confirmed that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105570 If continuation sheet Page 13 of 35 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 105570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indigo Manor 595 N Williamson Blvd Daytona Beach, FL 32114 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 Resident #92's information was not there. LPN E said she had worked in the facility for almost two years. When asked if she had ever participated in an elopement drill, she said no, not on her shift. Perhaps they were conducted on her days off. An interview was conducted with the front desk receptionist on 4/12/23 at 10:02 a.m. She reported she worked Mondays through Fridays from 8:00 a.m. to 5:30 p.m. Another staff member relieved her when she went to lunch. The facility was not a locked facility. The receptionist was asked how she knew which residents were at risk for elopement and who could sign out and leave independently. She said she knew residents who wandered had the alarm (Wanderguard). The sensor is right here on the side of the wall. (She gestured to the wall flanking the reception desk.) If the residents went past the sensor by themselves, she knew that was not good. When the alarm went off, staff came running. She kind of knew which residents could come and go, but she just started here mid-March, so she was still learning. There was an elopement risk book in the drawer. She was not sure if it was up to date, but she had access to the electronic medical records. The receptionist retrieved the elopement book from the drawer. Upon review, it identified nine residents as at risk for elopement in the front section of the book. Resident #92's information was not included. The Receptionist was asked if she could locate Resident #92's information or photograph in the book. She reviewed the electronic medical record, then the elopement binder, explaining where his information should be. After searching the binder, the receptionist was unable to locate any photo or information for Resident #92. LPN F was interviewed on 4/12/23 at 10:22 a.m. She was working the second floor south unit, where Resident #92 now resided. LPN F said all residents were assessed on admission, and if they were identified as at-risk for elopement, or if they exhibited wandering behaviors, the family and physician were called and a Wanderguard was placed. The Nurse Practitioner could authorize the device's use. Normally, the Wanderguards were kept downstairs on the certified unit or in central storage. When the need was identified, the device could be placed within five to ten minutes. LPN F explained that she would not want to put that off since residents could be quick on their feet when they wanted to be. It only takes a split second when you take your eye off of them. LPN F again reinforced that she wouldn't wait to place a device when needed. The other option would be to get a physician's order and put the resident on one-on-one supervision. More frequent checks would be a suggestion, but she would check more frequently than every hour. A lot can happen in one hour. The UM updates the elopement books, but the nurse could probably do it too. Elopement training is done several times a year and they do drills, but she was not sure how often. She said she heard about Resident #92's elopement. Resident #92 was ambulatory with a fairly stable gait and was quick on his feet. She explained that since the incident, he had been placed on this unit and a Wanderguard was applied. LPN F produced the elopement book for 2 south, and Resident #92's information was included. The second floor north wing Elopement book was reviewed and found Resident #92 was on a list of residents who wore a Wanderguard, however, further review found no photograph or demographic information for him. LPN K looked through the book on 4/12/23 at 10:38 a.m. She confirmed Resident 92's information was not in the book. LPN K was asked how the elopement binders were used. She replied that, in all honesty, she did not use the book at all. The Director of Nursing (DON) was interviewed on 4/13/23 at 9:39 a.m. He stated elopement training was provided on hire and elopement drills were conducted every six to 12 months, or in response to an incident. He stated there were no written procedures for elopement drills or for obtaining and placing Wanderguards. CNA I was interviewed on 4/13/23 at 10:17 a.m. She explained she was one of the staff who found (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105570 If continuation sheet Page 14 of 35 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 105570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indigo Manor 595 N Williamson Blvd Daytona Beach, FL 32114 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 Resident #92 after his elopement. On the day of the event after the Code Indigo (elopement) was announced, CNA I asked who the resident was. She and the Assisted Living Facility (ALF) Administrator immediately went to her car and drove off-campus. They turned right onto the boulevard and found Resident #92 at the north end of the property at the intersection. He was standing on the corner facing North. They pulled the car up to him, and he said, I am allowed to leave. He said he was looking for a woman, so CNA I replied, Here I am, I am here! Resident #92 then willingly got into the car and was returned to the facility. An interview was conducted with the Administrator at 12:40 p.m. on 4/13/23. She was asked if there was a receptionist on duty when Resident #92 left the building on the day of the incident. She stated she did not know if the receptionist was at the desk at the time, and stated this was not a locked facility. When asked if the elopement book was what the receptionists used for identifying residents at risk, she confirmed it was. The Administrator returned to the conference room at 1:00 p.m. to report that there was a manager at the desk the day of the incident, as they were between receptionists. The facility's records were reviewed. A written statement from the Assisted Living Facility (ALF) Administrator was included, which verified on the day of the event, she and CNA I went to search for Resident #92. They rode down [boulevard name] boulevard and found Resident #92 walking along the sidewalk in non-skid socks. He stated he was looking for a woman and was unaware that he had eloped. The statement was signed by the ALF Administrator on 3/3/23. The file contained the meeting sign-in sheet for the elopement training that the facility report said was provided in response. The training was conducted on 3/1/23 with 14 staff in attendance. Only three of the staff were floor nurses; 2 LPNs and 1 registered nurse (RN). The remainder of the staff were all department heads, including but not limited to, the Maintenance Director, the Human Resources Director, Admissions Coordinator, ALF Administrator and Dietician. A review of the employee roster at the time of the survey revealed there were 211 staff members. Thirty-two (32) were licensed nurses (RNs and/or LPNs). There was no evidence any of the floor nurses had received any re-training on elopement risk identification or prevention following the event. One elopement response drill was conducted on 2/28/23 with 24 staff members signed as having been in attendance. A review of the facility's policy titled Elopement (undated) read: The facility ensures residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered-plan addressing the unique factors contributing to wandering or elopement risk. Policy Explanation and Compliance Guidelines: 1. Wandering is random or repetitive locomotion that may be goal-directed (e.g., The person appears to be searching for something such as an exit) or non-goal directed or aimless. 2. Elopement occurs when a resident leaves the premises of a safe area without authorization (e.g., an order for discharge or leave of absence) and/or any necessary supervision to do so. 3. The facility is equipped with door locks/alarms to help avoid elopements. 4. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105570 If continuation sheet Page 15 of 35 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 105570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indigo Manor 595 N Williamson Blvd Daytona Beach, FL 32114 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 5. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks and monitoring for effectiveness and modifying interventions when necessary. Residents Affected - Few 6. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering: a. Resident will be assessed for risk of elopement and unsafe wandering up on admission and throughout their stay by the interdisciplinary care plan meeting. b. The ID (Interdisciplinary) Team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior or minimize risks associated with hazard will be added to the care plan and communicated with appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopement. e. Charge nurses and UMs will monitor the implementation of interventions, response to interventions and document accordingly. f. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff. The section titled Tips for Prevention of Elopement included, but were not limited to: -Involve family in the prevention strategy by supervising resident during key risk times. -Room placement for easy observation . -.Involve the activities department in the prevention strategy; involve resident in small groups and activities that engage resident's attention at key risk times . -Never assume everyone knows the resident is a wanderer; make it clear to dining room aides, new staff and whoever is involved in the resident's care . -Consider color coded wristbands as an alert to staff. -Consider the use of a personal alarm for the resident . (Photographic evidence obtained) On 4/13/23 at approximately 1:00 p.m., after being advised of concerns about Resident #92's elopement and the facility's response, the Administrator and Director of Nursing entered the conference room. They asked why relocating Resident #92 to a secure floor and placing a Wanderguard was not a sufficient response to his elopement. They were advised of the following investigative findings and resulting concerns: 1. Three of four of the facility's elopement books failed to contain Resident #92's information. 2. The in-service training the facility provided in response to the incident only included three of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105570 If continuation sheet Page 16 of 35 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 105570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indigo Manor 595 N Williamson Blvd Daytona Beach, FL 32114 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 32 licensed floor nurses. Most training attendees did not work the floor and were not responsible for assessing risk or implementing interventions. Because three different floor nurses failed to act appropriately and either place a Wanderguard, implement sufficient supervision or relocate Resident #92 to a secure unit, there was a likelihood the mistake would be repeated if nurses were not retrained. 3. The facility policy on elopement was vague and allowed for subjective decision-making by nurses related to the implementation of interventions. There were no specific guidelines for nurses on how to respond when residents were actively exit-seeking or wandering persistently; and 4. Only one drill had been conducted in response to the incident. Fourteen out of 211 employees participated. Three (3) of 4 licensed staff interviewed during the survey had never participated in an elopement drill, including one nurse of two years. When advised the lack of urgency and appropriate response to correct the systemic problem contributed to a likelihood of recurrence, the Administrator and DON acknowledged the concern. The facility's acceptable Immediate Jeopardy removal plan included the following immediate actions to remove the IJ that were verified on 4/26/2023: Resident #92 was assessed with no injuries, moved to the second floor of the facility, and a Wanderguard was applied on 2/28/2023. Verified on site on 4/13/2023 during recertification survey. On 4/13/2023, nine residents identified as at risk for elopement had their care plans reviewed and updated by the DON/designee to reflect current wandering and elopement risk. The facility's list of at-risk residents was reviewed on 4/26/2023, which now included a 10th new admission. All at risk residents were residing on the secure second floor as of 4/26/2023. The facility's Assessment Scoring report, dated 4/14/2023, included all residents on all floors and their elopement assessment risk scores. Anyone at risk with a score of one or higher was checked off and noted as at risk. Three of the 10 residents' care plans were reviewed, indicating they had been updated appropriately per the IJ removal plan. The DON/designee re-evaluated all residents for risk for wandering/elopement using the Elopement Risk assessment on 4/13/23. 100% of residents were assessed and marked as at risk if their score was above 1. The Assessment Scoring report, dated 4/14/2023, confirmed the review included all residents on all floors. The DON and Administrator received education on abuse, neglect, and exploitation by Corporate representatives on 4/13/2023. On 4/13/2023, all nursing staff working on all shifts received education on abuse, neglect, and exploitation (ANE) from the DON/designee. All staff received education on their next scheduled workday. On 4/14/2023, ANE training was provided to 68 staff. 26 more were trained by 4/21/2023. 100% of working staff were documented as having been trained in ANE as of 4/21/2023. The facility's Elopement and Wandering Residents policy was reviewed/revised on 4/13/2023 to include Wanderguard placement for all residents identified at risk. Verified through staff interviews and review of the facility policy addendum, which was updated 4/13/2023 to include Wanderguard application to residents identified at risk. It read that all residents would be assessed, and a score of 1 or greater would result in the placement of a Wanderguard. The DON and Administrator would be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105570 If continuation sheet Page 17 of 35 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 105570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indigo Manor 595 N Williamson Blvd Daytona Beach, FL 32114 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 notified. If the device was unavailable, 1:1 supervision would be implemented. Level of Harm - Minimal harm or potential for actual harm One Elopement Drill was conducted on 2/28/2023 during the 7-3 shift. Twenty-four staff members were in attendance. Residents Affected - Few Additional drills were conducted and documented on: 4/13/23 on 7-3 shift with 10 staff participating. Exercise Planning and After Action Report was completed and the Drill Evaluation form was completed. 4/14/23 on 7-3 shift with 13 staff participating. Exercise Planning and After Action Report was completed and the Drill Evaluation form was completed. 4/17/23 on 3-11 shift with 23 staff participating. Exercise Planning and After Action Report was completed and the Drill Evaluation form was completed. 4/19/23 on 11-7 shift with 14 staff participating. Exercise Planning and After Action Report was completed and the Drill Evaluation form was completed. A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented on 4/13/2023. The facility's PIP for F689 with start date 4/13/23 was reviewed. Goal: appropriately assess resident for elopement and provide appropraute interventions to keep residents safe from harm in a timely manner. Delay may be construed as abuse and neglect. Root cause analysis was identical and barriers were identified. Tasks included education of staff about wandering, elopement, resident safety (including DON and Administrator), current residents to have risk evaluations, at risk residents would have wanderguards placed, care plans were updated for those residents, elopement drills to be conducted monthly on alternating shifts, new admissions to be assessed, books to be updated and audited daily in the morning meeting and in the afternoon at the stand-down meeting. All audits were to be reviewed at QAPI meetings for recommendations. Upon notification of an elopement risk score of greater than or equal to 1, the care plan will be updated by the DON/designee. Staff interviews and a review of the facility's policy addendum on 4/26/2023, which was updated on 4/13/2023 to include Wanderguard application to residents identified at risk verified the IJ removal plan was followed. The policy read that all residents would be assessed, and a score of 1 or greater would result in the placement of a Wanderguard. The DON and Administrator would be notified. If the device was unavailable, 1:1 supervision would be implemented. During a 4/26/2023 interview with LPN T at 9:48 a.m., she stated she had recently received traning in elopement prevention and response. There was a class and the Administrator comes around and quizzes us. One of the training sessions was in the last week or so. All new admissions are to be assessed immediately, and if they scored higher than a zero, they were fit with a Wanderguard or assigned 1:1 (one staff member to one resident supervision) until the device could be placed. She stated she had participated in an elopement drill. She knew that there was a list of residents who were at risk in the binder at the nurses' station. The Elopement book was reviewed and contained 10 residents at risk. During a 4/26/2023 interview with LPN K at 9:50 a.m., she stated she recently received training and had to particpate in an elopement drill. Each unit designated a nurse and assigned responsibilities. We have a resident who volunteers to hide. On admission all residents were assessed for elopement (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105570 If continuation sheet Page 18 of 35 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 105570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indigo Manor 595 N Williamson Blvd Daytona Beach, FL 32114 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 risk as soon as possible. If they scored a 1 or higher, they were fitted with a Wanderguard or provided 1:1 supervision until a Wanderguard was available. She was to notify the DON, Unit Manager, and Administrator. A list of residents at risk was in the binder at every nurses' station, and they updated it now with every single new admission. Wanderguards were on the medication carts. During a 4/26/2023 interview with LPN F at 10:00 a.m., she stated she recently received elopement training and participated in elopement drills. On admission, if a resident was assessed as at risk, and they scored a 1, they were fitted with a Wanderguard, or 1:1 supervision was provided until aWanderguard could be located. Usually, they were available. Now they are making sure Wanderguards were on the medication carts and were easily accessible. They could still move residents upstairs too, away from the exit doors where they could see outside. There was an elopement book that listed residents who were at risk for elopement. During a 4/26/2023 interview with Unit Manager S at 10:10 a.m., she stated the elopement policy was recently updated and training was recevied on abuse; everyone was trained. On admssion, every resident received an elopement assessment, and if they scored a 1 or higher, they were to have a Wanderguard. The DON and Administrator were to be notified and the elopement book was to be updated. We put them on 1:1 supervision if the cart (medication cart) does not have a device, but we now keep one on every cart so they are always available. After hours you need to be able to get to them easily; they don't do much good locked in an office. We did a bunch of elopement drills, I cant even tell you how many. She stated she did at least three or four, and they did them on different shifts. We hid a patient volunteer who loved doing the drills. She felt like the star of the show. It was good. Everyone did really good the more we did it. Communication between the units was good too. During a 4/26/2023 interview with Receptionist J at 10:20 a.m., she stated she she knew which residents were at risk for elopement and could not be left unattended. The elopement risk book was observed on the desk behind her chair. She knew which residents were at risk because of their Wanderguards, and she was learning who was at risk so she could identify them each by sight. She kept her eye on everyone now, even on the residents who were not at risk. The binder was updated and included an updated (4/13/2023) Elopement policy and all face pages for at risk residents. Ten residents were currently listed. <b[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105570 If continuation sheet Page 19 of 35 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 105570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indigo Manor 595 N Williamson Blvd Daytona Beach, FL 32114 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that one (Resident #70) of 26 residents receiving respiratory treatment, from a total of 52 residents in the sample, was provided respiratory care consistent with professional standards of practice and the resident's comprehensive care plan. The facility was administering oxygen at a greater flow rate than was ordered. Residents Affected - Few The findings include: On 4/10/23 at 12:17 p.m., Resident #70 was observed in his room sitting in a wheelchair and receiving oxygen (O2) via nasal cannula from an O2 concentrator. The oxygen flow rate was set at three liters per minute (L/min). (Photographic evidence obtained) On 4/11/23 at 10:12 a.m., Resident #70 was observed lying in his bed. He was receiving O2 via nasal cannula at a flow rate of three L/min. (Photographic evidence obtained) When the resident was asked what his oxygen flow rate should be, he replied, I don't know. On 4/12/23 at 11:56 a.m., Resident #70 was observed in his room resting in bed. He was receiving O2 via nasal cannula at a flow rate of three L/min. (Photographic evidence obtained) Certified Nursing Assistant (CNA) O was asked to check Resident #70's oxygen concentrator and confirm that the O2 level was three L/min. After looking at the O2 concentrator, she confirmed the resident's flow rate was three L/min. When asked how she knew what the resident's oxygen flow rate should be, she stated CNAs did not touch that equipment and if she had questions, she would ask a nurse. A review of Resident #70's medical record revealed that he was admitted to the facility on [DATE] with diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD) with acute exacerbation and pneumonia. A review of the physician's order, dated 2/4/23, revealed: Oxygen at two L/min via mask, continuously every shift for shortness of breath (SOB). A review of the resident's Minimum Data Set (MDS) assessment, dated 2/10/23, revealed that Resident #70 had a brief interview for mental status (BIMS) score of 12 out of a possible 15 points, indicating minimal to moderate cognitive impairment. He was noted as requiring the use of oxygen. A review of the resident's care plan, dated 2/17/23, with a target date of 5/07/23 revealed: Focus: Alteration in Respiratory Status due to chronic obstructive pulmonary disease, started on steroid medication, on antibiotics for pneumonia. Interventions included: Administer oxygen as needed per physician's order. Monitor oxygen saturations on room air and/or oxygen. Monitor oxygen flow rate and response. A review of the resident's April 2023 electronic medication administration record (eMAR) revealed the following order: O2 at two L/min via mask continuously every shift for shortness of breath (SOB). Nursing staff were documenting that the resident was receiving oxygen at two L/min. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105570 If continuation sheet Page 20 of 35 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 105570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indigo Manor 595 N Williamson Blvd Daytona Beach, FL 32114 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 0695 Level of Harm - Minimal harm or potential for actual harm On 4/12/23 at 12:07 p.m., an interview was conducted with Licensed Practical Nurse (LPN) F, who was assigned to Resident #70. She confirmed that the oxygen flow rate on Resident #70's concentrator was set at three L/min. When she was asked how she knew the correct flow rate for Resident #70, she replied, By looking at the order in the computer. She was asked to check the resident's physician's order. After doing so, LPN F stated, I have it to two L/min. I'm going to fix it now. Residents Affected - Few On 4/13/23 at 11:36 a.m., LPN P stated oxygen flow rates were set based on physicians' orders and they were checked in the computer by the nursing staff at the start of every shift. On 4/13/23 at 12:13 p.m., an interview was conducted with the Director of Nursing (DON). When asked how the correct oxygen flow rate settings on oxygen concentrators were communicated from one staff person to another, she replied, They look at the orders. There should be a doctor's order for the settings. When asked whether the facility provided the nursing staff with specific training on respiratory interventions or care, including oxygen and nebulizer treatments, the DON stated, It has not been provided since I've been here for five months, but we will be having a career fair on April 4th and there will be education with the respiratory therapist present. When she was asked if a higher flow rate than was ordered could result in harm to the resident, she replied, It depends on the resident and his/her condition, but yes, it can. A review of the facility's undated policy and procedure titled Oxygen Administration revealed: Oxygen is administered to residents who need it, consistent with professional standards of practice, comprehensive person-centered care plans, and the residents' goals and preferences. Oxygen is administered under the orders of a physician, except in the case of an emergency. According to the PSNet (Patient Safety Network - Accessed on 4/14/23 at 7:00 p.m.) at https://www.psnet.ahrq.gov, an official website of the Department of Health and Human Services, Harms of excessive oxygen administration can cause a number of adverse effects including absorption atelectasis (loss of lung volume caused by the resorption of air within the alveoli, the small air sacs of the lungs) and increased mismatch between ventilation (the process of air flowing into the lungs during inhalation and out of the lungs during exhalation) and perfusion (blood flowing within lungs), which impairs elimination of carbon dioxide and thus leads to acidosis (acid builds up). The hypercarbia (increased carbon dioxide) can lead to dyspnea, fatigue, and confusion. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105570 If continuation sheet Page 21 of 35 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 105570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indigo Manor 595 N Williamson Blvd Daytona Beach, FL 32114 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on observations, staff and resident interviews, medical record review, and a review of the facility's dialysis agreement, the facility failed to ensure shared communication between the nursing home and the dialysis center for one (Resident #269) of two residents receiving hemodialysis services, from a total of 52 residents in the sample. Residents Affected - Few The findings include: A medical record review for Resident #269 revealed no communication with the dialysis clinic she attended. A review of the resident's current physician's orders revealed an order dated 3/31/23 for [Dialysis Center Name] Dialysis: M/W/F (Mondays, Wednesdays, and Fridays). On 4/13/23 (Thursday) at 9:30 a.m., Resident #269 was observed in her room, awake. She stated she went to dialysis yesterday. She was asked if she brought a communication book or binder with her to and from her dialysis appointments. She stated, I bring a magazine to read. She was asked if facility staff give her a binder for dialysis staff to chart her weights and vital signs and any medications given at dialysis as a communication tool for the dialysis center and the facility. She stated, No, I don't bring anything like that. On 4/13/23 at 9:40 a.m., Licensed Practical Nurse (LPN) D was asked if Resident #269 had a dialysis communication book that she brought with her to her dialysis appointments. LPN D stated, No, I'm putting one together now. She was observed putting together a white binder with blank dialysis communication sheets (with Resident #269's name on each sheet). She was asked if the resident had a communication book before this one that she was currently making. She stated no. She was asked how facility nursing staff communicated with the dialysis center for weights, vital signs, and medications given during the appointments as well as other pertinent information. She stated, We can call them. She was asked if any of this information from dialysis was charted in the resident's medical record. She replied, Not the weights and vital signs. I have charted my phone calls with dialysis about the medication that we didn't have for her. I was on the medication cart on Monday doing medication pass and I saw she didn't have her Cinacalcet (Medication used to treat hyperparathyroidism (overactive parathyroid gland) in the dialysis patient according to www.ncib.nlm.nih.gov, accessed on 4/14/23 at 2:00 p.m.) on the cart. So, I made several calls back and forth between the dialysis center and our pharmacy. I charted those calls. She was asked how many doses of this medication the resident missed. She stated, It looks like about six doses were missed. She was asked if a dialysis communication book could have prevented some of the doses from being missed. She replied, possibly. A review of the facility's Nursing Home Dialysis Transfer Agreement (with the Dialysis Center being utilized by Resident #269) revealed: Page 2; Section 3: Designated Resident Information: Facility shall ensure that all appropriate medical, social, administrative, and other information accompany all Designated Residents at the time of transfer to the Center. (h) Any other information that will facilitate the adequate coordination of care, as reasonably determined by the Center. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105570 If continuation sheet Page 22 of 35 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 105570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indigo Manor 595 N Williamson Blvd Daytona Beach, FL 32114 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 0698 . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105570 If continuation sheet Page 23 of 35 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 105570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indigo Manor 595 N Williamson Blvd Daytona Beach, FL 32114 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 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on staff and resident interviews, and medical record review, the facility failed to provide routine medications to one (Resident #269) in a total sample of 52 residents. Residents Affected - Few The findings include: On 4/10/23 at 3:20 p.m., a medical record review for Resident #269 revealed the resident had not been receiving Cinacalcet (Medication used to treat hyperparathyroidism (overactive parathyroid gland) in the dialysis patient according to www.ncib.nlm.nih.gov, accessed on 4/14/23 at 2:00 p.m.) 90 mg (milligrams), one tablet by mouth daily for chronic kidney disease CKD (ordered on 4/1/23). A progress note written on 4/10/23, revealed, [Provider name] at the dialysis center is saying they don't provide this medication, Cinacalcet. [Provider name] said the pharmacy is supposed to fill it, that the resident is not part of the bundle. Writer called pharmacy again from the facility phone at 1907 (7:07 p.m.) on 4/10/23. Pharmacy sending a 5-day supply of the medication. The medication will be on the next run. MD (physician's) office and family aware that the resident has missed doses of the medication. (authored by Licensed Practical Nurse (LPN) D) A review of electronic medication administration record (eMAR) revealed six doses were missed between 4/1/23 and 4/10/23. Further review of Resident #269's medical record revealed an admission date of 4/1/23 and diagnoses which included end-stage renal disease (ESRD) and dependence on renal dialysis. A review of her physician's orders revealed an order dated 4/1/23: Cinacalcet tablet 90 mg, one tablet by mouth daily for chronic kidney disease. A review of the progress notes revealed: 4/4/23: Contacted [Provider name] dialysis to see if they provide Cinacalcet 90 mg for the resident, because the pharmacy says they do not supply the medication. They would need to get authorization and dialysis does not provide the medication as well. (Authored by LPN L) 4/5/23: Spoke with the pharmacist, stated medication is being sent out with this afternoon's delivery, NP informed. (Authored by LPN E) 4/10/23: Never received from pharmacy, writer contacted pharmacy. Waiting to hear back. Resident, MD (physician), and family aware of missed dose. (Authored by LPN D) 4/10/23: Spoke to pharmacy about medication Cinacalcet. Facility hasn't received medication since admission. Pharmacy saying because dialysis center is supposed to give this medication even on days resident isn't at dialysis. Writer reached out to dialysis center. Waiting for a call back. (Authored by LPN D) On 4/11/23 at 9:25 a.m., Resident #269 was asked who administered her medication Cinacalcet. She stated, I don't know. The facility says the dialysis center should give it, and the dialysis center says the facility should give it. She was asked if she had missed any doses. She stated, I don't know. Yes, I think I have missed some doses because they can't figure out who is supposed to be giving it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105570 If continuation sheet Page 24 of 35 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 105570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indigo Manor 595 N Williamson Blvd Daytona Beach, FL 32114 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 4/13/23 at 9:30 a.m., LPN L was asked if she was caring for Resident #269 today. She stated yes. She was asked if the resident had received her Cinacalcet today. LPN L stated yes. She was asked to provide the medication card for review. She produced two medication cards from the medication cart. One with three tablets (one missing two left) and a second card with two tablets (one left). She was asked if the resident had received the medication each day she had been here. She stated, No, I called the pharmacy and went back and forth, because the pharmacy said dialysis should be providing it and dialysis said the nursing home should be providing it. Our pharmacy finally sent it, so she received the dose yesterday and today. On 4/13/23 at 9:40 a.m., LPN D was asked to explain the doses of Cinacalcet that had not been administered to Resident #269. LPN D stated, I was on the medication cart on Monday (4/10/23) doing medication pass, and I saw she didn't have her Cinacalcet on the cart. So, I made several calls back and forth between the dialysis center and our pharmacy. Dialysis said they don't provide the medication and our pharmacy said dialysis should provide it. Our pharmacy finally agreed to send a 5-day supply. That was on Monday 4/10/23. She was asked if the medication was available in the facility's emergency medication kit/device. She stated, We use a Pyxis machine and no, it's not available in there. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105570 If continuation sheet Page 25 of 35 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 105570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indigo Manor 595 N Williamson Blvd Daytona Beach, FL 32114 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of resident records and interviews with staff, the facility failed to ensure psychotropic medications were only utilized with appropriate monitoring for one (Resident #63) of five residents reviewed for unnecessary medications, from a total of 52 residents in the sample. Residents Affected - Few The findings include: A record review for Resident #63 found she was admitted on [DATE]. A review of the quarterly minimum data set (MDS) assessment, with an assessment reference date of 3/10/23, revealed that Resident #63 had a brief interview for mental status (BIMS) score of 14 out of a possible 15 points, indicating she was cognitively intact and independent with daily decision making. She required limited assistance with activities of daily living. Active diagnoses included heart failure, malnutrition, depression, schizophrenia, insomnia and aftercare following hip joint prosthesis. Resident #63 received antipsychotics and antidepressants on seven of seven days during the MDS look-back period. Antipsychotics were received on a routine basis and a gradual dose reduction (GDR) had not been attempted. This was documented as clinically contraindicated by a physician on 2/28/23. Resident #63 was care planned on 9/2/22 (last reviewed/revised 3/14/23) for her multiple medical conditions and for the potential for drug-related complications related to her psychotropic medication use (antipsychotics, antidepressants and sleep aids). The goal was to be free of psychotropic medication complications through the next review date. Interventions included but were not limited to: Monitor for side effects and report to physician. Antipsychotic medication- sedation, drowsiness, dry mouth, constipation, blurred vision, extrapyramidal side effects (EPS - drug-induced movement disorders), weight gain, edema, postural hypotension, sweating, loss of appetite, and urinary retention. Monitor for target behaviors/symptoms of antipsychotic medication and document. Monthly pharmacy review, consent from patient, and medications as ordered. (Photographic evidence obtained) Resident #63 had a physician's order dated 9/1/22 for Mirtazapine 7.5 milligrams (mg) every night at bedtime for depression, Risperidone 3 mg every 12 hours for paranoid schizophrenia (dated 11/15/22) and Venlafaxine HCL (hydrochloride) 25 mg, give 0.5 tab (12.5 mg) every night at bedtime for depression (3/29/23). (Photographic evidence obtained) A review of the psychiatric notes revealed that the psychiatrist saw Resident #63 last on 3/28/23 and noted the resident was at baseline. He reported the team considered a GDR on 8/19/22, 9/1622, 10/21/22, 11/29/22, 2/28/23 and 3/28/23, but it could not be achieved as Resident #63 would not have tolerated it. Further review of the clinical record including the medication administration records (MARs), found there was no indication the resident's episodes of psychosis or depression, and related behaviors were being monitored by nursing staff. There was no indication the facility was monitoring for the use, efficacy or side-effects of anti-psychotic and anti-depressant medication for this resident. An interview was conducted with Licensed Practical Nurse (LPN) F on 4/13/23 at 1:34 p.m. She explained that residents with behaviors and psychotropic medications were monitored for the medication side effects and the behavior on the MAR. She was asked to review Resident #63's record. After doing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105570 If continuation sheet Page 26 of 35 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 105570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indigo Manor 595 N Williamson Blvd Daytona Beach, FL 32114 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 0757 Level of Harm - Minimal harm or potential for actual harm so, she confirmed there was no monitoring being conducted. LPN F said the admitting nurse was expected to set that up on the MAR, and that it needed to be added for Resident #63. . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105570 If continuation sheet Page 27 of 35 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 105570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indigo Manor 595 N Williamson Blvd Daytona Beach, FL 32114 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 its medication error rate was less than 5%, based on three errors over 27 opportunities for two (Residents #31 and #260) of five residents observed during medication administration, and resulting in an error rate of 11.11%. Residents Affected - Few The findings include: On 4/12/23 at 8:17 a.m., Licensed Practical Nurse (LPN) B was observed preparing medication for Resident #31. After administering the resident's pills, she held her Budesonide Formoterol Fumarate Inhalation Aerosol 160-4.5 micrograms per actuation (mcg/act) and puffed it twice into her mouth. The nurse did not offer the resident water, nor did she instruct the resident to rinse her mouth and spit after administering the inhaler. On 4/12/23 at 8:28 a.m., LPN B was observed preparing medications for Resident #260. Reading an order which read Aspirin 81mg (milligrams) oral chewable, give two tablets by mouth daily, LPN B poured two tablets from the enteric-coated aspirin 81 mg bottle. The expiration date on the bottle was illegible. (Photographic evidence obtained) LPN B was asked if she could read the expiration date. She confirmed she was unable to read/confirm an expiration date on the bottle. She proceeded to leave two enteric-coated aspirin tablets in the medication cup. She was asked what she would do with a medication that she can't confirm an expiration date for. Without answering, she tossed the full bottle into her open trash container on the side of medication cart and left the two poured tablets in the medication cup. LPN B brought medications to Resident #260 and was stopped just inside the resident's room. She was asked if she was going to administer the medication in the cup. She stated yes. She was advised she could not administer the enteric-coated aspirin if she could not confirm an expiration date. She went back to her medication cart and removed the two aspirin tablets and tossed them into the open trash can on the side of her medication cart. She was asked if she realized she had also poured the incorrect form of aspirin. She stated no. During a medical record review for Resident #31, her current orders revealed: 3/27/23: Budesonide Formoterol Fumarate Inhalation Aerosol, 160-4.5 micrograms per actuation (mcg/act), two puffs, inhale orally two times a day for COPD. Rinse mouth and spit after use. During a medical record review for Resident #260, her current orders revealed: 4/8/23: Aspirin 81 mg oral tablet chewable, give two tablets by mouth one time daily for clot prevention. Information on Budesonide Formoterol Fumarate Inhalation Aerosol (trade name: Symbicort) found on the manufacturer's website, www.mysymbicort.com (accessed on 4/12/23 at 1:45 p.m.) stated: Symbicort may cause serious side effects, including: Fungal infection in your mouth or throat (thrush). Rinse your mouth with water without swallowing after using Symbicort to help reduce your chances of getting thrush. A review of the facility's policy titled Administration Procedures for All Medications (revised 8/2020) revealed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105570 If continuation sheet Page 28 of 35 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 105570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indigo Manor 595 N Williamson Blvd Daytona Beach, FL 32114 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 III. Five rights (at a minimum) Level of Harm - Minimal harm or potential for actual harm 1. Check the expiration date on the package/container before administering any medication. 2. Prior to removing the medication from the container: Residents Affected - Few a. Check the label against the order on the MAR (Medication Administration Record). . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105570 If continuation sheet Page 29 of 35 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 105570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indigo Manor 595 N Williamson Blvd Daytona Beach, FL 32114 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to store all drugs and biologicals in locked compartments for three (Residents #31, #260, and #133) in a total sample of 52 residents. The findings include: On 4/10/23 at 12:45 p.m., a bottle of Flonase nasal spray was observed on Resident #31's bedside table in plain sight. She stated, Oh, they forgot and left it there this morning. I'll remind them when they come back. I only take it once a day. (Photographic evidence obtained) On 4/11/23 at 8:40 a.m., a bottle of Flonase nasal spray was observed on Resident #31's bedside table. (Photographic evidence obtained) On 4/12/23 at 8:28 a.m., Licensed Practical Nurse (LPN) B was observed administering medications to Resident #260. She started to administer a Trelegy Ellipta Aerosol Powder breath-activated inhaler, but the resident stopped her and said she already took that inhaler this morning. The resident pointed to a box on her bedside table which revealed several medications in plain sight. These medications included: Trelegy inhaler, Symbicort inhaler, Albuterol inhaler, ear wax removal drops, and a small see-through plastic container with nine various pills inside. LPN B asked the resident why she had the Trelegy inhaler in her room. The resident said she had it from home. The nurse did not ask about the other visible medications, nor did she ask the resident whether she had already self-administered the Trelegy inhaler. LPN B told the resident, I'll have to find out if you can keep this at bedside, but it's fine. She left the resident's room without removing any of the medications. (Photographic evidence obtained) On 4/12/23 at 8:38 a.m., LPN D was asked if medications should be left in residents' rooms. She stated, No, not unless they have an order for self-administration. She was asked to observe Resident #260's bedside table. Upon entering the room, LPN D confirmed the presence of a Trelegy inhaler, an Albuterol inhaler, a Symbicort inhaler, ear wax drops, and a small clear plastic pill box with nine unidentified pills inside. The nurse explained to the resident that she could not keep medications at her bedside unsecured. The resident became upset and stated, I do my Trelegy inhaler every morning at around 6:00 in the morning and I rinse my mouth out. I don't want to wait for the nurse because I don't know when she's coming in, and they don't give me anything to rinse my mouth out after I use it. I have my Albuterol inhaler because it's my rescue inhaler. My doctor told me I can use it for two puffs up to four times a day as needed. Yesterday I used it once after therapy. I only use it usually once or twice a day. She was asked if she told staff when she had used her inhalers. She stated, No, none has ever asked. The resident was agreeable to allowing the nurse to remove medications from her room until she was assessed for self-administration of medications. On 4/13/23 at 9:33 a.m., Resident #133 was observed sitting up in bed, awake. Medication was observed on her bedside table in her bucket, in plain sight. She was asked what the medication was. She stated, Oh, those are for if I have gas. She was asked if the staff knew she had them. She replied, I don't know, nobody has asked. They are right there; you can see them. (Photographic evidence obtained) The medication package revealed Simethicone softgels. There were 16 tablets remaining. The baggie also contained one unidentifiable oval shaped white tablet. LPN L entered the room. She was asked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105570 If continuation sheet Page 30 of 35 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 105570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indigo Manor 595 N Williamson Blvd Daytona Beach, FL 32114 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some if she was caring for Resident #133 today. She stated yes. She was asked if she was aware that the resident had medications on her bedside table. She stated, No, I didn't know those were there. She was asked if the resident should have medications on her bedside table. She stated, As long as she has an order for them, but she is alert and oriented. She was asked if the resident had an order to have medications at the bedside. She stated, I'm not sure, I'll have to look it up. She left the resident's room, leaving the medications on the bedside table. LPN L looked the resident up on her medication cart laptop and stated, No, she doesn't have an order. She was asked what she would do now. She stated, I'll notify her provider and my unit manager. On 4/13/23 at 12:41 p.m., Resident #133 was observed in her room, sitting up in her wheelchair, watching TV. The same medications observed earlier in the day were observed on her bedside table, in her bucket, visible without moving any items. The resident was asked if any staff had asked her about the medication in her bucket. She stated no. A review of the medical record for Resident #31 revealed an order for: 3/26/23: Feluccas nasal suspension 50 mcg/act: 2 sprays in both nostrils one time daily for allergies. There was no order found for self-administration of medication. A review of the medical record for Resident #133 did not reveal an order for Simethacone. There was no order found for self-administration of medication. A review of the medical record for Resident #260 revealed an order for: 4/8/23: Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 200-62.5-25 mcg/act: 1 inhalation, inhale orally one time a day for SOB/COPD, rinse mouth and spit after administering. There were no orders found for the Symbicort Inhaler, Albuterol Inhaler, ear wax drops, or self-administration of medications. A review of the facility's policy titled Self-Administration of Medications (revised 8/2020) read: Policy: In order to maintain the resident's highest level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team (or equivalent) has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer. A review of the facility's policy titled Storage of Medications (revised 8/2020) stated: Policy: Medications and biologicals are stored safely, securely, and properly, following the manufacturers' recommendations or those of the supplier. The medication supply is accessible to the licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105570 If continuation sheet Page 31 of 35 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 105570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indigo Manor 595 N Williamson Blvd Daytona Beach, FL 32114 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, and facility policy and procedure review, the facility failed to follow proper food safety and sanitation practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility, by failing to ensure the ice machine located in the kitchen and one of three microwaves located on the 1st floor at the nursing station was clean. Food safety and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: A tour of the kitchen was conducted on 4/12/23 at 10:50 a.m. The ice machine located next to the three-compartment sink was observed with a pink, slimy substance that was in close proximity to the ice in the internal shoot of the ice machine. (Photographic evidence obtained) During the tour, the microwave in Nourishment Room One of three located at the nursing station on the 1st floor was observed with a buildup resembling fungal growth. (Photographic evidence obtained) An interview was conducted on 4/12/23 at 2:24 p.m. with Licensed Practical Nurse (LPN) M, who confirmed that the microwave was used to reheat residents' food. An interview was conducted on 4/12/23 at 2:36 p.m. with LPN D, Unit Manager, who confirmed that the night shift staff was responsible for cleaning the microwave. She stated, They are making plans to take the microwave out. An interview was conducted on 4/13/23 at 2:24 p.m. with Dietary Aide Q, who reported she was not sure who was responsible for cleaning the ice machine and did not know how often it was cleaned. An interview was conducted on 4/13/23 at 2:47 p.m. with Certified Dietary Manager R, who confirmed that the Dietary Department staff wiped the outside of the ice machine daily and the Maintenance Department provided deep cleaning of the ice machine monthly. Nursing was responsible for cleaning the microwave, and to keep the nourishment room and area near the nursing station clean. A review of the facility's policy and procedure titled Cleaning and Sanitizing Dietary Areas and Equipment Overview (undated), revealed: All kitchen areas and equipment shall be maintained in a sanitary manner and be free of buildup of food, grease, or other soil. The facility will provide sanitary food service that meets state and federal regulations. (Copy obtained) Reference: FDA Food Code 2022. https://www.fda.gov/media/164194/download (Accessed on 4/14/23 at 3:15 p.m.) Annex 3. Public Health Reasons/Administrative Guidelines. 4-602.11 Equipment Food-Contact Surfaces and Utensils. Page 461 . Surfaces of utensils and equipment contacting food that is not time/temperature control for safety food such as iced tea dispensers, carbonated beverage dispenser nozzles, beverage dispensing circuits or lines, water vending equipment, coffee bean grinders, ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. Some equipment manufacturers and industry associations, e.g., within the tea industry, develop guidelines for regular cleaning and sanitizing of equipment. If the manufacturer does not provide cleaning specifications for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105570 If continuation sheet Page 32 of 35 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 105570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indigo Manor 595 N Williamson Blvd Daytona Beach, FL 32114 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 food-contact surfaces of equipment that are not readily visible, the person in charge should develop a cleaning regimen that is based on the soil that may accumulate in those particular items of equipment. Annex 4. Equipment, Utensils, and Linens. 4-602.12. Cooking and Baking Equipment. Page 129. (B) The cavities and door seals of microwave ovens shall be cleaned at least every 24 hours by using the manufacturer's recommended cleaning procedure. 4-602.13 Nonfood-Contact Surfaces. Nonfood-Contact Surfaces of Equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105570 If continuation sheet Page 33 of 35 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 105570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indigo Manor 595 N Williamson Blvd Daytona Beach, FL 32114 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observations, staff and resident interviews, and medical record review, the facility failed to maintain resident medical records that were accurately documented for one (Resident #269) in a total sample of 52 residents. The findings include: On 4/10/23 a medical record review for Resident #269 revealed the resident had not been receiving Cinacalcet 90 mg, one tablet by mouth daily (ordered 4/1/23). Further review of the record revealed a progress note written by Licensed Practical Nurse (LPN) D on 4/10/23, which read, [Dialysis center employee] at the dialysis center is saying they don't provide this medication, Cinacalcet. [Dialysis center employee] said the pharmacy is supposed to fill it; that the resident is not part of the bundle. Writer called pharmacy again from the facility phone at 1907 (7:07 p.m.) on 4/10/23. The pharmacy is sending a 5-day supply of the medication. The medication will be on the next run. MD (physician's) office and family aware that the resident has missed doses of the medication. A review of the electronic medication administration record (eMAR) revealed the medication was signed out as having been administered on April 1, 2, 3, and 7, 2023. On April 4, 5, 6, 8, 9, and 10, 2023, the medication is signed out as not available. On 4/11/23 at 9:25 a.m., during an interview with Resident #269, she was asked who administered her Cinacalcet medication. She stated, I don't know. The facility says the dialysis center should give it, and the dialysis center says the facility should give it. She was asked if she had missed any doses. She stated, I don't know. Yes, I think I have missed doses because they can't figure out who is supposed to be giving it. On 4/13/23 at 9:40 a.m., LPN D was asked if Resident #269 had missed any doses of her prescribed medication, Cinacalcet. She confirmed that the resident had missed doses of the medication since it was ordered. She was asked if she knew why the medication was signed off as having been given on April 1, 2, 3, and 7, 2023, if it was not available. She stated, No, I don't. On 4/13/23 at 10:03 a.m., in an interview with LPN K, she was asked if she had signed out and administered the medication Cinacalcet for Resident #269 on April 1 and 2, 2023. She stated, I'm not sure, that was too long ago for me to remember for sure. She was asked if she signed the medication out on the eMAR as administered. She stated yes. On 4/13/23 at 10:15 a.m., in an interview with LPN M, she was asked if she had signed out and administered the medication Cinacalcet for Resident #269 on April 7, 2023. She stated, Honestly, I can't remember if I gave it. She was asked if she signed the medication out on the eMAR as administered. She stated yes. On 4/13/23 at 10:25 a.m., in an interview with LPN L, she was asked if she had signed out and administered the medication Cinacalcet for Resident #269 on April 3, 2023. She stated, I thought I went back and struck that out. She was asked again if she signed the medication out on the eMAR as administered. She stated, Yes, but I didn't administer it. I meant to go back and strike it out as not given. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105570 If continuation sheet Page 34 of 35 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 105570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indigo Manor 595 N Williamson Blvd Daytona Beach, FL 32114 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 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, staff interviews, and facility policy and procedure review, the facility failed to ensure process surveillance, the review of practices by staff directly related to resident care, specifically hand hygiene, for two residents (#31 and #260) from a total sample of 52 residents. Residents Affected - Some The findings include: On 4/12/23 at 8:17 a.m., Licensed Practical Nurse (LPN) B was observed preparing medications for Resident #31. Gloves were not donned during this preparation. LPN B did not perform hand hygiene prior to preparing the medications, or before or after administering the medications. Gloves were not donned during this medication administration. The nurse returned to the medication cart at 8:27 a.m., and without performing hand hygiene, she proceeded to prepare medications for Resident #260. Gloves were not donned during this preparation or during medication administration. LPN B did not perform hand hygiene prior to preparing the medications, or before or after administering the medications. She returned to her medication cart at 8:35 a.m. and proceeded to prepare medications for her next resident. She was stopped and asked if she performed hand hygiene before beginning a medication pass, before handling medication, and before contact with a resident. She stated, I usually do. She was asked if anyone from management had observed her during her medication pass. She stated no. On 4/12/23 at 8:38 a.m., in an interview with LPN D, she was asked what the expectation for hand hygiene was during medication pass/administration. She stated, The nurse should be either washing with soap and water or using hand sanitizer in between each resident and whenever they are coming in or out of a resident room. They should always use soap and water if their hands are visibly soiled. She was asked if it was acceptable to pass medications to residents without performing hand hygiene between residents. She stated no. She was asked if staff were monitored for compliance with hand hygiene during medication pass. She stated, If there is a problem identified, yes. A review of the facility's policy titled Administration Procedures for All Medications (effective date 9/2018), revealed: Policy: Medications will be administered in a safe and effective manner. Procedures: Administration: 3. Cleanse hands using anti-microbial soap and water or facility approved hand sanitizer before beginning a med pass, before handling medication, and before contact with a resident. 12. When finished administering medication to each resident, wash hands with antimicrobial soap and water or facility approved hand sanitizer. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105570 If continuation sheet Page 35 of 35