Inspection·October 3, 2023

F 0569 $2,213.13. (Photographic evidence obtained) Level of Harm - Minimal harm or potential for actual harm During a follow-up interview with the BOM on 10/3/23 at 1:00 pm, she confirmed the account balances above were correct for Residents #2, #6, and #7. She also confirmed that Residents #2 and #7 had been discharged for more than 30 day and their refunds had not been issued. Resident #6 was still at the facility. When asked if Resident #6 was notified for being over the limit of $2000, she said, No. Residents Affected - Some A review of the facility's policy titled Resident Personal Funds (dated 1/20/2019) revealed the following: Notice of Certain Balances: The facility must notify each resident that received Medicaid benefits; a. When the amount in the resident 's account reaches $200 less than the SSI resource limit for one person and; b. If the amount in the account, in addition to the value of the resident's other nonexempt resources, reaches the SSI resource limit for one person , the person may lose eligibility for Medicaid or SSI. Conveyance upon Discharge, Eviction or Death: Upon discharge, eviction or death of a resident with a personal fund deposited with the facility, the facility will convey with 30 days the resident's funds and a final account of those funds to the resident or in case of death, the individual or probate jurisdiction administering the resident's estate, in accordance with State law. (Photographic evidence obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105570 If continuation sheet Page 2 of 4 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2023 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observations, interviews, and facility policy review, the facility failed to maintain the kitchen in a safe and sanitary manner due to a ceiling area having a plastic sheet covering an opening that was dripping liquid where food is prepared, and by failing to maintain missing ceiling tiles in the dish room. The findings include: During a visit to the kitchen on 10/02/23 at 12:06 pm, the ceiling was observed with three plastic bags covering an opening. One of the areas was covered by a bag near the tray line taped with black and red duck tap. A brown liquid was observed dropping water on the floor. Water was also observed on the floor at the tray line where the carts were parked. In the dish room there were missing tiles in the ceiling. (Photographic evidence obtained) During an interview with the certified dietary manager (CDM) on 10/02/23 at 12:15 pm, she confirmed there was liquid dripping close to the tray line and there were missing tile pieces in the dish room. When asked what the status was to repair these areas, she stated the maintenance manager would have more details. An interview was conducted with the Maintenance Director on 10/02/23 at 12:48 pm. He stated the issue had been going on for the last 6 months. He explained the issue started with the duct work main on the second floor and they were waiting for the issue to be fixed first before repairing the kitchen. He added that he had contacted several companies, but they were not willing to do the job, because it was just too much. He stated that he just called another company and was waiting for their quote. When asked to provide the invoices of the inspections or communication for the companies that he had contacted without success, he said that she did not have it. He provided a list of Alternating Current (AC) repair companies names and phone number, but no information of when they were contacted or the feedback. (Copy obtained). When asked about the liquid observed dripping from the plastic bag, he said, I have been draining the water holding up on the plastic bags weekly. When asked about the missing tiles in the dish room, he said, Yes I am aware of missing tiles, I just haven't had gotten the time to fix it. On 10/03/23 at 3:00 pm, the Administrator was asked about the condition of the kitchen ceiling. He said, It was like this when I came on board about a month ago and I'm working on it. He added that there was an issue on the second floor and Occupation Safety and Health Administrator (OSHA) officials were involved and therefore they had to take care of that first. He had no updates on the status of the repair of the kitchen. He mentioned that the facility had developed a PIP for repair of the dish room tiles and resident's would be informed that they would be served on disposable utensils as the repair is done. A review of the facility's policy titled Preventative Maintenance Program reveled the following: A Preventive Maintenance Program shall be developed and implemented to ensure the provision of safe, functional, sanitary, and comfortable environment for residents, staff and the public. Policy Explanation and Complained Guidelines: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105570 If continuation sheet Page 3 of 4 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2023 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 1. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the building, grounds and equipment are maintained in a safe and operable manner. 2. The Maintenance Director shalt assess all aspects of the physical plant to determine if Preventative Maintenance (PM) is required. Required PM may be determined from manufactures' recommendations, maintenance requests, grand rounds, life safety requirements or experience. (Photographic evidence obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105570 If continuation sheet Page 4 of 4