Health inspection·January 28, 2021

F 0656 Level of Harm - Minimal harm or potential for actual harm (brief summary of resident care needs for each individual resident) provided the information about how many people were needed to complete the resident's care. She was asked to review the Kardex for Resident #122. The information in the Kardex was reviewed with the CNA, and it documented that Resident #122 required a two-person assist for all ADL care. Employee F was asked if there was another staff member assisting her with care this morning and she stated no. Residents Affected - Few 2. A record review was conducted for Resident #30, which reported an admission date of 9/19/17 with diagnoses including hypertensive heart disease with heart failure and hepatic failure. A review of the current physician's orders noted Thrombo-Embolus Deterrent (TED) hose/stockings for bilateral lower extremities (BLE) daily, on in AM, and off in PM, dated 9/28/20. The current care plan was reviewed, which noted under a focus for Activities of Daily Living (ADL) self care performance deficit related to cardiac issues, an intervention for TED stockings to BLE daily, on in AM and off in PM with an initiation date of 10/2/20. The current Treatment Administration Record (TAR) was reviewed, which did not note any TED stockings being applied or taken off. (Photographic evidence obtained) Resident #30 was observed on 1/24/21 at 12:11 PM, in his room sitting in a wheelchair. He was wearing shorts with no TED hose observed. Resident #30 was observed on 1/25/21 at 2:42 PM, in his motorized wheelchair in the hall with no TED hose on his lower extremities. Resident #30 was observed on 1/26/21 at 9:30 AM, in his room in a wheelchair with no TED hose on his lower extremities. An interview was conducted with the resident at the time of the observation, and he reported he had never had or worn TED stockings. He stated if he had them, he would wear them. An interview was conducted with Employee E, Licensed Practical Nurse (LPN), on 1/26/21 at 9:39 AM concerning Resident #30's TED stockings. The LPN reported working at the facility for the past two months, and had never seen the resident wearing TED stockings. Employee E checked the treatment Administration Record (TAR) and reported that the use of TED stockings was not listed. She was asked to check the physician's orders, and reported there was a physician's order for the resident to wear TED stockings daily. Employee E entered Resident #30's room and confirmed that the resident was not wearing TED hose/stockings. The LPN stated she would get him TED stockings. The LPN confirmed the resident did have an order for TED stockings and he was not wearing them. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105651 If continuation sheet Page 2 of 10 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 105651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/28/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center of Day 325 S Segrave Street 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one (Resident #34) of one resident sampled for a review of range of motion services from a total of 31 sampled residents. The findings include: On 01/24/21 at 2:09 PM, Resident #34 was observed lying in bed in Semi-Fowlers position (lying on her back with her head and torso raised between 15 and 45 degrees). Her left hand was contracted and was placed close to her chin. When Resident #34 was asked to open her hand, she stated she could not open it. The middle, ring and 5th fingers were firmly squeezed in the palm of her hand. A hand splint was observed on the nightstand beside the resident's bed. (Photographic evidence obtained) On 01/25/21 at 10:33 AM, Resident #34 was observed in the dining room participating in an activity. Her left hand was held close to her chest. She was not wearing a splint. On 01/27/21 at 2:39 PM, Resident #34 was observed lying in bed on her back. When she was asked to open her left hand, she stated, It hurts. Red fingernail marks were observed on the palm of her hand where the contracted fingers were pressing. A hand splint was observed on the nightstand at the resident's bedside. A review of Resident #34's medical record revealed that she was admitted to the facility on [DATE]. Her diagnoses included cerebral infarction and contracture of the left hand. A review of her quarterly minimum data set (MDS) assessment, dated 11/28/20, revealed the resident had a brief interview for mental status (BIMS) score of 99, indicating that she was unable to complete the interview. She also required extensive assistance with bed mobility and transfers. She required supervision with eating and she was totally dependent on staff for toileting. Resident #34 was assessed with a need for splint or brace assistance via the restorative nursing program. Further review of the record revealed physician's orders for the therapy department to assist with the resident's restorative program. A review of the resident's care plan revealed the following focus area: Resident has a need for restorative intervention to maintain wearing schedule of soft palm guard to decrease risk of skin breakdown with intervention for restorative nursing to ensure skin is clean, intact and dry. Provide gentle PROM (passive range of motion) to the left digits during hand hygiene. Apply soft palm guard as resident allows and tolerates. Remove soft palm guard on evening shift. On 01/27/21 at 10:00 AM, Employee B, Certified Nursing Assistant (CNA)/Restorative Aide, confirmed that Resident #34 had not been wearing the hand splint. She stated the resident had been refusing to wear the splint for the last three months due to a complaint of pain. She added that the facility's policy was to discontinue restorative interventions if the resident refused services on three consecutive attempts. When asked why the services for Resident #34 were not then discontinued, she reported that her restorative nurse was no longer working at the facility, and she was not sure who to report to. When asked if she had any documentation of the resident having refused care/splinting, she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105651 If continuation sheet Page 3 of 10 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 105651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/28/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center of Day 325 S Segrave Street 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 0688 stated she had none. Level of Harm - Minimal harm or potential for actual harm On 01/27/21 at 10:58 AM during an interview with Employee A, Licensed Practical Nurse (LPN)/Unit Manager, she confirmed that Resident #34 was still on restorative therapy and was to wear a soft hand splint every morning shift and have it removed during the evening shift. When asked whether the resident refused treatment/splinting, Employee A stated she is not aware. She checked the restorative notes and stated there was only one day (01/27/21) that the resident was documented as having refused. She added that if the resident refused treatment, it should be discontinued. She also mentioned that if the order was not discontinued, it should be carried out and documented. When asked to whom the restorative aide reported, Employee A stated she was in charge of her unit as the restorative nurse had resigned a week ago. Residents Affected - Few A review of the facility policy and procedure titled,Restorative: Nursing Care Implementation and ScreeningRehab/Skilled, Therapy & Rehab (revised 12/28/2020), revealed: . To provide appropriate restorative nursing care to each resident . To provide appropriate treatment for the resident's activities of daily living - Each resident will receive restorative nursing care to the extent possible, based on individual strengths, needs and problems as identified in nursing assessments. The restorative care will be outlined in the resident's nursing care plan. Care includes safe measures to prevent complications and contractures, maintain strength and self- care abilities including eating and dressing, promote mobility and feeling of well being. Activities of daily living - Residents are provided appropriate treatment and services to attain/ maintain functional abilities in activities of daily living. Any resident who is unable to carry out independent activities of daily living will receive necessary services to prevent further diminishing of independent abilities in bathing dressing/undressing, grooming, transfer, ambulation, toileting, eating and use of speech, language or other functional systems. - Based on the resident's comprehensive assessment, the location ensures that the resident's ability in activities of daily living does not decline except when unavoidable for reasons of disease progression, deterioration of physical condition associated with disability or refusal of care/treatment by the resident or legal representative. Evidence of any of these reasons will be reflected in the clinical record -The goal of restorative nursing acre is to attain and maintain the maximum possible independence and/or prevent rapid declines through the interventions for each resident. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105651 If continuation sheet Page 4 of 10 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 105651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/28/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center of Day 325 S Segrave Street 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure that residents who required dialysis received such services and associated care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #40) of one resident receiving peritoneal dialysis, from a total of 31 residents the sample. Residents Affected - Few The findings include: A medical record review for Resident #40 revealed that he was admitted to the facility on [DATE] with a re-entry on 11/30/20. His diagnoses included end-stage renal disease (ESRD) with dependence on dialysis, transient ischemic attack (TIA) and cerebral infarction without residual deficit. A review of the admission minimum data set (MDS) assessment, dated 12/06/20, revealed the resident was assessed as having a brief interview for mental status (BIMS) score of 15 out of a 15 possible points, indicating intact cognition. He was independent for all functions of daily living such as bed mobility, transferring and toileting. A review of the current physician's orders, revealed the following orders: Sevelamer HCL tablet (lowers blood phosphorus levels of dialysis patients), 800 milligrams (mg), give 2 tablets with meals for dialysis. Peritoneal dialysis to run in 6 phases different dialysate strength. Call [dialysis center] with numbers and directions 386 258 7719 weight and vital signs Heparin 1000 units/ml (units per milliliter), infuse 6 ml in the peritoneal cavity in the afternoon every Monday for fibrin in solution/insert in heater bag related to dependence on renal dialysis Gentamycin 0.1%, apply to peritoneal catheter site topically one time a day for dialysis Eliquis 5 mg two times a day (BID) for blood clots Aspirin 81 mg everyday (QD) for blood clots Resident to be monitored every hour while connected to peritoneal dialysis. Check tubing placement and ensure it is not wrapped around the foot pedals and wheels of he bed every evening and night. Exit site care - remove old dressing, cleanse with cleaning agent (except) inner to outer, pat dry, apply gentamycin on a split 2X2, cover with sterile 4X4, window frame with tape Full set of vital signs after disconnected dialysis (0800 need blood pressure, pulse, temperature and pain) Immediately report swelling, warmth or redness around the site, pus/drainage from the site. Chill or fever more than 100 degrees. Dizziness/fainting when standing up or shortness of breath (SOB) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105651 If continuation sheet Page 5 of 10 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 105651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/28/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center of Day 325 S Segrave Street 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 [NAME]- vite B complex folic acid QD (daily). Level of Harm - Minimal harm or potential for actual harm A review of the care plans revealed the resident was careplaned for a need of dialysis treatment related to renal failure with the following interventions: Peritoneal dialysis to run in 6 phases different dialysate strength call [dialysis center] with numbers and direction 386 258 7719, resident self-administers peritoneal dialysis, monitor/document/report to health care provider as needed (PRN) for any signs and symptoms of infection of dialysis access sites to abdomen and right chest: redness, swelling, warmth or drainage. Provide exit site care and treatment as ordered. Residents Affected - Few During an interview with Resident #40 on 01/26/21 at 1:55 PM, he stated he did his own peritoneal dialysis. He stated he had been trained by the [dialysis center] nurses on how to perform the treatment. He mentioned that while he lived at home, the dialysis nurse would visit weekly, but when he moved to the facility, the dialysis nurse visited once a month. He added that the facility nurses were supposed to report the weights and vital signs to the dialysis nurse weekly. Resident #40 said that it was important for the nurses to report his weights and vital signs to the dialysis center becasue he used two different dialysate which were dependent on his blood pressure and weight. When asked about the dressing chnage to the dialysis port he said, The facility staff do not do anything for me. I do it myself. The resident was on anticoagulant medication which put him at high risk of bleeding. He mentioned that he had been admitted to the hospital in November due to malfuctioning of the peritoneal dialysis access. He further stated he was put on hemodialysis for three weeks. He stated that a hemodialysis port was retained on his right upper chest. He said the nephrologist would make a determination of when it would be taken off during his next appointment. On 01/26/21 at 2:10 PM, a 4X4 gauze dressing tapped with paper tape was observed on the exit site. No date or staff initials were on the dressing. The resident stated he had changed the dressing in the morning after the treatment. During an interview on 01/27/21 at 10:40 AM with Employee C, Registered Nurse (RN), she stated she was responsible for taking care of Resident #40. When asked whether she had done a dressing change or completed an assessment on the resident's dialysis port, she replied, We do not do anything for him. He does everything for himself unless he asks for help. When asked if she reported the vitals signs to the dialysis nurse, she said only if the they are abnormal. On 01/27/21 at 10:49 AM, Employee A, Licensed Practical Nurse (LPN)/Unit Manager, stated [dialysis center] conducted an in-service for facility nurses regarding the resident's peritoneal dialysis. When asked about resident dialysis treatments, she stated that resident does his own dialysis, however, facility nurses were supposed to oversee the resident starting and stopping treatment. She also stated nurses were supposed to assess the dialysis exit site daily and performed the dressing change. She stated the facility protocol for dressing change was to initial the new dressing with staff initials and the date the bandage was changed. When asked if there was documentation to verify nursing had been changing the resident's dressing, she checked the medication administration record (MAR) and treatment administration record (TAR), and stated it was not documented. When asked whether the nursing staff notified the dialysis nurse of the resident's vital signs and weight, she stated she was not sure because it was not documented. A review of the January 2021 MAR and TAR revealed that the order for exit site care - remove old dressing cleanse with cleaning agent (except) inner to outer pat dry, apply gentamycin on a split 2X2 cover with sterile 4X4 window frame with tape, and order to immediately report swelling, warmth or redness around the site, pus drainage from the site. Chill or fever more than 100 degrees (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105651 If continuation sheet Page 6 of 10 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 105651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/28/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center of Day 325 S Segrave Street 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 Dizziness/fainting when standing up or shortness of breath (SOB) had not be signed as having been completed from january 1-27, 2021. (Copies obtained) A review of the facility's policy and procedure titled, Physician/Practioner Orders - Rehab/Skilled revised on 11/20/20, revealed: Residents Affected - Few -To provide individualized care to each resident by obtaining appropriate, accurate and timely physician/practitioner orders Wounds: Orders must be obtained for wound care including product to be used when to change and when to reassess. A licensed nurse must provide the wound care. According to the National Library of Medicine at https://pubmed.ncbi.nlm.nih.gov/33225827, exit-site infections increase the risk of developing peritoneal dialysis peritonitis and peritoneal dialysis technique failure. [NAME] L, [NAME] MM, Fan S. 'Persistent Colonization of Exit Site is Associated with Modality Failure in Peritoneal Dialysis'. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105651 If continuation sheet Page 7 of 10 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 105651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/28/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center of Day 325 S Segrave Street 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation and interview, the facility failed to post the nurse staffing data on a daily basis at the beginning of each shift. This data should include: facility name, current date, resident census, total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Residents Affected - Many (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses. (C) Certified nurse aides. The findings include: On 01/24/21 at 12:30 PM, the staffing schedule posted at the nurse's station on a white board on North, South and Hope units noted two certified nursing assistants (CNAs) and one nurse for all three shifts (6:00 AM- 2:00 PM, 2:00 PM-10:00 PM, and 10:00 PM- 6:00 AM). The staffing ratio was not posted. Additional observations on 01/25/21 at 9:30 AM, 01/26/21 at 9:39 AM, and 1/27/21 at 11:15 AM, revealed that the staffing ratio was not posted. On 01/27/21 at 11:28 AM, the Administrator confirmed that the staffing ratios had not been posted since 1/18/21 after the Director of Nursing (DON) resigned. She stated the facility's DON was the designated person to do that task and had resigned. She added that the task was also delegated to the Unit Managers, however, the facility has had a high staff turnover, and the current Unit Managers and DON were new to their positions. they had not had the training on how to perform the task. She mentioned that she would teach the DON how to do the ratios and would ensure it was posted daily. On 01/28/21 at 2:13 PM, the Administrator was asked if the ratios had been posted. She hesitated then stated she had asked the DON to post them in the morning. The Administrator went to the lobby where the ratio should be posted and confirmed that the ratios had not been posted. She stated she would post them as soon as she concluded her meeting. On 01/28/21 at 3:00 PM, the DON provided a completed copy of the ratios for review. She stated they would implement a process for the night shift supervisor to complete the form, which the DON would review and post every day. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105651 If continuation sheet Page 8 of 10 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 105651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/28/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center of Day 325 S Segrave Street 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure as needed antipsychotic medication was limited to 14 days, or had documented rational and an indicated duration by the attending physician or prescribing practitioner for one (Resident #62) of five residents with a medication review, from a total of 31 residents in the sample. The findings include: A record review for Resident #62 found she was admitted to the facility on [DATE] with diagnoses including vascular dementia with behavioral disturbance and bipolar disorder. A review of the resident's electronic medical record found that she had current physician's orders beginning on 12/22/2020 for ABH (Ativan, Benadryl, Haldol) Transdermal Gel, apply 1 milliliter (ml) every 6 hours as needed for agitation. The order did not have an end date. A review of the resident's January 2021 Medication Administration Record (MAR) revealed that she was administered the medication 14 times from 1/1/2021 to 1/23/2021. During an interview with the Acting Director of Nursing (DON) on 1/27/2021 at 1:00 PM, she was asked for evidence that the as needed ABH gel was reviewed every 14 days. During further interview with the Acting DON on 1/27/2021 at 1:58 PM, she stated she spoke to the Pharmacist and he informed her that the as needed ABH gel should have a stop date. She added that the Pharmacist informed her that because Resident #62 was a hospice patient, it was difficult for the facility to get a stop date. She stated she was aware the medication should only be written for 14 days, and the hospice doctor or facility doctor should assess the resident and determine if the medication order should continue. During an interview with Resident #62's nurse (Employee G) on 01/27/2021 at 1:50 PM, she stated the hospice nurse came to the facility all the time and reassessed Resident #62's medication. She stated all of the paperwork would be in the facility's computer program. She was asked who was responsible for writing the orders for Resident #62's medication. She stated, Resident #62's hospice provider had a physician, and the facility had a physician that both oversaw her medications. She was asked who prescribed the as needed ABH gel and she replied that she did not know. During further interview with the Acting DON on 1/27/2021 at 2:59 PM, she stated she called Resident #62's hospice provider and they were not able to provide any evidence of having re-evaluated Resident #62 for the ABH gel. She stated the Pharmacist had identified the as needed ABH gel was limited to 14 days and hospice wrote back that they wanted the resident to no longer be reviewed by psychiatric services. She stated the previous DON was not doing her job with the pharmacy review and the Unit Manager was not aware the medication should only have been written for 14 days. During another interview with the Acting DON on 1/28/2021 at 11:41 AM, she was asked who was responsible for ensuring the accuracy of medication in the facility. She stated the individual responsible for writing the prescription would have been the physician that saw the resident in the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105651 If continuation sheet Page 9 of 10 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 105651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/28/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center of Day 325 S Segrave Street 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few She stated the Unit Managers had the responsibility of ensuring the medication was accurately entered into the electronic medical record with an end date. During an interview on 1/28/2021 at 12:00 PM with the Unit Manager (Employee A) for the unit Resident #62 resided on, she stated she was the Unit Manager in December of 2020. She was asked who was responsible for writing the orders for the as needed ABH gel for Resident #62. She stated the hospice doctor wrote all of the resident's orders. She stated that the Psychiatrist discontinued Resident #62's ABH gel but hospice restarted it. She stated the hospice doctor wrote the orders and the resident's facility doctor signed off on all of the orders. She stated she could not recall if she checked Resident #62's medication orders. She stated she was aware the as needed ABH gel should have had a stop date and should not be for more than 14 days. She could not recall if the order was for 14 days when it was received in December and she stated she would check it. During an interview with the facility's Pharmacy Consultant on 1/28/21 at 12:15 PM, he stated the as needed ABH gel should have been written for 14 days unless it had an earlier hard stop end date. He stated he did tell the DON and supervisors about the medications that needed stop dates and it did not get addressed. He stated he completed narcotic destruction the last day the previous DON was working at the facility and he addressed his concern with her. During a telephone interview on 1/28/2021 at 1:05 PM with the Nurse Practitioner for Resident #62's physician, she stated the last prescription they wrote for ABH gel was on 9/15/2020 and it was scheduled every 4 hours. She stated any changes made after 9/15/2020 to the medication were done by the hospice physician. She stated the hospice physician should have known to write the order for 14 days so it was probable an oversight. During an additional interview with the Acting DON on 1/28/2021 at 1:47 PM, she provided an order from the hospice physician dated 11/4/2020 with the following instructions, Do not change psych order. She also provided the 12/22/2020 hospice physician's order dated 12/22/2020 to Start ABH 1/12.5/1 gel topically Q 6 PRN. There was no end date given. At the time the Acting DON presented the information she stated she had checked again and the facility had no other record past the 12/22/2020 order addressing Resident #62's continued need for the medication. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105651 If continuation sheet Page 10 of 10