Health inspection·April 22, 2021

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, clinical record review, staff interview and facility policy and procedure review, the facility failed to provide care and treatment in a timely manner, in accordance with professional standards of practice, the plan of care and the resident's choices for pain management and identifying a change of condition after a fall for 1 (#47) out of 4 residents sampled for accidents, from a total of 36 sampled residents. Resident #47 sustained a fracture of the hip and femur bones when he fell, but the first x-rays indicated no fractures. Three days later the resident requested transfer to the hospital due to extreme pain. Failure to manage pain and identify a change of condition after a fall negatively impacted Resident #47's ability to maintain his highest practicable, physical well being. Residents Affected - Few Professional Standard of Care is defined in Chapter 766.102 as the prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which in light of all relevant surrounding circumstances is recognized as acceptable and appropriate by reasonably prudent similar health care providers. The findings include: During an interview on 04/22/2021 at 1:05 PM with Resident #47, he confirmed that he had fallen in his room on 01/21/2021. He was in the hallway outside his room talking to Employee O, CNA and did not have his nasal cannula on. When he returned to his room, he felt dizzy, the room started spinning and he fell. He stated, Oh yeah I was in a lot of pain! He knew the first x-ray was negative, but the pain just got worse. He finally had to tell the nurse he wanted to go to the hospital. He stated, I knew something was really wrong. A titanium pin was surgically placed in his hip. He now uses a wheelchair to ambulate for long distances because he must have oxygen continuously. A record review for Resident #47 revealed he was admitted on [DATE]. His diagnoses included intertrochanteric type left proximal femoral neck fracture, history of pneumonia, other nonspecific abnormal finding of lung field, emphysema, pulmonary fibrosis, chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease. (Photographic evidence obtained) Nursing notes revealed Resident #47 had a fall on 01/21/2021 at 12:20 AM. He was observed sitting on the floor in his room, near the doorway. He reported that he got dizzy and lost his balance and fell on the floor. He reported that he did not hit his head. He complained of pain in his left leg and hip. He was unable to bear weight on his left leg. The nurse documented that he was wincing in pain as the Certified Nursing Assistant (CNA) helped him off the floor and into his bed. The physician was called, and he ordered x-rays to be taken of the left hip and leg. A mobile imaging company was called and conducted the diagnostic test at 2:30 AM. (Photographic evidence obtained) Review of the nursing note dated 01/21/2021 at 10:21 AM revealed it read: Status post (S/P) fall: resident remains in bed, continues to complain of left leg and hip pain, routine pain medication given, ordered x-rays completed and results returned, reviewed with provider, no new orders, all areas negative for fracture/dislocation, resident made aware, encouraged resident to start moving left leg as much as can be tolerated, staff assisting with care. (Photographic evidence obtained) Review of the nursing note for Resident #47 dated 01/21/2021 at 10:12 PM revealed it read: Resident remained in bed all shift. Resident complaint of increased pain to left leg and hip. Resident not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105840 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 105840 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory L Bennett Memorial Veterans Nursing Home 1920 Mason Avenue Daytona Beach, FL 32117 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Actual harm Residents Affected - Few using left leg saying he cannot move it on his own. X-rays completed earlier in day. Resident medicated for pain per orders and took a dose of Baclofen earlier in shift. Resident had some blanching of skin to both lower legs, oxygen at 90% with oxygen in place. Vital signs remain within normal limits. Resident turned and repositioned off left hip using pull sheet and barrel roll to move resident. Resident took medication as scheduled. Supervisor aware, will continue to monitor. (Photographic evidence obtained) Review of the nursing note dated 01/22/2021 at 2:36 PM revealed it read: S/P: Resident alert, requiring modified assistance with activities of daily living (ADLs) and transfers, complaint of left leg pain this morning, but scheduled Lortab was effective, vital signs within normal limits, noted with a bruise on left elbow, no swelling, or bruises on left lower extremities, will continue to monitor. (Photographic evidence obtained) Review of the nursing note for Resident #47 dated 01/22/2021 at 10:05 PM revealed it read: S/P fall: Assisted with care this shift. Encouraged to ask for staff for aid when getting out of bed. Complaint of pain to the left leg and side of body. No bruises noted. Medicated as directed. Oxygen (O2) therapy on continuous. No distress noted. (Photographic evidence obtained) Review of the nursing note dated 01/23/2021 at 6:18 AM revealed it read: Resident has not slept much these past hours. Complaint of pain in left hip, and leg, requested and received Tylenol 650 milligrams (mg) with positive effect x 2. Baclofen also given. Resident is needing more assistance with ADLs. Unable to bear weight on his left leg. Incontinence care given as needed (PRN). (Photographic evidence obtained) Review of the nursing note dated 01/23/2021 at 12:23 PM revealed it read: S/P fall: remains requesting assistance with ADLs and transfers, able to move all extremities as tolerated, expressing signs and symptoms of weakness, vital signs within normal limits. Will continue to monitor. (Photographic evidence obtained) Review of the nursing note for Resident #47 dated 01/23/2021 at 11:18 PM revealed it read: Nursing note: Resident remained in bed all shift, requires more assistance with ADLs and transfers per CNAs. Resident took all medication as directed. Continues to voice concern of pain from left leg and continues to keep leg motionless even after encouragement to move. Resident had an incontinence episode x1 with incontinence care provided. Will continue to monitor. (Photographic evidence obtained) Review of the nursing note dated 01/24/2021 at 10:30 AM revealed it read: This morning resident complained of lots of pain on left leg and chest/muscle spasms. Baclofen given with some effect. Pulse 124, temperature: 100.5 degrees Fahrenheit ('F) stating not feeling good. Physician notified. New orders given for electro-cardiogram (EKG). Resident remains closely monitored, state feeling a little better. Temperature decreased to 99.1'F. Mobile imaging company called. Resident made aware of new order. (Photographic evidence obtained) Review of the nursing note for Resident #47 dated 01/24/2021 at 6:50 PM revealed it read: EKG completed. Waiting for the final report to arrive. Resident complaint of pain to the left hip down to his left knee upon movement. No bruising noted to this area. Assistance needed with transferring. O2 on continuous. (Photographic evidence obtained) Review of the nursing note dated 01/24/2021 at 9:50 PM revealed it read: Physician reviewed EKG. Resident has been expressing his wish to be transferred to the hospital due to his increased pain to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105840 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 105840 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory L Bennett Memorial Veterans Nursing Home 1920 Mason Avenue Daytona Beach, FL 32117 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 the left hip and leg. Physician ordered to the emergency room (ER). The resident was transported. (Photographic evidence obtained) Level of Harm - Actual harm Residents Affected - Few A review of Resident #47's Medication Administration Record (MAR) from 01/21/2021 at 12:20 AM through 01/24/2021 at 9:50 PM revealed, he was assessed for pain using a pain rating scale of 0-10 with ten being the worst pain. On the day shift on 01/21/2021, he reported a 9/10. On the evening shift on 01/22/2021, he reported a 4/10. On the day shift on 01/24/2021, he reported a 7/10. Nursing staff documented giving the resident PRN pain medication on 01/21/2021 at 1:54 AM, 11:59 AM and 5:10 PM; on 01/22/2021 at 3:40 PM and 11:12 PM; on 01/24/2021 at 8:16 AM. Nurses noted: Pain. Left leg and hip. Resident request. (Photographic evidence obtained) A review of Resident #47's hospital admission Document date 01/25/2021 at 12:27 AM, revealed it read: Date of admission [DATE]. Chief Complaint: fall 3 days ago. Increased left hip pain. X-ray of the hip done on admission shows acute intertrochanteric type left proximal femoral neck fracture with soft tissue swelling. No dislocation. Plan: Orthopedic surgeon was consulted. The patient is scheduled for surgery today. Patient will require an inpatient admission for anticipated stay of 3 days for hip fracture. (Photographic evidence obtained) A review of Resident #47's Minimum Data Set (MDS) dated [DATE] revealed his ADL functioning was assessed as requiring one staff member assist or set up help only, supervision, oversight, encouragement or cueing for bed mobility, transfers, walking in his room or the corridor, locomotion on and off the unit and dressing. He was independent with eating and toilet use. He was not steady, but able to stabilize without staff assistance when moving from a seated to standing position, walking, turning around, moving on and off the toilet. For surface-to-surface transfers he required the assistance of staff to stabilize. He had impairment on one side in the lower extremity. He used a walker and wheelchair for mobility devices. He reported having no pain in the last 5 days of the assessment period. (Photographic evidence obtained) A review of the Point of Care History for ADLs from 01/21/2021 at 12:20 AM until 01/24/2021 at 9:50 PM, revealed the resident required increased assistance with all ADLs. He did not walk or bear weight on his legs. (Photographic evidence obtained) A review of Resident #47's Care Plan dated 10/19/2018 revealed it read Problem: Falls. Resident is at risk for falls related to history of falls, impaired mobility, neuropathy, antihypertensive and psychotropic medication use. The care plan was updated on 01/21/2021 for follow up with x-ray s/p fall. A new problem was added to the care plan on 01/23/2021. It read: Has a fracture of left hip s/p fall. A new problem area was added on 01/25/2021. It read: Risk for falls and fracture related to diagnosis of osteoporosis. Has a fracture of left femoral and intertrochanter s/p fall. Problem area: Resident is at risk for altered breathing/respiratory distress related to diagnosis of Chronic Obstructive Pulmonary Disease (COPD), Emphysema, Pulmonary fibrosis. Interventions included O2, 2 liters via nasal cannula continuously. Problem area: Pain. Resident is at risk for alteration in comfort. Interventions included: Provide repositioning and other non-medical interventions for pain management as needed. Observe decreased range of motion, resistance to care related to pain. Contact physician as needed for revision of pain management if current plan ineffective. (Photographic evidence obtained) During an interview with the Director of Nursing (DON) and the Risk Manager (RM), Employee F, on 04/22/2021 at 3:44 PM, Employee F stated there is a discussion of falls in the morning meeting with the interdisciplinary team, and information is included that is available at the time. Investigations (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105840 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 105840 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory L Bennett Memorial Veterans Nursing Home 1920 Mason Avenue Daytona Beach, FL 32117 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Actual harm Residents Affected - Few are conducted after the fall by the RM. The DON stated, I review the nursing notes every morning. She was asked to describe the assessment process when a resident falls. She stated, The nurse does an assessment at the time of the fall. They ask the resident 'Are you in pain?', and vital signs are taken. The nurse and the Certified Nursing Assistant (CNA) will write a statement for the incident. There is an Event Details Form with a check list the nurse uses to tell what happened. The date, time, interventions, and anything pertinent are documented. The DON reviewed the Event Details form dated 01/21/2021 for Resident #47's fall. She confirmed that the oxygen saturation levels, and vital signs were not documented at the time of the fall. The DON stated they assess for pain and fractures. The nurse would also check for external rotation and shortness of the leg. She was informed that the nursing notes did not mention shortness of the leg or external rotation of the hip being conducted. The DON could not confirm that it was done. The nursing notes did not indicate that the physical therapy (PT)/rehab department screened the resident for a fracture. The DON read the nursing notes for Resident #47 and confirmed. She stated that PT screenings are done for most falls. She agreed that mobile x-rays are not always accurate. When asked if PT screened the resident at the time of the fall or during the three days after the fall prior to being sent to the hospital, they stated they were not sure. They left the interview to go and see if they could find a PT screening of Resident #47. Upon returning to the interview, the DON produced a Rehabilitation Screen form dated 01/24/2021 that read: Will eval indicated upon return. (Photographic evidence obtained) When asked when they decide to send a resident out to the hospital after a fall, the DON stated, If they hit their head, if they have a change in ADLs/functioning. After reviewing the nurse's notes, the DON confirmed the change in his condition between the time of the fall on 01/21/2021 and 01/24/2021 when he requested to go to the hospital. She reported that resident had an incontinence episode, which he never had before and a decline in ADLs. He required more assistance with his ADLs. She noted an increase in self-reported pain and continued to keep his leg motionless. He was choosing not to move his left leg. She stated that the physician should have been notified of the change of condition, and with the significant change in his condition, he should have been sent out to the hospital. The nursing notes did not indicate what information was relayed to the physician regarding the resident's condition/presentation. The nurse on duty notified the physician on 1/24/2021 at 10:30 AM. The resident was sent out to the hospital at 9:50 PM. An EKG was ordered and done at 6:50 PM. The resident expressed on 1/24/21 at 9:50 PM that he wished to go to the hospital. The DON read the nursing notes and confirmed there was a delay in treatment. The DON and RM confirmed that they did not do a thorough investigation. During an interview with Employee E, RN, on 04/22/2021 at 4:33 PM, she stated that she was the Risk Manager at the time of Resident #47's fall. She spoke with the nurse on duty after the fall, but does not have a statement by either the nurse or Employee O, the CNA who found him on the floor. She could not say what happened or why the resident fell. She thinks it was because he did not have his nasal cannula on. She did not know if the PT department screened the resident after the fall because it happened at night and she was not in the facility. She could not provide evidence that she followed up after the first x-rays came back negative. Review of the facility policy and procedure entitled Fall and Fall Risk Management revealed it read: The facility will ensure that the resident's environment remains as fee from accident hazards as possible and each resident receives adequate supervision and assistance devices to prevent accidents. A fall includes a.) a resident is found on the floor but the means by which he/she got to the floor was un-witnessed. The facility will identify appropriate resident specific interventions to reduce the risk of falls. Examples of initial approaches might include but are not limited to physical therapy screening/evaluations and treatment if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105840 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 105840 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory L Bennett Memorial Veterans Nursing Home 1920 Mason Avenue Daytona Beach, FL 32117 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete indicated. Fall risk may also be impacted by pain, decline in physical condition and/or underlying medical condition which may require assessment/treatment by the physician. Monitoring Subsequent Falls and Fall Risk: 1. The clinical team will monitor and document each resident's response to interventions intended to reduce falls or risk of falls. 3. If the resident continues to fall, the clinical team, in conjunction with the physician will re-evaluate the situation and determine whether it is appropriate to continue and/or change current interventions. (Photographic evidence obtained) Event ID: Facility ID: 105840 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 105840 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory L Bennett Memorial Veterans Nursing Home 1920 Mason Avenue Daytona Beach, FL 32117 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 record review, staff interview and policy and procedure review, the facility failed to monitor resident behaviors and potential side effects related to the use of psychotropic medication for one (Resident #74) of five residents reviewed for unnecessary medications from a total of 36 residents in the sample. Residents Affected - Few The findings include: A record review for Resident #74 revealed he was admitted on [DATE], with the following diagnoses: history of alcohol use, major depressive disorder recurrent episode, suicidal in the past, and adjustment diagnosis of mixed anxiety and depression. A review of the physician orders on 4/22/21, revealed an order for Sertraline 150 mg (milligram) by mouth daily for major depression. Behavior monitoring documentation and/or side effect monitoring documentation was not found in the medical record. An interview was conducted with the Director of Nursing (DON) on 4/22/21 at 12:54 PM. The DON confirmed there was no documentation for behavior monitoring for Resident #74 related to the use of Sertraline. An interview was conducted with the pharmacist on 4/22/21 at 1:58 PM. She verified there was no documented behavior monitoring for Resident #74 related to the use of Sertraline. She added that Sertraline has a black box warning for suicidal ideation. It is important to monitor for any thoughts of suicidal ideation, depression, constipation, diarrhea, difficulty sleeping and any increased appetite. When asked about behavior monitoring, she stated, Yes, we should have done a BMFR. BMFR stands for behavior modification flow record and we use it to monitor for cognitive behaviors. A review of facility policy, titled Psychotropic Medication guidelines, on 4/22/21 at 1:04 PM, stated antidepressants should include daily monitoring for presence of target behaviors and any adverse effects of the medication. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105840 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 105840 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory L Bennett Memorial Veterans Nursing Home 1920 Mason Avenue Daytona Beach, FL 32117 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation, food distribution and service practices to prevent the outbreak of foodborne illness with the potential to affect all of the residents in the facility. The facility failed to ensure that the dietary staff implemented the facility policy for the proper procedures for hand hygiene, disposable glove use, and proper sanitation practices in the kitchen when staff failed to change gloves when they became contaminated, and to wash their hands between glove changes during the lunch meal service. The findings include: On 4/19/2021 at 10:25 AM, the initial tour of the kitchen was conducted. A smoking device identified as a Vape was observed on the prep table across from the steamers and the fryer in the kitchen (Photographic evidence obtained). The Dietary Manager stated the vape belonged to Employee K, Dietary Staff, and she asked him to remove the device. The three-compartment sink was set up with a pan soaking in the sanitizer sink. The sanitizer was identified as Quaternary Ammonium and tested by a dietary staff member. The first test revealed the Quaternary Ammonium sanitizer level was 500 parts per million (ppm). The staff member then added more water to the sink and tested it again. The second test revealed 200 ppm of Quaternary Ammonium used. In the dry food storage area, expired cereal was observed in several bins. The expiration dates were 10/2020 and 03/2020 (Photographic evidence obtained). On 4/21/2021 at 11:25 AM, a second observation of the kitchen was conducted. Food temperatures were taken revealing the hot-holding temperature of the pureed green beans was 124 degrees Fahrenheit ('F). After several failed attempts to reheat the beans by Employee K, the Dietary Manager was able to reheat the green beans to 171 'F. Employee L was observed setting up the meal trays at the beginning of the tray line. She was wearing disposable latex gloves. She touched other surfaces with her gloved hands, thus contaminating them, as she was setting up the trays with stainless steel utensils. The utensils were stored in a dish rack with the eating ends facing upward (Photographic evidence obtained). She was observed taking a fork, spoon, and knife for each tray out of the dish rack by the eating end of each utensil. She then put them on the trays. She did not doff her gloves after contaminating them, wash her hands with soap and water or don new gloves. She did not get clean utensils for the trays. Employee N was observed preparing sandwiches with gloved hands. She wrapped the sandwiches in plastic wrap and then took a pen out of her pocket and wrote on the labels for the sandwiches. She applied a label to each sandwich and put the pen back in her pocket. She then took new bread slices out of a bread bag and laid them out on the prep table cutting board and began to spread them with peanut butter. She did not doff the contaminated gloves, wash her hands, or don new gloves. on 4/21/21 at 11:55 AM, Employee K doffed his gloves and donned new gloves without washing his hands. Employee K was observed taking off dirty gloves and placing them next to clean scoop plates and put on clean gloves. He was then observed touching a rag used to wipe the serving line and changed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105840 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 105840 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory L Bennett Memorial Veterans Nursing Home 1920 Mason Avenue Daytona Beach, FL 32117 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 his gloves. He put the dirty gloves on top of the other set of dirty gloves next to the scoop plates. He was observed three additional times taking his gloves off and pulling out a tray of corn muffins with bare hands and putting on new gloves while placing the dirty gloves with the other dirty gloves next to the scoop plates. Employee K was then observed removing plastic wrap from a food container and placing it in the same pile with the dirty gloves. The plastic wrap rolled from the pile of gloves and onto a resident scoop plate. He then moved the trash off of the plate and continued to fix the resident's meal on the contaminated plate. Review of the facility policy and procedure entitled Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices #3102, effective 11/27/2017 revealed it read: Food Services employees shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. 6. Employees must wash their hands: a. After personal body functions; b. After using tobacco, eating, or drinking; c. Whenever entering or re-entering the kitchen; d. before coming into contact with any food surfaces; e. After handling raw meat, poultry, or fish and when switching between working with raw food and working with ready-to-eat food, f. After handling soiled equipment or utensils; g. During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; and/or h. After engaging in other activities that contaminate hands. 10. Gloves are considered single-use items and must be discarded after completing the task for which they are used. The use of disposable gloves does not substitute for proper handwashing. 14. Personnel may not smoke or use other tobacco products, eat, drink or chew gum in the food preparation area. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105840 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 105840 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory L Bennett Memorial Veterans Nursing Home 1920 Mason Avenue Daytona Beach, FL 32117 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on kitchen food service observations, staff interviews, and facility policy and procedure review, the facility failed to ensure all essential kitchen equipment was maintained in safe operating condition by not ensuring proper maintenance of the mechanical, high temperature dishwashing machine and walk-in freezer. Residents Affected - Many The findings include: On 4/19/2021 at 10:25 AM, the initial kitchen tour was conducted. Employee J was asked to run the high temperature mechanical dish machine. He ran the machine a couple of times to get the machine up to the right temperature. When asked what the temperature of the wash cycle and final rinse cycle should be, he stated the wash cycle temperature should be 160'F (Fahrenheit) to 180'F and the final rinse cycle should be 180'F. He ran the dish machine and the actual temperature for the wash cycle was 158'F-159'F and the temperature for the final rinse cycle was 183'F-184'F. On 4/22/201 at 9:20 AM, a second operation of the dish machine was observed. Employee M was operating the dish machine. She rinsed and loaded dirty dishes onto racks and pushed them into the dish machine. The temperature of the dish machine was 145'F-147'F. When Employee M was asked what temperature the wash cycle temperature was supposed to be, she replied, 160'F or higher. She did not know why the temperature was only reaching 145'F-147'F and did not know how long it had been like that (Photographic evidence obtained). During an interview with the Dietary Manager on 04/22/2021 at 9:30 AM, she stated that the specifications for the dish machine were on the side of the machine. The specifications were observed on a silver plaque attached to the side of the machine, not readily observed by staff. The plaque read: Wash cycle 160'F (Photographic evidence obtained). She stated that she was not aware that the dish machine had not reached the temperature of 160'F. Record review of the temperature log for the dish machine revealed no temperatures had been recorded for 04/21/2021 and 04/22/2021 (Photographic evidence obtained). During the initial tour of the kitchen on 04/19/2021 at 10:25 AM, the temperature reading of the internal thermometer of the freezer was 21'F. A record review of the freezer temperature log revealed freezer temperatures ranged from 5'F to 20'F from 04/10/21 to 04/19/2021. During an interview with Dietary Manager on 4/19/2021 at 11:20 AM, she stated that the freezer has had maintenance calls a couple of times since 4/10/2021. Review of the facility Policy and Procedure entitled Sanitization revealed it read: 8. Dishwashing machines must be operated using the following specifications: High-Temperature Dishwasher (Heat Sanitization) a. Wash temperature (150'F-165'F) for at least forty-five seconds (Photographic evidence obtained). . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105840 If continuation sheet Page 10 of 10