Inspection·October 17, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 01/19/21 - Stye Lubricant (White petroleum-mineral oil) 57.7-31.9%, small amount to both eyes at bedtime (HS) A review of the resident's care plan (revised on 10/4/24), revealed that he was blind in both eyes related to visual nerve damage. Interventions included arranging items in the room within the resident's reach (call bell, TV remote, personal hygiene items). Furniture in the room was to be arranged consistently, conveniently and safely. The care plan also indicated that the resident had a cognitive deficit, periods of confusion and impaired decision making related to his overall health status. Intervention - Introduce yourself and explain what you are going to do prior to providing care. Orient to time and place as needed. A review of the Quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) of 10/3/24, revealed that Resident #2 had a brief interview for mental status (BIMS) score of 13 out of 15 possible points, indicating intact cognition. The assessment also documented the resident's severe visual impairment. In an interview on 10/17/24 at 11:28 a.m., Certified Nursing Assistant (CNA) B was asked about Resident #2's functional status. She stated he was blind and required minimal assistance and cueing with his ADLs due to blindness. She stated he could make his needs known. When asked how he called staff for assistance, she replied, When he is in the bathroom he can pull the cord in the bathroom because he feels the cord and pulls it, but he does not use the one at bedside because he cannot see the buttons. Normally he yells out and if he is in the wheelchair, he propels himself to the doorway and starts calling and waving. We also try to anticipate his needs and check on him. During an interview with the Administrator on 10/17/24 at 4:01 p.m., she explained that when staff noted that a resident might benefit from certain equipment, they should notify the unit manager who would bring the issues to the interdisciplinary team (IDT). The resident might be referred to physical therapy for assessment of needs and the facility would take it from there. When asked about Resident #2's call light, she stated she had not thought about it. She further stated she was unaware of any type of call light that the resident would benefit from. She added that Resident #2 yelled out for help and staff also checked on him frequently. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105840 If continuation sheet Page 2 of 11 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 10/17/2024 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on record review, interviews, and a review of the facility's policy and procedure, the facility failed to ensure that residents were properly screened for a mental disorder (MD) or intellectual disability (ID) prior to admission, and that individuals identified with a MD or ID were evaluated and received care and services appropriate to their needs for one (Resident #48) of a total survey sample of 31 residents. Resident #48's Pre-admission Screening and Resident Review (PASRR) was incomplete with numerous areas of the form left blank. Incomplete PASRR forms can result in residents not receiving appropriate help/services and/or could create a delay in the process. Residents Affected - Few The findings include: A record review was conducted for Resident #48 noting an admission date of 11/26/2021 and a previous admission date of 04/13/2018. His diagnoses included anxiety, depression (other than bipolar), manic depression (bipolar disease), and post traumatic stress disorder (PTSD). The resident's Quarterly minimum data set (MDS) assessment, dated 09/27/2024, revealed that the resident had a Brief Interview for Mental status (BIMS) score of 10 out of 15 possible points. Scores between 08 and 12 indicate moderate cognitive impairment. A review of Resident #48's PASRR, dated 01/19/2018, revealed that it was incomplete. Page one areas for the legal representative's name and address, the medicaid identification number, other health insurance name and number, whether the resident was private pay, and the facility name, address, city, state, zip code and phone number that the hospital was requesting admission to were left blank. Page two was entirely blank; Section A areas for indicating that the resident had diagnoses including anxiety, depression, bipolar disorder, and other (post-traumatic stress disorder) were left blank. Section B areas related to intellectual disability information were left blank. The area for any services received was left blank, and the source(s) of information was left blank. No new Level l, and/or request for Level ll evaluation and determination had been completed since this PASRR, dated 01/19/2018, was completed. (copy obtained) A review of Resident #48's active physician's orders included the following orders: 10/17/2024 - Other test: Lithium level for impulsiveness one time, 12:00 am - 7:00 am 10/16/2024 - Other test: Lithium level for impulsiveness one time, 12:00 am - 7:00 am 10/12/2024 - Trazodone tablet 100 mg, amount: 100 mg, oral BID at 8:00 a.m. and 8:00 p.m. for major depressive disorder, recurrent, moderate 08/21/2024 through 10/12/2024 (discontinued date) - Trazodone tablet 100 mg, amount: 100 mg, oral TID (three times a day) at 9:00 a.m., 1:00 p.m., and 8:00 p.m. for major depressive disorder, recurrent, moderate 08/20/2024 - Other test: Lithium level for bipolar disorder, current episode mixed, mild-treatment once a day on the 3rd Tuesday of the Month, 12:00 am - 7:00 am 03/19/2024 through 10/16/2024 (discontinued date) - Lithium carbonate capsule 150 mg, amount: 300 mg orally, special instructions: give 1 capsule dose 300 mg BID, 9:00 AM, 8:00 PM for bipolar disorder, current episode mixed, mild treatment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105840 If continuation sheet Page 3 of 11 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 10/17/2024 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 0645 Level of Harm - Minimal harm or potential for actual harm 02/13/2024 - Clonazepam (Schedule IV tablet) 0.5 mg (milligrams), amount: 0.5 mg orally BID (twice daily) at 2:00 p.m. and 8:00 p.m. for anxiety disorder, unspecified 02/13/2024 - Clonazepam (Schedule IV tablet) 1 mg, amount: 1 mg orally once a day at 9:00 a.m. for anxiety disorder, unspecified Residents Affected - Few 10/11/2023 - Lacks capacity 07/27/2023 - Antidepressants Fluvoxamine, Trazadone - Document each depression behavior per shift, every shift; day evening, and night. 06/09/2021 - Clonazepam behavior monitoring every shift; day, evening, and night (copy obtained) An interview was conducted with the Social Services Director (SSD), a licensed clinical social worker (LCSW), on 10/15/24 at 12:09 p.m. She stated nursing staff assisted her with completing resident assessments to identify a history of depression. Assessments were completed quarterly and as needed. If signs of depression were identified, the resident would be referred to the psychiatric team. A resident identified as having a newly evident or possible MD, ID or a related condition after admission would be assessed to ensure they had a disorder. Residents found to have a disorder were reported and referred to determine whether or not a PASRR Level II was needed. The SSD was responsible for ensuring that a referral was sent to the appropriate state-designated authority. Another interview was conducted with the SSD on 10/17/2024 at 11:39 a.m. She stated the facility was currently working through the process of identifying residents with a possible MD, ID or a related condition prior to admission to the facility, and she currently did not have access to the state-designated authority. She further stated the Director of Nursing (DON) could assist but she was currently away from the facility. An interview was conducted with the Administrator on 10/17/2024 at 12:28 p.m. She confirmed that the DON was responsible, but she was out of the facility, was not expected back next week, and the SSD was new to the facility and did not have access to the state-designated authority. A review of the facility's policy and procedure titled Social Service Practice Guidelines (effective date: 03/22/19), revealed: Standard: The facility will provide mental health and social services consistent with the resident care plan: PASRR: Social Services personnel who have a Master of Social Work (MSW) OR licensed in the State of Florida as a Clinical Social Worker (LCSW), or Mental Health Counselor (LMHC) are Delegated Level l screeners. Review all resident Pre-admission Screening and Resident Review (PASRR) for completeness and accuracy prior to a residents' admission to facility. If relevant PASRR information is missing, such as mental health diagnosis, then a new Level l, and Level ll if indicated, must be completed prior to admission. If the Level l must be completed promptly after discovery, within 72 hours. If the new Level l indicate that a Level ll is required, the nursing facility should complete a Resident Review (for significant change if applicable) and/or request a PASRR Level ll evaluation and determination within the provider portal (https://floridapasrr.kepro.com/). (copy obtained) According to the National Center for PTSD at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105840 If continuation sheet Page 4 of 11 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 10/17/2024 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few https://www.ptsd.va.gov/professional/treat/cooccurring/ncd_cooccurring.asp (Accessed on 10/31/24 at 2:25 p.m.), Research findings over the past decade have shown a connection between posttraumatic stress disorder (PTSD) and neurocognitive disorders (NCD) among older adults and survivors of traumatic brain injuries. NCD refers to the group of disorders in which the primary clinical concern is acquired cognitive impairment rather than developmental cognitive impairment. As cognitive deficit can occur in a number of domains (i.e., complex attention, executive function, learning and memory, language, perceptual-motor, and social cognition), the broader definition of NCD is also useful when decline occurs in a single domain, rendering the term dementia inaccurate (1). . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105840 If continuation sheet Page 5 of 11 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 10/17/2024 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 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that one (Resident #89) of a total survey sample of 31 residents, received care and services timely, in accordance with professional standards of practice, by failing to schedule physician-ordered magnetic resonance imaging (MRI). Failure to provide care timely poses a risk to residents' health due to delayed interventions. Residents Affected - Few The findings include: During a facility tour on 10/15/2024 at 10:39 a.m., Resident #89 was observed seated in his wheelchair outside his room. He asked to be put back in bed. He stated he was always sleepy and fatigued and did not know what was wrong with him. A review of the resident's medical record revealed that he was admitted to the facility on [DATE] with diagnoses including dementia, Parkinson's disease, psychotic disorders with hallucinations due to unknown physiological condition, major depressive disorder, anxiety disorder, insomnia, and other fatigue and tiredness. A review of the active physician's orders revealed orders for the following: 09/10/2024 - MRI of the brain related to Parkinson's disease 11/03/2022 - Nuplazid (atypical antipsychotic used for Parkinson's disease) 34 milligrams (mg) once a day (QD) and Levodopa - Carbidopa (Sinemet - combination medication/Dopamin promoter) 25 - 100 mg three times a day (TID) for Parkinson's disease. A Nursing Progress Note dated 09/10/2024 read, Neurology consult MRI without contrast and laboratory test sent order for the MRI and awaiting laboratory results. (Photographic copy obtained) In an interview on 10/16/2024 at 9:39 a.m., Registered Nurse ( RN) C was asked about Resident #89's MRI results. She said, There was an order for it but I don't think it's scheduled. When asked how nurses knew when residents had scheduled appointments, she replied that the scheduled date and time was normally added to the orders. She confirmed that there was nothing on the orders to indicate that the MRI was scheduled. She added that she would follow up with the unit manager and the unit secretary, as they were responsible for scheduling appointments. A follow-up interview was conducted on 10/16/2024 at 10:42 a.m. with RN C. She stated the unit manager had confirmed that the MRI had not been done and she had faxed it again. She stated the unit secretary was normally notified when an appointment was needed so she could follow up. RN C stated she had also asked the unit secretary about the order, and the unit secretary said that she was not aware of it. During an interview with the Administrator on 10/17/2024 at 4:01 p.m., she stated the facility utilized a community liaison to schedule resident appointments and that the unit clerks should follow up at least weekly to check on the status. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105840 If continuation sheet Page 6 of 11 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 10/17/2024 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on interviews and record review, the facility failed to provide food that accommodated resident preferences, by failing to provide options of similar nutritive value to residents who requested a different meal/snack choice for one (Resident #91) of four residents reviewed for nutrition, from a total survey sample of 31 residents. Resident #91, diagnosed with type 2 diabetes and blood sugar readings at times reaching 219 mg/dL, expressed a desire for sugar-free foods and snacks; however, they were not provided. The findings include: During a tour of the facility on 10/15/2024 at 10:27 AM, Resident #91 was observed sitting up in her bed fully dressed and watching television. She complained that the facility had no diabetic food or desserts, and she stated she had been asking for sugar free items. They push ice cream a lot. A review of the resident's medical record revealed an admission date of 09/12/2022 and diagnoses including type 2 diabetes mellitus w/other specified complications: chronic kidney disease, stage 4 (severe), and hyperglycemia. A review of the Quarterly minimum data set (MDS) assessment, dated 09/09/2024, revealed that Resident #91 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 possible points, indicating intact cognition. The assessment also documented that the resident was independent for eating. A review of Resident #91's care plan with a revision date of 09/11/2024, revealed the facility was to provide a regular diet and thin liquids as ordered, a scoop plate, and double vegetables. They were to monitor labs, monitor weight, and notify the medical doctor or registered dietitian. They were to determine and honor the resident's food preferences as much as possible. A review of the active physician's orders revealed the following orders: 09/24/2024 - Levemir U-100 Insulin 100 unit/ml (units per milliliter), 35 units subcutaneously once daily at 8:00 a.m. 08/02/2024 - Check expiration date of Levemir every Monday once a day on Monday 7:00 a.m.-3:00 p.m. 09/21/2023 - Diet: regular/thin liquids, scoop plate with all meals, double vegetables. A review of the resident's blood sugar readings from 09/17/2024 through 10/17/2024 revealed a range between 60 mg/dL - 219 mg/dL (milligrams per deciliter). (Photographic copies obtained) According to Medical News Today at https://www.medicalnewstoday.com/articles/type-2-diabetes-blood-glucose-levels-2 (Accessed on 10/31/24 at 3:15 p.m.): For individuals with T2D (type 2 diabetes), health experts recommend aiming to keep blood sugars between 80 and 130 milligrams per deciliter (mg/dL) before a meal and less than 180 mg/dL 2 hours after. According to the Centers for Disease Control and Prevention (CDC) at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105840 If continuation sheet Page 7 of 11 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 10/17/2024 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 0806 https://www.cdc.gov/diabetes/treatment/index.html (Accessed on 10/31/24 at 3:20 p.m.): Level of Harm - Minimal harm or potential for actual harm A blood sugar target is the range you try to reach as much as possible. These are typical targets: Before a meal: 80 to 130 mg/dL. Two hours after the start of a meal: Less than 180 mg/dL. Residents Affected - Few A quarterly nutritional review dated 06/12/2024 at 9:52 a.m. revealed a history of hypertension, hyperlipidemia, diabetes, congestive heart failure and cerebral vascular accident with right-sided weakness. Resident receives a regular diet with double veggies and is able to feed herself. Resident utilizes a scoop plate related to right-sided weakness. Resident documented meal intake is generally >75%. Resident generally avoids consuming desserts. A quarterly nutritional review dated 03/13/2024 at 9:24 a.m. revealed diagnoses including chronic kidney disease - stage 4, congestive heart failure, anemia, diabetes and hypertension. Resident receives a regular diet with double veggies and uses a scoop plate for dining independence. Resident generally consumes 75% or more of meals. She generally does not consume any sweet desserts related to her diagnosis of diabetes. In an interview with Consultant Certified Dietary Manager (CDM) G on 10/17/2024 at 3:15 p.m., she stated the facility provided low-concentrated sweets, no added salt, regular, mechanical, and pureed diets. When asked to explain Resident #91's diagnosis and diet, CDM G stated, She is alert and oriented and tolerates a regular diet. She eats in the dining room and selects what she wants. She avoids desserts. I have never recommended to change her diet. We try to liberalize the diets as much as possible. The residents and the medical doctor do their own thing. When asked whether she had consulted with the medical doctor regarding the resident's diagnosis and her diet, CDM G replied, No, her diet was written in 2023; that was before me. She should be on Low Concentrated Sweets but unless her blood sugars have been out of control, I would have left it alone. CDM G stated she talked to the resident about four months ago related to her weight. The resident asked for some diet items but did not complain about her diet. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105840 If continuation sheet Page 8 of 11 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 10/17/2024 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on kitchen food service observations, staff interviews, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility's nourishment rooms, by failing to seal and date mark open food products in the nourishment rooms, clean residue build up in the ice machine drain hose and coffee dispenser hood, and clean in and around the ice machine dispenser ports and tray. Food handling and sanitation are 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 10/16/2024 at 11:29 AM. During the tour, observations of the nourishment room on the Delta Hall unit revealed one jar of open peanut butter on the plastic bin shelf, and one open bundle of bread on the plastic bin shelf with no date marking. During the same tour, two open bundles of bread with no date marking were observed on the shelf on the Alpha Hall unit. Observations of the freezer, located in the nourishment room on the Alpha Hall unit, revealed one open carton of [NAME] vanilla ice cream tied in a plastic bag with no name or date marking, one open carton of vanilla ice cream, and one carton of strawberry ice cream tied together in a plastic bag with no name or date marking, one frozen ice cream bar with no name or date marking, and one frozen Drumstick ice cream with no name or date marking. Also, observations on the Alpha Hall unit nourishment room revealed brown residue build up in the ice machine drain hose connected to the sink, brown residue covering the coffee dispenser hood, lime scale-like build up around the coffee machine hot water dispenser nozzle, and lime scale-like build up in and around the ice machine dispenser ports and tray. On 10/17/24 at 1:36 PM, the same observations were made in the Alpha Hall unit nourishment room. (Photographic evidence obtained) During the kitchen tour on 10/16/2024 at 11:29 AM, an interview was conducted with the certified dietary manager (CDM). He confirmed that there were two nourishment rooms. Dietary staff and housekeeping shared responsibility for checking and cleaning the nourishment rooms. Housekeeping cleaned the refrigerators. Dietary staff stocked the nourishment rooms based on request. Snacks and supplements were provided to the unit on the snack cart. An interview was conducted on 10/17/2024 at 10:02 AM. with Dietary Aide D who stated she was not familiar with the facility's policy and procedure for date marking food, but when asked what happened when a food item was opened, used, and placed back on the shelf, she replied, Wrap, label, date, store in the refrigerator for 3-4 days then discard. When asked who was responsible for cleaning the nourishment rooms, she replied, The CNA (certified nursing assistant) delivers food on the cart to each nourishment room. Dietary staff check the refrigerator to ensure food is labeled. Employee D stated she did not know if there was a freezer. When asked who was responsible for checking and cleaning kitchen equipment in the nourishment room, she replied, Housekeeping checks and cleans the microwave and coffee maker. Housekeeping checks the nourishment rooms daily. Employee D was not sure how problems related to equipment in the nourishment rooms were reported. An interview was conducted on 10/17/24 at 10:24 AM with [NAME] E, who reported that when a food item was opened, used, and placed back on the shelf, it was wrapped, sealed, dated and labeled, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105840 If continuation sheet Page 9 of 11 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 10/17/2024 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 - Some discarded within three days. Dietary aides checked and stored the refrigerator and freezer in the nourishment rooms. Maintenance cleaned the ice machine. I think nursing maintains the equipment in the nourishment rooms. When there was a problem with equipment in the nourishment room, nursing or a dietary staff member reported it to the kitchen manager. An interview was conducted on 10/17/24 at 10:40 AM with Food Service Administrator F. She confirmed that when a food item was opened, used, and placed back on the shelf, the item was labeled with the open date, pull date, date used, expiration date, and was discarded after three days. The facility's policy was to label and date everything. When asked who cleaned the nourishment rooms, Employee F replied, Dietary visits daily, housekeeping cleans, and nursing staff logs temperatures of the refrigerator and freezer. Dietary stores food in the nourishment rooms. Housekeeping checks and cleans kitchen equipment in the nourishment room daily. Maintenance is responsible for cleaning the ice machine in the nourishment room. The ice machine is digital so it will alarm when it needs to be cleaned. When there is a problem with equipment in the nourishment room, nursing staff will report it to maintenance. If the coffee machine is not working, it is reported to Dietary. An interview was conducted on 10/17/24 at 10:57 AM with Consultant Certified Dietary Manager (CDM) G who confirmed that the facility's policy and procedure for date marking food was to label when opened and discard after three days. She reported that nursing staff cleaned and stored food in the nourishment rooms. She was not sure which staff member was responsible for cleaning and checking kitchen equipment in the nourishment rooms. She also was not sure who was responsible for cleaning the ice machine in the nourishment room, but when there was a problem with equipment in the nourishment room, the nursing staff reported it to maintenance via phone call or face-to-face. An interview was conducted on 10/17/24 at 1:36 PM with Regional Maintenance Employee H and the facility's Maintenance Director. Employee H stated Employee I was new to the facility. Employee H confirmed that Housekeeping cleaned nourishment rooms daily and Maintenance cleaned and checked the ice machine filter monthly. Employee H stated the drain hose was last checked on 7/25/2024. An interview was conducted on 10/17/24 at 1:42 PM with Housekeeping Employee J. She confirmed that Housekeeping was responsible for checking equipment in the nourishment rooms. Housekeeping and nursing staff checked the refrigerators and freezers. Housekeeping cleaned the cabinets and drawers. Maintenance checked equipment in the nourishment rooms. Housekeeping reported broken equipment to nursing staff, and nursing staff submitted work orders. A review of the facility's policy and procedure titled Cleaning Guidelines (dated 11/20/2017), revealed: Standard: The food service area shall be maintained in a clean and sanitary manner. 12. Ice machines and ice storage containers will be drained, cleaned and sanitized per manufacturer's instructions and regularly. Plastic ware, china and glassware that cannot be sanitized or are hazardous because of chips, cracks or loss of glaze shall be discarded. Damaged or broken equipment that cannot be repaired shall be discarded. A review of the facility's policy and procedure titled Foods Brought by Family/Visitors (dated 12/8/21) revealed: Standard: The facility will provide storage/refrigeration of limited amounts of food brought in by family and visitors . 7. Food items and snacks kept on the nursing units must be maintained as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105840 If continuation sheet Page 10 of 11 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 10/17/2024 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 - Some indicated below: b. All food belonging to residents must be labeled with the resident's name, the item and the use by date. (Copy obtained) Reference: FDA Food Code 2022 Annex 5. Conducting Risk-Based Inspections Annex 5 - C. Intervention Strategies for Achieving Long-term Compliance. 4. Establish First-In-First-Out (FIFO) Procedures. Page 31. https://www.fda.gov/media/164194/download (Accessed on 5/24/2024): Product rotation is important for both quality and safety reasons. First-In-First Out (FIFO) means that the first batch of products prepared and placed in storage should be the first one sold or used. Date marking foods as required by the Food Code facilitates the use of a FIFO procedure in refrigerated, ready-to-eat, TCS foods. The FIFO concept limits the potential for pathogen growth, encourages product rotation, and documents compliance with time/temperature requirements. Equipment, Utensils, and Linens. 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. 4-6 Cleaning of Equipment and Utensils, 4-601 Objective, Equipment Food-Contact Surfaces and Utensils. (A) Equipment Food Contact Surfaces and Utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105840 If continuation sheet Page 11 of 11