Inspection·September 28, 2023

F 0658 9/20/23: 123/36 Level of Harm - Minimal harm or potential for actual harm 9/21/23: 129/64 9/24/23: 157/66 Residents Affected - Few 9/25/23: 157/66 8/3/23: 121/70 8/4/23: 121/70 8/5/23: 121/70 8/6/23: 121/70 8/13/23: 128/68 8/14/23: 122/62 8/15/23: 136/63 8/26/23: 137/73 8/29/23: 122/68 8/30/23: 130/80 8/31/23: 130/80 7/2/23: 134/72 7/23/23: 122/70 7/24/23: 164/66 7/25/23: 128/72 7/26/23: 128/72 7/27/23: 128/72 7/28/23: 128/72 6/8/23: 135/65 6/14/23:126/60 6/15/23: 126/60 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105930 If continuation sheet Page 2 of 18 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 105930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Healthcare & Rehabilitation Center 120 Chipola Ave Deland, FL 32720 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 0658 6/16/23: 123/60 Level of Harm - Minimal harm or potential for actual harm 6/17/23: 123/60 6/18/23: 123/60 Residents Affected - Few 6/19/23: 123/60 6/20/23: 123/60 6/21/23: 123/60 6/22/23: 123/60 5/24/23: 134/78 5/25/23: 136/82 In an interview with the Director of Nursing on 9/28/23 at 8:05 a.m., she was asked if the facility had a policy regarding checking vital signs in accordance with medication administration. She stated, No, there is no separate policy, it's a professional standard to check the resident's vital signs if the doctor ordered to check them with the medication. Systolic Blood Pressure (SBP) is the top number of the blood pressure reading. According to Mayo Clinic, Midodrine is used to treat low blood pressure (hypotension). It works by stimulating nerve endings in blood vessels, causing the blood vessels to tighten. As a result, blood pressure is increased. (mayoclinic.org/drugs-supplements/midodrine-oral-route/description/drg-20064821 - accessed on 9/28/23 at 4:00 p.m.) A review of the facility's policy titled Standards and Guidelines: Medication Administration (revised 1/1/21) revealed: Standard: It will be the standard of this facility to administer medication in a timely manner and as prescribed by the physician, unless otherwise clinically indicated or necessitated by other circumstances such as lack of availability of medication or refusals of medication by the resident. Guidelines: 2. The Director of Nursing Services is responsible for the supervision and direction of all personnel with medication duties and functions. 3. Medications should be administered in a timely manner and in accordance with the physician's orders. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105930 If continuation sheet Page 3 of 18 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 105930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Healthcare & Rehabilitation Center 120 Chipola Ave Deland, FL 32720 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review, staff interview, and a review of the facility's policies and procedures, the facility failed to ensure that residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing for one (Resident #26) of 12 residents receiving pressure ulcer treatment, from a total sample of 28 residents. Residents Affected - Few The findings include: On 9/27/23 at 11:50 a.m., Registered Nurse (RN) A was observed preparing wound care supplies from the treatment cart for Resident #26. He dispensed Zinc Oxide 20% into a small medication cup. He was asked to explain the treatment order. He stated, It's Zinc Oxide ointment to his sacral area daily. RN A rubbed the Zinc Oxide ointment 20% on Resident #26's sacral area. The area was reddened and dusky in color. When RN A returned to the treatment cart, he was asked to look at the tube of Zinc Oxide ointment. He took it from the cart. He was asked what percent of Zinc Oxide the order was for. He stated, I'm not 100% sure; I know it's for Zinc. He was asked how he prepared for his wound care treatments. He stated he reviewed the orders in the computer in the morning and wrote the treatments on paper, then signed off all his treatments at the end of the day. He was asked to review the wound care order for Resident #26. Upon bringing the resident's orders up on the computer screen, RN A stated, Oh, the order states Zinc 10%. A review of Resident #26's medical record revealed a 9/22/23 physician's order that read: Zinc Oxide Ointment 10%: Apply to sacrum topically every day and evening shift for pressure wound and as needed. A review of Resident #26's September 2023 electronic treatment administration record (eTAR) revealed an order written on 9/22/23 for Zinc Oxide Ointment 10%: Apply to sacrum topically every day and evening shift for pressure wound and as needed. It was not signed off by nursing to indicate that the treatment had been administered on 9/22, 9/23, 9/24, 9/25, or 9/26. A review of the facility's policy and procedure for Standards and Guidelines for Wound care (revised 1/15/21), noted the standard of the facility was to provide assessment and identification of residents at risk of developing pressure ulcers using the following guidelines: Wound care procedures and treatments should be performed according to physician's orders and documented in the clinical record when treatments are performed. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105930 If continuation sheet Page 4 of 18 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 105930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Healthcare & Rehabilitation Center 120 Chipola Ave Deland, FL 32720 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 9/25/23 at 12:00 p.m., Resident #43 was observed lying in bed with her oxygen (02) concentrator set at 2 L/min. Oxygen was being delivered via nasal cannula (n/c). Residents Affected - Few On 9/26/23 at 9:00 a.m., Resident #43 was observed lying in bed awake with her O2 concentrator set at 2 L/min with oxygen being delivered via n/c. (Photographic evidence obtained) She was asked if she knew her O2 flow rate setting and whether she had ever changed her own oxygen setting. She stated, No, I can't reach that. The nurse does that. On 9/26/23 at 12:33 p.m., Resident #43 was observed lying in bed awake with her O2 concentrator set at 2 L/min with oxygen being delivered via n/c. (Photographic evidence obtained) On 9/27/23 at 8:25a.m., Resident #43 was observed lying in bed awake with her O2 concentrator set at 2 L/min with oxygen being delivered via n/c. (Photographic evidence obtained) LPN G entered the room to set up the resident's breathing treatment. She was asked what treatment the resident was receiving. She stated Ipratropium Albuterol. The nurse set up the breathing treatment and left the room without checking the resident's oxygen flow rate. On 9/27/23 at 8:41 a.m., LPN G was observed removing the resident's breathing treatment mask. She did not check the oxygen flow rate setting on the concentrator. It was set at 2 L/min. On 9/27/23 at 11:43 a.m., Resident #43 was observed lying in bed awake with her O2 concentrator set at 2 L/min with oxygen being delivered via n/c. (Photographic evidence obtained) On 9/28/23 at 5:34 a.m., Resident #43 was observed lying in bed with the head of her bed elevated. Her eyes were closed and her respirations were 18 per minute. Her nasal cannula was in place and her oxygen flow rate was set at 2 L/min. (Photographic evidence obtained) On 09/28/23 at 6:35 a.m., LPN D was asked if she was caring for Resident #43 this shift. She stated yes. She was asked who checked and monitored the oxygen settings for residents with oxygen ordered. She stated, the nurses do. She was asked how often oxygen rates/settings were checked. She stated, on rounds, every two hours. She was asked what Resident #43's oxygen setting orders were. She stated, I think it's 2 L/min. She was asked to confirm what the order was. She checked the physician's orders and stated, Oh, it's 3 L/min. She was asked to check the resident's flow rate setting. Upon entering the room and checking Resident #43's oxygen concentrator, the nurse stated, Oh, it's on 2 L/min right now. It's hard to see. I just changed it to 3 L/min. A review of the resident's medical record revealed an order dated 2/10/23 for Oxygen: 3 L/min via n/c with humidification every shift for Chronic Obstructive Pulmonary Disease (COPD). Further review of the medical record revealed a care plan: Focus (6/10/21, revised 9/11/23) The resident has altered respiratory status/difficulty breathing related to Congestive Heart Failure (CHF), COPD, sleep apnea. Goals: (revised 7/7/23) The resident will have no signs/symptoms of poor 02 absorption through the review date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105930 If continuation sheet Page 5 of 18 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 105930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Healthcare & Rehabilitation Center 120 Chipola Ave Deland, FL 32720 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Interventions: (7/1/21, revised 10/24/22) Oxygen settings: O2 @ 3 L/min per nasal cannula as ordered. Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure titled Oxygen Administration (revised 1/15/21) revealed: Standard: It is the standard of this facility to provide guidelines for safe oxygen administration. Residents Affected - Few Guidelines: 1. Verify there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration. 2. Review the resident's care plan for any special needs of the resident. 4. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter as is ordered by the physician, or required to provide for the needs of the resident. Based on observation, interview, and record review, the facility failed ensure that residents who needed respiratory care, received oxygen therapy as ordered for two (Residents #11 and #43) of 18 residents receiving oxygen therapy from a total sample of 28 residents. The findings include: 1. On 9/25/23 at 12:05 p.m., Resident #11 was observed lying in bed with the TV on, her eyes closed, and receiving oxygen via nasal cannula at 2.5 Liters per minute (L/min). (Photographic evidence obtained) A review of her medical record's active orders revealed a 2/9/23 physician's order for Oxygen at 2 L/min via nasal cannula every shift. Further review of the physician's orders revealed the following: A 2/9/23 order: Change oxygen tubing weekly and PRN (as needed) every night shift, every Sunday. A 2/9/23 order: Albuterol Sulfate Nebulization Solution (2.5 mg/3ml) 0.083%, 1 application inhale orally via nebulizer every 6 hours as needed for shortness of breath (SOB). A 2/9/23 order: Budesonide Inhalation Suspension 0.5 mg/2.0 ml (milligrams per milliliter), inhale orally two times a day for SOB. A 4/10/23 order: SPO2 every shift as needed for oxygen saturation. A 7/12/23 order: Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) mg/3ml, inhale orally every 6 hours for SOB. A 9/25/23 order: Continuous Positive Airway Pressure (CPAP) at bedtime for SOB and every 24 hours as needed for SOB. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105930 If continuation sheet Page 6 of 18 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 105930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Healthcare & Rehabilitation Center 120 Chipola Ave Deland, FL 32720 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm A 9/26/23 order: Bilevel Positive Airway Pressure (BIPAP) can be used intermittently if needed and in the morning remove BIPAP. A 9/26/23 order: Clean CPAP filter once a week, every night shift, every Sunday, and clean CPAP and water chamber every night shift. Residents Affected - Few On 9/25/23 at 2:23 p.m., another observation was made of Resident #11 lying in bed wearing her nasal cannula with the oxygen concentrator set at 2.5 L/min. (Photographic evidence obtained) On 9/26/23 at 11:13 a.m., another observation was made of Resident #11 lying in bed wearing her nasal cannula with an empty humidifier (turned off) and the oxygen concentrator set at 2.5 L/min. (Photographic evidence obtained) On 9/26/23 at 2:50 p.m., another observation was made of Resident #11 lying in bed wearing her nasal cannula with the oxygen concentrator set at 2.5 L/min. The humidifier was turned on and filled with water. (Photographic evidence obtained) A review of the medical record revealed that Resident#11 was readmitted to the facility on [DATE] with an initial admission date of 1/16/2022. Her diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease (COPD); congestive heart failure (CHF); morbid (severe) obesity with alveolar hypoventilation; generalized anxiety disorder, and cognitive/communication deficit. A review of the Quarterly Minimum Data Set (MDS) assessment, dated 6/30/23, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 possible points, indicating intact cognition. The resident was assessed and required extensive assistance with two people for bed mobility and toileting. Transfer activity did not occur. A review of the care plan, initiated on 1/25/23, revealed that the resident had altered respiratory status/difficulty breathing related to sleep apnea. Interventions included administering medication/puffers as ordered. Monitor for effectiveness and side effects, change oxygen tubing weekly and PRN, and oxygen settings: oxygen via nasal prongs at 2L (liters per minute) as ordered. A review of the Treatment Administration Record (TAR) for September 2023 revealed: Oxygen at 2 L/min via nasal cannula every shift for oxygen, start date: 2/9/2023. (Copy obtained) A review of a 9/27/23 progress note at 3:39 p.m. revealed, Resident daughter was in to visit resident and resident asked her to turn up her oxygen and she did. Resident informed us of this when asked and daughter confirmed it over the phone. Educated daughter and resident to call for nurse when assistance is needed. On 9/27/23 at 3:00 p.m., Licensed Practical Nurse (LPN) F confirmed that Resident #11's oxygen setting was supposed to be 2.0 L/min. She stated Resident #11 did not change her own oxygen settings and she did not refuse oxygen therapy. Resident #11 would like to wear her CPAP 24 hours, but she was ordered to wear it at night and have it off during the day. When asked who provided ongoing monitoring of the resident's oxygen therapy, LPN F replied, the nurse. When asked who was responsible for ensuring the resident's oxygen flow rate was set according to the physician's order, she replied, the nurse. Correct oxygen settings are identified by checking orders. The night shift nursing staff are responsible for changing residents' oxygen tubing. Correct settings are communicated from one staff person to another via shift report. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105930 If continuation sheet Page 7 of 18 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 105930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Healthcare & Rehabilitation Center 120 Chipola Ave Deland, FL 32720 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 9/27/23 at 4:47 p.m., the Director of Nursing (DON) was asked how correct oxygen flow rate settings were communicated from one staff member to another. She replied, by checking the order in computer. On 9/28/23 at 9:04 a.m., a telephone interview was conducted with Resident #11's responsible party. She verified that her sister was at the facility visiting Resident #11 on Wednesday, 9/27/23, and accidentally hit the oxygen concentrator, readjusting the setting. She confirmed that her sister was not at the facility on Monday or Tuesday, 9/25/23 or 9/26/23. A review of the facility's policy and procedure titled Standards and Guidelines: Oxygen Administration, Manual-Nursing-Pulmonary (reviewed/revised: 01/15/2021) revealed: Guidelines: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105930 If continuation sheet Page 8 of 18 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 105930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Healthcare & Rehabilitation Center 120 Chipola Ave Deland, FL 32720 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to ensure that it's medication error rate was not 5% or greater. There were two errors with 28 opportunities for error resulting in an error rate of 7.14% and affecting one (Resident #74) of eight residents observed during medication administration. Residents Affected - Few The findings include: On 9/26/23 at 9:30 a.m., Licensed Practical Nurse (LPN) B was observed preparing medications for Resident #74. LPN B administered the oral medications first, then set up a nebulizer inhalation treatment: Budesonide Inhalation: 0.5 milligrams (mg)/2 milliliters (ml) suspension. LPN B placed the inhalation mask over the resident's mouth and nose. She then told the resident she would return in 10 minutes to remove the mask. After 10 minutes had passed, LPN B returned and removed the mask. She was asked if she had completed medication administration for Resident #74. She stated yes. LPN B did not offer Resident #74 water or instruct her to rinse her mouth and spit after completing the inhalation treatment. In an interview with Resident #74 on 9/26/23 at 9:45 a.m., she was asked if staff ever assisted or instructed her to rinse her mouth with water and spit the water out after receiving an inhalation treatment. She stated no. Budesonide is a steroid-based inhalation medication for which professional standards of administering include educating and assisting the patient to rinse their mouth with water after each dose and spit the water out. Rinse your mouth with water and spit out the water. Do not swallow the water. This helps prevent hoarseness, throat irritation, and infections in the mouth. (www.mayoclinic.org/drugs-supplements/budesonide-inhalation-route/proper-use/drg-20071233 - Accessed on 9/26/23 at 10:30 a.m.) On 9/26/23 at 12:50 p.m., while reconciling the medications given to Resident #74, it was observed on the electronic Medication Administration Record (eMAR) that Formoterol Fumarate inhalation nebulizer solution 20 micrograms (mcg)/2 milliliters (ml): Inhale 2 ml twice a day was signed off as having been administered at 9:00 a.m. on 9/26/23. This medication was not observed as having been administered to Resident #74 during the morning medication administration observation. In an interview with LPN B on 9/26/23 at 12:55 p.m., she was asked if she had administered the Formoterol Fumarate inhalation nebulizer solution to Resident #74 this morning. She stated, No, I haven't given it yet, the two nebulizers are given separately, the second one is in the fridge, the Formoterol. She was asked if she had signed it off as given at 9:00 a.m. today. She stated Yes, I'm going to get it now and give it to her. A review of the facility's policy titled Standards and Guidelines: Medication Administration (revised 1/1/21) revealed: Standard: It will be the standard of this facility to administer medication in a timely manner and as prescribed by the physician, unless otherwise clinically indicated or necessitated by other circumstances such as lack of availability of medication or refusals of medication by the resident. Guidelines: 3. Medications should be administered in a timely manner and in accordance with the physician's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105930 If continuation sheet Page 9 of 18 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 105930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Healthcare & Rehabilitation Center 120 Chipola Ave Deland, FL 32720 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 orders. Level of Harm - Minimal harm or potential for actual harm 7. After successfully identifying the resident to receive the medication administration, the individual administering the medication should ensure that the right medication, right dosage, right time, and right method of administration are verified. Residents Affected - Few 13. When the medications are administered, the individual administering the medication must record in the resident's medical record/MAR. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105930 If continuation sheet Page 10 of 18 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 105930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Healthcare & Rehabilitation Center 120 Chipola Ave Deland, FL 32720 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on staff interviews, medical record review, and facility policy and procedure review, the facility failed to ensure its residents remained free of significant medication errors. This impacted one (Resident #74) of eight residents observed during medication administration, out of 28 residents in the total sample. Resident #74 received medication for low blood pressure outside of the ordered parameters for 44 of 128 doses administered. Residents Affected - Few The findings include: During medication reconciliation completed for Resident #74, an order was reviewed, which read: Start date 5/23/23: Midodrine 5 milligrams (mg): Give 5 mg by mouth one time a day for low blood pressure; hold if systolic blood pressure is greater than 120. Further review of the medical record included the Electronic Medication Administration Record (eMAR), which revealed this medication was signed off as having been administered 44 times when the SBP was recorded above 120 mmhg (millimeters of mercury), out of 128 doses signed off as administered from the resident's date of admission through the date of medication reconciliation. The record review revealed a SBP greater than 120 on the following dates: 9/1/23: 142/81 9/2/23: 142/81 9/4/23: 142/81 9/5/23: 140/75 9/6/23: 140/75 9/7/23: 137/74 9/11/23: 124/64 9/13/23: 128/60 9/14/23: 153/47 9/15/23: 129/58 9/20/23: 123/36 9/21/23: 129/64 9/24/23: 157/66 9/25/23: 157/66 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105930 If continuation sheet Page 11 of 18 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 105930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Healthcare & Rehabilitation Center 120 Chipola Ave Deland, FL 32720 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 0760 8/3/23: 121/70 Level of Harm - Minimal harm or potential for actual harm 8/4/23: 121/70 8/5/23: 121/70 Residents Affected - Few 8/6/23: 121/70 8/13/23: 128/68 8/14/23: 122/62 8/15/23: 136/63 8/26/23: 137/73 8/29/23: 122/68 8/30/23: 130/80 8/31/23: 130/80 7/2/23: 134/72 7/23/23: 122/70 7/24/23: 164/66 7/25/23: 128/72 7/26/23: 128/72 7/27/23: 128/72 7/28/23: 128/72 6/8/23: 135/65 6/14/23:126/60 6/15/23: 126/60 6/16/23: 123/60 6/17/23: 123/60 6/18/23: 123/60 6/19/23: 123/60 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105930 If continuation sheet Page 12 of 18 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 105930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Healthcare & Rehabilitation Center 120 Chipola Ave Deland, FL 32720 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 0760 6/20/23: 123/60 Level of Harm - Minimal harm or potential for actual harm 6/21/23: 123/60 6/22/23: 123/60 Residents Affected - Few 5/24/23: 134/78 5/25/23: 136/82 In an interview with the Director of Nursing on 9/28/23 at 8:05 a.m., she was asked if the facility had a policy regarding checking vital signs in accordance with medication administration. She stated, No, there is no separate policy, it's a professional standard to check the resident's vital signs if the doctor ordered to check them with the medication. In an interview with the Advanced Practice Registered Nurse (APRN) on 9/28/23 at 11:42 a.m., she was asked about the Midodrine order for Resident #74. She stated, I came here at the end of July. I believe she's (Resident #74) had some transient hypotension with periodic blood pressure drops. She hasn't had any hypotension since August, so I will discontinue the Midodrine and see how she does. Systolic Blood Pressure (SBP) is the top number of the blood pressure reading. According to Mayo Clinic, Midodrine is used to treat low blood pressure (hypotension). It works by stimulating nerve endings in blood vessels, causing the blood vessels to tighten. As a result, blood pressure is increased. (mayoclinic.org/drugs-supplements/midodrine-oral-route/description/drg-20064821 - accessed on 9/28/23 at 4:00 p.m.) According to Drugs.com at www.drugs.com/mtm/midodrine.html - Accessed on 9/28/23 at 4:00 p.m.), Midodrine can increase blood pressure even when you are at rest. Midodrine should be used only if you have severely low blood pressure that affects your daily life. Your blood pressure will need to be checked before and during treatment with midodrine. Check your blood pressure while you are lying down, and check it again with your head elevated. Follow all directions on your prescription label. Do not take midodrine in larger or smaller amounts or for longer than recommended. Midodrine can increase your blood pressure even while you are lying down or sleeping (when blood pressure is usually lowest). Long-term high blood pressure (hypertension) can lead to serious medical problems. A review of the facility's policy titled Standards and Guidelines: Medication Administration (revised 1/1/21) revealed: Standard: It will be the standard of this facility to administer medication in a timely manner and as prescribed by the physician, unless otherwise clinically indicated or necessitated by other circumstances such as lack of availability of medication or refusals of medication by the resident. Guidelines: 2. The Director of Nursing Services is responsible for the supervision and direction of all personnel with medication duties and functions. 3. Medications should be administered in a timely manner and in accordance with the physician's orders. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105930 If continuation sheet Page 13 of 18 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 105930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Healthcare & Rehabilitation Center 120 Chipola Ave Deland, FL 32720 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 0760 . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105930 If continuation sheet Page 14 of 18 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 105930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Healthcare & Rehabilitation Center 120 Chipola Ave Deland, FL 32720 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, staff interviews, and a review of the facility's policy and procedure for Standards and Guidelines for Wound Care, the facility failed to ensure that resident medical records were complete and accurately documented, in accordance with accepted professional standards and practices, for two (Residents #65 and #26) of 12 residents receiving pressure ulcer treatment, from a total sample of 28 residents. The findings include: 1. An observation of Resident #65 was made on 9/25/23 at 3:00 p.m. She was observed lying in bed with an air mattress, positioned with pillows. The resident's medical record was reviewed and revealed that she was admitted to the facility on [DATE]. Her diagnoses included the following: mild protein calorie malnutrition, unspecified contact dermatitis, and osteomyelitis of sacral and sacracoccygeal region. Her care plan was reviewed and noted that she had a pressure ulcer of the sacral area which reopened in December 2022. A 9/27/23 physician's treatment order was reviewed which revealed: Cleanse and rinse sacrum with Dankins for odor control, apply Metronidazole gel 1% and collagen powder, and cover with silicone foam border daily and as needed. The September 2023 Treatment Administration Record (TAR) was reviewed, which revealed that treatments were not signed off as having been provided by nursing on September 4, 6, 9, 12, or 14. A review of the progress notes revealed no wound care documentation on the days the pressure ulcer treatment verification was missing on the TAR. An interview was conducted with Licensed Practical Nurse (LPN) E on 9/28/23 at 11:00 a.m. She reported that dressing changes were sometimes performed by the nurses and were documented on the TAR after completion. An interview was conducted with RN A on 9/28/23 at 11:55 a.m. He reported dressing changes were documented on the TAR after completion. He reviewed the September 2023 TAR for Resident #65 and confirmed the missing initials to verify that treatment had been provided in September on the dates previously mentioned. A review of the facility's policy and procedure for Standards and Guidelines for Wound care (revised 1/15/21), noted the standard of the facility was to provide assessment and identification of residents at risk of developing pressure ulcers with the following guidelines: Wound care procedures and treatments should be performed according to physician's orders and documented in the clinical record when treatments are performed. An interview was conducted with the Director of Nursing (DON) on 9/28/23 at 12:23 p.m. The DON stated documentation of wound treatments should be documented on the TAR. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105930 If continuation sheet Page 15 of 18 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 105930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Healthcare & Rehabilitation Center 120 Chipola Ave Deland, FL 32720 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. A review of Resident #26's medical record revealed a 9/22/23 physician's order that read: Zinc Oxide Ointment 10%: Apply to sacrum topically every day and evening shift for pressure wound and as needed. A review of Resident #26's September 2023 electronic treatment administration record (eTAR) revealed an order written on 9/22/23 for Zinc Oxide Ointment 10%: Apply to sacrum topically every day and evening shift for pressure wound and as needed. It was not signed off by nursing to indicate that the treatment had been administered on 9/22, 9/23, 9/24, 9/25, or 9/26. On 9/28/23 at 8:30 a.m. during an interview with RN A, he was asked why the Zinc Oxide treatment had not been signed off as having been completed on seven occasions in September 2023. He stated whoever provided the treatment should have signed it off in the record. He stated the expectation was that treatments were to be signed off after completion. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105930 If continuation sheet Page 16 of 18 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 105930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Healthcare & Rehabilitation Center 120 Chipola Ave Deland, FL 32720 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and a review of the facility's policies and procedures for Infection Control and Guidelines for Wound Care, the facility failed to prevent the potential development and transmission of infection by not following infection prevention techniques during a wound dressing change for one (Resident #65) of three residents observed during wound care, from a total sample of 28 residents. Residents Affected - Few The findings include: An observation of Resident #65 was made on 9/25/23 at 3:00 p.m. She was observed lying in bed with an air mattress, positioned with pillows. The resident's medical record was reviewed and revealed that she was admitted to the facility on [DATE]. Her diagnoses included the following: mild protein calorie malnutrition, unspecified contact dermatitis, and osteomyelitis of sacral and sacrococcygeal region. Her care plan was reviewed, and it noted that she had a pressure ulcer of the sacral area which reopened in December 2022. A 9/27/23 physician's treatment order was reviewed which revealed: Cleanse and rinse sacrum with Dakin's (antiseptic solution) for odor control, apply Metronidazole gel 1% and collagen powder, and cover with silicone foam border daily and as needed. An interview with Registered Nurse (RN) A was conducted on 9/27/23 at 2:30 p.m. He stated the resident's wound was improving. The wound care physician saw her weekly and had changed treatments multiple times. RN A stated the resident had a large wound on her sacrum which was a Stage IV. The order for the treatment was reviewed and supplies were gathered. RN A washed his hands and applied gloves. Two staff members were holding the resident on her right side. The old dressing was removed by RN A. He did not remove his gloves and wash his hands after removing the old dressing. Instead, he proceeded to clean the wound with antiseptic solution, then applied Metronidalzole 1%, which was mixed with collagen powder. He then applied a gauze dressing and a border dressing. The dressing was dated. He then closed a red biohazard bag with supplies and the old dressing, wash his hands and took the bag to the soiled utility room. He washed his hands again and asked how he did. When he was asked about his process of removing the soiled dressing, cleansing the wound and applying a new dressing, he confirmed that he did not wash his hands or change gloves after removing the soiled dressing. A review of the facility's policy and procedure: Nursing Infection Control (dated 1/15/21), revealed that gloves should be changed during patient care when moving from a contaminated body site to a clean body site. A review of the facility's policy and procedure: Standards and Guidelines for Wound Care (revised 1/15/21) revealed that the standard of the facility was to provide assessment and identification of residents at risk of developing pressure ulcers using the following guidelines: Wound care treatment should maintain proper technique as indicated by the type of wound and physician orders. An interview was conducted with the Director of Nursing (DON) on 9/28/23 at 12:23 p.m. The DON reported when staff were changing dressings, going from soiled to clean and removing old dressings, gloves should be removed, hands should be washed and new gloves should be donned. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105930 If continuation sheet Page 17 of 18 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 105930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Healthcare & Rehabilitation Center 120 Chipola Ave Deland, FL 32720 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105930 If continuation sheet Page 18 of 18