Inspection·September 23, 2021

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of her annual minimum data set (MDS) assessment, dated 7/7/21, revealed the resident had a brief interview for mental status score of 14, indicating cognitively intact. She also required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. A review of Resident #11's current physician orders revealed the following: 5/16/2021: resting left hand splint- remove at hs.; 7/30/2021: PT (Physical Therapy) to eval and treat. (Physical Therapy Discharge summary dated [DATE]; 9/1/2021: ST (Speech Therapy) to eval and treat; 9/13/2021: Resident to wear left resting splint for 12 hours daily as tolerated, may remove for hygiene. Apply in am and off in 12 hours. (Copy obtained) A review of the resident's care plan with revision date of 8/11/21, revealed the following focus area: Resident has an ADL self-care performance deficit r/t activity impaired mobility, left side hemiplegia, left hand contracture, traumatic brain injury. Interventions included assistance with splint or brace PRN. Resident to wear left resting hand splint for 12 hours as tolerated may remove splint for hygiene, apply in am and off in 12 hrs. (Copy obtained) On 9/23/21 at 9:45 AM, Resident #11 was observed lying in her bed, dressed in day clothes. She stated, she was waiting for someone to come back to get her up. Her left arm did not have a splint in place. When she was asked if she would be wearing her left-hand splint today. She stated, I'd like to, but I don't know where it is. A visual sweep of her room did not reveal a splint in sight. Resident stated she hasn't seen or used her splint since she moved to this unit from the [NAME] unit, about a month ago. She stated when she was on the [NAME] Unit, her splint was kept on her bedside table, and she wore it daily. During the interview with Resident #11, Employee C, Certified Nursing Assistant (CNA)/Restorative Aide entered the room. When she was asked if she was caring for resident #11 today. She stated, I'm working with her for restorative this morning. When she was asked if she would be applying the resident's left-hand splint this morning. She stated, No, I don't think she has a splint, I haven't seen her wear one since I've been working with her. I think, I did see her wearing one when she was on the [NAME] unit, but that was before she was on the restorative program. Employee C stated that she works with Resident #11 Monday thru Friday, each day. When she was asked how long she had been performing restorative therapy with Resident #11. She stated, I started her restorative therapy on August 26 of this year. When she was asked who would apply the splint if she had one ordered. She stated, Usually the CNA would but if I see a splint isn't on when I am doing restorative, then I would apply it. When she was asked if she uses a [NAME] to guide the care the resident receives. She stated, Yes. A review of the [NAME] information for Resident #11 with Employee C revealed, Assistance with splint or brace PRN; resident to wear left resting hand splint for 12 hours daily as tolerated, may remove splint for hygiene- apply in am and off in 12 hours. Employee C confirmed that Resident #11 had not been wearing the hand splint and she should be. (Copy obtained) 2. A review of Resident #13's medical record revealed that he was admitted on [DATE]. His diagnoses included cellulitis of lower limbs, and osteoarthritis. A review of his quarterly MDS assessment, dated 7/7/21 revealed the resident had a BIMS score of 13, indicating cognitively intact. With limitation in range of motion on one side of upper and lower extremity. A review of resident's care plan revised on 9/6/21 revealed a need for restorative intervention to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105937 If continuation sheet Page 2 of 7 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 105937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center of Del 450 North McDonald Avenue Deland, FL 32724 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few prevent physical and functional decline with interventions for active range of motion to bilateral lower extremities all planes x 10-20 repetitions x 2 sets as tolerated. The functional maintenance plan for Resident #13 was reviewed and noted services for therapy ended on 8/3/21 with a recommendation for active range of motion on both lower extremities, all planes x 10-20 reps x 2 sets or as tolerated and the objective is for resident to maintain joint integrity on both lower extremities/range of motion on both lower extremities and maximum strength of both lower extremities. The physical therapy plan of care dated 8/2/21 was signed by the physician, and the discharge plan noted to remain in long term care with updated restorative nursing program. A review of the documentation for restorative revealed resident received services twice weekly on 9/7, 9/9, 9/15, 9/16, 9/20 and 9/22/21. On 9/21/21 at 9:22 AM, an interview and observation with Resident #13 was conducted in his room. He reported that therapy had finished, and he was receiving restorative for range of motion for both legs and it is hit and miss. He stated, the restorative CNA gets pulled to the floor to work an assignment, so he does not get the services. He reported the range of motion should be five days a week and he has never refused the restorative services. On 9/22/21 at 11:47 AM, an interview was conducted with Employee C, CNA/Restorative Aide. She reported that Resident #13 receives bilateral lower reps with 2 sets of 20 range of motion. She stated, It is ordered 5 times a week, but if I am working on the floor and have been assigned to resident care, I am unable to perform restorative duties. She reported she works Monday-Friday and once a week she is pulled from restorative to be a CNA on the floor. When she was asked what happens if a resident refuses, she replied If a patient refuses, I document and tell the nurse. If the resident refuses, I will go back in afternoon and try again, then report it. When she was asked if Resident #13 refuses restorative services, she replied, He never refuses restorative services but will refuse showers. On 9/22/21 at 3:12 PM, an interview was conducted with Employee D, MDS coordinator. After reviewing Resident #13's documentation for restorative services from 9/7-9/22/21, she confirmed, he only received the services twice a week instead of the 5 days as ordered. The documentation reviewed revealed services were provided on 9/7, 9/9, 9/15, 9/16, 9/20 and 9/22. On 9/23/21 at 10:00 AM, an interview was conducted with the interim DON. The DON stated, she had been at the facility for 1 week and was acclimating to the restorative program. The DON stated, she spoke to the CNA restorative aide, who confirmed she gets pulled to the floor at least once a week for resident care. When she was asked if there was a backup plan or if another CNA was available to provide the services. She replied, There is no back up plan, we only have 1 CNA on restorative that works Monday through Friday. The DON confirmed Resident #13 had received services 9/7, 9/9, 9/15, 9/16, 9/20 and 9/22 and not 5 days a week. The DON was asked about having a written physician order for the services and she stated, As a nurse, I like to have physician orders. The policy states we do not need a physician order. The time frame is 5 times a week for everyone on services. The policy says 7 days a week. I will be changing the restorative program. On 9/23/21 at 11:06 AM, an interview with Resident #13 was conducted in his room. He reported receiving restorative yesterday and stated, I really need the stretching, it helps with my pain. I hope, I can stay on restorative, and they do it five times a week like they are supposed to, I need it. A review of the facility policy and procedure titled, Restorative Nursing Care Policy and Procedure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105937 If continuation sheet Page 3 of 7 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 105937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center of Del 450 North McDonald Avenue Deland, FL 32724 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm revised 4/21/21 revealed the goal of restorative nursing care is to attain and maintain the maximum possible independence and or prevent rapid declines through the interventions for each resident. Under procedure it is noted restorative services should be seven days a week. . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105937 If continuation sheet Page 4 of 7 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 105937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center of Del 450 North McDonald Avenue Deland, FL 32724 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 and staff interviews, the facility failed to monitor resident behaviors and potential side effects related to the use of psychotropic medication for one (Resident #25) of five residents reviewed for unnecessary medications from a total of 20 residents in the sample. Residents Affected - Few The findings include: A record review for Resident #25 revealed she was admitted on [DATE], with the following diagnoses: urinary tract infection (UTI); unspecified dementia without behavioral disturbance; syncope and collapse; anxiety disorder; major depressive disorder; adjustment disorder with mixed anxiety and depressed mood. A review of physician orders on 6/11/21, revealed an order for Seroquel 25 mg (milligram) by mouth every 12 hours for dementia, depression, and delusional ideation. A review of Resident #25's medication administration records (MAR) for July through September 2021 revealed no behavior monitoring documentation and/or side effect monitoring documentation for the antipsychotic medication, Seroquel. A review of the medication record review (MRR) in August 2021 and September 2021 revealed a pharmacy recommendation to start antipsychotic monitoring on the MAR for Seroquel. On 9/22/21 at 2:52 PM, an interview was conducted with Employee A, Licensed Practical Nurse (LPN). She confirmed that Resident #25 had an order for Seroquel 25 mg every 12 hours. She added that the resident has displayed some behaviors, including excessive sadness, tearful, outbursts and anxiety. When she was asked about behavior monitoring, she stated it was in place, but she was unable to provide any documentation to show it was happening. On 9/22/21 at 3:54 PM, an interview was conducted with the Director of Nursing (DON). She verified there was no documented behavior monitoring for Resident #25 related to the use of Seroquel, and could not explain why the behavior monitoring was not a part of the MAR. On 9/23/21 at 11:32 AM, a follow up interview was conducted with the DON. The DON confirmed the pharmacist recommendation in August 2021 and September 2021 to add behavior monitoring for Resident #25 related to the use of Seroquel. She stated that the previous DON initialed that it was implemented in 8/2021, however, it was not. She added that all pharmacy recommendations are to be reviewed by the DON to ensure they are implemented. She once again confirmed there was no documented behavior monitoring for Resident #25. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105937 If continuation sheet Page 5 of 7 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 105937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center of Del 450 North McDonald Avenue Deland, FL 32724 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review and facility policy and procedure review, the facility failed to properly store medication in locked compartments, allowing only authorized personnel access to them for one (Resident #10) of 20 sampled residents, by leaving a medication cup with pills in it and a bottle of artificial tears on the resident's bedside table and failing to ensure the resident took the medications. The findings include: An interview was conducted with Resident #10 on 9/20/21 at 1:04 PM. During the interview, a clear pill cup containing one white oblong shaped tablet was observed on the resident's overbed table. Resident #10 stated it was a pain pill which she gets every four hours. She stated the nurse brings it to her, and then she takes it on her own as needed. On 9/21/21 at 2:29 PM, a second interview was conducted with Resident #10. During the interview, and a clear bottle of artificial tears was observed on the resident's overbed table. Resident #10 stated, she used the eye drops for her dry eyes. On 9/22/21 at 9:32 AM, the bottle of artificial tears was still at the bedside along with two (one black and one orange) unidentified round tablets. Resident #10 stated the pills were from the morning medications and were her iron and stool softener pill. She then stated, I'll take them later. A medical record review for Resident #10 revealed she was admitted on [DATE] and readmitted on [DATE] with diagnoses that included specified fracture of unspecified pubis, acute kidney failure, non-pressure chronic ulcer of unspecified part of right lower leg and essential hypertension. A review of the quarterly minimum data set (MDS) dated [DATE] revealed Resident #10 scored a 14 out of 15 on the brief interview for mental status (BIMS), indicating cognitively intact. A review of physician's orders for Resident #10 revealed Tylenol extra strength 500 mg by mouth three times a day, Methadone HCI tablet 2.5 mg by mouth every 12 hours, Mirtazapine 7.5 mg by mouth at bedtime, Artificial tears 1.4% instill 1 drop every four hours as needed, Acetaminophen extra strength 500 mg by mouth every four hours as needed. A review of Resident #10's medication administration record (MAR) for September 1st- 21st, 2021 revealed no documentation eye drops were given during this time. A review of the care plan for Resident #10, last revised on 8/31/21 revealed no documentation related to self-administration of medication. Further medical record review revealed no documentation an assessment for self-administration of medication was conducted for Resident #10. During an interview on 9/22/21 at 9:37 AM with Employee A, a Licensed Practical Nurse (LPN), she stated there are no residents currently in the facility who have been assessed and approved for self-administration of medication. When asked about Resident #10, she stated she leaves medication at her bedside because she takes her medications at her leisure. During the interview, Employee A reviewed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105937 If continuation sheet Page 6 of 7 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 105937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center of Del 450 North McDonald Avenue Deland, FL 32724 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the September 2021 MAR for Resident #10. It reflected all medications scheduled for 9:00 AM on 9/22/21 had been administered. When questioned if the resident had taken the medications, the LPN replied, she did not know and proceeded to the resident's room. Upon entering the room, the LPN observed medications and eye drops at bedside. Employee A questioned Resident #10 on why she had not taken the medications. When the resident replied that she would take them later, Employee A advised the resident that she would have to take the medications, or they would be discarded. When the resident refused to take the medications, Employee A discarded them in the sharp's container inside of the resident's room, leaving the eye drops on the over bed table. When asked if the eye drops were supposed to remain in the resident's room for self-administration, Employee A stated she didn't know if there was an order for the eyes drops. The nurse returned to the cart and verified there was an as needed order for the eye drops and stated they shouldn't be at bedside. During an interview on 9/23/21 at 10:32 AM with Employee B, the Clinical Learning Development Specialist, she stated that the MAR should not be updated prior to the medication administration. She also stated unless there is an order and/or an assessment for self-administration of medications, residents should not be allowed to administer their own medications and under no circumstances should medications be left at bedside. She stated that residents who self-administer medications must store their medications in a locked box provided by the facility. A review of the facility's policy and procedures on Resident Self-Administration of Medication with reviewed/revised date of 11/18/2020 revealed: Per procedures, The Resident Self-Administration of Medications user defined assessment (UDA) must be completed to determine if the resident can safely administer medications and to create a plan to assist the resident to be successful in this process. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105937 If continuation sheet Page 7 of 7