Inspection·June 22, 2023

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of a Provider/Practioner note, dated 6/14/2023 at 5:48 p.m., revealed the resident's oxygen saturation was 91% with the use of supplemental oxygen. On 06/21/23 at 10:00 a.m., an interview was conducted with Certified Nursing Assistant (CNA) E, who confirmed that nursing provided ongoing monitoring of Resident #11's oxygen therapy. The nurse was responsible for ensuring that the resident was receiving oxygen at the flow rate ordered by the physician. She stated Resident #11 did not refuse her oxygen therapy. CNA E was not sure if the resident had ever changed her own oxygen flow rate. On 06/21/23 at 10:12 a.m., accompanied by Licensed Practical Nurse (LPN) F, Resident #11's oxygen concentrator was observed to be set to administer oxygen at 3.5 L/min. (Photographic evidence obtained) LPN F confirmed that Resident #11's physician's order was for a flow rate of 3 L/min. Changes in Resident #11's condition regarding her respiratory care was communicated to the Unit Manager, Director of Nursing (DON), family and physician. Correct oxygen settings were identified on the MAR and communicated from one staff person to another verbally during shift reports. Resident #11 did not refuse oxygen or change her own oxygen flow rate settings. On 06/21/23 at 2:14 a.m., the DON confirmed that the correct oxygen settings were identified by reviewing the resident's physician's orders. A review of the facility's policy and procedure for Oxygen Administration (revised October 2010), revealed: Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 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: 105937 If continuation sheet Page 2 of 5 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 06/22/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility, by failing to complete temperature logs for the dish machine and ice cream box, properly clean and sanitize the kitchen ice machine, fryer, upper and lower-level of convection oven, can opener, oven tray lines, and grill; date mark numerous open food packages in the dry storage room, on the bread rack, under the food prep table, in the refrigerator, and in the freezer. Food handling and sanitation is 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 6/19/2023 at 11:20 a.m. During the tour, no temperature log for June 2023 was displayed for the ice cream box, and incomplete temperature logs for June 2023 were displayed for the dish machine and sanitizing sink. The bread rack next to the reach-in cooler had several open bundles of bread with no date markings. The prep table on the opposite side of the reach-in cooler had one open bin with onions and one open bin with potatoes, and two open boxes of bananas with no date markings. Expired milk was observed in the walk-in refrigerator along with no date marking on one open box of squash and one aluminum pan of tomatoes. No date markings were observed on one open package of veggie burgers, hamburgers, and a bag of french fries in the walk-in freezer. No date marking was observed on one open aluminum pan of hotdogs in the reach-in cooler next to the bread rack. In the dry storage room, there were no date markings observed on one bag of pecans, one bag of macaroni, or one jar of barbecue sauce. The ice machine located next to the serving line had black biological growth spots and a pink, slimy substance that were in close proximity to the internal chute of the ice machine. These same observations of the pecans, bread, and squash, were made again on 6/20/2023 at 10:14 a.m., 10:17 a.m., 10:19 a.m., and 10:32 a.m. (Photographic evidence obtained) A follow-up tour of the kitchen was conducted on 6/21/2023 at 10:55 a.m. The can opener pixel holder was greasy and filled with food debris. The inside, left and right door area of the top and bottom convection oven next to the grill was covered with grease buildup. The grill grate was filled with food debris and grease buildup, the grill tray was filled with ashes, the oven burners were filled with grease buildup, the oven tray and fryer tray were filled with food debris and grease, and another oven tray was filled with food debris and a liquid substance. Inside another oven, grime buildup was observed, the fryer next to the grill was covered with food debris and grease, and the oven side next to the fryer was filled with grease buildup. Observations were made of bread left torn open and bread with no date markings on the bread rack. Tubing on the drink machine was covered with black biological growth spots. (Photographic evidence obtained) An interview was conducted on 06/22/23 at 10:13 a.m. with Dietary Aide A. When asked who was responsible for documenting temperature logs in the dish room, she replied, the cook. When asked who was responsible for documenting temperature logs for the ice cream box, she replied, There is no specific staff, it is whoever is assigned to do it. When asked who was responsible for stocking the dry storeroom, she replied that she was not sure but sometimes the lead manager. When asked who was responsible for stocking the refrigerator and freezer, she replied, The staff that receives the delivery and puts up the food. She confirmed that the facility's policy for date marking was to date and use (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105937 If continuation sheet Page 3 of 5 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 06/22/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many opened products within 2-3 days. When asked what happened when a food item was opened, used, and placed back in the refrigerator or freezer, she replied, Opened food is sealed, labeled with the date opened and the expiration date. When asked what happened when bread was opened, used, and placed back on the bread rack, she replied that staff should check the expiration date. Once the bread was opened, staff were to label the package with the date opened and an expiration date. She stated she was unsure of the exact date. Opened bread is used fast. Dietary Aide A reported all staff were assigned cleaning tasks that were identified on a chore list. The can opener should be cleaned daily, and the cooks clean the kitchen equipment every 2-3 days or weekly. Sometimes Maintenance or the [NAME] would clean and sanitize the ice machine. She stated since her employment with the facility over the last nine months, she observed the ice machine being cleaned two times. An interview was conducted on 06/22/23 at 10:52 a.m. with [NAME] B, who stated the dishwasher was responsible for documenting temperature logs in the dish room. The Dietary Aide assigned was responsible for documenting temperature logs for the ice cream box. The Lead Manager or the staff assigned was responsible for stocking the dry storeroom and the refrigerator and freezer. He confirmed that the facility's policy for date marking was to label food items with the date opened and an expiration date. When a food item was opened, used, and placed back in the refrigerator or freezer it was labeled and dated. When bread was opened, used, and placed back on the bread rack, the bread was labeled and discarded after three days. The [NAME] cleaned kitchen and food service equipment every 3-4 days, and the grill was brushed daily. He stated the facility had an outside vendor who came to deep clean the kitchen equipment, but since the new ownership took over, there was currently no one scheduled to provide the deep cleaning. When asked how often the ice machine was cleaned, he replied, I don't remember how often it is cleaned or who cleans it. No one is really assigned to clean it. An interview was conducted on 06/22/23 at 11:11 a.m. with Dietary Aide C, who stated the staff member completing the task was responsible for documenting on the temperature logs. The prep staff was responsible for documenting on the temperature logs for the ice cream box. The staff assigned to put the truck delivery away was responsible for stocking the dry storeroom and refrigerator/freezer. She confirmed that the facility policy for date marking was to seal the food item, label the food item with the date received, date opened, and expiration date. Bread was to be wrapped, dated with the open and expiration date, and used by the 10th day. The cook was responsible for cleaning kitchen and food service equipment. When asked how often kitchen equipment was cleaned, she replied, They try to clean every night after dinner and deep clean weekly. She was unable to report when or how often the ice machine was cleaned, and stated any staff member could clean it. An interview was conducted on 06/22/23 at 11:31 a.m. with the Lead Food Service Assistant, who confirmed that the morning [NAME] was responsible for documenting on the temperature logs. Dietary Aides were responsible for documenting on the temperature logs for the ice cream box. Dietary Aides were responsible for stocking the dry storeroom and the refrigerator/freezer. She confirmed that the facility's policy for date marking was to date mark the item with a received date, opened date, and expiration date. When a food item was opened, used, and placed back in the refrigerator or freezer, the item was date marked with the day opened, the expiration date, and was discarded after seven days. The [NAME] was responsible for cleaning kitchen and food service equipment. Kitchen equipment was cleaned usually every night and Dietary Aides cleaned the ice machine two times per week. A review of the facility's policy and procedure for Cleaning and Sanitizing Dietary Areas and Equipment (Undated) revealed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105937 If continuation sheet Page 4 of 5 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 06/22/2023 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 0812 All kitchen areas and equipment shall be maintained in a sanitary manner and be free of buildup of food, grease, or other soil. The facility will provide sanitary foodservice that meets state and federal regulations. Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure for Sanitation of Ice Machine (Undated) revealed: Residents Affected - Many It is the policy of this facility that the ice machine shall be sanitized twice monthly by dietary. A review of the facility's policy and procedure for Food Receiving and Storage (dated July 2014) revealed: Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: 6. Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). Such foods will be rotated using a first in - first out system. 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). According to the 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 1/23/2023): Product rotation is important for both quality and safety reasons. First-In-First Out (FIFO) means that the first batch of product 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. Chapter 4. Equipment, Utensils, and Linens. 4-6 Cleaning of Equipment and Utensils, 4-601 Objective, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. 4-602.11 Equipment Food-Contact Surfaces and Utensils. Page 4-20. (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: 105937 If continuation sheet Page 5 of 5