Inspection·April 2, 2025

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few major life activities that would otherwise be appropriate for the individual's developmental stage. It further documented the concentration, persistence, and pace: The individual has serious difficulty in sustaining focused attention for long enough period to permit the completion of tasks commonly found in work settings or in work-like structured activities occurring in school or home settings, manifests difficulties in concentration, inability to complete simple tasks within an established time period, makes frequent errors, or requires assistance in the completion of these tasks. The form documented that the resident had a related neurocognitive disorder. And finally, the form, dated and signed on 07/17/2024 at 1:30 PM, documented that the MSW spoke to Resident #6's legal guardian, who consented to the information being shared. On 04/02/2025 at 2:25 PM, the Administrator provided a copy of the resident's Florida PASRR Level II Receipt of Referral Packet Notice of Missing Required Documentation sent to the facility and dated 07/31/2024. The letter read, We have received a referral to complete a PASRR Level II Review on [Resident #6]. In order to complete the PASRR Level II evaluation and determination, we ask that you send a copy of the following required documents: - Informed Consent - Minimum Data Set (MDS) - Patient Transfer/Continuity of Care (3008) - Relevant Case Notes/Records of Treatment The letter further noted, This information should be sent to us within five business days from the date of this notice. If the information is not submitted within the requested timeframe, we will close the request. During an interview with the Administrator on 04/02/2025 at 2:25 PM, he stated, I couldn't find anything in our system other than the copy of the Florida PASRR Level II Receipt of Referral Packet Notice of Missing Required Documentation, dated 07/31/2024. He explained that he was not aware of whether or not any of the requested documentation for a Level II PASRR for Resident #6 was submitted, and he would need to check with the Director of Social Services when the employee returned from leave. The Administrator also noted that the facility did not have a policy and procedure for PASRR. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105937 If continuation sheet Page 2 of 19 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 04/02/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to develop comprehensive care plans that included measurable objectives and timeframes to meet residents' medical, nursing, mental, and psychosocial needs for four (Residents #1, #40, #24 and #31) of 30 residents reviewed for care planning from a total survey sample of 30 residents. The findings include: 1. On 3/30/25 at 11:30 AM, Resident #1 was observed in bed with a pressure relieving mattress, catheter bag hanging at bedside, bilateral boots to prevent pressure wounds, and a peripherally inserted central catheter (PICC) line in the left upper arm. A review of the medical record revealed that Resident #1 was initially admitted on [DATE]. On 2/21/25, he had an unplanned discharge to an acute care hospital with return anticipated. On 3/1/25, he was readmitted from the hospital. Resident #1's diagnoses included multiple sclerosis, contractures of both knees, pressure ulcer of the left buttocks-Stage 4, chronic pain, hydronephrosis, dementia, history of transient ischemic attack (TIA), extended spectrum beta lactamase (ESBL) resistance and sepsis. A review of the quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/4/25 revealed that the resident had a brief interview for mental status (BIMS) score of 15 out of 15 possible points, indicating intact cognition. No behaviors were noted including refusal of care. The resident required a mechanical lift and two-person assistance with care activities. A review of the physician's orders dated 3/1/25 revealed: Methocarbamol Oral Tablet 500 milligrams (mg), 2 tablets four times a day (QID) (muscle relaxant) Rivaroxaban Oral Tablet 20 milligrams (mg), 1 tablet daily (QD) (anticoagulant) Primidone Oral Tablet 50 milligrams (mg), 1 tablet daily (QD) (anticonvulsant) Lasix (anti-diuretic) Oral Tablet 40 milligrams (mg), 1 tablet every other day (QOD) (diuretic) Occupational Therapy (OT) clarification order: OT evaluation and treatment 5 x week for self -care. ADLs (activities of daily living), therapeutic activities, neuromuscular re-education in order to return to prior level of function (PLOF). Suprapubic catheter care every shift, cleanse site and replace t-sponge. Flush PICC Line: Flush lumens every 12 hours with 10 ml (milliliters) normal saline. Catheter: Suprapubic catheter 18 FR (French) with 10 cc (cubic centimeter) balloon to dependent drainage. Change catheter monthly, PRN (as needed) if dislodged or plugged and unable to clear with irrigation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105937 If continuation sheet Page 3 of 19 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 04/02/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Scrotum MASD (moisture-associated skin damage) wound treatment as follows: Clean with NS (normal saline). Pat apply silver sulfadiazine 1% cream. Leave open to air. IV - Dressing Change - PICC transparent dressing change every week and as needed (PRN). A review of the resident's care plan (start date 3/4/25, target completion date 3/11/25) revealed no focus area, goals, or interventions for prescribed diuretic or anticoagulant medication. There were no focus areas, goals, or interventions for a PICC line, urinary catheter care, or MASD. In a 4/2/25 interview at 12:05 p.m. with Licensed Practical Nurse (LPN) A/Minimum Data Set (MDS) Coordinator, she explained that the care plan goals were derived from diagnoses, physicians' orders, and any pertinent information obtained from residents' records. She stated the purpose of the care plan was to enhance resident-centered care. She was asked to review Resident #1's care plan for anticoagulants, diuretics, PICC line , catheter and MASD. After opening the resident's record she said, Oh, this is incomplete; it should be more than two pages. There are goals that are missing interventions. She confirmed that there was no care plan in the resident's record for a PICC line, urinary catheter, diuretic, anticoagulant, or MASD. She stated she would expect all those issues and medications to be care planned. During a 4/2/25 interview at 12:39 p.m. with LPN E/Unit Manager, she stated during daily clinical meetings, all new admissions' records were reviewed to ensure the documentation was complete. She further stated the clinical team also reviewed order listings for new orders, risk management notes, and updated the care plan. 2. A review of Resident #40's medical record revealed an admission date of 2/18/24. The resident's medical diagnoses included Parkinson's disease without dyskinesia (involuntary, uncontrolled muscle movements), without mention of fluctuations and depression. A review of the 5-day MDS assessment, dated 3/3/25, revealed a BIMS score of 15/15, indicating intact cognition. Medications included injections on one of seven days, as well as antianxiety, antidepressant, anticoagulant, and antibiotic medications received during the assessment period. A review of Resident #40's active physician's orders revealed: Hydrocodone-acetaminophen (combination opioid-over-the-counter analgesic pain medication) oral tab 7.5-325 mg, give 1 tablet by mouth every 6 hours as needed for moderate pain (2/18/2025) Document pain on scale 0-10 every shift for monitoring. Provide pain medication and/or non-pharmaceutical pain relief per order as needed (2/19/2025) Apixaban (anticoagulant) oral tab 5 mg, give 1 tablet by mouth two times per day for deep vein thrombosis prophylaxis (2/19/2025) Behavior monitoring: daytime sleepiness; difficulty concentrating; fatigue; irritability; aggressiveness every shift behavior monitoring due to use of hypnotic medication (2/19/2025) Mirtazapine (antidepressant) oral 1 tablet 15 mg by mouth at bedtime related to depression, unspecified (2/21/2025) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105937 If continuation sheet Page 4 of 19 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 04/02/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Lorazepam (benzodiazepine) oral tablet 0.5 mg, give 1 tablet by mouth every 24 hours as needed at bedtime for anxiety and insomnia (3/7/2025) DNR (do not resuscitate) (3/3/2025) A review of the resident's care plan (revision date 3/11/25) revealed no focus areas, goals or interventions for the resident's use of anticoagulant, opioid, antidepressant, or benzodiazepine medications. (Copy obtained) A review of the March 2025 and April 2025 medication administration records (MARs) and treatment administration records (TARs) revealed that medications were provided as ordered; however, no behavior monitoring was located in the records. During an interview on 4/2/25 at 11:50 a.m. with LPN A/MDS Coordinator, she stated she updated care plans by reviewing the residents' hospital records or medical records, through resident and family meetings, and by reviewing the physicians' orders. Nursing completed the initial baseline care plan. The MDS department scheduled care plan meetings. They usually occurred at three weeks. When the resident's MDS assessment was completed, the care plan opened up and was subsequently completed in the resident's record. The baseline care plan was completed on paper. When asked how she ensured that all care plans were complete, LPN A replied that was accomplished through audits. There was a review date and target complete date that she monitored. She also monitored input from other departments. She signed off the completion of the care plan during the care plan meeting with the families and/or residents. Care plan meetings were held on Tuesdays. Residents were added to the care plan schedule. The purpose of the care plan was to ensure that all staff were on the same page and understood the residents' needs. The care plan was due for completion seven days after the MDS assessment was closed. Staff knew specific interventions that should be implemented related to a resident's care and services by either the baseline care plan or the care plan or kardex system. LPN A was asked to identify where Resident #40's care plan addressed specific care, services, and interventions for his use of anticoagulant, opioid, antidepressant, and benzodiazepine medications, as well as for pain management. LPN A confirmed there were no care plans for these medications or for pain management. When asked who reviewed the MDS assessments, LPN A stated the Director of Nursing (DON) reviewed and signed off on them. The MDS department would let the Director of Nursing know that the MDS assessments were ready to be reviewed and signed. During a 4/2/25 interview with LPN B at 12:05 p.m., she stated she was responsible for monitoring her residents' behavior. Certified Nursing Assistants (CNAs) reported anything they saw/heard, and nursing documented what was reported, then observed the resident, placed interventions, and notified the physician or members of the interdisciplinary team. Nursing was able to find a resident's specific care, services and interventions on the resident's MAR/TAR. Resident behaviors were documented in the electronic medical record (EMR) on a progress note or in the 24-hour report. When she was asked to point out where Resident #40's behavior monitoring was being documented, she stated there was no supplementary information added to the order, so no information was showing on the TAR for behavior monitoring. When she was asked how she knew a resident's behavior was being monitored, she replied that if Resident #40 had a behavior issue reported, it would have been documented in the progress notes. 3. On 3/30/25 at 2:00 p.m., Resident #24 was observed lying in bed. When she was greeted and asked how she was doing, she stated, I'm feeling better after a few days of vomiting and not feeling well. She was asked if she had eaten her lunch. She replied, No, I haven't had much of an appetite, but I (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105937 If continuation sheet Page 5 of 19 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 04/02/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was able to eat some of my breakfast. She was asked if she was currently taking antibiotics. She replied, Yes, I am taking antibiotics after being so sick the other day. On 3/31/25 at 12:38 p.m, a record review revealed that Resident #24 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus - type II. The resident had a documented fever on 3/28/25, and experienced nausea and vomiting with symptoms that started on 3/27/25. A review of the quarterly MDS assessment, dated 12/27/24, revealed the resident had a BIMS score of 10/15, indicating moderate cogniitve impairment, and received insulin injections, antidepressant, diuretic, and antibiotic medications during the assessment period. On 3/31/25 at 12:46 p.m., a review of the resident's care plan revealed the following focus areas: Focus: Impaired cognitive function/dementia or impaired thought processes related to current health status (initiated 3/27/24, revised 3/13/25) Focus: Diabetes mellitus (initiated 4/1/24, revised 10/2/24) Focus: Altered respiratory status - requires oxygen (initiated 5/30/24, revised 3/13/25) There was no care plan related to the new onset symptoms of nausea/vomiting or fever (102.1 on 3/28/25), or initiation of antibiotic use for indication of fever. On 3/31/25 at 12:55 p.m., a review of the resident's active physician's orders revealed: Does the resident have nausea, vomiting, loss of appetite, or diarrhea? Conduct temperature check after meals and at bedtime for Infection Control (3/31/25) RSV (Respiratory Syncytial Virus), UA (Urinalysis) with reflex to C&S (culture and sensitivity), Sent uncollected 3/31/25 3:57 PM, one time only related to muscle weakness, generalized (3/28/25) CBC w/diff (Complete Blood Count with differential), CMP (Comprehensive Metabolic Panel), Waiting to be sent, one time only related to muscle weakness, generalized (3/28/25) Ceftriaxone Sodium Injection Solution Reconstituted 1 gram, inject 1 gram intramuscularly one time a day for fever for four days (3/29/25 - 4/2/25). On 3/31/25 at 1:00 p.m., a review of the resident's progress notes revealed that the resident vomited on 3/27/25, and was seen by the APRN (Advanced Practice Registered Nurse) on 3/28/25 for symptoms of fever 102.1 F (Fahrenheit), vomiting, risk for dehydration, suspected infection, and was given new orders for IV (intravascular) fluid bolus for 1 day, a urinalysis, culture & sensitivity, comprehensive metabolic panel, and a complete blood count. (No results were available for any of the lab tests ordered.) Ceftriaxone Sodium Injection Solution Reconstituted 1 Gram IM (intramuscularly) was ordered daily for four days for fever. On 4/1/25 at 11:43 a.m., an interview was conducted with LPN C. She was asked the following: Have you received training/education for how to identify and prevent abuse and neglect? Of course. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105937 If continuation sheet Page 6 of 19 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 04/02/2025 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 0656 Do you believe you have enough staff to give your residents the care they need? We do. Level of Harm - Minimal harm or potential for actual harm Who is responsible for transcribing lab orders? Sometimes the nurses do it and sometimes the doctors or the nurse practitioners have access to the medical record, and they put in their own lab orders. Residents Affected - Few How long does it take for the faclity to receive lab results? It depends on which lab test is ordered, usually it's pretty quick. What is the typical wait time to receive lab results? I would say within a day or so. Who is responsible for collecting urine samples from the residents? The nurses. Are urine samples collected on any particular shift? No, whenever a STAT (immediate) urine is ordered, we go ahead and collect the sample right then and put it in the refrigerator for the lab to pick it up. What do you do with the lab results when you receive them? Report to the doctor. On 4/2/25 at 11:54 a.m., an interview was conducted with LPN A. She was asked the following: Who is responsible for initiating the resident care plan on admission? I look for their diagnoses in the hospital records to start the care plan. I talk to the CNAs (certified nursing assistants) and family to get more information about the resident, and review the physician orders. We have up to 14 days to complete the comprehensive care plan. Each department adds their own parts of the comprehensive care plan. I monitor all the departments' input and make sure everything is completed before it is signed off as completed. Is the initial baseline resident care plan documented on paper? Yes. What is the purpose of the resident care plan? The care plan itself is so everybody is on the same page on how to take care of the resident. What are some of the medication categories that should be addressed in a resident's care plan? I personally care plan antibiotics, antidepressants, antianxiety, psychotropics, diuretics, hypnotics, anticoagulants, antiplatelets, and IV medication. When there is a change in condition, who is responsible for updating the resident care plan? That is nursing and myself would do that, and it's based on the order summary that the Unit Manager runs in the mornings. We review it, but the nurses can update the care plan anytime they initiate an order. LPN A was asked to access the care plan for Resident #31 in the EMR. She was asked to find a care plan that addressed her recent antibiotic use or any indication for infection. LPN A stated, I don't see a care plan for any indication of infection or current antibiotic use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105937 If continuation sheet Page 7 of 19 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 04/02/2025 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 0656 On 4/2/25 at 12:48 p.m., an interview was conducted with LPN E. Level of Harm - Minimal harm or potential for actual harm She was asked the following: Residents Affected - Few When she was asked who was responsible for updating a resident care plan, she stated she ran a summary of new orders every morning and reviewed those orders with the clinical team to ensure that everything had been addressed. She named the MDS nurses as staff who would actually access a resident's care plan in the EMR and update the care plan intervention, or goals, with pertinent input from the clinical team during the morning clinical meeting. What is the purpose of the resident care plan? It's a plan to tell us how to take care of the resident. She was asked to access Resident #24's current care plan in the EMR and find a care plan focus for the current order for antibiotic use and the indication. I can't find anything. Who is responsible for transcribing lab orders? Whoever receives the order. How long does it take for the facility to receive lab results? It's based on the lab; if it's STAT it's taken to the hospital, and it usually reports in 5-6 hours or sometimes before that, and if it's not ordered STAT, the lab technicians usually come in the morning to draw the lab, and the results come back by that afternoon. Who receives the results? They come into [EMR] and some lab results come by fax. All nurses are responsible for looking out for lab results. I usually check first thing in the morning as part of my routine and bring the results to the morning clinical meeting. Who is responsible for collecting urine samples from the residents? The nurses. Are urine samples collected on any particular shift? Not really. What is the facility's process for making sure lab specimens are collected in a timely manner? If you have a urinalysis that is not a STAT order, the night shift will collect it and the lab picks it up in the morning. If it's a STAT order, the nurse collects it right then. What is the facility's process for making sure lab orders are followed through on in a timely manner? We have a list that the lab technician uses to note what labs were drawn, and which specimens were collected or picked up. We can also check in [EMR] to review them with the clinical team in the morning meeting to determine if labs were collected or not. How many days a week does the facility have lab services? Monday through Sunday but on the weekends they only come if we have STAT orders. She was asked to access the EMR for Resident #24 and review the lab orders. She confirmed that the resident had labs for RSV, urinalysis with reflex culture, and CMP & CBC with differential orders on 3/28/2025. She was asked to provide the results. She stated, I'm not sure why these results have not come back yet. I will contact the lab and get back with you on what I find out. On 4/2/25 at 4:00 p.m., LPN E returned to provide an update on the lab results. She stated, The new (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105937 If continuation sheet Page 8 of 19 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 04/02/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm nurse documented that the labs had been collected when really they had not. She wasn't aware of how that should have been documented. 4. On 3/30/25 at 1:58 p.m., Resident #31 was observed with a large, purple-colored bruise on her left forearm. When she was asked about the area, Resident #31 stated, It was worse; it's gotten better. Residents Affected - Few On 4/1/25 at 12:16 p.m., a record review revealed that Resident #31 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, Type II diabetes mellitus with diabetic peripheral angiopathy without gangrene/with hyperglycemia, mood [affective] disorder, anxiety disorder, wedge compression fracture of first, second, fourth and fifth lumbar vertebra, heart failure, chronic obstructive pulmonary disease, atrial fibrillation and a diagnosis of dementia documented on the psychiatric evaluation dated 2/11/25. On 4/1/25 at 12:16 p.m., a review of the quarterly MDS assessment, dated 1/25/25, revealed a BIMS score of 14/15, indicating intact cognition. MDS documentation also indicated that the resident received insulin injections, antidepressant, anticoagulant, and diuretic medications during the assessment period. On 4/1/25 at 12:16 p.m., a review of the resident's current care plan revealed the following focus areas: Focus: The resident uses antidepressant medication related to Depression (Initiated: 10/31/2024, Revision on: 10/31/2024) Focus: The resident has pain/discomfort related to multiple back fractures, compression fractures, neuropathy. (Initiated: 10/31/2024, Revision on: 01/10/2025) There were no care plans available that addressed resident care for anticoagulant use, diuretic use, insulin use or Advanced Directives/DNR (Do Not Resuscitate). On 4/1/25 at 12:16 p.m., a review of the resident's active physician's orders revealed: Furosemide (diuretic) oral tablet 40 mg, Give 1 tablet by mouth in the morning related to Heart Failure (10/24/2024) Humalog Injection Solution 100 unit/ml (units per milliliter) (Insulin Lispro), inject as per sliding scale subcutaneously before meals and at bedtime related to type II DM (diabetes mellitus) (10/25/2024) Eliquis (anticoagulant) oral tablet 2.5 mg, give 1 tablet by mouth two times a day related to Atrial fibrillation (12/4/2024 ) Lantus Solo Star Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine), inject 20 units subcutaneously in the morning related to type II DM with hyperglycemia (1/10/25) Trazodone (antidepressant) Oral tablet 50 mg, give 1 tablet by mouth one time a day for sleep (1/7/25) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105937 If continuation sheet Page 9 of 19 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 04/02/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Sertraline (selective serotonin reuptake inhibitor - can be used to treat depression or anxiety) Oral Tablet 25 mg (2/12/25) Hydrocodone-Acetaminophen (combination opioid-over-the-counter analgesic pain medication) Oral Tablet 5-325 mg, give 1 tablet by mouth every 8 hours as needed for pain (2/18/25) Residents Affected - Few Antidepressant Medication - Observe for behavior (specify) every shift, (11/14/24) Antidepressant Medication - Side Effects monitor every shift (11/14/24) Donepezil (acetylcholinesterase inhibitor) 10 mg by mouth at bedtime for dementia (10/24/24) DNR (Do not resuscitate) (1/6/25). On 4/2/25 at 11:54 a.m., an interview was conducted with LPN A/MDS Coordinator. She was asked to access the initial care plan for Resident #31 and find a focus area that addressed anticoagulant use. I do not see one. She was asked to find a care plan focus area that addressed diuretic use. There is indication for diuretic use under her care plan for falls, for nutrition and for incontinence. She was asked to find a care plan focus area that addressed the resident's Advanced Directive status for DNR. I do not see one. She was asked to find a care plan focus area that addressed Diabetes Mellitus and insulin use. I do not see one. On 4/2/25 at 12:48 p.m., an interview was conducted with LPN E/Unit Manager. She was asked to access the current care plan for Resident #31 in the EMR and find a care plan focus area that addressed anticoagulant use. I don't see it. She was asked to find a care plan focus that addressed the resident's Advanced Directive status for DNR. I don't see it. She was asked to find a care plan focus area that addressed Diabetes Mellitus and insulin use. It's not there. A review of the facility's policy and procedure for Comprehensive Care Plans, (implemented 3/20/25, revised 2/27/25, reviewed [NAME] President of Operations), revealed: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental psychological needs, and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105937 If continuation sheet Page 10 of 19 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 04/02/2025 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 0656 Policy Explanation and Compliance Guidelines: Level of Harm - Minimal harm or potential for actual harm 1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. All services provided or arranged by the facility, as outlined by the comprehensive care plan, must meet professional standards of quality, and incorporate culturally competent and trauma-informed care as indicated. Residents Affected - Few 2. The comprehensive care plan will be developed within seven days after completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rational for deciding whether to proceed with care planning will be evidenced in the clinical record. 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105937 If continuation sheet Page 11 of 19 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 04/02/2025 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 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 interview, the facility failed to provide treatment and care in accordance with professional standards of practice for two (Residents #304 and #305) of 30 residents in the total survey sample. Resident #304 was not provided adequate care for a Jackson Pratt (JP) drain, and the facility failed to obtain a timely hospice consult per physician's orders for Resident #305, who was admitted on [DATE], with a physician's order for Consult [provider name] Hospice dated 3/12/25 at 12:55 PM. As of 4/2/25, three weeks after the order was written and on the last day of the survey, there was no documented evidence that a hospice consult had been obtained. Residents Affected - Few The findings include: 1. A review of Resident #304's medical record revealed an admission date of 3/7/25 with a re- entry on 3/26/25. Diagnoses included encounter for surgical aftercare following surgery, non-pressure chronic ulcer of lower leg with unspecified severity, diabetes mellitus type II, pressure ulcer of the sacral region stage III, need for assistance with personal care, calculus of gall bladder and bile duct with acute and chronic cholecystitis with obstruction, cellulitis, and dementia. A review of the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (AHCA form 5000-3008), dated 3/26/25, revealed that the resident had a JP drain at the abdomen upon transfer from the hospital to the facility on 3/26/25. (Copy obtained) A review of the resident's progress notes revealed a physician's progress note dated 3/28/25, indicating that the resident was seen for follow-up after a recent hospital re-admission. During her hospitalization, she was initially scheduled for a computed tomography (CT) of her chest to rule out pulmonary embolism (PE); however, an incidental finding of gallstones was noted and she underwent a cholecystectomy (gall bladder removal). Currently, she had two laparoscopic sites (incision sites) covered with 2x2 gauze and Tegaderm, as well as a JP drain in her right upper quadrant draining serosanguinous fluid. Plan: Post-cholecystectomy status: - Keep surgical sites clean and dry. Do not remove dressings unless instructed by your healthcare provider. - Monitor JP drain output and report any significant changes in color, amount, or consistency of drainage. - Report any signs of infection such as increased redness, swelling, warmth, or fever. - Gradually increase activity as tolerated, but avoid strenuous activities for at least 4-6 weeks. - Follow up with surgeon as scheduled for drain removal and wound check. (Copy obtained) A review of the active physician's orders revealed a physician order dated 3/26/25 for Flagyl (antibiotic) 500 milligrams (mg) two times a day (BID) related to surgical aftercare following surgery on the digestive system. There were no orders for care of the JP drain care or monitoring for signs and symptoms of infection. (Copies obtained) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105937 If continuation sheet Page 12 of 19 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 04/02/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm 2. A review of Resident #305's medical record revealed an admission date of 3/11/25 with diagnoses including non-displaced intertrochanteric fracture of the right femur, anorexia, dementia, muscle wasting and atrophy, cognitive communication deficit, depression, anemia, and cardiomyopathy. A review of the active physician's orders revealed: Residents Affected - Few 3/11/25 - Eliquis (anticoagulant) 2.5 mg BID (twice daily) for deep vein thrombosis (DVT). 3/12/25 - Furosemide (diuretic) 40 mg (milligrams) daily for congestive heart failure (CHF). 3/12/25 - Trazadone (serotonin antagonist and reuptake inhibitor - can be used for depression or as a sedative) 50 mg at bedtime (HS) for depression. 3/12/25 - Consult hospice related to dementia. A review of the resident's progress notes revealed a nursing progress note dated 3/12/25, indicating that Resident #305 was moved from 206B to 101A, closer to the nursing station, due to restlessness/irritability. A psychiatric consult was ordered. A new order was received for Trazodone at HS. The resident's family member was made aware of the room change and the resident's status, and a new order was received for a hospice consultation. A review of all of the resident's progress notes with Licensed Practical Nurse (LPN) E/Unit Manager from the date of admission [DATE]) through 4/2/25, revealed no information indicating that the physician's 3/12/25 hospice order was followed through on. LPN E confirmed there was no documentation indicating follow through A review of the Social Worker's notes revealed no information indicating that the physician's 3/12/25 hospice order was followed through on. A review of the physician's progress note dated 3/18/25 revealed that the reason for the visit was a follow-up due to dementia, insomnia, CHF, and muscle weakness. It was noted that the resident was observed being wheeled around the facility in her wheelchair by her family member, and was seen being fed lunch by her family member during rounds. She exhibited behavioral issues, including biting staff members and spitting out her pills. Concerns were raised by both the resident's family member and the staff regarding her memory issues and tendency to wander, as well as her getting up out of her wheelchair. The resident's family member had scheduled an appointment with hospice for Thursday. A review of the resident's current care plan (initiated on 3/11/25) revealed that there was no indication for hospice. No hospice certification paperwork was provided upon request. A review of the admission 5-day Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 3/17/25, revealed that the resident's brief interview for mental status (BIMS) score was left blank. The assessment documented that resident exhibited hallucinations, delusions, and wandering behaviors that interfered with her participation in activities or social interactions. In an interview on 4/2/25 at 12:38 PM, Licensed Practical Nurse (LPN) E/Unit Manager, stated she had worked at the facility for about a year. When asked how she was notified of new orders, she explained that during the daily clinical meeting, all new admissions' records were reviewed to ensure that the documentation was complete. She stated the clinical team also reviewed the order listing for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105937 If continuation sheet Page 13 of 19 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 04/02/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few new orders and risk management noted and updated the care plan. When asked about Resident #305's functional status, LPN E stated the resident was confused and dependent on staff for all activities of daily living (ADL). When asked if the resident was receiving hospice services, LPN E said, The consult was placed on 3/12/25 and the Social Services Director (SSD) was to arrange for the services. She stated the SSD was not in the facility; therefore, she could not tell what the progress was on the consult. She reviewed the resident's record and said, There is no certification paperwork. Normally, when a resident is picked up by hospice, the nursing department is left with admission paperwork. Additionally, the nurses complete a progress note on the same. When asked about Resident #304's care, she stated that resident was sent to the emergency room on 3/19/25 for elevated temperature, decreased breath sounds on the left side, and decreased oxygen saturation. Resident #304 returned to the facility on 3/26/25 after gastrointestinal (GI) surgery. She had for flagyl for surgical after care. When asked if the resident had any indwelling devices, LPN E stated she was not aware. She reviewed the resident's record and confirmed she had a JP drain and there was no order for care of the drain. She added that if there was no order, the nurses should document under the progress notes. She confirmed that there were no progress notes related to JP care and monitoring of the output. She said,If it's not documented it's not done. She also confirmed that the Flagyl antibiotic did not have a stop date. A review of the facility's policy titled Provision of Physician Ordered Services (reviewed 7/21/24), revealed that the purpose of the policy was to provide a reliable process for the proper and consistent provision of physician-ordered services according to professional standards of quality. Definition: Professional Standards of Quality means that care and all services are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting. Policy Explanation and Compliance Guidelines: 1. Facility will maintain a schedule of diagnostic tests (laboratory and radiology) in accordance with the physicians' orders. No diagnostic tests or consultation requests will be performed without specific physician, physician assistant, nurse practitioner or clinical nurse specialists' orders in accordance with State law, including scope of practice laws. 2. Qualified nursing personnel will submit timely requests for physician-ordered services (laboratory, radiology, consultations) to the appropriate entity. 3. Qualified nursing personnel will receive and review the diagnostic test reports or consults and communicate the results to the ordering physician, physician's assistant, nurse practitioner or clinical nurse specialist within 24 hours of receipt unless the reports fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders. Ordering provider will be notified of results upon receipt if deemed critical and/or require immediate attention. 4. Documentation of consultations, diagnostic tests, the results, and date/time of physician notification will be maintained in the resident's clinical record. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105937 If continuation sheet Page 14 of 19 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 04/02/2025 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 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 interview and record review, the facility failed to establish an infection prevention and control program (IPCP) that included a system for preventing, identifying, reporting, investigating, and controlling infections, specifically, the spread of a gastrointestinal infection (GI) affecting 15 (Residents #208, #32, #42, #36, #22, #207, #21, #24, #35, #51, #40, #1, #8, #14 and #20) of 50 residents living in the facility. Failure to control the spread of infection can result in serious harm to residents, staff, volunteers, visitors, and other individuals providing services to the facility. Facility staff also failed to implement enhanced barrier precautions (EBP) for two (Residents #1 and #304) of two residents with indwelling devices from a total survey sample of 30 residents. Residents Affected - Some The findings include: On 3/30/25 at 11:00 AM, upon entrance to the facility, Licensed Practical Nurse (LPN) G notified the survey team that there was a gastrointestinal (GI) outbreak and stated approximately 50% of the residents were symptomatic with vomiting and diarrhea. She recommended the use of surgical masks while in the facility. Staff were observed with surgical masks. No personal protective equipment (PPE) was observed outside residents' rooms or signs notifying staff and visitors of illness. In an telephone interview on 03/30/25 at 11:30 AM, the Director of Nursing (DON)/Infection Control Preventionist was asked to provide more information related to resident status and how the symptoms began. She said, The symptoms started on Friday (3/28) morning. Residents reported that the pizza they ate the previous night might have upset their stomachs. She said residents were provided with hydration. At this time, I'm not sure how many residents have symptoms. I was unwell yesterday. The DON added that she was enroute to the facility and would provide more information upon arrival. In an interview on 03/30/25 at 11:45 AM, LPN F stated there were eight residents on her unit (West Wing) that were symptomatic. Three residents started exhibiting symptoms on Friday and five other residents started exhibiting symptoms on Saturday (3/29). She stated resident vital signs were within normal limits (WNL). She confirmed that there were no residents on any type of isolation precautions including enhanced barrier precautions. She provided a list indicating that 13 residents had symptoms. (Residents #208, #32, #42, #36, #22, #207, #21, #24, #35, #51, #40, #1, and #8) In a follow-up interview on 03/30/25 at 12:00 PM, LPN G stated there were 11 residents on her unit (East Wing) that were symptomatic. She mentioned that five residents started having diarrhea and vomiting on Friday, and six additional residents started experiencing symptoms on Saturday. She confirmed that there were no residents on any type of isolation precautions including enhanced barrier precautions. On 03/30/25 at 12:30 PM, the DON stated four residents started showing signs and symptoms on Friday morning. These residents stated that whatever they ate on Thursday night may have upset their stomachs. Of the four residents, three were prescribed IV (intravenous) fluids and one resident who was alert oriented was encouraged to drink fluids. The DON added that there were two employees who also had symptoms. As of last night, three more residents started having symptoms, and the Medical Director ordered stool for Oval and Parasite (O&P) for salmonella, shigella, norovirus and requested an Enzyme Immunoassay (EIA) immediately (STAT). When asked to describe the precautions currently in place, the DON stated the facility was utilizing universal precautions until they had confirmed results. She stated she had not contacted the Department of Health (DOH) for guidance, but would do so by the end of the day and initiate a line listing ( method of tracking infections). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105937 If continuation sheet Page 15 of 19 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 04/02/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a tour on 03/30/25 at 2:00 PM, Resident #24 was observed lying in bed. She stated she was feeling better after a few days of vomiting and not feeling well. A review of her medical record revealed that the resident stated she vomited on 3/27/25. She was visited by the APRN (advanced practice registered nurse) on 3/28/25 (Friday) for symptoms of a fever at 102.1 degrees Fahrenheit (F) and vomiting, with a risk for dehydration and infection suspected. She was prescribed new orders for Rocephin (antibiotic) 1gram (gm) intramuscularly (IM) x 4 days and an intravenous (IV) fluid bolus x1 day. In an interview on 03/31/25 (Monday) at 9:29 AM, the DON stated she had initiated the line listing. (Copy obtained) She stated as of last night (Sunday) all of the residents' symptoms had resolved. When she was asked for the laboratory results, she stated she had not received the results yet. On 03/31/25 at 10:38 AM, Resident #40 stated he was not doing great. He stated he felt nauseated. On 03/31/25 at 11:00 AM, Resident #207 stated she had diarrhea this morning. She further stated she had been nauseated with vomiting and diarrhea for the last three days. A review of the line listing, dated 3/30/25, and provided on 3/31/25 at 9:30 AM, revealed that Residents #40 and #207's symptoms had resolved as of 3/30/25. (Copy obtained) A joint interview was conducted on 03/31/25 at 3:26 PM with the DON and the Administrator. The DON stated she had not yet received the laboratory results. She was asked if there were any other residents that exhibited symptoms today. The DON replied, no. After three inquiries, the DON repeated that all residents' symptoms had resolved. She stated she conducted rounds in the morning with the Unit Manager and no symptoms were noted. She stated there had been no symptoms as far as she was aware of up to the time of this interview. She stated she was waiting for the lab results. She confirmed that there were no residents who had symptoms reported. When asked the names of the residents who had samples obtained, she replied that Residents #36 and #207 had samples obtained. When she was asked when the samples were obtained, she replied, this morning. She was again asked if there were residents that still had symptoms. She said, Just those two and it was one time in the morning. When she was asked to review the line listing she provided in the morning dated 3/30/25, she confirmed that Resident #36 was not added and the list indicated that Resident #207's symptoms were resolved as of 3/30/25. She added Resident #36 to the line listing in the presence of the surveyor. Residents #14 and #20 were added to the list on 4/1/25 making 16 the total number of residents listed on the report. In a follow-up interview on 4/1/25 at 1:55 PM, the DON confirmed that there were two new residents with loss of appetite or vomiting. She added that she reached out to the Department of Health (DOH) on 3/31/25 and was advised to put the residents with symptoms on contact isolation until they were symptom-free for 48 hours. She stated she was also advised to discontinue communal dining and group activities until after 48 hours of no symptoms in the facility. 2. On 3/30/25, Resident #1 was observed in bed with a pressure relieving mattress, a catheter bag hanging at bedside, boots to prevent pressure wounds bilaterally, and a peripherally inserted central catheter (PICC) line in the left upper arm. There was no door sign or PPE (personal protective equipment) for enhanced barrier precautions. A review of the resident's medical record revealed that Resident #1 was admitted on [DATE] with a re-entry on 3/1/25. Diagnoses included multiple sclerosis, contractures of both knees, a pressure ulcer at the left buttocks - Stage IV, chronic pain, hydronephrosis, dementia, a history of Transient (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105937 If continuation sheet Page 16 of 19 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 04/02/2025 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 0880 Ischemic Attack (TIA), extended spectrum beta lactamase (ESBL) resistance and sepsis. Level of Harm - Minimal harm or potential for actual harm A review of the physician's orders dated 3/1/25 revealed: Suprapubic catheter care every shift, cleanse site and replace t- sponge. Residents Affected - Some Flush PICC Line: Flush lumens every 12 hours with 10 ml (milliliters) normal saline. Catheter: Suprapubic catheter 18 FR (French) with 10 cc (cubic centimeter) balloon to dependent drainage. Change catheter monthly, PRN (as needed) if dislodged or plugged and unable to clear with irrigation. Scrotum MASD (moisture-associated skin damage) wound treatment as follows: Clean with NS (normal saline). Pat apply silver sulfadiazine 1% cream. Leave open to air. IV Dressing Change - PICC transparent dressing change every week and as needed (PRN). 3. Resident #304 was admitted to the facility on [DATE] with a re-entry on 3/26/25. Diagnoses included: Encounter for surgical aftercare following surgery. Non-pressure chronic ulcer of lower leg with unspecified severity, diabetes mellitus type II, pressure ulcer of the sacral region stage III, need for assistance with personal care, calculus of gall bladder, and bile duct with acute and chronic cholecystitis with obstruction, cellulitis, and dementia. A review of the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (AHCA form 5000-3008), dated 3/28/25, revealed that the resident had JP (Jackson Pratt) drain to the abdomen. (Copy obtained) A physician's progress note dated 3/28/25 revealed that the resident was seen for follow-up after a recent hospital readmission. During her hospitalization, she was initially scheduled for a computed tomography (CT) of her chest to rule out pulmonary embolism (PE); however, an incidental finding of gallstones was noted and she underwent a cholecystectomy (gallbladder removal). Currently, she had two laparoscopic sites covered with 2x2 gauze and Tegaderm, as well as a JP drain in her right upper quadrant draining serosanguinous fluid. There was no door sign or PPE (personal protective equipment) for enhanced barrier precautions. In a follow-up interview on 4/1/25 at 1:55 PM, the DON was asked if there were any current residents on enhanced barrier precautions. She said, no. She was then asked which residents should be on enhanced barrier precautions and she said she was not sure. A review of the facility's policy and procedure titled Infection Outbreak Response and Investigation (reviewed on 5/1/2024), revealed: Policy: It is the policy of the facility to respond to outbreaks of infectious diseases within the facility to stop transmission of pathogens and prevent additional infections following standards of practice and CMS (Centers for Medicare and Medicaid Services) and CDC (Centers for Disease Control and Prevention) guidelines. Definitions: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105937 If continuation sheet Page 17 of 19 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 04/02/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Outbreak generally refers to the occurrence of more cases of a communicable disease than expected in a given area or among a specific group of people over a particular period of time. If a condition is rare or has serious health implications, an outbreak may involve only one case. Policy Explanation and Compliance Guidelines: Residents Affected - Some 1. Recognition of outbreak: a. Changes in condition and/or signs and symptoms of infection shall be reported according to procedures for infection reporting. b. The following triggers shall prompt an investigation as to whether an outbreak exists: - An increase over baseline infection rate (i.e. ten percent or more increase). ii. A sudden cluster of infections on a unit or during a short period of time (i.e. three or more cases). - A single case of a rare or serious infection (i.e. invasive group A Strep, foodborne pathogens, active TB, acute hepatitis, Legionella, chicken pox, measles, COVID-19). - An outbreak will be defined according to current definitions used by local and state health departments. - An outbreak will be reported to the local and/or state health department in accordance with the state's reportable diseases website. 3. Outbreak investigations. - When the existence of an outbreak has been established, an investigation will begin. - The Infection Preventionist/designee shall be responsible for coordinating investigation. The Infection Preventionist will be the liaison between the health department and the facility. - A line list about each person affected by the outbreak will be maintained. - The incubation period, period of contagiousness, and date of most recent case will be used in making the determination that the outbreak is resolved. - A summary of the investigation will be documented and reported to QAPI committee and health department, if indicated. A review of the facility's policy and procedure titled Enhanced Barrier Precautions (reviewed on 2/28/25), revealed: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definitions: Enhanced barrier precautions (EBP) refers to an infection control intervention designed to reduce (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105937 If continuation sheet Page 18 of 19 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 04/02/2025 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 0880 transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. Level of Harm - Minimal harm or potential for actual harm Policy Explanation and Compliance Guidelines: Residents Affected - Some 1. Prompt recognition of need: a) All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions. b) All staff receive training on high-risk activities and common organisms that require enhanced barrier precautions. c) The facility will have the discretion on how to communicate to staff which residents require the use of EBP, as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities. 2. Initiation of Enhanced Barrier Precautions: a) The facility will have the discretion in using EBP for residents who do not have a chronic wound or indwelling medical device and are infected or colonized with an Multidrug resistant organism (MDRO) that is not currently targeted by Centers for Disease Control and Prevention (CDC) but may be considered epidemiologically important. b) An order for enhanced barrier precautions will be obtained for residents with any of the following: I. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters) even if the resident is not known to be infected or colonized with a MDRO. (Peripheral IVs, continuous glucose monitors, insulin pumps, or ostomies without an associated indwelling medical device are not an indication for EBP.) II. Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105937 If continuation sheet Page 19 of 19