Health inspection·June 16, 2025

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure actions documented in a performance improvement plan (PIP) for pest control were implemented, measured for success, and tracked performance to ensure that improvements were realized and sustained, based on failure to maintain a sanitary, orderly, and comfortable interior free of pest for two (room [ROOM NUMBER] and #230) of four rooms sampled. There were 121 residents residing in the facility at the time of this survey. The findings include: On 06/12/25 at 11:03 AM, a live roach was observed in Resident #1's room (room [ROOM NUMBER]B), near the corner of the room. (Photographic evidence obtained) On 06/12/25 at 12:13 PM, a fly was observed on Resident #5's bed (room [ROOM NUMBER]B) along with live and dead roaches observed behind the resident's oxygen concentrator located in the corner of the resident's room. (Photographic evidence obtained) On 06/12/25 at 12:17 PM, the same fly was observed, unmoved and in the same location on the resident's bed. The resident and his roommate said that they informed the facility staff of insects in the room. (Photographic evidence obtained) On 06/12/25 at 2:18 PM, eight small ants were observed on the wall adjacent to Resident #1's bed (room [ROOM NUMBER]) and under the light fixture above the resident's bed. (Photographic evidence obtained) Resident interviews conducted on 06/12/2025 from 10:31 am to 11:03 am with four alert and oriented residents (Residents #2, #3, #4 and #5) noted pests have been observed in their rooms and staff were informed about the pests and they continue to see pests in their room. Staff interviews conducted on 06/12/2025 from 11:32 am to 11:57 am with Certified Nursing Assistant (CNA) A, Licensed Practical Nurse (LPN) B, and Contracted Aramark housekeeping staff member C noted they have seen pests in resident rooms and have noted their observations in the pest sighting binders located at the nurse's stations. On 06/12/25 at 4:00 PM, an interview was conducted with the Director of Maintenance. He reported that he worked at the facility for approximately one year. He stated that he had not noticed bugs in the facility, but this is Florida. He further explained that staff are supposed to write pest sightings in the binders at the nurse's stations. He said that he doesn't look in the pest sighting binders (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 9 Event ID: 106061 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 106061 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgecrest Healthcare and Rehabilitation Center 1200 North Stone Street Deland, FL 32720 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)