University East Rehabilitation Center

F-F835.

A review of Resident #1's medical record revealed an admitted [DATE REDACTED]. Her diagnoses included, but were not limited to, metabolic encephalopathy (brain dysfunction leading to altered consciousness, cognitive decline and other neurological symptoms), attention and concentration deficit following cerebral infarction (stroke); extended-spectrum beta-lactamase resistance (ESBL - bacterial infection resistant to antibiotics); dementia in other diseases classified elsewhere, unspecified severity with agitation; general anxiety disorder; schizoaffective disorder; and a need for assistance with personal care.

A review of the resident's 3/2/25 physician's orders revealed:

- Donepezil Oral tablet 10 milligrams (mg) - give 1 tablet by mouth at bedtime for dementia.

- Quetiapine (antipsychotic) Fumarate Oral tablet 50 mg - give 1 tablet by mouth one time a day for anxiety.

- Quetiapine Fumarate Oral tablet 50 mg - give 3 tablets by mouth at bedtime for anxiety.

- Alprazolam (benzodiazepine - slows the nervous system) oral tablet 0.5 mg - give 1 tablet by mouth every morning and at bedtime for anxiety.

- Sertraline HCL (hydrochloride) (selective serotonin reuptake inhibitor - can be used to treat depression, obsessive compulsive disorder, posttraumatic stress disorder, social anxiety disorder

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 42 105262 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105262 B. Wing 04/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blue Lake Post Acute 991 E New York Ave 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 0867 and/or panic disorder) oral tablet 100 mg - give 1 tablet by mouth one time a day for depression.

Level of Harm - Immediate - 1:1 monitoring every shift - discontinued on 3/7/25. jeopardy to resident health or safety Additional physician's orders included:

Residents Affected - Few - 3/7/2025 - 30-minute monitoring for behaviors, (This order, 30-minute monitoring, was discontinued on 3/19/25). No documentation for increased/frequent monitoring was found from

3/19/2025 through 4/1/2025.

- 3/24/2025 - Ciprofloxacin HCL (antibiotic) oral tablet 500 mg - give 500 mg by mouth two times a day for urinary tract infection (UTI) for 14 days.

- 4/1/2025 - One-on-one monitoring for behaviors - every shift.

A review of the Psychotropic Evaluation nursing note dated 3/2/2025, revealed that Resident #1 had behaviors (e.g. combativeness, verbal disruptions) that were harmful to self or others or limited participation

in activities. Increased in acuteness. She could be aggressive with staff. Resident has anxiety or nervousness that impairs his/her quality of life or limits participation in activities.

A review of a Behavior Note dated 3/3/2025 revealed: Resident has pulled out her peripherally inserted central catheter (PICC) line from her right upper arm. Some bleeding was observed, pressure applied and Tegaderm (transparent, waterproof, sterile medical dressing) placed after it stopped. Resident remains aggressive, attempting to bite several staff members and kick. New order for Haldol (antipsychotic) intramuscularly (IM) given per Advanced Practice Registered Nurse (APRN) - Ineffective, continues to walk around yelling and screaming. Redirected as staff walks along with her.

A review of the Provider Encounter dated 3/14/25 revealed that the resident wandered and attempted to hit and bite staff. She continued to refuse clothing changes as needed. Psychiatry was consulted to see resident and schedule next week. The Haldol order remained in place for behavioral management. (Psychiatry notes were requested but not provided during the survey.)

An Encounter note dated 3/20/25 recommended that the resident continue with 30-minute behavior checks for safety monitoring. (The order was not implemented. Copies obtained)

An Encounter note dated 4/2/25 revealed that Resident #1 was seen for a behavioral follow up. She was found in a male resident's bed last night with what appears to be inappropriate touching and sexual behavior. Resident was returned to one-on-one (1:1) care.

A Nursing Progress note dated 4/2/25 read, Resident is up pacing around in her room, up and down in her bed, difficult to redirect, very aggressive with staff, swinging at them, screaming out loud, cursing, knocked over everything on her bedside table, attempted to get in a bed with a resident in the bed, displayed aggressive behavior when trying to redirect. New order given to administer Haldol 0.5 mg IM (intramuscularly - in the muscle) due to aggressive behavior. She remains on 1:1 care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 42 105262 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105262 B. Wing 04/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blue Lake Post Acute 991 E New York Ave 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 0867 A review of the Admission 5-day minimum data set (MDS) assessment with a reference date of 3/6/25, revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 01 out of 15 possible Level of Harm - Immediate points, indicating severe cognitive impairment. The resident was noted to be delusional, and physically and jeopardy to resident health or verbally aggressive with wandering behavior. She received antipsychotic, antianxiety, antidepressant, and safety antibiotic medications during the assessment period.

Residents Affected - Few A review of the Care Plan (initiated 4/1/25, revised 4/1/25) revealed that the resident had Impaired Cognitive Function/Dementia or Impaired Thought Processes related to dementia, schizoaffective disorder, difficulty making decisions and psychotropic drug use. The resident will be able to communicate basic needs on a daily basis. The care plan noted that the resident had a behavior problem of making inappropriate sexual advances to other residents, aggression and other inappropriate behaviors with a history of UTIs, pacing, wandering, disrobing, inappropriate response to verbal communication, violence, aggression towards staff/others. Pulled out PICC line. Pulled out Foley (urinary) catheter. Resident will have fewer episodes of undesired behaviors. The resident will have no evidence of behavior problems. 1:1 care (downgraded, failed attempt) frequent checks 1:1 caregiver reinitiated 4/1. Move to a room away from patient she appears to favor.

2. A review of Resident #2's medical record revealed an admitted [DATE REDACTED] and a discharge date of [DATE REDACTED]. His diagnoses included dysphagia (difficulty swallowing) following cerebral infarction (stroke), type 2 diabetes mellitus (DM), difficulty walking, lack of coordination, and hypertension (HTN). No psychiatric diagnoses/mental health disorders were noted.

A review of Resident #2's 3/18/25 physician's orders revealed:

- Occupational therapy (OT) - Resident to be seen 5 times a week for 60 days with a focus on therapeutic exercises, therapeutic activity, self-care management, neuromuscular re-education training, group treatment when appropriate, and wheelchair management.

- Skilled physical therapy (PT) services following hospitalization for 5 times a week for 4 weeks for therapeutic exercises, therapeutic activities, neuromuscular re-education, gait training, group therapy and manual.

- Clopidogrel bisulfate (inhibits blood clotting) 75 mg via percutaneous endoscopic gastrostomy (PEG) tube (feeding tube passed into a resident's stomach through the abdominal wall) one time a day (QD) for deep vein thrombosis (DVT).

- Amlodipine 10 mg via PEG QD for HTN.

- Ezetimibe (cholesterol medication) 10 mg via PEG at bedtime for hyperlipidemia.

- Lantus (insulin) 100 unit/ml (units per milliliter) inject 16 units subcutaneously (beneath the skin) at bedtime for DM.

There was no physician's order for one-on-one (1:1) supervision. (Copies obtained)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 42 105262 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105262 B. Wing 04/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blue Lake Post Acute 991 E New York Ave 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 0867 A review of Resident #2's Admission 5-day MDS, with a reference date of 3/24/25, revealed that the resident had a BIMS score of 12 out of 15 possible points, indicating moderate cognitive impairment. No behaviors Level of Harm - Immediate were noted. He reported feeling depressed with little to no interest in doing things. He ambulated with a cane jeopardy to resident health or and required partial to moderate assistance with transfers. He did not receive psychotropic medications safety during the assessment period.

Residents Affected - Few A review of Resident #2's Care Plan, initiated on 4/3/25, revealed that the resident had a focus area for Behavior related to hypersexuality and was noncompliant with dietary restrictions. Interventions included the following: 1. Administer medications as ordered. Monitor side effects and effectiveness. 2. Caregivers to provide opportunity for positive interaction, attention. Stop and talk to him/her as passing by. 3. If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. 4. Monitor behavior episodes and attempt to determine the underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. 5. Praise any indication of the resident's progress/improvement in behavior. All interventions were initiated on 4/3/25, two days after the event. There was no intervention for increased supervision for Resident #2 from the care plan initiation date through his transfer to the sister facility on 4/6/25. (Copy obtained)

The Care Plan revealed a focus area for Impaired Cognitive Function/Dementia or Impaired Thought Processes related to impaired decision making, initiated on 4/1/25. Interventions included, but were not limited to, the following: 1. Administer medications as ordered. Monitor/document for side effects and effectiveness. 2. Ask yes/no questions in order to determine the resident's needs. 3. Communicate with the resident/family/caregivers regarding resident's capabilities and needs. 4. Cue, reorient and supervise as needed. 5. Monitor/document and report PRN (as needed) any changes in cognitive function, specifically changes in decision making ability, memory, recall, and general awareness, difficulty expressing self, and difficulty understanding others. There was no intervention for increased supervision for Resident #2 after the 4/1/25 incident through the resident's transfer to the sister facility on 4/6/25. (Copy obtained)

A Physician's Note dated 4/2/25, revealed that the resident was seen for behavioral follow-up status post incident with resident. Female resident was found in the resident's bed with likely inappropriate touching or sexual behavior noted. The female resident is quite confused. He (Resident #2) was placed on one-on-one care for observation. He was told about the inappropriateness of his behavior. He appeared to be slightly confused but is aware of inappropriate behavior.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 42 105262 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105262 B. Wing 04/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blue Lake Post Acute 991 E New York Ave 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 0867 During an interview on 4/07/25 at 3:30 p.m., Registered Nurse (RN) A stated she had been employed by the facility for about a year as a floor nurse. In November 2024 she was promoted to evening supervisor. As of Level of Harm - Immediate Friday (4/4/25), she was asked to be the interim Director of Nursing (DON) since the previous DON had jeopardy to resident health or resigned. When asked if she was familiar with Residents #1 and #2, she stated Resident #1 was confused, safety verbally and physically aggressive towards staff, and refused care and medications. She stated the resident had not had any sexually inappropriate behaviors before this incident with Resident #2. Resident #2 was Residents Affected - Few alert and oriented x3 (person, place and time). He had no behaviors except noncompliance with diet orders.

She stated on 4/1/24 she was working on the floor on the 200 hall. At 5:30 p.m., Residents #1 and #2 were observed in the dining area watching television. She was at the nurses' station with Licensed Practical Nurse (LPN) C, and they were completing their daily documentation. She stated at approximately 6:00 p.m., Resident #1 was seated on Resident #2's walker. LPN C separated the two residents. The residents were again observed holding hands, and she approached both residents and explained to Resident #2 that he could not hold hands with resident #1 because she was not alert and oriented. The residents were separated again. She then left the area to attend to another resident and left LPN C at the nurses' station. She stated

she was not present in Resident #2's room when the two residents were found there.

On 4/7/25 at 1:25 p.m., the Administrator confirmed that Resident #2's one-on-one (1:1) supervision was discontinued because Resident #1 was the resident who initiated the sexual behavior.

During an interview on 4/07/25 at 3:30 p.m., Registered Nurse (RN) A stated she had been employed by the facility for about a year as a floor nurse. In November 2024 she was promoted to evening supervisor. As of Friday (4/4/25), she was asked to be the interim Director of Nursing (DON) since the previous DON had resigned. When asked if she was familiar with Residents #1 and #2, she stated Resident #1 was confused, verbally and physically aggressive towards staff, and refused care and medications. She stated the resident had not had any sexually inappropriate behaviors before this incident with Resident #2. Resident #2 was alert and oriented x3 (person, place and time). He had no behaviors except noncompliance with diet orders.

She stated on 4/1/24 she was working on the floor on the 200 hall. At 5:30 p.m., Residents #1 and #2 were observed in the dining area watching television. She was at the nurses' station with Licensed Practical Nurse (LPN) C, and they were completing their daily documentation. She stated at approximately 6:00 p.m., Resident #1 was seated on Resident #2's walker. LPN C separated the two residents. The residents were again observed holding hands, and she approached both residents and explained to Resident #2 that he could not hold hands with resident #1 because she was not alert and oriented. The residents were separated again. She then left the area to attend to another resident and left LPN C at the nurses' station. She stated

she was not present in Resident #2's room when the two residents were found there.

A telephone interview was conducted on 4/7/25 at 3:50 p.m., with LPN B. She stated she had worked in the facility for about a year and on 4/1/25, she was coming in to work her 7:00 p.m. to 7:00 a.m. shift when the assigned nurse mentioned that Residents #1 and #2 were having behaviors. At that time, they noticed that neither Resident #1 nor Resident #2 were in the dining area. LPN B and LPN C then went to Resident #2's room together at approximately 6:55 p.m. looking for the residents. As they walked into Resident #2's room,

they saw that his right hand was inside of Resident #1's pants. LPN B stated she and LPN C separated the residents and LPN C notified the Administrator (referring to the Administrator in Training (AIT).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 42 105262 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105262 B. Wing 04/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blue Lake Post Acute 991 E New York Ave 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 0867 On 4/8/25 at 11:45 a.m., a visit was made to the sister facility where Resident #2 had been discharged after

the incident. Resident #2 was observed in the bed adjacent to the window with his eyes closed. He was Level of Harm - Immediate clean and appropriately dressed. There was a rollator walker and a cane at his bedside. He opened his eyes, jeopardy to resident health or and an interview was conducted at this time. Resident #2 stated he was a little sleepy. When asked if he was safety unwell, he replied, no. When he was asked when and why he was discharged to this sister facility, he said,

They transferred me here a few days ago. I did not have a choice. When asked if he could recall the 4/1/25 Residents Affected - Few incident in the other facility where a female resident was found in his bed, he replied, A female resident? Yes, she was in my bed. He declined to provide further details about the incident. He said, I don't want to answer any more questions.

On 4/8/25 at 12:07 p.m., a joint interview was conducted with LPN L/MDS Nurse and Registered Nurse N/Director of Nursing (DON) at the sister facility. They both stated they were involved with the admission process. They both stated that a care plan was established from the resident's diagnoses, physician's orders, and any additional information from the medical record. When they were asked about Resident #2's functional status, LPN L stated Resident #2 had a BIMS score of 14 out of 15 possible points, indicating intact cognition was ambulatory with the use of a walker. They both stated Resident #2 was transferred from

the sister facility because of a sexual encounter with another resident and the need for long-term care placement. When asked if they had established any behavior care plan for this resident, they stated the behavior care plan established was only related to non-compliance with the resident's diet. They added that

they did not initiate a sexual behavior care plan because they were informed that the other female resident initiated the sexual act.

In an interview on 4/8/25 at 12:30 p.m., the facility's Medical Director stated he conducted rounds at the facility every Tuesday and Thursday, and during each visit, he asked the Administrator if there was anything to report. He stated he had just left the sister facility and was informed that surveyors were in the facility for a complaint investigation, but he was not provided details. He said that he contacted the facility Administrator to ask him whether he needed to make him aware of anything. When the Administrator then notified the Medical Director of the 4/1/25 incident between Residents #1 and #2, the Medical Director asked, What is

this about? I am not aware. The Medical Director stated a brief overview of the incident was provided by the Administrator. He stated he told the Administrator, I'm not aware. I just came back from that facility and was not notified. As the Medical Director and QAPI committee member, I should be made aware. The Medical Director stated he would not comment on the incident because he had to review the documentation first. He stated he was not informed that Resident #2 had been transferred to the sister facility, but he would visit the resident after this interview.

An interview was conducted on 4/8/25 at 1:43 p.m. with Resident #1's spouse. He stated he was contacted by the facility when the incident occurred. This was the first time anything like this had happened. He was asked how he felt his wife would have responded to the actions of Resident #2 if she was not cognitively impaired. He stated that in her previous life his wife was very modest. She would have been very upset over Resident #2's actions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 42 105262 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105262 B. Wing 04/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blue Lake Post Acute 991 E New York Ave 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 0867 During an interview on 4/8/25 at 2:19 p.m., the Administrator and the Administrator in Training stated they had identified areas of improvement related to failure to provide enough supervision to Resident #1 after Level of Harm - Immediate several observations of new behaviors. It was confirmed with the Administrator that an ad hoc QAPI (Quality jeopardy to resident health or Assurance and Performance Improvement) meeting had not been held. When the Administrator was asked safety why an ad hoc QAPI meeting was not conducted, he replied that there was no reason to do so. When he was asked if the Medical Director was notified of the incident after it occurred, he said that he tried to contact Residents Affected - Few him, but was unable to reach him, so he notified the Medical Director's Advanced Practice Registered Nurse (APRN). He confirmed that he did not follow up with the Medical Director.

A telephone interview was conducted on 4/8/25 at 5:37 p.m. with LPN C. She stated she had worked at the facility for about a year. She confirmed that she was assigned to Residents #1 and #2 on 4/1/25. She explained that she was sitting at the nurses' station at approximately 6:00 p.m. and observed Resident #1 rubbing Resident #2's shoulder and trying to pull him close to her while grabbing his hand. Resident #2 allowed her to do so after being told three times that Resident #1 was not as alert and oriented as him and

he should not allow the behavior. This behavior went on over the course of 15-20 minutes. Resident #1 was also observed trying to sit on Resident #2's walker. Resident #2 was informed that he should not allow her to do that. Resident #1 was redirected and went back to the chair she was sitting in before - away from Resident #2. Both residents continued to watch television with the other residents. At approximately 6:30 p.m. , LPN C went to complete blood glucose monitoring on a resident near the dining room. When she came out of that resident's room, the night shift nurse had arrived (LPN B). LPN A noticed that the two residents (#1 and #2) were not in the dining room any longer. Together with the night nurse (LPN B) at approximately 6:55 p.m., LPN C quickly went to Resident #2's room and observed Resident #1 lying in his bed on her back fully clothed with her pants unbuttoned and her zipper down while Resident #2 stood to the right of her fully clothed with his right hand inside of Resident #1's pants. When he saw the nurses, he quickly pulled his hand out of her pants. Resident#1 was quickly assisted out of the room while Resident #2 remained in his room. LPN C confirmed that she and LPN B entered the room at the same time. She stated she notified the evening supervisor, the DON, and the Administrator. She stated both residents were placed on 1:1 supervision. She confirmed that she was not contacted by any administrative team member at facility about

the 4/1/25 incident until 4/8/25. On 4/8/25, the Administrator contacted her, and she explained to the Administrator what occurred exactly as she had in her previously written statement.

A review of the facility's policy titled Quality Assurance and Performance Improvement Policy for Skilled Nursing Center (effective 2/1/24, reviewed 1/1/25), revealed:

Policy Statement:

The purpose of Quality Assurance and Performance Improvement (QAPI) is to continually take a proactive approach to assure and improve the way we provide care and engage with our patients, employees, and other stakeholders so that we may fully realize our vision, mission, and commitment to caring pledge.

Procedure:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 42 105262 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105262 B. Wing 04/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blue Lake Post Acute 991 E New York Ave 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 0867 All employees and contracted staff are responsible for the quality of care and services within their respective departments and are expected to participate in the QAPI Program. Each center must develop, implement, Level of Harm - Immediate and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the jeopardy to resident health or outcomes of care, quality of life, and resident choice. safety

It is the expectation of the SNF (skilled nursing facility) QAPI Program that the center will follow the Residents Affected - Few established QAPI process to guide and direct the operations of the location. The executive leadership sets

the expectation and provides the resources for implementation.

Quality Assurance Performance Improvement (QAPI) information flows up and down the organization in an organized format. The center culture supports the premise that knowledge is shared, and information flows freely. Improvements in processes or outcomes as a result of the QAPI Program are communicated throughout the center and to stakeholders (residents, families and vendors).

When improvement opportunities are identified through quality assessment activities, the center takes action to improve performance, including education, modification of systems and processes, or formal Performance Improvement Projects.

IV. PERFORMANCE IMPROVEMENT PROJECTS (PIPs):

As part of its QAPI Program, the SNF develops, implements, and evaluates performance improvement projects.

- The facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the center must reflect the scope and complexity of the facility's services and available resources.

- The center must set priorities for its performance improvement projects based on the results of quality monitoring that consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 42 105262

F-F867.

1. A review of Resident #1's medical record revealed an admitted [DATE REDACTED]. Her diagnoses included, but were not limited to, metabolic encephalopathy (brain dysfunction leading to altered consciousness, cognitive decline and other neurological symptoms), attention and concentration deficit following cerebral infarction (stroke); extended-spectrum beta-lactamase resistance (ESBL - bacterial infection resistant to antibiotics); dementia in other diseases classified elsewhere, unspecified severity with agitation; general anxiety disorder; schizoaffective disorder; and a need for assistance with personal care.

A review of the resident's 3/2/25 physician's orders revealed:

- Donepezil Oral tablet 10 milligrams (mg) - give 1 tablet by mouth at bedtime for dementia.

- Quetiapine (antipsychotic) Fumarate Oral tablet 50 mg - give 1 tablet by mouth one time a day for anxiety.

- Quetiapine Fumarate Oral tablet 50 mg - give 3 tablets by mouth at bedtime for anxiety.

- Alprazolam (benzodiazepine - slows the nervous system) oral tablet 0.5 mg - give 1 tablet by mouth every morning and at bedtime for anxiety.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 42 105262 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105262 B. Wing 04/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blue Lake Post Acute 991 E New York Ave 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 0835 - Sertraline HCL (hydrochloride) (selective serotonin reuptake inhibitor - can be used to treat depression, obsessive compulsive disorder, posttraumatic stress disorder, social anxiety disorder Level of Harm - Immediate jeopardy to resident health or and/or panic disorder) oral tablet 100 mg - give 1 tablet by mouth one time a day for depression. safety - 1:1 monitoring every shift - discontinued on 3/7/25. Residents Affected - Few Additional physician's orders included:

- 3/7/2025 - 30-minute monitoring for behaviors, (This order, 30-minute monitoring, was discontinued on 3/19/25). No documentation for increased/frequent monitoring was found from

3/19/2025 through 4/1/2025.

- 3/24/2025 - Ciprofloxacin HCL (antibiotic) oral tablet 500 mg - give 500 mg by mouth two times a day for urinary tract infection (UTI) for 14 days.

- 4/1/2025 - One-on-one monitoring for behaviors - every shift.

A review of the Psychotropic Evaluation nursing note dated 3/2/2025, revealed that Resident #1 had behaviors (e.g. combativeness, verbal disruptions) that were harmful to self or others or limited participation

in activities. Increased in acuteness. She could be aggressive with staff. Resident has anxiety or nervousness that impairs his/her quality of life or limits participation in activities.

A review of a Behavior Note dated 3/3/2025 revealed: Resident has pulled out her peripherally inserted central catheter (PICC) line from her right upper arm. Some bleeding was observed, pressure applied and Tegaderm (transparent, waterproof, sterile medical dressing) placed after it stopped. Resident remains aggressive, attempting to bite several staff members and kick. New order for Haldol (antipsychotic) intramuscularly (IM) given per Advanced Practice Registered Nurse (APRN) - Ineffective, continues to walk around yelling and screaming. Redirected as staff walks along with her.

A review of the Provider Encounter dated 3/14/25 revealed that the resident wandered and attempted to hit and bite staff. She continued to refuse clothing changes as needed. Psychiatry was consulted to see resident and schedule next week. The Haldol order remained in place for behavioral management. (Psychiatry notes were requested but not provided during the survey.)

An Encounter note dated 3/20/25 recommended that the resident continue with 30-minute behavior checks for safety monitoring. (The order was not implemented. Copies obtained)

An Encounter note dated 4/2/25 revealed that Resident #1 was seen for a behavioral follow up. She was found in a male resident's bed last night with what appears to be inappropriate touching and sexual behavior. Resident was returned to one-on-one (1:1) care.

A Nursing Progress note dated 4/2/25 read, Resident is up pacing around in her room, up and down in her bed, difficult to redirect, very aggressive with staff, swinging at them, screaming out loud, cursing, knocked over everything on her bedside table, attempted to get in a bed with a resident in the bed, displayed aggressive behavior when trying to redirect. New order given to administer Haldol 0.5 mg IM (intramuscularly - in the muscle) due to aggressive behavior. She remains on 1:1 care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 42 105262 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105262 B. Wing 04/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blue Lake Post Acute 991 E New York Ave 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 0835 A review of the Admission 5-day minimum data set (MDS) assessment with a reference date of 3/6/25, revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 01 out of 15 possible Level of Harm - Immediate points, indicating severe cognitive impairment. The resident was noted to be delusional, and physically and jeopardy to resident health or verbally aggressive with wandering behavior. She received antipsychotic, antianxiety, antidepressant, and safety antibiotic medications during the assessment period.

Residents Affected - Few A review of the Care Plan (initiated 4/1/25, revised 4/1/25) revealed that the resident had Impaired Cognitive Function/Dementia or Impaired Thought Processes related to dementia, schizoaffective disorder, difficulty making decisions and psychotropic drug use. The resident will be able to communicate basic needs on a daily basis. The care plan noted that the resident had a behavior problem of making inappropriate sexual advances to other residents, aggression and other inappropriate behaviors with a history of UTIs, pacing, wandering, disrobing, inappropriate response to verbal communication, violence, aggression towards staff/others. Pulled out PICC line. Pulled out Foley (urinary) catheter. Resident will have fewer episodes of undesired behaviors. The resident will have no evidence of behavior problems. 1:1 care (downgraded, failed attempt) frequent checks 1:1 caregiver reinitiated 4/1. Move to a room away from patient she appears to favor.

2. A review of Resident #2's medical record revealed an admitted [DATE REDACTED] and a discharge date of [DATE REDACTED]. His diagnoses included dysphagia (difficulty swallowing) following cerebral infarction (stroke), type 2 diabetes mellitus (DM), difficulty walking, lack of coordination, and hypertension (HTN). No psychiatric diagnoses/mental health disorders were noted.

A review of Resident #2's 3/18/25 physician's orders revealed:

- Occupational therapy (OT) - Resident to be seen 5 times a week for 60 days with a focus on therapeutic exercises, therapeutic activity, self-care management, neuromuscular re-education training, group treatment when appropriate, and wheelchair management.

- Skilled physical therapy (PT) services following hospitalization for 5 times a week for 4 weeks for therapeutic exercises, therapeutic activities, neuromuscular re-education, gait training, group therapy and manual.

- Clopidogrel bisulfate (inhibits blood clotting) 75 mg via percutaneous endoscopic gastrostomy (PEG) tube (feeding tube passed into a resident's stomach through the abdominal wall) one time a day (QD) for deep vein thrombosis (DVT).

- Amlodipine 10 mg via PEG QD for HTN.

- Ezetimibe (cholesterol medication) 10 mg via PEG at bedtime for hyperlipidemia.

- Lantus (insulin) 100 unit/ml (units per milliliter) inject 16 units subcutaneously (beneath the skin) at bedtime for DM.

There was no physician's order for one-on-one (1:1) supervision. (Copies obtained)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 42 105262 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105262 B. Wing 04/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blue Lake Post Acute 991 E New York Ave 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 0835 A review of Resident #2's Admission 5-day MDS, with a reference date of 3/24/25, revealed that the resident had a BIMS score of 12 out of 15 possible points, indicating moderate cognitive impairment. No behaviors Level of Harm - Immediate were noted. He reported feeling depressed with little to no interest in doing things. He ambulated with a cane jeopardy to resident health or and required partial to moderate assistance with transfers. He did not receive psychotropic medications safety during the assessment period.

Residents Affected - Few A review of Resident #2's Care Plan, initiated on 4/3/25, revealed that the resident had a focus area for Behavior related to hypersexuality and was noncompliant with dietary restrictions. Interventions included the following: 1. Administer medications as ordered. Monitor side effects and effectiveness. 2. Caregivers to provide opportunity for positive interaction, attention. Stop and talk to him/her as passing by. 3. If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. 4. Monitor behavior episodes and attempt to determine the underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. 5. Praise any indication of the resident's progress/improvement in behavior. All interventions were initiated on 4/3/25, two days after the event. There was no intervention for increased supervision for Resident #2 from the care plan initiation date through his transfer to the sister facility on 4/6/25. (Copy obtained)

The Care Plan revealed a focus area for Impaired Cognitive Function/Dementia or Impaired Thought Processes related to impaired decision making, initiated on 4/1/25. Interventions included, but were not limited to, the following: 1. Administer medications as ordered. Monitor/document for side effects and effectiveness. 2. Ask yes/no questions in order to determine the resident's needs. 3. Communicate with the resident/family/caregivers regarding resident's capabilities and needs. 4. Cue, reorient and supervise as needed. 5. Monitor/document and report PRN (as needed) any changes in cognitive function, specifically changes in decision making ability, memory, recall, and general awareness, difficulty expressing self, and difficulty understanding others. There was no intervention for increased supervision for Resident #2 after the 4/1/25 incident through the resident's transfer to the sister facility on 4/6/25. (Copy obtained)

A Physician's Note dated 4/2/25, revealed that the resident was seen for behavioral follow-up status post incident with resident. Female resident was found in the resident's bed with likely inappropriate touching or sexual behavior noted. The female resident is quite confused. He (Resident #2) was placed on one-on-one care for observation. He was told about the inappropriateness of his behavior. He appeared to be slightly confused but is aware of inappropriate behavior.

A Physician's Note dated 4/4/25, revealed that Resident #2 was evaluated for discharge. He will be discharged to another skilled nursing facility, as he had a sexual encounter with another resident at this facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 42 105262 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105262 B. Wing 04/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blue Lake Post Acute 991 E New York Ave 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 0835 On 4/7/25 at 1:25 p.m., the Administrator and the Administrator in Training (AIT) were interviewed regarding

the timeline of events as related to the 4/1/25 incident between Residents #1 and #2. The Administrator Level of Harm - Immediate stated on 4/1/25 at approximately 6:00 p.m., Residents #1 and #2 were in the dining room area. Resident #1 jeopardy to resident health or was observed tapping Resident #2's shoulder. The assigned nurse, Licensed Practical Nurse (LPN) C, who safety was at the nurses' station, separated the residents. Approximately five minutes later, Resident #1 was observed attempting to sit on Resident #2's walker. Again, the residents were separated and put at different Residents Affected - Few ends of the dining area. Resident #2 was educated and voiced understanding. At approximately 6:30 p.m., LPN C went to conduct blood glucose monitoring for another resident and walked away from the dining area. When she returned, she noticed that both Resident #1 and Resident #2 were not in the dining area. LPN C walked to Resident #2's room and found both residents (#1 and #2). Resident #1 was observed in Resident #2 's bed lying supine, fully clothed, with her pants unbuttoned and her zipper down. Resident #2 stood to

the right of her. He was fully clothed with his hand inside of Resident #1's pants. He quickly pulled his hand out of her pants when the nurse walked in. The Administrator confirmed that Resident #2's one-on-one (1:1) supervision was discontinued because Resident #1 was the resident who initiated the sexual behavior.

During an interview on 4/07/25 at 3:30 p.m., Registered Nurse (RN) A stated she had been employed by the facility for about a year as a floor nurse. In November 2024 she was promoted to evening supervisor. As of Friday (4/4/25), she was asked to be the interim Director of Nursing (DON) since the previous DON had resigned. When asked if she was familiar with Residents #1 and #2, she stated Resident #1 was confused, verbally and physically aggressive towards staff, and refused care and medications. She stated the resident had not had any sexually inappropriate behaviors before this incident with Resident #2. Resident #2 was alert and oriented times three (person, place and time). He had no behaviors except noncompliance with diet orders. She stated on 4/1/24 she was working on the floor on the 200 hall. At 5:30 p.m., Residents #1 and #2 were observed in the dining area watching television. She was at the nurses' station with Licensed Practical Nurse (LPN) C, and they were completing their daily documentation. She stated at approximately 6:00 p.m., Resident #1 was seated on Resident #2's walker. LPN C separated the two residents. The residents were again observed holding hands, and she approached both residents and explained to Resident #2 that he could not hold hands with resident #1 because she was not alert and oriented. The residents were separated again. She then left the area to attend to another resident and left LPN C at the nurses' station. She stated

she was not present in Resident #2's room when the two residents were found there.

A telephone interview was conducted on 4/7/25 at 3:50 p.m. with LPN B who stated she had worked in the facility for about a year and on 4/1/25, she was coming in to work her 7:00 p.m. to 7:00 a.m. shift when the assigned nurse (LPN C) mentioned that Residents #1 and #2 were having behaviors. At that time, they noticed that neither Resident #1 nor Resident #2 were in the dining area. LPN B and LPN C then went to Resident #2's room together at approximately 6:55 p.m. looking for the residents. As they walked into Resident #2's room, they saw that his right hand was inside of Resident #1's pants. LPN B stated she and LPN C separated the residents and LPN C notified the Administrator (referring to the AIT). LPN B explained that she completed a witness statement and pushed it under the Administrator's door. When asked if the written statement was in addition to/followed by a telephone interview, she replied, No one called me. I typed up my observations. She provided a copy of her statement.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 42 105262 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105262 B. Wing 04/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blue Lake Post Acute 991 E New York Ave 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 0835 A follow-up interview was conducted on 4/7/25 at 4:31 p.m. with the Administrator who was asked for any surveillance videos. He stated the surveillance video cameras were not working. When asked again if there Level of Harm - Immediate was another witness to the incident, he said, There were no other witnesses. He was asked about the jeopardy to resident health or witness noted in the federal incident report. The Administrator stated she was another nurse who was safety assisting with a respiratory program. He further stated this other nurse was asked by LPN C (assigned nurse) if she had seen the residents. LPN C and this other nurse then both walked into Resident #2's room. Residents Affected - Few The Administrator stated this other nurse/witness entered Resident #2's room after the assigned nurse (LPN C) and did not witness what happened. When asked if he had a witness statement from this second nurse,

the Administrator stated he might not have put it in the investigative file that had been provided to the surveyor. He stated he would provide it. At 4:53 p.m., the Administrator provided a statement indicating that

a phone interview was conducted on 4/1/25 with LPN I, whose name was on the statement. The statement indicated that LPN I did not witness the incident. When asked why LPN I was not on the schedule for 4/1/25,

the Administrator stated the staffing person may have forgotten to add LPN I since she was not working a medication cart. He further stated he would provide an updated schedule. The reprinted schedule provided for review did not match the name of LPN B (who witnessed the incident with LPN C) or LPN I; it indicated LPN J. A review of the employee roster printed on 4/7/25 revealed that there was no employee by the name of LPN I, who was noted in the witness statement, on the facility's roster.

Another interview was conducted with the Administrator on 4/7/25 at 5:08 p.m. He was asked about the differing names on the federal incident report, the witness statement he provided, and the schedule for 4/1/25. He stated LPN B went by LPN J's name. When asked why the schedule had a different name (LPN J), he walked out of the room stating he would clarify with the staffing department.

Another follow up interview was conducted on 4/7/25 at 5:50 p.m. with the Administrator who stated he contacted LPN B, and she confirmed that she entered the room at the same time with LPN C and witnessed Resident #2 removing his hand from Resident #1's pants. He stated he had contacted LPN C and was unable to reach her. He added that with the new information he would close the investigation and substantiate the abuse allegation.

On 4/8/25 at 11:45 a.m., a visit was made to the sister facility where Resident #2 had been discharged after

the incident. Resident #2 was observed in the bed adjacent to the window with his eyes closed. He was clean and appropriately dressed. There was a rollator walker and a cane at his bedside. He opened his eyes, and an interview was conducted at this time. Resident #2 stated he was a little sleepy. When asked if he was unwell, he replied, no. When he was asked when and why he was discharged to this sister facility, he said,

They transferred me here a few days ago. I did not have a choice.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 42 105262 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105262 B. Wing 04/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blue Lake Post Acute 991 E New York Ave 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 0835 On 4/8/25 at 12:07 p.m., a joint interview was conducted with LPN L/MDS Nurse and Registered Nurse N/Director of Nursing (DON) at the sister facility. They both stated they were involved with the admission Level of Harm - Immediate process. They both stated that a care plan was established from the resident's diagnoses, physician's orders, jeopardy to resident health or and any additional information from the medical record. When they were asked about Resident #2's safety functional status, LPN L stated Resident #2 had a BIMS score of 14 out of 15 possible points, indicating intact cognition was ambulatory with the use of a walker. They both stated Resident #2 was transferred from Residents Affected - Few the sister facility because of a sexual encounter with another resident and the need for long-term care placement. When asked if they had established any behavior care plan for this resident, they stated the behavior care plan established was only related to non-compliance with the resident's diet. They added that

they did not initiate a sexual behavior care plan because they were informed that the other female resident initiated the sexual act.

During an interview on 4/8/25 at 2:19 p.m., the Administrator and the AIT were asked if there were any identified opportunities for improvement. The Administrator stated there was a missed opportunity for Resident #1 regarding her behaviors. He further stated there were opportunities on 4/1/25 when Resident #1 had behaviors and staff could have provided more supervision, but they walked away. When asked if they had identified opportunities for improving their abuse investigation and reporting, the Administrator replied, What exactly? He was reminded that he had mentioned on 4/7/25 that the allegation could not be verified, and then at the end of the day he stated that the allegation was substantiated. He said that per LPN C they could not verify the allegation. He confirmed that he did not obtain a statement from Resident #2.

A telephone interview was conducted on 4/8/25 at 5:37 p.m. with LPN C. She stated she had worked at the facility for about a year. She confirmed that she was assigned to Residents #1 and #2 on 4/1/25. She explained that she was sitting at the nurses' station at approximately 6:00 p.m. and observed Resident #1 rubbing Resident #2's shoulder and trying to pull him close to her while grabbing his hand. Resident #2 allowed her to do so after being told three times that Resident #1 was not as alert and oriented as him and

he should not allow the behavior. This behavior went on over the course of 15-20 minutes. Resident #1 was also observed trying to sit on Resident #2's walker. Resident #2 was informed that he should not allow her to do that. Resident #1 was redirected and went back to the chair she was sitting in before - away from Resident #2. Both residents continued to watch television with the other residents. At approximately 6:30 p.m. , LPN C went to complete blood glucose monitoring on a resident near the dining room. When she came out of that resident's room, the night shift nurse had arrived (LPN B). LPN A noticed that the two residents (#1 and #2) were not in the dining room any longer. Together with the night nurse (LPN B) at approximately 6:55 p.m., LPN C quickly went to Resident #2's room and observed Resident #1 lying in his bed on her back fully clothed with her pants unbuttoned and her zipper down while Resident #2 stood to the right of her fully clothed with his right hand inside of Resident #1's pants. When he saw the nurses, he quickly pulled his hand out of her pants. Resident#1 was quickly assisted out of the room while Resident #2 remained in his room. LPN C confirmed that she and LPN B entered the room at the same time. She stated she notified the evening supervisor, the DON, and the Administrator. She stated both residents were placed on 1:1 supervision.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 42 105262 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105262 B. Wing 04/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blue Lake Post Acute 991 E New York Ave 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 0835 A review of the Administrator's job description (effective January 2025), revealed that the primary purpose of

the Administrator was to oversee, manage and direct the day-to-day functions and overall operations of the Level of Harm - Immediate facility in accordance with current federal, state and local government regulations that govern long-term care jeopardy to resident health or facilities and the Operators requirements. The Administrator's focus is on maintaining the highest degree of safety quality care for the resident/patient while achieving the facility's business objectives. As the Administrator, you are delegated the Governing Body and administrative authority, responsibility, and accountability Residents Affected - Few necessary for carrying out your assigned duties.

CUSTOMER SERVICE

- Demonstrates positive customer service when performing the role of the Administrator, with residents, family members, internal and external staff.

- Displays flexibility, team spirit, compassion, respect honesty, politeness and accountability when dealing with residents, family members and facility staff.

- Demonstrates an awareness of and sensitivity for resident's rights in all interfaces with residents and family members.

- Develops an environment that allows for creative thinking, problem solving and empowerment in the development of a facility management team.

- Communicates effectively via open, straightforward communication, including the use of listening skills.

- Seeks validation of knowledge base, quality, decision-making and skill level by actively questioning when necessary.

- Utilizes survey information to address areas of importance as defined by our customers.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

- Leads facility management staff in developing and working from a business plan that focuses on all aspects of facility operations, including setting priorities and job assignments.

- Serves on various committees of the facility (i.e., Infection Control, Quality Assurance & Assessment, etc.)

Committee Functions:

- Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies.

- Evaluate and implement recommendations from the facility's committees as necessary.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 42 105262 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105262 B. Wing 04/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blue Lake Post Acute 991 E New York Ave 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 0835 - Consult with department directors concerning the operation of their departments to assist in eliminating/correcting problem areas, and/or improvement of services. Ensure that an adequate number of Level of Harm - Immediate appropriately trained professional and auxiliary personnel are on duty at all times to meet the needs of the jeopardy to resident health or residents. safety

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 42 105262 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105262 B. Wing 04/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blue Lake Post Acute 991 E New York Ave 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 0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Level of Harm - Immediate jeopardy to resident health or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42442 safety Based on staff interviews, resident and facility record reviews, and a review of facility policies and Residents Affected - Few procedures, the facility's Quality Assessment and Quality Assurance Committee (QAA) failed to develop and implement appropriate plans of action to correct identified quality deficiencies, particularly those that caused adverse outcomes. This resulted in a lack of improvement of their systems and processes. This failure contributed to the sexual abuse of one (Resident #1) out of three residents reviewed for abuse. It also placed all other vulnerable female residents at a likelihood for serious adverse outcomes related to potential sexual abuse from Resident #2.

Immediate Jeopardy (IJ) at a scope and severity of J (isolated) was identified on April 7, 2025 at 3:50 p.m.

On April 1, 2025, at 6:55 p.m., Immediate Jeopardy began.

On April 8, 2025, at 6:15 p.m., the Administrator was notified of the IJ determination and was provided with Immediate Jeopardy Templates. Immediate Jeopardy was ongoing as of the survey exit on April 8, 2025.

The findings include:

Cross reference