Inspection·February 11, 2021

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 implement interventions in a fall risk care plan to ensure appropriate use of restraints for one of one (Resident #70) resident reviewed for restraints in a total sample of 43 residents. The findings include: On 02/08/21 at 11:00 AM, Resident #70 was observed sitting in his wheelchair on the secure unit of the facility. He was observed wearing a cloth-type lap belt that tied behind the wheelchair on both sides and went between his legs. Resident #70 did not respond to questions and spent the majority of time that he was observed looking up toward the ceiling with his eyes both open and closed. Record review for Resident #70 revealed he was admitted to the facility on [DATE] with diagnoses including schizophrenia, generalized anxiety disorder, psychoactive substance abuse with psychoactive substance-induced anxiety disorder, auditory hallucinations, pseudobulbar affect, and dementia with behavioral disturbance. Record review of the 1/11/2021 Quarterly Minimum Data Set (MDS) assessment found that he had a Brief Interview for Mental Status (BIMS) score that could not be assessed. He was severely impaired for decision making. He had short- and long-term memory problems. He required extensive, two-person physical assistance for bed mobility and transfers. He required extensive assistance of one person for eating. Record review of the current physician's orders for Resident #70 found a 2/2/2021 order for a slider belt while up in a chair due to schizophrenia, poor safety awareness, and poor impulse control with a history of dizziness. It was to be released for medications, activities of daily living (ADLs), meals and activities. Record review of the fall risk care plan found the 2/11/2020 intervention of slider seat belt when in wheelchair release for meals, ADLs, toileting, and supervised activities. On 2/09/2021 at 2:44 PM, Resident #70 was observed sitting in his wheelchair in the small dining/activity room on the secure unit. The TV was on. Resident #70 had the cloth lap belt on. An interview was conducted at the time of observation with Employee A, the certified nursing assistant (CNA) that was in the room. She stated Resident #70 wore the lap belt at all times except when he went to sleep. She stated she gave him lunch today and she kept the lap belt on. On 2/10/2021 at 11:50 AM, Resident #70 was observed sitting in the dining room on the secure unit waiting for lunch. The restorative nurse (Employee B) was observed placing a food tray in front of Resident #70. A few minutes later, she was observed sitting down next to the resident. She informed Resident #70 it was time to eat and removed his mask. She then began assisting him with the meal. Employee B was asked if the resident's slider belt needed to be removed while he was eating. She stated, I thought someone else had removed it. She was asked if she was aware there were physician's orders and the resident was care planned to remove the slider belt when she was eating and she stated she was aware. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105052 If continuation sheet Page 2 of 8 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 105052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seaside Health and Rehabilitation Center 324 Wilder Blvd Daytona Beach, FL 32114 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105052 If continuation sheet Page 3 of 8 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 105052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seaside Health and Rehabilitation Center 324 Wilder Blvd Daytona Beach, FL 32114 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to ensure all emergency drug boxes were kept locked at all times for one of four medication rooms. The facility also failed to ensure there were no expired over-the-counter medications on the medication carts for one of six medication carts. The findings include: An observation of the medication room on Station 3 was conducted on [DATE] at 10:45 am with the Unit Manager (UM). There was a bag of intravenous fluid (IV) 0.9% Sodium Chloride (NaCl) solution 1000 ml (milliliters) found on the counter. The bag did not have a resident's name. The UM was asked if there was a resident currently receiving IV fluids. She said there was a resident that was ordered fluids and IV antibiotics. She stated she assumed the nurse who took the order removed the IV fluid from the IV emergency box. She was asked what date it was removed, and she said she would need to check the Medication Administration Record (MAR) to see which nurse received the order. She was asked how the facility documented when medications were removed from the emergency boxes. She provided a log book that contained entries for medications removed from the emergency boxes. She was asked if there was an entry for the removal of the NaCl fluid. She said she could find no entry. Inspection of the IV emergency box found that the box was not locked. The UM verified that the IV box was unlocked and had not been resealed after opening. An inspection of the front hall medication cart on Station #3 was conducted on [DATE] at 11:00 am with Licensed Practical Nurse (LPN) F. During the observation of the over-the-counter medications in the top drawer, an opened bottle of Aspirin 325 mg (milligrams) that expired in [DATE] was found. She immediately removed the bottle. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105052 If continuation sheet Page 4 of 8 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 105052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seaside Health and Rehabilitation Center 324 Wilder Blvd Daytona Beach, FL 32114 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm Based on record review and interviews, the facility failed to ensure routine and 24-hour emergency dental care was provided for one (Resident #107) of two residents reviewed for dental services, from a sample of 43 residents. Residents Affected - Few The findings include: During an interview with Resident #107 on 2/9/2021 at 9:28 AM, he stated, I've been asking to see a dentist for eleven months. I chipped my tooth last month while eating rice and beans. They keep blaming COVID and putting it off. I've asked different people more than once. A tooth on the right upper side of the resident's mouth was observed with a chip in it. Resident #107 was asked whether the chipped tooth was causing him any pain. He stated, Yes, off and on, not constantly. A review of the Quarterly Minimum Data Set (MDS) assessment, dated 1/18/2021, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15 points, indicating the resident was cognitively intact. No oral pain was reported during this assessment reference period. A review of the Annual MDS assessment, dated 4/20/2020, revealed the following documentation under the dental section: Obvious or likely cavity or broken natural teeth? Yes. Inflammed or bleeding gums or loose natural teeth? Yes. Mouth or facial pain, discomfort, or difficulty with chewing? No. Unable to examine? No. A medical record review for Resident #107 revealed a care plan conference sign-in sheet, dated 4/3/2020, was signed as having been attended by the Minimum Data Set (MDS) Nurse, the Social Services Director, Life Enrichment Director and Dietary Manager. There were hand-written notes on the sheet, one of which was concern about teeth. Further review of the medical record revealed a nurse's note written on 4/7/2020 that read, Pt (patient) complains of a rough tooth, appears that a tooth on upper left region of mouth is broken. Dental consult recommended. No evidence of a dental consult was found in the doctor's orders in the resident's chart. A review of the care plans revealed no focus, goal, or interventions related to the resident's dental status. The facility's dental services policy was reviewed: Dental Services Policy (November 2001) Dental services shall be made available to all residents requiring such services. Policy Interpretation and Implementation: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105052 If continuation sheet Page 5 of 8 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 105052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seaside Health and Rehabilitation Center 324 Wilder Blvd Daytona Beach, FL 32114 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 0791 1. Dental services are available to all residents requiring routine and emergency dental care. Level of Harm - Minimal harm or potential for actual harm 2. Social services or designee will be responsible for assisting the resident (and family) in making necessary appointments. Residents Affected - Few 3. All requests for routine and emergency dental services should be directed to the social services department or designee as soon as possible so that adequate arrangements can be made. On 2/10/2021, during an interview with the Social Services Director (SSD), he was asked to explain how dental services worked at the facility. He stated, Yes, we have two dental programs. One works with residents who have liability insurance, and one is for residents who have no dental insurance. We make sure all residents who want dental services can get them. When asked whether dental services were an admission order, or did they need to be requested, the SSD stated, It needs to be requested, it's not an admission order. It was explained to the SSD that no dental orders, dentist notes, referrals, consults or appointments could be found in Resident #107's medical record. When asked whether the SSD could show when the resident had been seen by a dentist in the past 11 months, he stated,I have this roster from [dental provider] that his guardian refused a dental consult. It's not dated, but it's a report for May 19, 2020 thru July 7, 2020. She is no longer his guardian. She was relieved of all guardian duties in the state of Florida. He has a new guardian, and I'll approach him to ask if he wants [Resident #107] re-enrolled in dental services. I'll also talk to [Resident #107] and ask him if he wants to re-enroll in dental services. When asked whether the SSD had any documentation verifying that the resident had a dental appointment at any time during his stay of almost three years, the SSD stated, No, I don't see anything in his chart. I looked at my notes, and I don't have anything written about him having seen a dentist since he's been here. A review of additional documentation submitted by the facility on 2/16/21 regarding Resident #107's dental status revealed the following: 1. A Notice of Declined Dental Services dated 1/27/2020. 2. A 4/7/2020 nurse's note indicated the resident complained about his tooth and a dental consult was recommended. 3. An 8/16/2020 nurse's note indicated the resident had no complaints of pain or discomfort. Nothing specific to oral status/pain was mentioned in the note. 4. A list of resident weights indicated no significant weight loss from April 2019 through Febryuary 2021. 5. A Social Services note dated 2/12/21, after the survey, revealed that the SSD spoke with the resident that day about his dental concerns and arranged a dental appointment for 3/3/21, after speaking with the resident's guardian, whose name was not the same as the guardian documented on 1/27/2020 Notice of Declined Dental Services. 6. Four hand-written statements, dated 2/12/21, after the survey, from two nurses and two other unidentified facility employees indicated Resident #107 had never complained to them of tooth problems or pain. 7. A statement from the Social Services Director, dated 2/15/21, indicated that he spoke with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105052 If continuation sheet Page 6 of 8 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 105052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seaside Health and Rehabilitation Center 324 Wilder Blvd Daytona Beach, FL 32114 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 0791 Level of Harm - Minimal harm or potential for actual harm Resident #107 on a regular basis, and the resident made him aware of any concerns he had. The SSD stated the resident never complained about any dental problems. The SSD went on to say that Resident #107 and his guardian had been encouraged to sign up for the facility's dental plan, but the resident and his guardian declined. No date was provided indicating when this conversation occurred. There was no indication that there had been a change in the resident's guardian. Residents Affected - Few After the 1/27/2020 Notice of Declined Dental Services and the change in the resident's guardian, there was no documented evidence that the SSD ever approached either the resident or his new guardian about emergent or routine dental services, even though the SSD stated he spoke with the resident on a regular basis. The resident's previous guardian may have declined services, but the new guardian was not approached until after this survey. The resident was alert and oriented and complained about intermittent oral pain and having asked repeatedly for a dental appointment when he was interviewed on 2/9/2021. The facility must assist residents in obtaining routine and emergent dental services as per the regulation. The facility's policy and procedure supports that. When the SSD was prompted by the surveyor at the time of the survey, he then approached the resident and guardian, dental services were not declined by this guardian or the resident, and the SSD was able to arrange dental services. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105052 If continuation sheet Page 7 of 8 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 105052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seaside Health and Rehabilitation Center 324 Wilder Blvd Daytona Beach, FL 32114 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview, the facility failed to maintain the ice machine in the facility kitchen to prevent the spread of foodborne illness and ensure the safety of the 138 residents that resided at the facility. The findings include: During a tour of the facility kitchen on 2/08/2021 at 11:09 AM, the interior of the ice machine was observed. The metal running across the interior top of the ice machine was covered with spots of a brown substance that ran the length of the metal. There was water condensation on the metal that could drop into the ice below. (Photographic evidence obtained) The Certified Dietary Manager (CDM) was asked at the time of observation if she could wipe the substance off. She obtained a paper towel, wiped the surface of the machine, and the substance transferred to the paper towel. During the interview with the CDM, she stated the maintenance department cleaned the interior of the ice machine once a month and the kitchen staff wiped it each day. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105052 If continuation sheet Page 8 of 8