Inspection·May 5, 2023

F 0622 tired and staff was able to direct him back to his room to sleep. Level of Harm - Actual harm Review of a Progress Note dated 4/05/23 at 6:45 AM, by the DON indicated the charge nurse told her resident #1 had eaten during the night and calmed down on his own without any medications. She documented resident #1 was in bed that morning and the physician had been notified of resident #1's behaviors with no new orders received. She wrote the charge nurse affirmed resident #1 was on one to one staff supervision at that time. Residents Affected - Few Review of an additional Progress Note by the DON dated 4/05/23 at 7:45 AM, read that she and the Nursing Home Administrator went to see resident #1 in his room to follow up on the reported disruptive behavior from the previous night. She explained resident #1 was not in his room and a search of the facility was initiated when he could not be located. The progress note showed the resident was located by staff and redirected back inside for breakfast. She described resident #1 as conversive and in a pleasant mood, but his thoughts were nonsensical. She indicated he was able to ambulate on his own with no injuries sustained. A few hours later the DON wrote another Progress Note dated 4/05/23 at 10:45 AM, which revealed, Writer notified PCP [Primary Care Physician] of resident behavior. PCP provided orders for resident to transfer to secured unit. Arrangements made to facilitate resident relocation. Review of the last Progress Note dated 4/05/23 at 3:11 PM, written by LPN A revealed, Resident transferred to (name of facility) in [NAME] to a locked down unit. On 5/04/23 at 10:59 AM, the Admissions Director stated resident #1 had been a resident at the facility previously so he was preapproved to return during the admission process from the hospital. She explained he was preapproved because the facility had cared for the resident previously and thus they could care for the resident again. The admission Director stated the DON came to her when she got to work on the morning of 4/05/23, after resident #1's elopement to say he had a change and she needed to look for alternative placement on a more secure unit. She explained she contacted every facility with a locked unit in the area and eventually expanded her search to [NAME] and Miami when local facilities could not accommodate him in their locked units. The admission Director explained she informed resident #1 and told him, The clinical team could not meet his care needs, and there were other facilities that would do his wound care that were more secure, and he gave her the approval to search for another facility. She elaborated, It all happened by noon and they picked him up before 4:00 PM. In a telephone interview on 5/04/23 at 10:37 AM, the resident's assigned nurse, LPN C, stated when she came in for her night shift at 7:00 PM on 4/04/23, resident #1 was pacing the halls, ranting, and mumbling to himself in an unintelligible way. She described resident #1's behavior as threatening to herself and the other staff, so she called the DON who directed her to place him on 1:1 observation and to call the doctor to see if there were any medications to help with his behaviors. LPN C explained a short time after that phone call resident #1 calmed himself down, was sleepy and went to bed in his room. She said they didn't have any problems with him the rest of the night and the one to one sitter remained with him. She stated sometime during the early morning he had an episode of incontinence, and he allowed the CNAs to assist him with incontinence care and change into clean clothes. LPN C then explained the procedure when residents were transferred or discharged from the facility was for the nurse to have the resident or their representative sign the Agency for Healthcare Administration (AHCA) transfer form. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105207 If continuation sheet Page 2 of 5 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Melbourne Healthcare and Rehabilitation Center 1415 S Hickory St Melbourne, FL 32901 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 0622 Level of Harm - Actual harm On 5/04/23 at 11:20 AM, LPN A stated she was the assigned day shift nurse for resident #1 when he eloped and was discharged to [NAME]. She described after resident #1 returned from outside she was told by another manager that he was going to another facility. LPN A stated she signed the transfer form but said she didn't have the resident sign it because she didn't think he would sign. Residents Affected - Few Review of resident #1's medical record revealed during less than 24 hours of his stay at the facility, he signed at least 14 documents on both 4/04/23 and on 4/05/23. These documents included the clinical consent to treat, the baseline care plan, the bed hold policy, the influenza and pneumonia vaccine consents, and the use of psychotropic drug therapy form. Review of the AHCA Nursing Home Transfer and Discharge Notice dated 4/05/23 revealed the reason for discharge was, Your needs cannot be met in this facility. The section for a brief explanation to support this action was left blank and no explanation as to what services could not be provided by the facility or what was to be provided at the receiving facility was given. The document was signed by LPN A on 4/05/23 but the resident signature was left blank as well as the section that indicated notice was given to the resident or representative. In an interview on 5/04/23 at 11:33 AM, CNA D stated she was assigned to sit with resident #1 when he was brought back to the facility. She said although he was a bit confused, he seemed to know where he was, and he was pleasant. She stated he was, ok and she had no problems with him nor felt threatened by him during her several hours observing resident #1 during one to one supervision in his room. She stated he did not curse, pace, or act angry and added he didn't have any inappropriate behavior during her time with him. In an interview on 5/04/23 at 12:00 PM, CNA E stated she was assigned to resident #1's care on 4/05/23 during the day shift. She described seeing resident #1 on the South wing at the nurse's station sitting in the weight chair, fussing but not carrying on. She offered him coffee which he declined, and she didn't see him again until he was brought back from outside after the elopement. She stated CNA D provided one to one supervision and she was in and out of the room during her shift several times. She described resident #1 as, okay, not upset, yelling or anything. She stated he never caused any problems the rest of her shift until he discharged in the afternoon. CNA E explained when the transport company arrived and tried to get resident #1 in the wheelchair he initially refused and wanted to walk, but after being re-directed, he complied with no problems. Review of the consult note dated 4/05/23 by the Psychiatric Advanced Practice Registered Nurse (APRN) revealed the chief complaint was new evaluation. The history and physical section described resident #1 upon arriving to the facility on 4/04/23 being placed on one to one observations due to his non-compliance and being intrusive. The APRN continued that resident #1 was able to exit the facility that morning and was brought back to the facility unharmed. She documented when she interviewed resident #1 he was in bed, alert and cooperative. He was able to describe to her that he lived on the streets and his intent was he thought he was going home. The APRN documented resident #1 had excessive anxiety and worry with aggravating factors of ongoing medical problems, life stressors and being in the facility. She indicated emotional and social support would help with these factors. She recommended regular follow up, psychiatric medication adjustment depending on the residents' presentation as long as he resided in the facility. The APRN documented, The patient denies homicidal ideation; has no intention of hurting others. She continued, Considering risks and protective factors, the patient appears to be at low risk of harming self or others intentionally. Review of the Order Summary Report dated 5/05/23 revealed resident #1 had orders for daily blood (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105207 If continuation sheet Page 3 of 5 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Melbourne Healthcare and Rehabilitation Center 1415 S Hickory St Melbourne, FL 32901 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 0622 Level of Harm - Actual harm Residents Affected - Few pressure medication, pain medication, and antipsychotic medication for agitation. Review of the Medication Administration Record for April 2023 revealed that although resident #1 had orders for medications he received none of the medications ordered during his approximate 18 hour stay from 4/04/23 to 4/05/23. Review of the Baseline Care Plan dated 4/04/23 and signed by resident #1 indicated problems, or potential concerns for falls, impaired skin integrity, recent infection, pain, assistance with activities of daily living and constipation. There were no care plans selected for behaviors or history of behaviors nor for use of psychoactive medications and therefore no interventions put into place. In interviews on 5/03/23 at 12:08 PM, and on 5/05/23 at 12:19 PM, with the DON, Administrator and the Regional Nurse, the DON stated she was at the facility for an early morning meeting on 4/05/23 and staff on the South wing told her the resident was good, he was resting and not to bother him. The staff had taken resident #1 off one to one monitoring as his behaviors had improved overnight and it was no longer a concern. She explained that a short time later she and the NHA discovered resident #1 was not in the facility and started a search. He was found outside a short time later and brought back to the facility. The DON described resident #1 as being easily re-directed back to the facility, and he was easily appeased with food, He liked eating. She said after the physician laid eyes on resident #1 that morning the team got together and as a group decided he needed to be discharged to a safer place. The physician wrote a discharge order to a secure unit based on his alcoholism. The DON explained that neither she nor the Administrator gave the AHCA transfer form to resident #1 and was not sure whether the nurse did. She stated she felt resident #1 being discharged to a secure unit in [NAME] was the best thing for resident #1, the other residents in the facility and the staff. The DON acknowledged the facility could not show what needs the resident had that could not be met by the facility and could not show what interventions had been made to provide the needed care to resident #1. She was unable to explain why they felt the facility was unable to care for resident #1 when he had no further elopement attempts and his behaviors were described by staff and the psychiatric consult as cooperative, calm, and non-threatening. She explained she felt resident #1 wanted to skedaddle out, and felt he was totally unpredictable. The DON stated we didn't know what was going to happen with his behavior, and explained he was discharged to [NAME] in too short a time to say what would happen. In a telephone interview on 5/05/23 at 10:32 AM, the physician stated he gave the order to discharge resident #1 to a secure unit as a mutual decision with facility administration. He stated resident #1 was aggressive, difficult, and non-compliant with an, explosive attitude. The physician explained he felt resident #1 posed a risk for the nursing staff and himself because he could not control his anger. He explained he did not feel he needed to send him back to the hospital for emergency psychiatric care and said when he was fine he was nice, but if you set limits on him he could explode. The physician stated he felt the staff at the facility was not equipped to take care of resident #1 at the time, because he needed more psychiatric help or closer supervision, but he agreed the fact that resident #1 had eloped from the facility also was a factor in the decision. The physician reiterated he was the covering physician and had tried to do what was best at the time. The admission Nursing Data Collection dated 4/05/23 at 2:08 PM, revealed documentation by Licensed Practical Nurse (LPN) A that resident #1 was oriented to person, place, time, and situation. He was able to transfer and ambulate independently. The document indicated he had depression or other mental health conditions which should be taken to care plan and a mental health consult requested. The Discharge and Orientation to Center section of the document indicated the plan to discharge, Once cellulitis is gone. LPN A documented she oriented resident #1 that afternoon to call lights, staff, life (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105207 If continuation sheet Page 4 of 5 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Melbourne Healthcare and Rehabilitation Center 1415 S Hickory St Melbourne, FL 32901 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 0622 enrichment schedule, business office, schedule, mealtimes, lighting and overbed table. Level of Harm - Actual harm In a telephone interview on 5/05/23 at 5:01 PM, in response to previous phone attempt made on 5/04/23 and on 5/05/23 the DON from the [NAME] skilled nursing facility where resident #1 currently resided stated he was on their secured, locked unit and asked him if he would agree to speak with the surveyor. He answered the phone and stated his name and knew he was in a facility in [NAME] but did not know how he had come to be there. He recalled he was originally from [NAME] and indicated several times he was worried about his stuff that was still in [NAME] somewhere. Resident #1 stated he had family including a brother and sister in [NAME], but he didn't think they knew he was in [NAME]. He relayed he had not had any visitors since he arrived in [NAME], nor had he spoken to any of his family as they didn't know where he was. Resident #1 again explained he did not remember how he came to be in [NAME], did not know how long he would be there and said he would like to return to [NAME] but was worried how he would get there. Residents Affected - Few In a telephone interview on 5/10/23 at 2:05 PM, from a returned call placed on 5/03/23 at 2:27 PM, the brother of resident #1 stated he and his family were shocked when he received a phone call from him on Monday saying he was in a nursing home in [NAME]. Resident #1's brother stated neither he nor any of resident #1's other family knew where resident #1 was after he was discharged from the hospital in April. He said no one from the facility contacted him to let him know his brother was being transferred to [NAME], explaining, I didn't know where he was. He said he had visited his brother in the hospital in [NAME] and was upset he was so far away he could not visit him there. He stated his brother was upset he was so far from his family and could not remember how he ended up in [NAME]. His brother told him he would try and figure out how he could get back to [NAME]. Review of the Facility Assessment Tool dated 12/10/22 revealed Psychiatric/Mood disorders were common diagnoses such as impaired cognition, psychosis, depression, anxiety and behavior that needs interventions that made up their resident profile and required complex medical care and management. The assessment indicated on average the facility had 4 residents with behavioral symptoms and cognitive performance in the last 3 months of the assessment. Section 2.1 of the assessment detailed the facility was able to give care to residents in the area of mental health and behavior to manage the medical conditions and medication related issues causing psychiatric symptoms and behavior and staff was able to assess, identify and manage deterioration of medical and psychiatric symptoms. Review of the Resident Transfer and Discharge Policy and Procedure dated 4/01/22 revealed the facility would maintain a transfer and discharge process that complied with regulatory requirements and maintained the resident's quality of care. The procedure detailed residents may be transferred or discharged as a result of different conditions including those necessary for the resident's welfare and the resident's needs cannot be met in the facility. The policy described that all transfers or discharges must be documented in the medical record and must include, The basis for the transfer, and, The specific resident need(s) that cannot be met, facility attempts to meet the resident needs and the service available at the receiving facility to meet the need(s). The policy indicated the previous documentation must be made by the resident's physician. The document further indicated that the facility should provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge for the facility in a form and manner the resident can understand. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105207 If continuation sheet Page 5 of 5