Inspection·June 22, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The electronic health record and paper chart kept at the North Unit nurses station contained a yellow-colored State of Florida DNRO (DH Form 1896 revised December 2002) that was signed by the physician on 11/19/202. The form did not have any applicable boxes checked for surrogate, proxy, court appointed guardian, or durable power of attorney as required when no informed consent could be directly obtained from the patient. The Patient's Statement portion noted an undated signature line that included the handwritten name of the resident's son and the word, verbal. The Care Plan Conference Sheet noted on 5/11/2022 a meeting was held and the resident's son participated with discussions that included, code status, dc (discharge) plans will remain at (facility name) long term care. On 6/21/2023 at 2:25 PM, the Social Services Director stated she was responsible for the advanced directives and DNR documents process. She explained the DNRO yellow form for incapacitated residents must include a box checked under the patient's statement with a physical signature and date. She said there was a process in place to secure signatures for family representatives who could not complete it with her face to face at the facility. She checked the medical record and acknowledged resident #52's DNRO form was not signed, nor was the resident's son the appointed health care surrogate. She stated the form also did not have any of the required applicable boxes checked. She said the form was completed before she began working at the facility and could not explain why it was not completed properly or later verified for accuracy. She said resident #52's DNRO was, not valid. Review of the facility's policies and procedures form CCG 00521 dated 2020 read, VIII. The Facility shall: A. not be required to provide care that conflicts with an advanced directive . PROCEDURE I B. The facility shall update and disseminate amended information as soon as possible, but no later than 90 days from the effective date of the changes . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105207 If continuation sheet Page 2 of 11 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 06/22/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a Preadmission Screening And Resident Review (PASARR) for a later identified Mental Illness (MI) for 1 of 1 resident reviewed for PASARR from a total sample of 36 residents, (#52). Findings: Review of resident #52's medical record revealed the resident was admitted to the facility on [DATE] from an acute care hospital with diagnoses including metabolic encephalopathy (brain function abnormality), rhabdomyolysis (muscle injury), and stroke. Diagnoses of other schizoaffective disorders, adjustment disorder with mixed anxiety, anxiety disorder, moderate dementia with behavioral disturbance, speech and language deficits, malnutrition, and dysphagia (difficulty swallowing) were added to the resident's plan of care after he was admitted . The medical record showed a PASARR screen was completed on 1/25/2021 by acute care hospital staff. Section I noted there was no Mental Illness (MI) present or suspected. The diagnosis of other schizoaffective disorders noted as, during stay was added to resident #52's plan of care, effective 8/04/2021. On 6/21/2023 at 1:46 PM, the Social Services Director said residents' PASARRs were reviewed by Admissions staff and any clinical questions or concerns were reviewed by the Director of Nursing (DON). She explained the former DON had completed any updates for residents who remained in the facility, and she was not a designated screener. On 6/22/2023 9:10 AM, the Interim DON provided a copy of the PASARR completed on 1/25/2021 located in the resident's medical record. She acknowledged the form indicated there were no known or suspected mental illnesses and schizoaffective disorder was included on the list in section I. She said the medical record showed on 8/04/2021 the diagnosis of other schizoaffective disorders was added and noted, during stay. On 6/21/23 at 4:33 PM, the Interim DON said she had not completed any PASARRs and she had just started working at the facility on 6/19/2023. She explained she was not aware who the designated screener was for the facility, and the former DON completed them. She could not explain why a PASARR was not completed for the resident after a mental illness was diagnosed. Review of the facility's policies and procedures dated 4/01/2022 titled, Pre-admission Screening and Resident Review (PASRR) program, read, 2. Coordination includes: . b. Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review . , and 5., A nursing facility must notify the state mental health authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who has mental illness or intellectual disability for resident review. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105207 If continuation sheet Page 3 of 11 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 06/22/2023 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASARR) level I for possible Serious Mental Illness (SMI) for 1 of 1 resident from a total sample of 36 residents (#55). Residents Affected - Few Findings: Review of resident #55's medical record revealed the resident was admitted to the facility on [DATE] from an acute care hospital with diagnoses to include schizoaffective disorder, major depressive disorder, psychotic disorder with delusions, unspecified dementia. A level I PASARR screen was completed on 2/11/2022 by acute care hospital staff. Section I inaccurately noted there was no Mental Illness (MI) present or suspected. The medical record revealed all the above diagnoses to be present on admission. Review of physician orders included Lexapro for depressive disorder with a start date of 2/16/22, Seroquel for schizoaffective with a start date of 5/12/23. On 6/21/23 at 10:00 AM, the Director of Nursing (DON) stated the Social Service Director (SSD) and the Director of Admissions should ensure the resident has an accurate PASARR upon admission. She stated the PASARR should be reviewed by the DON for accuracy when the resident was admitted to the facility. The DON said the SSD should also review it for accuracy. Review of the facility's policy and procedure titled, Pre-admission Screening and Resident Review (PASRR) program, dated 4/01/2022 read: The facility will coordinate assessments with the pre-admission screening and resident review (PASRR) program. Coordination includes: Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105207 If continuation sheet Page 4 of 11 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 06/22/2023 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement care and services to maintain or prevent decline in Activities of Daily Living (ADL) abilities, for 1 of 3 residents reviewed for Rehabilitation and Restorative services from a total sample of 36 residents, (#98). Residents Affected - Few Findings: Review of the medical record revealed resident #98 was admitted on [DATE] and re-admitted on [DATE] from an acute care hospital and had diagnoses that included stroke, encephalopathy (brain dysfunction), aphasia (difficulty speaking/understanding speech), dysphagia (difficulty swallowing), malnutrition, gastrostomy dependence (feeding tube), lack of coordination, muscle weakness, syncope (fainting) and collapse, heart failure, dependence on supplemental oxygen, type 2 diabetes mellitus, and depression. The Minimum Data Set (MDS) admission assessment with Assessment Reference Date (ARD) 5/22/2023 noted the resident was unable to complete the Brief Interview for Mental Status and was assessed by staff to have moderately impaired cognitive skills for decision making, inattention fluctuations, and no behaviors or rejections of evaluation or care for health and well-being. The assessment noted it was very important for the resident to participate and engage in her daily routines and preferences. She was noted to be totally dependent on staff to complete ADLs, required an indwelling urinary catheter, was incontinent of bowel, received more than 51% of nutrition from a tube feeding, was at risk for developing pressure injuries, received skilled Speech and Language (SLP) therapy services for 3 days, Occupational Therapy (OT) for 5 days, and Physical Therapy (PT) for 5 days during the lookback period. On 6/19/2023 at 2:30 PM, resident #98 was observed awake in bed and her daughter was sitting at her bedside. The resident's daughter stated that her mother had been hospitalized for a while after she had a massive stroke before coming to the facility. She explained she was distressed that the resident had not received therapy services for at least a week after she had progressed and improved over the past month. She said the only range of motion or muscle exercise assistance her mother received since then was provided by her when she visited every day. She indicate her mother had already gotten worse with moving in bed. She said therapy staff told her they had tried to get approval to continue therapy but they weren't able to. She was visibly upset while she explained therapy stopped providing services because, we can't pay. The Order Summary Report included physician's orders for Full Code status, left resting hand splint, skilled PT services 5 times per week for 30 days starting on 5/17/2023, speech therapy for 30 days with 20 total visits, starting on 5/17/2023, and OT 5 times per week for 30 days starting on 5/16/2023. On 6/21/2023 at 12:23 PM, the Therapy Director said residents' length of skilled therapy services was sometimes affected by contractual payment agreements between the discharging hospital and the facility, because the hospital was paying for a specific number of days. She reviewed the resident's medical record and explained the resident was discharged from therapy services because it was her, last covered day. She said after therapy services ended on 6/13/2023, therapy staff developed a functional maintenance/restorative program of exercises to be provided by nursing services so the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105207 If continuation sheet Page 5 of 11 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 06/22/2023 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few could maintain the progress she made and prevent declines. She provided an undated copy of the Functional Maintenance Program Instructions form that outlined an individualized program of exercises for the resident. She could not explain why there was no date on the form and stated the services should have been started on 6/14/2023. She said she had given the form to the Director of Nursing (DON) to implement. Review of the medical record revealed a letter of agreement was completed by the hospital prior to the resident's admission to the facility for payment of care and services including skilled therapy for 30 days. The comprehensive care plan included focus items that showed the resident was interested in her choice of activities, had impaired communication with an intervention for SLP treatment, risk for skin injury, risk for respiratory complications with interventions to assist with positioning to maximize lung functioning, ADL and mobility impairment with dependence on staff assistance and a goal to minimize complications through nursing and therapeutic interventions. The OT Evaluation and Plan of Treatment assessed the resident required services to facilitate her increased ability to participate in functional daily activities, and the use of a left-hand splint to reduce the risk of further immobility. The report noted skilled services were required to gain strength, restore cognitive and perceptual abilities, and maximize rehabilitation potential and without treatment, the resident was at risk for further decline in function, immobility, compromised general health, and decreased ability to return to her prior level of supervision. The OT Discharge Summary completed on 6/12/2023 noted the resident had responded and consistently progressed during the last 30 days of treatments but she had not reached her, highest practicable level. The prognosis for functional maintenance was, good with consistent staff follow-through with a risk of developing contractures (muscle tightening) and further decline in her ADL functioning abilities without maintenance exercises. The PT Evaluation and Plan of Treatment noted the resident required services to facilitate improvement in self-functioning with treatments for restoration/compensation, use of assistive devices, compensatory strategies to minimize falls, and enhance the resident's quality of life by improving her ability to return to her prior level of functioning. The PT Discharge Summary completed on 6/13/2023 noted the resident had made consistent progress throughout the plan of treatment, recommendations for an exercise program to continue, long term care, and a good prognosis to maintain her level of functioning abilities with, consistent staff follow-through. The Functional Maintenance Program Instructions form for the resident noted instructions for staff to provide active and passive range of motion activities 3 to 5 times per week and transferring from the bed to a high back wheelchair for 4 to 6 hours, 3 to 5 times per week. Review of the Task Listing Report for Certified Nursing Assistants (CNAs) did not include instructions or tasks to complete resident #98's Functional Maintenance Program exercises. On 6/22/2023 at 10:03 AM, the interim South Unit Manager said she received the Restorative/Functional Maintenance program on 6/21/2023 to enter into CNA tasks so Restorative CNAs could complete exercises with the resident according to the individualized plan. She explained the resident's program had not been implemented because she was not aware of, nor had she been provided the plan of care. She stated that Restorative CNAs reported to her, and they documented completion of Restorative/Functional Maintenance exercises in the CNA task software. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105207 If continuation sheet Page 6 of 11 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 06/22/2023 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 0676 Level of Harm - Minimal harm or potential for actual harm On 6/21/2023 at 4:37 PM, the interim DON said resident #98 had not received functional maintenance/restorative nursing services because there was a delay in receiving the program from the Therapy Director. She said she received the plan earlier that day right after it had been developed. She explained that she was unable to locate restorative program forms for any residents and she did not know which residents were received restorative services. She stated, I'm not sure they every existed. Residents Affected - Few Review of the facility's policies and procedures dated 4/01/2022 titled Specialized Rehabilitative and Restorative Services, read, 4. The facility will provide restorative services such as . walking, transfer training, . Range of Motion (ROM), splint and brace, eating and/or swallowing, . care and communication, when necessary as indicated by the assessment of the Interdisciplinary team. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105207 If continuation sheet Page 7 of 11 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 06/22/2023 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain a physician order for oxygen therapy for 1 of 1 resident reviewed for oxygen of a total sample of 36 residents, (#79). Residents Affected - Few Findings: Resident #79 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, and anxiety. On 6/20/23 at 1:36 PM, the resident was seen lying in bed with oxygen at 2 liters per nasal cannula. On 6/21/23 at 9:10 AM, the resident was seen sitting up in bed with oxygen at 2 liters per nasal cannula. On 6/21/23 at 9:20 AM, a review of resident #79's medical record revealed no order for oxygen therapy. Review of the Medication Administration Record and Treatment Record reflected no documentation of oxygen being administered for resident #79. On 6/21/23 at 9:30 AM, Registered Nurse B stated resident #79 was on oxygen but he could not find an order in the computer for the resident's oxygen liter flow. He stated it may be in the hospice book. On 6/21/23 at 9:40 AM, the South wing Unit Manager (UM) acknowledged there was no physician order for oxygen therapy for resident #79. The UM stated the hospice nurse gave the facility written orders to place in the electronic medical record (EMR) because they did not have access to the EMR. She clarified there was no order for oxygen in the resident's hospice chart. On 6/22/23 at 12:48 PM, the Director of Nursing stated her expectation was that residents on oxygen would have a physician order for oxygen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105207 If continuation sheet Page 8 of 11 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 06/22/2023 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure behavior monitoring and side effects of antipsychotic medication were documented for 2 of 5 residents reviewed for unnecessary medications out of a total sample of 36 resident, (#55, #67). Residents Affected - Few Findings: 1. Resident #67 was readmitted to the facility on [DATE] with a previous admission on [DATE] with diagnoses of dementia, Alzheimer's disease, malignant neoplasm of prostate, bipolar disorder, and hallucinations. Review of quarterly Minimum Data Set (MDS) with assessment reference date of 4/30/23 revealed shortand long-term memory problems. The resident's care plan initiated 1/23/23 revealed a focus for potential side effects related to psychotropic medications with interventions to observe for potential side effects, notify physician and psych services to follow. Review of the resident's physician orders revealed antipsychotic medication, Risperidone 1 milligram (mg) ordered 1/27/23 to be given by mouth twice a day for dementia, psychotic disturbance, mood disturbance, anxiety, hallucinations, and bipolar disorder. A physician order dated 4/29/23 noted antianxiety medication, Diazepam 2 mg, give 1 mg by mouth at hours of sleep for anxiety. Review of behavioral note dated 7/25/22 showed monitor for mood and behaviors. Psych note dated 4/4/23 revealed resident #67 has a history of dementia with behaviors and is taking Risperidone for bipolar disorder. Psych note dated 5/1/23 and 6/1/23 showed staff to document and monitor behaviors. Review of resident #67 physician orders for the month of June 2023 revealed no order for behavior or side effect monitoring, and no documentation noted on medication administration record (MAR) or treatment administration record (TAR) for behavior or side effects monitoring. On 6/21/23 at 10:57 AM, the interim Director of Nursing said behavior monitoring and side effect monitoring were done for residents receiving psychotropic medications. She stated it is a batch order and it has to be activated by nursing and documented on the MAR. She stated the unit managers monitored nursing documentation but ultimately, she was responsible. On 6/21/23 at 1:10 PM, Licensed Practical Nurse (LPN) H stated nurses were to assess and document on residents' psychotic medications for behavior monitoring and side effects. On 6/21/23 at 1:24 PM, Registered Nurse (RN) B stated resident #67 had no behaviors, and did not yell out. He stated they were supposed to monitor, and document behaviors and side effects on the MAR if a resident received psychotropic medications. He stated the resident received the medication for dementia. Review of physician orders entered into the MAR with RN B revealed medications related to unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, hallucinations, unspecified bipolar with dementia. On 6/21/23 at 5:02 PM, during a telephone interview, the facility's consultant pharmacist stated behavior monitoring for psychotropic medications was a routine part of their drug regimen review, and she could not explain how it was missed for resident #67. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105207 If continuation sheet Page 9 of 11 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 06/22/2023 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Resident #55 was admitted to the facility on [DATE] with diagnoses to include schizoaffective depression, psychotic disorder, anxiety disorder, and mood disorder. Review of the physician active orders noted antianxiety medication, Lorazepam (Ativan) Gel 25mg/ml, apply to wrist topically every 8 hours as needed for anxiety, antipsychotic medication, Seroquel 100 mg once a day and 300 mg at bedtime for schizoaffective disorder, antidepressant medication, Trazadone 100 mg at bedtime for depression. There was no order noted for behavior monitoring. Review of the MAR and TAR reflected no documentation of behavior monitoring for any of the psychotropic medications. On 6/21/23 at 3:53 PM, the interim DON stated resident's new orders and admission orders were reviewed Monday through Friday and in clinical morning meeting, which is how they ensured behavior monitoring, and side effect monitoring was ordered for residents on psychotropic medications. The DON did not explain how behavior and side effect monitoring was missed. Review of the facility's policy for Psychotropic Drug Use with no effective date showed each customer receiving antipsychotic medications for organic mental disorders is observed for episodes of the behavioral symptoms being treated and /or manifestation(s) of the disordered thought process, adverse reactions and side effects. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105207 If continuation sheet Page 10 of 11 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 06/22/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure psychotropic medications that were ordered as needed (PRN), did not exceed beyond 14 days without documented rationale for 1 of 5 residents sampled for unnecessary medications of a total sample of 36 residents, (#55). Findings: Resident #55 was admitted to the facility on [DATE] with diagnoses of schizoaffective disorder, depression, psychotic disorder, anxiety disorder, and mood disorder. Review of the physician orders dated 4/26/23, Lorazepam (Ativan) gel 2 milligrams per milliliter (mg/ml), apply to wrist topically every 8 hours as needed (PRN) for anxiety. The order did not have a stop date. Review of the medical record revealed no rationale to continue the Lorazepam order beyond the 14 day period. On 6/21/23 at 4:08 PM, the Director of Nursing stated antianxiety medications that were ordered PRN must be stopped after 14 days and the doctor must see the resident to renew the order. On 6/22/23 at 5:37 PM, Registered Nurse B stated if the PRN psychotropic medications such Lorazepam did not have a stop date, it should be given only 7 to 14 days. She added that if the physician did not write a stop date, I guess the resident needs the medication so I would continue to give it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105207 If continuation sheet Page 11 of 11