Inspection·December 3, 2024

F 0609 away from her, instead of towards her was discussed and reported to the DON on 11/02/24 by RN B. Level of Harm - Minimal harm or potential for actual harm On 12/02/24 at 3:37 PM, in an interview conducted with CNA A, who was accompanied by the Assistant Director of Nursing, the CNA confirmed that on 11/01/24 she was resident #1's assigned CNA. She stated the resident required total care with her ADLs, and verbalized that prior to the resident's fall on 11/01/24, the resident required one person assist for ADLs, and mechanical lift with two persons for transfers. CNA A recalled that on 11/01/24 at approximately 9:00 PM to 10:00 PM while providing incontinence care for the resident, she turned the resident to her left side away from her, by crossing the resident's legs, and pulling the pad or bedsheet. She said the resident was lying on her left side and demonstrated that she was standing on the right side of the resident's bed. CNA A said resident #1 reached towards the bedside table on the left of her bed and fell from the bed. She said she tried to grab the resident but could not hold on to her, and the resident sustained an injury to her right temple. Residents Affected - Few On 12/02/24 at 4:48 PM, the Evening Supervisor recalled that on 11/01/24 at approximately 10:00 PM-11:00 PM, she was called to the South Wing. She verbalized that Licensed Practical Nurse B, and CNA A were with resident #1, who was lying on the floor on her back. The Supervisor said she observed a scratch to the resident's right temple, and the nurse was applying pressure to the area and monitoring the resident's blood pressure. She recalled CNA A stated the resident rolled out of bed when she was trying to change her. She recalled that after the resident was sent to the Emergency Room, CNA A re-enacted the scene for her, and she notified the DON. The Supervisor said in the reenactment the CNA had turned the resident away from her to provide care. On 12/03/24 at 8:22 AM, in a telephone interview, the resident's family member stated the resident had dementia, spoke English but had reverted back to her native language Hungarian. The family member said the resident could not move her body, could not grab something or move if asked/told to. She recalled that on 11/01/24 the facility notified the family that the resident had a fall and had to go to the hospital. She said the facility dropped the resident, and recalled the resident's roommate at the time told her that at approximately 10:00 PM, resident #1 soiled herself, and needed changing. The roommate recounted that one CNA came in, pulled the bedsheet, and rolled the resident off the bed, and she hit the ground hard. The family member said she completed a grievance on 11/02/24 and documented negligence in the care of resident #1. On 12/03/24 at 11:38 AM, the DON acknowledged that an Immediate [State Survey Agency] report should have been completed for the incident on 11/01/24. She stated she had access to the reporting system on the weekend, but at the time of the incident she was focusing on the fact that CNA A followed the resident's plan of care pertaining to the number of persons required to provide incontinence care for resident #1. On 12/03/24 at 12:01 PM, the Social Service Director (SSD) recalled that on 11/04/24 she received a grievance pertaining to resident #1 that was documented by the resident's daughter on 11/02/24 at 12:00 PM and placed under the SSD's door. The SSD stated that on 11/04/24 she along with the Administrator and the DON called the resident's daughter, and at that time the daughter wanted to vent her frustration and kept using the word neglect. The SSD stated the facility then decided to do a reportable, since the resident's daughter wanted, more than a grievance process. Review of the grievance documented by the resident's daughter dated 11/02/24 at 12:00 PM, indicated the resident fell out of bed, due to the negligence of her CNA. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105207 If continuation sheet Page 2 of 3 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 12/03/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interviews with staff involved and record review of resident #1's medical record revealed the incident with resident #1 occurred on 11/01/24 at approximately 10:45 PM. CNA A neglected to use the proper technique for turning/positioning while providing incontinence care for the resident. A grievance alleging negligence was documented on 11/02/24 at 12:00 PM, however this was not acknowledged or acted upon until 11/04/24. An Immediate [State Survey Agency] report pertaining to neglect was not submitted until 11/04/24 at 6:26 PM, 42 hours after the allegation was made. The facility's policy Abuse: Florida dated April 1, 2022, read, The facility will ensure that all alleged violations involving .neglect .are reported immediately, but not later than 2 hours after the allegation is made .or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and other officials (including to the State Survey Agency). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105207 If continuation sheet Page 3 of 3