Inspection·October 27, 2022

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 10/27/2022 at 12:52 pm with Resident #52, she stated she could smoke at anytime with the exception of meal times, when the staff requested that all residents come inside to eat. On 10/27/2022 at 1:05pm during an interview with the Administrator, he was asked about the process for determining whether a resident was a safe smoker. He advised that the nurses were responsible for conducting the smoking assessments. He was asked for the policy related to safe smoking. He said that he would check with the nurses regarding this policy. He was asked if residents could keep their cigarettes and lighters in their possession. He stated that residents could not keep their own smoking supplies. He stated the smoking supplies were kept in a lockbox. He stated the box was kept at the nurses' station, and the designated certified nursing assistant (CNA) took the smoking box out to the smoking area. During an interview on 10/27/2022 at 1:20 pm with CNA E, she stated she had been employed at facility for approximately three months. She was asked to describe her typical work routine. She stated she generally clocked in around 6:45 am and checked her assignment for the day, which was written on an assignment board located at the time clock. She stated she was usually assigned to the smoking area. She stated she retrieved the smokers' box from the nurses' station, then headed out to the smoking area. She was asked when the smokers were permitted to smoke. She replied that they could go out before and after meals. She stated she gave each resident two cigarettes, and she had the lighters and lit the cigarettes for the residents. She stated each resident had their own smoking supplies, which were stored in a plastic bag labeled with their name and room number, and that the plastic bags were kept in the smokers' lockbox held at the nurses' station. She stated smokers were not permitted to keep cigarettes and lighters on them. She stated there were designated smoking times throughout the day, before and after meals from 7:00 am until 11:00 pm, at which time she stated the door to the smoking area was locked. She was asked if any of the residents could go out to smoke on their own, and she replied that some of the smokers who could stand up to enter the keypad code to the door could go out by themselves. She stated she let the residents know when she is going to be away from the smoking area, and instructed them not to go out without her supervision. She denied observation of residents with cigarettes and lighters in their possession. She showed the lockbox which she brought to the smoking area. It appeared to be a toolbox with a lock which contained several clear plastic storage bags containing smoking supplies labeled with resident names and room numbers. During an observation of the designated smoking area at 1:30 pm on 10/27/2022 with CNA E, eleven residents were observed smoking unsupervised. The smoking lockbox was observed unattended in the area. When asked about this, CNA E stated a staff member should have been there. She speculated that maybe they had to leave to take care of something else. CNA E then exited the smoking area, leaving the eleven residents smoking without staff supervision. A review of the facility's policy and procedure revealed: Section: Basic Care Procedures Policy Title: Supervised Smokers Policy Number: NP.I -168 Effective Date: 10/15/2022 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105311 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 105311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Daytona Beach Health and Rehabilitation Center 1055 3rd Street Daytona Beach, FL 32117 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 0689 Supersedes: 05/03/2022 Level of Harm - Minimal harm or potential for actual harm 2. Smoking materials should be kept at the nurse's station, and staff should be informed to include electronic cigarettes and vaping materials. Staff should assist residents with recharging devices when needed and ensure safety. Residents Affected - Few 3. No fire igniting materials (matches/lighters) should be kept in resident/guest(s) possession. Smokers should obtain lighting materials from staff. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105311 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 105311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Daytona Beach Health and Rehabilitation Center 1055 3rd Street Daytona Beach, FL 32117 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Based on record reviews and interviews, the facility failed to 1) Maintain a hospice plan of care and documentation of care in the resident record, 2) Designate a member of the facility's interdisciplinary team to coordinate care with Hospice, and 3) Coordinate Hospice care for two (Residents #57 and #68) of 20 residents reviewed for hospice services/coordination of care, from a total sample of 38 residents. The findings include: 1) A review of Resident #57's medical record revealed an admission date of 2/14/2022 with diagnoses including cerebral palsy; Benign Prostate Hypertrophy; obstructive and reflux uropathy, unspecified; hypokalemia; other specified persistent mood disorders; angina pectoris, unspecified; personal history of urinary tract infections; type 2 diabetes mellitus without complications; chronic pain syndrome; epilepsy unspecified, not intractable, without status epilepticus; localized edema; major depressive disorder, recurrent, mild; morbid obesity due to excess calories; hyperlipidemia; essential hypertension; paraplegia; encounter for palliative care. A review of the Significant Change Minimum Data Set (MDS) assessment, dated 9/8/22, revealed he was receiving Hospice services. A review of the physician's orders revealed that on 9/2/22, a Hospice consult was ordered. On 10/26/22 at 1:05 PM, a review of the medical record for Resident #57 revealed no documents related to the Hospice provider. 2) A review of Resident #68's medical record revealed that the resident was admitted to the faclity already on Hospice services on 8/16/22. His diagnoses included hypertension, peripheral vascular disease, chronic kidney disease, stage 3, pain, type 2 diabetes mellitus, depression, pulmonary hypertension, functional quadriplegia, anxiety disorder. On 10/26/22 at 3:15 PM, a review of the medical record for Resident #68 revealed no documents related to the Hospice provider. On 10/26/22 at 1:40 PM, an interview was conducted with the Director of Social Services (DSS). When asked of her involvement with the Hospice process, she stated when there was an order for Hospice, she would call it in, or if a resident is declining, staff might ask her to call the family. The DSS explained that at times, she would work with the Hospice social worker, but she mostly worked with the residents. She was not aware of a Hospice coordinator in the facility. There were three Hospice providers that residents and family could choose from. She stated Resident #57 was admitted to Hospice on 9/5/2022. Per the DSS, care plan conferences were held quarterly and as needed. The last care plan meeting for Resident #57 was on 9/27/2022, which included the interdisciplinary team. Resident #57 and Hospice were invited but both declined. The DSS deferred to the Minimum Data Set (MDS) Office for the sign-in sheet for care plan meetings and the Business Office for signed Hospice consent. She stated Hospice care plans should be in the residents' charts. On 10/26/22 at 2:00 PM, an interview was conducted with the Administrator. He stated he believed the Hospice coordinators were the unit managers. On 10/26/22 at 2:02 PM, an interview was conducted with Employee B. Inquired about any signed Hospice consents the facility had for Resident #57. Per Employee B, the only signed consent for Hospice (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105311 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 105311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Daytona Beach Health and Rehabilitation Center 1055 3rd Street Daytona Beach, FL 32117 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 0849 she had was the Facility Notification of Hospice Admission/Change consent. Level of Harm - Minimal harm or potential for actual harm On 10/26/22 at 2:05 PM, the Director of Nursing (DON) was interviewed and was asked who in the facility was the Hospice coordinator. She stated she thought Social Services was in charge of Hospice coordination. The DON was not aware that there was no documentation on the Hospice charts. She stated she would follow up with the Hospice provider. Residents Affected - Few On 10/26/22 at 3:00 PM, the DON produced the hospice consent which was signed by Resident #57. She stated the resident had the paperwork in his nightstand drawer. The DON provided a list of residents receiving services from this specific Hospice provider (Resident #57 and Resident #68). On 10/27/22 at 1:42 PM, Employee C was asked if she was the Hospice Coordinator. She stated the facility did not have one as far as she knew. She further explained, If a resident needs Hospice, we let Social Services know. On 10/27/22 at 1:51 PM, Employee D was asked if she was the Hospice Coordinator. She stated she was not, but if a resident was declining and needed services, she notified Social Services. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105311 If continuation sheet Page 5 of 5