Inspection·June 17, 2025

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Based on interview with Long-Term Care Ombudsman, record review, staff interviews, and facility policy review, the facility failed to provide a copy of the Nursing Home Transfer and Discharge Notice (NHTDN) to the local Long-Term Ombudsman office for three (Resident #1, Resident #4, and Resident #5) out of five residents reviewed for discharge. The findings include: During an interview with the Long-Term Care Ombudsman on 6/13/25 at approximately 11:00 AM, she stated that the Long-Term Care Ombudsman office had only received one Transfer/Discharge notification from the facility for several months. 1. Review of Resident #1's admission record showed an admit date of 5/15/25. Review of Resident #1's NHTDN dated 5/23/25 did not show the local Long Term Care Ombudsman was notified of transfer to homeless shelter. 2. Review of Resident #4's admission record showed an admit date of 4/2/25. Review of Resident #2's NHTDN dated 4/24/25 did not show the local Long Term Care Ombudsman was notified of transfer to home. 3. Review of Resident #5's admission record showed an admit date of 4/12/25. Review of Resident #5's NHTDN was not dated and did not show the local Long Term Care Ombudsman was notified of transfer to home. An interview was conducted with the Social Services Director (SSD) on 6/17/25 at approximately 12:41 PM. She confirmed that she was responsible for providing the notification of transfer and discharge to the local state ombudsman office. She explained that once the form was completed by all disciplines, and the resident or resident representative signed the form, she would then send a copy of the notification to the ombudsman office via email. When she was asked to provide the email verification for Resident #1, Resident #4, and Resident #5, she stated she was going to resend them all now. No email verifying the Transfer/Discharge notification was provided to the Ombudsman for Resident #1, Resident #4, and Resident #5 was received. An interview with was conducted with the Administrator on 6/17/25 at approximately 1:48 PM. She stated that her expectation for the Transfer/Discharge notice was that the SSD email a copy of all Transfer/Discharge notifications issued to the Long-Term Care Ombudsman office on the first day of each month, with the previous month transfer/discharges. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 105311 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 06/17/2025 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)