Inspection·March 28, 2024

F 0610 Respond appropriately to all alleged violations. 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 report suspected staff abuse of a resident to the state licensing authority for 1 of 4 residents reviewed for Abuse, of a total sample of 12 residents, (#5). Residents Affected - Few Findings: Review of the medical record revealed resident #5, a vulnerable [AGE] year old male was admitted to the facility from an acute care hospital on 1/23/23 with diagnoses of spinal stenosis (narrowing), failure to thrive, malnutrition, impaired cognitive functioning and awareness symptoms, peripheral vascular disease (impaired circulation in the limbs), Chronic Obstructive Pulmonary (Lung) Disease, right foot drop, and contractures (muscle/tendon shortening/rigidity). The Minimum Data Set Quarterly Assessment with Assessment Reference Date 10/26/23 noted resident #5 scored 9 out of 15 on the Brief Interview for Mental Status that indicated he was moderately cognitively impaired. The assessment showed the resident had no indicators of psychosis, and he had not rejected evaluation or care. The resident had functional and range of motion limitations of his upper and lower limbs, was dependent on staff to complete Activities of Daily Living (ADLs) and mobility functions in and out of bed, was always incontinent of bowel and bladder functions, and received high-risk anti-depressant medication during the look-back period. The Order Summary Report documented resident #5 had active physician's medication orders that included Remeron 15 milligrams at bedtime for depression. On 3/27/24 at approximately 2:00 PM, resident #5 was in his room lying in bed and stated, I don't want to talk. Review of the Comprehensive Care Plan included focuses for malnutrition, psychosocial well-being risks, limited physical mobility, ADL self-care performance deficits, impaired cognitive function/dementia and thought processes, memory loss, dependence on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits, immobility, and chronic disease processes, and communication deficits with interventions that included to ensure/provide a safe environment. The August 2023 Reportable Event Log noted an allegation of abuse concerning resident #5 occurred on 8/17/23 at 9:45 PM. On 3/27/24 at 3:15 PM, Certified Nursing Assistant (CNA) B recalled an incident that occurred during the 3:00 PM to 11:0 PM shift on 8/17/23. She explained she had assisted CNA A to provide resident (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: 105325 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 105325 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Space Coast Healthcare and Rehabilitation Center 125 Alma Blvd Merritt Island, FL 32953 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)