Inspection·May 26, 2022

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few behavior monitoring or side effect monitoring for the antipsychotic medication had been added to the MAR or TAR. When asked if they should have been added she confirmed they should have been added and stated she would add both to the system. She confirmed that the order for the antipsychotic medication was added on [DATE] and that there was no record of behavior or side effect monitoring for the medication. During an interview with the Psychiatric Advanced Nurse Practitioner on [DATE] at 10:58 a.m., she confirmed that Resident #26 was prescribed the antipsychotic medication prior to his admission to the facility. She further stated she had seen the resident twice since his admission. She also confirmed that there was no behavior monitoring being conducted for this resident. During an interview with the Assistant Director of Nursing (ADON) on [DATE] at 11:01 a.m., she stated she was familiar with Resident #26. The resident had severe anxiety and was taking the antipsychotic medication prior to his admission. He was scheduled to see the facility's psychiatric provider who came in weekly. She stated he had physical behaviors. She described the resident as panicky, weak, and tired. She stated the certified nursing assistants (CNAs) and nurses were responsible for resident behavior monitoring. If there were any side effects, the nurses were responsible for documenting them on the MAR. Behavior monitoring was ordered for all residents on psychotropic medication upon admission when the medication orders were put in the system. She confirmed that this was not done for Resident #26. When asked why it wasn't done, she replied, There isn't a reason it shouldn't be there. She looked further into the resident's record and added that there was no monitoring for side effects or behavior added to the order for the psychotropic medication. She stated, I will be honest, it should be there. We are in the process of transferring into a new system, so there's charting by exception, but it hasn't been done yet, so that order should be there. 3. A review of Resident #11's [DATE] MAR and TAR revealed no documented evidence of behavior monitoring related to the use of psychotropic medication. A review of Resident #11's medical record revealed the resident was admitted on [DATE]. Primary diagnoses included vascular dementia with behavioral disturbance; generalized anxiety disorder; and major depressive disorder, recurrent and severe with psychotic symptoms. A review of the resident's [DATE] Physician's Order Sheets, revealed active orders for the following: Mirtazapine, 1 tablet, 30 mg by mouth four times daily for depression; Seroquel (quetiapine) 1 tablet, 25 mg, administer 12.5 mg by mouth two times daily for dementia; Xanax (alprazolam), 1tablet, 0.25 mg by mouth every 8 hours for anxiety; ok to continue current psychotropic medications, Gradual Dose Reduction (GDR) contraindicated at this time due to continued aggressive outbursts at times; side effects: Anti-Anxiety Medication use - observe resident closely for significant side effects every shift, day, night; side effects: Anti-Depressant Medication use - observe resident closely for significant side effects every shift, day, night; side effects: Antipsychotic Medication use - observe resident closely for significant side effects every shift, day, night; side effects. A review of the Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed that Resident #11 had a Brief Interview for Mental Status (BIMS) score of 8 out of a possible 15 points, indicating moderate cognitive impairment. A review of the active Care Plan revealed that the resident had a focus on diagnoses of depression, anxiety, and psychosis, and was At Risk for Drug Related: hypotension, gait disturbance, cognitive impairment, behavioral impairment, ADL (activities of daily living) decline, decreased appetite, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105458 If continuation sheet Page 2 of 4 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 105458 B. Wing (X3) DATE SURVEY COMPLETED A. Building 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ormond Rehabilitation and Nursing Center 103 Clyde Morris Blvd Ormond Beach, FL 32174 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 abnormal involuntary movements related to the use of Seroquel, Xanax, and Remeron. Level of Harm - Minimal harm or potential for actual harm A review of the Nursing Note dated [DATE] at 8:31 p.m., revealed that Resident #11 had been restless off and on this shift calling on phone with repetitive questions and coming up to nurse's station making repetitive statements; difficult to redirect. Residents Affected - Few A review of the Nursing Note dated [DATE] at 3:18 p.m. revealed that Resident #11 was very anxious this shift, restless and pacing back and forth out of room, and calling on phone for pain relief. With medication given Resident #11 continued to be anxious. Notified Doctor and received new order to increase Xanax to three times per day. Notified daughter. A review of the Psychotropic Review/Behavior Form, dated [DATE], revealed decreases attempted in 2/2022 were unsuccessful - increase in symptoms caused medication orders to resume, needed to maintain function. Gradual dose reduction not recommended at this time. A review of the Psychotropic Review/Behavior Meeting Form, dated [DATE], revealed reduction not needed, outburst and behaviors have minimized but do still occur. Psychiatric services following. Gradual dose reduction not recommended at this time. During an interview with the Director of Nursing (DON) on [DATE] at 11:55 a.m., the DON confirmed there was no behavior monitoring ordered for this resident. A review of the facility's policy for Psychotropic Medication (last revised on [DATE]) revealed that nursing duties included: Monitor psychotropic drug use daily noting any adverse effects such as increased somnolence or functional decline. (Photographic evidence obtained) 2. A review of the medical record revealed that Resident #38 was admitted on [DATE] with diagnoses including dementia without behaviors; insomnia, depression, and a cognitive/communicative deficit. A review of the Quarterly MDS assessment, dated [DATE], revealed the resident's BIMS score was documented as a 6 out of a possible 15 points, indicating severely impaired cognition. The resident was receiving antipsychotic and antidepressant medications. A review of the [DATE] Physician's Order Sheets, revealed the following active orders: [DATE] Lexapro (antidepressant) 10 mg daily for depression [DATE] Side effects monitoring for antidepressant medication use [DATE] Seroquel (antipsychotic) 25 mg twice daily for unspecified psychosis; [DATE] Side effects monitoring for antipsychotic medication use. A review of Resident #38's active Care Plan revealed focus areas for Risk for Complications and Side Effects of Antipsychotic Medications; Risk for Side Effects of Antidepressant Medications; and Cognitive Deficit related to dementia. The resident was noted as seeing and speaking to her deceased husband. A psychotropic review was conducted on [DATE] which read, Continues to have hallucinations. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105458 If continuation sheet Page 3 of 4 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 105458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ormond Rehabilitation and Nursing Center 103 Clyde Morris Blvd Ormond Beach, FL 32174 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 A review of the resident's [DATE] MAR and TAR revealed no documentation to verify behavior monitoring or psychotropic medication side effects monitoring was being conducted. On [DATE] at 12:20 p.m., an interview was conducted with the DON, who stated behavior monitoring was documented on the Medication Administration Record (MAR) and was to be done every shift. Residents Affected - Few On [DATE] at 11:15 a.m., an interview was conducted with the ADON. When asked when behavior monitoring was to be ordered for residents receiving psychotropic medications, the ADON stated when the medication is started. When asked if there was a reason why it would not be ordered, the ADON stated there were no reasons why behavior monitoring would not be ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105458 If continuation sheet Page 4 of 4