Inspection·September 10, 2021

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, clinical record review and facility policy and procedure review, the facility failed to ensure that three (Resident #59, #62 and #85) of five residents on oxygen therapy, had a physician's order for oxygen use, and failed to administer oxygen at the ordered flow rate for one (Resident #197) of five residents reviewed for oxygen use, from a total of 42 residents in the sample. This could result in the resident not receiving appropriate care and/or clinical complications. Residents Affected - Few The findings include: 1. A review of Resident #59's medical record noted an admission date of 7/7/21 with diagnosis that included: acute kidney failure, chronic atrial fib, pacemaker, venous insufficiency PVD, diabetes, HTN, urethral stricture, depression, panic disorder. A review of physician's orders for Resident #59 revealed no order for the use of oxygen. On 9/7/21 at 2:35 PM, Resident #59 was observed receiving oxygen via nasal cannula at 2 liters per minute (lpm) via oxygen concentrator. On 9/8/21 at 1:30 PM and again on 9/9/21 at 10:12 AM, Resident #59 was observed receiving oxygen via nasal cannula at 2 lpm via oxygen concentrator During an interview on 9/9/21 at 2:20 PM, Employee I, LPN was asked what the oxygen order was for Resident #59. She said, he was currently receiving 2 liters, but she would review the orders. After reviewing the orders, she said, she did not find the oxygen order in the chart. She was asked where oxygen administration was documented, and she replied, in the MAR. When asked if oxygen was documented on the MAR for Resident #59, she reviewed the MAR and said the order was not there. She was asked how long Resident #59 had been receiving oxygen, she said, he had it when he was transferred over from the north wing about a month ago. A review of the hospital transfer form dated 7/3/21 found no order for oxygen. A review of the medication record from the hospital dated 7/7/21 did not include an order for oxygen. A review of the APRN initial visit upon admission on [DATE] found no documentation regarding the need for oxygen or that resident had requested oxygen. A review of Resident #59's care plan revealed the use of oxygen was not addressed. During an interview with the unit manager on 9/9/21 at 2:30 PM, she confirmed Resident #59 did not have a physician's order for oxygen and he was not care planned for oxygen use. On 9/9/21 at 2:58 PM, Employee I, LPN reported that she called the APRN regarding Resident #59's oxygen order. The APRN told her that yesterday when she visited the resident, he requested to have oxygen because he felt better with it on. The APRN gave a new order for oxygen 2 liters as needed. 2. On 9/7/21 at 3:39 PM, Resident #62 was observed in his room. He was receiving oxygen via nasal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105565 If continuation sheet Page 2 of 10 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 105565 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coastal Health and Rehabilitation Center 820 N Clyde Morris Blvd 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cannula and his room concentrator was running and set at 2.5 liters per minute (lpm). Resident #62 confirmed that his oxygen was supposed to be set at 2.5 lpm. A review of Resident #62's medical record noted an admission date of 7/29/21 with diagnosis that included: medically complex conditions, atrial fibrillation, coronary artery disease, diabetes mellitus and asthma or chronic obstructive pulmonary disease (COPD). A review of physician's orders for Resident #62 revealed no order for the use of oxygen. (Photographic evidence obtained) A review of the admission/5-day minimum data set (MDS) assessment dated [DATE] revealed Resident #62 had a brief interview for mental status (BIMS) score of 13, indicating cognitively intact. Resident #62 was care planned on 7/29/21 for his multiple medical conditions; however, the care plan did not address the use of oxygen. (Photographic evidence was obtained) On 9/8/21 at 12:43 PM, Resident #62 was observed in his room eating lunch. His oxygen concentrator was running and set at a flow rate of 2.5 lpm, with his nasal cannula out of his nose. Resident #62 stated the cannula was off so he could eat. During an observation and interview with Resident #62 on 9/9/21 at 9:10 AM, his oxygen concentrator was running and set at a delivery rate of 2.5 lpm. His nasal cannula was not in place. Resident #62 stated, he was having no difficulty breathing, but that he sometimes did. That was why he used oxygen. He then put his nasal cannula back in place. During an interview on 9/9/21 at 9:31 AM with Employee F, Certified Nursing Assistant (CNA), she stated that Resident #62 used oxygen continuously and the nurse sets the oxygen flow rate. On 9/10/21 at 8:53 AM, Resident #62 was observed in his room watching television. His oxygen concentrator was running at a flow rate of 2.5 lpm with nasal cannula in place. A review of a nursing progress note dated 8/20/21, reported Resident #62 had oxygen in place at 2 lpm with nasal cannula. On 8/22/21, a progress note reported the resident's oxygen level was running a bit low and the Nurse Practitioner was notified. No orders were received. A progress note dated 9/5/21, stated Resident #62 was on oxygen. During an interview on 9/9/21 at 10:45 AM with Employee G, Licensed Practical Nurse (LPN), she reported Resident #62 experienced shortness of breath when he got up to go to the restroom. This morning his oxygen saturation rates were 99%. When told Resident #62 had been receiving oxygen since admission without an order until this morning, she looked up inquisitively and checked the order. Employee G confirmed there had been no order up to today. She did not know why. She said, That's weird explaining that doesn't seem right. Normally there is an order for oxygen. The physician's orders for Resident #62 were reviewed again and revealed the north wing Unit Manager had entered an order into Resident #62's electronic record on 9/9/21 for oxygen at 2 lpm via nasal cannula. On 9/10/21 at 8:53 AM, Resident #62 was observed in his room, with his cannula in place and the concentrator flow rate running at 2.5 lpm. 3. On 9/07/21 at 3:34 PM, Resident #85 was observed in the activities room with a portable oxygen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105565 If continuation sheet Page 3 of 10 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 105565 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coastal Health and Rehabilitation Center 820 N Clyde Morris Blvd 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few tank. The resident was wearing a nasal cannula and oxygen flow rate was set at 2 lpm. (Photographic evidence was obtained) A review of Resident #85's medical record noted an admission date of 2/9/21 with diagnosis that included: hypertension, anxiety, depression, embolism and thrombosis of superficial veins of the right upper extremity, and failure to thrive. Resident was noted to have shortness of breath with exertion and when lying flat and was assessed to receive oxygen while a resident of the facility. A review of physician's orders for Resident #85 revealed no order for the use of oxygen. A review of the quarterly MDS assessment dated [DATE] revealed Resident #85 had a BIMS score of 10, indicating moderate cognitive impairment with limited assistance from staff with activities of daily living. Resident #85 was care planned on 8/23/21 for her multiple conditions and medical diagnoses including for respiratory complications related to pneumonia. Interventions included oxygen, as ordered. On 9/8/21 at 12:54 PM, Resident #85 was observed in the north unit television (TV) room with her oxygen tank. She was wearing a nasal cannula and oxygen flow rate was set at 2 lpm. On 9/9/21 at 9:23 AM, Resident #85 was observed again in TV area on the north unit. She was receiving oxygen via her portable tank at 2 lpm. During an interview on 9/9/21 at 11:14 AM with Employee C, Registered Nurse (RN), she stated Resident #85 received continuous oxygen at 2 lpm and used a portable tank frequently, as she was up a lot. On 9/9/21 at 2:44 PM, Resident #85 was observed in the activities area. Her nasal cannula was in place and the tank set at 2 lpm, however the portable tank was empty. (Photographic evidence obtained). When asked if she was having any trouble breathing, resident stated, Yes, I need oxygen. She was asked if she could tell if there was any oxygen flowing from her nasal cannula. She closed her mouth, breathed through her nose, and said, No. During an interview on 9/9/21 at 4:17 PM with Employee K, RN, he stated the oxygen flow rate instructions for all residents is in the care plan and in the physician's orders. On 9/9/21, the north wing unit manager added a physician's order into Resident #85's electronic record for oxygen at 2 lpm via nasal cannula for comfort as needed. On 9/10/21 at 8:52 AM, Resident #85 was observed in bed with her eyes closed. She was receiving oxygen via nasal cannula and concentrator at 2.5 lpm instead of the ordered 2 lpm. (Photographic evidence was obtained). During an interview on 9/10/21 at 11:18 AM, the north wing unit manager was asked about Resident #85's oxygen. He stated there would be a physician's order for any oxygen use. On admission, the nursing staff would look at the hospital records and take the order off from there. He was advised Resident #85 had been receiving oxygen throughout the survey without an order. He was asked how nurses across 3 shifts daily could continue to assist with oxygen use, settings and portable tanks and not question that there was no order for oxygen. He reviewed the electronic record and said Resident #85 had an order in the past, but it was discontinued in March 2021. He had no explanation as to why the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105565 If continuation sheet Page 4 of 10 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 105565 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coastal Health and Rehabilitation Center 820 N Clyde Morris Blvd 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 0695 Level of Harm - Minimal harm or potential for actual harm oxygen was administered ongoing without an order and no explanation as to how nursing staff knew what flow rate to provide Resident #85. When told of the observation of the incorrect flow rate on 9/10/21, after the order was obtained, he stated his nurses are trained to get down at eye level to read the flow rate gage on the concentrators. He stated that his expectation would be to set the flow rate per the physician's order unless otherwise specified. Residents Affected - Few 4. On 9/7/21 at 11:01 AM, Resident #197 was observed in her room receiving oxygen via nasal cannula at 2.5 lpm. A review of Resident #197's medical record noted an admission date of 8/26/21 with diagnosis that included: pneumonia, asthma/COPD and respiratory failure. She received oxygen while not a resident and while a resident. A review of physician's orders for Resident #197 revealed she was to receive oxygen at 2 lpm A review of the admission MDS assessment dated [DATE] revealed Resident #197 had a BIMS score of 15, indicating cognitively intact. Resident #197 was care planned on 8/27/21 for her altered respiratory status and difficulty breathing related to her COPD and status-post tracheostomy. Interventions included monitor for signs of respiratory distress and provide oxygen as ordered. On 9/9/21 at 10:04 AM, Resident #197 was observed for a second time in her room receiving oxygen via nasal cannula at 2.5 lpm. An interview was conducted on 9/09/21 at 4:17 PM with Employee K, RN. He stated, Resident #197 was a chronic patient and received continuous oxygen at 2 lpm. He stated the oxygen flow rate instructions for all residents is in the care plan and in the physician's orders During an interview on 9/10/21 at 11:13 AM with the north wing unit manager, he was told of the observations made of incorrect oxygen flow rates. He explained, his nurses were trained to get down at eye level to read the gage on the concentrator. His expectation was the oxygen should be set per the physician's order unless otherwise specified. A review of the facility policy Oxygen Administration included: Preparation, verify that there is a physician order for oxygen administration, review the residents care plan to assess any special needs of the resident, assemble equipment and supplies needed. Equipment and supplies needed: portable oxygen cylinder, nasal cannula, humidifier bottle, No Smoking/Oxygen in Use sign, regulator and personal protective equipment. Assessment: before administering oxygen and while resident is receiving oxygen therapy, assess for following, signs or symptoms of cyanosis, hypoxia, oxygen toxicity, vital signs, lung sounds, arterial blood gases and oxygen saturation and other laboratory results as applicable. Documentation: after completing the oxygen setup or adjustment the following information should be recorded in the residents medical record. The date and time the procedure was performed, name and tile of the individual who performed procedure, rate of oxygen flow, route and rationale, frequency and duration of treatment, reason for as needed, all assessment data obtained before, during and after procedure, how resident tolerated the procedure. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105565 If continuation sheet Page 5 of 10 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 105565 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coastal Health and Rehabilitation Center 820 N Clyde Morris Blvd 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Few Based on record review, staff interviews and facility policy and procedure review, the facility failed to monitor resident behaviors and potential side effects related to the use of psychotropic medication for one (Resident #85) of five residents reviewed for unnecessary medications, from a total of 42 residents in the sample. The findings include: A review of Resident #85's clinical record revealed she was admitted on [DATE] with a primary diagnosis of anxiety and depression. A review of the physician's orders on 8/28/21, revealed an order for Buspirone HCI 10 mg (milligram) via G-tube for anxiety, Seroquel 200 mg via G-tube for depression and Escitalopram Oxalate 10 mg via G-tube for anxiety and depression. Behavior monitoring documentation and/or side effect monitoring documentation was not found in the medical record. The order history for Resident #85 revealed behavior and side effects monitoring was discontinued 10/18/20. (Photographic evidence was obtained) A review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #85 had a BIMS score of 10, indicating moderate cognitive impairment. Antipsychotic, antidepressants and antianxiety medications were documented as given during the 7 day assessment period. Antipsychotic medications were routinely given to her and the physician documented a gradual dose reduction (GDR) was contraindicated. Resident #85's care plan dated 8/23/21 revealed psychotropic medication use for Buspar (Buspirone) anti-anxiety, Lexapro (Escitalopram oxalate) antidepressant and Seroquel (antipsychotic). Interventions included to observe for side effects and to observe and document behaviors. She was care planned for a behavioral problem, including crying out when frustrated, childlike behavior and pulling out her gastrostomy tube. Interventions included to monitor her behavior. (Photographic evidence obtained). Resident #85 was last seen by a psychiatrist on 8/6/21 for her depression with psychosis, anxiety, insomnia, and dementia with behavioral disturbances. No changes were recommended and a GDR was reported to be contraindicated at the time. An interview was conducted with the north wing Unit Manager on 9/10/21 at 3:18 PM. The Unit Manager confirmed there was no documentation for behavior monitoring for Resident #85 related to the use of Buspar, Lexapro and Seroquel. He did not know why it was not documented and confirmed that all psychotropic medications require behavior and side effect monitoring to be in place. A review of the facility policy and procedure titled Behavioral Assessment, Intervention and Monitoring revised [DATE] states: 3. The facility will comply with regulatory requirements related to the use of medications to manage behavioral changes. Assessment: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105565 If continuation sheet Page 6 of 10 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 105565 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coastal Health and Rehabilitation Center 820 N Clyde Morris Blvd 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3. The nursing staff will identify, document and inform the physician about specific details regarding changes in individuals mental status, behavior and cognition including: a. Onset, duration intensity and frequency of behavioral symptoms; b. Any precipitating or relevant factors or environmental triggers (e.g. medication changes, infection, recent transfer from hospital); and c. Appearance and alertness of the resident and related observations. 4. New onset or changes in behavior will be documented regardless of the degree of risk to the resident or others. Management: 8. The care plan will include, at a minimum: a. A description of the behavioral symptoms . b. Targeted and individualized interventions for the behavior or psychosocial symptoms; c. The rationale for the interventions and approaches; and, e. How the staff will monitor for the effectiveness of the interventions. 10. When medications are prescribed for behavioral symptoms, documentation will include: h. Monitoring for efficacy and adverse consequences. Monitoring: 4. The nursing staff and the physician will monitor for side effects and complications related to psychoactive medications; for example, lethargy, abnormal involuntary movements, anorexia or recurrent falling. Photographic evidence was obtained . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105565 If continuation sheet Page 7 of 10 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 105565 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coastal Health and Rehabilitation Center 820 N Clyde Morris Blvd 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews and facility policy and procedure review, the facility failed to ensure medications were properly labeled for two (Resident #78 and Resident #79) of 6 residents who were selected for medication administration observation. This placed the resident at risk for a medication error related to unsafe medication administration. The findings include: A review of Resident #78's clinical record revealed an admission date of 8/2/21. A review of the admission minimum data set (MDS) dated [DATE] revealed, she had a Brief Interview of Mental Status (BIMS) score of 4, indicating severe impairment. A review of Resident #79's clinical record revealed an admission date of 8/3/21. A review of the admission MDS dated [DATE] revealed, she had a BIMS score of 7, indicating severe impairment. Her care plan indicated, she was on antibiotic therapy with interventions that included, Administer medications as ordered. An observation of medication administration with Employee C, Registered Nurse (RN) on 9/9/21 at 8:07 AM revealed her preparing medications for two residents at the same time. She placed 9 tablets in one medication cup for Resident #78 and placed 6 tablets in another medication cup for Resident #79. During an interview with the nurse at the time of the observation, she confirmed medications were pulled and placed in an unmarked medication cup. Employee C, RN stated that both residents occupied the same room. She then marked an A on one medication cup and a B on the second medication cup, which already had the tablets dispensed. (Photographic evidence obtained) On 9/9/21 at 8:15 AM, Employee C, RN was observed giving Resident #78 the medication cup marked with the letter A. The nurse then gave Resident #79 the medication cup marked with the letter B. During an interview with Employee C, RN on 9/9/21 at 8:18 AM, she confirmed that both residents took the medications, she had poured and brought into the resident room on a Styrofoam tray at the same time. An interview was conducted with the Director of Nursing on 9/10/21 at 3:31 PM. The DON confirmed that staff should not be pulling medications out for more than one resident at a time. A review of the facility policy and rocedure named Administering Oral Medications documented at General Guidelines, Follow the medication administration guidelines for the safe administration of oral medications. A review of the facility documented dated 1.8.2021, Mandatory Education for all Nurses was conducted and indicated at the bottom of the provided form, Remember that the nurse must only prepare and administer medication for one patient at a time. There are no exceptions to this! . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105565 If continuation sheet Page 8 of 10 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 105565 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coastal Health and Rehabilitation Center 820 N Clyde Morris Blvd 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations and staff interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety, that included labeling and dating food food items, and thawing food in a safe and sanitary manner, placing the residents at risk of exposure to food-bourne illnesses. The findings include: An initial tour of the kitchen was conducted on 9/7/21 at 9:20 AM with the Certified Dietary Manager (CDM). During the tour, an opened package of what the CDM identified as chicken patties was observed in the freezer wrapped in cellophane but not labeled or dated. The CDM stated, I will take care of that and removed the package. In the reach-in/prep refrigerator, there was a clear plastic container containing approximately one quart of what the CDM identified as tuna salad. The container was loosely covered in cellophane, but not dated. The CDM removed the container from the refrigerator then showed both unlabeled items to the cook, who insisted he labeled the tuna that morning. (Photographic evidence obtained) A follow up visit to the kitchen was conducted on 9/10/21 at 9:30 AM. The walk-in refrigerator was observed with a pack labeled chicken wrapped in foil and cellophane. It was thawing, as evidenced by the coating of frost across the package, and resting on top of a cardboard box that contained more chicken. There was no tray to catch any juices, should they drip onto the lid of the cardboard box. The CDM observed the chicken, confirming it should be on a tray. He quickly placed the packet on a tray and stated, he would educate his dietary staff. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105565 If continuation sheet Page 9 of 10 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 105565 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coastal Health and Rehabilitation Center 820 N Clyde Morris Blvd 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure the resident call system was functioning for 2 (Resident #28 and Resident #75) of 96 residents reviewed for access to a functioning resident call system. Residents Affected - Few The findings include: A review of Resident #28's medical record revealed an admission date of 12/29/20 with a brief interview of mental status (BIMS) score of 15, indicating intact cognitive response. A review of Resident #75's medical record revealed an admission date of 10/18/13 with Diagnoses which included, acquired absence of right and left legs above knee. A review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #75 had a BIMS score of 15, indicating intact cognitive response. He has functional limitation in range of motion and at risk for injury with impairment on both sides of lower extremity. The care plan for Resident #75 revealed he was at risk for falls/injury related to bilateral above knee amputation (AKA). Interventions included, call light within reach when in room. On 9/7/2021 at 3:23 PM, 3:27 PM and 3:29 PM, Resident #28 and Resident #75 were observed trying to activate the call system using the pneumatic bulb at the bedside. Resident #75 and Resident #28 confirmed their call light was activated, but neither of them functioned. During an interview with Resident #75 on 9/7/21 at 3:29 PM, he stated in front of Employee B, RN Unit Manager, the call light did not operate for about one to two weeks. Resident #75 stated, he knew the call system did not operate, when the little red button did not light up. An interview was conducted with Employee A, RN and Employee B, RN Unit Manager on 9/7/21 at 3:27 PM and 3:29 PM. Employee B, RN Unit Manager attempted to activated the call light for Resident #28 and Resident #75, without success. Employee A, RN and Employee B, RN Unit Manager confirmed the call system was inoperable. During an interview the Maintenance Director on 9/7/21 at 4:22 PM, he stated that facility staff checked the call light system one time a month. However, after the check was completed, maintenance relied on staff and the residents to report any concerns. The Maintenance Director said that because Resident #28 and Resident #75's was located on an outside wall, when it rained, moisture built up and caused the system to go out. There was no call light system check in effect except one time a month. On 9/7/21 at 3:45 PM, Employee B, RN Unit Manager provided the survey team with a handwritten document that indicated, Resident #28 and Resident #75's call system did not work and maintenance was notified. A review of the facility procedure titled, Nurse Call System indicated: 1. Each nurse call system shall be tested on a quarterly basis. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105565 If continuation sheet Page 10 of 10