Inspection·May 18, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm An interview was conducted with the Registered Nurse Supervisor (RNS) on 05/18/23 at 1:12 PM. She stated she was responsible for PCA training. Education about resident dignity and privacy was provided upon hire and throughout employment. When told of the observation involving PCA F, the RNS replied, Oh! That's too bad. The RNS explained that staff were taught to stop, knock and ask during the resident rights portion of orientation training. They were reminded of this with every other training topic she covered. Residents Affected - Few 2. A complaint was received by the Agency for Health Care Administration (AHCA) on March 30, 2023. A review of the complaint found an unnamed resident with dementia had entered another resident's room at least ten times. The uninvited resident allegedly ransacked the room, pulled personal belongings out of the closet and drawers, and dismantled equipment belonging to the resident occupying the room. The resident with dementia resided in room [ROOM NUMBER]-B at the time of the complaint. During a conversation with Resident #39 on 05/15/23 at 11:03 AM, she complained that Resident #43 was coming into her room and taking her blankets, stuffed animals, clothes and other items. Resident #39 placed a stop sign on her door with a note that read, NO [RESIDENT #43]. She was told she was not allowed to post that on her door and staff kept removing the personal note from her door. At the time of the interview, there was no sign observed on the door. In a second interview with Resident #39 on 05/15/23 at 2:00 PM, she again mentioned the stop sign on her door. She had put it back up. Her room (202) was observed with a mesh banner suspended across the threshold. It was approximately one foot high and secured to each side of the door jamb with Velcro tape. There was a large red STOP sign at the center of the banner. Under it was a piece of paper with a NO and Resident #43's first name handwritten in bold print. The paper, which was approximately three inches high and six inches wide, was taped under the stop sign and was easily visible to residents, staff or visitors passing in the hallway. Observations conducted throughout the survey from 05/15/23 to 05/18/23, found the banner was displayed daily on an intermittent basis and included the paper with Resident #43's first name on it. (Photographic evidence obtained) Resident #43 was observed on 05/16/23 at 2:29 PM on her nursing unit. She was in her wheelchair and was scooting herself down the long hallway. She used her hands and feet to make short, rapid movements and was able to scoot herself to the opposite end of the hall. After asking a nurse where a post office was, Resident #43 scooted herself back to the nurses' station at a slow but deliberate pace. An interview was conducted with Licensed Practical Nurse (LPN) G on 05/17/23 at 10:07 AM. She reported that while Resident #43 was the sweetest lady, she was very demented and wandered. Resident #43 was confused, thinking her room was here and then there, and wandered into other residents' rooms. Staff redirected her out of the rooms. LPN G said some residents probably found the behavior intrusive, but Resident #43 was often just looking for someone to talk to. Resident #39 had placed a stop sign on her door with a No [Resident #43] warning on it as a deterrent. Certified Nursing Assistant (CNA) H was interviewed on 05/17/23 at 10:22 AM. She explained that Resident #43 was a busy-body who sundowned (displayed increased confusion, agitation or restlessness in the evening) and wandered the halls all night. Sometimes when she came in 7:00 AM for her shift, Resident #43 was still up. Resident #43 went into other residents' rooms and took their belongings on a daily basis. CNA H redirected her from going into other residents' rooms, but she liked to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105565 If continuation sheet Page 2 of 15 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 05/18/2023 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 0550 Level of Harm - Minimal harm or potential for actual harm communicate and have conversations. A lot of the unit's residents complained; they didn't like her in their rooms. Resident #43 had gone into resident rooms and defecated in their toilets, making a mess in one room. Resident #43 was going in Resident #39's room and taking her toys. Resident #39 was afraid, so now she hung a sign on the door that said, STOP [Resident #43]. CNA H said Resident #43 didn't know any better. Residents Affected - Few Resident #43 was observed on 05/17/23 at 3:30 PM scooting herself around the unit and visiting with other residents. CNA I was interviewed on 05/17/23 at 3:31 PM. She described Resident #43 as a firecracker but sweet and loving. She wandered throughout the facility. Some residents complained, but they were mostly used to her and knew she couldn't help it. CNA I had told Resident #39 she couldn't have the STOP sign with Resident #43's name on it, but Resident #39 didn't care and put it back up herself when it was taken down by staff. A record review for Resident #43 found an admission Minimum Data Set (MDS) assessment dated [DATE]. It noted she had a brief interview for mental status (BIMS) score of 6 out of a possible 15 points, indicating severe cognitive impairment. Delusions were present. Her diagnoses included, but were not limited to, encephalopathy and non-Alzheimer's dementia. Resident #43 was care planned on 03/16/23 for her behavioral needs, wandering/pacing in hallways, and looking for her room, but went into other resident rooms. She needed to be redirected at times when wandering. The goal was to cooperate with care through the next review. Interventions noted Resident #43 recognized her name on barriers/signs, which deterred her from entering certain areas. (Photographic evidence obtained) A record review for Resident #39 found her MDS assessment, dated 04/07/23, assessed her with a BIMS score of 15, reflecting intact cognition. An interview was conducted with the Social Services Director (SSD) on 05/18/23 at 1:41 PM. She was asked about resident complaints related to Resident #43's wandering behavior. She reported one resident, Resident #39, was very protective of her space. They provided her a STOP banner to put up in her doorway. Resident #39 made the sign addition displaying Resident #43's name on it. Despite staff removing it, Resident #39 continued to make and place additional signs with Resident #43's name on them. The SSD expressed understanding that was a dignity concern for Resident #43. A review of the facility's policy Resident Rights (revised December 2016) read, Employees shall treat all residents with kindness, respect and dignity. It read: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. A dignified existence. b. Be treated with respect, kindness and dignity. ; . h. be supported by the facility in exercising his or her rights. . t. privacy and confidentiality. ; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105565 If continuation sheet Page 3 of 15 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 05/18/2023 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 0550 . hh. staff will knock and request permission before entering residents' rooms. Level of Harm - Minimal harm or potential for actual harm ii. Residents' private space and property shall be respected at all times. (Photographic evidence obtained) Residents Affected - Few A review of the facility's Quality Assurance/Performance Improvement Plan found the facility's Vision was to pioneer healthcare by creating a compassionate, memorable and dignified existence for every person served. It stated the facility strived to treat patients, their families and staff with the highest level of dignity and respect by promoting an environment of continuous improvement and service excellence. The Mission was that the facility was committed to the physical, emotional and spiritual well-being of residents. It strived to provide excellent service for residents of every culture in a supporting, caring, homelike environment, and to maintain a high level of dignity and individuality. (Photographic evidence obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105565 If continuation sheet Page 4 of 15 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 05/18/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on observation, medical record review, and interviews, the facility failed to update and resubmit a Preadmission Screening and Resident Review (PASRR) for one (Resident #48) of two residents reviewed for PASRR, from a total sample of 39 residents. Resident #48 received a new diagnosis which required a new PASRR to be submitted. The findings include: A review of Resident #48's medical record revealed and admission date of 10/27/20 and diagnoses including major depressive disorder, generalized anxiety, dementia, and post-traumatic stress disorder (PTSD). Further review of the resident's diagnoses revealed that PTSD was added on 10/28/20 and again on 10/30/22. The PASRR was reviewed and noted a Level I without any diagnoses checked. It was dated 10/22/20 and indicated no need for a Level II. The electronic medical record was reviewed, and no additional PASRR was found after the new diagnosis. Resident #48 was observed sitting up in bed eating breakfast on 05/17/23 at 8:35 AM. He received his medications from the nurse and took them with pudding. He was alert, and was speaking with the nurse and this writer. An interview was conducted with the Director of Nursing (DON) on 05/17/23 at 2:30 PM. She reviewed the resident's electronic medical record and confirmed that the PASRR, dated 10/22/20, was the only one in the record. The DON reported that the Social Services Director (SSD) notified her of new diagnoses for the residents, and then she filled out the paperwork and sent it out for a Level II review. The SSD followed up to see whether a Level II was required, to ensure an approval for a PASRR level II was received, and then placed the information in the resident's medical record. The DON confirmed that there were new diagnoses of PTSD for Resident #48 and a new PASRR should have been generated. An interview was conducted with the DON on 05/18/23 at 8:25 AM. She supplied the copy of the PASRR requested, and reported that last night (05/17) she found the diagnoses for PTSD on 10/28/20 and also on 10/30/22. The information was submitted for another PASRR last night. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105565 If continuation sheet Page 5 of 15 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 05/18/2023 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on observations, record review, interviews, a review of the facility's policy and procedure for Antipsychotic Medication Use, and the facility's Pharmacy Consultant Services Agreement, the facility failed to ensure that its pharmacy consultant reported irregularities to the attending physician, the facility's medical director, and the director of nursing, and that these reports were acted upon for one (Resident #78) of five residents reviewed for unnecessary medications, from a total sample of 39 residents. Resident #78 was receiving psychotropic medications (Seroquel, Lexapro, and Remeron), but he was not being monitored for behaviors or side effects related to these medications, and the pharmacy consultant did not identify or report this as required when completing the monthly review. The findings include: An observation was made of Resident #78 on 5/16/23 at 10:50 a.m. He was in his room lying in bed watching television. He stated he was concerned about his daughter taking his roommate to New York as his roommate requested. His roommate tried to get his daughter to do things for him, and Resident #78 did not like it. An observation was made of Resident #78 on 5/18/23 at 9:40 a.m. He was in his room lying in bed watching television. He stated his roommate was nuts and started talking about his daughter and his roommate going to New York. He stated, My daughter is not taking him to New York. I will take her car away from her. He said he did not want to get out of bed when he was asked about getting up for the day. A medical record review was conducted for Resident #78, which noted an admission date of 10/1/20 and a re-entry on 10/7/21 with the following diagnoses: major depressive disorder, generalized anxiety disorder, pseudobulbar affect, and adjustment disorder. The care plan was reviewed, which was updated on 4/19/23, and noted that the resident had a diagnosis of depression, refused to ask for assistance when needed, refused to use his walker, refused to use his call light, and made false allegations against staff and other residents. Behavioral Psychiatric Services made a note on 4/26/23, which described Resident #78 as having made bizarre statements about his roommate and his daughter going to New York. He was noted with delusional thinking about his daughter and his roommate and needed to be monitored closely. A review of the resident's current Physician's Order Sheets for May 2023 revealed the following: Lexapro 30 mg (milligrams) every day (ordered 10/7/21), Remeron 15 mg at bedtime (ordered 10/8/21), and Seroquel 50 mg at bedtime (ordered 11/4/21). No order for behavior monitoring or side effect monitoring could be found for the Lexapro, Remeron or Seroquel. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105565 If continuation sheet Page 6 of 15 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 05/18/2023 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 0756 Level of Harm - Minimal harm or potential for actual harm A review of the May 2023 Medication Administration Record (MAR) revealed no documented behavior monitoring or side effect monitoring for Seroquel, Lexapro, or Remeron. A review of the resident's MAR from January 2023 through April 2023 revealed no documented behavior monitoring or side effect monitoring for Lexapro, Remeron or Seroquel. Residents Affected - Few A review of the Pharmacy Recommendations from November 2022 through April 2023 revealed no recommendations to monitor for behaviors or side effects related to the use of Seroquel, Lexapro or Remeron. The pharmacy consultant did recommend a gradual dose reduction (GDR) of Seroquel on 2/22/23 from 50 mg to 25 mg at bedtime. On 3/29/23, the pharmacy consultant requested a GDR for Remeron 15 mg and Lexapro 20 mg, however, the physician declined, reporting failed reductions in the past. No documentation was found from the pharmacy consultant to monitor for behaviors or side effects related to the use of psychotropic medications. A review of the pharmacy recommendations for 11/27/22, 12/20/22, 1/16/23, and 4/24/23, revealed no recommendations at all. An interview was conducted with Licensed Practical Nurse (LPN) A on 5/17/23 at 11:35 a.m. She was asked where behavior monitoring documentation could be found in the electronic medical record. LPN A stated behavior monitoring was documented on the Medication Administration Record (MAR). She was asked to review the MAR for Resident #78 regarding his behavior monitoring and side effects for Seroquel, Lexapro, and Remeron. LPN A stated the resident should have behavior and side effect monitoring for psychotropic medications, but it was not documented on his MAR. An interview was conducted with the Director of Nursing (DON) on 5/17/23 at 11:40 a.m. She stated behaviors should be monitored along with side effects for psychotropic medications. The DON reviewed the MAR for Resident #78 and confirmed that no behavior monitoring, or side effect monitoring was on the May 2023 MAR for Seroquel, Lexapro or Remeron. She reported the Seroquel should be monitored for behaviors and all three medications should be monitored for side effects. The DON stated, It (behavior and side effect monitoring) should be there. Maybe it fell off. When the medications are keyed into the computer, behavior monitoring, and side effect monitoring should be added. She reviewed the March and April 2023 MARs and confirmed there was no documentation of behavior monitoring or monitoring for side effects there either. The DON stated, This is scary. We did a gradual reduction review on him not too long ago. She was unable to locate a physician's order for monitoring of behaviors and side effects, but stated the policy and procedure for psychotropic medications noted behaviors must be monitored if a resident was receiving psychotropic medication, and side effects should also be monitored. A review of the Antipsychotic Medication Use policy and procedure (revised December 2016) revealed that under the heading of Policy Interpretation and Implementation bullet point # 2 read: The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms and risks to resident and others. #17. Nursing staff shall monitor and report any of the following side effects and adverse consequences of antipsychotic meds which includes a list of neurologics: akathisia, dystonia, extrapyramidal effects, akinesia or tardive dyskinesia, stroke or TIA (transient ischemic attack) to attending physician. An interview was conducted with the DON on 5/18/23 at 8:40 a.m. She reported looking for behavior monitoring for Resident #78 back through January 2023 and was unable to find any behavior monitoring or side effect monitoring for Seroquel, Lexapro or Remeron. She stated an audit was completed last night (5/17) of half of the medical charts and would continue with the other half to audit for behavior monitoring. A performance improvement plan (PIP) was also started. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105565 If continuation sheet Page 7 of 15 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 05/18/2023 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A telephone interview was conducted with the facility's Registered Pharmacist (RPh) Consultant on 5/18/23 at 8:50 a.m. The RPh reported coming to the facility monthly, communicating with the DON, looking at medication carts, medication rooms, and destroying narcotics with the DON. The facility had an electronic medical record which was reviewed monthly at home by the RPh. She stated part of the process was to suggest GDR's, lab work, and monitoring of psychotropic medications. The team met monthly and included the DON, Psychiatric nurse from Behavioral Services, their pharmacist and the facility's consultant pharmacist. The RPh stated the team reviewed each resident monthly, discussed GDRs, results, behaviors, and the residents' history. The RPh provided a psychiatric report to the DON and Psychiatric nurse monthly. A medication review was conducted by the RPh and Behavioral Services. Regulations were followed and the meetings lasted an hour. The RPh stated all residents should have behavior monitoring and side effect monitoring for all psychotropic medications. She stated the team discussed behaviors monthly. Resident #78 was discussed monthly and had failed GDRs multiple times. The resident was receiving Lexapro, Remeron, and Seroquel. After reviewing the electronic medical record, she confirmed there was no documentation for behavior monitoring or side effect monitoring for this resident's psychotropic medications. She stated, I was unaware this was missing. He should have behavior monitoring and monitoring of side effects. The resident has been on psychotropic medications for a long time, and we have had lots of discussions concerning him. It is hard to believe behavior monitoring is not part of this, which I didn't see in the MAR. He has auditory hallucinations and behaviors. Daily monitoring of behaviors and side effects of psychotropic medications should be in the electronic record. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105565 If continuation sheet Page 8 of 15 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 05/18/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on observations, record review, interviews, and a review of the facility's policy and procedure for Antipsychotic Medication Use, the facility failed to ensure that one (Resident #78) of five residents reviewed for unnecessary medications, from a total sample of 39 residents, received behavior monitoring and monitoring of side effects for the use of psychotropic medications (Seroquel, Lexapro, and Remeron). The findings include: An observation was made of Resident #78 on 5/16/23 at 10:50 a.m. He was in his room lying in bed watching television. He stated he was concerned about his daughter taking his roommate to New York as his roommate requested. His roommate tried to get his daughter to do things for him, and Resident #78 did not like it. An observation was made of Resident #78 on 5/18/23 at 9:40 a.m. He was in his room lying in bed watching television. He stated his roommate was nuts and started talking about his daughter and his roommate going to New York. He stated, My daughter is not taking him to New York. I will take her car away from her. He said he did not want to get out of bed when he was asked about getting up for the day. A medical record review was conducted for Resident #78, which noted an admission date of 10/1/20 and a re-entry on 10/7/21 with the following diagnoses: major depressive disorder, generalized anxiety disorder, pseudobulbar affect, and adjustment disorder. The care plan was reviewed, which was updated on 4/19/23, and noted that the resident had a diagnosis of depression, refused to ask for assistance when needed, refused to use his walker, refused to use his call light, and made false allegations against staff and other residents. Behavioral Psychiatric Services made a note on 4/26/23, which described Resident #78 as having made bizarre statements about his roommate and his daughter going to New York. He was noted with delusional thinking about his daughter and his roommate and needed to be monitored closely. A review of the resident's current Physician's Order Sheets for May 2023 revealed the following: Lexapro 30 mg (milligrams) every day (ordered 10/7/21), Remeron 15 mg at bedtime (ordered 10/8/21), and Seroquel 50 mg at bedtime (ordered 11/4/21). No order for behavior monitoring or side effect monitoring could be found for the Lexapro, Remeron or Seroquel. A review of the May 2023 Medication Administration Record (MAR) revealed no documented behavior monitoring or side effect monitoring for Seroquel, Lexapro, or Remeron. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105565 If continuation sheet Page 9 of 15 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 05/18/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the resident's MAR from January 2023 through April 2023 revealed no documented behavior monitoring or side effect monitoring for Lexapro, Remeron or Seroquel. A review of the Pharmacy Recommendations from November 2022 through April 2023 revealed no recommendations to monitor for behaviors or side effects related to the use of Seroquel, Lexapro or Remeron. An interview was conducted with Licensed Practical Nurse (LPN) A on 5/17/23 at 11:35 a.m. She was asked where behavior monitoring documentation could be found in the electronic medical record. LPN A stated behavior monitoring was documented on the Medication Administration Record (MAR). She was asked to review the MAR for Resident #78 regarding his behavior monitoring and side effects for Seroquel, Lexapro, and Remeron. LPN A stated the resident should have behavior and side effect monitoring for psychotropic medications, but it was not documented on his MAR. An interview was conducted with the Director of Nursing (DON) on 5/17/23 at 11:40 a.m. She stated behaviors should be monitored along with side effects for psychotropic medications. The DON reviewed the MAR for Resident #78 and confirmed that no behavior monitoring, or side effect monitoring was on the May 2023 MAR for Seroquel, Lexapro or Remeron. She reported the Seroquel should be monitored for behaviors and all three medications should be monitored for side effects. The DON stated, It (behavior and side effect monitoring) should be there. Maybe it fell off. When the medications are keyed into the computer, behavior monitoring, and side effect monitoring should be added. She reviewed the March and April 2023 MARs and confirmed there was no documentation of behavior monitoring or monitoring for side effects there either. The DON stated, This is scary. We did a gradual reduction review on him not too long ago. She was unable to locate a physician's order for monitoring of behaviors and side effects, but stated the policy and procedure for psychotropic medications noted behaviors must be monitored if a resident was receiving psychotropic medication, and side effects should also be monitored. A review of the Antipsychotic Medication Use policy and procedure (revised December 2016) revealed that under the heading of Policy Interpretation and Implementation bullet point # 2 read: The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms and risks to resident and others. #17. Nursing staff shall monitor and report any of the following side effects and adverse consequences of antipsychotic meds which includes a list of neurologics: akathisia, dystonia, extrapyramidal effects, akinesia or tardive dyskinesia, stroke or TIA (transient ischemic attack) to attending physician. An interview was conducted with the DON on 5/18/23 at 8:40 a.m. She reported looking for behavior monitoring for Resident #78 back through January 2023 and was unable to find any behavior monitoring or side effect monitoring for Seroquel, Lexapro or Remeron. She stated an audit was completed last night (5/17) of half of the medical charts and would continue with the other half to audit for behavior monitoring. A performance improvement plan (PIP) was also started. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105565 If continuation sheet Page 10 of 15 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 05/18/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observations, a review of resident records, and interviews with staff, the facility failed to maintain accurate medical records for one (Resident #9) of one resident reviewed for skin impairment, from a total of 39 sampled residents. The findings include: Resident #9 was observed on 05/16/23 at 9:49 AM. The entire top of her right hand was bruised and purple in color. Resident #9 was unable to report what happened to her hand. On 05/16/23 at 2:23 PM, Resident #9 was interviewed again. She stated she was doing well and denied pain. When asked what happened to her hand she said, Well, I bruise very easily. She was again unable to report what happened and began talking about money and an airport. Resident #9's hand was still purple in color. An observation of Resident #9 on 05/17/23 at 8:49 AM, found the top of her hand was now a faded purple. A record review for Resident #9 found a quarterly Minimum Data Set (MDS) assessment, dated 02/06/23. Resident #9 was assessed with memory problems and severely impaired cognitive skills for daily decision making. She required extensive assistance with activities of daily living (ADLs). Diagnoses included hypertension, non-Alzheimer's dementia, Parkinson's disease and atrial fibrillation (a-fib). Resident #9 was care planned on 08/04/21, and last reviewed/revised on 05/08/23, for her anticoagulant (AC) medication use related to a-fib. The goal was to be free from discomfort or adverse reactions related to AC use through the review date. Interventions included medications as ordered, and avoid activity that could result in injury. Monitor/document/report adverse reactions of AC therapy. She was also care planned on 02/11/23, and last reviewed on 05/08/23, for risk for skin impairment related to fragile skin, incontinence, risk for malnutrition, malnutrition, anticoagulant/antiplatelet medications, and weakness/decreased mobility. The goal was to be free of any new skin impairment through the review date. Interventions included minimizing pressure to bony prominences, assisting to wear protective garments as tolerated and as ordered, and to monitor/observe skin while providing routine care. Notify the nurse for any area of concern as indicated. Skin checks weekly and as indicated. Use caution during transfers and bed mobility to reduce friction and prevent striking arms, legs and hands against sharp or hard surfaces. (Photographic evidence obtained) Resident #9 had a physician's order dated 12/16/22, to observe for excessive bruising, hematuria (blood in urine), hemoptysis (coughing up blood), or other bleeding every shift for anticoagulant/hematological agent use. Instructions were to immediately report abnormalities to the physician. She had an order dated 08/04/21 for Aspirin, enteric coated, 81 milligrams every day, and an order dated 11/07/22, for weekly skin checks every evening shift every Mondays/Tuesdays. (Photographic evidence obtained) Weekly skin checks were conducted for Resident #9 on the following dates with no documentation of any bruising or other skin issues: April 4, 14, 17 and 25, 2023, May 2 and 9, 2023. (Photographic evidence obtained) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105565 If continuation sheet Page 11 of 15 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 05/18/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the Certified Nursing Assistant daily charting for the last 30 days found red areas were noted on Resident #9 multiple days, but the locations of those areas were not noted. An interview was conducted with Licensed Practical Nurse (LPN) G on 05/17/23 at 9:59 AM. She stated Resident # 9 could get agitated and forgot she couldn't walk. She had a lot of falls or attempted falls. She did have a bruise, and she recently had a blood draw. LPN G speculated that the bruising was from the lab work. She stated any skin issues should be documented on the weekly skin checks. If an issue was identified on one day, then the next skin check could say, No new issues. The nurses were able to look back at the previous week's skin check to see if anything was noted. LPN G was advised of the missing documentation related to Resident #9's bruised hand. She was asked to review the record at her earliest opportunity to locate the skin check that captured the affected area. LPN G said she would look. Certified Nursing Assistant (CNA) H was interviewed on 05/17/23 at 10:22 AM. She stated residents' skin was observed every day during the provision of care. A lot of residents are on blood thinners and get red spots. Any new skin issues were documented and reported to the nurse. The bruise on Resident #9's hand was reported to the nurse. CNA H stated LPN G thought the bruising was from the blood draw, explaining it came up a day or two after the lab came. The Director of Nursing (DON) was interviewed on 05/17/23 at 12:36 PM, and was asked to review Resident #9's skin checks to locate any documentation of the significant bruising to her right hand. She stated she would look. The area was described to her and she confirmed her expectation was that the discoloration should have been noted. She reported LPN G completed a skin check for Resident #9 today. A review of the skin check completed on 05/17/23 at 10:24 AM by LPN G found that under the comments, discoloration was noted to Resident #9's right hand. (Photographic evidence obtained) Neither LPN G nor the DON produced any prior skin checks indicating that there was bruising and discoloration to Resident #9's right hand. The facility had no specific policy and procedure for skin checks, however, the policy for Prevention of Pressure Ulcers (revised July 2017) instructed: Risk Assessment: 1. Assess resident on admission for existing pressure ulcer/injury risk factors. Repeat the risk assessment weekly and upon and change in condition. .4. Inspect the skin on a daily basis when performing or assisting with personal care/activities of daily living. Monitoring: 1. Evaluate, report and document potential changes in the skin. (Photographic evidence obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105565 If continuation sheet Page 12 of 15 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 05/18/2023 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, facility policy review, the facility's hospice contract review, and medical record review, the facility failed to 1) Ensure residents receiving hospice services had evidence of medical record communication with the hospice provider for seven (Residents #13, #81, #1, #38, #4, #100, and #89) of eight residents receiving hospice services, 2) Ensure evidence of signed contracts for services in the Electronic Medical Record (EMR) for six (Residents #13, #81, #1, #38, #101, and #89) of eight residents receiving hospice services, and 3) Designate a facility hospice coordinator for eight (Residents #13, #81, #1, #38, #4, #101, #100, and #89) of eight residents receiving hospice services. The findings include: A medical record review revealed that Resident #13 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), unspecified protein-calorie malnutrition, acute Congestive Heart Failure (CHF), acute kidney failure with tubular necrosis, urinary tract infection, and schizophrenia. A review of Resident #13's Minimum Data Set (MDS) Significant Change in Condition assessment, dated 03/03/23, revealed impaired vision, adequate hearing, clear speech, makes self understood, and usually understands. The resident's Brief Interview for Mental Status (BIMS) score was recorded as 10 out of a possible 15 points, indicating moderate cognitive impairment. The resident was without behaviors; required extensive assistance for Activities of Daily Living (ADL), and only required supervision for eating. Resident #13 had an active Do Not Resuscitate order and an order for hospice on 02/24/23. A review of Resident #13's Care Plan revealed the following focus areas: Restorative nursing for eating/swallowing History of refusing medications Receiving Palliative care/Hospice services from [hospice provider] with interventions to Collaborate with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are addressed. On 05/18/23 at 8:45 AM, a review of the electronic medical record (EMR) revealed no signed hospice contract, and a review of the paper chart at 8:55 AM, revealed no communication notes from the hospice provider. A review of the [hospice provider] Nursing Facility Services Agreement, last updated on 04/21/16, revealed on page seven, item (l): Facility shall designate a member of the Interdisciplinary Group to be responsible for coordinating the facility's care of a Resident with Hospice. Page 13-14, item, 6, Records, (a) Creation and Maintenance of Records. Each party shall prepare and maintain complete and detailed records concerning the Hospice Patient receiving Facility Services (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105565 If continuation sheet Page 13 of 15 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 05/18/2023 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many or Hospice Services under this Agreement in accordance with prudent record-keeping procedures and as required by applicable federal and state laws and regulations and Medicare and Medicaid program guidelines. Each clinical record shall completely, promptly and accurately document all services provided to, and events concerning, the Hospice Patient, including evaluations, treatments, progress notes, authorizations to admission to Hospice and/or Facility, physician orders entered pursuant to this Agreement and discharge summaries. Each record shall document that the specified services are furnished in accordance with this Agreement and shall be readily accessible and systemically organized to facilitate retrieval by either party. Facility and Hospice shall cause each entry made for Facility Services or Hospice Services provided to be signed and dated by the person providing Facility Services and Hospice Services. On 05/18/23 at 8:55 AM, an interview was conducted with the Director of Nursing (DON). When asked who the hospice coordinator was, the DON stated it was the Social Services Director (SSD). When asked where communication between the facility and the hospice provider was kept, the DON stated, They should be in the chart. On 05/18/23 at 9:00 AM, an interview was conducted with the SSD. When asked if she was the facility's Hospice Coordinator, she asked, What do you mean by coordinator? It was explained that the Hospice Coordinator was the point person for hospice services. She stated, No, all I do is coordinate the hospice referral process. She further stated she received the order, sent the referral to the hospice provider, and followed up to ensure the consultation took place. She stated she participated in care plan meetings, and when there was a hospice resident, sometimes the hospice provider came to the facility, but her only participation was as the SSD, like she was for all other residents. She stated the hospice provider did not always attend the care plan meetings. On 05/18/23 at 9:12 AM, an interview was conducted with Certified Nursing Assistant (CNA) C. When asked if she knew when the hospice provider came to see Resident #13, she stated, Oh yeah, they come in and bathe him and take him out to smoke. When asked if they left any documentation for the facility about care/services they provided during their visit with the resident, she stated she did not know. On 05/18/23 at 9:14 AM, an interview was conducted with Registered Nurse (RN)/MDS Coordinator D. When she was asked if the hospice nurse met with her when they were visiting residents, she stated, The hospice nurses usually go and speak with the assigned nurse to find out how much pain medication they are receiving and any updates. When asked whether the hospice provider left any visit notes for the facility, she replied no. On 05/18/23 at 9:20 AM, an interview was conducted with Licensed Practical Nurse (LPN) E. When asked how the hospice provider communicated with the staff, she stated, When the nurse comes in, they come talk to the person caring for the resident to find out if they need any refills for medications, when was the last time they had pain medication, and how often they were needing medications. She further stated, After the visit they check back in with us and give us an update. When asked if they left any visit notes, LPN E replied, No, it's all verbal. On 05/18/23 at 9:40 AM, the DON reported that she was unable to find a copy of the hospice contract for Resident #13 and would call the hospice provider for a copy. On 05/18/23 at 10:38 AM, an interview was conducted with the RN Case Manager for the hospice provider. When asked if the hospice provider left visit notes with the facility, he stated, Only if they (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105565 If continuation sheet Page 14 of 15 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 05/18/2023 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many ask for them. I was just in the Interdisciplinary Team (IDT) meeting and they were blowing up my phone. When I spoke with them they asked me about visit notes. When he was asked how the hospice provider communicated with the facility, he stated, When they (hospice staff) come in, they check with the nurse to see if there are any new issues or concerns. After the visit they follow up with the nurse if there have been any changes. When asked how the hospice provider knew whether the CNAs were coming to the facility to provide care, he stated he conducted supervisory visits every 14 days and the CNAs had an electronic documentation system. He stated he trusts his staff and hadn't had any complaints or concerns with residents' care. when asked how the CNA notified the facility of whether there had been changes in the resident's skin, he stated, They call me and I remind them to inform the assigned nurse before they leave. A review of the following residents receiving hospice services revealed the following: Resident #13 - no contract; no notes Resident #81- no contract; no notes Resident #1- no contract; no notes Resident #38- no contract; no notes Resident #4- no notes Resident #101- no contract Resident #100- no notes Resident #89- no contract; no notes . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105565 If continuation sheet Page 15 of 15