Inspection·June 14, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, interviews, and review of facility standards and guidelines for elopement and wandering, the facility failed to immediately report, or within 24 hours of the event, an alleged violation of neglect for one (Resident #2) of two residents sampled for elopement, to the State Survey Agency. The findings include: Review of the facility's 2024 Federal Reports revealed no reports had been filed electronically as required for Resident #2. A review of Resident #2's medical record revealed he was a [AGE] year-old male who was admitted to the facility on [DATE] and left the faciity on 4/28/2024. His diagnoses included pneumonia, unspecified organism, anxiety disorder, anemia, other chronic pain, dorsalgia, unspecified, hypertension, chronic kidney disease, stage three, unspecified, difficulty in walking, not elsewhere classified, and muscle weakness (generalized). The resident was prescribed Ativan, one milligram (mg) twice a day for anxiety. A review of a local hospital progress note dated 4/17/2024 documented that although Resident #2 is alert and oriented to person and place, the resident appears to lack the insight into his overall medical condition and the related judgement to make good medical decisions for himself. A hospital psychiatry progress note documented that Resident #2 does not have decisional capacity and next of kin agrees with placement into a skilled nursing facility for rehabilitation when the resident is medically stable for discharge. On 6/13/2024 at 10:00 AM, observations of the exterior perimeter of the facility revealed no fence surrounding the facility, a busy parking lot, busy boulevard and uneven terrain. On 6/13/2024 at 5:59 PM, an interview was conducted with the Director of Nursing (DON) regarding Resident #2. The DON revealed that on 4/28/2024, at approximately 1:00 AM, the Supervisor or former supervisor called her to inform her that the Resident #2 wanted to leave. The DON contacted the Regional Nurse at 1:37 AM to inform him the Resident left. The DON phoned the Advanced Registered Nurse Practitioner (ARNP) call service and the ARNP called the DON at 2:28 AM and asked why the DON was calling so early in the morning. The DON informed the ARNP that the Resident #2 wanted to be discharged . The DON received the discharge order. A nurse went to the resident's room to inform him that he was going to be discharged and found that the Resident was gone. The nurse called the DON back to inform her that the Resident was gone. Staff called the Resident #2's primary emergency contact (resident's daughter) to inform her that the resident was missing. The daughter said that the Resident was (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 105565 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 06/14/2024 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)