Health inspection·September 11, 2025

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the facility's Transfer and Discharges policy, the facility failed to notify resident/responsible parties in writing of discharges and transfers, and omitted required information including the date of and the reason for the transfer, the location to which the resident was being transferred, a statement of appeal rights, information about the appeal process, and the State Long-Term Care Ombudsman contact information for one (Resident #1) of four residents reviewed for discharge. The facility also failed to provide a copy to the local Ombudsman office.The findings include:A closed record review for Resident #1 revealed an admission date of 6/21/25 and a discharge from the facility on 7/20/25. Her diagnoses included, but were not limited to, multiple sclerosis, difficulty in walking, chronic obstructive pulmonary disease (COPD), anxiety disorder, and depression.Review of Resident #1's 5-day initial Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/25/25, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. She required partial assistance for self-care, supervision or touching assistance for toileting, bathing, partial/moderate assistance for lower body dressing/putting on or taking off footwear. The resident was also dependent with transfers. Review of the care plan for Resident #1 initiated on 6/21/25 revealed active discharge planning was occurring. A Physician's order for Resident #1, dated 7/17/25, stated, May DC on 7/20/25 with HHC. SN: med mgmt. & teaching PT/OT. Home exercise program, balance strengthening coordination ADL & Gait Training. DME: Standard wheelchair HT:60 Wt.: 162 lbs.A review of the Discharge summary dated [DATE] for Resident #1 completed by nursing in the electronic chart revealed it did not list any discharge medications, follow up appointment or name of continuing care physician, or a summary of care for Physical Therapy and Occupational Therapy. There was no signature of the resident or resident representative noting understanding of discharge. Section f1 of the discharge summary for the community ombudsman name/address/phone number was blank. Section g1 Resident/Representative, ‘g2 date and time, and g3 name of title of person presenting this information were all left blank. (Photographic evidence obtained)On 8/8/25, an email was sent to the office of the Long-Term Care Ombudsman. On the same day a return email was received, the office replied, Resident #1 never received a discharge notice, nor were we copied on anything.On 8/13/25 at 2:30 pm, an interview was conducted with the Social Services Director (SSD). When asked why Resident #1 was discharged , she stated her 100 Medicare days had been exhausted. She explained that she obtained a discharge order dated 7/17/25 for Resident #1. When asked why she waited until 7/20/25, the day of the discharge to give the notice to the resident, she said, That is what I do with the notice of discharges. When the SSD was asked about sending discharge notices to the Ombudsman office, she replied, I haven't sent any. She then said, I have no excuse for this. On 8/13/25 at 2:45 PM, an interview was conducted with the Director of Nursing regarding discharges. When asked about how the facility plans discharges, she stated the social Page 1 of 2 105565 105565 09/11/2025 Coastal Health and Rehabilitation Center 820 N Clyde Morris Blvd Daytona Beach, FL 32117

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few services manager does the discharges. When asked about a care plan for discharge, she stated it should be incorporated in the resident's care plan. Further review of the record for Resident #1 revealed there was no Nursing Home Transfer and Discharge Notice provided for the discharge, as required. A review of the facility's Transfers and Discharge policy, last revised 02/2024 revealed under procedure section 2, is noted that under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge. In section marked B The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility.Under section 3 it states the resident and/or representative (sponsor) will be notified in writing of the following:a. The reason for the transfer or dischargeb. The effective date of the transfer or dischargec. The location to which the resident is being transferred or discharged d. A statement of the resident's rights to appeal the transfer or discharge i: The name, address and telephone number of the Office of the State Long-term Care Ombudsman;Under section 4 of the policy, A copy of the notice will be sent to the Office of the Long-term Care Ombudsman. (Photographic evidence obtained) 105565 Page 2 of 2