Inspection·April 28, 2022

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for the last two weeks with no meal/snack. He said the facility did not provide breakfast in the facility, and no meal or snack was sent with him for the last two weeks. The staff were supposed to put a sandwich in a yellow bag, and drop it in the bag on the back of the wheelchair (he pointed to bag hanging on the back of his wheelchair). They have not done this for the last two weeks. He confirmed he did not refuse the lunch bag or snacks. He said the bus left at 6:00 AM, so he had to be at the front porch at 5:45 AM, and he returned around 12:00 PM to 1:00 PM from dialysis. An off-hours facility site visit was made on 4/27/2022 at 5:45 AM. An observation was made of Resident #56 at 5:45 AM in the hall near his room. He stated he was ready to go out to the bus stop. He was asked if the facility provided him with a snack, breakfast or a bagged lunch. He said no. Resident #56 said, I saved a deli sandwich (ham) from yesterday and I ate that at 4:00 AM. He said, Now it has been about three weeks since the facility provided me with the yellow bag that had a snack in it. Resident #56 stated the yellow bag was supposed to be put in the refrigerator in the snack room so the certified nursing assistant (CNA) could retrieve the bag and place it in his dialysis bag in the morning. An observation was made of CNA C on 4/27/2022 at 5:48 AM. She pushed Resident #56 in his wheelchair out to the front area with no snack or lunch. An observation was made on 4/28/2022 at 5:49 AM of the orthopedic unit nutrition room. A refrigerator was observed in that room. The refrigerator was opened and no yellow snack bag, sandwich or breakfast meal could be located for Resident #56 to take to dialysis with him. (Photographic evidence obtained) An interview was conducted with CNA C on 4/27/2022 at 5:52 AM. She was observed walking toward the kitchen and stated Resident #56 did not always get his snack bag or lunch, but she was going to the kitchen to retrieve it. She said she did not work every day and could only speak for the days she worked. She confirmed that for some time now, the dietary services staff had not shown up on time and did not make the resident's sandwich. The door may be locked and we cannot find snacks or sandwiches to give to residents. CNA C stated she told several people. The transportation staff member (CNA J/Transport) knew and she told dietary staff, but they were constantly changing so she could not recall who she told. She stated a couple of times she had to send Resident #56 to dialysis without even a snack. On 4/27/2022 at 5:55 AM, an observation was made of [NAME] D rushing around in the kitchen because CNA C reported to the kitchen to get a snack made for Resident #56 to take with him to dialysis. The snack was not ready. [NAME] D confirmed that Resident #56 did not have any snacks or lunch prepared for the day. She stated it was the job of the evening dietary aid to prepare the snacks and meals for dialysis residents. Because we have been so short-staffed and everyone is new, it is possible the evening aids do not even know about making the resident snacks and lunch who need them the next morning. [NAME] D pointed to the dialysis resident list on the wall in the kitchen and stated, We were provided with the list of residents on dialysis. It is just that in the evening there may be only one aide so they forget to make the snack bags. (Copy obtained) On 4/27/2022 at 5:58 AM, CNA C was observed as she rushed out to the front of the building to the bus taking Resident #56 to dialysis. The bus driver had finished strapping Resident #56 in. Resident #56 was interviewed at this time and stated, It has been three weeks now since I received that bag. He thanked CNA C, and stated he would have the bus driver drop the yellow meal bag in his dialysis bag. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105580 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 105580 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlton Shores Healthcare and Rehabilitation Cente 1350 S Nova Rd Daytona Beach, FL 32114 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 4/27/2022 at 9:23 AM, an interview was conducted with the interim Regional Director of Culinary Services who stated the Certified Dietary Manager (CDM) quit on 4/27/2022. He provided the procedure outline showing how to provide residents who needed to leave the facility with a nutritious snack to meet their dietary needs. A copy of the outline was requested. On 4/27/2022 at 9:35 AM, an interview was conducted with CNA J/Transportation. She confirmed that she arranged transport for three buildings. She stated she was aware of some problems with Resident #56 getting his dialysis trip snack/lunch, but thought it had been taken care of. CNA J confirmed that a dialysis list was sent to the kitchen and the dietary staff were expected to prepare the meals the day before dialysis because Resident #56's chair time was early. On 4/27/2022 at 10:20 AM, an interview was conducted with the interim Dietary Manager. He stated there was no process for preparing the dialysis meals. Staff were expected to make the meal. There was no defined procedure for getting the meal to the resident. Shortly after the interview with the interim Dietary Manager on 4/27/2022 at 10:24 AM, he provided the policy for Contracted Organization Hospitality Services Bagged Meals, which revealed that individuals who required a meal away from the facility would be provided with a bagged meal. This included those attending medical appointments, dialysis, extended trips for treatments, or for other purposes. (copy obtained) None of the staff interviews supported knowledge of this policy. An interview was conducted with the Chief Clinical Officer (CCO) and the Regional Director of Regulatory Compliance (DRC) regarding how resident dialysis orders were entered. They confirmed by review of Resident #56's medical record at 1:53 PM on 4/27/2022, that no task or specific care plan was generated by the diet slip order entered for Resident #56. They stated they would load up a care plan and task so the CNA would be updated to send a meal with the resident. On 4/27/2022 at 2:00 PM, an interview was conducted with the Director of Nursing (DON), CCO and DRC. They indicated there was no identified procedure that ensured Resident #56 received his meals over the last two weeks. A review of Resident #56's medical record confirmed there was no diet order instructing staff that a meal must be provided prior to dialysis. There was no instruction to provide a snack/or bagged lunch to take to dialysis in Resident #56's Care Plan or CNA task list. They stated Resident #56 refused to take the meals at times and wanted to provide nursing notes that documented Resident #56's refusal. Only one note within the past 3 -4 weeks was identified with a refusal to accept a dietary snack because the resident felt nauseated. No other note or refusal of the meal/snack bag was located in the medical record over the last two weeks. An interview was conducted on 4/27/2022 at 2:20 PM with the COO and DRC. They provided a document dated 4/27/2022 at 2:15 PM. It read: Spoke with a staff member at the dialysis center and the staff member stated, On the days that [Resident #56] brings lunch, she has herself removed it and given him his sandwich and he ate it. The resident is not allowed to have food or drink on the floor while receiving dialysis. On 4/28/2022 at 8:00 AM, a telephone interview was conducted with the dialysis center staff member whose name was provided by the nursing facility on 04/27/2022 at 2:15 PM. The staff member knew Resident #56 and stated he was not permitted to eat while on the dialysis machine. Once off the machine, we take the resident back to the lobby. If he had a sandwich he asked the nurse who retrieved it from his bag. She confirmed she would also help him get the sandwich out of the bag. She was asked whether she had provided him with a snack/sandwich in the last three weeks and she said no. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105580 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 105580 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlton Shores Healthcare and Rehabilitation Cente 1350 S Nova Rd Daytona Beach, FL 32114 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 4/28/2022 at 8:51 AM, an interview was conducted by telephone with the dialysis center Registered Dietician (RD). She confirmed she saw Resident #56 yesterday (4/27/2022) and he had a sandwich. She confirmed she personally spoke to the facility in the past about Resident #56 needing breakfast before he came to dialysis. She confirmed she called and left messages and even spoke with the food supervisor who was no longer at the facility. The RD stated Resident #56 should not have to save a deli sandwich from the night before to eat because he was going to dialysis with no food. The RD confirmed Resident #56 was permitted to bring food, he just could not eat the food while in the dialysis treatment area. She stated Resident #56 showed her his lunch bag when she saw him yesterday at the dialysis center. An interview was conducted with the CCO on 4/28/2022 at 10:03 AM to discuss two newly introduced documents for Resident #56. One document was a care plan section and [NAME] report that was updated on 4/27/2022. The care plan read, Offer/Provide resident (#56) with bagged breakfast on dialysis days (Monday, Wednesday and Friday leaves at 5:30 AM usually.) The [NAME] read, Offer/Provide Resident with a bagged breakfast on dialysis days (Monday, Wednesday and Friday leaves at 5:30 AM usually.) The CCO confirmed the care plan was updated after it was brought to her attention during the survey. She stated they corrected it after a meeting on 4/27/2022. An interview was conducted with Licensed Practical Nurse (LPN) I/Unit Manager, on 4/28/2022 at 1:43 PM. She indicated there was supposed to be a diet slip that provided special instructions. Once the order was entered all of the staff should know that Resident #56 needed a meal prepared for the days he went to dialysis. A review of the medical record was completed with LPN I, and she confirmed there was only one diet order entered with no special instructions for the current admission. The diet slip was dated 12/17/2021 and was entered by a staff member that was no longer employed at the facility. When that order was put in, the staff member should have initiated the appropriate tasks and information provided for Resident #56, who was supposed to receive a meal on dialysis days to take with him to the center. A review of the facility's policy, standards and guidelines, indicated this facility would provide the necessary care and services to those residents receiving hemodialysis while they were a resident at the facility. Line 11 revealed that if the resident required a meal to be sent with them to the dialysis center, one would be provided by the facility. Date last revised was 03/01/2021. A review of the facility's policy provided by the interim Dietary Manager on 4/27/2022 at 10:24 AM, indicated a procedure was in place to provide individuals requiring a meal away from the facility would be provided with a bagged meal. This included those attending medical appointments, dialysis, extended trips for treatments or for other purposes. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105580 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 105580 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlton Shores Healthcare and Rehabilitation Cente 1350 S Nova Rd Daytona Beach, FL 32114 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews with staff, and reviews of the facility's Medication Destruction Policy and the Omnicare Med Pass Checklist, the facility failed to ensure its medication error rate was not 5% or greater (rate 6.67%) for two (Residents in rooms 110B and 304) of seven residents observed during medication administration. Residents Affected - Few The findings include: A medication administration observation was conducted with Registered Nurse (RN) K on 4/26/22 at 4:00 p.m. for the resident in room [ROOM NUMBER] B. RN K reviewed the Medication Administration Record (MAR) and pulled Hydralazine 10 milligrams (mg) for blood pressure and Hydrocodone 10-325 mg for pain from the medication cart. After approaching the resident in room [ROOM NUMBER] B and taking the resident's blood pressure (93/60), RN K decided not to administer the Hydralazine and instead, call the physician. The resident took the Hydrocodone. RN K took the medication cup with the Hydralazine, discarded it in the trash can in the resident's room, and proceeded to walk out of the room. She was called back and asked what was done with medications not taken by the residents. She replied, I could dispose of it in the Sharps container or use the dissolver on the medication cart. She was asked to retrieve the pill from the resident's trash can and dispose of it properly. She removed the pill from the trash can and discarded it in the Sharps container on the wall in the resident's room. On 4/29/22 at 4:35 p.m. the Director of Nursing (DON) stated she was providing education to RN K and other nurses about the appropriate disposal of medications not taken by residents. She confirmed the Hydralazine should not have been thrown in the resident's trash can; there was a dissolver on the cart for that purpose. A medication administration observation was conducted with RN G on 4/27/22 at 8:29 a.m., who was collecting medications for the resident in room [ROOM NUMBER]. RN G reviewed the MAR and pulled Alpha Lipolic Acid 600 mg, Carvediolol 6.25 mg, Doxazosin 4 mg (which fell on the mouse pad on the medication cart and the nurse then used a corner of the medication card to pick it up and put it in the medication cup), Glipidzide 2.5 mg, MultiVitamin with minerals, Hydralazine 75 mg, hydrochlorothiazide 50 mg, Losartan 100 mg, Vitamin D 5000 international units (IU), and Tylenol 650 mg into the medication cup. RN G confirmed placing the dropped pill (Doxazosin) in the medication cup and not disposing of it. He took the medication cup to resident's room with the dropped, contaminated Doxazosin in the cup and gave it to the resident. An interview was conducted with the Chief Clinical Officer (CCO)/RN on 4/28/22 at 10:02 a.m. concerning the disposal of medication not taken, and dropped pills being placed in medication cups for administration to residents. The CCO stated if a pill was dropped on the medication cart surface, it should be destroyed in the chemical dissolution drug disposal container on the cart, and pills not taken should be destroyed in the same container. A pill dropped on the cart should not be given to a resident. A review of the Medication Destruction Policy (dated 1/15/21) revealed the disposal of all medications should be in accordance with state and federal guidelines for the safe disposition of controlled substances which renders such medications undesirable and unusable. The Omnicare Med Pass Checklist was reviewed, which noted under infection control: medications are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105580 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 105580 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlton Shores Healthcare and Rehabilitation Cente 1350 S Nova Rd Daytona Beach, FL 32114 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 0759 dispensed without touching; gloves used when handling medications. Level of Harm - Minimal harm or potential for actual harm . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105580 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 105580 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlton Shores Healthcare and Rehabilitation Cente 1350 S Nova Rd Daytona Beach, FL 32114 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. Based on observations, interviews and document review, the facility failed to ensure the appropriate labeling/storage of medications for four (Residents #48, #55, #77 and #206) of seven residents sampled. Pre-pouring medication placed each resident at risk for a medication administration error by risk of provided the incorrect medications. The findings include: On 4/27/2022 at 5:11 AM, an observation was made of Licensed Practical Nurse (LPN) A's medication cart. Three unlabeled medication cups were observed with an assortment of tablets of different shapes, sizes and colors inside. An interview was conducted with LPN A at the time of observation and she stated the medications were pulled for Residents #48, #55, #77 and #206. She confirmed the three medication cups had four different resident medications that included two pain pills in the same cup. LPN A stated the blue Oxycodone (narcotic pain medication) was for Resident #55 and the other tablet was for Resident #48. Both were controlled substances. (Photographic evidence obtained) On 4/27/2022 at 5:28 AM, LPN A was asked what she was going to do with all of the pre-poured medication. She stated, give the medications. On 4/27/2022 at 1:00 PM, an interview was conducted with the Chief Clinical Officer (CCO) who stated pre-poured medication was not allowed. An interview was conducted with the CCO and the Director of Quality on 4/28/2022 at 3:00 PM. They both stated pre-poured medication was not permitted. A review of Resident #48's medical record revealed he had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points, indicating intact cognition. A review of Resident #48's care plan revealed a focus area for pain medication therapy. An intervention read, Administer analgesic medications as ordered by Physician. A review of Resident #48's Medication Administration Record (MAR) revealed that on 4/27/2022, the initials documented next to the administration of Norco 7.5-325 mg (milligrams) were those of LPN A at 6:00 AM. A review of Resident #55's medical record revealed she also had a BIMS score of 15. Her care plan revealed she had a focus area for pain medication which included the intervention Administer medications as ordered by physician. The MAR for Resident #55, dated 4/27/2022, revealed the initials for LPN A next to the administration of Percocet tablet 5-325 mg at 4:00 AM on 4/27/2022. The blue tablet was confirmed in the unmarked medication cup at 5:11 AM along with a white oblong tablet for Resident #48 that was described by LPN A as Norco. A review of Resident #77's medical record revealed he had a BIMS score of 14, indicating intact cognition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105580 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 105580 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlton Shores Healthcare and Rehabilitation Cente 1350 S Nova Rd Daytona Beach, FL 32114 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 The care plan for Resident #77 indicated he received thyroid replacement therapy. A review of the MAR for Resident #77 revealed that LPN A documented the administration of Tramadol HCL tablet 100 mg on 4/27/2022 at 6:00 AM. A review of Resident #206's medical record revealed that she had a BIMS score of 15, indicating intact cognition. The care plan for Resident #206 indicated she was on antidepressant medication and anticoagulant therapy. A review of the facility's Omnicare Medication Pass Checklist used for nursing services revealed under Medication Cart Security, line 3, Medications are not pre-poured or pre-documented. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105580 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 105580 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlton Shores Healthcare and Rehabilitation Cente 1350 S Nova Rd Daytona Beach, FL 32114 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 - Few 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. Based on record reviews, interviews, and a review of the hospice agency contract, the facility failed to maintain a hospice plan of care, hospice visits and documentation of care in the resident record for one (Resident #75) of four residents reviewed for hospice services/coordination of care, from a total sample of 43 residents. The findings include: An interview was conducted with Resident #75's daughter on 4/25/22 at 12:41 p.m. She reported her mother was receiving hospice care and the caregiver came to visit on Mondays, Wednesdays, and Fridays, but was not bathing the resident if she was already dressed. A call had been placed to the hospice agency and they were notified of the concern. Resident #75 was lying in bed covered up with blankets and had mats on the floor beside her bed. Lunch was on the bedside table and her daughter was going to assist her with lunch. A medical record review was conducted for Resident #75 which noted an admission date of 9/8/2020 with diagnoses including severe protein calorie malnutrition and cerebral atherscelrosis. A physician's recertification for hospice, dated 3/1/22, noted the primary hospice diagnosis was cerebral atherosclerosis with vascular dementia without behavioral disturbance. The care plan for the facility was reviewed, which noted the resident was diagnosed with a terminal condition and was presently under hospice care for an end-stage diagnosis with an intervention to work cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs were met. The hospice contract was re-signed on 2/11/22. An interview was conducted with the Registered Nurse (RN)/Unit Manager for the Cardiac and Sub-acute Unit on 4/27/22 at 4:30 p.m. concerning a request for the plan of care, physician's recertification, documented visits and care from hospice. The Unit Manager reported faxing, and emailing for the last several hours trying to receive the documents requested, but had not received them as of this time. The documents were requested at 2:00 p.m. on 4/27/22. An interview was conducted with the Director of Regulatory Compliance (DRC-RN) at 8:45 a.m. on 4/28/22 after receiving the hospice documentation requested. The DRC-RN reported having to call the hospice provider again late yesterday afternoon to receive the information. He reported the information was not on site. An interview was conducted with Certified Nurses Assistant (CNA) O at 9:30 a.m. on 4/28/22. She reported Resident #75 required total care with bathing. The hospice CNA came in on Mondays, Wednesdays and Fridays and provided the resident's showers. If the hospice CNA did not show up, the facility CNAs gave the resident her shower. When asked if she spoke to the hospice nurse or staff about the resident, she reported no. An interview was conducted with the Social Services Director (SSD) and the Director of Nursing (DON), RN, on 4/28/22 at 1:25 p.m. The DON reported she was the contact person for hospice services and one of the other hospice agencies popped into her office and gave updates on their residents and asked whether anything else was needed. The DON confirmed the assigned hospice agency was contacted several times yesterday asking for information, and the Director of Regulatory Compliance also called them yesterday afternoon, before the facility finally received the information. There had been a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105580 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 105580 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlton Shores Healthcare and Rehabilitation Cente 1350 S Nova Rd Daytona Beach, FL 32114 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 discussion with the Chief Compliance Officer and the Director of Regulatory Compliance about a plan to follow up with hospice about visits and maintaining a current plan of care on site. She reported the team was also looking at discussions with each hospice nurse to keep up with their plan and orders and keeping documentation on site. The SSD reported an order for hospice was received from the physician and hospice was contacted for a visit. Residents Affected - Few An interview was conducted with Licensed Practical Nurse (LPN) L at 1:38 p.m. on 4/28/22. She confirmed that Resident #75 received hospice services and the nurse came in to visit the resident today. LPN L reported that the nurse asked if the resident needed any prescription refills and she replied no. When asked whether she spoke with the hospice nurse before she left, LPN L replied no. A review of the contract for hospice services for the facility revealed on page 6 under medical records documentation: Hospice will retain responsibility for ensuring requirements related to hospice medical records are met. Facility shall allow access to appropriate medical records and permit the inclusion of hospice care plans and other appropriate documentation in Hospice Patient's Facility Medical Record. Hospice shall coordinate with Facility to ensure documentation of services is completed. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105580 If continuation sheet Page 10 of 10