Inspection·December 15, 2022

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a baseline/interim care plans in a timely manner related to intravenous (IV) antibiotics and psychotropic medication use for 1 of 1 newly admitted resident reviewed for IV antibiotic therapy and mood/behavioral services of a total sample of 52 residents, (#311). Findings: Resident #311's medical record revealed he was admitted to the facility on [DATE] from an acute care hospital with diagnoses of severe sepsis, alcohol induced pancreatitis, enterocolitis due to clostridium difficile toxin, pneumonia, and alcohol withdrawal delirium. Resident #311 was observed on 12/12/22 at 10:35 AM, lying in bed with his spouse sitting at the bedside. He was noted to have a right upper arm IV line with bag of antibiotics (Vancomycin) currently infusing via IV pump and empty bag IV antibiotics (Zosyn) hanging from pole. The wife said he had been on a lot of drugs to help manage his anxiety and agitation. On 12/13/22 at 3:40 PM, resident #311 was observed in bed, and wife sitting at the bedside. The IV pole was noted with empty bags of IV antibiotics. The resident's wife indicated he was feeling better today, and explained they changed his sedation medication (Ativan) to as needed from scheduled routine. Resident #311 was observed on 12/14/22 at 8:55 AM, asleep in bed with IV antibiotic (Vancomycin) infusing via IV right upper arm and his spouse who was at the bedside said they had to give him medication last night due to being restless and anxious. Review of resident #311's medical record revealed that he or his representative signed consent for Psychoactive Medication Ativan to be given BID (twice per day) for jitters and restlessness. The medication administration record (MAR) revealed the nurse gave Ativan per orders from 12/8/22 to 12/13/22 for symptoms of anxiety and alcohol withdrawal delirium. The IV orders were dated 12/7/22 for STAT (immediate) placement of IV for antibiotics Vancomycin and Zosyn for sepsis for 10 days. On 12/14/22 at 1:09 PM, the Resident Care Specialist (RCS) A said she was one of the nurses who was responsible for completing the Minimum Data Set (MDS) assessments as well as care plans. She explained the interim/baseline care plans were initiated on admission. She noted her supervisor, the MDS Coordinator attended the morning meetings where residents were reviewed and care plans were updated to reflect new orders. The RCS reviewed resident #311's care plans, and acknowledged there were no interim care plans for IV antibiotics or psychotropic medications. On 12/14/22 at 1:18 PM, during a telephone interview, the Lead RCS explained the admission nurse or unit manager were responsible to initiate or update the interim care plans since his comprehensive care plan was not due until 12/19/22. She added the interim care plan was a work in progress and not all updates were done at the morning meetings. She indicated the nurse who received the new orders was responsible for updating the interim care plan. On 12/14/22 at 1:30 PM, the [NAME] Unit Manager (UM) reviewed the medical record and acknowledged (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105793 If continuation sheet Page 2 of 4 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 105793 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Oaks Nursing and Rehab Center 2225 Knox McRae Dr Titusville, FL 32780 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident #311 was on psychotropic medication, Ativan since 12/6/22 for alcohol withdrawal and anxiety. She said, it was the UM's responsibility to ensure the interim/baseline care plan was completed. The Assistant Director of Nurses (ADON) joined interview and reviewed the resident's medical record and verified he had psychotropic medications ordered since his admission on [DATE] and IV antibiotic ordered on 12/7/22, the day after admission. The ADON explained, nurses were responsible for completing the interim care plan for IV therapy and Social Services (SS) staff were responsible for initiating interim care plan for psychotropic drugs. The ADON explained, they should have initiated the care plan when the resident started IV antibiotic therapy and acknowledged there were no baseline care plans for IV antibiotic therapy or psychotropic medications until it was brought to their attention by the surveyor. On 12/14/22 at 2:09 PM the SS Assistant (SSA) said she usually visited new residents within 72 hours of admission and it was the responsibility of the SS Director (SSD) to initiate the baseline/interim care plan for a resident on psychotropic medications. The SSA reflected and said, she did not know why the baseline care plan was not initiated for resident #311. On 12/14/22 at 2:54 PM the SSD said she was new and learning how to do the care plans. She added that when she worked at a prior facility, MDS staff did all the care plans. She was not aware she was responsible to initiate interim care plans for residents on psychotropic medications. The SSD said it was important that a resident with a history of alcohol abuse to have current plan of care to reflect his history and current interventions, but did not understand why she would need to do them. On 12/15/22 at 11:16 AM, the Director of Nursing (DON) said she thought interim care plans only needed to include falls, activities of daily living, skin, pain, and nutrition needs. She added she was not aware the interim care plans should also reflect IV antibiotic therapy and psychotropic medications. She said she thought those could wait until the comprehensive care plan was completed. The DON stated, I am not good at care plans and don't know when they are supposed to be initiated. The facility's Baseline (Interim/Initial/IPOC) Plan of Care, revised 2/18/19 read, The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care .A comprehensive care plan can be developed in place of the Baseline Care Plan .including, but not limited to .physician orders .The nurse will consider the following areas when developing individualized care plan for each resident .Update the Interim (Initial) Plan of Care on and ongoing basis, as necessary, until the Comprehensive Plan of Care is finalized . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105793 If continuation sheet Page 3 of 4 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 105793 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Oaks Nursing and Rehab Center 2225 Knox McRae Dr Titusville, FL 32780 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide dental services in a timely manner for 1 of 2 residents reviewed for dental services, out of a total sample of 52 residents, (#53). Residents Affected - Some Findings: Resident #53 was admitted to the facility on [DATE] with diagnoses of polyneuropathy, cardiac pacemaker and major depressive disorder. On 12/12/22 at 11:39 AM, resident #53 stated she lost her upper partial denture 6 months ago, in June. She recalled she filed a grievance at that time and was told the facility would pay to have it replaced. She stated she had not seen a dentist since that time and added she had never been without teeth and wanted to have the partial denture replaced. On 12/14/22 at 2:01 PM, the Social Services Assistant (SSA) confirmed a grievance was filed June 15, 2022. She stated she did not know what happened to resident #53's partial denture but a replacement was in the works. On 12/14/22 at 3:04 PM, the Social Services Director (SSD) stated when a resident reported lost items, the facility would first search for the item and if not located, the facility would replace the missing item. She clarified if a resident lost a denture and it was unable to be located, the resident would be placed on the dental list to be seen on the next visit. On 12/14/22 at 3:34 PM, the SSA provided paperwork which revealed resident #53 was scheduled to be seen by dental services 10/19/22. She stated the resident was out of the facility at the time of the visit and was not seen. The SSA was unable to explain why the dental referral was scheduled in October when the facility became aware of the missing partial denture in June. A review of resident #53's medical record revealed no documentation to indicate why a referral did not occur within 3 days of the facility becoming aware of the missing partial denture as per facility policy. The record also did not contain any documentation of steps taken to ensure resident #53 could eat and drink adequately while awaiting dental services. The facility's policy and procedure for Dental Services revised 8/29/17 read, The facility will refer residents with lost or damaged dentures for dental services within three days of notification. If the referral cannot occur within three days, the facility will provide documentation of measures implemented to ensure the resident's hydration and nutrition status are maintained. The document identified the social services designee was responsible for coordinating dental services in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105793 If continuation sheet Page 4 of 4