Inspection·February 11, 2021

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a person-centered care plan for vision for 1 of 2 residents reviewed for vision/hearing of a total sample of 40 residents, (#11). Findings: Resident #11 was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included cerebral infarction, cerebral ischemia, dementia and schizoaffective disorder. The resident's quarterly Minimum Data set (MDS) assessment with assessment reference date 12/03/20 revealed the resident's vision was assessed to be highly impaired with no corrective lenses. Her cognition was severely impaired, with a brief interview of mental status (BIMS) score of 0/15. A review of the resident's clinical records revealed a care plan for vision could not be found. On 02/11/21 at 10:24 AM, the Corporate Senior Resident Care Specialist stated the facility did not have a current MDS Coordinator. She said that MDS assessments were completed by doing a seven day look back at the resident's clinical records, and included interviews with staff, and residents as needed. On 02/11/21 at 2:08 PM, the Director of Nursing (DON) stated that care plans were developed from the MDS assessment. The DON added the Social Services Director was responsible to develop the vision care plan. Review of the resident's MDS revealed the section for vision was assessed by the Corporate Senior Resident Care Specialist. On 02/11/21 at 2:48 PM, the DON stated that in review of the resident's clinical records, she could not identify a care plan for vision for the resident. The DON said that a vision care plan should have been developed and stated that the Corporate Senior Resident Care Specialist was not available for interview. The facility's policy, Comprehensive Person-Centered Care Plans revised on 2/18/2019 read, The facility must develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105904 If continuation sheet Page 2 of 7 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 105904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atlantic Shores Nursing and Rehab Center 4251 Stack Blvd Melbourne, FL 32901 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure hand splints were applied as per physician orders for 2 of 2 residents reviewed for mobility of a total sample of 40 residents, (#53, #68). Findings: 1. Resident #53 was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, heart failure, and abnormal posture. The resident's physician orders dated 1/12/21 noted right resting hand splint to be applied daily by nursing during morning care and worn as tolerated by resident. The quarterly Minimum Data Set (MDS) assessment, with assessment reference date 1/13/21, revealed the resident's cognition was severely impaired, with a brief interview of mental status (BIMS) score of 03/15. The resident required extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. Observations on 02/08/21 at 11:26 AM, and at 12:39 PM showed resident #53 in her room. Her right hand was contracted and she was not wearing a splint. On 02/10/21 at 11:06 AM, Licensed Practical Nurse (LPN) D stated the resident's right hand was contracted, but she was not sure if the resident had splints. The resident's physician's orders were reviewed with LPN D. The LPN stated that an order for right resting hand splint was entered in the resident's electronic medical record on 1/12/21 by the Rehab Program Manager. LPN D said the resident did not have any splints on currently and did not have a splint on when she was in the resident's room approximately one hour ago. On 02/10/21 at 11:33 AM observation with LPN D showed resident #53 out of bed, sitting in chair. Her right hand was contracted, and the resident was not wearing a splint on her right hand. On 02/10/21 at 12:13 PM, Certified nursing assistant (CNA) E acknowledged the resident's right hand was contracted, and the resident did not have a splint for her right hand. On 02/10/21 at 2:11 PM, the Rehab Manager stated that resident #53 was discharged from Occupational Therapy (OT) on 1/12/21. An order for right hand resting splint was placed on 1/13/21, and the resident's activities of daily living (ADL) self-care deficit care plan was updated on 1/12/21 with an intervention for splint application. The Rehab Manager stated that a list of residents to wear splints was provided to the Director of Nursing (DON). The Rehab Manager added that nursing and therapy were responsible to ensure splints were applied to residents. The Rehab Manager added the resident had a standard hand splint, and all CNAS were trained by therapy to don/doff the standard splint. She said staff were to document when the splint was applied, when it was taken off, and the resident's tolerance for the splint. Review of the clinical records at this time did not identify documentation of donning/doffing of the right-hand splint for the resident. The Rehab Manager acknowledged there was no documentation of donning/doffing of the splint. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105904 If continuation sheet Page 3 of 7 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 105904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atlantic Shores Nursing and Rehab Center 4251 Stack Blvd Melbourne, FL 32901 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the OT Evaluation and Plan of Treatment for certification period 12/23/20-3/22/21 for resident #53 revealed the short term goal was, Staff will increase ability to don/doff splint .using R(right) elbow orthosis and R wrist/hand orthosis wearing schedule during daily tasks in order to .maintain joint integrity and prevent contracture progression . On 02/10/21 at 2:39 PM, the resident's physician's orders, and ADL- self-care deficit care plan were reviewed with the DON. She acknowledged there was an order for right hand splint for the resident. She also acknowledged the care plan included an intervention for daily splint application. The DON stated that the order for splint was not entered correctly in the electronic medical records and did not populate on the resident's Treatment Administration Record (TAR) for sign off by nursing. She stated the order populated in the general order, and nursing should have followed up for splint application. The DON noted that orders were reviewed by the Interdisciplinary Team (IDT) in the morning meetings. She said a twenty-four hour order listing was also conducted, and the team would be aware of residents on splint by review of the list provided by therapy. She stated the order for the resident's splint was missed. The DON noted that nurses were responsible to review the physician orders to ensure orders were implemented. She added that nursing should have ensured the resident's splint was applied. On 02/11/21 at 10:00 AM, the Rehab Manager stated that splints were ordered to prevent further contractures and if the splint was not applied, contractures could increase/worsen. The resident's care plan Self-care deficit related to decreased strength and endurance created on 11/16/18 with revision on 1/24/20 included interventions dated 1/12/21 for, Right Resting Hand splint to be applied daily by nursing during AM care and worn as tolerated by resident. 2. Resident #68 was admitted to the facility on [DATE]. His diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and contracture of left hand. The resident's physician order dated 1/13/21 read, Left resting hand splint to be applied daily by nursing during AM care and worn as tolerated by resident. The quarterly MDS assessment with assessment reference date 1/27/21, revealed the resident's cognition was intact with a brief interview of mental status (BIMS) score of 15/15. The resident required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. He was totally dependent on staff for transfers and had impairment on one side of his upper extremities. The resident's OT Evaluation and Plan of Treatment for the certification period 12/4/20-1/15/21 read, .Nursing is managing patient's contracture impairment, RNP (Restorative Nursing Program) for splinting to be set up. The OT Discharge Summary revealed the resident received OT therapy from 12/4/20-1/4/21. The summary noted, Restorative Nursing Program set up for L(left) UE (upper extremity) orthosis, staff to demo. OT Treatment Encounter Note dated 1/4/21 read, .Pt made aware of discharge from skilled OT services to begin Restorative Nursing Program for UE exercises and for splint application. The resident's care plan Requires assistance with ADL self-care performance created on 6/03/19 and revised on 1/13/21 included, Left resting Hand splint to be applied daily by nursing during AM care and worn as tolerated by Resident. Skin checks pre/post application. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105904 If continuation sheet Page 4 of 7 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 105904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atlantic Shores Nursing and Rehab Center 4251 Stack Blvd Melbourne, FL 32901 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 02/10/21 at 10:47 AM, resident #68 was lying in bed on his back. His left hand was contracted and the resident was not wearing a splint. On 02/10/21 at 11:35 AM, resident #68 stated he wore a splint on his right hand, but the splint took feet and went away. Resident #68 stated that when he first went to Rehab, he was given the left-hand splint. He said he did not know where the splint was and had asked the staff about it. At this time, LPN D acknowledged resident #68 was not wearing a splint to his left hand. A review of the resident's physician orders with LPN D noted an order for resting hand splint dated 1/13/ 21. On 02/10/21 at 11:15 AM, CNA F stated that resident #68 required assist of two persons for most of his ADLs and did not have a splint for his left hand. On 02/10/21 at 2:11 PM, the Rehab Manager stated that if residents required splints, therapy would train the Restorative CNA to don and doff the splint. This task would then be transitioned to nursing after twelve weeks. The Rehab Manager stated resident #68 was discharged from OT on 1/04/21 and an order for splint was placed on 1/13/21 for left upper orthosis. On 02/10/21 at 2:39 PM, the DON stated that trials of splints were started by therapy prior to residents' discharge from therapy. The resident would then be discharged from therapy with recommendation to nursing status post training of the Restorative CNA for donning/doffing. A review of the resident's orders and care plan was conducted with the DON. She acknowledged the physician order for daily application of splint and stated that nursing should ensure splint was applied as ordered. She stated that nurses were responsible to review the resident's physician orders, to ensure orders were implemented. On 02/11/21 at 10:00 AM, the Rehab Director stated that resident #68 had a splint prior to his admission to the facility, and therapy monitored the resident to ensure the splint was still applicable and appropriate. She said the splint was ordered to prevent further contracture, and if it was not applied, the contracture could worsen. If that happens, therapy would have to do ROM, to open the resident's hands, and would possibly have to change his splint. The Rehab Manager stated that therapy and nursing were responsible to monitor splints in the facility. She stated there was a breakdown in communication. The Facility Assessment dated October 23,2020 indicated that services and care offered based on the residents' needs included Mobility .contracture prevention/care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105904 If continuation sheet Page 5 of 7 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 105904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atlantic Shores Nursing and Rehab Center 4251 Stack Blvd Melbourne, FL 32901 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 obtain physician orders for 1 of 2 residents dependent on oxygen therapy of a total sample of 40 sampled residents, (#12). Residents Affected - Few Findings: Resident #12 was initially admitted to the facility on [DATE] then readmitted on [DATE]. His diagnoses included acute respiratory failure, pneumonia, chronic obstructive pulmonary disease, lung transplant status and dependence on supplemental oxygen. The 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required oxygen therapy. On 02/08/21 at 2:06 PM, resident #12 was resting in bed. He was alert and oriented. He had oxygen via nasal cannula attached to a concentrator with setting of 4 liters per minute (LPM). He stated he was dependent on oxygen especially when walking in the room as he had a hard time breathing. He said he did not touch the control knob of the oxygen concentrator as he did not want to be liable if something happened. On 02/09/21 at 9:57 AM, resident #12 was reclining in bed. He was receiving oxygen by nasal cannula at 4 LPM. He stated he needed to be on oxygen continuously. On 02/09/21 at 2:29 PM, Licensed Practical Nurse (LPN) B stated resident #12 required continuous oxygen at 2 LPM. She added he needed to be reminded to put it on. She also stated that nurses had to make sure the concentrator was calibrated correctly. She noted that nurses were to follow the physician's order because oxygen was considered a medication. On 02/09/21 at 2:42 PM, the Unit Manager (UM) observed resident #12's oxygen flow setting and stated it was set at 4.5 LPM. She checked the physician's orders and said there was no current oxygen order for this resident. She then reviewed the hospital discharge orders and stated there was an order for oxygen to be administered at 3 LPM via nasal cannula continuously. She said the hospital order was not transcribed onto the resident's current medication regime. On 02/11/21 at 10:37 AM, the Director of Nursing (DON) stated that upon admission to the facility, the admitting nurse should have called the physician to verify orders. She said there was no evidence the physician was notified of the hospital oxygen order. A review of the Policy and procedure on Oxygen Administration with a revised date of 05/22/2018 indicated that under Procedure #1. Check physician's order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105904 If continuation sheet Page 6 of 7 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 105904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atlantic Shores Nursing and Rehab Center 4251 Stack Blvd Melbourne, FL 32901 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the physician provided a rationale for declining a pharmacy recommendation and failed to provide an order for gradual dose reduction (GDR) for psychotropic medications, for 1 of 5 residents in a total sample of 40 residents, (#51). Findings: 1. Resident #51 was admitted to the facility on [DATE] with diagnoses including, depression, and anxiety. A review of the monthly pharmacy Consultation Report dated 12/02/20 revealed a recommendation to attempt a gradual dose reduction (GDR) for the antidepressant Citalopram 10 milligrams (mg) for resident #51. The form revealed the physician gave a verbal order on 12/20/20 to decline the recommendation for a GDR but did not include a rationale. On 2/11/21 at 4:24 PM, the Director of Nursing (DON) acknowledged there was no rationale included in the physician's order to decline the GDR. The DON did not provide an answer as to why the physician order did not include a rationale. 2. A further review of the monthly pharmacy Consultation Report showed the consultant pharmacist made a recommendation on 8/10/20 to attempt a GDR for the antidepressant, Trazadone 50 milligrams (mg) at bedtime for resident #51. The physician's response dated 9/27/20 revealed he accepted the recommendation for a GDR, however the physician did not specify the reduced dose of Trazadone. A review of Medication Administration Record (MAR) from September 2020 to February 2021 revealed resident #51 received Trazadone 50 mg daily at bedtime. The Medication Review Report revealed the dose for Trazadone was not reduced as per the pharmacist's recommendation and the resident continued to receive Trazadone 50 mg for 4.5 months after the recommendation was made by the pharmacist. On 2/11/21 at 4:45 PM, the UM acknowledged there was an order for a GDR for Trazadone 50 mg for resident #51. The UM did not explain why the GDR was not followed up with an order for dose reduction. On 2/11/21 at 4:22 PM, the Director of Nursing (DON) acknowledged the physician ordered a GDR for Trazadone 50 mg but did not specify a reduced dose. She stated that any new order should have been acted upon by the physician by providing an order for reduced dose. A review of Policy and Procedure Medication Regimen Review (MMR) effective date 11/28/16, revealed the following: .Physician/Prescriber to either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105904 If continuation sheet Page 7 of 7