Inspection·December 22, 2022

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to complete and electronically transmit Minimum Data Set (MDS) assessments timely for 1 of 5 residents reviewed for MDS assessment completion and submission from a total sample of 42 residents, (#75). Residents Affected - Few Findings: Resident #75 was admitted to the facility on [DATE]. A review of resident #75's medical record revealed the MDS quarterly assessment had an assessment reference date (ARD) of 11/11/22. Review of the history of the quarterly MDS assessment showed it was completed on 12/19/22, locked and accepted on 12/19/22. On 12/20/22 at 2:54 PM, the Licensed Practical Nurse MDS Coordinator reviewed the resident's medical record and stated his quarterly assessment was due 14 days from the ARD date, 11/25/22. She confirmed the quarterly assessment was not completed and submitted until 12/19/22, 24 days late. The MDS Coordinator stated she was responsible for ensuring MDS assessments were submitted timely and explained she had too much on her plate at that time. On 12/20/22 at approximately 3:00 PM, the Director of Nursing acknowledged resident #1's MDS quarterly assessment was late as noted by the MDS Coordinator. He stated he became aware of the late MDS assessments near the end of November 2022. The facility's Resident Assessment Instrument Process revised 3/27/18 contained the regulatory timeframes for MDS assessments and directed staff must follow the schedule for opening, completing and transmitting MDS assessments. The document noted the specific timing of the completion date to be, within 14 days of the Assessment Reference Date . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105904 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 105904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to electronically transmit Minimum Data Set (MDS) quarterly assessments timely for 2 of 2 residents reviewed for MDS assessments, from a total sample of 42 residents, (#73, #72). Residents Affected - Few Findings: 1. Resident #73 was admitted to the facility on [DATE] . A review of the resident's medical record revealed the MDS quarterly assessment dated [DATE] had not been transmitted. 2. Resident #72 was admitted to the facility on [DATE] with a previous admission on [DATE]. A review of the resident's medical record revealed the MDS quarterly assessment dated [DATE] had not been transmitted. On 12/20/22 at 2:53 PM, the Licensed Practical Nurse (LPN) MDS Coordinator stated MDS Quarterly, Annual and Discharge assessments submissions were due in 14 days from the Assessment Reference Date (ARD). She validated the Quarterly assessments for resident #73 and resident #72 were greater than 120 days, and was not submitted timely. She stated her superiors as well as corporate personnel were aware she was late with MDS assessment submissions. She stated, it is my responsibility to make sure Quarterly assessments are transmitted timely. Review of LPN MDS Coordinator job description of Resident Care Specialist Manager signed and dated on 12/1/22, showed under Summary Within the scope of practice as defined by the state, develops, implements, and coordinates the RAI process. Maintains compliance in accordance with current professional practice standards, physician's orders, company policies and procedures, and local state, and federal regulations. The facility's Resident Assessment Instrument (RAI) Process Policy revised 3/27/18 revealed PROCEDURE 5. The facility must follow the schedules for all MDS assessments and tracking forms as set forth in the RAI manual. This includes the timing for opening, completing and transmitting of the assessments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105904 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 105904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 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 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 interview, and record review, the facility failed to develop a baseline/interim care plan related to fall risk for 1 of 2 residents reviewed for hospitalization of a total sample of 42 residents, (#99). Findings: Resident #99 's medical record revealed she was admitted to the facility on [DATE] from an acute care hospital with diagnoses of dizziness, repeated falls, and muscle weakness. The AHCA (Agency for Healthcare Administration) Form 5000-3008 dated 9/23/22 showed primary diagnoses included orthostatic (to stand up) falls and patient risk alerts included falls. The form noted the resident ambulated with an assistive device and needed assistance of 1 staff person for transfers. The 5 Day Minimum Data Set (MDS) assessment dated [DATE] showed the resident had 1 fall without major injury since her admission to the facility. The baseline care plans created on 9/28/22 included ADL (Activities of Daily Living) Self Care Performance, Decreased Nutritional Status, Impaired Communication, Impaired Gas Exchange, Impairment to Skin Integrity, Person Centered Care and Plan to Return Home with Family. There was no evidence that a Fall Risk interim/baseline care plan was initiated. On 10/9/22 resident #99 was transferred to the hospital after a fall with skin tear and did not return to the facility as of 12/21/22. There was no baseline care plan initiated to address risk for falls or interventions to mitigate the risk. On 12/21/22 at 3:47 PM, the MDS Coordinator verified resident #99 did not have a care plan initiated for falls. She explained a care plan for fall risk should have been initiated as the resident was at risk and had history of falls. She noted it had been difficult to keep up with the care plans as she was the only staff person doing the assessments since June 2022. 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: 105904 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 105904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #44 was admitted to the facility on [DATE] with diagnoses to include end stage renal disease, type 2 diabetes, osteoarthritis, asthma, and dementia. The resident's quarterly MDS assessment dated [DATE], revealed the resident was cognitively intact. On 12/20/22 at 12:37 PM, the resident stated she did not know anything about a care plan meeting. She stated no one had ever said anything about attending a care plan meeting and she had never received a written invitation to a care plan meeting. Review of the resident's medical record revealed she was admitted on [DATE] and had an admission and Medicare 5-day MDS assessment completed on 8/19/22 and a quarterly MDS assessment on 11/18/22 that was still in progress. There was no documentation in the record to indicate the resident had attended a care planning meeting. 3. Resident #67 was admitted to the facility on [DATE], with diagnoses to include peptic ulcer, mood and anxiety disorder. Her MDS quarterly assessment dated [DATE], revealed she was cognitively intact. On 12/20/22 at 12:39 PM, the resident stated she had never attended a care plan meeting. Review of the resident medical record noted an admission and Medicare 5-day MDS assessment completed on 7/29/22. A quarterly MDS assessment was completed on 10/29/22. There was no documentation in the record to indicate the resident had attended a care planning meeting. On 2/20/22 at 3:12 PM, the MDS Coordinator stated care plan meetings were scheduled two weeks from the Assessment Reference Date and quarterly assessments. She stated a care plan invite form was filled out and taken to the resident room and she invited the family using a letter or a phone call. She said residents #44 and #67 have not had a care plan meeting to date. I am behind because there are usually 2 people in MDS but I have been by myself pretty much since June. She explained corporate office helped with the assessments and would send someone to help when they could. Review of the Care Plan Conference policy, revised date 2/18/19 revealed: Facility staff have a responsibility to assist resident to engage in the care planning process, e.g., helping residents and resident representatives, if applicable understand the assessment and care planning process; holding care planning meetings at the time of day when the resident is functioning best; planning enough time for information exchange and decision-making; encouraging a resident's representative to participate in care planning and attend care planning conferences. Fundamental Information: The interdisciplinary team, in conjunction with the resident, resident's family, surrogate or representative, will develop the plan of care based on the comprehensive assessment. The care plan conference is held to identify resident needs, establish obtainable and measurable goals. Review of the Resident Care Specialist (MDS Coordinator) job description revealed the following:Direct Care Related Responsibilities: Work directly with the resident to evaluate their needs, document (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105904 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 105904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the evaluation, develop the residents care plan, and discuss the care plan with the resident's family and other team members in accordance with applicable laws, regulations, and standards. Indirect Care Related Responsibilities: Assure that care planning component is developed with input from staff, physician, resident, and family. Based on record review, and interview, the facility failed to involve residents and/or their representatives in the care planning process for 3 of 3 residents reviewed for care planning of a total sample of 42 residents, (#19, #44, #67). Findings: 1. Review of resident #19's medical record revealed she was admitted to the facility on [DATE] with diagnoses that included dementia, depression, and anxiety. Review of resident #19's Minimum Data Set (MDS) Change in Status assessment with Assessment Reference Date (ARD) 9/08/22 revealed she had a Brief Interview for Mental Status score of 0 which indicated she was severely cognitively impaired. On 12/20/22 at 9:29 AM, during a telephone interview, resident #19's daughter and Power of Attorney (POA) stated she had only been invited to and attended one care plan meeting since her mother was admitted to the facility. She explained the care plan meeting was held around the summer time and she had not heard of any other care planning meetings since then. On 12/20/22 at 3:08 PM, the MDS Coordinator explained her responsibilities included completing assessments, inviting residents and/or representatives to care plan meetings, and attending the meetings. She stated she scheduled care plan meetings 2 weeks after the ARD. She indicated care plan meetings were held a couple of times per week and included participation from members of the interdisciplinary team such as social services, dietary, activities, the resident and/or resident representative. She indicated she used a form to invite residents. She said she was behind inviting people to care plan meetings. When asked for copy of the letters she had sent to resident #19's POA, she stated she did not have very many. She stated she wrote it in her calendar. Later at 3:37 PM, she provided a copy of a Care Plan Attendance Log dated 5/19/22 which showed participation of resident #19's POA via phone conference. The MDS Coordinator stated she was only able to find this conference log. She explained there should have been another care plan meeting in August, but she could not find evidence of any other meetings. She indicated the purpose of care plan meeting was to review and update the care plan and provide an opportunity for the resident or representative to voice any concerns. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105904 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 105904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 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 a physician order for 1 of 1 resident receiving oxygen, failed to follow physician ordered dosage for oxygen administration for 2 of 2 residents, and failed to monitor water in the oxygen humidifier for 1 of 1 resident out of 8 residents reviewed for oxygen therapy of a total sample size of 42 residents, ( 89, 551, 76, 38). Residents Affected - Some Findings: 1. Resident #89 was admitted to the facility on [DATE] with diagnoses of anxiety disorder, vascular dementia, and transient ischemic attack. Review of the resident's medical record showed a Minimum Data Set (MDS) admission assessment dated [DATE] that did not show oxygen therapy. Review of the care plan dated 9/26/22 showed no focus, goals, or interventions for oxygen. Review of the resident's physician orders active and discontinued from 9/26/22 to current showed no orders for oxygen. On 12/19/22 at 10:49 AM and 12:16 PM, resident #89 was noted with oxygen via nasal cannula infusing at 2 liters per minute. On 12/19/22 at 12:37 PM, Licensed Practical Nurse (LPN) A stated resident #89 received oxygen at 2 liters per nasal cannula. He stated the resident's oxygen was checked in the mornings. LPN A reviewed resident #89's physician orders and said there were no orders for oxygen. The LPN did not explain why the resident received oxygen therapy when there were no physician orders for oxygen to be administered. 2. Resident #551 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, pneumonia, acute respiratory failure with hypoxia, and emphysema. Review of resident's care plan dated 12/6/22 revealed a focus for impaired gas exchange/ineffective airway clearance with interventions for medications and treatments to be given as ordered. Review of the resident's physician orders dated 12/6/22 showed oxygen via nasal cannula at 2 liters per minute every shift. Review of nurse's progress note dated 12/8/22 at 11:30 PM, read oxygen infusing at 3 liters per minute. On 12/19/22 at 9:57 AM, and 12:14 PM, noted the resident's oxygen infusing flow meter set at 3 liters per minute. On 12/19/22 at 12:31 PM, the resident's assigned nurse, LPN A acknowledged the resident's oxygen was set at 3 liters per minute. LPN A reviewed the physician orders and reported a physician order dated 12/6/22 showed oxygen was ordered at 2 liters per minute. He stated the resident's oxygen was checked in the morning but added he had not checked for the correct flow rate. 3. Resident #76 was initially admitted to the facility on [DATE] with diagnoses of chronic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105904 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 105904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 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 obstructive pulmonary disease, and acute chronic respiratory failure with hypoxia. Level of Harm - Minimal harm or potential for actual harm Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] showed the resident received oxygen. Review of the care plan initiated on 3/28/22, and revised on 10/28/22 revealed focus, goal and interventions for impaired gas exchange. Residents Affected - Some On 12/19/22 at 12:15 PM, the resident was observed with oxygen infusing at 3 liters per minute with humidifier bottle. The humidifier bottle was empty. On 12/19/22 at 12:44 PM, LPN A acknowledged the humidifier was empty and was unsure how long it had been empty. On 12/19/22 at 12:48 PM, the Director of Nursing (DON) stated the nurses were responsible to ensure oxygen was administered as ordered, and should follow physician orders. He said, if a resident was receiving oxygen, there has to be a doctor's order for the oxygen. Review facility policy Physician Orders revised 10/24/17 revealed PURPOSE Physician orders are obtained to provide a clear direction in the care of the resident. Review of the facility's Policies and Procedures for Oxygen Administration revised 5/22/18 showed under PROCEDURE 1. Check Physician's Order. 9. If using a reusable humidifier, fill bottle to the correct level with distilled water and attach to the oxygen unit. 11. Turn the unit on to the desired flow rate and assess equipment for proper functioning. 4. Resident #38 was admitted to the facility on [DATE] with diagnoses of acute respiratory failure, chronic obstructive pulmonary disease, anxiety, and atrial fibrillation. Review of the resident's medical record revealed a physician order dated 1/24/22 for oxygen via nasal canula at 3 liters per minute, every shift. The resident's care plan for oxygen therapy included intervention to administer oxygen as indicated and as per physician orders. The Minimum Data Set, quarterly assessment dated [DATE], reflected the resident had shortness of breath on exertion, when sitting, at rest, and when lying, and used oxygen. On 12/19/22 at 11:30 AM and 1:23 PM, resident #38's oxygen concentrator showed it was set at two liters per minute. On 12/19/22 at 1:25 PM, LPN C reviewed the resident's physician orders and stated the oxygen was ordered at 3 liters per minute. LPN C then checked the resident's oxygen flow rate and acknowledged it was set at 2 liters. She noted the resident had breathing issues and her oxygen should be on the liter flow ordered by the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105904 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 105904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 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 drug regimen review was done monthly for 2 of 5 residents, (#7 and #67), and failed to address a pharmacy recommendation for 1 of 5 residents (#63) reviewed for unnecessary medications of a total sample of 42 residents. Findings: 1. Resident #7 was admitted to the facility on [DATE] with diagnoses to include heart disease, diabetes, dementia, heart failure, anxiety, and schizophrenia. Review of the Medication Regimen Review Report revealed no monthly pharmacy reviews for resident #7 to indicate the pharmacist had reviewed the resident's drug regimen for the months of July, August and September 2022. 2. Resident #67 was admitted to the facility on [DATE] with diagnoses of diverticulosis, peptic ulcer, suicidal ideations, mood disorder, anxiety disorder, and post-traumatic stress disorder. Review of the Medication Regimen Review Report revealed no monthly pharmacy reviews for resident #67 to indicate the pharmacist had reviewed the resident's drug regimen for the months of July, August, and November 2022. 3. Resident #63 was admitted to the facility on [DATE] with diagnoses that included hypertension, anxiety disorder, major depressive disorder, alcohol abuse, and bone density disorder. Resident #63's care plan for acid reflux disease initiated 4/12/22 included intervention to give medications as ordered. Review of the physician's orders revealed an order for Protonix tablet delayed release 40 milligrams (mg) by mouth twice a day for acid reflux disease dated 5/03/22. Protonix (Pantoprazole) is a drug that decreases the amount of acid produced in the stomach. It is recommended to be used at the lowest dose for the shortest amount of time needed to treat the condition. Published observational studies suggest use of this drug was associated with an increased risk of severe colon infection and bone density related fractures when taken more than once a day over a long period of time (retrieved on 12/28/22 from www.drugs.com). Review of the Medication Administration Report for November and December 2022 revealed resident #63 received the Protonix tablet delayed release 40 MG tablet twice a day from 11/01/22 to 12/21/22. Review of the consulting pharmacy Consultation Report for 10/01/22-10/31/22 revealed a recommendation to change the ordered Pantoprazole (Protonix) 40 MG twice a day to Omeprazole 20 MG once daily unless there was an indication that required it to be given twice a day. The rationale given for the recommendation was, dosing more frequently than once daily may increase the risk for adverse effects like bone density type fractures and colon infections. The report listed several references the consulting pharmacist used to make the recommendation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105904 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 105904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 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 In interviews on 12/22/22 at 1:07 and 1:53 PM, the Director of Nursing (DON) explained he was new and stated the Consultant Pharmacist emailed the monthly reviews to himself and the Assistant Director of Nursing. He indicated the reviews would then be printed and given to the Unit Managers to review any recommendations with the physicians. The DON stated he could not find the physician signed consultation report from October for resident #63 and did not know if any physician had even reviewed it. He stated he did not know how the previous DON ensured pharmacy recommendations were reviewed by the physicians. He said he realized, The system was broken previously. On 12/22/22 at 2:16 PM, during a telephone interview, the Consultant Pharmacist stated he was on vacation and did not have his computer so he would not be able to answer any questions about specific residents. He explained his process was to review the medication regimen of all residents including new admissions monthly and make recommendations as necessary. He said he emailed the all consults to the facility monthly but if something is urgent, I would contact the Director of Nursing. He explained the physician did not have to agree with his recommendations, but had to respond to them. The Consultant Pharmacist described the purpose of having the pharmacist review the medications was to benefit the resident and improve their medication safety. He stated he felt as a pharmacist the recommendations were important to ensure the therapy the residents were on were the best for them. The Medication Regimen Review policy and procedure document with most recent revision date 3/03/20, described the procedure for staff to ensure the physician or other responsible parties received the medication review and acted upon the recommendations contained in them. The document described the procedure for the attending physician to document in the resident's health record that any irregularity was reviewed and what if any action was taken to address it, including any rationale if no changes were made. Additional procedures included actions for the facility staff to make if the recommendations were not addressed by the attending physician in a timely manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105904 If continuation sheet Page 10 of 10