Health inspection·September 25, 2024

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the admission record for Resident #67 revealed an initial admission date of 4/13/22 and a re-admission date of 5/10/22. Diagnosis listed on the admission record included other specified anxiety disorders dated 5/5/23. Review of the psychiatry note for Resident #67 dated 7/10/23 read, This is a [AGE] year-old patient with past history of anxiety and insomnia. On 5/5/23 patient was anxious. Patient was presented with compulsive behaviors of touching and playing with stomach. Patient reported itching around the site. Presented increased or worsening depression. Started Sertraline at 50 mg QD (milligrams every day) for anxiety and Hydroxyzine at 10 mg Q12H PRN (milligrams every 12 hours as needed) for anxiety and itching. DX (diagnosis): Other specified anxiety disorders. Review of the minimum data set quarterly assessment dated [DATE] documented Resident #67 active diagnosis included anxiety disorder and psychotic disorder. Review of Resident #67's clinical record failed to show documentation that the resident had been referred for a Level II PASARR evaluation following the diagnosis of other specified anxiety disorders on 5/5/23. During an interview on 9/24/24 at 1:17 PM, the Director of Nursing confirmed the facility should have done a new screening when the resident received the new diagnosis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105002 If continuation sheet Page 2 of 13 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 105002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beach Street Health and Rehabilitation Center 1001 S Beach Street 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure each resident was screened for a mental disorder or intellectual disability prior to admission to ensure those individual identified with mental disorders or intellectual disabilities are evaluated and receive care and services in the most appropriate setting for one (Resident #4) out of 37 residents sampled for Preadmission Screening and Resident Review (PASARR). Residents Affected - Few The findings include: Review of the admission record for Resident #4 documented an initial admission date of 1/2/2018 with readmission dates following hospital stays on 12/28/23 and 3/29/24. Diagnoses included cerebral palsy unspecified (onset date 1/2/2018), generalized anxiety disorder (onset date 10/26/2020), bipolar disorder unspecified (onset date 1/2/2018), and major depressive disorder (onset date 5/20/2022). Review of the PASARR Level 1 screening for Resident #4 dated 12/28/2023 did not document anxiety disorder, bipolar disorder, depressive disorder or a related condition of cerebral palsy. The Level I screening for Resident #4 documented on page 5: No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASARR evaluation not required. Review of the Minimum Data Set Annual Assessment for Resident #4 dated 6/17/2023, Section I documented the resident has cerebral palsy, anxiety disorder, depression and bipolar disorder. It further documented the resident is taking antipsychotic and antidepressant medication, the antipsychotic is received on a routine basis, and a gradual dose reduction (GDR) has not been attempted. During an interview on 9/24/2024 at 3:10 PM, the Director of Nursing stated that the Level 1 Preadmission Screening and Resident Review (PASARR) for [Resident #4's Name] was not accurate. Review of the policy titled Resident Assessment - Coordination with PASARR Program, date reviewed, 9/18/2023, read, Policy: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105002 If continuation sheet Page 3 of 13 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 105002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beach Street Health and Rehabilitation Center 1001 S Beach Street 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 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 staff failed to provide central venous catheter dressing changes as ordered in accordance with professional standards of practice for one (Resident # 237) out of one resident reviewed with a peripherally inserted central catheter, out of a total sample of 37 residents. Residents Affected - Few The findings include: During an observation on 9/23/2024 at 10:25 AM, Resident #237 was sitting in bed with a right arm single lumen peripherally inserted central catheter (PICC) line. The transparent dressing was lifting up at the edges, exposing the insertion site. The date on the dressing was 9/10/2024. During an interview on 9/23/2024 at 10:30 AM, Resident #237 stated, They have not changed this (the PICC line dressing) since I was admitted , I get antibiotics for a blood infection. I have not been offered a dressing change. During an observation on 9/23/2024 at 2:30 PM, Resident # 237 was observed sitting up in bed with a right upper arm single lumen PICC line with date of 9/10/2024 on the transparent dressing, with the edges of dressing lifting up exposing the insertion site. Review of the admission record documented that Resident #237 was admitted to the facility on [DATE] with the following diagnoses: Sepsis due to enterococcus (a life-threatening condition that occurs when the body's immune system has an extreme response to an infection or injury), Type 2 diabetes mellitus with hyperglycemia (high blood glucose), and essential (primary) hypertension. Review of Resident #237's physician orders dated 9/20/2024 reads, Change central line catheter site dressing every week with only transparent dressing. Change needleless access device every day shift every fri (Friday). Review of Resident #237's physician orders from 9/12/2024 through 9/24/2024 revealed there were no orders for central line catheter site dressings changes prior to 9/20/2024. During an observation of medication administration for Resident #237 on 9/24/2024 at 1:27 PM, Staff E, Licensed Practical Nurse (LPN) flushed the right upper arm PICC Line with 5 milliliters of normal saline. Staff E, LPN did not verify PICC line placement by aspirating to check for blood return prior to administering the normal saline and did not use a push-pause motion when administering the normal saline flush. During an interview on 9/24/2024 at 1:38 PM with Staff E, LPN, she stated, I did take care of him (Resident #237) after the 17th, I did not change his dressing or check it, I should have, all PICC lines get changed every 7 days, so his dressing should have been changed on September 17th. He has not refused to have his dressing changed, because I didn't ask to change it when I took care of him. I should have checked for placement by verifying whether it had a blood return. I did not use a push pause when I flushed his line. We should check whether a dressing is current every day when we flush the line or give the antibiotic. During an interview on 9/24/2024 at 2:04 PM, the Director of Nursing (DON) stated, All midline or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105002 If continuation sheet Page 4 of 13 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 105002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beach Street Health and Rehabilitation Center 1001 S Beach Street 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 PICC line dressings get changed every week. We should have changed his (Resident #237) dressing on the 17th. I 'm not sure why it was not completed. We don't need an order to change the dressing, it would be a standard of care to change it every 7 days at least, more often if it needs it. Review of the policy and procedure titled Central Venous Catheter Dressing Changes last review date of 1/25/2024 reads, Policy: Central venous catheter dressings will be changed at specific intervals, or when needed, to prevent catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings, Preparation: 2. A physicians order is not needed for the procedure, General guidelines: 1. Apply and maintain sterile dressing on intravenous access devices. Dressings must stay clean, dry, and intact. 5. Change transparent semi-permeable membrane (TSM) dressings every 5 to 7 days and PRN (when wet, soiled, or not intact). Review of the policy and procedure titled Flushing Midline and Central line IV catheters last review date of 1/25/2024 reads, Policy: Midline and central line IV catheters (CVAD's) will be flushed to maintain patency; to prevent mixing of incompatible medications and solutions; and to ensure entire dose of medication is administered into the venous system. Flushing Technique: 2. Use a push-pause motion or pulsing motion for flushing technique. 3. Aspirate the CVAD catheter for blood return to confirm patency prior to administration of medication and solutions. Procedure: Flushing to maintain patency of catheter: 4. Aspirate slowly for blood return to ensure patency of catheter. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105002 If continuation sheet Page 5 of 13 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 105002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beach Street Health and Rehabilitation Center 1001 S Beach Street 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 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** 2. During an observation on 9/23/24 at 12:31 PM, Resident #187 was receiving oxygen from a concentrator via a nasal cannula. The concentrator was set at 4 liters and the humidification bottle was wrapped in plastic, empty, and was not hooked up to the concentrator. Residents Affected - Few During an interview on 9/23/24 at 12:41 PM, Resident #187 confirmed that 4 liters of oxygen was correct. Review of the admission record for Resident #187 revealed the resident was admitted on [DATE] with diagnosis that included: Chronic Obstructive Pulmonary Disease With (Acute) Exacerbation, Acute Respiratory Failure With Hypoxia and Acute Respiratory Failure With Hypercapnia (elevated level of carbon dioxide in the blood). Review of the physician orders for Resident #187 dated 9/3/24 read Oxygen at 2 liters/min (minute) via nasal cannula, humidification: Yes. During an observation on 9/24/24 at 8:38 AM, Resident #187 was receiving oxygen from a concentrator via a nasal cannula. The concentrator was set at 2.5 liters and the humidification bottle was wrapped in plastic, empty, and was not hooked up to the concentrator. During an interview on 9/24/24 at 3:14 PM, with Staff D, Registered Nurse regarding his observation of Resident #4's concentrator, he stated, The humidification is not connected. The liters are currently slightly above 2 liters. [Resident #187's name] had previously told the therapist that his oxygen was to be set on 4 but she stated that she corrected him. When asked what the physician orders were for Resident #187, he stated, The order is for 2 liters with humidification. Review of the policy and procedure titled Oxygen Administration last date revised 5/4/2022, last approval date of 1/25/2024 reads, Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Policy explanations and compliance guidelines: 1. Oxygen is administered under orders of a physician. Except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. Based on observation, interview, and record review, the facility staff failed to ensure that oxygen was administered consistent with professional standards of practice for two (Residents #80 and #187) out of four residents reviewed for respiratory care, from a total of 37 residents sampled. The findings include: 1. Review of Resident #80's admission record revealed the following diagnoses: cerebral infarction, unspecified (a stroke), acute respiratory failure with hypoxia (low levels of oxygen in the blood), acute pulmonary edema (fluid in the lungs), essential (primary) hypertension (high blood pressure), major depressive disorder, hypothyroidism, unspecified, and hemiplegia (paralysis of one side of the body), unspecified affecting right dominant side. Review of Resident #80's physician orders dated 4/8/24 reads, Oxygen at 2 liters/ min (minute) via nasal cannula with Humidification PRN (pro re nata) [as needed]-to keep O2 (oxygen) sat (saturation) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105002 If continuation sheet Page 6 of 13 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 105002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beach Street Health and Rehabilitation Center 1001 S Beach Street 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 0695 above 90% as needed for SOB (shortness of breath). Level of Harm - Minimal harm or potential for actual harm Review of Resident #80's nursing progress notes from 9/16/2024 through 9/24/24 revealed there was no documentation related to change of condition or need to increase oxygen. Residents Affected - Few During an observation on 9/23/24 at 11:34 AM, Resident #80 was observed sitting at bedside in a wheelchair with oxygen being administered via nasal cannula. The oxygen concentrator was administering oxygen at 3.5 liters with no humidification. The oxygen concentrator was across the room from the resident and out of the reach of the resident. During an observation on 9/24/24 at 7:23 AM, Resident #80 was observed in bed, with the oxygen concentrator at the head of the bed outside of the reach of the resident. The oxygen concentrator was administering oxygen at 3 liters nasal cannula with no humidification. During an interview on 9/24/24 at 7:25 AM, Resident #80 stated, I cannot reach that (the oxygen concentrator), I don't try to change the oxygen, the nurses do that. During an interview on 9/24/24 at 8:00 AM, Staff A, LPN stated, The oxygen should be at 2 liters, I'm not sure how it's at 3 liters. I will need to change that. No, there is no humidification, I have to see the order to see if she needs that. We should be checking what the rate of oxygen at least once a shift. We do walking rounds; I did not check the oxygen when I did them today. During an interview on 9/24/24 at 12:19 PM, the Director of Nursing (DON) stated, I expect staff to assess residents on oxygen at a minimum daily and make sure that we are following the orders for correct oxygen administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105002 If continuation sheet Page 7 of 13 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 105002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beach Street Health and Rehabilitation Center 1001 S Beach Street 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 observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in a secured manner to limit unauthorized access to medications for three (Residents #78, #74, and #6) out of six residents reviewed for medication storage. The findings include: 1. During an observation on 9/23/2024 at 12:24 PM of Resident #78's room, one bottle of Tylenol PM (acetaminophen 500 milligrams (mg)) and diphenhydramine HCL 25 mg was sitting on dressing table unsecured. During an interview on 9/23/2024 at 12:24 PM Resident #78 stated I take one tablet every night and they know that I have it and take it. During an observation on 9/23/2024 at 2:50 PM of Resident #78's room, one bottle of Tylenol PM (acetaminophen 500 milligrams (mg)) and diphenhydramine HCL 25 mg was sitting on dressing table unsecured. During an observation on 9/24/2024 at 07:55 AM of Resident #78's room one bottle of Tylenol PM (acetaminophen 500 milligrams (mg)) and diphenhydramine HCL 25 mg was sitting on dressing table unsecured. During an observation in Resident #78's room on 9/24/2024 at 1:38 PM with Staff A, License Practical Nurse (LPN), one bottle of Tylenol PM (acetaminophen 500 milligrams (mg)) and diphenhydramine HCL 25 mg was sitting on dressing table unsecured. During an observation in Resident #78's room on 9/24/2024 at 1:42 PM with Staff C, LPN, one bottle of Tylenol PM (acetaminophen 500 milligrams (mg)) and diphenhydramine HCL 25 mg was sitting on dressing table unsecured. 2. During an observation on 9/23/2024 at 12:41 PM of Resident #74's room, one tube of Zinc ointment 20% was lying on the dresser. During an interview on 9/23/2024 at 12:41 PM with Resident #74, the resident stated, I don't know what that is or what it's for. During an observation on 9/24/2024 at 8:58 AM of Resident #74's room, one tube of Zinc ointment 20% was lying on the dresser unsecured. During an observation on 9/24/2024 at 1:38 PM of Resident #74's room, one tube of Zinc ointment 20% was lying on the dresser unsecured. During an observation in Resident #74's room on 9/24/20924 at 01:38 PM with Staff A, LPN, one tube of Zinc ointment 20% was lying on the dresser unsecured. During an observation on 9/24/2024 at 01:42 PM with Staff C, LPN of Resident #74's room, one tube (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105002 If continuation sheet Page 8 of 13 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 105002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beach Street Health and Rehabilitation Center 1001 S Beach Street 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 of Zinc ointment 20% lying on the dresser unsecured Level of Harm - Minimal harm or potential for actual harm 3. During an observation on 9/23/2024 at 12:58 PM of Resident #6's room, one tube of Muscle rub menthol 2% ointment was on the bedside table unsecured. Residents Affected - Few During an interview on 9/23/2024 at 12:58 PM with Resident #6, the resident stated, My friend comes in and will rub the cream anywhere that I hurt. During an observation on 9/24/2024 at 8:58 PM of Resident #6's room, one tube of Muscle rub menthol 2% was lying on the dresser unsecured. During an observation in Resident # 6's room on 9/24/20924 at 1:38 PM with Staff A, LPN, one tube of Muscle rub menthol 2% was on bedside table unsecured. During an observation in Resident # 6's room on 9/24/2024 at 1:42 PM with Staff C, LPN, one tube of Muscle rub menthol 2% on bedside table unsecured. During an interview on 9/24/2024 at 1:38 PM with Staff A, LPN, she stated, Medication cannot be at the bedside or the residents rooms. All medications has to be locked in the medication cart and a physician must write an order for self-administration. During an interview on 9/24/2024 at 1:45 PM with Staff C, LPN, she stated, Medication cannot be in the room unsecured. All medication must be secured in the medication cart. During an interview on 9/24/2024 at 1:58 PM with the Director of Nursing (DON), the DON stated, Medications are to be secured. No medications are to be in the residents rooms unsecured. All medications are to be locked in the medication cart. Review of facilities policy and procedure titled Medication Storage dated 01/25/2024 read It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and or medications=rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security .a. All drugs and biologicals will be stored in locked compartments (i.e. medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls . c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. (Photographic evidence obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105002 If continuation sheet Page 9 of 13 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 105002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beach Street Health and Rehabilitation Center 1001 S Beach Street 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure proper sanitation and food storage practices were adhered to in order to prevent the outbreak of foodborne illnesses. Residents Affected - Some The findings include: During an initial tour of the kitchen with the Certified Dietary Manager on 9/23/2024, beginning at 11:00 AM, the following was observed: Three (3) salads prepared on individual plates with no date or label in reach in refrigerator #1. Two (2) undated cut halves of honey dew melon, 2 undated cut quarter slices of honey dew melon and 1 undated cut half of a watermelon without dates stored in the produce refrigerator. One (1) undated and unlabeled bag of diced vegetables stored in the produce refrigerator. Five (5) undated and unlabeled 5-ounce containers of pureed fruit in the pastry freezer. One (1) uncovered, undated and unlabeled picture of a red drink. Two (2) undated and unlabeled pitchers of beverages stored underneath raw meat products in the meat freezer. During an interview on 9/23/2024 beginning at 11:00 AM, the Certified Dietary Manager acknowledged not all food items stored in the kitchen were labeled and dated. She confirmed all food items should be labeled, dated and covered. She confirmed beverages should not be stored underneath raw meat products. Documentation provided by the facility related to facility practices of storage for Temperature Control for Safety (TCS) Foods, undated, read, Labeling and storing of TCS food correctly ensures our ingredients are safe to use in food served to our customers. All TCS food we prepare and keep for over 24 hours must be labeled and used within 7 days. The document continued Transfer or rewrite labels with the original Use By date from the first container if you move labeled items to different containers. Put Ready-to-Eat food on top, raw meat and fish below and raw poultry on bottom. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105002 If continuation sheet Page 10 of 13 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 105002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beach Street Health and Rehabilitation Center 1001 S Beach Street 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and policy and procedure review, the facility failed to maintain an infection prevention and control program designed to help prevent the transmission of communicable diseases and infection, by 1) failing to perform appropriate hand hygiene during medication administration for four (Residents #51, #80, #238, and #71) of eight residents observed for medication administration, and 2) failed to follow acceptable standards of care for enhanced barrier precautions for a central venous catheter for one (Resident #237) resident during medication administration from a total survey sample of 37 residents. Failure to follow proper infection control standards increases the risk of adverse health outcomes for facility residents, staff, and other facility occupants. Residents Affected - Some The findings include: 1. During an observation of medication administration on 9/23/2024 at 12:03 PM, Staff B, Registered Nurse (RN), returned to the medication cart from the nurses station, removed medication cart keys from their pocket, unlocked the medication cart, activated the computer and typed on the computer. Then Staff B, RN removed insulin from the medication cart, and went to Resident #51's room, entered the room without performing hand hygiene, did not don gloves and administered insulin to Resident #51. Exited the residents room and returned to the medication cart without performing hand hygiene. During an interview on 9/23/2024 at 12:08 PM, Staff B, RN stated, I don't know why I didn't wash my hands or put gloves on. I guess you just make me nervous. I should have done that, I should have washed my hands and put on gloves before I gave him (Resident #51) the insulin. During an observation of medication administration on 9/24/2024 at 8:05 AM, Staff A, Licensed Practical Nurse (LPN) returned to the medication cart from a residents room, reached into pocket for keys unlocked the medication cart and began to prepare medications for Resident #80 without performing hand hygiene. Staff A entered Resident #80's room without performing hand hygiene and administered medications to the resident. Staff A exited the room without performing hand hygiene and returned to the medication cart. During an observation of medication administration on 9/24/2024 at 8:23 AM, Staff A, LPN returned to the medication cart, reached into pocket removed keys and unlocked the medication cart, Staff A prepared medications for Resident #238 without performing hand hygiene, entered Resident #238's room without performing hand hygiene, administered medications to the resident and exited the room returning to the medication cart and began preparing another residents medications without performing hand hygiene. During an interview on 9/24/2024 at 8:28 AM, Staff A, LPN stated, I should have washed my hands, I'm not sure why I didn't, I guess I was just nervous. During an observation of medication administration on 9/24/2024 at 9:00 AM, Staff A, LPN returned to the medication cart from the nurses station, reached in her pocket, removed keys, unlocked the medication cart, activated the computer and typed on the computer keyboard. Staff A prepared medications for Resident #71 without performing hand hygiene, entered Resident #71's room without performing hand hygiene and administered Resident #71's medications. Staff A exited the residents room and returned to the medication cart without performing hand hygiene. 2. During an observation of medication administration on 9/24/2024 at 1:27 PM there was enhanced (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105002 If continuation sheet Page 11 of 13 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 105002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beach Street Health and Rehabilitation Center 1001 S Beach Street 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some barrier precautions signage on Resident #237's doorway, but there was no personal protective equipment of gowns available either inside or outside of the room. Staff E, LPN assembled all supplies to administer an Intravenous (IV) antibiotic and prepared the IV antibiotic to infuse. Staff did not perform hand hygiene and donned gloves; staff did not don a gown. Staff E went to cleanse the needleless connector and there was no needleless connector on the Peripherally inserted central catheter. Staff E, LPN reached into pocket with gloved hand and got a needleless connector attached it to the peripherally inserted catheter and administered 5 milliliters of normal saline without cleansing the needleless connector with alcohol and attached the intravenous tubing and began to infuse the antibiotic. During an interview on 9/24/2024 at 1:38 PM, Staff E, LPN stated, I should have washed my hands before I put my gloves on. He is on enhanced barrier precautions so I should have also had on a gown. I'm not sure why I didn't do these things. During an interview on 9/24/2024 at 2:05 PM, the Director of Nursing stated,I expect all staff will follow our infection control policies for hand washing and enhanced barrier precautions. Review of the policy and procedure titled, Medication Administration last approval date of 1/25/2024 reads, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy explanation and compliance guidelines: 4. Wash hands prior to administering medication per facility policy. Review of the policy and procedure titled, Hand Hygiene last approval date of 1/25/2024 reads, Policy: Staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Policy explanation and compliance guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. Hand hygiene table documents: Between resident contacts; Before applying and after removing personal protective equipment (PPE) including gloves; and before preparing or handling medications. Review of the policy and procedure titled Flushing midline and central line IV catheters last approval date of 1/25/2024 reads, Procedure: 1. Perform hand antisepsis. [NAME] non-sterile gloves. 2. Disinfect needleless connection device with antiseptic solution. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105002 If continuation sheet Page 12 of 13 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 105002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beach Street Health and Rehabilitation Center 1001 S Beach Street 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation and interview, the facility failed to provide a safe, functional, and comfortable environment for residents, by not ensuring proper repair of hand rails in the north and south wings of the facility. The findings include: During an observation on 9/23/2024 at 11:59 AM of railings on South [NAME] wing, four caps were observed missing off of the end of the railing in the hall. The opened area of the rail was observed to have jagged metal exposed. During an observation on 9/24/2024 at 11:10 AM of railings on North [NAME] wing, three caps were observed missing off of the end of the railing in the hall. The opened area of the rail was observed to have jagged metal exposed. During an observation on 9/24/2024 at 11:40 AM with the Director of Maintenance, he confirmed the railings in South [NAME] and North [NAME] wing had missing caps with jagged metal exposed. During an interview with the Administrator on 9/24/2024 at 1:17 PM, the administrator stated, I know all of these need to be fixed. Review of the facilities policy and procedure titled Safe and Homelike Environment dated 1/25/2024 read In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment . This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk .3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105002 If continuation sheet Page 13 of 13