Inspection·March 31, 2022

F 0842 Level of Harm - Minimal harm or potential for actual harm A record review of Resident #81's electronic Medication Administration Record (eMAR) for March 2022 revealed the BiPAP device was signed off, indicating it was used, on every shift (day, evening, night) by the facility nurses for the entire month of March 2022. A Key Code at the bottom of the eMAR revealed the number 2 was to be used for any medication/treatment refused. The code had not been used all month. (Photographic evidence was obtained) Residents Affected - Few During an interview with Employee B, Certified Nursing Assistant (CNA) on 3/30/22 at 1:41 PM, she confirmed that she had never seen Resident #81 use the BiPAP machine. During an interview with Employee C, Registered Nurse (RN) on 3/30/22 at 2:34 PM, she thought Resident #81 used her BiPAP, but had never seen her using it. She explained that if the resident refused to use the machine, staff would code the electronic medication or treatment administration record to indicate resident refusal. Employee C, RN reported that Resident #81 was alert and oriented. A second interview was conducted with Resident #81 on 3/31/22 at 9:50 AM. During the conversation, she again denied ever using the BiPAP while a resident of the facility. She only used it at home. Observation at this time found the BiPAP in same location on the bedside table, and the snorkel (nosepiece) had not moved since the first observation. (Photographic evidence was obtained) A review of Resident #81's nursing progress notes during the month of March 2022 revealed no refusals or explanations that the device was not used. On 3/31/22 at 10:17 AM, an interview was conducted with Employee A, Licensed Practical Nurse (LPN) regarding Resident #81. She stated that she did not know if Resident #81 used her BiPAP machine. She was asked to review the resident's March eMAR. After reviewing the eMAR, she confirmed that the nurses had signed off that the machine was being used during the day, evening, and night shift from 3/1-3/29/22. She explained that Resident #81 was alert and oriented and, to her knowledge, had never refused any medications or treatments. Employee A, LPN added that if she had refused any treatment, the nurse should enter a 2 in the corresponding signature box to indicate refusal. Employee A, LPN confirmed that Resident #81 was an accurate enough historian to self-report not using the device. An interview was conducted with Employee D, Registered Nurse/Unit Manager on 3/31/22 at 10:40 AM. She stated, she reviewed Resident #81's March eMAR for the BiPAP, and confirmed it was signed off as used on every shift. She explained that it was not her expectation that it would be signed off as being used when it was not. In addition, she expressed certainty that the device would not be used on every shift. 2. A record review for Resident #91 revealed an admission date of 12/12/18, with diagnoses including but not limited to specified interstitial pulmonary disease (disorders that cause scarring of the lung tissue), systolic congestive heart failure, hypertension, muscle weakness and heart failure. A review of the annual MDS assessment dated [DATE], assessed her as rarely/never able to make herself-understood and rarely/never able to understand others. The resident required assistance with all activities of daily living (ADLs) and was assessed with severely impaired cognitive skills for daily decision making. A review of Resident #91's physician's order dated 10/28/22 revealed orders for: Geri-sleeves to all extremities: remove for bathing and daily skin inspection. (Photographic evidence was obtained) On 3/28/22 at 10:58 AM, Resident #91 was observed in her room with a laceration approximately 2.5 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105038 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 105038 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Center for Rehabilitation and Nursing 2810 South Atlantic Avenue New Smyrna Beach, FL 32169 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 0842 Level of Harm - Minimal harm or potential for actual harm inches on her right forearm which was surrounded by a large bruise. An oversized rectangle foam bandage was falling off and the wound was exposed. The left elbow had a bruise which was approximately 3 x 2 inches. There was also a bandage on Resident #91's left wrist. An interview was attempted with Resident #91 at this time; however, she was unable to explain her injuries. Both of Resident #91's arms were exposed during the observation. Residents Affected - Few A review of care plan for Resident #91 revealed she was care planned on 2/16/22 for self-care performance deficit related to her requiring limited to total assistance with ADLs. The goal was to maintain her current level of function through the next review. Interventions included to encourage resident with daily clothing choices, and Geri sleeves (protective sleeves worn on the arms) on all extremities. (Photographic evidence was obtained) Additional observations of Resident #91 revealed her arms were bare, and she did not have Geri sleeves on her arms during the following dates. 3/28/22 at 12:37 PM 3/29/22 at 12:05 PM 3/29/22 at 9:17 AM 3/29/22 at 12:08 PM 3/29/22 at 4:00 PM 3/30/22 at 9:25 AM 3/30/22 at 9:50 AM 3/30/22 at 12:44 PM 3/31/22 at 10:00 AM A record review of Resident #91's electronic Treatment Administration Record (eTAR) for March 2022 revealed the sleeves were signed off as applied on the day, evening, and night shifts. Further record review revealed the eTAR was documented that Resident #91 had her sleeves on for the past four days (3/28-3/31/22). (Photographic evidence was obtained) A review of Resident #91's nursing progress notes for March 2022 revealed there were no refusals noted and no explanation that the Geri sleeves were removed by the resident. On 3/30/22 at 1:37 PM, an interview was conducted with Employee B, CNA. She reported Resident #91 seemed to bruise easily and had Geri sleeves, but when staff put them on, the resident took them right off. On 3/30/22 at 2:30 PM, an interview was conducted Employee C, RN. She reported Resident #91 had Geri sleeves which she removed. She explained that the resident kept them on if she had on long sleeves, because then, she didn't know they were on. She stated that when the resident removed her bandages it should be documented. She explained there was a code on the eTAR that would be used for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105038 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 105038 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beachside Center for Rehabilitation and Nursing 2810 South Atlantic Avenue New Smyrna Beach, FL 32169 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few removing/refusing them. She could not recall if it was a 2 or a 3, but that it was supposed to be used to indicate refusal. The CNAs applied the Geri sleeves and staff try to reapply if she removes them. She confirmed that any removal should be documented. On 03/31/22 at 10:06 AM, an interview was conducted with Employee A, LPN. She reported, Resident #91's skin was very fragile. She said, the CNAs normally applied her Geri sleeves, and the resident would remove them. Sometimes the night shift got her up and applied them, or the day shift would do it if they were not on when they came in. When Employee A, LPN was told that Resident #91 Geri sleeves had not been observed on her since 3/28/22, she reviewed the physician's order and confirmed they should be applied to all extremities, every day. During an interview with the Unit Manager on 3/31/22 at 11:45 AM, she reported that the nurse on duty had corrected the situation for Resident #91 by applying the Geri sleeves. She confirmed her expectation was that nurses documented all refusals on the eTAR or eMAR using the codes for Refused or See nurses note. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105038 If continuation sheet Page 4 of 4