Inspection·March 28, 2024

F 0583 Level of Harm - Minimal harm or potential for actual harm cart, an open binder with personal health information was not secured for privacy and confidentiality. (Photographic evidence obtained) On 03/28/2024 at 9:47 AM, an interview was conducted with LPN H. She stated she realized that she had left the binder open. I just a left a couple of minutes ago. Residents Affected - Some A review of the facility's policy and procedure titled HIPAA Sanctions Policy (implemented 11/27/2019), revealed: 1. The facility, as a covered entity under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), will implement policies and procedures to prevent, detect, contain, and correct any HIPPA violations. 2. All employees are expected to comply with all policies and procedures regarding the protection of personal identifiable health information of our residents. 6. Examples of violations include, but are not limited to: d. the negligent mishandling of confidential information. (Copy obtained) . 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 03/28/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observations, staff interviews, record review, and facility policy review, the facility failed to ensure that residents who required respiratory care received such care consistent with professional standards of practice for three (Residents #110, #146, and #150) of 25 residents who required oxygen therapy from a total sample of 50 residents. Residents Affected - Few failed to ensure that physicians' orders for respiratory care were followed as prescribed, and when not followed, the reasons were recorded in the residents' medical record during that shift for three (Residents #110, #146, and #150) of 25 residents requiring oxygen therapy, from a total sample of 50 residents. The findings include: 1. On 3/25/2024 at 10:18 am, Resident #110 was observed lying in bed wearing a nasal cannula. Resident #110's oxygen concentrator was observed with a flow rate set at 2.5 L/min (liters per minute). On 3/25/2024 at 1:46 pm, another observation was made of Resident #110 lying in bed wearing a nasal cannula with the oxygen flow rate set at 2.5 L/min. (Photographic evidence obtained) On 3/28/2024 at 9:20 am, a third observation was made of Resident #110's oxygen concentrator with a flow rate set at 2.5 L/min. (Photographic evidence obtained) A review of the resident's medical record revealed active physician's orders for oxygen at 2 L/min via nasal cannula every shift, dated: 11/9/2023. A review of the resident's Quarterly Minimum Data Set (MDS) assessment, dated 2/16/2023, revealed he had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 possible points, indicating intact cognition. A review of the resident's active care plan, initiated on 11/23/2023, revealed: oxygen therapy related to chronic obstructive pulmonary disease (COPD). Interventions included administering oxygen via __(specify) L/min and administering medications as ordered by the physician. Monitor/document side effects and effectiveness. The resident's Medication Administration Record (MAR) for March 2024 indicated no oxygen had been documented as administered for 3/18/2024 on the evening shift. All other oxygen was documented as having been provided at 2 L/min via nasal cannula as ordered by the physician, as opposed to 2.5 L/min as observed twice on 3/25/24 and once on 3/28/24. On 3/28/2024 at 9:31 am, Registered Nurse (RN) I stated Resident #110 would change his oxygen settings and sometimes unplug the machine. When asked how staff addressed this behavior with the resident, she stated, Staff reiterate to the resident the importance of his oxygen therapy. The nurse is responsible for providing ongoing monitoring of the resident'a oxygen therapy. Nurses are also responsible for ensuring that residents receive correct oxygen orders. Correct oxygen settings are identified in the order and the MAR. Central supply or nursing staff change residents' oxygen tubing every seven days or as needed. Correct oxygen settings are communicated from one staff person to another in report. RN I stated Resident #110 changed his own oxygen flow rate setting. He did not refuse oxygen therapy; he was not noncompliant but would forget. No documentation was noted in the resident's (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 03/28/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm progress notes related to the resident changing his own oxygen setting or education provided to the resident regarding changes to oxygen settings. On 3/28/2024 at 1:27 pm, the Assistant Director of Nursing (ADON) confirmed that the correct oxygen settings were identified in the orders and MAR. Residents Affected - Few 2. On 3/24/2024 at 3:10 PM, Resident #146 was observed with oxygen therapy in progress and a flow rate of 2 L/min via nasal cannula. (Photographic evidence obtained) On 3/25/2024 at 10:08 AM, the resident was observed with oxygen therapy in progress. The flow rate was set at 2 L/min via nasal cannula. (Photographic evidence obtained) A review of the resident's MDS assessment, dated 2/12/2024, revealed he had a Brief Interview for Mental Status (BIMS) score of 14/15, indicating intact cognition. There were no behaviors noted. A review of the resident's physician's orders revealed a 2/6/24 order for oxygen at 3 L/min via nasal cannula every shift. 3. On 3/24/24 at 3:57 PM, Resident #150 was observed receiving oxygen infusing at 3.5 L/min via nasal cannula. (Photographic evidence obtained) On 3/25/24 at 10:55 AM, the resident was observed receiving oxygen infusing at 2.5 L/min via nasal cannula. (Photographic evidence obtained) A review of the admission MDS assessment, dated 2/8/24, revealed a BIMS score of 15/15, indicating intact cognition. The MDS further revealed no psychosis or behaviors indicated. A review of resident's physician's orders revealed an order dated 2/1/24 for oxygen at 4 L/min via nasal cannula every shift. A review of the facility's Nursing Manual: Standards and Guidelines: SG Respiratory Care and Oxygen Administration, Section Respiratory, Issued 3/2020, pages 1-2. Standard: It is the standard of this facility for respiratory guidelines for respiratory care and safe oxygen administration. Guidelines: 1. Verify that there is a physician's order for respiratory procedures or oxygen use. Review the physician's order for oxygen administration. 4. Oxygen therapy is administered by way of oxygen mask, nasal cannula, and/or nasal catheter as is ordered by the physician or required to provide for the needs of the resident. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105038 If continuation sheet Page 4 of 4