Inspection·December 1, 2022

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as was possible, and failed to provide adequate supervision for four (Residents #19, #25, #3, and #26) of four residents who smoked, kept their lighters in their rooms, and either used oxygen or were near oxygen concentrators. This practice endangered residents, staff and other building occupants. The findings include: On 11/28/2022 at 12:32 PM, Resident #19 was observed wearing a nasal cannula (tubing used to deliver oxygen through the nose) connected to an O2 (oxygen) concentrator. When asked if he knew what his O2 flow rate was supposed to be, he said he took care of it himself and didn't need the staff, but he didn;t provide a flow rate setting. The concentrator was running at 5 LPM (liters per minute). Additionally, a cigarette lighter was observed between the bed and the oxygen concentrator on the floor on top of a fall mat. Resident #19 was asked if he was permitted to have a lighter in his room, and he replied yes. On 11/29/2022 at 8:35 AM, Resident #19's O2 concentrator was observed to be set at 5 LPM, and the cigarette lighter was on the side of his bed. (Photographic evidence obtained) On 11/29/22 at 3:15 PM, Resident #19 was observed sitting on the side of his bed with his oxygen concentrator next to him and set at 5 LPM. He was asked where he kept his cigarettes and lighter. He stated, In my lock drawer. He was asked if his lighter was locked up now. He stated, It might be in my pocket. He was asked how many lighters he had, and he replied one. A No Smoking: Oxygen sign was observed on the outside of Resident #19's door. On 11/29/22 at 3:20 PM, Resident #25 was observed with two packs of cigarettes and a lighter sitting on top of his dresser. An oxygen storage closet was located aproximately 10 feet from his room. On 11/29/22 at 3:25 PM, Resident #3 was observed with vaping materials on top of his side table. His roommate was on oxygen therapy. On 11/29/22 at 3:31 PM, an interview was conducted with the Director of Nursing (DON) regarding the use of lock boxes by the residents. She stated lock boxes were obtained by residents if they wanted to contain personal property. When she was asked about residents who smoked and their cigarettes/lighters, she said if the resident was an unsupervised smoker, they could have a lock box to keep their cigarettes in when they were not smoking. When asked if this included cigarette lighters, she replied yes. When asked if smoking items were to be secured when not in use, she said yes. On 11/29/22 at 5:14 PM, an interview was conducted with the Risk Manager regarding assessments for residents who smoked, to determine whether they should be supervised while smoking. She said residents were assessed by nursing supervisors (floor, unit managers) for smoking status determination. When asked about the frequency of the assessments, she said residents who smoked were assessed upon admission, and reassessed quarterly or as necessary, such as a resident giving another resident a cigarette, or for a change in condition. When asked if independent smokers were to have smoking materials locked up, she replied she was unsure and would have to find out. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105840 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 105840 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory L Bennett Memorial Veterans Nursing Home 1920 Mason Avenue Daytona Beach, FL 32117 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 0689 Level of Harm - Minimal harm or potential for actual harm On 11/29/22 at 5:24 PM, an interview was conducted with Resident #19's physician regarding his O2 orders. The physician said Resident #19 had an order for O2 at 2 LPM as needed, and she knew the flow rate was 2 LPM, because she looked at it during rounds. She added that to her knowledge, she hadn't known the resident to change the flow regulator, nor had she witnessed him changing the flow regulator. Only the staff nurses set the concentrator flow rates according to the physicians' orders. Residents Affected - Some On 11/30/22 at 7:20 AM, an interview was conducted with LPN O. He was asked if Resident #25 smoked. He stated yes. He was asked if the resident kept his smoking materials locked in his room. LPN O stated, I think they just took it all away, and that's why he's in a mood this morning. On 11/30/22 at 7:55 AM, a package of cigarettes and a blue disposable lighter were observed on Resident #26's nightstand, next to his bed on the window side. (Photographic evidence obtained) On 11/30/22 at 8:30 AM, a Smoking Risk Factor review was conducted for four of four independent smokers, indicating that one (Resident #19) of four was rated No Problem for their capability to follow safe smoking practices, while all others were rated a Moderated Problem. Resident #19 had his lighter on top of a fall mat for two days, and then placed his lighter in his pocket on the evening of 11/29/22, which was not a secured drawer or container per the facility's Smoking and Tobacco Use Policy. On 11/30/22 at 8:45 AM, the DON presented a QAPI Plan titled Storage of Smoking Materials, with a plan of action submission date of 11/29/22. In this submission, the plan identified three of four independent smokers with lighters in their rooms that were not stored in a secure container, and a root cause analysis of residents needing to be re-educated on the storage of smoking materials per facility policy. On 11/30/22 at 9:18 AM, progress notes revealed that the Administrator entered Resident #26's room at approximately 6:15 PM on 11/29/22, he removed a lighter from Resident #26's bed and two from from his top dresser drawer. On 11/30/22 at 7:45 AM, he anottated that he had spoken with Resident #26 and explained the issue with unguarded lighters, why he confiscated the lighters, and the resident stated he understood. On 11/30/22 at 9:33 AM, progress notes revealed that the Administrator annotated on 11/29/22 at approximately 6:10 PM, that he entered Resident #25's room and observed that a cup holder on the resident's wheelchair contained a lighter and two packs of cigarettes. He explained the issue with the lighter to Resident #25 and removed it. On 11/30/22 at 9:54 AM, progress notes revealed the Administrator annotated that on 11/29/22 at approximately 6:30 PM, he entered Resident #19's room and asked the resident where his lighter was, and the resident stated it was in his pocket (which is not a secured drawer or container per the facility's Smoking and Tobacco Use Policy) and he knew to keep it locked up. The Administrator reiterated the importance of keeping the lighter secured, and Resident #19 said he understood. The lighter was not confiscated. On 11/30/22 at 10:26 AM, progress notes revealed the Administrator annotated that on 11/29/22 at approximately 6:20 PM, he went to Resident #3's room and observed a lighter in an ashtray in front of Resident #3's TV. He removed the lighter and explained the problem with leaving lighters in the open to the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105840 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 105840 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory L Bennett Memorial Veterans Nursing Home 1920 Mason Avenue Daytona Beach, FL 32117 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 0689 A review of the facility's policy titled, Smoking and Tobacco Use, revealed: Level of Harm - Minimal harm or potential for actual harm On Page three under Resident Smoking Guidlines, Residents with Independent Smoking Privileges, (d) read that Residents with independent smoking priveleges may maintain all smoking articles in a secure drawer or container in their rooms. Residents Affected - Some On Page 4 under Resident Smoking Guidlines, Residents with Independent Smoking Privileges, note read that Residents with independent smoking priveleges who do not comply with the above quidelines will forfeit their independent smoking privileges pending review by the Interdisciplinary Team. On Page 4 under Periodic Checks for Smoking Articles, para. 2, read, Articles found in violation will be removed by the nurse or designee who will store them for the resident in a secure location. On Page 4 under Designated Smoking Areas, para. 3, read, Oxygen use is prohibited in smoking areas. Although oxygen is safe and non-flammable by itself, having combustable articles or accelerants near it will aid in rapidly burning everything around it, thus recommending that there should be zero open flames near oxygen devices or storage units, or at least least five feet away from oxygen units that are active or stored. Vapers (e-cigarettes), which have an internal heating mechanism and are at the forefront of burn accidents by users receiving oxygen therapy, should not be easily accessible either. Resources: Centers for Disease Control and Prevention. Fatal fires associated with smoking during long-term oxygen therapy-Maine, Massachusetts, New Hampshire, and Oklahoma. Morbidity and Mortality Weekly Report. American Lung Association. Using oxygen safely. [NAME] Y, Légaré M, [NAME] F. E-cigarette use in patients receiving home oxygen therapy. Can Respir J. 2015;22(2):83-5. doi:10.1155/2015/215932 . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105840 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 105840 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory L Bennett Memorial Veterans Nursing Home 1920 Mason Avenue Daytona Beach, FL 32117 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 and resident interviews, medical record review, and facility policy and procedure review, the facility failed to ensure that one (Resident #39) of 21 residents receiving respiratory care, were provided such care per physician's orders. Residents Affected - Few The findings include: On 11/28/22 at 1:00 PM, Resident #39 was observed lying in bed. In an interview, he stated he had a CPAP (Continuous Positive Airway Pressure) device that was brought here by his wife, but that the CPAP was broken, and he never got to use it. The resident further stated he had been waiting for a new CPAP for over two months. He was asked if his sleep was disturbed from not having his CPAP. He stated he didn't sleep well without the CPAP. No CPAP device was observed in his room. On 11/30/22 at 9:10 AM, Resident #39 was observed lying in bed. He stated he hadn't heard anything about his CPAP device yet. He further stated he didn't get a good night's rest and he slept off and on throughout the night. He stated again that he slept better with his CPAP. A medical record review for Resident #39 revealed diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Obstructive Sleep Apnea (OSA), and morbid obesity. Further review of the record revealed current physician orders which included: 10/4/22: Call [physician] for CPAP settings. Discontinued physician's orders revealed: 10/4/22: Patient to use CPAP at bedtime (order discontinued 10/17/22). A review of the eMAR (electronic medication administration record) for October 2022 revealed the CPAP order was signed off as item unavailable on October 4, 6, 7, 8, 9, 12, 13, 14, and 16. The CPAP was signed off as having been administered on October 5 and 11, and it was signed off as refused on October 10. A progress note, dated 9/3/2022, revealed, . [Resident #39] stated he had a good first night, slept well, wants to see social services on Monday to try to get another CPAP, his at home is broken, message left with [Employee F] in social services. The progress note was authored by Registered Nurse (RN) C. A review of Resident #39s History and Physical, dated 9/8/2022, with his facility doctor, revealed a note which read, Morbid obesity with obstructive sleep apnea, discussed a CPAP machine and he states in the process of being fixed. On 12/01/22 at 8:49 AM in an interview with RN C, she was asked if she was caring for Resident #39 today. She replied yes. She was asked if the resident had a CPAP device. She stated the resident was not admitted with a CPAP and that family brought his CPAP device in. She stated it was given to Unit Clerk D. On 12/01/22 at 9:03 AM in an interview with Social Services Employee F, she was asked if she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105840 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 105840 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory L Bennett Memorial Veterans Nursing Home 1920 Mason Avenue Daytona Beach, FL 32117 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 Residents Affected - Few recalled working on getting a functioning CPAP device for Resident #39. She stated during one of his Interdisciplinary Team (IDT) meetings, the CPAP device was brought up by nursing and no one ever came back to her about it again. On 12/01/22 at 9:13 AM in an interview with Unit Clerk D, she was asked if she knew about a CPAP device for Resident #39. She stated the resident's wife brought in a CPAP device around the end of September 2022, and she gave it to Registered Nurse (RN) G, who she stated was currently out on leave. She further stated the CPAP had been sitting in the unit manager's office ever since. On 12/01/22 at 10:08 AM in an interview with RN H, she was asked what her current position in the facility was. She replied she was currently the interim unit manager on the Delta unit, covering for RN G. She was asked if she could provide information about Resident #39's CPAP device. She stated the resident's wife brought a CPAP device to the facility in early October 2022, and an order was obtained to obtain the settings from the resident's pulmonologist. When the settings were obtained, the CPAP was plugged in, and the device was found to be broken. She was asked if any attempts had been made to fix the device or replace it since that date. She stated No, usually when the machine is broken, the family gets it fixed. I just went down and spoke with him to see if he still wants a machine. He told me he does want a machine, so I'm calling today for an appointment for him to be fitted for a new CPAP machine. The VA (Veterans' Administration) will pay 100% for a new CPAP. On 12/01/22 at 11:41 AM in an interview with the Director of Nursing (DON), she was asked about Resident #39's CPAP device. She stated, I believe he did not have his with him and it did not work for a while before he was admitted here. His wife was going to see if she could get it fixed, but I'm not sure what happened after that. If it couldn't be repaired, we could get him reassessed for a new one. A review of the facility policy titled CPAP and BiPAP Equipment (Effective Date 3/20/2017) revealed: Standard: The facility will provide routine cleaning and maintenance to minimize infection and ensure maximum functioning of the equipment. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105840 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 105840 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory L Bennett Memorial Veterans Nursing Home 1920 Mason Avenue Daytona Beach, FL 32117 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 - Many 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 observations, staff interviews, and facility policy review, the facility failed to store all drugs and biologicals in locked compartments. This failure involved the Delta 5 hallway medication cart, Delta 5 hallway treatment cart, Delta 3 hallway medication cart, Alpha 5 hallway treatment cart, Alpha 5 hallway medication cart, Alpha 3 hallway medication cart, and four separate nurses on two different shifts during three different days. The findings include: On 11/28/22 at 3:08 pm, the medication cart on Delta 5 hallway was observed to be unlocked as evidenced by the locked popped open. The first two drawers were opened and bottles of prescription medications were observed. (Photographic evidence obtained) No staff were observed in the area of this medication cart. On 11/29/22 at 3:50 pm, the treatment cart on Delta unit was observed to be unlocked and unattended. (Photographic evidence obtained) At this same time, the medication cart on Delta 3 was observed to be unlocked and unattended. The cart was observed to be unattended and unlocked for two full minutes. (Photographic evidence obtained) Registered Nurse (RN) K approached the medication cart but did not say anything. She was asked if this was her medication cart. She stated yes. She was asked if she walked away from her cart, leaving it unlocked and unattended. She stated yes. She was asked if this was her usual practice. She stated, No, I lock it when I walk away. She was asked if she had left the treatment cart (located next to this medication cart) unlocked and unattended. She stated yes. On 11/30/22 at 7:17 am, the treatment cart located on Alpha 5 hall was observed to be unlocked and unattended. (Photographic evidence obtained) The medication cart on Alpha 5 was also observed to be unlocked and unattended at this same time. (Photographic evidence obtained) Licensed Practical Nurse (LPN) L approached the medication cart. She was asked if she was responsible for this medication cart. She stated yes. She was asked if it was her practice to leave the medication cart unlocked when it was left unattended. She stated, No, I had an emergency. She was asked what the nature of the emergency was. She stated, I had to check a Foley (urinary catheter) because they told me the urine color wasn't right. She was asked if she should lock the medication cart before attending to an emergency situation. She stated, I had an emergency and I had to go down the hall. She was asked why the treatment cart next to her medication cart was unlocked and unattended. She stated, I got a g-tube (feeding tube) dressing out of the cart. She was asked if she left the cart unlocked and unattended after getting the g-tube dressing. She stated, Yes. I meant to come back and lock it. On 11/30/22 at 5:15 pm, the treatment cart on Delta 5 hallway was observed to be unlocked and unattended. (Photographic evidence obtained) RN J approached the treatment cart after three minutes of it being observed unlocked and unattended. She was asked if the treatment cart was usually left unlocked when unattended. She stated, Occasionally it's unlocked. I just took something out of there. On 11/30/22 at 5:25 pm, the medication cart on Alpha 3 hallway was observed to be unlocked and unattended. (Photographic evidence obtained) LPN M approached the medication cart after four minutes of observation of the cart being unlocked and unattended. She was asked if this medication cart was assigned to her. She stated yes. She was asked if she knew why the cart was left unlocked and unattended. She stated, I had an emergency. She was asked what the nature of the emergency was. She stated, A (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105840 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 105840 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory L Bennett Memorial Veterans Nursing Home 1920 Mason Avenue Daytona Beach, FL 32117 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 - Many resident was calling out to go to the bathroom. She was asked how long it would take to lock the medication cart. She stated, Quick, push the button. In an interview with the Director of Nursing (DON) on 12/01/22 at 11:34 am, she was asked what her expectation was for medication carts and treatment carts being secured. She stated, If the nurse is stepping away from the area where she can't see the cart, she should be locking the cart. She was asked if there was any reason a medication cart or treatment cart would be unlocked and unattended. She stated, No, there shouldn't be. Maybe in a dire emergency. She was asked what emergency situation would justify a nurse leaving her medication cart unlocked and unattended. She stated, I would say if a code blue was called, and she stepped away for that emergency that would be justified. That's all I can think of. She was asked if a nurse being told that urine in a Foley (urinary catheter) bag is a different color, or a resident calling out for help to go to the bathroom be considered a dire emergency. She stated, No, they should still lock the carts as they walk away. The lock can be pushed in as you're walking by or away. A review of the facility's policy for Storage of Drugs and Biologicals (effective date: 5/4/2016) revealed, Standard: In accordance with state and federal laws, the facility will store all drugs and biologicals in locked compartments/containers under proper temperature controls, and permit only authorized personnel to have approved methods of access. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105840 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 105840 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory L Bennett Memorial Veterans Nursing Home 1920 Mason Avenue Daytona Beach, FL 32117 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 observations, interviews, medical record review, and facility policy review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for one resident (Resident #194) of seven residents requiring urinary catheter care, from a total sample of 27 residents. Residents Affected - Few The findings include: On 11/29/22 at 9:22 am, Resident #194 was observed lying in bed. A urinary catheter bag was observed on the door side of his bed, was not covered with a dignity bag, and was approximately half full of clear, yellow urine. The bag was touching the floor. (Photographic evidence obtained) On 11/30/22 at 2:50 pm, Resident #194's urinary catheter bag was observed uncovered with clear, yellow urine. It was lying against the bed frame and floor of his room. (Photographic evidence obtained) Registered Nurse (RN) J entered the room to answer the call light. She did not address the urinary catheter bag lying against the bed frame and floor. Upon leaving the room at 2:15 pm, she was interviewed and was asked if she was assigned to Resident #194 today. She stated, No, I just saw his call light on and answered it. She was asked if urinary catheters should be elevated off the floor. She replied, I'm not really sure, I can find out. But they probably really shouldn't be touching the floor. She was asked if she had noticed Resident #194's urinary catheter bag touching the floor. She said no. She was not observed going back into his room. On 12/01/22 at 8:45 am, Resident #194 was observed lying in bed. His urinary catheter bag was observed on the left side (door side) of the bed, uncovered, with the bottom of the bag touching the floor. (Photographic evidence obtained) On 12/01/22 at 12:25 pm, Resident #194 was observed sitting up in a wheelchair in his room. His urinary catheter bag was uncovered and on the floor. (Photographic evidence obtained) He was asked how long he had been up in his chair. He stated, A while, maybe an hour. I ate lunch in my chair. In an interview with Certified Nursing Assistant (CNA) I on 12/01/22 at 12:36 pm, she was asked if urinary catheter bags should be touching the floor. She stated, No, they shouldn't be touching the floor. When they are up in a chair, the urinary bag is in a privacy bag, and when they are in bed, it hangs in the holes on the side of the bed, up off the floor. She was asked if she was caring for Resident #194 today. She stated yes. She was asked if she was aware that Resident #194's urinary catheter bag was currently lying on the floor. She stated, Yes, I was getting him a new privacy bag. The old one got ripped on the night shift and he needs a new one. She was asked how long he had been sitting up in his wheelchair. She stated, We got him up for lunch, about an hour ago. In an interview with the Director of Nursing (DON) on 12/01/22 at 11:25 am, she was asked what the expectation for the care of urinary catheters/bags was. She stated, Catheter care every shift, and empty the drainage bag. The catheter is changed monthly unless otherwise specified by the doctor. She was asked what the infection control expectations for the care of urinary catheters/bags were. She stated, Catheter care every shift. Using sterile technique with the catheter. We use privacy bags when the resident is up in a chair and then when they're in bed, the catheter bag should be up off the floor, whether it's in a privacy bag or not. She was asked if staff were expected to elevate the catheter bag up off the floor if it was observed touching the floor. She stated, Yes, nurses and CNAs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105840 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 105840 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emory L Bennett Memorial Veterans Nursing Home 1920 Mason Avenue Daytona Beach, FL 32117 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 (Certified Nurses Aides) can do that. That is provided as education to staff and is an expectation. Level of Harm - Minimal harm or potential for actual harm A medical record review for Resident #194 revealed the following orders: Residents Affected - Few 11/17/22: Change Foley (urinary catheter) catheter every month on the 16th of every month (mixed incontinence) 11/15/22: Change urinary drainage system every Friday 11/17/22: Foley Catheter care every shift. Cleanse with soap and water day, eve, and night. Further medical record review revealed a care plan which outlined the following plan for care of infection prevention related to this urinary catheter: Date implemented: 11/29/22 Focus: Resident has potential for infection related to urinary catheter due to neuropathy. Goal: Will remain free of infection related to urinary catheter through the next review date. Interventions: Flush catheter per orders. Change catheter per orders. Monitor for signs/symptoms of UTI (Urinary Tract Infection) and notify MD. Change drainage bag per policy. Provide dignity bag when OOB (out of bed). Provide catheter care every shift and PRN (as needed). A review of facility policy titled Urinary Catheter Indication and Maintenance (revised 6/9/17) revealed (Part 3: Procedures) 4. Maintain catheter tubing and drainage bag off the floor with privacy bag as appropriate. \ FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105840 If continuation sheet Page 10 of 10