Inspection·November 18, 2021

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bell should be placed within all residents' reach while in bed. She also confirmed there was no manual call bell in the room. Staff G did confirm that Resident #19 would not be able to speak or be interviewed related to his care and services. On 11/18/2021 at 10:40 a.m. Staff E, LPN verified Resident #19 was a fall risk and has had falls out from his bed in the past, and he is to have floor mats on either side of his bed when he is in bed. She also confirmed that he does not usually use the call light but confirmed the cord was wrapped and tangled in a manner that it could not be used. She also confirmed there was not a manual call bell in the room. Review of Resident #19's admission Record revealed he was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record revealed diagnoses to include: cerebral infarction, dementia, dysphagia, schizophrenia, depression, and bipolar. The most current Quarterly Minimum Data Set (MDS) assessment, dated 9/2/2021, revealed in Section C for Cognitive Patterns a Brief Interview for Mental Status score of none, and Short Term/Long Term memory problems with Severely Impaired Decision Making Skills. Section G - Functional Status indicated for Activities of Daily Living (ADLs) to include extensive assist with one person with bed mobility, total dependence with two person assist and two persons for transfers, totally dependent on staff with personal hygiene, and total dependent on staff with bathing. Section J - Health Conditions indicated Resident #19 has had falls since admission. Review of the current Order Summary Sheet for the month of 11/2021, revealed Resident #19 had physician orders for the following: - Floor mats to both sides of bed every shift for safety (original order date 7/19/2021). Review of the current care plans with the next review date of 12/2/2021 revealed the following area: Resident is at risk for falls and fall related injury related to generalized weakness, requires staff assist with transfers, is not ambulatory, uses w/c [wheelchair] as primary locomotion, has poor safety awareness, use of Anticoagulants, psychotropic medications. Indicated falls on 3/31/21, 5/25/31, 6/10/21, 7/17/2021 and 10/25/2021. Interventions included: floor mats to bilateral sides of mats, utilizes manual bell prn (as needed) when call light system is not working, keep call light within reach. On 11/18/2021 at 11:40 a.m. the Assistant Director of Nursing (ADON) revealed the facility did not have any specific policies for floor mat placement. She did confirm that when residents are ordered and care planned for use of floor mats, they are to be positioned on the floor when the resident is in bed. The facility policy titled, Answering of Call Lights, with the last revision date of 3/2021 revealed: The purpose of this procedure is to ensure timely response to the resident's requests and needs. The general guideline #4 revealed; Be sure the call light is plugged in and functioning at all times. #5 revealed; When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. #7 revealed; Report all defective call lights to the nurse supervisor promptly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105071 If continuation sheet Page 2 of 18 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 105071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayside Care Center 811 Jackson St N Saint Petersburg, FL 33705 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 0656 (Photographic Evidence Obtained) Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105071 If continuation sheet Page 3 of 18 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 105071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayside Care Center 811 Jackson St N Saint Petersburg, FL 33705 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and medical record review, the facility failed to provide Activities of Daily Living (ADL) care related to fingernail care during three of three days observed (11/16/2021, 11/17/2021, and 11/18/2021) for one resident (#1) of thirty-two sampled residents. Residents Affected - Few Finding included: On 11/16/2021 at 2:10 p.m., 11/17/2021 at 7:30 a.m., 12:08 p.m., 2:00 p.m., and on 11/18/2021 at 8:45 a.m., and 10:00 a.m. Resident #1 was observed in his room, lying in bed with both hands observed with long fingernails and dark brown material noted underneath the fingernails on all fingers. The same brown matter was observed during all dates and times Resident #1 was visited. Resident #1 was observed alert but with confusion and was unable to speak related to his care and services. On 11/18/2021 at 11:11 a.m. an interview was conducted with Staff I, Certified Nursing Assistant (CNA). She observed and confirmed Resident #1's fingernails on both hands were elongated and also with brown matter caked under all of the nails. She did not know if the brown matter was in his nails the previous three days but revealed the expectation would be that his nails be trimmed and cleaned weekly or if soiled. Staff I verified that nail care would be documented on the CNA Activities of Daily Living flow sheets in the personal hygiene area. On 11/18/2021 at 11:40 a.m. an interview with Staff H, Licensed Practical Nurse (LPN) confirmed Resident #1 had brown matter under all of his fingernails and that his nails were also elongated in a manner that needed trimming. Staff H stated personal hygiene includes the cleaning and maintaining of fingernail care. Staff H further confirmed that all direct care staff are responsible for the cleaning of fingernails but as far as the trimming, mostly nurses handle that task. Review of Resident #1's admission Record revealed he was admitted to the facility on [DATE] and readmitted from the hospital on 9/20/2021 and the diagnoses included: encephalopathy, mood disorder, dementia, major depressive, and convulsions. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed in Section C for Cognitive Patterns a Brief Interview for Mental Status score of 2 out of 15, which indicated the resident was severely impaired. Section G- Functional Status showed for Activities of Daily Living to include extensive assist with one person assist for dressing with personal hygiene. Review of Resident #1's CNA ADL flow sheet for the month of 11/2021 revealed staff documented Personal Hygiene for the dates of 11/16/2021, and 11/17/2021 as completed, indicating that nail care was provided. Review of the current care plan initiated on 12/22/20 and with the next review date of 12/6/2021 revealed the following focus areas: - Resident #1 has a self-care deficit with ADLs related to: cognitive deficit related to dementia , impaired mobility. Resident participates with ADLSs cues from staff. Interventions to include but not limited to; cue/encourage resident to participate in ADL tasks, provide hands on assistance with dressing, grooming, bathing as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105071 If continuation sheet Page 4 of 18 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 105071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayside Care Center 811 Jackson St N Saint Petersburg, FL 33705 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 11/18/2021 at 1:00 p.m. an interview with the Assistant Director of Nursing (ADON) confirmed the task personal hygiene includes nail care with either trimming and or cleaning. She revealed staff are to observe resident fingernails daily and if elongated, report to the nurse, if soiled, to clean per ADL cleaning protocol. She also revealed staff are to document in the ADL flow sheet daily when these tasks are completed. A review of the policy titled, Activities of Daily Living (ADLs), Supporting with a last revision date of 3/2018, revealed the policy statement documented as: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 1. of the interpretation section revealed: Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADL) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADL are unavoidable. 2. of the interpretation section revealed: Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care). 5. of the interpretation section revealed: A resident's ability to perform ADL will be measured using clinical tools, including the MDS. Functional decline or improvement will be evaluated in reference to the Assessment Reference Date (ARD) and the following MDS definitions to include e. Total Dependence - Full staff performance of an activity with no participation by resident for any aspect of the ADL activity. Resident was unwilling or unable to perform any part of the activity over entire 7 day look-back period. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105071 If continuation sheet Page 5 of 18 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 105071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayside Care Center 811 Jackson St N Saint Petersburg, FL 33705 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 observations, staff interviews and record review, the facility failed to ensure respiratory care consistent with professional standards of practice was implemented for one resident (#19) of six residents receiving respiratory treatment. Residents Affected - Few Findings included: On 11/16/21 at 12:05 p.m. Resident #19 was observed in his room and lying flat in bed under the covers. Resident #19 was utilizing oxygen via a nasal cannula. Observations of the oxygen concentrator gauge revealed a flow rate of 2.5 liters per minute. Resident #19 was again observed in his room and in bed at 1:35 p.m. on 11/16/21. He was observed utilizing oxygen with the concentrator gauge reading 2.5 liters per minute. On 11/17/21 at 8:30 a.m. Resident #19 was observed in his room and lying flat in bed with the covers pulled all the way down past his feet. He was observed moving his feet and legs up and down and back and forth. Resident #19 was observed with oxygen tubing leading from the oxygen concentrator. The oxygen concentrator gauge read a flow rate at 2.5 liters per minute. Resident #19 was not presenting with labored breathing but was observed with tubing in his mouth and not in nasal cannula. On 11/17/21 at 12:18 p.m. Resident #19 was observed in his room and in bed in the same position, The call light cord and button were observed out from his reach and entangled down below his bed and he was receiving oxygen with the oxygen concentrator gauge reading 2.5 liters a minute. On 11/18/21 at 7:58 a.m. Resident #19 was observed in his room and lying in bed flat and on top of the covers. Resident #19 was observed receiving oxygen and the oxygen concentrator gauge reading was 2.5 liters per minute. On 11/18/2021 at 9:20 a.m. Staff G, Certified Nursing Assistant (CNA) confirmed the call light was placed and tangled under the bed. She believed he did not use it but stated the call light cords and bell should be placed within all residents' reach while in bed. She also confirmed there was no manual call bell in the room. Staff G did not know what Resident #19's oxygen flow rate should be and that was the nurses' responsibility. Staff G did confirm that Resident #19 would not be able to adjust the flow rate on his oxygen concentrator and would not be able to speak or be interviewed related to his care and services. On 11/18/2021 at 10:40 a.m. Staff E, LPN confirmed Resident #19 was lying in bed and utilizing oxygen. She revealed oxygen concentrator gauge showed the oxygen flow rate was running at 2.5 liters per minute and then changed her mind and stated it was running closer to 3.0 liters per minute. She verified verbally that the oxygen flow rate was to be on 4 liters per minute continuously. Review of Resident #19's admission Record revealed he was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record revealed diagnoses to include: cerebral infarction, dementia, dysphagia, schizophrenia, depression, and bipolar. The most current Quarterly Minimum Data Set (MDS) assessment, dated 9/2/2021, revealed in Section C for Cognitive Patterns a Brief Interview for Mental Status score of none, and Short Term/Long Term (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105071 If continuation sheet Page 6 of 18 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 105071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayside Care Center 811 Jackson St N Saint Petersburg, FL 33705 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 memory problems with Severely Impaired Decision Making Skills. Section G - Functional Status indicated for Activities of Daily Living (ADLs) to include extensive assist with one person with bed mobility, total dependence with two person assist and two persons for transfers, totally dependent on staff with personal hygiene, and total dependent on staff with bathing. Section O - Special Treatments indicated the resident utilized oxygen therapy. Residents Affected - Few Review of the current Order Summary Sheet for the month of 11/2021, revealed Resident #19 had physician orders for the following: - Oxygen 4 liters Per Minute per nasal continuous each shift for oxygenation continuously (original order 12/7/2020). Review of the current care plans with the next review date of 12/2/2021 revealed the following area: Resident has potential for alteration in mood/behavior related diagnoses of schizophrenia, Bipolar, and dementia. Is followed by Hospice care for end of life. Does not keep nasal cannula in place, continuously fiddles and removes it. He is cognitively unable to understand risks with interventions in place to include: Monitor Oxygen as ordered, assist with application of Oxygen as need. On 11/18/2021 at 11:40 a.m. the Assistant Director of Nursing (ADON) revealed the facility did not have any specific policies for oxygen use. She clarified that if a resident is ordered for a specific oxygen flow rate, it is it be set as the order reads, at all times. (Photographic Evidence Obtained) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105071 If continuation sheet Page 7 of 18 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 105071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayside Care Center 811 Jackson St N Saint Petersburg, FL 33705 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility did not ensure the medication error rate was below 5.00%. A total of twenty-nine medications were observed, and twenty-eight late medications were identified for two residents (#58 and #9) of three residents observed. The late medications constituted a medication error rate of 96.55 percent. Residents Affected - Few Findings included: On 11/16/21 at 10:36 a.m., an observation was conducted of Staff A, Licensed Practical Nurse (LPN) administering the following medications: - Eliquis Tablet 5 Milligrams (MG) Give one (1) Tablet by mouth two times a day - Divalproex Sodium ER Tablet Extended Release 24 Hour 500 MG twice a day - Latuda Tablet 29 MG by mouth once a day - Lisinopril Tablet 10 MG by mouth one time a day -Aspirin EC Tablet Delayed Release 81 MG by mouth once a day - Atorvastatin Calcium Tablet 20MG by mouth one time a day On 11/16/21 at 11:01 a.m. Staff A, LPN indicated she could not find the following medications for Resident #58 in her medication cart. - Pantoprazole Sodium Tablet Delayed Release 40 MG by mouth one time a day - Metformin HCL ER (OSM) Tablet Extended Release 24 Hour 500 MG by mouth two times a day - Famotidine Tablet 20MG by mouth one time a day. Staff A, LPN was then observed pulling them from the facility's Emergency Drug Kit (EDK). Staff A, LPN was observed attempting to administer the medications to Resident #58. During the observation Resident #58 would not take the medications from Staff A, LPN who became noticeably upset, and then flustered by the resident's refusal. The Assistant Director of Nursing (ADON) administered all the medications to Resident #58 at that time. An immediate interview was conducted with Staff A, LPN and the ADON. Staff A, LPN stated, The physician is not aware the medications are late, no one ever told me the physician had to be told when the medications are late. The ADON stated, The nurse will call the physician when she gets back to tell them that the medications are late. If the nurse needed help, then she should call for help, she should have called us, myself, or the DON (Director of Nursing). I am going to have to hold training for the agency nurses and go over a few things. On 11/16/21 at 11:50 a.m., an observation was conducted of the ADON, administering to Resident #9 the following medications: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105071 If continuation sheet Page 8 of 18 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 105071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayside Care Center 811 Jackson St N Saint Petersburg, FL 33705 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 0759 - Cranberry Tablet 450 MG by mouth once a day Level of Harm - Minimal harm or potential for actual harm - Apixaban Tablet 5 MG by mouth twice a day Residents Affected - Few - Breo Ellipta Aerosol Powder Breath Activated 200-25 Microgram (MCG)/ Inhalation (INH) two (2) puff inhale by mouth once a day - Multi-Vitamin/Minerals by mouth one time a day - Lasix Tablet 40 MG (Furosemide) by mouth one time a day - Senna-Time S Tablet 8.6-50 MG by mouth one time a day - Vilazodone HCL Tablet 10 MG by mouth one time a day with 20mg to equal 30 MG - Artificial Tears Solution 1 % Instill 1 drop in both eyes twice a day - Ascorbic Acid Tablet 250 MG Give 2 Tablet by mouth two times a day - Benztropine Mesylate Tablet 0.5 MG by mouth two times a day - Metoprolol Tartrate Tablet 25 MG by mouth two times a day - Tolterodine Tartrate Tablet 1 MG by mouth two times a day - Buspirone HCL Tablet 15 MG by mouth three times a day - Gabapentin Capsule 300 MG by mouth three times a day - Ferrous Sulfate tablet 325 MG by mouth one time a day - Fentanyl Patch 72 Hour 75 MCG/HR Apply one (1) patch transdermal one time a day every 3 days - Lamotrigine Tablet 200 MG by mouth one time a day - Myrbetriq Tablet Extended Release 24 Hour 50 MG by mouth one time a day - Roflumilast Tablet 500 MCG Give 500 MG by mouth one time a day. Record review of active Physician Orders and the Medication Administration Record (MAR) for Residents #9 and #58, revealed the medications administered to the residents were scheduled to be administered at 9:00 a.m. An interview was conducted on 11/17/2021 at 11:10 a.m., with the DON. During the interview she was informed of twenty-eight medications being administered late to two residents. The DON indicated she knew about the medications being administered late and was notified by the ADON. The DON stated, My expectations is that the nursing staff are doing their medication pass in a timely fashion, and to let us know if they need help. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105071 If continuation sheet Page 9 of 18 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 105071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayside Care Center 811 Jackson St N Saint Petersburg, FL 33705 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 11/17/2021 at 1:29 p.m., an interview was conducted via telephone with the Pharmacy Consultant. During the interview the Pharmacy Consultant stated, We routinely counsel staff at the facility to stay within the one hour before and one hour after the medication is due to be given. Sometimes we have nurses that do not follow it. A facility policy titled, Administering Medications, with a revision date of April 2019, Pages 01 of 05 revealed under Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 7. Medications are administered within one (1) hour of their prescribed time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105071 If continuation sheet Page 10 of 18 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 105071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayside Care Center 811 Jackson St N Saint Petersburg, FL 33705 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 0760 Ensure that residents are free from significant medication errors. 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 ensure one resident (#28) was free of a significant medication error by staff (C, D) failing to contact the physician for approval prior to administering Zolpidem (sleeping pill) outside of the prescribed time and allowing the resident to go outside of the building alone, and the facility failed to ensure one resident (#28) was administered tremor medication as ordered to maintain the highest practicable mental and physical well-being out of three residents sampled. Residents Affected - Few Findings included: During an interview and observation of Resident #28 on 11/15/21 at 10:07 a.m. the resident stated she has constant tremors and movement of legs if she does not get her medication. Resident #28 stated over the last two days she has not had any of the medication that controls her tremors. The resident was observed crying, stomping her left foot uncontrollably and moving around the room in distress. An interview on 11/15/21 at 1:07 p.m. with Staff C, Licensed Practical Nurse (LPN) confirmed Resident #28 did not receive her Carbidopa 50 mg (milligram) -Levodopa 200 mg-Entacapone-200 mg. Staff C stated she did not have any in the medication cart, so she asked the unit manager, Staff D, LPN what she could do, and Staff D suggested she give the Carbidopa 25 mg -Levodopa-100 mg, which was due and add one more Carbidopa 25 mg -Levodopa-100 mg to replace the Carbidopa 50 mg-Levodopa 200 mg-Entacapone-200 that was not in the cart. During an interview with Resident #28 on 11/15/21 at 1:50 p.m. she stated she asked for her antianxiety medication because she went outside and was waiting for her transportation to take her to the store. She said while she was out front waiting, she felt extremely weak and started to panic and became short of breath. She said she was so weak she could not wheel herself back in the building and used her phone to call the front desk to have the nurse come get her. Resident #28 stated she had no idea why she felt so weak and then she had an anxiety attack. Resident #28 stated she was asked on Sunday (11/14/21) by the unit manager (Staff D, LPN) if she wanted to take her Zolpidem (sleeping pill) between 1:00 p.m. and 3:00 p.m. since her tremors were so bad, and the nurse could not get her Carbidopa 50 mg-Levodopa 200 mg-Entacapone-200 mg. Resident #28 then said that while [Staff C,LPN)] and [Staff D, LPN] were in her room on 11/15/21 giving her the extra Carbidopa 25 mg -Levodopa-100 mg, they talked about the Zolpidem because she was suffering from the tremors and felt like her leg was going to break and back was going to crumble. Then [Staff D] told [Staff C] to give her the Zolpidem around 10:50 a.m. on 11/15/21. The resident stated she knew that was her sleeping pill but had no idea it would make her so weak when she had the plans to get on the bus and go to the store around 2:00 p.m. on 11/15/21. During an interview on 11/15/21 at 2:19 p.m. with Staff D, LPN/Unit Manager he stated he worked on the weekend and gave Resident #28 her Carbidopa 50 mg-Levodopa 200 mg-Entacapone-200 mg on Saturday and Sunday and ordered more for the resident before he left on Sunday. Staff D stated he thought about giving Resident #28 her Carbidopa 25 mg - Levodopa 100 mg to replace her missing Carbidopa 50 mg-Levodopa 200 mg-Entacapone-200 mg but did not do that. He stated her Carbidopa 50 mg-Levodopa 200 mg-Entacapone-200 mg was not sent due to billing or insurance issues and confirmed the Director of Nursing was working on getting it. Staff D, denied giving or speaking to Resident #28 about Zolpidem. He stated he was not aware of her ever receiving the Carbidopa 25 mg - Levodopa 100 mg instead of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105071 If continuation sheet Page 11 of 18 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 105071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayside Care Center 811 Jackson St N Saint Petersburg, FL 33705 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 0760 Carbidopa 50 mg-Levodopa 200 mg-Entacapone-200 mg. Level of Harm - Minimal harm or potential for actual harm An interview on 11/15/21 at 2:21 p.m. with Staff C, LPN revealed that Staff D, LPN/Unit Manager told her to give the extra Carbidopa 25 mg - Levodopa 100 mg to replace the Carbidopa 50 mg-Levodopa 200 mg-Entacapone-200 mg and confirmed Staff D gave her approval to give the Zolpidem and told her he called the physician so she did not call the physician but documented that the physician was notified. Staff C stated that she had no idea Resident #28 had plans to leave the facility for the store when the Zolpidem was given. Staff C confirmed she did not document the extra dose of Carbidopa 25 mg - Levodopa 100 mg given to the resident during her 11/15/21 9 a.m. medications. Residents Affected - Few During a phone interview with the Pharmacist from the facility pharmacy on 11/15/21 at 3:22 p.m. He stated the resident's Carbidopa 50 mg-Levodopa 200 mg-Entacapone-200 mg was sent out the morning of 11/15/21 after an order came in on 11/15/21 and the pharmacy sent 60 tablets (a 30-day supply). The Pharmacist confirmed the order was placed on 10/19/21 for 60 pills so that should have her covered 4 more days. The Pharmacist confirmed an order was attempted on 11/14/21 but was too soon to be sent out. The Pharmacist confirmed that Zolpidem should never be given during the daytime unless the physician authorizes it and the resident stays in bed. During an interview on 11/15/21 at 3:41 p.m. the Director of Nursing (DON) confirmed she ordered Resident #28's Carbidopa 50 mg-Levodopa 200 mg-Entacapone-200 mg on the morning of 11/15/21 and stated the medications should be ordered before the resident is out of the medication, and in this case the resident's insurance would not cover the medication as it was four days early. So, the facility will cover the cost. The DON confirmed nurses should not change or alter the physician order without discussing the medication with the physician and should document any missed medications or alterations in the medication. The DON stated she was not aware the resident was given Zolpidem during the daytime and stated if the physician authorized it; a new order should have been written and documented in the notes. During a phone interview on 11/15/21 at 4:14 p.m. with the Nurse Practitioner (NP) he confirmed he was on call since 7:00 a.m. (11/15/21) and no one called and asked about giving Zolpidem during the daytime and responded, Zolpidem should never be given during the day! Then repeated, Not in the morning, . It's not safe at all! The NP confirmed that he spoke with the other on call NP from last night and she confirmed the only one they spoke to about Resident #28 was a call from Resident #28 complaining she did not get her Carbidopa 50 mg-Levodopa 200 mg-Entacapone-200 mg for the last couple days and said the DON was not helping her get it. The NP stated they have call logs and the facility did not call for approval of the Zolpidem or the double dose of Carbidopa 25 mg - Levodopa 100 mg. The NP confirmed he would have given the ok to give two doses of Carbidopa 25 mg - Levodopa 100 mg if the nurse would have called and asked about it. The NP stated he would not have approved the Zolpidem in the morning and reiterated the nurse should have never discussed the options with the resident without speaking to the prescriber of the medication. He confirmed the resident should never have been allowed out of the building after given Zolpidem in the morning and will need to be watched for safety and encouraged to lay down and sleep. During an interview with the Administrator on 11/16/21 at 8:07 a.m. she stated she started an investigation and revealed several people have been suspended pending the investigation. During an interview on 11/16/21 at 3:10 p.m. the Assistant Director of Nursing (ADON) confirmed Staff D, LPN/UM was suspended due to making a judgement call to give Resident #28 her Zolpidem during the daytime without contacting the physician. The ADON confirmed she received a call from the front (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105071 If continuation sheet Page 12 of 18 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 105071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayside Care Center 811 Jackson St N Saint Petersburg, FL 33705 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few desk on 11/15/21 that the resident was outside around 12:30 p.m. and was having difficulty breathing and anxiety. The ADON stated the resident was taken back to her room when she assessed her and called the doctor to get a dose of her antianxiety medication for 1:00 p.m. instead of 2:00 p.m. due to the increased anxiety and her tremor medications not given properly. The ADON confirmed the resident told her she was supposed to go shopping and will usually take an [name of transportation company] but came back in due to the shortness of breath. A review of the admission Record showed Resident #28 was admitted on [DATE] and readmitted on [DATE] with diagnoses of Parkinson's, restless leg syndrome, bipolar disorder, major depressive disorder, generalized anxiety disorder, psychosis, and fibromyalgia. Review of the November 2021 physician orders revealed: - Zolpidem Tartrate tablet 10 mg: Give one tablet by mouth at bedtime for insomnia. Ordered 8/3/20 and discontinued on 11/15/21. - Zolpidem Tartrate tablet 10 mg: Give one tablet by mouth every 24 hours as needed for insomnia and may give at bedtime. Ordered on 11/15/21 to start on 11/16/21. - Carbidopa 25 mg - Levodopa 100 mg for Parkinson's disease every 4 hours started 10/22/19. - Carbidopa 50 mg-Levodopa 200 mg - Entacapone 200 mg: give one tablet by mouth two times a day for tremors, ordered on 4/14/20. Review of the November 2021 Medication Administration Record (MAR) revealed the resident received Zolpidem on 11/14/21 and 11/15/21. The November 2021 MAR also revealed the resident received Carbidopa 50mg-Levodopa 200 mg - Entacapone 200 mg on 11/13/21 and 11/14/21 for the 9:00 a.m. and 9:00 p.m. dose. Review of the Carbidopa 25 mg - Levodopa 100 mg revealed the resident given one tablet as ordered on 11/13/21, 11/14/21 and 11/15/21 every four hours. Review of the narrative nursing notes dated 11/15/21 at 10:59 a.m., revealed Staff C, LPN documented: Resident given Zolpidem dose at 10:52 a.m. on this day, Per MD (medical doctor) and supervisor. Resident complaint of being awake all night related to the extreme discomfort and severe pain felt from chronic leg pains and leg spasms. Review of the eMAR (electronic medical record) administration notes dated 11/15/21 at 8:12 a.m., revealed Staff C, LPN stated insurance issue at this time with this medication. No dose available at this time. Resident and MD aware. Review of the eMAR administration note dated 11/14/21 at 9:43 p.m. revealed Resident #28 given Zolpidem at bedtime for insomnia. Review of the Situation, Background, Appearance, Review and Notify (SBAR) form dated 11/15/21 at 1:05 p.m. revealed, the resident with a change in condition, symptoms included at 12:30 p.m. increased anxiety and difficulty breathing. other neurological symptoms started getting better and Klonopin pulled from the EDK [emergency drug kit] on at 13:05 p.m. (1:05 p.m.) Review of Minimum Data Set (MDS) dated [DATE] Section C - Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score as 15 meaning cognitively intact. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105071 If continuation sheet Page 13 of 18 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 105071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayside Care Center 811 Jackson St N Saint Petersburg, FL 33705 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 0760 Level of Harm - Minimal harm or potential for actual harm Review of the care plan revealed the resident's potential for adverse side effects for psychotropic medications: antidepressant for treatment of depression for treatment of depression/bipolar disorder, hypnotic for insomnia, and antianxiety for treatment of anxiety initiated on 1/14/14. Interventions included: Administer medications as ordered, Observe for effectiveness of psychotropic medications. Observe for adverse side effects related to psych medication use: report to the physician as needed. Residents Affected - Few In addition, another Focus Area was for alteration in comfort related to fibromyalgia, arthritis, lower back pain and muscle spasms initiated 1/14/14. Interventions included: administer medications as ordered and monitor for effectiveness and for adverse side effects. Observe for nonverbal side effects of pain: grimacing, restlessness, irritability, pulling away, moaning, crying. Notify the physician as needed. During an interview and observation of Resident #28 on 11/17/21 at 8:45 a.m. she said she was in bad shape on 11/15/21 due to not receiving her medication. Resident #28 stated, I feel it coming up my leg. It's not pain, it's a state of suffering! My left leg felt like it was going to break, I felt like my back was going to crumble! My priorities in life with my condition are, God is #1, tremor medication (Carbidopa 50 mg-Levodopa 200 mg-Entacapone- 200 mg) is #2, and (Carbidopa-25 mg -Levodopa- 100 mg) is #3 that's how important the tremor medications are to me. During the observation the resident was observed without tremors and confirmed she had received her medication correctly since the evening of 11/15/21. Review of facility policy for Charting and Documentation, revised July 2017, one page revealed: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 3. Documentation in the medical record will be objective, complete, and accurate. Review of facility policy for Administering Medications, revised April 2019, two pages, revealed: Medications are administered in a safe and timely manner, and as prescribed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105071 If continuation sheet Page 14 of 18 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 105071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayside Care Center 811 Jackson St N Saint Petersburg, FL 33705 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, facility policy review, interviews, and the Plan of Correction (POC) review, the facility failed to ensure it had a functioning Quality Assurance Committee. The facility was actively involved in the effective creation, implementation and monitoring of the POC for deficient practice at

F695 identified during a recertification survey, conducted on 11/15/2021 through 11/18/2021. The POC completion date was 12/18/2021. On 1/11/2022 on the revisit survey deficient practice was again identified at F695. Findings included: 1. During the recertification survey ending on 11/18/2021 the deficient practice was identified due to the facility failing to ensure respiratory care was consistent with professional standards of practice for one resident of six residents receiving respiratory treatment. One resident's oxygen flow rate was not in accordance with physician orders. 2. The facility developed a plan of correction that included: Facility Administrator and/Director of Nursing/or Designee to provide education to nurse with an emphasis on: .II. Nurses on oxygen flow rate as per physician order # of liter per minutes, how to view the flow gauge. III. Review of facility oxygen policy will be reviewed with the nursing staff and newly hired nurses will be educated on oxygen policy. Nursing staff to audit oxygen flow gauge and reviewed physician order. 3. During the revisit survey on 1/11/22 the facility failed to ensure respiratory care was provided consistent with professional standards of practice for two (Resident #2, Resident #3) of four residents sampled. 4. Review of the facility's oxygen administration policy revised October 2010 revealed: Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physicians orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. 3. Assemble the equipment and supplies as needed. General Guidelines: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105071 If continuation sheet Page 15 of 18 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 105071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayside Care Center 811 Jackson St N Saint Petersburg, FL 33705 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 0867 1. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter. Level of Harm - Minimal harm or potential for actual harm b. The nasal cannula is a tube that is placed approximately one-half inch into the resident's nose. It is held in place by an elastic band placed around the resident's head. Residents Affected - Few Documentation: After completing the oxygen set-up or adjustment, the following information should be recorded in the resident's medical record: 1. The date and time that the procedure was performed 2. The name and title of the individual who performed the procedure. 3. The rate of oxygen flow, route, and rationale. 4. The frequency and duration of the treatment 5. The reason for prn [as needed] administration 6. All assessment data obtained before, during, and after the procedure. 5. Resident #2 was admitted to the facility on [DATE] from an acute care hospital. The diagnoses included, but are not limited to, dementia, memory deficit following unspecified Cerebrovascular disease (CVA), and chronic obstructive pulmonary disease (COPD). An observation of Resident #2 was conducted on 1/11/22 at 9:55 a.m. The resident was observed to be in the bed dressed in day clothes, watching television. The resident was observed to have a nasal cannula on with his oxygen flow rate set to 4 liters per minute (LPM). The resident stated he is supposed to be on 2 LPM, but he feels good right now. Review of Resident #2's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating moderate cognitive impairment. Review of Resident #2's physicians order, with a start date of 12/9/21 and no end date, indicated may apply oxygen at 2 LPM via nasal cannula as needed (prn) for maintaining oxygen saturations greater than or equal to 92%. Review of Resident #2's Treatment Administration Record (TAR) revealed no documentation the Resident #2 was receiving prn oxygen. Further observation conducted on 1/11/22 at 11:54 a.m. revealed Resident #2 to be lying in bed, eyes closed, nasal cannula in his nose, and his oxygen concentrator set on 4 LPM. An interview was conducted with Staff A, LPN on 1/11/22 at 11:55 a.m. Staff A, LPN entered Resident #2's room and confirmed his oxygen was set to 4 LPM. The nurse confirmed in the electronic medical record the physicians' orders stated the oxygen was to be set at 2 LPM. Staff A, LPN indicated Resident #2 had oxygen saturation readings of 97% during the night, and the most recent oxygen saturation reading was also 97%. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105071 If continuation sheet Page 16 of 18 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 105071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayside Care Center 811 Jackson St N Saint Petersburg, FL 33705 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 0867 Level of Harm - Minimal harm or potential for actual harm An interview was conducted with the Director of Nursing (DON) on 1/11/22 at 12:35 p.m. The DON confirmed Resident #2's oxygen was to be set on 2 LPM. The DON stated Resident #2 had a history of being non-compliant and aggressive and is very concerned about his oxygen so he may have changed his oxygen settings himself because when she looked at it yesterday it was set to 2 LPM. She stated she was unsure if he was care planned to change his oxygen settings. Residents Affected - Few Review of Resident #2's care plan revealed there was no focus area related to the resident being noncompliant with his oxygen settings. Review of Resident #3's admission record revealed the resident was readmitted to the facility on [DATE] diagnoses, including but not limited to, COPD and other forms of chronic ischemic heart disease. An observation was conducted on 1/11/22 at 10:00 a.m. Resident #3 was observed in bed, eyes closed, dressed in day clothes, sleeping over her made bed, and a nasal cannula in her nose. The oxygen concentrator was observed to be set at 3 LPM. Further observation was conducted on 1/11/22 at 11:45 a.m. Resident #3 was observed to be up in her wheelchair, talking on the phone, with her nasal cannula in her nose. The oxygen concentrator was set at 2 LPM. Review of Resident #3's physicians orders revealed there was not an order for oxygen administration. On 1/11/22 at 12:30 p.m. Staff B, Registered Nurse (RN) confirmed Resident #3 had her oxygen on and oxygen was being administered. Staff B, RN looked in Resident #3's Electronic Medical Record (EMR) and confirmed there were no physician orders for oxygen administration. She stated the resident just returned to the facility and the order must have been missed. She stated she would notify the DON to get the order put back into the computer because she needs an oxygen order to administer the oxygen. On 1/11/22 at 12:32 p.m. the DON was interviewed. She stated Resident #3 was at another facility with COVID-19 and returned to the facility on 1/4/22. She confirmed Resident #3 receives oxygen. She reviewed the resident's physician orders and confirmed there were no oxygen orders in place. 6. Review of the facility's policy Quality Assurance and Performance Improvement (QAPI) Program revised February 2020 revealed: Policy Statement: This facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. Policy Interpretation and Implementation: The objective of the QAPI program are to: 1. Provide means to measure current and potential indicators for outcomes of care and quality of life. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105071 If continuation sheet Page 17 of 18 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 105071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayside Care Center 811 Jackson St N Saint Petersburg, FL 33705 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 0867 Level of Harm - Minimal harm or potential for actual harm 2. Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. 3. Reinforce and build upon effective systems and processes related to the delivery of quality care and services. Residents Affected - Few 4. Establish systems through which to monitor and evaluate corrective actions. Implementation 1. The QAPI committee oversees implementation if our QAPI plan, which is the written component describing the specifics of the QAPI program, how the facility will conduct its QAPI functions, and the activities of the QAPI committee. 2. The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include: a. Tracking and measuring performance b. Establishing goals and thresholds for performance measurement. c. Identifying and prioritizing quality deficiencies. d. Systematically analyzing underlying causes of systemic quality deficiencies; e. Developing and implementing corrective action or performance improvement activities; and f. Monitoring or evaluating the effectiveness or corrective action/performance improvement activities and revising as needed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105071 If continuation sheet Page 18 of 18