Health inspection·December 1, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some staff were to notify her of dirty ones. The ESC reported resident rooms were deep cleaned and privacy curtain tracks were cleaned monthly. The policy - Method of Cleaning, undated, revealed: Every facility in our system may have different dynamics to deal with, and every situation should be handled accordingly. But some general cleaning practices, routines, and systems need to be put in place and followed. Here are some broad methods to keep in mind when training and following up with staff. The policy educated staff of the following: TOP DOWN: always start cleaning surfaces, ledges, shops, etcetera., at the top and work your way down. Clean the face of areas as well. Move furniture around, clean behind not commonly moved furnishings. If a resident is present, speak with them, and let them know what you are doing. Privacy check privacy curtains, linens, and the overall condition of the room (Note any maintenance concerns). Remove all debris from floors, counters, and edges. (Photographic evidence was obtained) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105071 If continuation sheet Page 2 of 24 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 12/01/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to confirm the accuracy of a Pre-admission Screening and Resident Review (PASRR) and to correct the document for six (Residents #9, #72, #18, #51, #43, and #26) out of forty residents sampled when mental illness or suspected mental illness diagnoses were identified and added to the resident's medical diagnoses. Findings included: 1. A review of Resident #9's admission Record showed an original admission date of 1/4/13. The admission Record included diagnoses and onset dates not limited to bipolar disorder (2/26/19), recurrent major depressive disorder (2/26/19), generalized anxiety disorder (2/26/19), and unspecified psychosis not due to a substance or known physiological condition (2/9/13). A review of Resident #9's PASRR, dated 11/2/16, showed the resident had a Serious Mental Illness (SMI) of bipolar disorder. The PASRR did not include the resident's diagnoses of recurrent major depressive disorder, generalized anxiety disorder, and unspecified psychosis not due to a substance or known physiological condition. A review of Resident #9's Level II Determination Summary Report, dated 8/27/13, showed the resident was diagnosed with mild recurrent major depressive disorder. The report did not include the diagnoses of bipolar disorder, generalized anxiety disorder, and unspecified psychosis not due to a substance or known physiological condition. A review of Resident #9's annual Minimum Data Set (MDS), dated [DATE], revealed the resident was not considered to have a serious mental illness and/or intellectual disability. The comprehensive assessment identified the resident had a seizure disorder or Epilepsy, anxiety disorder, psychotic disorder, bipolar disorder, and recurrent major depressive disorder while receiving antianxiety, antidepressant, and hypnotic medications. The Advanced Practitioner Registered Nurse (APRN) note, dated 11/7/23, revealed the resident had a medical history of generalized anxiety disorder, bipolar disorder, and paranoid thoughts and behaviors. The Social Service Director (SSD) stated on 12/1/23 at 8:33 a.m., she would notify the Director of Nursing (DON) when a new PASRR was needed and the DON was the only person able to complete a new PASRR. The SSD stated on 12/1/23 at 8:46 a.m., Resident #9 had a level I PASRR and the diagnoses of bipolar and psychosis was not captured in a Level II and should have been redone. 2. A review of Resident #72's admission Record showed the resident was admitted on [DATE] with diagnoses of unspecified convulsions, unspecified recurrent major depressive disorder, and unspecified anxiety disorder. The admission Record revealed diagnoses with onset dates of unspecified insomnia (3/8/23), mild current episode depressed bipolar disorder (8/9/22). A review of Resident #72's PASRR, dated 4/28/22, showed the resident had a mental illness or suspected mental illness of anxiety disorder and did not include the diagnoses of unspecified recurrent major depressive disorder, unspecified insomnia, and mild current episode depressed bipolar disorder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105071 If continuation sheet Page 3 of 24 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 12/01/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident #72's quarterly Minimum Data Set (MDS) dated [DATE], did not include PASRR information. The comprehensive assessment revealed the resident had a seizure disorder or Epilepsy, anxiety disorder, depression (other than bipolar), and bipolar disorder. The resident received antipsychotic, antidepressant, and hypnotic medications. During an interview, on 12/1/23 at 8:49 a.m., the Social Service Director reviewed Resident #72's PASRR and medical diagnoses and stated the diagnoses of depression and bipolar were not captured on the resident's PASRR and should have been redone. 3. A review of Resident #18's admission Record revealed Resident #18 was admitted to the facility initially on 10/16/2018 and readmitted on [DATE] with diagnoses to include but not limited to Unspecified Adult Failure to Thrive, Schizoaffective Disorder Bipolar Type, Type 2 Diabetes Mellitus without Complications, Major Depressive Disorder, Bipolar Disorder, Unspecified, Anxiety Disorder, Unspecified. A review of the Quarterly MDS dated [DATE], showed section C- Cognitive Patterns, Brief interview for Mental Status, BIMS score of 14 which indicated the resident had intact cognition. A review of Resident #18's level one Pre-admission Screening and Resident Review (PASRR) dated 7/16/2019 showed, Resident # 18 had no Mental Illness or suspected Mental Illness indicted. There was no PASRR referral for a level II resident review upon newly diagnosis of Major Depressive Disorder, Single Episode, Unspecified, Bipolar Disorder, Unspecified, Schizoaffective Disorder, Bipolar Type. During an interview on 12/1/2023 at 8: 30 a.m., with the Social Worker (SW), she said she was responsible for reviewing and making sure the PASRR's were completed and updated accurately. She said Resident #18's PASRR should have been updated and referred for a Level II upon his new diagnoses, but it was not done. 4. A review of Resident #26's admission Record revealed Resident #26 was admitted on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Type 2 Diabetes Mellitus with diabetic neuropathy, Major Depressive Disorder, insomnia, and other co-morbidities. A review of Resident #26's PASRR Level I Assessment, dated 10/28/2020 revealed no qualifying mental health diagnosis and no PASRR Level II was required. A review of Resident #26's admission Record revealed a new diagnosis of Post-Traumatic Stress Disorder (PTSD) on 11/09/2021, bipolar disorder on 5/24/2023, schizoaffective disorder on 06/06/2023 and the resident was not assessed for PASRR Level II. A review of Resident #26's MDS with an Assessment Reference Date (ARD) of 09/26/2023 revealed diagnoses of schizophrenia, bipolar, depression, and post-traumatic stress disorder and the resident was not assessed for PASRR Level II. A review of the medical record revealed the resident was not assessed for PASRR Level II. 5. A review of Resident #43's admission Record revealed Resident #43 was admitted on [DATE] with diagnoses of anxiety, cognitive communication deficit and other co-morbidities. A review of Resident #43's PASRR Level I Assessment, dated 10/26/2021 revealed a diagnosis of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105071 If continuation sheet Page 4 of 24 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 12/01/2023 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 0644 anxiety with no other qualifying mental health diagnosis and no PASRR Level II was required. Level of Harm - Minimal harm or potential for actual harm A review of Resident #43's MDS with an ARD of 08/24/2023 revealed diagnoses of Parkinson's Disease, anxiety, depression, and schizophrenia. Residents Affected - Some A review of the medical record revealed the resident was not assessed for PASRR Level II, with the new mental health diagnoses. 6. A review of Resident #51's admission Record revealed Resident #51 was admitted on [DATE] with a diagnosis of psychosis and other co-morbidities. A review of Resident #51's PASRR Level I Assessment, dated 12/18/2020 revealed no qualifying mental health diagnosis and no PASRR Level II was required. A review of Resident #51's admission Record revealed a new diagnosis of psychotic disorder with delusions, Mood Disorder, major depressive disorder, recurrent, moderate on 2/25/2021, and schizoaffective disorder on 09/21/2021 and the resident was not assessed for PASRR Level II. A review of Resident #51's MDS with an ARD of 08/15/2023 revealed a diagnosis of depression, psychotic Disorder and schizophrenia. A review of the medical record revealed the resident was not assessed for PASRR Level II, with the new mental health diagnosis. During an interview on 12/01/2023 at 8:31 a.m., the Social Service Director (SSD), verified Resident #26, #43 and #51's admission PASRR did not reveal the resident's current mental health diagnosis'. The SSD said with a new mental health diagnosis the resident would need a new PASRR Level II completed. During an interview on 12/01/2023 at 10:14 a.m., the Director of Nursing (DON) stated the expectation was a Level II PASRR should be completed for a new qualifying mental health diagnosis. The DON stated, We need to revamp our process. A PASRR policy and procedure was requested during the survey. No policy and procedure was given to the surveyors prior to exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105071 If continuation sheet Page 5 of 24 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 12/01/2023 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one (Resident #55) of three residents sampled failed to have a baseline care plan developed and implemented within 48 hours of admission. The findings include: Review of Resident #55's admission Record revealed, Resident #55 was admitted on [DATE] for short term rehabilitation and was successfully discharged home on [DATE], return not anticipated. Resident #55 had a change of condition and was readmitted on [DATE]. Resident #55 was admitted with the following diagnoses: seizures, acute kidney failure, diabetes, pleural effusion, atherosclerotic heart disease, atrial fibrillation, asthma, major depressive disorder, and other co-morbidities. Review of Resident #55's physician orders showed: Venlafaxine HCl ER Oral Capsule Extended Release 24 Hour 37.5 MG per day for depression; Depakote ER Oral Tablet Extended Release 24 Hour 250 MG (Divalproex Sodium) give three (3) tablets at at bedtime for epilepsy; Humalog Kwikpen 100 UNIT/ML Solution pen-injector, Inject 5 unit, three times a day for diabetes; Levetiracetam Oral Tablet 500 MG (Levetiracetam) give 3 tablet, two times a day for epilepsy; Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine), Inject 20 unit at bedtime for diabetes. On 11/28/2023 at 8:30 a.m., Resident #55 was observed sitting on the edge of the bed. Resident #55 stated I just got back; I fell at home. On 11/29/2023 at 1:40 p.m., an interview was conducted with Staff D, Certified Nursing Assistant (CNA). Staff D stated knowledge of residents' care comes from the computer. Staff D stated knowledge of Resident #55 from a prior admission, as nothing was in the computer for Resident #55. An interview was conducted with Staff C, Licensed Practical Nurse (LPN)/Unit Manager on 12/1/2023 at 9:45 a.m. Staff C stated when a new admission came into the facility, the nurse admitting or readmitting the resident completed an admission Nursing Comprehensive Eval-BCP V9 2. Staff C stated this document had the baseline care plan imbedded in the evaluation. Documents were printed and discussed with the resident and/or responsible party. An interview was conducted with the Director of Nursing (DON) on 12/1/2023 at 10:00 a.m. The DON stated the expectation was the nurse admitting the resident completed the Clinical admission Evaluation with the base line care plan. The nurse had 48 hours to develop and discuss the base line care plan with the resident and/or responsible party. The DON confirmed the admission Nursing Comprehensive Eval-BCP V9 2 was blank where the base line care plan information should have been. Review of the facility policy and procedures titled Care Plans - Baseline dated March 2022 showed: Policy: A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. Policy Interpretation and Implementation: 1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105071 If continuation sheet Page 6 of 24 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 12/01/2023 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete health care information necessary to properly care for the resident including, but not limited to the following: a. Initial goals based on admission orders and discussions with resident/representative; b. Physicians orders; c. Dietary orders; d. Therapy services; e. Social services; and f. PASARR recommendations, if applicable. 2. The baseline care plan is used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered comprehensive care plan (no later than 21 days after admission). The baseline care plan is updated as needed to meet the resident's needs until the comprehensive care plan is developed 4. The resident and/or representative are provided a written summary of the baseline care plan (in a language that the resident/representative can understand) that includes, but is not limited to the following: a. The stated goals and objectives of the resident; b. A summary of the resident's medication and dietary instructions; c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility; and d. Any updated information based on the details of the comprehensive care plan, as necessary. 5. Provision of the summary to the resident and/or resident's representative is documented in the medical record. Event ID: Facility ID: 105071 If continuation sheet Page 7 of 24 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 12/01/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to revise the comprehensive care plan for one (Resident #17) of one sampled residents for dental services. On 11/28/2023 at 10:00 a.m., Resident #17 was observed laying in bed dressed in her night cloths, and missing her bottom teeth. During an interview on 11/28/2023 at 10:00 a.m., Resident # 17 said she had a hard time eating her food because she was missing a few teeth. She said she spoke with the dentist when they came to the facility and told them that she wanted dentures so she could eat her food properly. She said she had been waiting for a while for someone to get back to her regarding her dentures, but she had not heard back from social services or the dentist. A review of the admission record showed Resident #17 was admitted to the facility on [DATE], with diagnoses to include but not limited to End Stage Renal Disease, Patient's Noncompliance with other Medical Treatment and Regimen Due to Unspecified Reason, Unspecified, Functional Dysphasia, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Bipolar Disorder Unspecified, Unspecified Psychosis not Due to a Substances Known Physiological Condition. A review of the Quarterly Minimum Data Set (MDS) dated [DATE], showed Section C- Cognitive Patterns, Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident # 17 had intact cognition. A review of the Dental care plan dated 4/4/2023 with a target completion date of 4/26/2023, showed Resident #17 had natural teeth with no dental issues and can perform oral care. Review of the care plan intervention showed to observed the resident for cares, lose or broken teeth, oral lesions, bleeding, mouth pain, report to physician as needed. An interview was conducted with Staff B, License Practical Nurse (LPN)/MDS Coordinator. Staff B said MDS was responsible for creating and revising care plans. She worked in the office with another MDS staff member. She was responsible for the Quarterly assessments, but she opened the assessment for each department head to review and complete their sections. She did not know what happened to Resident #17's Quarterly assessment and why it was not showing it was updated. When she opened the resident assessment, it showed the care plan was created on 4/4/2023 and the next review was 1/16/2023. There was a note in the resident's chart showing it was reviewed but the review date was not reflected in the system. The nurses were responsible for completing the resident's assessment related to dental care. Staff B said I should have revised the care plan to reflect the resident had missing teeth and made changes to her interventions, It's an error on my part. A review of the facility policy titled, Care Planning - Interdisciplinary Team dated March 2022, showed policy statement: The interdisciplinary team is responsible for the development of the resident care plan. Policy Interpretation and Implementation 1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105071 If continuation sheet Page 8 of 24 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 12/01/2023 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 0657 Resident care plans are developed according to the timeframes and criteria established by § 483.21. Level of Harm - Minimal harm or potential for actual harm 2. Residents Affected - Few Comprehensive, person-centered care plan are based on the resident assessments and development by an interdisciplinary team (IDT) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105071 If continuation sheet Page 9 of 24 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 12/01/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to store the urinary catheters of two (Residents #70 and #60) out of seven residents in a sanitarily manner and to obtain physician orders for the care of an urinary catheter for one (Resident #60) out of the two sampled residents. Findings included: 1. An observation was made on 11/28/23 at 10:25 a.m. of Resident #70 sitting in a wheelchair in the East-hall day room. The resident's urinary drainage bag was observed hanging from the bottom of wheelchair with tubing containing golden milky liquid lying on the floor. Photographic evidence was obtained. On 11/28/23 at 10:28 a.m., Staff I, Licensed Practical Nurse/Unit Manager (LPN/UM), was observed putting Resident #70's catheter tubing into a privacy bag. The staff member stated she observed the tubing (on the floor) when she witnessed this writer taking a photo of the tubing. A review of Resident #70's admission Record showed the resident was admitted on [DATE] and included the diagnoses of unspecified neuromuscular dysfunction of bladder and unspecified chronic kidney disease stage 3. A review of Resident #70's Order Summary Report included orders instructing staff to change the urinary catheter bag and tubing once monthly and as needed for blockage or signs of infection and to ensure the resident had a securing device for the urinary catheter as needed for prevention of tugging and pulling. The review of Resident #70's care plan showed the resident had an alteration in elimination as evidence by (AEB): is continent of bowel, (pronoun) is at risk for constipation related to (r/t) impaired mobility-non ambulatory, has indwelling Foley urinary catheter r/t diagnosis (dx) neurogenic bladder, dx Benign prostatic hyperplasia, chronic kidney disease stage III (CKD III). The interventions included but not limited to maintain closed drainage system and keep drainage bag below level of the bladder. Provide catheter privacy bag. A review of Resident #70's comprehensive Minimum Data Set (MDS), dated [DATE], showed a Brief Interview for Mental Status score of 1, which indicated severe cognitive impairment. The MDS revealed the resident required extensive 2-person assist for bed mobility, total dependent upon 2-persons for transfers and toileting. 2. An observation was made of Resident #60's catheter hanging from the bottom of the resident's wheelchair with the catheter tubing and drainage bag lying on the floor. (Photographic evidence was obtained). A review of Resident #60's admission Record showed the resident was admitted on [DATE] and re-admitted on [DATE]. The record included a diagnosis not limited to unspecified neuromuscular dysfunction of bladder. A review of Resident #60's Order Summary Report, active orders as of 12/1/23, showed the report did (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105071 If continuation sheet Page 10 of 24 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 12/01/2023 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 0690 not include physician orders for the care of the resident's urinary catheter. Level of Harm - Minimal harm or potential for actual harm A review of Resident #60's November Medication and Treatment Administration Records (MAR/TAR) showed no physician orders for the care of the resident's urinary catheter and revealed staff had not documented the care of the resident's urinary catheter. Residents Affected - Few On 12/1/23 at 9:34 a.m., Resident #60 said the staff cleaned the catheter every day, three times a day. A review of Resident #60's October TAR included physician orders instructing staff: - Change urinary catheter bag and tubing once monthly and and as needed every night shift every 1 month starting on the 10th for 28 days, discontinued on 10/18/23. - Ensure resident has securing device for urinary catheter, discontinued 10/25/23. - Perform urinary catheter care with soap and water every shift, discontinued 10/25/23. The care plan for Resident #60 revealed the resident had an alteration in elimination AEB (as evidenced by): has indwelling (Foley) catheter d/t neurogenic bladder and colostomy, risk for constipation d/t impaired mobility - does not ambulate. 11/4/23 Vaginal yeast infection-resolved. The interventions included but not limited to: - Irrigate urinary catheter with 30-60 cubic centimeters (cc) Normal Saline (NS) as needed (PRN) for blockage or sluggishness. - Provide catheter care and pericare every (q) shift and as needed. - Maintain closed drainage system and keep drainage back below level of the bladder. Provide catheter privacy bag. - Observe catheter function every (q) shift and empty bag as needed. Observe for color, order, clarity. During an interview on 12/1/23 at 2:38 p.m., the Director of Nursing (DON) stated the urinary tubing should not be stored on the floor. The Cleveland Clinic article - Urine Drainage and Leg Bag Care, located at https://my.clevelandclinic.org/health/articles/14832-urine-drainage-bag-and-leg-bag-care, revealed: - Arrange the catheter tubing so that it does not twist or loop. When you are getting into bed, hang the urine bag beside the bed. You can sleep in any position as long as the bedside bag is below your bladder. Do not place the urine bag on the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105071 If continuation sheet Page 11 of 24 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 12/01/2023 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to monitor the blood pressure related to the use of a hypotensive medication and to administer a hypotensive medication within the physician ordered parameters for two (Residents #39 and #59) out of five residents sampled for unnecessary medications. Residents Affected - Few Findings included: 1. A review of Resident #39's admission Record revealed the resident was admitted on [DATE] and with diagnoses not limited to unspecified Cardiomyopathy, essential (primary) hypertension, and unspecified atrial fibrillation. A review of Resident #39's Order Summary Report, active as of 12/1/23, showed the resident was ordered the following: - Midodrine HCl oral tablet 5 mg - Give 1 tablet by mouth every 8 hours as needed for hypotension. Ordered 10/14/23. The Order Summary Report did not include an order to obtain Resident #39's blood pressure. Review of Resident #39's November 2023 Medication Administration Record (MAR) showed the resident's blood pressure had not been obtained every 8 hours related to the administration of Midodrine. The Weights and Vital Summary identified the blood pressure of Resident #39 had not been obtained on 11/5, 11/9, 11/18, 11/19, 11/23, 11/27, and 11/29/23. The summary revealed the resident's blood pressure had been obtained one time on 11/1, 11/2, 11/3, 11/4, 11/6, 11/7, 11/8, 11/10, 11/11, 11/12, 11/13, 11/14, 11/15, 11/16, 11/17, 11/21, 11/22, 11/24, 11/25, 11/26, 11/28, and 11/30/23. The resident's blood pressure had been obtained twice on 11/10 and 11/20/23. The care plan for Resident #39 included the following focus: - Has the potential for complications related to an alteration in cardiac function due to (d/t) diagnosis (dx) of hypertension (HTN), a-fib, hyperlipidemia, and hypotension. The interventions related to this focus instructed staff to administer medications as ordered, observe for effectiveness and for side effects, and to obtain vital signs as ordered and as needed. On 12/1/23 at 3:01 p.m., the Director of Nursing (DON) stated staff should be obtaining blood pressures for Resident #39 every 8 hours and there should be hypotension parameters for the use of Midodrine. 2. A review of Resident #59's admission Record showed the resident was admitted on [DATE] and included diagnoses not limited to paroxysmal atrial fibrillation and atherosclerotic heart disease of native coronary artery without angina pectoris. A review of Resident #59's Order Summary Report, active as of 12/1/23, identified an order for Midodrine hydrochloride (HCl) 5 milligram (mg) - Give 2 tablet by mouth every 8 hours for hypotension (HTN), Hold Midodrine if systolic blood pressure (SBP) greater than (>) 110. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105071 If continuation sheet Page 12 of 24 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 12/01/2023 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The review of November Medication Administration Record (MAR) identified Resident #59 had been administered Midodrine 53 out of 90 opportunities despite a SBP of greater than 110. A review of Resident #59's care plan included the following focus area: - Has potential for complications related to an alteration cardiac function due to diagnosis of Coronary Artery Disease (CAD), hyperlipidemia, and hypertension. On 12/1/23 at 2:53 p.m., the Director of Nursing (DON) confirmed staff were medicating Resident #59 with Midodrine for a systolic blood pressure greater than 110, outside of ordered parameters. The DON stated staff were not reading the (physician) orders. The review of September, October, and November 2023 Pharmacy Medication Regimen Review (MRR) identified there were no pharmacy recommendations for either Resident #39 or Resident #59. The policy - Medication Therapy, revised April 2007, revealed Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks. All medication orders will be supported by appropriate care processes and practices. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105071 If continuation sheet Page 13 of 24 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 12/01/2023 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, record review, and interview, the facility failed to ensure the medication error rate was less than 5.00%. Forty-two medication administration opportunities were observed and five errors were identified for two (#54 and #55) of three residents observed. These errors constituted a 11.9% medication error rate. Residents Affected - Some Findings included: 1. On 11/30/23 at 7:53 a.m., an observation of medication administration with Staff E, Licensed Practical Nurse (LPN), was conducted with Resident #54. The staff member dispensed the following medications: - Aspirin 81 milligram (mg) Enteric Coated tablet over-the-counter (OTC) - Iron 325 mg OTC tablet - Multi-Vitamin with mineral OTC tablet - Coenzyme Q 10 OTC tablet - Vitamin B12 1000 microgram (mcg) OTC tablet - Tamsulosin 0.4 mg capsule - Clopidogrel 75 mg tablet - Metoprolol Tartrate 50 mg tablet - Pantoprazole 20 mg Delayed Release (DR) tablet - Sertraline 50 mg tablet - Amlodipine 10 mg tablet - Oxycodone Immediate Release (IR) 5 mg tablet Staff E confirmed dispensing 12 tablets/capsules prior to entering Resident #54's room and administering the medications. A review of Resident #54's November Medication Administration Record (MAR) showed the resident was ordered on 11/20/23, Sertraline 50 mg - Give 75 mg by mouth one time a day for depression. 2. On 11/30/23 at 8:24 a.m., an observation of medication administration with Staff A, Licensed Practical Nurse (LPN), was conducted with Resident #55. The staff member obtained a blood glucose level of 424 from the resident. The resident had been served breakfast and had finished a bowl of oatmeal. The staff member dispensed the following medications: - Cefdinir 200 mg capsule (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105071 If continuation sheet Page 14 of 24 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 12/01/2023 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 - Clopidogrel 75 mg tablet Level of Harm - Minimal harm or potential for actual harm - Vitamin B12 1000 mcg OTC tablet - Eliquis 2.5 mg tablet Residents Affected - Some - Famotidine 2- 10 mg tablets - Fluticasone nasal spray - Folic acid 1 mg tablet - Isosorbide mono 60 mg Extended Release (ER) tablet - Lisinopril 10 mg tablet - Metoprolol Succinate 50 mg ER tablet - Nifedipine ER 60 mg tablet - Levetiracetam 500 mg tablet - Humalog insulin KwikPen 15 units Staff A dialed the insulin pen to 15 units, explaining 5 units for a standing order and 10 units per the sliding scale of 424. The observation identified the staff member was unable to document the location of administration of the sliding scale insulin, a notice on the electronic record revealed a progress note would need to be completed. The staff member stated she would have to reach out to the Unit Manager as the system was not allowing documentation. Staff A administered the oral medications, administered insulin into the the left abdominal quadrant, and allowed the resident to self-administer nasal spray into each nostril. The staff member asked the resident if they remembered the education (on administration) and reminded the resident to smell the roses. Immediately following the medication administration, Staff A returned to the medication cart and charted with the administration of 5 units that 10 units sliding scale was administered and MD notification. The order for Resident #55's sliding scale instructed staff were to administer units (10) and call MD for a blood sugar (level) of greater than 400. The staff member documented a blood sugar of 424 with the standing insulin order and 400 for the sliding scale of same insulin. The observation did not reveal the MD was notified and review on 11/30/23 at 10:00 a.m. and on 12/1/23 at 2:12 p.m., of the resident's Medication Administration notes did not show the MD was notified of the residents 424 blood glucose level. A review of the Resident #55's November Medication Administration Record (MAR) showed Staff A documented the resident had received the ordered Fluticasone-Salmetrol 100/50 mcg/act aerosol powder, had administered one (1) tablet of Levetiracetam not the ordered 3, and did not document the administration of Fluticasone Propionate Nasal Suspension. The staff member did not prime/air shot the insulin pen prior to the administration of the medication, stating priming was done with the first dose after opening the pen but did not have to after that. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105071 If continuation sheet Page 15 of 24 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 12/01/2023 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 The policy - Administering Medications, revised April 2019, identified Medications are administered in a safe and timely manner, and as prescribed. The interpretation and implementation of the policy revealed: - The director of nursing services supervises and directs all personnel who administer medications and/or have related functions. Residents Affected - Some - Medications are administered in accordance with prescriber orders, including any required time frame. - The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. - As required or indicated for a medication, the individual administering the medication records in the resident's medical record: the date and time the medication was administered, the dosage, the route of administration, the injection site (if applicable), any complaints or symptoms for which the drug was administered, any results achieved and when those results were observed, and the signature and title of the person administering the drug. During an interview on 12/1/23 at 2:26 p.m., the Director of Nursing (DON) stated the expectation was to have no errors and staff were to follow physician orders. The DON said the staff do not prime insulin pens and manufacturer was discussed, the DON stated she did not know insulin pens were to be primed. The manufacturer website, https://uspl.lilly.com/humalog/humalog.html#ug1, instructed uses on Priming your Pen. The instructions identified the reason for priming the Humalog insulin KwikPen was: Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. The manufacturer instructed: - Step 6: To prime your Pen, turn the Dose Knob to select 2 units. - Step 7: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. - Step 8: Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. - If you do not see insulin, repeat priming steps 6 to 8, no more than 4 times. - If you still do not see insulin, change the Needle and repeat priming steps 6 to 8. Small air bubbles are normal and will not affect your dose. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105071 If continuation sheet Page 16 of 24 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 12/01/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure medications were stored in a manner such that unauthorized personnel, visitors, and residents did not have access to medications in three medication carts, one of two treatment carts, and ensure overstocked medications were stored in a locked medication room. Findings included: On 11/28/23 at 10:18 a.m., the unlocked and unattended West-Low medication cart was observed parked in a hallway leading to staff offices on the [NAME] hall. After photographic evidence was obtained, Staff A, Licensed Practical Nurse (LPN) arrived to the cart and stated I locked it before confirming the cart had been unlocked. On 11/30/23 at 7:25 a.m., the [NAME] hall treatment cart was observed unlocked and unattended while parked next to the West-High medication cart. Staff E, LPN, confirmed the cart should have been locked. During the task of medication administration, on 11/30/23 at 8:36 a.m., 5 over-the counter (OTC) medication bottles were left on the West-High cart as Staff E was in a resident room administering medications. When returning to the cart an unknown resident was observed sitting in a wheelchair within speaking distance to the staff member. On 11/30/23 during a medication administration observation at 8:36 a.m., Staff A confirmed the Humalog insulin KwikPen was opened and undated with the date of opening. The staff member stated it was probably opened yesterday as it was a new order. The staff member placed the insulin pen in the medication cart without dating it. The Humalog manufacturer showed on the website, https://uspl.lilly.com/humalog/humalog.html#ug1, instructed users to Throw away the HUMALOG Pen you are using after 28 days, even if it still has insulin left in it. On 12/1/23 at 10:07 a.m., an observation was made of a bookcase inside the East Hall Unit Manager's office, located in the resident's day room. One shelf of the bookcase held multiple bottles of the liquid medication Lactulose, another shelf had multiple blister packs of medications (one was Gabapentin) banded together, and one shelf held a box of nebulizer medication. Staff I, Licensed Practical Nurse/Unit Manager (LPN/UM), stated the medications were overstock that did not fit in the medication carts. On 12/1/23 at 10:20 a.m., after an interview, Staff I left the office and the hall leaving the door open and the medications unattended, two residents were sitting in the day room and one resident was sitting directly outside of the room. On 12/1/23 at 10:25 a.m., Staff G, LPN confirmed the medications continued to be on the bookshelf and the door was open. The staff member was observed on phone then went into the day room and locked the Unit Manager's office door. On 12/1/23 at 10:33 a.m., an observation was conducted with Staff F, LPN of the East-Low medication cart. The cart contained 5 medication bottles, each contained a vial of undated insulin. The staff member confirmed the bottles were dated but the insulin vials were not dated. Each of the vials had a pharmacy tag attached with a space to write the open date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105071 If continuation sheet Page 17 of 24 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 12/01/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 12/1/23 at 10:40 a.m., an observation of West-High medication cart was conducted with Staff H, LPN. The third drawer of the cart contained 2 unidentified loose tablets. On 12/1/23 at 2:33 p.m., the Director of Nursing (DON) said when medications were to be returned to the pharmacy, they were bagged up and the Unit Manager kept them in the office for pharmacy to take back. The DON stated overstock medications, as described by the Unit Manager, were to kept in the med room not in the office. The DON stated vials of insulin should be dated on the little pharmacy tab label, and loose pills get pushed out of the packaging. The DON was aware of the observation of the unlocked medication cart (West-Low) and the treatment cart (West). The policy - Administering Medications, revised April 2019, identified During the administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. The policy - Medication Labeling and Storage identified The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys. The policy interpretation and implementation revealed: - The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. - Compartments (including but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. - Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. - Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. - Multi dose vials that have been opened or accessed (e.g. needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105071 If continuation sheet Page 18 of 24 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 12/01/2023 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 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure laboratory tests were obtained per physician orders and acted upon in a timely manner for two (Residents #86 and #43) out of three residents sampled for laboratory services. Findings included: 1. Review of Resident #86's admission Record showed the resident was admitted on [DATE] and re-admitted on [DATE]. The resident's admission Record included diagnoses not limited to type 2 Diabetes Mellitus with hyperglycemia, unspecified anxiety disorder, unspecified atrial fibrillation, essential hypertension, and unspecified not intractable epilepsy without status epilepticus. A medication administration note on 10/3/23 at 10:55 a.m., documented by Staff F, Licensed Practical Nurse (LPN) revealed Resident #86 had no behaviors at that time. A review of Resident #86's Situation, Background, Assessment, and Recommendation (SBAR), dated 10/3/23 identified the resident suffered a fall. The evaluation revealed the physician was notified at 12:00 p.m. on 10/3/23 of the fall and recommended labs/education/floor mats. The evaluation did not include any additional information on the Change in Condition and did not identify the education provided or which labs had been ordered by the physician. The SBAR Summary note, effective 10/3/23 at 12:08 p.m., and written by Staff I, LPN/Unit Manager (UM), showed Resident #86 was observed on the floor beside bed and the resident had reported sliding out of bed. The note revealed the primary care physician was notified of the fall, had ordered labs for resident, bed at lowest position and floor mats. The note did not identify the type of labs ordered for the resident. The situation portion of the evaluation instructed staff to obtain at the time of evaluation resident/patient vital signs, weight, and blood sugar. The documented blood pressure, pulse, respiration rate, temperature, and oxygen level was obtained at 9:45 a.m. on 10/1/23, 2 days prior to the incident. A review of Resident #86's October Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not identify any laboratory tests were ordered on 10/3/23 by the physician. The progress notes for Resident #86, dated 10/3, 10/4, 10/5, and 10/6/23 did not identify the resident had refused any laboratory testing. A review, on 11/30/23 of the Laboratory vendors binder located on the East wing nursing station did not reveal labs had been requested to be drawn for Resident #86 on 10/3, 10/4, 10/5 or 10/6. On 11/30/23 at approximately 1:30 p.m., Staff F, Licensed Practical Nurse (LPN) said when a laboratory order was received, staff got paperwork, and wrote the lab request in the vendor's binder. On 11/30/23 at 2:04 p.m., Staff F stated when a resident refused lab tests, staff called the primary physician, and documented the refusal. Staff F was not aware of what labs were ordered on 10/3/23 for Resident #86. Staff F said when lab results came through the computer, staff reviewed them, and faxed the results to whoever ordered them unless it was critical results then the provider was called and staff documented the notification. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105071 If continuation sheet Page 19 of 24 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 12/01/2023 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 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 11/30/23 at 2:13 p.m., the Director of Nursing (DON) reviewed the facility's documentation of Resident #86's fall on 10/3/23 and confirmed the report did not show labs were ordered. The DON reported the resident refused lots of treatments, labs, and accucheck's (glucose monitoring). She reviewed the progress notes from 10/3/23 and confirmed the physician had been notified of the resident's fall and labs were ordered and Staff I had completed, on 10/3/23, the SBAR and progress note. The DON stated the expectation was if a resident refused, staff were to notify the physician and if they continued to refuse they would be care planned for the refusal. She stated even if care planned for refusal staff was to reapproach and try again, wouldn't mean stop trying we would keep trying. The DON reviewed lab results for Resident #86 and confirmed there were no results from 10/4/23 and stated results would have been reported to the facility by 3 p.m., the facilities electronic medical record was integrated with the lab. She stated she printed out the lab requisition, put it into the vendors binder under the date to be drawn. The lab came every morning and checked the orders on the unit. On 11/30/23 at 2:28 p.m., the DON reviewed the progress note and asked Staff I what labs were ordered on 10/3/23. Staff I reported not remembering which labs were ordered for Resident #86. The DON stated the resident had come back from the hospital with intravenous antibiotics and was very non-compliant with care. She confirmed there was no documentation the resident had refused labs on either 10/3 or 10/4 and stated nurses had to get into the habit of documenting refusals. The care plan for Resident #86 included the following focuses and interventions: - Has potential for complications related to (r/t) an alteration in cardiac function due to (d/t) diagnosis (dx) of: hyperlipidemia, hypertension (HTN), and atrial fib. The interventions instructed staff to Labs & diagnostic tests as ordered; update physician of results. - (Resident) prefers to deviate from plan of care with treatments, refusing wound care, is capable of understanding risks associated with deviation from plan of care. (Resident's) physician is aware of his wishes. The interventions included: Inform resident/responsible party about risks related to deviation from plan of care, use calm approach. Explain cares. If refusing or resisting care; reapproach later, and Update physician of resident's deviation from plan of care. The policy- Medication and Treatment Orders, revised July 2016, identified Orders for medications and treatments will be consistent with principles of safe and effective order writing. The policy revealed: - Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, the date and the time of the order. A review of Resident #43's Minimum Data Set (MDS) dated [DATE] showed Resident #43 with diagnoses of: Parkinson's disorder, schizoaffective disorder, anxiety, cognitive communication deficit and other co-morbidities. A review of the resident's psychiatric provider note dated 10/24/2023 revealed the resident being referred by staff due to Manic symptoms. Providers recommendations were: Depakote ER 500 mg once daily, may want to increase this dose after checking level. Will start resident on Seroquel 200 mg nightly. LABS; Depakote level and CMP (comprehensive metabolic profile) in am. A review of Resident #43's physician Order Summary Report revealed a physician order for complete (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105071 If continuation sheet Page 20 of 24 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 12/01/2023 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 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few metabolic profile without eGFR and a valproic acid (Depakote) level dated 10/24/2023 with a start date of 10/25/2023. A review of Resident #43's physician Order Summary Report revealed a physician order for complete metabolic profile without eGFR and a valproic acid (Depakote) dated 10/25/2023 with a start date of 10/25/2023. A review of the resident's Psychiatric Periodic Evaluation dated 11/14/2023 revealed resident had a present problem of recent hypomanic episode. The providers recommendations were: Depakote ER 500 mg once daily, may want to increase this dose after checking level. LABS; reordered Depakote level and CMP (comprehensive metabolic profile) again (not done last). A review of the resident's medical record showed no laboratory results since August 17, 2023. An interview was conducted with Staff A, Licensed Practical Nurse (LPN) on 11/30/2023 at 9:45 a.m. Staff A, LPN stated when lab orders were received, we complete the paperwork for our laboratory to come out then place the order on the Treatment Administration Report (TAR). The TAR informed the nurse when the laboratory should be coming for the blood draw. Staff A, LPN confirmed there was an order for a CMP and Depakote level in October, 2023. Staff A, LPN stated, I cannot find the results. The labs must not have been drawn as they are not signed off as completed on the TAR I don't know why they would not have been completed Staff A said Resident #43 was complaint with labs and medications. Review of the facility policy and procedures titled, Lab and Diagnostic Test Results - Clinical Protocol dated November 2018 showed: Assessment and Recognition: 1. The physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. 2. The staff will process test requisitions and arrange for tests. 3. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility. Review by Nursing Staff: 1. When test results are reported to the facility, a nurse will first review the results. a. If staff who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure for reporting and documenting the results and their implications, another nurse in the facility (supervisor, charge nurse, etc.) should follow or coordinate the procedure. 2. Before contacting the physician, the person who is to communicate results to a physician will gather, review, and organize the information and be prepared to discuss the following (to the extent that such information is available): a. The individual's current condition and details of any recent changes in status, including vital signs and mental status; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105071 If continuation sheet Page 21 of 24 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 12/01/2023 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 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few b. Major diagnoses, allergies, current medications, any recent pertinent lab work, actions already taken to address results and treat the resident/patient, and pertinent aspects of advanced directives (for example, limitations on testing and treatment); c. Having diagnostic tests were obtained (for example, as a routine screen or follow up; to assess a condition change or recent onset of signs and symptoms, or to monitor a serum medication level); d. Our test results may relate to the individual's current condition and treatment; e. Any concerns and questions the physician will be expected to address regarding the resident. 3. A nurse will identify the urgency of communicating with the attending physician based on physician request, the seriousness of any abnormality, and the individual's current condition. 4. A nurse will try to determine whether the test was done: a. As routine screen or follow up; b. To assess a condition change or recent onset of signs and symptoms; c. To monitor drug level. (1) The reason for getting a test often affects the urgency of acting upon the result. (2) If the reason for performing the test cannot be identified, the nurse should proceed as though the tests were ordered to assess a condition change or recent onset of signs and symptoms. Identifying Situations that Warrant Immediate Notification: 1. Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: -The physician has requested to be notified as soon as result is received. -Whether the result should be conveyed to a physician regardless of other circumstances (that is, the abnormal result is problematic regardless of any other factors). -Whether the resident/patient's clinical status is unclear or he/she has signs and symptoms of acute illness or condition change and is not stable or improving, or there are no previous results for the comparison. 2. High or toxic serum medication levels. If a test was obtained to monitor the blood level of a medication and the level is reported as high (above therapeutic range) or toxic, the nurse will notify the physician promptly and will not give the next dose until the situation has been reviewed by the physician laboratories may differ in their ranges of abnormal and their criteria for panic results. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105071 If continuation sheet Page 22 of 24 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 12/01/2023 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 0791 Provide or obtain dental services for each resident. 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 coordinate dental services in accordance with professional standards of practice for one (Resident #17) of six residents sampled for dental care. Residents Affected - Few Findings included: On 11/28/2023 at 10:00 a.m. Resident #17 was observed laying down in bed and missing her bottom teeth. Resident #17 said she has a hard time eating her food because she was missing a few teeth. She said she spoke with the dentist when they came to the facility and told them that she wanted dentures so she could eat her food properly. She said she had been waiting for awhile for someone to get back to her regarding her dentures, but she has not heard back from social services or the dentist. A review of the admission Record showed Resident #17 was admitted to the facility on [DATE] with diagnoses to include but not limited to end stage renal disease, functional dysphasia, and, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. A review of the Quarterly Minimum Data Set (MDS), dated [DATE], showed in Section C- Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. A review of the dental care plan, dated 4/4/2023, with a target completion date of 4/26/2023, showed Resident #17 had natural teeth with no dental issues. can perform oral care. Review of the care planned interventions showed to observed resident for care, loose or broken teeth, oral lesions, bleeding, mouth pain, report to physician as needed. A review of an email communication titled, External Newly Enrolled Residents - [faciltiy name], dated 8/22/2023, showed Resident #17 was enrolled in the dental program effective September 2023. Review of the [Provider Name] Dental Services Patient Progress Report, dated 10/24/2023, showed Resident #17 was present for oral care. It was noted that the resident had upper full, and lower partial dentures. An interview was conducted on 11/30/2023 at 3:28 p.m. with the Social Services Director (SSD). She said the facility had a contract with [Provider Name] but only the residents who were eligible could get enrolled. Resident #17 was seen by [Provider Name] on 7/ 26/2023, 9/14/2023, 10/30/2023 and 11/29/2023. Resident #17 mentioned to [Provider Name] that she wanted dentures, but there was a billing problem at that time, so the resident did not receive her dentures. The SSD said she expected [Provider Name] to follow up with Resident #17 or her family to coordinate care regarding obtaining her dentures. The SSD said she should have followed up with [Provider Name] to make sure those services were being coordinated or looked for an outside dental service that could have accommodated Resident #17 needs. Review of the facility policy titled, Dental Services, revised December 2016, showed the Policy Heading as: Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan care. Policy Interpretation and Implementation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105071 If continuation sheet Page 23 of 24 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 12/01/2023 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 0791 1. Routine and 24-hours emergency dental services are provided to our residents through: Level of Harm - Minimal harm or potential for actual harm a. Contract agreements with a licensed dentist that comes to the facility monthly: b. Referral to the resident's personal dentist; Residents Affected - Few c. Referral to community dentists; or d. Referral to health care organizations that provide dental services. 4. Selected dentist must be available to provide follow-up care. Failure of a dentist to provide follow-up services will result in the facility's right to use its consultant dentist to provide the resident's dental needs. 6. Social Service representatives will assist residents with appointments, transportation arrangements, and for reimbursement of dental services under state plan, if eligible. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105071 If continuation sheet Page 24 of 24