Inspection·September 28, 2023

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** 2. Review of Resident #29's admission record showed the resident was admitted on [DATE] and was diagnosed with Bipolar II Disorder on 3/24/2021. Review of Resident #29's PASRR dated 7/27/2017 read, Section I: PASRR Screen Decision-Making. A. MI or suspected MI (check all that apply): anxiety disorder and depressive disorder. Review of Resident #29's Minimum Data Set titled Annual-None dated 6/28/2023 read, Section I- Active Diagnosis. Psychiatric/Mood Disorder. I5900. Schizophrenia. Yes. Review of Resident #29's care plan revised on 9/5/2023 read, Has behavioral tendencies of grabbing, pushing, yelling/screaming, making allegations, abusive language, threatening, choosing to stay in bed, rejecting care/appointments/medication/hip savers/meals/labs. 3. During an observation on 9/25/2023 at 12:15 AM, Resident #86 was sitting in her wheelchair stating she would hit another resident. No actual altercation occurred, just verbal threatening. Review of Resident #86's admission record revealed the resident was admitted on [DATE] with a diagnosis of Schizophrenia. Review of Resident #86's Level I PASRR dated 8/14/2021 read, Section I: PASRR Screen Decision-Making. A. MI (Mental Illness) or suspected MI (check all that apply): [No illness was checked off]. Review of Resident #86's Minimum Data Set titled Admission-None dated 7/25/2023 read, Section I- Active Diagnosis. Psychiatric/Mood Disorder. I600. Schizophrenia. Yes. Review of Resident #86's care plan initiated on 8/6/2023 read, Episodic behavioral tendency to yell at times r/t [related to] dementia, ALZ [Alzheimer], and schizophrenia, AJD [Adjustment] with anxiety. During an interview on 9/27/2023 at 2:11 PM, the Director of Nursing stated, [Resident #86's name] and [Resident #29's name] did not have a review evaluation preformed due to their diagnoses. They should have had Level II recommended. During an interview on 9/27/2023 at 2:40 PM, the Director of Nursing stated, The facility does not have a policy for PASRR. We follow the regulations. Based on record review and interview, the facility failed to ensure 3 of 3 residents reviewed for Preadmission Screening and Resident Review (PASRR), Residents #10, #29 and #86, were referred to the appropriate state designated authority for a Level II evaluation and determination. Findings include: 1. Review of Resident #10's Level I PASRR dated 1/15/2021 revealed the resident was admitted to the facility with no diagnosis or suspicion of serious mental illness or intellectual disability indicated and no level II PASRR evaluation was required. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105324 If continuation sheet Page 2 of 5 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 105324 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayview Center 301 S Bay St Eustis, FL 32726 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 Review of Resident #10's admission record revealed the resident was originally admitted to the facility on [DATE] and was subsequently diagnosed with schizoaffective disorder, depressive type, with onset date of 3/9/2021. Review of Resident #10's physician's order, active as of 9/27/2023, showed the resident was prescribed with Ativan/Benadryl/Haldol (ABH) Cream 1/25/0.5 milligrams apply to wrist or back topically every 6 hours related to schizoaffective disorder, depressive type and anxiety disorder, with a start date of 2/6/2023. Review of Resident #10's clinical records reveal no documentation that the resident was later identified with a newly evident or possible serious mental disorder and was referred to the appropriate state designated authority for a Level II evaluation and determination. During an interview on 9/27/2023 at 11:31 AM, the Director of Nursing stated the facility was unable to locate documentation indicating Resident #10's Level I PASRR had been revised to show the new diagnosis of schizoaffective disorder, depressive type, and initiate a Level II PASRR screening. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105324 If continuation sheet Page 3 of 5 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 105324 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayview Center 301 S Bay St Eustis, FL 32726 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and policy review, the facility failed to ensure food was safely stored and served. Residents Affected - Some Findings include: During a walk-through tour of the kitchen on 9/25/2023 at 9:42 AM with the Certified Dietary Manager (CDM), there was a gallon container of lemonade with an expiration date of 8/2023 in the walk-in cooler, and a flat of raw shell eggs stored on top of a case of fully cooked boiled eggs. During an interview on 9/25/2023 at 9:15 AM, the CDM stated that the container of lemonade belonged to the activities department and should have been disposed of in August, and the raw shell eggs should not have been stored over fully cooked foods. CDM stated that in best practice, eggs are treated the same as meats or other proteins. During an observation of the dining for lunch on 9/25/2023 at 12:15 PM in the main dining room, Staff A, Certified Nursing Assistant (CNA), was serving lunch. A resident asked Staff A to put mayonnaise on the sandwich. Staff A picked up the bread from the sandwich with her bare hand, applied the mayonnaise, and placed the bread back on the sandwich. During an interview on 9/25/2023 at 12:20 PM, when asked about handling ready-to-eat foods with bare hands, Staff A, CNA, stated that she had washed her hands and was not aware she could not pick up the bread with her bare hands. Review of the policy and procedure titled Preventing Foodborne Illness dated July 2014 read, Policy Interpretation and Implementation . 3. All employees who handle, prepare, or serve food will be trained in the practice of safe food handling and preventing foodborne illness. Review of the policy and procedure titled Standards and Guidelines: Storage dated July 2023 read, Policy Interpretation and Implementation. Refrigerator Storage . Store raw meat away from vegetables and cooked foods. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105324 If continuation sheet Page 4 of 5 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 105324 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayview Center 301 S Bay St Eustis, FL 32726 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure staff followed infection control standard for performing hand hygiene during medication administration for 2 out of 7 observations of medication administration. Residents Affected - Few Findings include: During an observation on 9/27/2023 at 8:16 AM, Staff B, Licensed Practical Nurse (LPN), exited a resident's room and went to the medication cart without performing hand hygiene. Staff B entered Resident #41's room to check if the resident was in her room. Staff B touched the resident's privacy curtain and pulled the bathroom door handle to push the door back and pulled the room door handle to further open the room door. Staff B did not perform hand hygiene. Staff B returned to the medication cart and poured medication. Staff B entered Resident #41's room and assisted the resident with administration of medication. Staff B helped Resident #41 by holding her hand with his hand to bring a water cup up for the resident to drink after medication administration. Staff B exited the room. Staff B did not perform hand hygiene. Staff B returned to the medication cart, and then went to get Resident #100 from the common area. The Assistant Director of Nursing gave Staff B a small bottle of hand sanitizer. Staff B touched Resident #100's arm and assisted her back to the medication cart by placing the hand sanitizer on the medication cart. The bottle of hand sanitizer fell behind the medication cart. Staff B poured medication and administered the medication to Resident #100 without performing hand hygiene. During an interview on 9/27/2023 at 8:27 AM, Staff B, LPN, stated, I should have done handwashing or used hand sanitizer between residents. During an interview on 9/27/2023 at 11:09 AM, the Director of Nursing stated that Staff B acknowledged that he did not wash his hands as he should during medication administration, and he had stated he was nervous and everything that could have gone wrong happened. The Director of Nursing confirmed staff were expected to wash their hands before and after patient care. Review of the facility policy and procedure titled Handwashing/Hand Hygiene with last review date of 1/2/2023 read, Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation . 7. Use an alcohol-based hand rub containing at least 62% alcohol or, alternatively, soap (antimicrobial or non-microbial) and water for the following situations . b. before and after direct contact with residents, c. before preparing or handling medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105324 If continuation sheet Page 5 of 5