Health inspection·November 27, 2019

F 0656 Level of Harm - Minimal harm or potential for actual harm Review of physician orders for nebulizer medication reflected Arformoterol tartrate nebulizer solution 15 mcg/2ml. one dose inhale orally via nebulizer two times a day for shortness of breath dated 11/25/19. Ipratropium-Albuterol solution 0.5-2.5 (3) mg/3ml one vial inhaled orally via nebulizer every 6 hours as needed for shortness of breath, wheezing one vial via updraft dated 10/29/19. Pulmicort suspension (Budesonide) one dose inhaled orally two times a day for copd, rinse after use. dated 11/25/19. Residents Affected - Few 2. Review of the care plan for Resident #151 reflected the resident focus area of tracheostomy and oxygen initiated 10/10/19 revised on 11/26/19. Interventions included the resident has oxygen therapy related to chronic respiratory failure and tracheostomy initiated on 11/26/19 and revised on 11/26/19. Interventions to administer oxygen as ordered initiated on 11/26/19. give medication as ordered by physician initiated 11/26/19. Monitor for signs and symptoms of respiratory distress and report to the physician. Respirations, pulse oximeter, in creased heart rate and restlessness initiated on 11/26/19. Suction as needed. Initiated on 11/26/19. Focus on tracheostomy related to breathing mechanics, initiated on 11/26/19. A goal to have no abnormal drainage around trach site through he review date, initiated on 11/26/19. Interventions include to give humidified oxygen as prescribed, initiated on 11/26/19. Suction as necessary initiated 11/26/19. Trach care per order dated 11/26/19. During observation of Resident #151 on 11/24/19 at 11:21 a.m., the resident was observed lying in her bed on her left side facing the door. Oxygen was observed at 1.5 liters with humidity at 28%. The head of the bed was elevated. During observation of Resident #151 on 11/25/19 at 5:00 p.m. the resident was observed lying in bed with the head of the bed at 30 degrees. Oxygen flowing at 2 liters with humidity set at 50%. Copious amounts of mucous coming from her tracheostomy. The humidified oxygen mask was lying on the resident's right shoulder area instead of the tracheostomy site. During an interview and observation of Resident #151 on 11/25/19 at 5:08 p.m. with the Senior Clinical Manager, she confirmed the resident needed to be suctioned with copious mucous coming from her trach. The collar was reapplied and the resident attempted to spit out all of the mucous in her mouth and inadvertently it came out of the trach tube. The Senior Clinical Manager confirmed the oxygen was set at 2 liters and humidity was around 50% with the Senior Clinical Manager changing it to 60% and stating she was going to check the order as she was unsure of the setting and would find the nurse to suction the resident. During an interview on 11/25/19 at 5:18 p.m. with staff member F, agency nurse stated the last time she saw Resident #151 was approximately 30 minutes ago. She stated the oxygen was set around 2 liters and did not know the humidity setting and went to the computer to find the order. Staff member F, agency nurse confirmed the oxygen should be set at 3 liters and confirmed she could not locate an order for the humidity. Staff member E, Senior Clinical manager came to the room to confirm she checked the settings and corrected the oxygen to 3 liters and humidity was set back to 28%. Review of physician orders reflected humidified oxygen per trach continuously at 28% every shift for shortness of breath dated 11/25/19. Humidified oxygen per trach as needed for shortness of breath dated 11/14/19. Oxygen at 3 liters per minute, every shift for respiratory failure dated 11/14/19. Suction trach reason for care: amount suction. characteristics of secretions, color, odor, viscosity, appearance of ostomy, (redness, drainage, open areas, surround skin issues, device used to secure trach, resident tolerance to procedure as needed for preventative measure dated 11/14/19. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105477 If continuation sheet Page 2 of 7 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 105477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/27/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bay Pointe Nursing Pavilion 4201 31st St S Saint Petersburg, FL 33712 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the progress notes dated 11/25/19 at 5:37 p.m. reflected the Senior Clinical Manager documented oxygen settings noted to be 2 liters per minute with humidification settings at 40%. Settings readjusted to 3 liters per minute with 28% humidification. Oxygen sats are 95% and physician notified. Review of the policy for oxygen administration and therapeutics 2.10.1 2 pages, dated 11/13 reflected Medication Administration via nebulizer. 6. Perform respiratory assessment to include quality of breath sounds, heart rate, and respiratory rate. 11. Instruct resident /patient to breathe slowly and deeply, holding each breath at the end of inspiration. 13. Drain excess medication by detaching nebulizer from gas source and shaking out and residual medication following completion of therapy. If rinsing is necessary, use sterile water or saline. 14. Store the dry nebulizer in a storage bag labeled with resident/ patients name, room number and date. 15. Perform respiratory assessment to include resident/patient's response to therapy. heart rate, respiratory rate, breath sounds, cough effort, and sputum production. 16. Document treatment in the medical record to include date and time of treatment, and findings from respiratory assessment. Review of the policy for oxygen administration and therapeutics 2.1.1 one page, effective 2013 reflected: The facility requires that a physician's order be obtained prior to the administration of oxygen. In an emergency, oxygen may be administered as per physician approved center protocol. The goals of oxygen therapy are as follows. Procedure: 1) Verify physician's order. Review of the policy for tracheostomy care 4.7.1 two pages reflected October 2019 from respiratory practice manual. The facility requires that qualified respiratory therapists or licensed nursing personnel perform tracheostomy care at least daily and as needed or per physicians orders to prevent buildup of secretions and infection of the airway around the tracheostomy tube. Review of the medication administration, section 7.0, table of contents 9/10 reflected section 7.8 page one of two reflected the resident 14. Monitor for medication side effects, including rapid pulse, restlessness and nervousness. 18) Administer therapy until medication is gone (mist has stopped) or until the designated time of treatment has been reached. 20) Obtain post-treatment pulse, respiratory rate and lung sounds and document findings on the MAR or in the resident's medical record following facility policy. 21) Rinse and disinfect the nebulizer equipment according to manufacturer's recommendations and facility policy. 23) When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105477 If continuation sheet Page 3 of 7 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 105477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/27/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bay Pointe Nursing Pavilion 4201 31st St S Saint Petersburg, FL 33712 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 observation, interview and record review, the facility failed to ensure two (#90 and #151) of three sampled residents, received respiratory care and services related to nebulizer treatments and cleaning for Resident #90 and tracheostomy care including humidified oxygen for Resident #151. Residents Affected - Few Findings Included: 1. During an interview on 11/25/19 at 10:20 a.m. with Resident #90, she confirmed she will give herself breathing treatments and confirmed the nurses do not listen to her lungs or check her oxygen level with each treatment. Resident #90 stated she has been send to the hospital several times for low oxygen levels. Resident #90 stated she was getting this treatment due to getting winded when she transfers from her bed to her wheel chair. During an interview on 11/25/19 at 11:20 a.m. with staff member C, LPN she confirmed she gave Resident #90 her breathing treatment and turned off the machine before she left the room. Staff member C, LPN confirmed she removed the mask from the resident and did not clean the nebulizer before putting the mask back in the bag. Staff member C, stated she listened to the residents lungs and checked her oxygen level. When asked what the oxygen level was before and after. Staff member C, LPN stated she did not document lung sounds or oxygen level because she had no where to document on the Medication administration record or treatment administration record. During an interview with the Interim Director of Nursing (DON), on 11/25/19 at 12:17 p.m. she confirmed the nurse should be evaluating lung sounds and checking oxygen level with nebulizer treatments. Review of the medical record for Resident #90 reflected the resident admitted on [DATE] with a readmission on [DATE] for diagnoses of respiratory failure Review of physician orders reflected change nebulizer tubing every week as needed label tubing with date when changed dated 10/30/19. Change nebulizer tubing every week, every night shift every Thursday for shortness of breath. Label tubing with date when changed dated 10/30/19. Change oxygen tubing and set up weekly as needed label tubing with date when changed, dated 10/30/19. Change oxygen tubing and set up weekly every night shift, every Thursday for shortness of breath, label tubing with date when changed, dated 10/30/19. Clean oxygen filter every Thursday for shortness of breath dated 10/30/19. Resident can self administer nebulizer treatments dated 11/25/19. Review of physician orders for nebulizer medication reflected Arformoterol tartrate nebulizer solution 15 mcg/2ml. one dose inhale orally via nebulizer two times a day for shortness of breath dated 11/25/19. Ipratropium-Albuterol solution 0.5-2.5 (3) mg/3ml one vial inhaled orally via nebulizer every 6 hours as needed for shortness of breath, wheezing one vial via updraft dated 10/29/19. Pulmicort suspension (Budesonide) one dose inhaled orally two times a day for copd, rinse after use. dated 11/25/19. Review of the medication administration record (MAR) for November reflected Arformoterol tartrate nebulization solution15 mcg/2ml, inhale orally via nebulizer two times a day for short of breath. Order date of 10/29/19 to discontinuation date of 11/25/19 at 2:33 p.m. Initials documented for this medication. Bedesonide suspension 0.5mg/2ml inhale orally two times a day for copd. Order date of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105477 If continuation sheet Page 4 of 7 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 105477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/27/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bay Pointe Nursing Pavilion 4201 31st St S Saint Petersburg, FL 33712 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 10/29/19 to discontinuation date of 11/25/19 requiring, Pain level and initials documented for this medication. Resident went to hospital on [DATE] after cardiology and admitted for low bp and low oxygen saturation returned on 10/29/19. Pulmicort suspension (Budesonide) one dose inhale orally two times a day for copd. Rinse after use. Dated 11/25/19 document lung sounds, minutes, oxygen saturations and initials. Ipratropium-albuterol solution 0.5-2.5 (3mg/3ml) one vial inhale orally via nebulizer every 6 hours as needed for shortness of breath and wheezing. one vial via updraft dated 10/29/19, document lung sounds, minutes, oxygen and initials. Review of the care plan reflected a focus area of oxygen therapy related to respiratory illness, COPD, Heart failure, chronic respiratory failure initiated 12/26/19, revised on 6/20/19. Interventions include special equipment oxygen initiated 12/26/18. Give medications as ordered by physician. Monitor/document side effects and effectiveness initiated 12/26/18 revised on 3/20/19. Administer oxygen as ordered initiated on 12/26/18 revised on 3/20/19. 2. During observation of Resident #151 on 11/24/19 at 11:21 a.m. the resident was observed lying in her bed on her left side facing the door. Oxygen was observed at 1.5 liters with humidity at 28%. The head of the bed was elevated. During observation of Resident #151 on 11/25/19 at 5:00 p.m. the resident was observed lying in bed with the head of the bed at 30 degrees. Oxygen flowing at 2 liters with humidity set at 50%. Copious amounts of mucous coming from her tracheostomy. The humidified oxygen mask was lying on the residents right shoulder area instead of the tracheostomy site. During an interview and observation of Resident #151 on 11/25/19 at 5:08 p.m. with the Senior Clinical Manager, she confirmed the resident needed to be suctioned with copious mucous coming from her trach. The collar was reapplied and the resident attempted to spit out all of the mucous in her mouth and inadvertently it came out of the trach tube. The Senior Clinical Manager confirmed the oxygen was set at 2 liters and humidity was around 50% with the Senior Clinical Manager changing it to 60% and stating she was going to check the order as she was unsure of the setting and would find the nurse to suction the resident. During an interview on 11/25/19 at 5:18 p.m. with staff member F, agency nurse stated the last time she saw Resident #151 was approximately 30 minutes ago. She stated the oxygen was set around 2 liters and did not know the humidity setting and went to the computer to find the order. Staff member F, agency nurse confirmed the oxygen should be set at 3 liters and confirmed she could not locate an order for the humidity. The Senior Clinical manager came to the room to confirm she checked the settings and corrected the oxygen to 3 liters and humidity was set back to 28%. Resident #151 was admitted on [DATE] and readmitted on [DATE] with diagnoses of pneumonia, acute and chronic respiratory failure, chronic obstructive pulmonary disease, tracheostomy and dementia. Review of physician orders reflected humidified oxygen per trach continuously at 28% every shift for shortness of breath dated 11/25/19. Humidified oxygen per trach as needed for shortness of breath dated 11/14/19. Oxygen at 3 liters per minute, every shift for respiratory failure dated 11/14/19. Suction trach reason for care: amount suction. characteristics of secretions, color, odor, viscosity, appearance of ostomy, (redness, drainage, open areas, surround skin issues, device used to secure trach, resident tolerance to procedure as needed for preventative measure dated 11/14/19. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105477 If continuation sheet Page 5 of 7 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 105477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/27/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bay Pointe Nursing Pavilion 4201 31st St S Saint Petersburg, FL 33712 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the progress notes dated 11/25/19 at 5:37 p.m. reflected the Senior Clinical Manager documented oxygen settings noted to be 2 liters per minute with humidification settings at 40%. Settings readjusted to 3 liters per minute with 28% humidification. Oxygen sats are 95% and physician notified. Review of the treatment administration record dated 11/25/19 reflected humidified oxygen per trach continuously at 28% every shift for shortness of breath. Order date 11/25/19. Humidified oxygen per trach continuously. Oxygen sat to maintain sats 90% or above every shift for shortness of breath. Order dated 11/14/19 and discontinued on 11/25/19. Review of the policy for oxygen administration and therapeutics 2.10.1 2 pages, dated 11/13 reflected Medication Administration via nebulizer. 6. Perform respiratory assessment to include quality of breath sounds, heart rate, and respiratory rate. 11. Instruct resident /patient to breathe slowly and deeply, holding each breath at the end of inspiration. 13. Drain excess medication by detaching nebulizer from gas source and shaking out and residual medication following completion of therapy. If rinsing is necessary, use sterile water or saline. 14. Store the dry nebulizer in a storage bag labeled with resident/ patients name, room number and date. 15. Perform respiratory assessment to include resident/patient's response to therapy. heart rate, respiratory rate, breath sounds, cough effort, and sputum production. 16. Document treatment in the medical record to include date and time of treatment, and findings from respiratory assessment. Review of the policy for oxygen administration and therapeutics 2.1.1 one page, effective 2013 reflected: The facility requires that a physician's order be obtained prior to the administration of oxygen. In an emergency, oxygen may be administered as per physician approved center protocol. The goals of oxygen therapy are as follows. Procedure: 1) Verify physician's order. Review of the policy for tracheostomy care 4.7.1 two pages reflected October 2019 from respiratory practice manual. The facility requires that qualified respiratory therapists or licensed nursing personnel perform tracheostomy care at least daily and as needed or per physicians orders to prevent buildup of secretions and infection of the airway around the tracheostomy tube. Review of the medication administration, section 7.0, table of contents 9/10 reflected section 7.8 page one of two reflected the resident 14. Monitor for medication side effects, including rapid pulse, restlessness and nervousness. 18) Administer therapy until medication is gone (mist has stopped) or until the designated time of treatment has been reached. 20) Obtain post-treatment pulse, respiratory rate and lung sounds and document findings on the MAR or in the resident's medical record following facility policy. 21) Rinse and disinfect the nebulizer equipment according to manufacturer's recommendations and facility policy. 23) When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105477 If continuation sheet Page 6 of 7 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 105477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/27/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bay Pointe Nursing Pavilion 4201 31st St S Saint Petersburg, FL 33712 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 Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure strawberries were stored and maintained in a safe and sanitary manner, and failed to appropriately store kitchen staff's drinks in two (2) of three (3) refrigerators sampled. Findings included During the initial kitchen tour on 11/24/19 at 9:45 a.m., an observation of the walk-in refrigerator included on the second shelf, a cardboard box that contained two (2) boxes of moldy strawberries. (Photographic Evidence Obtained.) Staff A, Kitchen Cook, confirmed the presence of both boxes of moldy strawberries, and quickly removed them throwing them into a nearby garbage receptacle. On 11/24/19 at 9:45 a.m. during an observation of the cook's refrigerator a white plastic bag with two (2) large cans of Mountain Dew soda drink was seen on the first shelf of the refrigerator. Staff A stated, That is mine, I forgot to date it. Staff A later revealed that storage of facility food items for resident meals such as butter, eggs and cheese are kept in the cook's refrigerator. An interview was conducted with the Certified Dietary Manager (CDM) on 11/27/2018 at 10:00 a.m., She was informed and asked about the concerns observed during the initial kitchen tour. She stated I went through the walk-in on Friday and cleaned it out, we had a big party in the facility. If you found two (2) boxes of moldy strawberries considering how many we had, then that is good. She further confirmed that her kitchen staff should not be storing their personal drink items in the cook's refrigerator. The CDM stated I have a special place on the bottom shelf of the walk-in and that is where they can keep their drinks. The CDM showed the surveyor the place that she expects her staff to put dated personal drink items that they bring into the facility kitchen for their own private use. A review of the facility's policy HCSG Policy 017, titled Receiving, Revised 9/2017, Page 01 of 06, included under Procedures reads: 6. All food items will be stored in a manner that ensures appropriate and timely utilization based on the principles of first in-first out (FIFO) inventory management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105477 If continuation sheet Page 7 of 7