Inspection·October 14, 2021

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Brief Interview Mental Status (BIMS) score of 15 of 15, which indicated the Resident #48 should have been able to be interviewed related to her care and services. Restraints: Not checked as used. Review of the previous quarterly MDS assessment dated [DATE] revealed: Restraints: Other, 1. Used less than daily. This assessment did not identify the use of a trunk restraint, but rather other. There was no documentation to indicate what other specified. Review of the Nursing Quarterly data collection dated 7/8/2021, revealed no documentation for utilization of restraints. Review of the Nursing Quarterly data collection dated 10/8/2021, revealed no documentation for utilization of restraints. On 10/14/2021 at 9:30 a.m., an interview with the Director of Nursing (DON), the Nursing Home Administrator (NHA), the MDS Coordinator, and the Physical Therapist was conducted. The Director of Nursing confirmed that Resident #48 had an order for a trunk restraint, specifically a [name brand] chair with thigh straps, since 6/8/2021. The DON confirmed that the last two Minimum Data Set (MDS) assessments, dated 7/8/21 and 10/8/21, did not identify that the resident used a trunk restraint. The DON further confirmed that the Quarterly Data Collection assessment, dated 7/8/2021 and 10/8/2021, both did not indicate Resident #48 used restraints. The MDS coordinator confirmed that the MDS assessments dated for 7/8/2021 and 10/8/2021 did not reflect that Resident #48 used a trunk restraint. The MDS coordinator indicated that they were trying to assess during those periods of whether she was actually using a restraint or not, and trying to assess for the least restrictive restraint. He revealed that the Interdisciplinary Team concluded that they would indicate the device as other, rather than a trunk restraint. The DON and the Nursing Home Administrator both confirmed the device Resident #48 used was a restraint and confirmed the restraint was for the trunk to prevent rising. The MDS coordinator revealed that they did not think to document in the assessments that Resident #48 utilized a trunk restraint because the Interdisciplinary team believed the thigh straps were something else. However, the DON, NHA, and MDS coordinator indicated that Resident #48 currently used a restraint that prevented her trunk from rising, therefore it should have been assessed as a trunk restraint. The policy overview revealed; The facility will promote quality of life and resident centered care. Restraints will be used only when necessary to treat a medical symptom and not used for staff convenience. The least restrictive restraint, for the shortest duration of time will be applied to assist the resident in reaching their highest level of physical and psychosocial well-being. The facility will demonstrated and document the presence of specific medical symptoms that require the use of the restraint to treat the cause of the symptom by evaluating resident condition, circumstances and environment. The evaluation includes determining if a device is a restraint or an assistive device. The policy definition of Physical Restraint is: Any manual method of physical or mechanical device, material, or equipment attached or adjacent to the resident's patient's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. The policy further indicated Restraints include, but are not limited to, the following: Chair that prevents rising, Devices used with a chair such as trays, tables, bars or belts that the resident cannot easily remove or that prevent them from rising. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105477 If continuation sheet Page 2 of 3 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 10/14/2021 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 0641 The Restraint management section of the policy indicated: Re-Evaluation resident status at the care plan and or standards of care meetings quarterly. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105477 If continuation sheet Page 3 of 3