Health inspection·January 12, 2024

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #81's Quarterly MDS, dated [DATE], showed a modification was made on 01/11/24 at 2:44 p.m. The modification showed Section J- Health Conditions showed question B. Reviewed PRN pain medications? now reflected the answer changed to Yes. (Photographic evidence obtained) During an interview on 01/12/24 at 9:30 a.m., Staff B, MDS Coordinator stated he did modify Resident #81's Quarterly MDS, dated [DATE], yesterday. Staff B, MDS Coordinator stated no one asked him to modify the MDS, however when he was asked to print Resident #81's MDS he noticed Section J- Health Conditions was marked wrong with the pain medications marked no. Staff B, MDS Coordinator stated Administration asked me to print the MDS sections so I checked them to make sure they were right before I printed them because I knew you were in the building and auditing them. Staff B, MDS Coordinator stated I wanted to make sure the MDS was correct before printing and giving it to you for review. During an interview on 01/12/24 at 9:40 a.m., the Administrator stated, I would not expect my staff to change documents after you have asked for them. The Administrator stated, I would expect them to print the original incorrect form to give to you and then fix the discrepancy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105477 If continuation sheet Page 2 of 12 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 01/12/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 record review and interviews the facility failed to refer one resident (#78) of 12 residents reviewed for Pre-admission Screening and Resident Review (PASRR), for a Level II review after a positive Level I PASRR revealed a need for further review. Findings included: Review of Resident #78's admission Record showed an original admission date of 07/28/23 with diagnoses included but not limited to unspecified mood [Affective] disorder onset date 07/28/23, other psychotic disorder onset date 07/28/23, Schizoaffective Disorder, Bipolar Type onset 12/14/23, Major Depressive Disorder, recurrent, moderate onset date 12/14/23, Schizoaffective Disorder, unspecified onset date 07/28/23, Bipolar Disorder, unspecified onset date 07/28/23 and generalized anxiety disorder onset date 10/19/23. Review of Resident #78's Discharge Return Anticipated Minimal Data Set (MDS) assessment dated [DATE], revealed under Section C-Cognitive Patterns, Resident #6 had a Brief Interview for Mental Status (BIMS) of 03 (severe cognitive impairment) and under Section I - Active Diagnoses, Resident #6 had diagnoses of Anxiety Disorder, Manic Depressive-Bipolar Disease, Psychotic Disorder and Schizophrenia. A review of Resident #78's I PASRR assessment, dated 07/14/23 revealed, under the section titled A. MI (Mental Illness) or suspected MI (check all that apply), the checkboxes for the selections Depressive Disorder, Bipolar Disorder, and Schizoaffective Disorder were checked. The assessment also revealed, under the section III titled Other Indications for PASRR Screen Decision-Making, the checkboxes for the selection B Concentration, persistence and pace was checked Yes. The assessment further revealed, under section IV titled, PASRR Screen Completion, the selection Individuals may not be submitted to a Nursing Facility. Use this form as required documentation to request a Level II PASRR evaluation because there is a diagnosis of or suspicion of Serious Mental Illness and Intellectual Disability. Further review of Resident #78's medical record showed no Level II PASRR available for review. During an interview on 01/12/24 at 10:38 a.m., the Director of Nursing (DON) stated she was responsible for all Residents' PASRR with the help from the Social Worker. The DON stated she would expect all the PASRR information to be included in the hard copy chart for all Residents. The DON reviewed Resident #78's PASRR dated 07/14/23 which showed under the section titled A. MI (Mental Illness) or suspected MI (check all that apply), the checkboxes for the selections Depressive Disorder, Bipolar Disorder, and Schizoaffective Disorder were checked. The assessment also revealed, under the section III titled Other Indications for PASRR Screen Decision-Making, the checkboxes for the selection B Concentration, persistence and pace was checked Yes. The assessment further revealed, under section IV titled, PASRR Screen Completion, the selection Individuals may not be submitted to a Nursing Facility. Use this form as required documentation to request a Level II PASRR evaluation because there is a diagnosis of or suspicion of Serious Mental Illness and Intellectual Disability. The DON stated let me look into this as no Level II PASRR was available in Resident #78's medical record. During an interview on 01/12/24 at 11:00 a.m., the DON provided a [company name] statement (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105477 If continuation sheet Page 3 of 12 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 01/12/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Preadmission Screening and Resident Review Screening dated 10/26/23 that showed, We cannot complete the screening. The reason is below: The case is being closed due to an incomplete submission packet. Written in the top right corner showed faxed all 11/13. The DON stated that she would have to continue to look further to see if the information was re-submitted for the level II. During an interview on 11/12/24 at 11:23 a.m., the DON stated she had a call out to [the state reviewing agency] because she looked in the electronic system and did not see where a new submission within [The state reviewing agency] online system was submitted for Resident #78 on 11/13/23. The DON stated she could not find any fax confirmation for any re-submission of a completed submission packet. The DON stated right now she did not have any proof or evidence that the facility ever completed a Level II review for Resident #78. Event ID: Facility ID: 105477 If continuation sheet Page 4 of 12 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 01/12/2024 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 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to implement and develop a care plan for a Functional Maintenance program/Restorative Nursing program for one resident (#17) out 34 sampled residents. Findings included: Review of Resident #17's admission Record revealed she was admitted to the facility on [DATE] from an acute care hospital. Her diagnoses included lack of coordination, repeated falls, unsteadiness on feet, need for assistance with personal care, cognitive communication deficit, acquired deformities of right foot, age related physical debility, personal history (healed) of traumatic fracture, and presence right artificial hip joint. An interview was conducted on 1/9/24 at 10:22 AM with Resident #17. She was observed to be in her room sitting in her wheelchair. She said she was not currently in therapy, but she feels she was making progress in therapy and now that she is no longer in therapy she feels she is not able to lift herself from the wheelchair and use her walker as well as she used to. She said she feels weaker now. She said she told the Nursing Home Administrator (NHA), but she has not heard anything from him since. Review of Resident #17's physician orders revealed an order with a start date of 7/25/23 with no end date for Restorative Nursing as needed. Review of Resident #17's TO (Occupational Therapy)-Therapist Progress & Discharge Summary dated 12/6/23 revealed the following. Analysis of Functional Outcome/Clinical Impression Pt [patient] provided with skilled OT to increase independence in ADL performance and related mobility. Pt made measurable progress attaining all of her long-term goals. Pt provided with Functional Maintenance program for BUE [bilateral upper extremities] ROM [range of motion]/strengthening exercises to maintain with provision of skilled OT. Review of Resident #17's Therapy Recommendations for Restorative/Functional Maintenance Program with a therapy discharge date of 12/6/23, revealed Passive and/or Active Assistance/ROM [range of motion] BUE [bilateral upper extremity] strengthening/ ROM exercises: Strengthening: using light resistance theraband [sic] 1lb [pound] hand weight, 2lb weighted [sic] 10 reps X [times] 3: Shoulder flex/ext [extension]/abduction. -Biceps curls -Triceps extensions. .General Recommendations: Pt to perform upper body exercises to maintain/increase strength to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105477 If continuation sheet Page 5 of 12 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 01/12/2024 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 performance of basic self care tasks and transfers. Level of Harm - Minimal harm or potential for actual harm The training record revealed 3 signatures. One Licensed Practical Nurse (LPN) signature dated 12/7/23. One Certified Nursing Assistant (CNA) signature dated 12/7/23, and Staff A, CNA signature dated 1/4/24. Residents Affected - Few Review of Resident #17's care plans did not reveal a care plan related to her Functional Maintenance program/Restorative program with measurable goals and interventions. An interview was conducted on 1/11/24 at 11:57 AM with the NHA. He said since the resident has been admitted he had been working very closely with the family and the resident regarding therapy. We actually just had a care plan meeting this morning for her and we are going to get her rescreened for therapy .we just reviewed all the therapy notes and she is stand by assist for all her ADLs and walking over 150 feet .this morning she said she's not confident getting up and walking so we just put in a therapy referral but we extended her therapy several times while she has been here to get her ready to go to an ALF [Assisted Living Facility]. An interview was conducted with the Director of Therapy (DOR) on 1/11/24 at 1:20 p.m. She said, Resident #17 was on Physical Therapy (PT) from 7/26/23 through 12/26/23. The resident received Occupational Therapy (OT) from 7/26/23-12/06/23 and she is currently on Speech Therapy for cognition. The DOR said When she was discharged from therapy, she was walking over 150 feet with supervision to stand by assist with the rolling walker. Stand by assist means we have a wheelchair there just in case if she needs to take a break or is feeling anxious. She was a standby assistant with transfers. That means someone is close enough to reach her if assistance is needed. When we discharged her from PT and OT, we discharged her with the restorative program, but our restorative aide no longer works here and there hasn't been a restorative aide for a while. When we discharge a resident to the restorative program, we write up a restorative plan and educate the CNAs on it but I can't be sure it is actually getting done. An interview was conducted with Resident #17 on 1/11/24 at 2:30 p.m. She was observed to be in her room sitting in her wheelchair with a [brand name therapy band] on her bed next to her. She said since I have stopped therapy, I have been getting zero exercise. I have this band and I will stretch it sometimes, but I am doing that myself and it isn't helping, I am getting weaker. I am going backwards because I'm not getting the exercises. I don't know what a Restorative Program is. I don't have weights, and no one brings me weights to do exercises. An interview was conducted with Staff A, CNA on 1/11/24 at 2:40 p.m. she said she works with Resident #17 every Tuesday and Thursday. She said she doesn't know anything about a Restorative program. We used to have a restorative aide, but he has not been here for a long time. If the residents need exercises that's something Therapy does. Staff A, CNA said she does not provide Resident #17 with exercises using weights or bands, That's something therapy does. An interview was conducted with the Director of Nursing (DON) on 1/11/24 at 4:03 p.m. She said we do not have a restorative program. I was never oriented to a restorative program since I started on October 31st, 2023. An interview was conducted with the DOR on 1/11/23 at 9:28 a.m. She said, The facility is supposed to provide the residents with restorative therapy according to our contract with them and I'm not sure it is actually getting done. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105477 If continuation sheet Page 6 of 12 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 01/12/2024 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 facility's policy Care Plan- Interdisciplinary Plan of Care from Interim to Meeting with a revision date of September 2023 revealed the following. Policy The facility shall support that each resident must receive [sic] and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility shall assess and address care issues that are relevant to individual residents, to include, but may not be limited to monitoring resident condition and responding with appropriate interventions. The comprehensive care plan is an interdisciplinary communication tool. It includes measurable objectives and time frames and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan is reviewed and revised periodically, and the services provided or arranged are consistent with each resident's written plan of care FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105477 If continuation sheet Page 7 of 12 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 01/12/2024 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to provide a Functional Maintenance program/Restorative Nursing program to maintain or improve resident activities of daily living (ADLs) for one resident (#17) out three residents reviewed for activities of daily living. Residents Affected - Few Findings included: Review of Resident #17's admission Record revealed she was admitted to the facility on [DATE] from an acute care hospital. Her diagnoses included but are not limited to lack of coordination, repeated falls, unsteadiness on feet, need for assistance with personal care, cognitive communication deficit, acquired deformities of right foot, age related physical debility, personal history (healed) of traumatic fracture, and presence right artificial hip joint. An interview was conducted on 1/9/24 at 10:22 AM with Resident #17. She was observed to be in her room sitting in her wheelchair. She said she was not currently in therapy, but she feels she was making progress in therapy and now that she is no longer in therapy she feels she is not able to lift herself from the wheelchair and use her walker as well as she used to. She said she feels weaker now. She said she told the Nursing Home Administrator (NHA), but she has not heard anything from him since. Review of Resident #17's physician orders revealed an order with a start date of 7/25/23 with no end date for Restorative Nursing as needed. An interview was conducted on 1/11/24 at 11:57 AM with the NHA. He said since the resident has been admitted he had been working very closely with the family and the resident regarding therapy. We actually just had a care plan meeting this morning for her and we are going to get her rescreened for therapy .we just reviewed all the therapy notes and she is stand by assist for all her ADLs and walking over 150 feet .this morning she said she's not confident getting up and walking so we just put in a therapy referral but we extended her therapy several times while she has been here to get her ready to go to an ALF [Assisted Living Facility]. An interview was conducted with the Director of Therapy (DOR) on 1/11/24 at 1:20 p.m. She said, Resident #17 was on Physical Therapy (PT) from 7/26/23 through 12/26/23. The resident received Occupational Therapy (OT) from 7/26/23-12/06/23 and she is currently on Speech Therapy for cognition. The DOR said When she was discharged from therapy, she was walking over 150 feet with supervision to stand by assist with the rolling walker. Stand by assist means we have a wheelchair there just in case if she needs to take a break or is feeling anxious. She was a standby assistant with transfers. That means someone is close enough to reach her if assistance is needed. When we discharged her from PT and OT, we discharged her with the restorative program, but our restorative aide no longer works here and there hasn't been a restorative aide for a while. When we discharge a resident to the restorative program, we write up a restorative plan and educate the CNAs on it but I can't be sure it is actually getting done. Review of Resident #17's OT-Therapist Progress & Discharge Summary dated 12/6/23 revealed the following. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105477 If continuation sheet Page 8 of 12 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 01/12/2024 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 0676 Analysis of Functional Outcome/Clinical Impression Level of Harm - Minimal harm or potential for actual harm Pt [patient] provided with skilled OT to increase independence in ADL performance and related mobility. Pt made measurable progress attaining all of her long-term goals. Pt provided with Functional Maintenance program for BUE [bilateral upper extremities] ROM [range of motion]/strengthening exercises to maintain with provision of skilled OT. Residents Affected - Few Review of Resident #17's Therapy Recommendations for Restorative/Functional Maintenance Program with a therapy discharge date of 12/6/23, revealed Passive and/or Active Assistance/ROM [range of motion] BUE [bilateral upper extremity] strengthening/ ROM exercises: Strengthening: using light resistance [therapy band name] [sic] 1lb [pound] hand weight, 2lb weighted [sic] 10 reps X [times] 3: Shoulder flex/ext [extension]/abduction. -Bicep curls -Tricep extensions. .General Recommendations: Pt to perform upper body exercises to maintain/increase strength to performance of basic self care tasks and transfers. The training record revealed 3 signatures. One Licensed Practical Nurse (LPN) signature dated 12/7/23. One Certified Nursing Assistant (CNA) signature dated 12/7/23, and Staff A, CNA signature dated 1/4/24. An interview was conducted with Resident #17 on 1/11/24 at 2:30 p.m. She was observed to be in her room sitting in her wheelchair with a therapy band on her bed next to her. She said since I have stopped therapy, I have been getting zero exercise. I have this band and I will stretch it sometimes, but I am doing that myself and it isn't helping, I am getting weaker. I am going backwards because I'm not getting the exercises. I don't know what a Restorative Program is. I don't have weights, and no one brings me weights to do exercises. An interview was conducted with Staff A, CNA on 1/11/24 at 2:40 p.m. she said she works with Resident #17 every Tuesday and Thursday. She said she doesn't know anything about a Restorative program. We used to have a restorative aide, but he has not been here for a long time. If the residents need exercises that's something Therapy does. Staff A, CNA said she does not provide Resident #17 with exercises using weights or therapy bands. That's something therapy does. An interview was conducted with the Director of Nursing (DON) on 1/11/24 at 4:03 p.m. She said we do not have a restorative program. I was never oriented to a restorative program since I started on October 31st, 2023. An interview was conducted with the DOR on 1/11/23 at 9:28 a.m. She said, The facility is supposed to provide the residents with restorative therapy according to our contract with them and I'm not sure it is actually getting done. Review of the facility's policy Restorative Nursing Programs and Guidelines with a revision date of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105477 If continuation sheet Page 9 of 12 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 01/12/2024 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 0676 October 2017 revealed the following: Level of Harm - Minimal harm or potential for actual harm Overview Residents Affected - Few The facility provides Restorative Nursing Programs that involve interventions to improve or maintain the optimal physical, mental and psychological functioning. The IDT [interdisciplinary team], resident and, or family identify the needs of the resident, and collaboratively determines appropriate Restorative Nursing Programs to achieve the resident's goals. The programs include: Contracture Management and Prevention -This program includes the provision of active and, or passive range of motion exercises/movements to maintain or improve joint flexibility as well as strength. This program also involves splint/brace assistance to protect joint and skin integrity. Mobility- This program improves or maintain self-performance in bed mobility, transfers, wheelchair mobility and walking. Activities of Daily Living- This program involves improvement or maintenance of the resident's self performance in dressing (including prosthetic care), grooming and bathing . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105477 If continuation sheet Page 10 of 12 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 01/12/2024 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 observations, record review, and interviews, the facility failed to maintain emergency supplies for tracheostomy care at bedside per physician's order and failed to obtain orders prior to administering oxygen for one resident (Resident #14) out of two sampled residents. Residents Affected - Few Findings included: On 01/10/24 at 9:30 a.m., the oxygen concentrator in Resident #14's room was observed on and set at 5 liters. On 01/12/24 at 9:40 a.m., the oxygen concentrator in Resident #14's room was observed on and set at 5 liters, the humidified air was set at 28%. The opposite end of the tubing connector attached to the oxygen concentrator was observed disconnected from the tracheostomy (trach) collar and on the floor. A review of the admission Record for Resident #14 showed the resident was initially admitted to the facility on [DATE] with diagnoses to include chronic respiratory failure with hypoxia, tracheostomy status, and respiratory disorders in diseases classified elsewhere. A review of the Quarterly Minimum Data Set (MDS), dated [DATE], Section O Special Treatments, Procedures, and Programs showed Resident #14 received the following respiratory treatments: oxygen therapy, suctioning, and tracheostomy care. A review of the Order Summary Report with active orders as of 01/12/24 revealed the following orders: Maintain Ambu bag at beside and replacement trach of equal size and one size down maintained at bedside every shift for preventative measure and Tracheostomy Type: Shiley size 6. Trach care daily and as needed. There was no order for oxygen found. A progress note dated 01/01/24 at 11:49 revealed intravenous antibiotic remains in progress for respiratory infection. Trach patient coughing up white secretions via trach. The care plan related to the tracheostomy initiated 04/26/17 revealed Resident #14 had a tracheostomy related to impaired breathing mechanics. Interventions included to give humidified oxygen per trach as tolerated, oxygen as ordered via trach, and maintain Ambu bag and replacement trach at bedside per order. On 01/12/24 at 9:42 am, Staff C, Licensed Practical Nurse (LPN), confirmed the oxygen concentrator was set at 5 liters. The tubing connector on the floor was pointed out and Staff C, LPN, stated she would change the tubing. Staff C, LPN was asked to verify the order for oxygen. She went to her computer, looked through the orders for Resident #14, and stated she could not find the order for oxygen. Staff C, LPN, then stated she would have to go verify the order for oxygen. The emergency supplies were observed. Observations revealed there was only a 6.4 and 6.5 Shiley located in the room. This (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105477 If continuation sheet Page 11 of 12 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 01/12/2024 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 was confirmed by Staff C, LPN, and Staff H, Registered Nurse (RN). Staff H, RN, stated he thinks the resident had a size 7 Shiley. The current physician's order revealed a replacement trach of equal size, and one size down should be maintained at bedside every shift and he had an order for a size 6 Shiley. Staff C, LPN, stated in the mornings she made sure everything was in place. She made her rounds to make sure the oxygen was on but didn't check the emergency supplies. Residents Affected - Few On 01/12/24 at 10:28 a.m., the Director of Nursing (DON) stated no size 5 Shiley exists so a size 4 would be the next step down. She stated there should have been an order in place for oxygen. The DON walked down to Resident #14's room and she confirmed the correct size for the replacement trach was not in the room. There was only a 6.4 and 6.5 Shiley located in the room. The policy provided by the facility Emergency Tracheostomy Tube Changes with an effective date of December 2022 revealed the following: The following supplies are to be kept at the bedside in a highly visible area of any resident who has a tracheostomy tube: Tracheostomy tubes- one the same size and one a size smaller. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105477 If continuation sheet Page 12 of 12