Inspection·April 2, 2024

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (Form 5000-3008) dated 03/06/24, showed Resident #1 received dialysis on Tuesday, Thursday, and Saturday. Review of a facility document titled, Pre-admission Screening Tool, dated 03/05/24, showed Resident #1 required HD on Tuesday, Thursday, and Saturday. The document indicated [name of dialysis facility] and the chair time, 6 a.m. Review of a document titled, SBAR (Situation Background Assessment Recommendation) Communication Form dated 03/09/24 at 10:15 a.m. showed, MD (Medical Doctor) at dialysis center requested [Resident #1] be sent to [name of the hospital] for dialysis treatment. Review of a facility Hospital Transfer form, dated 03/09/24 at 10:00 a.m., showed Resident sent to hospital for dialysis treatment. On 04/02/26 at 10.06 a.m., an interview was conducted with Staff A, Licensed Practical Nurse, (LPN). She stated she had dialysis residents in hall 600. She stated to her knowledge her residents had not missed dialysis. She said, But, there was a resident on the other side, earlier in March, she missed two dialysis appointments because of transportation. She ended up being hospitalized . I heard the transport bus broke or something. She was not assigned to me directly. Staff A stated she made sure the Certified Nurses Assistants (CNAs) got the residents up on time. She stated they did not want them to miss their chair time. She stated the nurses completed documentation before and after dialysis. On 04/02/26 at 10:12 a.m., an interview was conducted with Staff B, Registered Nurse (RN)/ Unit Manager. She stated she had a dialysis resident in hall 300. She stated there were times residents missed appointments because of the transport company. She stated they could be unreliable. She stated Medical Records scheduled all dialysis transportation. She stated the facility did not have an emergency plan and they do not have a vehicle. She said, The plan is to reschedule the appointment for the next day or get orders to send the resident to the hospital. She stated each resident had a dialysis communication book they brought to the center for dialysis staff to fill out. She stated their nurses fill out their portion for post dialysis care. On 04/02/26 at 10:20 a.m., an interview was conducted with Staff C, LPN. She stated the only issue they had was with transportation, which would normally be set up by Medical Records. She stated the nurses filled out the form, gave the resident their medications, and gave them a meal from the kitchen. She stated they would try and get them in for a later chair time. She stated she made repeated calls to the transportation company and if they could not get them in, they notified dialysis and the doctor. She stated she was not aware of any residents missing dialysis recently. An interview was conducted with the Director of Nursing (DON) on 04/02/26 at 11:18 a.m. She stated Resident #1 was admitted to the facility on [DATE] and had dialysis set up. She said, It was set up for Tuesday, Thursday and Saturday, chair time at 6 a.m. She stated the hospital typically sets up the first appointment, but in this case they did not. When she was admitted she was not able to get in for the 6 a.m. chair time which was scheduled for the following day. We called and rescheduled. She went in at 8:30 a.m. and had a shortened chair time. She returned at 12:30 p.m. The DON stated a shortened chair time meant dialysis shortened her chair time and she did not know why. She said it had to do with their scheduling. The DON stated transportation did not show up for her 6 a.m. chair time again on 03/07/24. She stated when the nurse called, they kept saying they were on their way. The DON stated the nurse on duty called the doctor, and eventually around 10 a.m. he ordered her to be (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 04/02/2024 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 0698 Level of Harm - Minimal harm or potential for actual harm transferred to the hospital. The DON stated their protocol if a resident missed an appointment was to call the dialysis center and set up a later chair time. The DON stated the facility had no vehicle available. They could not transport her. The DON stated they had analyzed the situation and the previous NHA was supposed to file a complaint with the insurance company. I don't know if it was filed. We notified the daughter of the appointments. The DON stated no other residents had missed dialysis. Residents Affected - Few On 04/02/26 at 12:09 p.m., the DON stated they had reviewed the incident which happened on a weekend. She stated Medical Records did not work weekends. She stated the weekend supervisor should have confirmed the chair time and transportation. The DON said, to my knowledge, I don't know if anyone called to confirm the appointments prior to her admission or upon admission. The DON stated there was no evidence it was confirmed because it was not documented. On 04/02/26 at 12:38 p.m. an interview was conducted with the Nursing Home Administrator (NHA) and the DON. The NHA stated she had just become aware of Resident #1 missing dialysis appointments. She said, I can't speak of that incident, but for the future we will make sure transportation for dialysis residents is secured. It normally takes them time to make sure the residents are ready. The DON stated the facility had gone through a staffing turnover. She stated they had identified they needed to put some systems in place. She stated they had started in-services on documentation. She stated they would educate on dialysis. On 04/02/26 at 12:12 p.m., the DON stated they had received a grievance for this patient. She stated to her knowledge they had resolved it for this patient. She said, We have no control of the transportation company. The DON stated they had a contingency plan. She said, We have other transportation companies that we could call. And the facility could pay for the transport. This is our emergency plan. I don't have the answer as to why this did not happen. The weekend supervisor dealt with that. I don't know if the nurses know of this option. The weekend supervisor chose to call the doctor and send her out. I know the hospital is for acute care. It is not for regular non-emergent services. I know. We will educate the nurses. Review of dialysis communication books for March 2024 revealed the following: There was one documented communication form dated 03/07/24. The pre- dialysis care portion was noted blank. The DON stated the dialysis forms should be filled out completely. She stated it was tool for the center and the facility to communicate. She stated the vitals should be documented and the site should be assessed. She stated they were to notify the doctor of anything out of the ordinary. Review of a facility policy titled, Dialysis Management (Hemodialysis), dated October 2021, showed the facility will coordinate care and services for hemodialysis residents. Facility will coordinate routine transportation for the resident. Contractual agreement will include but not limited to, the following: Medical and non-medical emergencies, development and implementation of resident care plan, interchange of information useful/necessary for the care of the resident. Under guidelines 1.) obtain physician orders to include but not limited to shunt access site-signs and symptoms to monitor such as pain, infection, or bleeding. 4.) Daily assessment and documentation of shunt or access site for bleeding, signs and symptoms of infection, redness/pain. Notify physician of abnormal findings. 8.) Complete the dialysis communication tool before and after dialysis and following up on any special instructions from the dialysis center. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105477 If continuation sheet Page 3 of 3