F 0584
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
Level of Harm - Minimal harm
or potential for actual harm
Based on observations and interviews, the facility failed to maintain linens in good condition.
Residents Affected - Few
The findings include:
On 02/26/24 at approximately 2:17 PM, Resident #218 was observed with a large hole in the linens as the
resident was resting in bed (photo evidence obtained). When asked abouth this, Resident #218 stated that
the staff had recently changed her linens.
On 02/27/24 at approximately 1:07 PM, Resident #218 was observed in bed eating lunch. During this
observation, it wass noted that the bottom sheet had a large hole in the upper corner.
In an interview on 02/28/24 at approximately 8:31 AM, Staff D, a Certified Nusing Assistant, was asked
what is their process if they find sheets that are ripped or have holes. She stated that the facility is
supposed to throw those out, so she sets it aside and sends it back to laundry.
On 02/28/24 at approximately 11:40 AM, a clean bottom fitted sheet was pulled from two different clean
linen carts down the 400 hallway. Both sheets were observed to have large holes in the corners. (photo
evidence obtained)
On 02/28/24 at approximately 11:45 AM in an interview, the Director of Nursing stated they are always
checking linen and she was surprised that they had any with holes.
On 02/28/24 at approximately 11:52 AM, the Administrator confirmed in an interview that they should not
have linens with holes on the beds and they will be completing an overall inventory.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
105487
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
105487
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/29/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bay Breeze Senior Living and Rehabilitation Center
3387 Gulf Breeze Parkway
Gulf Breeze, FL 32561
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on observation, interview, and policy review, the facility failed to secure medications for 1 of 8
residents reviewed. (Resident #54).
The findings include:
On 2/27/24, an observation was made of Resident #54's room. The resident was lying on their right side,
facing away from the door, with a cup of unidentified medications sitting on the residents over the bed table
in a medication administration cup. Resident #54 stated the nurse just left them there.
(Photographic evidence obtained)
On 2/27/24 at approximately 10:25 am, an interview was conducted with Nurse A, a Licensed Practical
Nurse, who confirmed the medications on the over the bed table were Resident #54's morning medications.
Nurse A stated she left the medications because she needed to get the resident a protein drink and bring it
back to the resident. Nurse A went on to state that she was trying to finish up another resident's
medications then she was coming back to Resident #54. Nurse A confirmed she should not leave the
medications on the over the bed table and should stay with the resident while they took their medications.
On 2/27/24 at approximately 10:30 am, an interview was conducted with the Director of Nursing, who
indicated her expectation of nurses to stay with the residents and watch them take their medications and to
not leave them on the over the bed table.
Review of facility policy titled Administration of Drugs, dated October 2019, stated Policy: Drugs will be
administered in a timely manner and as prescribed by the resident's attending physician or the Center's
Medical Director. Under Policy Interpretation and Implementation: 8. Unless otherwise specified by the
resident's attending physician, routine drugs should be administered as scheduled. 9. The nurse
administering the drug must record such information on the resident's EMAR before administering the next
resident's drugs.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105487
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
105487
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/29/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bay Breeze Senior Living and Rehabilitation Center
3387 Gulf Breeze Parkway
Gulf Breeze, FL 32561
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 observations, interview and record review, the facility failed to maintain infection control practice
for 1 of 4 residents observed during medication administration observations. (Resident #60)
Residents Affected - Few
The findings include:
On 2/29/24 at approximately 9:17 am, an observation was made of medication administration to Resident
#60 by Nurse B, a Licensed Practical Nurse. Nurse B entered the room to administer medications but did
not place a barrier between the medication inhaler for Budesonide-Formoterol Fumarate Aerosol 165-4.5
micrograms (MCG), (a sterodial inhaled medication used to control Chronic obstructive pulmonary disease)
and the resident's over the bed table. After the medication was administered, Nurse B returned the inhaler
to the medication cart.
On 2/29/24 at approximately 9:20 am, an interview was conducted with Nurse B, who indicated that she did
not place a barrier between the inhaler and the over the bed table. Nurse B acknowledged that this was an
infection control issue.
On 2/29/24 at approximately 10:00 am, an interview was conducted with the Director of Clinical Services,
who stated his expectation was for the nurse to place a barrier between medications and the over the bed
table for infection control.
A review of the facility policy titled Administration of Drugs, dated October 2019, indicated, Drugs will be
administered in a timely manner and as prescribed by the resident's attending physician or the Center's
Medical Director . Policy Interpretation and Implementation: 18. Ensure all infection control practices are
followed during the administration of medications (i.e.: using a barrier for multidose medications, cleaning of
equipment/tools between residents, hand hygiene, exterior handling of containers, etc.).
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105487
If continuation sheet
Page 3 of 3
