Health inspection·May 22, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observations, record reviews and interviews, the facility failed to follow the plan of care for 1 of 2 residents sampled for pressure injuries. (Resident #36) Residents Affected - Few The findings include: On 5/19/25, Resident #36 was observed lying in bed. There was no low air loss mattress in use. Further observations on 5/20/25 at 1:24 PM and 3:32 PM as well as on 5/21/25 at 8:45 AM and again at 11:40 AM revealed Resident #36 lying in bed with no low air loss mattress in use. On 5/20/25, a record review was conducted for Resident #36. The care plan, revised last on 7/1/24, contained skin impairment interventions which included the use of a low air loss mattress. (photographic evidence obtained). A review of the orders showed no physician orders for a low air loss mattress. On 05/21/25 at 09:49 AM, an interview with the Director of Nursing (DON) was conducted. The DON was asked who is responsible for ensuring care plans are implemented. The DON stated that Minimum Data Set nurses and clinical managers follow up on this. The DON stated the resident had been on a low air loss mattress but it was removed for cleaning and has not been placed back on the bed yet and acknowledged it was not on the bed at this time. On 5/21/25 at 10:01 AM, the Central Supply staff checked the mattress and stated it was a regular mattress. Page 1 of 2 105487 105487 05/22/2025 Bay Breeze Senior Living and Rehabilitation Center 3387 Gulf Breeze Parkway Gulf Breeze, FL 32561

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observations and interviews, the facility failed to maintain 2 of 3 garbage dumpsters located behind the facility for waste managment. Residents Affected - Few The findings include: On 5/19/2025 at approximately 10:40 AM, an observation was made of the 3 dumpsters located to the rear of the facility. This observation revealed that dumpster #1 was without a door on the side to secure the waste located inside the dumpster, which could lead to pests having access to the waste. Dumpster #3 was noted to have a rusted hole area to the right lower front corner. (Photographic evidence obtained) The Registered Dietician was interviewed during these observations. She indicated that she was unaware of how long the dumpsters had been in this condition. On 5/19/25 at approximately 10:58 AM, an interview was conducted with the Administrator, who indicated that she noted the door missing off the garbage dumpster last summer and had contacted the waste managment company, whom she did not get a reply from. The Administrator indicated that she would contact the waste management company to have the dumpsters replaced. 105487 Page 2 of 2