Inspection·June 23, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete on what she was doing. The male resident who was trying to get someone's attention continued through the meal by saying Ma'am, Ma'am, Ma'am. He was not approached by staff, even by 12:40 p.m. when the tray for the sixth resident was delivered. On 06/23/22 at 1:33 p.m., the surveyor interviewed the Director of Food and Nutrition Services about the meal service on the third floor. The Director of Food and Nutrition Services stated the facility just started the soup program (serving residents soup before their meal trays are served) to encourage residents to come to the dining room. The dining rooms on both the second and third floors reopened three weeks ago. The residents didn't want to come to the dining room before that for fear of catching the SARS-CoV2 virus. Since the dining rooms have reopened, the residents in attendance in the dining rooms have not been consistent from day to day. The surveyor requested a written facility policy about the tray service; however, the policy provided was not specific about the meal tray service. Event ID: Facility ID: 105650 If continuation sheet Page 2 of 20 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 105650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshore Pointe Nursing and Rehab Center 3117 W Gandy Blvd Tampa, FL 33611 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews, review of the Advanced Directive audit and review of the facility policy on Advanced Directives, and interviews with facility staff, the facility failed to ensure there was a physician's order for the code status of Do Not Resuscitate (DNR) and failed to ensure the DNR code status was reflected in the electronic medical record for two residents (#42 and #49) out of 27 residents reviewed in the initial pool. Findings included: 1. A review of the admission Record revealed Resident #42 was readmitted into the facility on [DATE] with the primary diagnosis of metabolic encephalopathy. Section C-Cognitive Patterns of the Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #42 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating cognitively intact. A review of the resident's Order Summary Report for June 2022 did not reflect an order for code status. A review of the Order Summary Report for discontinued orders for 05/01/22 to 06/30/22 revealed the following orders: DNR with an order date of 05/30/22, Full Code with an order date of 05/30/22. A review of the banner on the electronic medical record revealed the code status was not listed. A review of the documents listed under the miscellaneous tab on the electronic record revealed a State of Florida DNR Order form dated 12/31/21. Resident #42's care plan related to Advanced Directives (DNR) created on 05/26/17 revealed the following intervention: Ensure advance directives are accurate and up to date. Review at least quarterly. On 06/20/22 at 3:53 p.m., the Director of Nursing (DON) stated the banner in the electronic record should reflect the code status and the residents must have a physician's order for full code or DNR. She stated the agency staff does not always put the code status in correctly in the electronic medical record. The DON confirmed Resident #42 did not have a code status reflected on the banner and he did not have an order for a code status. She stated staff should look at the banner or the order if a resident was coding for the code status. She stated Resident #42 was discharged and readmitted on [DATE] and the order must have fallen off. The DON confirmed Resident #42 went to the hospital and upon return on 06/16/22 until now, the resident did not have an order for DNR. On 06/20/22 at 4:15 p.m., the Administrator reported audits related to code status were done weekly by social services. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105650 If continuation sheet Page 3 of 20 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 105650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshore Pointe Nursing and Rehab Center 3117 W Gandy Blvd Tampa, FL 33611 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 06/20/22 at 4:42 p.m., the Social Services Director (SSD) stated they run a report from their electronic medical record for the audits related to code status. She reported Resident #42 went to the hospital the week before and that was probably why the order fell off. The SSD reported she had initially uploaded the DNR form on 01/05/22 as it had been signed on 12/31/21. The SSD reported the resident had a code status of DNR since December. A review of the audit provided by the facility reflected a lot of empty lines indicating no information for many of the residents. She reported she did not know what happened because her assistant ran the audit report. She stated she did not know how the omission of the code status for Resident #42 was not picked up during the audit and confirmed Resident #42, at this time, did not have a code status. On 06/22/22 at 10:07 a.m., Staff A, Licensed Practical Nurse (LPN) stated she looks at the orders to look up a code status. On 06/22/22 at 10:08 a.m., Staff B, LPN stated she looks in the hard charts for code status. 2. A review of medical record indicated Resident #49 was re-admitted on [DATE] with diagnoses including end stage renal disease, atherosclerotic heart disease, anemia in chronic kidney disease and dementia with behavioral disturbances. When reviewing Resident #49's physical chart at the nurses' station, a yellow copy of a DNR order was observed as the front page of the chart. The DNR order was unsigned. (Photographic Evidence Obtained) There was no current DNR order in the resident's record. An interview was conducted on 6/20/22 at 3:50 p.m. with Staff D, LPN. She stated the nursing unit does not have a DNR book and each resident's DNR was kept on the front page of their physical chart. Staff D pulled a resident's chart and demonstrated the yellow DNR was found as the front page. An interview was conducted on 6/20/22 at 3:56 p.m. with the interim Director of Nursing (DON). The DON stated the yellow DNR form should not be in the resident's chart until it is signed. She confirmed this could cause confusion in a code situation. A review of the facility policy titled, Advanced Directives, review date of 5/24/16, documented the policy as, The resident has the right to accept or refuse medical or surgical treatment and, at the individual's option, formulate an advance directive. The procedure section revealed: 5. The attending physician must document in the medical record the discussion with the resident or surrogate regarding choices and decision of advance directives. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105650 If continuation sheet Page 4 of 20 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 105650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshore Pointe Nursing and Rehab Center 3117 W Gandy Blvd Tampa, FL 33611 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one resident (#22) out of 27 residents reviewed in the initial pool, received the necessary incontinence care to maintain personal hygiene. Residents Affected - Few Findings included: On 06/20/22 at 1:38 p.m., Resident #22 was observed in his room with a family member. Resident #22 was sitting in a reclining wheelchair. The family member was upset because the resident was wet and the floor was wet underneath the resident's wheelchair. The family member stated the resident was really wet today and she told the staff several hours ago that he was wet. The aide came and changed his roommate and then left. He was currently so wet, the floor beneath him was wet with urine. She just told another staff person that he needed to be changed and they got the Certified Nurse Aide (CNA) to change him. The family member said this doesn't happen very often. The family member seemed upset about the situation. A review of the admission Record showed the resident was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #22's diagnoses included the following: cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), congestive heart failure, chronic kidney disease, dementia with behavioral disturbance, anemia, polyneuropathy (a condition in which a person's peripheral nerves are damaged), anxiety, spinal stenosis (condition where spinal column narrows and compresses the spinal cord), muscle spasms, cognitive communication deficit, lack of coordination, legal blindness, Alzheimer's disease, history of falling, muscle weakness, unsteadiness on the feet, and abnormalities of gait and mobility. Resident #22 was an elderly person. According to Resident #22's most recent resident assessment, the Quarterly Minimum Data Set assessment (MDS), with an assessment reference date of 03/23/22, the resident had a short and long term memory problem, with severely impaired decision-making abilities regarding tasks of daily life, and had inattentive behavior that was continuously present and did not fluctuate. The assessment indicated Resident #22 required extensive assistance with toilet use with 2+ persons to physically assist and was totally dependent with personal hygiene with 1 person physical assist. The assessment also revealed Resident #22 was always incontinent of urine and frequently incontinent of bowel. The resident was identified as at risk for pressure ulcer development. Resident #22 experienced a decline in his urinary and bowel incontinence between the admission MDS with an assessment reference date of 10/22/21, and the Quarterly MDS of 03/23/2022. The comprehensive person centered care plan for Resident #22 with a focus area of incontinence initiated on 12/25/21, included the following interventions: monitor for infection, notify nursing if incontinent during activities, pericare as needed after incontinence episodes, and use disposable briefs. There was also a care plan focus area for Activities of Daily Living which included toileting, and the intervention included was total assist check and change. On 06/22/22 at 10:02 a.m., Resident #22 was in the TV room sitting at a table with three other residents. No odors or wetness was observed. On 06/22/22 at 1:17 p.m., Resident #22 was in his room with a family member. The family member said he has been clean and dry since she has been here. She did not visit yesterday. She said that the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105650 If continuation sheet Page 5 of 20 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 105650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshore Pointe Nursing and Rehab Center 3117 W Gandy Blvd Tampa, FL 33611 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 0677 Level of Harm - Minimal harm or potential for actual harm staff don't change him unless she asks them to when she visits and she has been there since this morning. Resident #22 did not have any signs of wetness or odor. On 06/23/22 at 8:25 a.m., Resident #22 was sitting behind the nurse's station. He had his eyes closed and appeared asleep. He was sitting in his reclining chair. There were no signs of wetness or odor. Residents Affected - Few On 06/23/22 at 12:14 p.m., the surveyor conducted an interview with the Director of Nursing (DON) and shared the observation of Resident #22 from the first day of the survey. The surveyor asked the DON about the documentation of the incontinence care the resident receives. The resident care plan was not specific to how often the staff should check and change and the DON was asked if there was documentation to show how often Resident #22 was changed. The DON printed the CNA Tasks from the electronic record showing the total # (number) of incontinent of episodes from 05/25/22 until 06/22/22. This information showed the resident was incontinent 1 to 6 times a day, with an average of 3.7 times per day for 26 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105650 If continuation sheet Page 6 of 20 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 105650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshore Pointe Nursing and Rehab Center 3117 W Gandy Blvd Tampa, FL 33611 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure there were no significant medication errors related to administration of insulin via an insulin pen for one resident (#32) out of one resident observed and out of eleven residents in the facility using insulin pens. Residents Affected - Few Findings included: An observation was conducted on 6/21/22 at 10:40 a.m. of Staff A, Licensed Practical Nurse (LPN) performing a blood glucose check and administering Insulin Aspart Solution to Resident #32. Staff A performed the glucose check indicating the resident had a blood glucose level of 201 and needed 4 units of insulin per her sliding scale orders. Staff A, LPN retrieved a new insulin pen from the medication storage room. The LPN opened, labeled, and dated the new insulin pen. She proceeded to put on the needle, turn the dial to 4 units of insulin, then administered the medication to the resident. The LPN did not prime the insulin pen before administration. A review of the admission Record indicated Resident #32 was admitted to the facility on [DATE] with diagnoses including Type II Diabetes Mellitus (DM) with diabetic neuropathy. A review of the Medication Administration Record for June 2022 showed physician orders for Insulin Detemir Solution 100 units/milliliter (u/ml) inject 10 units subcutaneously at bedtime related to Type II DM with diabetic neuropathy, and an order for Insulin Aspart Solution 100 u/ml to be injected subcutaneously before meals and at bedtime with a sliding scale. The sliding scale indicated for a blood glucose between 201-250 the resident should receive 4 units of insulin. An interview was conducted with Staff A, LPN on 6/21/22 at 11:00 a.m. Staff A, LPN stated she did not prime the insulin because it is a pen, and you don't need to. She explained to administer insulin using the pen, you attach the needle, turn the dial to the number of units you need to give, then give the insulin. She stated she doesn't ever prime an insulin pen before giving insulin, even if it is a new pen. She stated priming the pen would waste medicine. Staff A, LPN confirmed she has never primed an insulin pen before administering insulin to a resident. An interview was conducted with Staff D, LPN on 6/21/22 at 11:05 a.m. Staff D stated she primes insulin pens before every use. She stated she didn't know how many units to prime the pen with, but just does 2 units. An interview was conducted with the acting Director of Nursing (DON) on 6/23/22 at 9:50 a.m. The DON stated insulin pens should be primed before every use; that is the standard practice of administration for insulin pens. The DON stated an in-service has been done previously regarding insulin administration, but not specific to insulin pens. An interview was conducted with the facility's Staff Development Coordinator (SDC)/ Registered Nurse (RN) on 6/23/22 at 9:55 a.m. The SDC stated a poster titled, Using Insulin Pen Delivery Systems, was hung in the medication rooms on 5/12/22. She stated they didn't know of any issues, but corporate sent the posters and she thought they would be a great educational tool. The DON provided documentation from an in-service conducted on 5/12/22 for licensed nurses. The objectives for the in-service included: administer-insulin using an insulin pen. The poster, Using (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105650 If continuation sheet Page 7 of 20 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 105650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshore Pointe Nursing and Rehab Center 3117 W Gandy Blvd Tampa, FL 33611 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Insulin Pen Delivery System, was used as reference in the in-service. The poster specifies to prime pen to remove air bubbles and ensure needle is open and working. Staff A, LPN signed in for attendance at the in-service on 5/12/22. A facility policy titled, Medication Pass Guidelines, revised 4/25/17, was reviewed. The policy stated 2a. The nurse is responsible to read and follow precautionary or instructions on prescription labels. The facility did not have a policy specific to the use on insulin pens. The institute for Safe Medication Practices (ISMP) lists insulin (all formulations and strengths) as a high-alert medication in long-term care settings. High-alert medications are drugs that bear a heightened risk for causing significant patient harm when used in error (e.g., wrong drug, wrong dose, wrong route, wrong resident.) ISMP stated consequences of an error with these drugs are more devastating to residents. (https://www.ismp.org/recommendations/high-alert-medications-long-term-care-list) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105650 If continuation sheet Page 8 of 20 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 105650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshore Pointe Nursing and Rehab Center 3117 W Gandy Blvd Tampa, FL 33611 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, resident and staff interview, facility menu review and meal substitution log review, the facility failed to follow the planned menus. This has the potential to affect 80 of 85 residents who consume food in the facility, including one resident (#46) and occurred for 3 of 3 meals observed during the survey. Findings included: During the lunch meal observation on the first day of the survey, 06/20/22 at 12:29 p.m., the lunch menu posted on the wall across from the main dining room showed the following foods that were planned to be served: Smothered pork chop Herbed rice (initially was planned as macaroni and cheese, but was changed) Southern style collard greens Bread or roll Frosted cake. The facility week at a glanced menu signed by a dietitian reflected the same - smothered pork chop, herbed rice, southern style collard greens, bread or roll and butter or margarine. During the lunch service (6/20/22), plain, unseasoned white rice instead of herbed rice was served and the frosted cake was not served, but rather a yellow cake with strawberry sauce poured on the top was served. The facility week at a glanced menu signed by a dietitian included the following menu items to be served for breakfast on Wednesday, 06/22/22: Cheese Omelet Toast Hot or cold cereal Choice of juice Milk Coffee/tea/decaffeinated coffee. Observation of the breakfast tray line on 06/22/22 from 7:55 a.m. to 8:43 a.m., revealed there was no omelet prepared, but rather scrambled eggs with green pepper. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105650 If continuation sheet Page 9 of 20 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 105650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshore Pointe Nursing and Rehab Center 3117 W Gandy Blvd Tampa, FL 33611 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 0803 Level of Harm - Minimal harm or potential for actual harm Observation of the breakfast meal on the second floor on 06/23/22 at 9:19 a.m. revealed residents received scrambled eggs with green peppers, a waffle with syrup, a sausage patty, orange juice, and coffee. The posted menu indicated the following foods were to be served for breakfast: Scrambled eggs with onions and peppers Residents Affected - Some Hash browns Danish Hot or cold cereal. The facility week at a glanced menu signed by a dietitian included the following menu items to be served for breakfast on Thursday, 06/23/22: Scrambled eggs with onions and peppers Hash brown patty Danish Hot or cold cereal Choice of juice Milk Coffee/tea/decaffeinated coffee. An interview was conducted with Resident #46 on 06/22/2022 beginning at 9:35 a.m. The resident had a daily newsletter that had been delivered by activities on the table next to her breakfast tray. When the surveyor commented on the planned menu for lunch, the resident harrumphed and said the residents never received what was listed on that newsletter. (This resident's Minimum Data Set Annual Assessment, dated 05/02/2022, revealed her Brief Interview for Mental Status was scored at 15, indicating intact cognition.) On 06/23/22 at 1:33 p.m., the surveyor interviewed the Director of Food and Nutrition Services about the planned menus not being followed. He said one of his cooks quit that morning. The surveyor requested the menu substitution log for May and June 2022. He provided a menu substitution log for June 2022 later at approximately 2:20 p.m. The only substitution on the June 2022 log was for the cheese omelet for breakfast on 06/22/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105650 If continuation sheet Page 10 of 20 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 105650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshore Pointe Nursing and Rehab Center 3117 W Gandy Blvd Tampa, FL 33611 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on meal observations, test tray observations, resident interviews and record reviews, the facility failed to provide resident meals that were palatable, attractive, and/or at an appetizing temperature for eight residents (#39, #46, #65, #77, #86, #137, #6 and #240) out of eight residents observed at the meal or interviewed about the facility food. Residents Affected - Some Findings included: Seven residents expressed during interviews during the survey concerns with food that included food not served at an appetizing temperature and food that was unpalatable. An interview with Resident #39 on 06/20/22 at 10:54 a.m., revealed, Food is just not good, I have been here since 12/2021. I came here cause the therapy is great. Resident #46 on 06/22/2022 at 9:35 a.m. reported the food is usually cold, especially at night with lunch usually warm. When asked about the always available menu she reported she doesn't bother with it. The daily newsletter which listed the day's menus was reviewed with the resident. The lunch was to be spaghetti with meat sauce. The resident reported there was so little sauce on the spaghetti, which isn't usually cooked enough. She reported they rarely got what was listed on the newsletter. (This resident's Minimum Data Set (MDS) Annual Assessment, dated 05/02/2022, was reviewed and noted for a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition.) In an interview with Resident #65 on 06/20/22 at 2:07 p.m., she reported the food was terrible. She reported that she can't eat pork and they always send her a grilled cheese sandwich. She added that she ordered out a lot. (This resident's MDS Quarterly Assessment, dated 05/18/2022, was reviewed and noted to include a BIMS score of 15, indicating intact cognition.) In an interview with Resident #77 on 06/21/22 at 10:46 a.m., she reported the food is always cold and they waste a lot of food. I tell them only [Cereal Name] at breakfast, but they send me the whole plate. An observation at 9:10 a.m. on 06/21/22 of the resident's breakfast revealed she received a biscuit, bacon, scrambled eggs, and cold cereal. There was no margarine or salt and pepper and the resident only ate the cold cereal. (This resident's MDS admission Assessment, dated 06/05/2022, was reviewed and noted to include a BIMS score of 14, indicating intact cognition.) On 06/21/22 at 9:15 a.m. Resident #240 stated the scrambled eggs are always cold. Who wants to eat cold eggs. Don't get used to eating cold scrambled eggs. An interview was conducted on 06/22/22 at 1:15 p.m. with Resident #86 in her room. She was sitting up in bed watching TV. Her lunch tray was on the overbed table. It included noodles and a green vegetable. She stated that she ate only her chicken. The Registered Dietitian (RD) entered the room and asked the resident, How is the food? Resident #86 stated, not good and added that her (family member) brings in microwave meals. There were other packaged foods observed in the resident's room. Two test trays were conducted on the second and third floor for the breakfast meal on 06/22/22. The results of these test trays were as follows: The Director of Food and Nutrition Services checked the food temperatures in the kitchen with the facility's calibrated thermometer at 06/22/22 at 7:55 a.m. The scrambled eggs were 168 degrees (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105650 If continuation sheet Page 11 of 20 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 105650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshore Pointe Nursing and Rehab Center 3117 W Gandy Blvd Tampa, FL 33611 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Fahrenheit (F), the oatmeal was 210 degrees F, the sausage was 187 degrees F, the pureed eggs at 180 degrees F, and the grits were 161 degrees F. These foods were on the steam table. The Director of Food and Nutrition Services also checked the temperature of an individual pint of milk, which was stored in cold Cambro cooler containers at 8:05 a.m., and the milk was 42 degrees F. The individual serving of orange juice was 41 degrees F. The glasses of orange juice were not stored on ice or a cooling device and were dispensed before the meal from the juice beverage dispenser. The test tray for the second floor was assembled at 8:21 a.m. It was placed on the tray cart at 8:23 a.m. and taken up to the second floor by 8:24 a.m. At 8:25 a.m., the meal cart was delivered to the second floor and a call went out to staff - aides and management staff - that the trays were on the floor. Staff came running to deliver the trays from the cart which was at the end of the resident hall. Staff were observed walking the trays up the hall to the resident rooms. At 8:03 a.m. the nurse was observed at the coffee cart attempting to obtain a cup of coffee for a resident and she noted the coffee carafe was empty. Another nurse was overheard telling the nurse to call the kitchen. The nurse was observed on the phone with the kitchen for more coffee and after two tries she hung up at 8:39 a.m. and commented that no one was answering the phone. The last tray was served to a resident at 8:41 a.m. Trays delivered to the residents were noted to contain no condiments except one pc (personal container) of margarine. Residents were observed to move objects around on the trays looking for salt and pepper. Two surveyors tested the second floor test tray on 06/22/2022 beginning at 8:43 a.m. The temperatures of the test tray items were taken with the surveyor's calibrated stem thermometer. The milk tested at 52 degrees F, the orange juice at 50 degrees F, the eggs at 84 degrees F, the oatmeal served in a 4 ounce sloped sided dish tested at 112 degrees F, and the toast was at 80 degrees F. The china plate was noted to not have a base warming plate under it and had been covered with a domed lid to keep it warm. The plate itself was cool to the touch. There were no condiments on the tray, to include no salt, pepper, or sugar. There was also no straw to use or cup to empty the 8 ounce container of milk into. The top of the oatmeal was cracked and dried out and there was no room in the dish to pour milk over the oatmeal or stir sugar, if available, into it. The served meal was bland in color - with pale yellow eggs with bits of green pepper, brown topped oatmeal, and the one slice of toast was pale yellow from the margarine and slightly brown from toasting. One of the two surveyors tasted the meal and reported the oatmeal was bland without sugar or milk and the eggs were cold and lumpy with a strong flavor of green pepper and not much else. The toast looked somewhat appetizing as it had been cut into quarters and spread with margarine. However it was almost impossible to bite into it and pull the toast away for a small piece to chew. The surveyor's teeth marks were barely visible in the quarter of toast that she tested. Both the milk and orange juice were cool to the taste. Residents were interviewed as to their acceptance of the breakfast meal. Resident #137 was interviewed after receiving her breakfast tray on 06/22/2022 at approximately 8:50 a.m. and she reported (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105650 If continuation sheet Page 12 of 20 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 105650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshore Pointe Nursing and Rehab Center 3117 W Gandy Blvd Tampa, FL 33611 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some that she couldn't eat the one slice of toast that she received as it was too hard, and she doesn't eat oatmeal or drink orange juice, so the three slices of bacon she got would be her breakfast. She had not received coffee, even though her diet slip indicated her preferred beverages were apple juice and coffee. Resident #65, on 06/22/2022 at approximately 9:00 a.m., called over to her roommate when her roommate asked where her salt and pepper were for her eggs, to say - you won't get any, we never get condiments. On 06/22/2022 at 9:35 a.m. a visit was made to Resident #46 to inquire about her meal. She reported that she always asks for a breakfast sandwich and this morning it was a sausage patty between two pieces of toast. The resident referred to her plate of toast crusts with the middle pulled out of the pieces of toast. Resident #46 said she ate the sausage but she couldn't eat the toast - it was too hard. Findings of the third floor test tray for breakfast on 6/22/22 were as follows: The Director of Food Service checked the temperature of the eggs and oatmeal on the steam table again at 8:32 a.m. The eggs were 152 degrees F and the oatmeal was 187 degrees F. The third floor test tray was put on the cart at 8:43 a.m., and the cart was taken to the elevator at 8:47 a.m. The tray cart arrived on the third floor at 8:50 a.m. On 06/22/22 at 8:49 a.m. trays were served from the meal cart by one staff person in the 300 hall at 8:52 a.m. A few minutes later, additional staff started serving meal trays. At 9:10 a.m., a staff person was heard saying she had two residents to feed. The test tray was removed from the tray cart at 9:11 a.m. to test. The plate had an insulated dome lid, but no heated base or insulated base. The juice was served in a plastic cup and there was no glass for the milk in a carton. The food temperatures were taken with the facility's calibrated digital thermometer. The temperature and taste of the foods on the third floor test tray were as follows: The temperature of the scrambled eggs was 82 degrees F and barely warm to taste. The flavor was acceptable. The temperature of the sausage was 95 degrees and tasted warm, but not hot. The flavor was good. The buttered toast did not taste warm and was chewy (the toast temperature was not taken). The toast was barely toasted in appearance - pale in color. The temperature of the milk was 50 degrees F and tasted cold. The temperature of the orange juice was 55 degrees F and tasted cold. There were no condiments provided on the tray. Photographic evidence taken of the tray. On 06/22/22 at 1:57 p.m., the surveyor interviewed the Director of Food and Nutrition Services about the use of heated plate bases to keep the food hot. He said they have a plate base warmer but it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105650 If continuation sheet Page 13 of 20 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 105650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshore Pointe Nursing and Rehab Center 3117 W Gandy Blvd Tampa, FL 33611 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some had been broken since last Thursday night. He had put a work order in to get it repaired. The surveyor requested a copy of the work order. At 3:08 p.m., the Director of Food and Nutrition Services provided the work order for the plate base warmer and said that it would be fixed that day. During the breakfast meal in the restorative dining area on 06/23/22 between 8:30 a.m. and 9:00 a.m., the surveyor observed Resident #6 sitting at a middle table. The table was at practically the same height as the resident's chin. Resident #6 was in a reclining wheelchair and seated at a table with another resident. Resident #6's pureed diet was not attractive. The pureed food was thin and comingled with the other pureed food on the dinner plate. There was a circle of pureed white food around the edge of the plate with a circle of yellow pureed food (eggs?) and another circle of pureed white food in the middle of the plate. The surveyor was unable to take a photo of the food because the resident was eating at the time. On 06/23/22 at 8:13 a.m., the Director of Food and Nutrition Services told the surveyor the plate base warmer was fixed and the bases were heated; however, the kitchen staff weren't putting the bases under the plates on the meal trays. The kitchen staff were currently working on the first cart at the time for second floor. The surveyor interviewed the Director of Food and Nutrition Services on 6/23/22 at 1:33 p.m. and shared the resident food quality concerns and test tray findings. The Director of Food and Nutrition Services was newly hired. He said he conducts meal rounds twice a week, but had not conducted any food quality audits, nor could he find any past food quality audits that were conducted before his employment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105650 If continuation sheet Page 14 of 20 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 105650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshore Pointe Nursing and Rehab Center 3117 W Gandy Blvd Tampa, FL 33611 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, resident and staff interview, and menu review, the facility failed to ensure each resident received and the facility provided food that accommodated resident preferences and/or appealing options of foods with similar nutritive value to residents who had requested a different meal choice. This affected four residents (#37, #77, #86, and #137) out of 38 sampled residents. Findings included: Four residents expressed concerns during interviews throughout the survey about the inability to get alternate meal choices or have their preferences honored once they have been made known. On 06/20/22 at 11:07 a.m. Resident #37 stated he has tried to reach dietary (by phone) to make changes and he is unable to reach anyone. He stated his roommate has also tried because he needs his menu changed. He stated they have both tried multiple times over more than a week to call the number and no one answers. On 06/21/22 at 10:46 a.m. Resident #77 stated the food is always cold and they waste a lot of food. She reported they asked her what she wanted for breakfast and she has told them to only send [Cereal Name]. She said they send her the whole plate of food every morning. But she only eats the cold cereal. An observation at 9:10 a.m. on 06/21/22 of the resident's breakfast revealed she received a biscuit, bacon, scrambled eggs, and cold cereal. There was no margarine or salt and pepper and the resident only ate the cold cereal. The resident's diet slip was reviewed and noted to include preferences and dislikes for the breakfast meal, such as dislikes eggs and hot cereal and prefers bacon and cold cereal. (This resident's MDS admission Assessment, dated 06/05/2022, was reviewed and noted to include a BIMS score of 14 indicating intact cognition.) An interview was conducted on 06/22/22 at 1:15 p.m. with Resident#86 in her room while she was sitting up watching TV. Her lunch tray was observed on the overbed table. She had been served noodles with chicken and a green vegetable. She stated that she ate only her chicken. The Registered Dietitian (RD) entered her room during the interview and asked the resident, How is the food? Resident #86 stated, not good. She confirmed she was aware of the alternate choices but when she tries to call the kitchen they do not answer. Resident #86 stated, I tried to call them yesterday and they would not answer to change food items. During a visit to Resident #137 during breakfast, on 06/22/2022 at 8:40 a.m., she reported that she had not received coffee yet. Resident #137 confirmed she had received one slice of toast, which the resident pronounced as hard. She received three slices of bacon, which she was happy about. She received a small bowl of oatmeal with the top hard and cracked as it had not been covered and a small glass of orange juice. She had received no coffee, salt or pepper or sugar. Again, she commented that the diet slip lists apple juice and coffee as preferred beverages but received neither one. The facility 4 week cycle planned menu included menu items that were always available. These menu items included cottage cheese and fruit plate, chef salad with dressing, hamburger on a bun with lettuce, tomato and onion, chicken tenders, and a grilled cheese sandwich. The Activities Department delivers to every resident a daily newsletter that includes the lunch and dinner menu and daily activities and the number to call the Dietary Department if you want to make a change. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105650 If continuation sheet Page 15 of 20 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 105650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshore Pointe Nursing and Rehab Center 3117 W Gandy Blvd Tampa, FL 33611 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation of the breakfast meal on 06/22/22 from 8:43 a.m. to 9:19 a.m., and an observation of the breakfast meal on 06/23/22 beginning at 9:07 a.m. in the second floor restorative dining room and on the hallways and resident rooms, it was revealed that residents did not receive basic condiments such as salt and pepper or sugar packets for cereal with their meals. On 06/23/22 at 8:13 a.m., the surveyor interviewed the Director of Food and Nutrition Services about the inability of residents to request alternate always available foods. The Director of Food and Nutrition Services said when people call the kitchen number, the calls sometimes go to the front desk. He said he has given his cell number to some residents so they can make requests. On 06/23/22 at 8:52 a.m., the surveyor called the number to the kitchen from the 3rd floor nurses' station. The phone rang 15 times and there was no answer before finally hanging up. On 06/23/22 at 1:33 p.m., the surveyor informed the Director of Food and Nutrition Services Dietary the phone number to request alternate foods was called and the phone rang 15 times and no one answered it. The surveyor also discussed the lack of condiments on the resident meal trays. The Director of Food and Nutrition Services said they serve condiments like tartar sauce, etc. and beverage condiments are available on the coffee carts. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105650 If continuation sheet Page 16 of 20 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 105650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshore Pointe Nursing and Rehab Center 3117 W Gandy Blvd Tampa, FL 33611 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and review of cleaning schedules and policies, the facility failed to ensure two Time-Temperature Control for Safety (TCS) foods were not stored too long and that preparation and serving equipment was maintained in clean condition. Findings included: During the Initial Kitchen Tour on 06/20/22 at 9:37 a.m., there was an opened gallon container of garlic cloves stored in the walk-in refrigerator that was date-marked 06/3/22. The container was less than half full. This food was stored past 7 days. This was observed by two surveyors. At 9:49 a.m., in the reach-in refrigerator #1, there was prepared vanilla pudding stored in a clear container with a green lid that was date-marked 06/4/22. This food was stored past 7 days. (Photographic Evidence Obtained) This was observed by two surveyors and the Nursing Home Administrator. During a follow up kitchen visit on 06/22/22 at 2:26 p.m., the shelf over the steam table had an accumulation of food splatter on the underside, which was directly over the steam table pans. (Photographic Evidence Obtained) There was also a clean large white cutting board with several black smudges on it stored on a rack with other cutting boards. (Photographic Evidence Obtained) The Director of Food and Nutrition Services was present at the time and took the cutting board to throw it away. During an observation of the lunch meal on 06/20/2022 beginning at 12:00 p.m. in the second floor dining room, the steam table was noted to be in use. A metal pot of soup was sitting in a steam table pan that had been placed in one of the wells, and a tray of small four ounce bowls had been placed next to the soup pot. The well under the soup pot had not been turned on to ensure the soup remained hot and within appropriate holding temperatures. The metal edging around the steam table wells was noted to be sticky with spilled, dried on food material and with crumbs along the entire length of the steam table. All four wells of the steam table contained approximately two inches of cloudy water. In addition, a shelf was observed below the level of the wells where the soup pot was sitting. A circular cheese puff snack (approximately 1 across) was noted next to a small clear glass. (Photographic Evidence Obtained) An observation again on 06/22/2022 at 9:15 a.m. revealed no one had cleaned the shelf and removed the cheese puff. An interview with the Maintenance Director and Housekeeping Supervisor at that time revealed the dietary department had the responsibility to maintain the steam table in a clean manner. 06/23/22 at 1:33 p.m., the surveyor interviewed the Director of Food and Nutrition Services about the identified concerns. The surveyor requested the kitchen cleaning schedules and written facility policy about food storage. About an hour later, the Director of Food and Nutrition Services provided the cleaning schedules and the policy. The facility Food Storage Principles policy, revised 06/18/2018, included the following: Purpose: To preserve food quality before and after food is prepared. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105650 If continuation sheet Page 17 of 20 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 105650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshore Pointe Nursing and Rehab Center 3117 W Gandy Blvd Tampa, FL 33611 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 0812 Level of Harm - Minimal harm or potential for actual harm Fundamental information: Proper food storage is essential for preserving food quality. This applies to foods stored prior to preparation, and also to prepared foods (leftovers) that are placed in storage. Storage factors that impact the preservation of quality include holding period. Procedure - Residents Affected - Some . 3. Label each package, box, can, etc., with the date of receipt, and when the item was stored after preparation. a. Discard foods that have exceeded their expiration date. b. Discard leftover foods that have not been used within 72 hours of preparation . 5. Label opened food items with Date Opened 6. Follow food storage principles and guidelines of refrigerated and frozen foods . The daily cleaning schedule reviewed included steam table and tray line to be cleaned after each meal by a dietary aide, and cutting boards to be cleaned after each use by a dietary aide. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105650 If continuation sheet Page 18 of 20 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 105650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshore Pointe Nursing and Rehab Center 3117 W Gandy Blvd Tampa, FL 33611 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 observation, interview and record review the facility failed to follow infection control practices related to include hand hygiene and the cleaning and disinfection of a glucometer for one (Resident #68) of three sampled residents. Residents Affected - Few Findings included: An observation was made on 06/20/22 at 11:35 a.m. of Staff C, Licensed Practical Nurse (LPN) performing a blood glucose check on Resident #68. Staff C, LPN was sitting at the nursing station and walked to the medication cart and was observed to don gloves without performing hand hygiene. She was observed to open the medication cart and remove a glucometer and lay it on top of the medication cart. She removed glucometer strips from the top drawer and inserted one into the glucometer. She removed a lancet and alcohol wipes from the medication cart. Then, the nurse and surveyor went into Resident 68's room and the nurse was observed to place the glucometer and lancet on a washcloth on the resident's bed. With her same gloved hands the nurse used an alcohol wipe to clean the middle finger of the resident's left hand. The nurse used the lancet to poke the resident's finger and then placed a drop of blood onto the glucometer strip. The resident's blood sugar reading was 163. Staff C was observed to remove her gloves and leave the room with the used glucometer after placing the lancet in the biohazard box in the room. The nurse was observed to use hand sanitizer on her hands while holding the glucometer in her hands. She laid the used glucometer on top of the medication cart. She began cleansing the glucometer with alcohol wipes. She then re-laid it on top of the medication cart. The resident required no insulin coverage. Immediately following the observation this surveyor then reviewed the observation of the use of blood glucose monitor for the resident with the Infection Control Officer (IFC) and Staff C. The IFC stated they were not to use alcohol wipes to clean the glucometers post use. He stated the staff was supposed to hand sanitize before donning and after doffing gloves. He stated she (Staff C) should have hand sanitized before the procedure, donned gloves, and prepared the glucometer. She should have placed all the supplies on/or in a barrier. She should have removed her gloves and hand sanitized. She should have taken the supplies into the room and placed them on a barrier and hand sanitized and don gloves. She was to perform the glucose monitoring and remove her gloves and hand sanitize. She should have donned gloves and taken the dirty glucometer to the medication cart. She was supposed to use bleach wipes and allow the glucometer to remain wet for three minutes. She then can remove her gloves and hand sanitize and replace in the glucometer into the medication drawer. The IFC reviewed the process with Staff C after the glucometer procedure and stated he was going to educate the whole building. Record review of facility's policy titled, Glucometer Skills Competency-Observation Required, not dated, showed: Cleaning and Disinfecting: 1. washed hands with soap and water 2. Dried thoroughly. 3. Applied gloves. 4. Assembled equipment and place on barrier (BGM and Germicidal Wipe). 5. Cleaned the Blood Glucose Meter (When visibly soiled). 6. Wiped all external areas of the meter until visibly clean. 7. Avoided wetting the meter test strip port. 8. Disinfected the Blood Glucose Meter (Before storage and after each use). 7. Disinfected the Blood Glucose Meter with germicidal wipe. 8. Placed Glucose Meter on a clean barrier. 9. Allowed Glucose Meter to air dry for a FULL 3 minutes on the Clear Barrier. 10. Removed Gloves. 11. Performed hand hygiene. 12. Able to verbalize to always refer to and follow Manufacturer's recommendations for usage, cleaning, and disinfection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105650 If continuation sheet Page 19 of 20 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 105650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshore Pointe Nursing and Rehab Center 3117 W Gandy Blvd Tampa, FL 33611 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of facility's policy titled, Guidelines for Cleaning and Disinfecting Blood Glucose Meter, not dated, read: 1. wash hands with soap and water and dry thoroughly. 2. apply gloves. 3. assemble equipment and place on barrier, blood glucose meter and germicidal wipes. 4. cleaning the blood glucose meter (when visibly soiled. clean the meter with a germicidal wipe, wipe all external areas of the meter until visibly clean, avoid wetting the meter test strip port. 5. disinfecting the blood glucose meter (before and after each use). disinfect the meter with a germicidal wipe, place glucose meter on clean barrier and allow to air dry for full 3 minutes, remove gloves an perform hand hygiene. Record review of the facility's policy titled, Infection Prevention and Control Program, revised October 2018, showed: 11. Prevention of Infection a. Important facts of infection prevention include: (3) educating staff and ensuring that they adhere to proper techniques and procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105650 If continuation sheet Page 20 of 20