Inspection·September 8, 2023

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Focus area: Resident has impaired cognitive function/impaired thought process, impaired safety, and communications deficits related to the progression of dementia. Interventions included: Communicate with family care givers regarding resident's capabilities and needs; Cue, reorient and supervise as needed; Engage resident in simple, structured activities; Keep routine consistent and try to provide consistent care as much as possible. Focus area: Discharge plan (initiated on 10/09/20) Resident in need of long-term care due to the level of care required. Goal: Resident will be able to verbalize/communicate required assistance post discharge and the services required to meet needs before discharge. Interventions included: (11/18/20) Apply for benefits for coverage of skilled nursing; Encourage family to bring in items from home to provide resident with familiar objects to encourage adjustment and ease transition; Observe resident for any adjustments issues related to long term care placement and refer for psychological/psychiatric services as needed. A review of a Physician note, dated 08/28/23, showed the following: Patient seen today for follow -up visit. She is sitting up in her wheelchair, . She currently does not appear to be in distress and denies any medical concerns. No concerns per nursing staff at the time of visit. Patient moving to ALF this week. Patient will benefit from hospital bed for repositioning assistance due to dementia, wheelchair dependency and deformity of neck. A review of a Psychiatry note, dated 7/13/23, showed, The patient is a long-term resident . She is very particular to share her room with roommates. The patient was seen as a follow -up. Patient is in private room and no incidents have been reported. As per the collected information and interview, it appears that the patient is stable with psych therapy at this time. The patient appears calm and in good mood. No distress. Appetite and sleep is adequate. As patient is doing well, no medication changes are need. A review of a Psychiatry note, dated 06/12/23, showed [Resident #5] had a history of dementia, delirium and anxiety, cognitive communication disorder. Alert with confusion and forgetfulness. Able to make needs known. Her speech is clear . Patient started on Trileptal on 05/05/22 due to poor impulse control, hoarding and tearfulness with positive results. She is very particular to share her room with roommates. Patient is being seen today 6/12/22 per request via telehealth according to staff, the patient reports her new roommate hit her back. No injuries were reported. Residents were transferred to another room . Assessed the patient sitting up. Reports feeling good at this time, patient is unable to recall incident due to dementia. No signs of psychosocial distress were noted. A review of progress notes for Resident #5, dated 9/1/23 9:50 a.m. showed The resident was discharged to [name of facility], via wheelchair, via [name of company] transportation. In no distress, escorted by [family member]. A review of and IDT note for Resident #5, dated 06/13/23, showed Resident out of bed in wheelchair, self-propels in room and in hallways. Resident went to room [ROOM NUMBER] B side of room, and it was reported by roommate that this resident hit roommate two times on the right shoulder blade and propelled self out of room. Skin check completed on this resident and there were no abnormal findings. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105650 If continuation sheet Page 2 of 8 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 09/08/2023 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 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of a nurses' progress notes for Resident #5, dated 06/12/23, showed Reported that this resident hit her roommate on the back. 'I didn't hit her' reported to Social Worker, DON (Director of nursing), and resident's family member. A review of a nursing progress note, dated 06/5/23, showed Spoke with Resident's [family member] to review information from last week's care plan. [Family member] stated she was very pleased with the care Resident #5 was receiving. A Care plan meeting note held via IDT (inter Disciplinary Team), dated 05/31/23, showed Neither resident nor family were in attendance. Per social services resident continues with potential for hoarding and wandering behavior, poor impulse control and physically/verbally abusive behavior but has not displayed any behaviors within the last quarter. She continues to receive psychoactive medications w/o (without) adverse effect. A review of care plan meeting notes dated 5/31/23, 3/28/23 and 3/1/23, showed Resident #5 Has not displayed any behaviors lately. Family expressed appreciation for care received and stated, 'I love everyone here, it's great.' On 09/07/23 at 12.56 p.m., an interview was conducted with Staff A, Certified Nursing Assistant. She said, Resident #5 was awesome, she was never angry. She did not look happy when she left. The [family member] was not happy either. It is not what they wanted. She did not want a roommate. We tried different people. I miss her. Staff A stated she heard the resident was in an altercation with another resident who was in her room. Staff A stated the resident was normally confused and thought people were in her house or stealing her things. Staff A said, She could not handle roommates. Everyone knew that. It was sad how she left. On 09/07/23 at 1:00 p.m. an interview was conducted with Staff B, CNA. He stated, She [Resident #5] was very pleasant. She roamed the facility. She did not bother anyone. I never heard she wanted to leave. Staff B stated the family member would visit quite often and she appeared happy with the placement. On 09/07/23 at 1.03 p.m., an interview was conducted with Staff C, CNA. She stated she remembers the resident. Staff C said, She was sweet, ambulated up and down halls all day. She liked to sing. I did not know she was leaving. I reported to work after a couple days off and found she was gone. I heard she went to an ALF. On 09/07/23 at 1:14 p.m., an interview was conducted with Staff D, CNA. She said, I remember her she spoke Spanish, she liked to dance, she didn't like cold food, she dressed up all the time, she was kind of a Diva, she was funny had no issues. Staff D stated she never heard the resident had hit another resident. She said, Not that I recall. She liked her space. I don't know why she left. I don't remember hearing she was leaving. I came in after a day off and heard she went to an ALF. Her [family member] visited quite often. She would calm her down if she was upset. She liked it here. Staff loved her too. On 09/07/23 at 1:45 p.m., an interview was conducted with the Social Services Director (SSD). The SSD stated Resident #5 transferred to an ALF per family request. He said, I came in on the tail end of it and helped facilitate her transfer. I set up her paperwork and she left. I did not get to know her. My understanding was that the [family member] was trying to get her to an ALF. The other SSD who no longer works at the facility handled this case. The SSD stated he was made to understand the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105650 If continuation sheet Page 3 of 8 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 09/08/2023 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 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident's family member was taking her to the other facility of her own choice. The SSD stated a typical discharge planning process starts on admission. It involves getting with family, finding out if they have community services, schedule follow -up, get orders to the facility home health care, arrange transportation and start discharge planning. He stated if a resident was a long-term resident, they would review plan to remain at the facility during care plan meetings and address any needs or update changes. The SSD said, I was not here when the planning started. I did not hear about the incident with another resident until much later. Just caught the end of it. My assistant was here. On 09/07/23 at 2:16 p.m. an interview was conducted with the Assistant Social Services Director (ASSD). She stated she knew Resident #5 quite well. She stated every time she got a roommate, there was an issue. The ASSD stated there was one roommate whom she would try and dress and feed. She wanted to take care of her. Another roommate was alert, she would remove her clothes from her side and move them to her own side and yell at her. she would get upset with housekeeping for touching her stuff. She did not want people in her room. This was an on-going thing. The SSD said, I remember my supervisor talking about her. She had a roommate who reported she was in her wheelchair and was facing the window and she apparently hit her twice. She yelled at her and then rolled herself out of the room. We reported the incident. Her care plan was updated related to potential to be aggressive. The issue of her not liking roommates was part of the discussion during meetings. I spoke with the [family member] about it. I forgot to put a note in. I dropped the ball on that. The SSD stated the resident was transferred because, We could not put another person in the room with her. We had to find another placement for her because we could not really meet her needs. The ASSD confirmed the discharge was a facility-initiated discharge because they could not meet her needs. The ASSD stated the option to offer Resident #5 a private room even if she was to self-pay was never discussed. The ASSD said, No, I don't know to my knowledge why this was not offered. We did not offer her a private room. It was never discussed in care plan meetings. On 09/07/23 at 2:36 p.m., an interview was conducted with the [NAME] President(VP) and the Regional Director of Clinical Services (RDCS). She stated they had received a letter from Resident #5's family member. The RDCS said, It was appalling to read her experience She stated they had gotten a 30-day notice to find a place because she could not be cared for here. The [family member] apparently found a secured unit. The problem was the NHA was new. She was depending on the Director of Nursing (DON) at the time. They did not follow protocol. They did not run the discharge through the VP per policy. The VP and I did not find out until yesterday. The resident is in a worse situation. She is in a room with 4 people. The RDCS stated they were working on readmitting the resident. The VP said, We can meet her needs. This was not a family-initiated discharge. It was facility initiated. It was not conducted per our policy, and we intend to fix that as soon as possible. On 09/8/23 at 09:39 a.m., a follow -up interview was conducted with the SSD and the ASSD. The SSD stated the NOMNC (Notice of Medicare Non-Coverage), and transfer discharge notices were not issued. The SSD said, From what I heard, the [family member] initiated the transfer. I have become aware this week that this was a Facility initiated discharge. It should have been handled differently. On 09/08/23 at 11:35 a.m., an interview was conducted with the Nursing Home Administrator. She stated the facility was working on a discharge plan according to the previous leadership. She said, They were working on finding placement for her. I never spoke to the family member. On 6/12/23 she had an incident. Another resident was admitted to the same room as her. The census was high. We used her room in error. We should not have put another resident in the room. The new resident said [Resident #5] hit her on the back. We removed the new admission. We reported the incident to law enforcement and [state agency]. They did not accept. The NHA said, I failed. I should not have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105650 If continuation sheet Page 4 of 8 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 09/08/2023 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 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few listened to the DON without fact-finding. I should have looked into it. I did not know the resident's [family member] was trying to get in touch with me. It hurts that she feels the facility failed them. It is not our standard of operation. We will do better. A review of a facility policy titled, Pre and Post Discharge Plan of Care, effective 10/24/22, revealed the following: Policy Pre-discharge Planning will be coordinated by the Social Services Development for the development of post-discharge plan of care. Discharge planning process: The center must develop and implement an effective discharge planning process that focuses on the resident's discharge goals and preparing the residents to be active partners in post-discharge care, effective transition of the resident from SNF [Skilled Nursing Facility] to post-SNF care, and the reduction of factors leading to preventable readmissions. Fundamental Information The Social Service Director or designee coordinates discharge plans through the pre-planning discharge process with the assistance of the IDT [Interdisciplinary Team] members. The post-discharge plan of care is required for the following types of transfer or discharge: 1-discharge due to the fact that the resident's health has improved significantly enough they no longer require services by the center; 2-if there was a pre-determined plan for discharge upon admission for the resident to return home or to a less restrictive environment; 3-discharge is necessary when a resident's welfare or needs can no longer be met by the center; 4-discharge is necessary when the safety of other individuals in the center would be endangered otherwise should the resident not be transferred. I. The center's discharge planning process will1. Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident. 2. Include regular reevaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes. 3. Involve the IDT in the on-going process of developing the discharge plan. 4. Consider caregiver/support person availability and the resident's or caregiver's/support person's capacity and capability to perform required care, as part of the identification of discharge needs. 5. Involve the resident and resident representative in the development of the discharge plan and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105650 If continuation sheet Page 5 of 8 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 09/08/2023 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 0622 inform the resident and the resident representative of the final plan. Level of Harm - Minimal harm or potential for actual harm 6. Address the resident's goals of care and treatment preferences. .9. Document complete on a timely basis based on the resident's needs and include in the clinical record . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105650 If continuation sheet Page 6 of 8 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 09/08/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure medications were administered as ordered for one resident (#3) out of two residents reviewed for medication administration. Findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses to include encounter for surgical aftercare following surgery on the digestive system, and obesity. A review of a Physician Order Summary report, date range 07/26/23 - 07/31/23, revealed the following orders: Levothyroxine Sodium oral tablet 75 MCG (Micrograms) Give 1 tablet by mouth in the morning for low thyroid with start date: 7/27/23. Enoxaparin Sodium injection (Lovenox) solution prefilled syringe 100 mg/ml (Milligram/Milliliter). Inject 1 application subcutaneously two times a day for DVT (Deep Vein Thrombosis) for 14 days with a start date: 7/28/23. A review of the Medication Administration Record (MAR) for Resident #3 showed the resident did not receive her injection 1 out 8 ordered administration times. Medication administration of Sodium injection (Lovenox) solution prefilled syringe 100 mg/ml was missed as follows: 07/29/23 Prior (p.m.) Lovenox injection was not administered. A review of MAR showed on 7/29/23, the resident did not receive her Levothyroxine Sodium oral tablet 75 MCG (microgram). Give 1 tablet by mouth in the morning for low thyroid. The record did not indicate why the medications were not administered as ordered. On 9/7/23 at 2:05 p.m. an interview was conducted with the Regional Director of Clinical Services (RDCS). She stated Upon means upon rising or morning dose and Prior means prior to bedtime or evening dose. She stated the times were adopted for their liberalized medication pass. On 9/8/23 at 2:45 p.m. a follow -up interview was conducted with the RDCS. She reviewed Resident #3's MAR a stated there was no good reason why the resident did not receive her injections. She said, I'm looking at this and there was no good reason. We will educate immediately. The least would be to document why the medications were missed. There is no good explanation. On 09/8/23 at 11:13 a.m., an interview was conducted with the Director of Nursing (DON). She stated the resident's should receive medications as ordered. The DON stated the nurse should notify the physician of any missed doses. The DON stated if medications were not administered for one reason or another, it would be documented. A review of a facility policy titled, Medication Pass Guideline, dated 04/25/27, revealed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105650 If continuation sheet Page 7 of 8 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 09/08/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few following: Purpose: To assure the most complete and accurate implementation of physicians' medication orders and to optimize drug therapy for each resident by providing for administration of drugs in an accurate, safe, timely, and sanitary manner. To systematically distribute medications to residents in accordance with state and federal guidelines. Fundamental Information: Physician orders--Medications are administered in accordance with written orders of the attending physician. Documentation: Record the name, dose, route, and time of medication on the Medication Administration Record. Initial the record after the medication is administered to the resident. Record the reason for not administering if not administered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105650 If continuation sheet Page 8 of 8