Health inspection·July 28, 2022

F 0656 - Hydroxyzine HCL 25 mg 1 PO x 8 hours PRN for itching. (6/23/2022). Level of Harm - Minimal harm or potential for actual harm Review of the progress notes dated from 4/8/2022 through 7/27/2022 revealed one note with documentation related to resident's forearms and read as follows. Nurse notes on 6/5/202, Pt has rashes on both arms which are not new. She scratched some areas on bilateral forearms. Cleaned with water and betadine. Bandages and a gauze wrap was applied supplied and labeled on both arms. Residents Affected - Few The skin assessment dated [DATE] indicated multiple closed scratch marks to BUE (bilateral upper extremities) and BLE (bilateral lower extremities). Receiving medication with good effect. Areas showing signs of improvement. No open spots at this time. There were no other skin assessments with documentation related to the scratches or scabs. On 7/27/2022 at 9:30 a.m., an interview with the Licensed Practical Nurse (LPN) Staff T revealed he was aware of Resident #29's upper arms scabbing and that things had been getting better. He also stated her arms were much worse in the past but did not give a specific timeframe. He indicated the resident she had a history of picking her arms. Staff T revealed he knew there was treatment to her right arm but could not provide any evidence for treatment for the left arm. He further indicated he would speak to Resident #29's Nurse Practitioner today (7/27/2022) to clarify the order. Staff T said the order was not clarified for Hydroxyzine HCL treatment for both arms. Staff T confirmed Resident #29 had a history of picking, but was unable to show documentation to support it. There were no nurse progress notes or care plans that indicated the resident picks at her arms, and no care planning problem area to support that behavior. On 7/27/2022 at 11:45 a.m., an interview with Resident #29's Nurse Practitioner revealed he had been treating her arms for what he believed to be Pruritis. He said there might be a neurological condition related to her picking at the areas and he would now order a psych consult to address it. Review of Resident #29's current care plans with a next review date of 8/7/2022, revealed the following areas: - ADL self care deficit r/t (related to) impaired balance, ROM (range of motion), history of fracture right ankle with interventions in place and as per observation - Does not cooperate with care r/t refusing meds at times with interventions in place as reviewed and observed There were no care plan problem areas related to either behaviors of picking, or treatment for arm rashes. On 7/28/2022 at 7:45 a.m., an interview with both the Assistant Director of Nursing (ADON) and Director of Nursing (DON) revealed they were aware Resident #29 had scabbing on her arms and the physician was treating the areas with ointment. They were not aware of the reason for the ointment until today (7/28/2022). After review of the electronic record they confirmed the resident has had this scabbing/itching since 6/5/2022. They confirmed the physician's orders for the current month of 7/2022 only indicated treatment for the right arm, and did not indicate treatment for the left arm. They confirmed the care plans with problem areas related to behaviors of picking were not developed. The DON and ADON did not know why the care plans were not developed, but confirmed that there should have been a care plan developed for either behaviors of picking or for skin conditions specific to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105786 If continuation sheet Page 2 of 9 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 105786 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayonet Point Health Center by Harborview 8132 Hudson Avenue Hudson, FL 34667 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 0656 rash/pruritis. Level of Harm - Minimal harm or potential for actual harm On 7/27/2022 the Director of Nursing provided the Comprehensive Resident Centered Care Plans policy and procedure, not dated, for review. Residents Affected - Few The Intent of the policy revealed: It is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service and intervention. It is utilized to plan for and manage resident care as evidenced by documentation from admission through discharged for each resident. The care plan will identify priority problems and needs to be addressed by the interdisciplinary team, and will reflect the resident's strengths, limitations and goals. The care plan will be complete, current, realistic, time specific and appropriate to the individual needs for each resident. It will be consistent with the medical plan of care and those disciplines that have direct involvement with the resident's care. The care plan will contain information about the physical, emotional, psychosocial, spiritual educational and environmental needs as appropriate. It is our (facility) purpose to ensure that each resident is provided with individualized, goal directed care, which is reasonable, measurable and based on resident needs. A resident's care should have the appropriate intervention and provide a means of interdisciplinary communication to ensure continuity in resident care. Procedure: (2.) The facility must develop and implement a comprehensive person centered care plan for each resident , consistent with the resident rights set forth at 483.10( c )(2) and 483.10( c )(3), that includes measurable objectives and timeframes to meet resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: (a) The services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well being as required under 483.24, 483.25 or 483.40. Developing the Care Plan: (3) Each discipline will check and / or add interventions/approaches to include but not limited to: (a) The intervention statements describe those measures performed by the staff to help the resident achieve the expected outcomes. (b) Interventional entries reflect activities that incorporate observations, assessments, management and teaching components that will restore, maintain and /or promote the resident's well-being. Updating Care Plans: (1) Care plans are modified between care plan conference when appropriate to meet the resident's current needs, problems and goals. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105786 If continuation sheet Page 3 of 9 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 105786 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayonet Point Health Center by Harborview 8132 Hudson Avenue Hudson, FL 34667 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 0656 (3.) The care plans will be updated and/ or revised for the following reasons: Level of Harm - Minimal harm or potential for actual harm a. Significant change in the resident's condition b. A change in planned interventions Residents Affected - Few c. Goals are obtained and new goals established to meet current resident needs and/or goals d. New diagnosis, new medications, or abnormalities (4.) Any revision, additions, or deletion to the care plan will be dated and initiated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105786 If continuation sheet Page 4 of 9 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 105786 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayonet Point Health Center by Harborview 8132 Hudson Avenue Hudson, FL 34667 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure behavior monitoring was in place for one (Resident #67) of three sampled residents on psychotropic medications. Findings Included: A review of admission records indicated Resident #67 was admitted on [DATE] with diagnoses including atrial fibrillation, unspecified dementia without behavioral disturbances, and alcohol abuse. A review of orders revealed an order for SEROquel Tablet 25 milligrams (mg). Give 25 mg by mouth at bedtime related to Unspecified .Dementia without Behavioral Disturbances. Start date: 01/04/22. Review of the electronic Medication Adminsitration Record (eMAR) and the electronic Treatment Administration Record (eTAR) for the months of May, June, and July of 2022 did not include any behavior or side effects monitoring for psychotropic medications. Resident #67's Minimum Data Set (MDS) dated [DATE] was reviewed. Section C. (Cognitive Patterns) revealed Resident #67 had a BIMS (Brief Interview for Mental Status) score of 1, which indicated severe cognitive impairment. Resident #67's MDS dated [DATE] was reviewed. Section N. (Medications) of the MDS indicated Yes-Antipsychotics were received on a routine basis only. Review of the care plan with a focus area dated 10/28/21 and revised on 07/27/22, revealed Resident #67 has cognitive deficits and mood disorder with episodes of unprovoked agitation, indifference, and poor decision making, leading to undesired behaviors .The goal dated 10/28/21 and revised on 07/27/22, revealed Resident #67 will be free from negative outcome related to (r/t) declination of medication .The interventions include .observe/report any change in condition (07/27/22) .A focus area dated 11/16/21 and revised on 07/27/22, revealed Resident #67 has impaired cognitive function/dementia and impaired thought processes r/t Dementia. The goal dated 11/16/21 and revised on 07/27/22, revealed Resident #67 will be able to communicate basic needs on a daily basis .No care plans were currently in place for behavioral monitoring or use of psychotropic medication. An interview was conducted on 07/27/22 at 9:24 a.m. with Staff B, Certified Nursing Assistant (CNA). She stated Resident #67 hollers out a lot and answers herself a lot. She noted Resident #67 has conversations with herself. Staff B said she usually reports changes in moods to the nurse. In an interview with the Director of Nursing (DON) conducted on 07/27/22 at 9:42 a.m., he stated the expectation for residents with Dementia taking antipsychotic medications was to have behavioral monitoring in place. Observed the DON look through Resident #67 orders to find an order for behavioral monitoring. The DON confirmed there was not an order in place for behavioral monitoring. Review of the Behavior and Psychoactive Management Problem under Facility's Behavior Management Program will consist of: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105786 If continuation sheet Page 5 of 9 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 105786 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayonet Point Health Center by Harborview 8132 Hudson Avenue Hudson, FL 34667 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 0758 Level of Harm - Minimal harm or potential for actual harm 3. Monitoring the resident's behavior(s) to establish patterns, determine intensity and behavior frequency, and identifying the specific (targeted) behavior(s) that are distressing to the resident which are decreasing the resident's quality of life. Under Behavior Management Team Care Process: Residents Affected - Few 1 .The behavior Management Team will effectively manage the psychoactive medication process for the residents by: d. Monitoring on a regular basis, and with change in the approaches implemented for effectiveness FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105786 If continuation sheet Page 6 of 9 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 105786 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayonet Point Health Center by Harborview 8132 Hudson Avenue Hudson, FL 34667 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 - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to follow their policy to 1. store medications appropriately in three of five (100-400 Hall) medication carts, failed to ensure controlled substances were appropriately stored in a locked drawer in one of two medications storage rooms (SSU Hall), and did not ensure expired tuberculin testing syringes were disposed of in one of two medication storage room refrigerators (100-300 Hall); 2. Failed to appropriately secure medications for two Residents (#67 and #334) of four residents. Findings included: A facility provided policy titled, Medication Storage, with no date, Page 01 of 01, was reviewed and read Policy: Medications must be stored in accordance with manufacturer's specifications and secured in locked storage areas in compliance with State and Federal requirements and accepted professional standards of practice. Access to medications is limited to only authorized personnel. Procedure: 1. Storage areas may include, but are not limited to, drawers, cabinet, medication rooms, refrigerators, and carts. 3. Schedule II-IV medications must be maintained in a separately locked, permanently affixed compartments or cabinets. 6. Prior to and after opening, all medications shall expire on the date specified by the manufacturer on the product label, unless the manufacturer has specifically indicated a shortened expiration once opened on the product label itself. 1. On 07/20/2022 at 3:10 p.m., an observation of the 400 Hall medication cart included in the second drawer from the top of the medication cart, two white round tablets, one half square white tablet, one quarter white tablet, and one round red tablet. Staff D, Registered Nurse (RN), confirmed the presence of the unsecured tablets. (Photographic Evidence Obtained.) On 07/27/2022 at 3:25 p.m., an observation of the medication the cart for 100-300 Halls included Twentyand one-half loose pills in the second drawer from the top of the medication cart, two loose tablets in the fourth drawer from the top of the medication cart, and in the third drawer from the top of the medication cart, three loose pills. Staff C, (RN), confirmed the presence of the unsecured medications. On 07/27/2022 at 3:48 p.m., an observation of the medication cart located on the 200-300 Odd Hall included one loose pink tablet in the second drawer from the top of the medication cart. Staff E, (RN) confirmed the presence of the unsecured tablet. An observation was conducted on 07/27/2022 of the medication storage room for 100-300 Halls. During the observation with Staff C, (RN) she confirmed the presence of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105786 If continuation sheet Page 7 of 9 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 105786 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayonet Point Health Center by Harborview 8132 Hudson Avenue Hudson, FL 34667 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 fifteen packets of Tubersol Injection 5/0.1 ML Tuberculin purified protein derivative (PPD) injections, that had various expiration dates in the refrigerator as follows: Level of Harm - Minimal harm or potential for actual harm (4) 7/19/2022 Residents Affected - Some (1) 7/22/2022 (1) 7/16/2022 (1) 7/15/2022 (1) 7/14/2022 (1) 7/15/2022 (6) 7/24/2022 During an observation on 07/27/22 at 04:30 p.m., of medication room (SSU Hall) with Staff F, (LPN), the lockbox, that was affixed to the refrigerator, was seen to be open and not locked. Staff F, (LPN) confirmed the presence of a small white box containing two vials of Schedule IV Narcotic medication of Lorazepam (Ativan) 2MG/ML in it. Staff F, (LPN) further revealed that the lockbox drawer should be closed for all controlled substances, and that he was not aware the lockbox was open. According to The United States Drug Enforcement Administration (DEA) drug scheduling alphabetical listing, dated July 25, 2022- List of Scheduling Actions, Controlled Substances and Regulated Chemicals (usdoj.gov), with URL link: https://www.deadiversion.usdoj.gov/schedules/orangebook/orangebook.pdf Page 11 of 19, Lorazepam (Ativan) DEA number 2885, is a Benzodiazepine, a Schedule IV medication and a considered a controlled substance. On 07/27/2022 at 4:54 p.m., an interview was conducted with the Director of Nursing (DON). During the interview the DON was informed of the fifteen expired (PPD) medications in one of two medication storage rooms and was shown the picture of it. He was also informed of observations of unsecured medications found in the three medication carts. The DON revealed that his staff had notified him of the loose medications prior to the interview. The DON stated, My expectation is that the refrigerator permanently affixed lockbox will be locked appropriately, all unsecured medications, and expired medications should be checked for daily by all staff. On 07/27/2022 at 5:15 p.m., an interview with the DON and Assistant Director of Nursing (ADON) was conducted. The DON revealed he removed the Scheduled IV narcotic medication from the refrigerator and placed it in a double locked drawer for disposal. He was replacing the medication and reordered from the pharmacy. The ADON stated We did not know about the issue of the drawer being broken in the lock box, and we will fix it. 2. An observation was made on 07/26/22 at 9:25 a.m. of a Nystatin Powder bottle in a basket on Resident #67's bedside table. Photographic evidence was obtained. An observation was made on 07/27/22 at 9:07 a.m. of a Nystatin Powder bottle in a basket on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105786 If continuation sheet Page 8 of 9 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 105786 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayonet Point Health Center by Harborview 8132 Hudson Avenue Hudson, FL 34667 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 bedside table of Resident #67. Photographic evidenced was obtained. Level of Harm - Minimal harm or potential for actual harm An observation was made of Staff A, Licensed Practical Nurse (LPN), on 07/28/22 at 9:13 a.m. looking into the basket on Resident #67's bedside table and pull the Nystatin Powder bottle out of it. Staff A stated the bottle of medication should not be in the basket. She said there was a Nystatin Powder bottle on the cart for Resident #67. Staff A stated Resident #67 did not have an order to self-administer the medication. Residents Affected - Some Review of Resident #67's admission Record revealed an admission date of 09/30/21 with a diagnoses of Atrial Fibrillation and local infection of the skin and subcutaneous tissue Unspecified. Review of Resident #67's orders revealed an order dated 06/22/22 for Nystatin Powder 10000 UNIT/GM to apply to abdominal folds topically every shift for abdominal fold redness. No documentation was found related to self-administering the medication. Review of the Minimum Date Set (MDS) dated [DATE] revealed in Section C. Resident #67 had a Brief Interview for Mental status (BIMS) score of 01, which indicated severe cognitive impairment. Review of the MDS dated [DATE] revealed in Section D. Resident #67 was rarely or never understood and a mood interview should not be conducted. Review of the admission Data Collection dated 09/30/21 revealed in Section O. Medication Review Resident #67 does not self-administer medications. 3. On 7/25/22 at 10:15 am, an observation was made of Resident #334 sitting in her room. During this time, a bottle of unsecured medication was observed on the bedside table. The medication was labeled [name brand], Natural laxative with an expiration date of 12/2021. (Photographic Evidence was taken). On 7/27/22 at 9:15 a.m., Resident #334 was observed relaxing in bed. The bottle of medication was still on the bedside table. She was asked if she used the medication. She stated her son brought it, but she never used it. On 7/27/22 at 9:40 a.m., an interview was conducted with Staff G, LPN. He explained that on admission, it is explained to the residents that outside medications are not allowed due to possible reactions with medications that the nursing home is giving or wandering residents that may take the medication. Staff G removed the medication and discussed the above procedure with Resident #334. (3) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105786 If continuation sheet Page 9 of 9