Health inspection·January 12, 2023

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals were stored properly. Findings include: During an observation on 1/9/2023 at approximately 12:05 PM, there was a bottle of Tylenol and an inhaler in Resident #45's top drawer of bedside table. During an interview on 1/9/2023 at approximately 12:05 PM, Resident #45 stated that the nurse told her not to keep her medication out in the open but to keep it in her drawer. During an observation on 1/11/2023 at 8:40 AM, there was an unattended medication cup with approximately 10 pills on Resident #45's bedside table. There were a bottle of Tylenol and several loose blister pill-packs in the top drawer of the resident's bedside table. There were no staff members in sight. (Photographic evidence obtained). During an interview on 1/11/2023 at 8:45 AM, Staff C, Registered Nurse (RN), confirmed the medication left unattended at the bedside and in the resident's top drawer. Staff C stated that medications should not be left unattended and that the nurse who administered the medications was new, an orientee. During an interview on 1/11/2023 at 8:45 AM, Staff D, Licensed Practical Nurse (LPN), the orientee, stated that they had no residents currently in the facility that self-administered medication. Review of the facility policy and procedure titled Medication and Medication Supply Storage and Disposal, with an effective date of 11/30/2014 reads, Central storage of medications is required for prescription, prescribed over-the-counter medications and CAM (Complimentary and Alternate Medicine.) Will be kept in a locked area, in their original labeled contained and may not be removed more than 2 hours prior to the scheduled administration. Med will be kept in a medication cart that locks and keys are only accessible to the licensed personnel distributing medication. Page 1 of 2 105846 105846 01/12/2023 Baya Pointe Nursing and Rehabilitation Center 587 SE Ermine Ave Lake City, FL 32025

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 ensure staff followed appropriate infection control precautions during serving the meal trays to prevent the possible development and transmission of communicable diseases and infections. Residents Affected - Few Findings include: During an observation on 1/9/2023 at approximately 12:17 PM, Staff A, Certified Nursing Assistant (CNA), placed the lunch tray on the overbed table in Resident #31's room. Staff A touched the overbed table, the bed linens, and the resident's right arm, and then exited the room. Staff A did not perform hand hygiene after touching Resident #31's overbed table, bed linens and the resident. Staff A removed another lunch tray from the food cart for another resident. During an observation on 1/9/2023 at approximately 12:20 PM, Staff B, CNA, touched the hand grips on Resident #61's wheelchair and positioned the wheelchair. Then, Staff B touched Resident #61's overbed table to position the table in front of the resident. Staff B proceeded to set up Resident #61's food tray, and then exited the room. Staff B then removed a tray from the food service cart and placed the food tray on the overbed table in front of Resident #47. Staff B cut Resident #47's meat and then exited the room and walked to the food service cart. Staff B touched 4 lunch trays on the food service cart, then picked up the tray for Resident #59 and placed the tray on the resident's overbed table. Staff B adjusted the overbed table and exited the room. Throughout the observation, Staff B did not perform hand hygiene. During an interview on 1/9/2023 at approximately 11:25 AM, Staff B, CNA, stated hand hygiene should be performed after resident care and could not state any other time to perform hand hygiene. During an interview on 1/9/2023 at approximately 12:30 PM, Staff A, CNA, stated hand hygiene should be performed after every 2 residents when serving food and hand hygiene would be performed after resident care. During an interview on 1/9/2023 at approximately 12:42 PM, the Director of Nursing (DON), stated that staff should perform hand hygiene after every resident was served a meal, and wash hands after every 3 residents. Review of the facility policy and procedure titled Handwashing/Hand Hygiene dated August 2019 reads, Policy Interpretation and Implementation . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-microbial) and water for the following situations . b. Before and after direct contact with residents . p. Before and after assisting a resident with meals. 105846 Page 2 of 2