Inspection·July 7, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few additional information on the Change in Condition): Notified MD [Medical Doctor], no new orders, informed him that family chose to take resident to ER [Emergency Room] in Gainesville. Review of the nursing progress note authored by Staff B, Registered Nurse (RN), dated 6/4/2023 at 5:33 PM for Resident #1 read, Resident stated that the night nurse had given her the wrong insulin. She stated that she told the nurse that it was the wrong insulin before the nurse gave it to her. Resident then complained of having chest pains and a stomachache around 0800 [8:00 AM]. I checked the residents [Sic.] blood sugar and it was 301. The residents [Sic.] daughter called facility upset and stated that no one notified her of the medication error and that she was going to come take her mother to [hospital's name and city of location] because she is too high risk to go to [local hospital's name]. The daughter told me to not give her mother anymore insulin or medication until she takes her to [hospital's name]. The daughter also stated that she was going to call the police and her attorney. At approximately 1130 [11:30 AM] the daughter arrived with a police officer [Resident #1's name] walked out of the facility with her daughter at approximately 1200 [noon]. During an interview on 6/19/2023 at 11:00 AM Staff I, Director of Nursing (DON) stated, This [medication error] was not reported to the physician when this occurred by the night nurse at 6:15 AM. It was not reported until about 11:30 in the morning. She came back in when [Assistant Director of Nursing's name] got hold of her. The staff should have called the doctor when the mistake occurred and obtained orders then. I can't tell you why she didn't. I'm not sure when the day shift nurse found out about the error. They just don't know or have any common sense that would make them call the doctor. They clearly don't understand the difference between long and short acting insulins. I guess we need to train them. During an interview on 6/19/2023 at 11:41 AM, Staff A, LPN, stated, I was helping out that night. I usually work days and usually work the LTC [long term care] unit and picked up a shift. I read her order and she had two different insulins. One insulin looked like it was in the wrong bag. I thought it was too much insulin, I gave it, the long acting the Lantus. Then I reread the order after the resident told me she didn't get that kind until the night. After that I just waited for the day nurse. I did not notify the doctor. I guess I just didn't think it was necessary and then I spoke with the day nurse, and she didn't say to call the doctor. She said, well we will just wait and see what her blood sugar does. I should have called. [Assistant Director of Nursing's name] messaged me and asked about it. I told him what happened and came in to write the progress note and I called the doctor then. I explained what happened. He did not give any new orders because the resident was leaving with her daughter, who was taking her to the hospital. I did tell the oncoming nurse and she didn't seem too concerned because it was a long-acting insulin. She did not tell me to call the doctor before I left. The resident said to me after I told her what I administered that she took that [Lantus insulin] at night not in the morning. I double checked the MAR and saw she was right. She had been given her Lantus the evening before. I just didn't think about it at all. During a telephone interview on 6/19/2023 at 11:50 AM, Staff B, RN, stated, I came on shift and the night shift nurse told me she had given the wrong insulin. I didn't tell her to call the doctor, said she notified him. At about 8 AM [Resident #1's name] was going to breakfast, and she told me about the med error. At that time, she was complaining she was weak and had a stomachache. I didn't check her blood sugar then; she was going to eat, and I told her if she didn't feel better to let me know. When she was coming back from breakfast, she was still feeling that way, so I got her to lay down. I went to do something else with another resident and then her daughter was on the phone, and I spoke to her. She was very upset, so I talked to her. After I got off the phone, I checked her insulin, and it was 301 at that time. After that, I spoke with her daughter and her daughter insisted I not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105846 If continuation sheet Page 2 of 36 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 105846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baya Pointe Nursing and Rehabilitation Center 587 SE Ermine Ave Lake City, FL 32025 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few give her anything more and stated she would take her to the ER because she didn't want her to go to anywhere but [hospital's name]. She told another nurse she was having chest pain sometime around then, but I wasn't worried about chest pain. I don't know why. I guess because her daughter was going to take her to the ER. I did not call the doctor about the chest pain or any other symptoms that she had. I should have called him. He was going to send her out and they would take her to [hospital's name] and I knew her daughter didn't want her to go there and so I just didn't think to call and notify him. I did not think to call 911 and let the resident or daughter refuse to go to the hospital. I should have. During a telephone interview on 6/19/2023 at 12:10 PM, the MD stated, I was not notified of this error when it occurred. I absolutely should have been notified and I would have ordered more frequent blood sugars to determine if there was a pattern of hypoglycemia [low blood sugar] and we would have been able to treat any potential hypoglycemic events. I was not aware that she had any episodes of chest pain or pressure, fatigue or abdominal discomfort. Again, I should have been notified and I would have had them send her to the hospital. During a telephone interview on 6/19/2023 at 12:30 PM, Resident #1 stated, I was having chest pain, sweating, and nausea when I left [NAME] Pointe because I was given the wrong insulin. So, my daughter brought me to [hospital's name] ED [Emergency Department]. I am still in the hospital now. But I'm not feeling too good. I don't think that my blood sugar was too low when I got to the hospital. I told them that they were giving me the wrong kind of insulin, but they didn't listen. They did not check my blood sugar after they did that. I told them when I went to breakfast that I wasn't feeling good, but they didn't listen. After breakfast, I told them again that I was having chest pains and feeling dizzy and nauseous, but they didn't listen until my daughter called. After that is when they checked on me. During an interview on 6/19/2023 at 1:41 PM, the Assistant Director of Nursing (ADON) stated, I was on call that day and don't remember what exact time I was called. Staff told me that the resident was being taken to the emergency room and that there had been a med error and what the error was. That the error was that Lantus had been given instead of the ordered insulin. I contacted the nurse, [Staff A's name], asked what happened. She explained everything. She did let me know that she had not contacted the doctor or completed any documentation. I told her that she needed to make sure she had an SBAR and MD notification documented. She stated she would come here immediately and come work on it. She should have immediately called the physician. I found out that the patient had chest pain also and that's why the family was so upset. We should have documented any symptoms and called the physician when she was having chest pain, and got an order to leave to the ED. If her daughter refused, because she didn't want to go to the nearest hospital, then she refused. But we did not call and get orders to send her out of the facility to the hospital and we should have. Review of the policy and procedure titled Administering Medications revised in April 2019 and last approved on 10/16/2022 read, Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation . 4. Medications are administered in accordance with prescriber orders, including any required time frame. 5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. Enhancing optimal therapeutic effect of the medication . 6. Medication errors are documented, reported, and reviewed by the QAPI [Quality Assurance Performance Improvement] committee to inform process changes and or the need for additional staff training . 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105846 If continuation sheet Page 3 of 36 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 105846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baya Pointe Nursing and Rehabilitation Center 587 SE Ermine Ave Lake City, FL 32025 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the policy and procedure titled Notification of Change in Condition with a revision date of 12/16/2020, read, Policy: The center to promptly notify the Patient/Resident, the attending physician, and the Resident Representative when there is a change in the status or condition. Procedure: The nurse to notify the attending physician and Resident Representative when there is a(n): Accidents, Significant change in the patient/ resident's physical, mental, or psychosocial status, Need to alter treatment significantly, New treatment, Discontinuation of a current treatment due to but not limited to: Adverse consequences, Acute condition, Exacerbation of a chronic condition . The nurse to complete an evaluation of the Patient/Resident. Document evaluation in the medical record. The nurse will contact the physician. In the event that the attending physician does not respond in a reasonable amount of time, the Medical Director may be contacted . Complete SBAR as indicated. Event ID: Facility ID: 105846 If continuation sheet Page 4 of 36 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 105846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baya Pointe Nursing and Rehabilitation Center 587 SE Ermine Ave Lake City, FL 32025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews with a resident and staff, resident record reviews and review of the facility policies and procedures, the facility failed to ensure residents were free from medical neglect when the staff failed to follow physicians' orders, resulting in insulin medication errors for 6 of 7 residents, Residents #1, #2, #3, #4, #5, and #6. Resident #1 was administered the wrong insulin and Residents #2, #3, #4, #5, and #6 were not administered physician ordered long-acting insulin. The body must have insulin working 24 hours a day. If there is no long-acting insulin administered and rapid acting insulin is not given within the past 3-4 hours, it is likely that the body will make ketones and will be at risk of developing life-threatening diabetic ketoacidosis (DKA) or Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS). Extremely high blood glucose can lead to Hyperosmolar Hyperglycemic Nonketotic Coma (HHNK), a life-threatening complication of uncontrolled diabetes mellitus. This syndrome is characterized by severe hyperglycemia, a marked increase in serum osmolality, and clinical evidence of dehydration without significant accumulation of keto acids, which can result when diabetic medications aren't taken as directed. DKA is caused by an overload of ketones present in your blood. When the cells don't get the glucose they need for energy, the body begins to burn fat for energy, which produces ketones. Ketones are chemicals that the body creates when it breaks down fat to use for energy. DKA is a life-threatening problem that affects people with diabetes. It occurs when the body starts breaking down fat at a rate that is much too fast. The liver processes the fat into a fuel called ketones, which causes the blood to become acidic. Findings include: Review of the medical record for Resident #6 documented diagnosis to include type 2 diabetes mellitus. Review of the physician orders for Resident #6 dated 7/13/2022 read, Lantus Solostar Subcutaneous Solution Pen-injector 100 unit/ml [milliliter] (Insulin Glargine) inject 10 units subcutaneously in the morning related to type 2 diabetes mellitus without complications. Review of the physician orders for Resident #6 dated 7/14/2022 read, Lantus Solostar Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine) inject 25 units subcutaneously at bedtime related to type 2 diabetes mellitus without complications. Review of the Medication Administration Record (MAR) for Resident #6 for the period of 4/1/2023 to 7/5/2023 showed on 4/1/2023 at 6:00 AM, Staff D, LPN (Licensed Practical Nurse) documented 11 (held per parameters) for Lantus Insulin, 4/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/2/23 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/3/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/4/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/4/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/5/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/7/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/8/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/8/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/9/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/9/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/10/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105846 If continuation sheet Page 5 of 36 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 105846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baya Pointe Nursing and Rehabilitation Center 587 SE Ermine Ave Lake City, FL 32025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some parameters) for Lantus Insulin, 4/13/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/13/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/14/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/17/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/18/2023 at 6:00 AM, Staff, C LPN, documented 11 (held per parameters) for Lantus Insulin, 4/18/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/19/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/21/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/22/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/22/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/23/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/23/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/24/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/26/2023 at 9:00 PM, Staff, C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/27/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/27/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/28/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/2/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/3/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/5/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/6/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/7/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/7/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/8/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/10/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/11/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/11/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/12/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/15/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/16/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/24/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/3/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/5/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/6/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/6/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/7/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/14/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/14/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/19/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/20/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/21/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/21/2023 at 9:00 PM, Staff, D LPN, documented 11 (held per parameters) for Lantus Insulin, 6/22/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 7/1/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 7/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 7/3/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin. Review of the medical record for Resident #4 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105846 If continuation sheet Page 6 of 36 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 105846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baya Pointe Nursing and Rehabilitation Center 587 SE Ermine Ave Lake City, FL 32025 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 0600 documented diagnosis to include type 2 diabetes mellitus. Level of Harm - Immediate jeopardy to resident health or safety Review of the physician orders for Resident #4 dated 3/7/2023 read, Levemir Flexpen Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Detemir) inject 35 units subcutaneously at bedtime related to Type 2 diabetes mellitus without complications. Residents Affected - Some Review of the MAR for Resident #4 for the period of 4/1/2023 to 7/5/2023 showed on 4/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/3/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/4/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/7/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/8/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/9/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/12/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/13/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/17/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/18/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/21/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/22/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/23/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/26/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/27/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/1/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/2/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/5/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/6/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/16/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/22/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/25/2023 at 9:00 PM, Staff A, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/30/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/2/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/3/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/5/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/6/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/7/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/19/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/20/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/21/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/26/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/30/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 7/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen. Review of the medical record for Resident #5 documented diagnosis to include type 2 diabetes mellitus. Review of the physician orders for Resident #5 dated 4/5/2023 read, Lantus Solostar Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine) inject 45 units subcutaneously every morning and at bedtime related to type 2 diabetes mellitus without complications. Review of the MAR for Resident #5 for the period of 4/1/2023 to 7/5/2023 showed on 4/7/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/8/2023 at 8:00 PM, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105846 If continuation sheet Page 7 of 36 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 105846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baya Pointe Nursing and Rehabilitation Center 587 SE Ermine Ave Lake City, FL 32025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/9/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/11/2023 at 8:00 PM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/12/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/13/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/13/2023 at 8:00 PM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/17/2023 at 6:00 AM, Staff F, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/18/2023 at 8:00 PM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/19/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/21/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 4/21/2023 at 8:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 4/22/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 4/23/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Solostar, 4/25/2023 at 8:00 PM, Staff G, LPN, documented 11 (held per parameters) for Lantus Solostar, 4/26/2023 at 6:00 AM, Staff G, LPN, documented 5 (hold see nurses notes) for Lantus Solostar, 4/27/2023 at 6:00 AM, Staff E, LPN, documented 11 (held per parameters) for Lantus Solostar, 5/2/2023 at 6:00 AM, Staff E, LPN, documented 11 (held per parameters) for Lantus Solostar, 5/5/2023 at 8:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 5/6/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 5/11/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 5/12/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 5/15/2023 at 8:00 PM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 5/17/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 5/20/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 6/2/2023 at 8:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 6/3/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 6/9/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 6/13/2023 at 6:00 AM, Staff H, LPN, documented 12 (insulin not required) for Lantus Solostar, 6/15/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 6/19/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 6/23/2023 at 6:00 AM, Staff H, LPN, documented 9 (other see nursing note) for Lantus Solostar, 6/30/2023 at 8:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Solostar, 7/1/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar. Review of the medical record for Resident #2 documented diagnosis to include type 2 diabetes mellitus. Review of the physician orders for Resident #2 dated 4/6/2023 read, Levemir Flexpen Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Detemir) inject 35 units subcutaneously at bedtime related to type 2 diabetes mellitus without complications. Review of the MAR for Resident #2 for the period of 6/1/2023 to 6/19/2023 showed on 6/6/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/14/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen. Review of the medical record for Resident #3 documented diagnosis to include type 2 diabetes mellitus. Review of the physician orders for Resident #3 dated 3/10/2023 read, Insulin Glargine Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine) inject 35 units subcutaneously at bedtime related to Type 2 diabetes mellitus without complications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105846 If continuation sheet Page 8 of 36 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 105846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baya Pointe Nursing and Rehabilitation Center 587 SE Ermine Ave Lake City, FL 32025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Review of the MAR for Resident #3 for the period of 5/1/2023 to 6/19/2023 showed on 5/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/2/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/6/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/7/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/10/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/11/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/16/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/20/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/29/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/4/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/2/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/8/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/12/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/13/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/16/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin. Review of the medical record for Resident #1 documented diagnosis to include type 2 diabetes mellitus and diabetic neuropathy. Review of the physician orders for Resident #1 dated 5/26/2023 read, Insulin Aspart Flexpen Subcutaneous Solution Pen- injector 100 unit/ml (Insulin Aspart) inject 21 units subcutaneously before meals related to type 2 diabetes mellitus with diabetic neuropathy. Review of the physician orders for Resident #1 dated 5/26/2023 read, Insulin Glargine Solostar Subcutaneous Solution Pen- injector 100 unit/ml (Insulin Glargine) inject 25 units subcutaneously at bedtime related to type 2 diabetes mellitus with diabetic neuropathy. Review of the MAR for Resident #1 for the period of 6/1/2023 to 6/4/2023 showed on 6/4/2023 at 6:00 AM, Staff A, LPN, documented 9 (other see nurses notes). Review of the nursing progress notes did not reveal a progress note on 6/4/2023 for 6:00 AM written by Staff A, LPN. Review of the change of condition SBAR (Situation, Background, Assessment and Recommendation) dated 6/4/2023 at 2:13 PM for Resident #1 read, A. Situation: 1 . gave Lantus instead of NovoLog this AM [morning]. 2. This started on: 06/04/2023 . C. Review and Notify. 1. Primary clinician notified: [Doctor's name]. 2. Date and Time notified: 06/04/2023 14:20 [2:20 PM]. 3. Recommendations of Primary Clinician (if any): no new orders . 7. Nursing Notes (for additional information on the Change in Condition): Notified MD [Medical Doctor], no new orders, informed him that family chose to take resident to ER [Emergency Room] in Gainesville. Review of the nursing progress note authored by Staff B, Registered Nurse (RN), dated 6/4/2023 at 5:33 PM for Resident #1 read, Resident stated that the night nurse had given her the wrong insulin. She stated that she told the nurse that it was the wrong insulin before the nurse gave it to her. Resident then complained of having chest pains and a stomachache around 0800 [8:00 AM]. I checked the residents [Sic.] blood sugar and it was 301. The residents [Sic.] daughter called facility upset and stated that no one notified her of the medication error and that she was going to come take her mother to [hospital's name and city of location] because she is too high risk to go to [local hospital's name]. The daughter told me to not give her mother anymore insulin or medication until she takes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105846 If continuation sheet Page 9 of 36 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 105846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baya Pointe Nursing and Rehabilitation Center 587 SE Ermine Ave Lake City, FL 32025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some her to [hospital's name]. The daughter also stated that she was going to call the police and her attorney. At approximately 1130 [11:30 AM] the daughter arrived with a police officer [Resident #1's name] walked out of the facility with her daughter at approximately 1200 [noon]. During an interview on 6/19/2023 at 11:00 AM, Staff I, Director of Nursing (DON), stated, Insulin is a high-risk medication that an error can cause problems with low blood sugars or with high blood sugars if they administer too much, the wrong kind or none. I was not aware that nurses were not administering insulin and documenting that it was being held because of parameters. There are no parameters for long-acting insulins in the residents' records. They should be administering these or at the very least calling and asking the doctor if they should administer the insulin when they do accuchecks [blood sugar monitoring]. This [medication error] was not reported to the physician when this occurred by the night nurse at 6:15 AM. It was not reported until about 11:30 in the morning. She came back in when [Assistant Director of Nursing's name] got hold of her. The staff should have called the doctor when the mistake occurred and obtained orders then. I can't tell you why she didn't. I'm not sure when the day shift nurse found out about the error. We did not look at all the residents' receiving insulin when the medication error was made. I didn't know that I needed to evaluate anyone else after [Staff A's name] made the mistake. They just don't know or have any common sense that would make them call the doctor. They clearly don't understand the difference between long and short acting insulins. I guess we need to train them. During an interview on 6/19/2023 at 11:41 AM, Staff A, LPN, stated, I was helping out that night. I usually work days and usually work the LTC [long term care] unit and picked up a shift. I read her order and she had two different insulins. One insulin looked like it was in the wrong bag. I thought it was too much insulin, I gave it, the long acting the Lantus. Then I reread the order after the resident told me she didn't get that kind until the night. After that I just waited for the day nurse. I did not notify the doctor. I guess I just didn't think it was necessary and then I spoke with the day nurse, and she didn't say to call the doctor. She said, well we will just wait and see what her blood sugar does. I should have called. [Assistant Director of Nursing's name] messaged me and asked about it. I told him what happened and came in to write the progress note and I called the doctor then. I explained what happened. He did not give any new orders because the resident was leaving with her daughter, who was taking her to the hospital. I did tell the oncoming nurse and she didn't seem too concerned because it was a long-acting insulin. She did not tell me to call the doctor before I left. The resident said to me after I told her what I administered that she took that [Lantus insulin] at night not in the morning. I double checked the MAR and saw she was right. She had been given her Lantus the evening before. I just didn't think about it at all. During a telephone interview on 6/19/2023 at 11:50 AM, Staff B, RN, stated, I came on shift and the night shift nurse told me she had given the wrong insulin. I didn't tell her to call the doctor, said she notified him. At about 8 AM [Resident #1's name] was going to breakfast, and she told me about the med error. At that time, she was complaining she was weak and had a stomachache. I didn't check her blood sugar then; she was going to eat, and I told her if she didn't feel better to let me know. When she was coming back from breakfast, she was still feeling that way, so I got her to lay down. I went to do something else with another resident and then her daughter was on the phone, and I spoke to her. She was very upset, so I talked to her. After I got off the phone, I checked her insulin, and it was 301 at that time. After that, I spoke with her daughter and her daughter insisted I not give her anything more and stated she would take her to the ER because she didn't want her to go to anywhere but [hospital's name]. She told another nurse she was having chest pain sometime around then, but I wasn't worried about chest pain. I don't know why. I guess because her daughter was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105846 If continuation sheet Page 10 of 36 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 105846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baya Pointe Nursing and Rehabilitation Center 587 SE Ermine Ave Lake City, FL 32025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some going to take her to the ER. I did not call the doctor about the chest pain or any other symptoms that she had. I should have called him. He was going to send her out and they would take her to [hospital's name] and I knew her daughter didn't want her to go there and so I just didn't think to call and notify him. I did not think to call 911 and let the resident or daughter refuse to go to the hospital. I should have. During a telephone interview on 6/19/2023 at 12:10 PM, the MD stated, I was not notified of this error when it occurred. I absolutely should have been notified and I would have ordered more frequent blood sugars to determine if there was a pattern of hypoglycemia [low blood sugar] and we would have been able to treat any potential hypoglycemic events. I was not aware that she had any episodes of chest pain or pressure, fatigue or abdominal discomfort. Again, I should have been notified and I would have had them send her to the hospital. During a telephone interview on 6/19/2023 at 12:30 PM, Resident #1 stated, I was having chest pain, sweating, and nausea when I left [NAME] Pointe because I was given the wrong insulin. So, my daughter brought me to [hospital's name] ED [Emergency Department]. I am still in the hospital now. But I'm not feeling too good. I don't think that my blood sugar was too low when I got to the hospital. I told them that they were giving me the wrong kind of insulin, but they didn't listen. They did not check my blood sugar after they did that. I told them when I went to breakfast that I wasn't feeling good, but they didn't listen. After breakfast, I told them again that I was having chest pains and feeling dizzy and nauseous, but they didn't listen until my daughter called. After that is when they checked on me. During an interview on 6/19/2023 at 1:41 PM, the Assistant Director of Nursing (ADON) stated, I was on call that day and don't remember what exact time I was called. Staff told me that the resident was being taken to the emergency room and that there had been a med error and what the error was. That the error was that Lantus had been given instead of the ordered insulin. I contacted the nurse, [Staff A's name], asked what happened. She explained everything. She did let me know that she had not contacted the doctor or completed any documentation. I told her that she needed to make sure she had an SBAR and MD notification documented. She stated she would come here immediately and come work on it. She should have immediately called the physician. I found out that the patient had chest pain also and that's why the family was so upset. We should have documented any symptoms and called the physician when she was having chest pain, and got an order to leave to the ED. If her daughter refused, because she didn't want to go to the nearest hospital, then she refused. But we did not call and get orders to send her out of the facility to the hospital and we should have. During an interview conducted on 6/19/2023 at 3:20 PM, Staff I, Director of Nursing (DON), stated, Each time 11 is documented the medication was not given per parameters, the nurses did not administer the long-acting insulin. Reviewing the orders, I see that there are no parameters to hold the medication and the insulin should have been administered. They were not following doctors' orders. They were not following the policies for medication administration and holding medications. They should have called the doctor if they were concerned about administering the medications. I have no idea why they would have held the insulin. I guess this is an education thing. They just don't know any better. I just don't know why they did this. During a telephone interview on 7/5/2023 at 2:10 PM, Staff C, LPN, stated, I was not really given a good in-service about insulin or medication errors. She told me to sign a piece of paper, the other DON. I did not get any text messages. I didn't know that we shouldn't hold the insulin, that we needed parameters to hold it. My understanding was that anything under 150, we should not administer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105846 If continuation sheet Page 11 of 36 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 105846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baya Pointe Nursing and Rehabilitation Center 587 SE Ermine Ave Lake City, FL 32025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety the insulin. I guess I just assumed that from the sliding scales maybe. Also, I was holding some insulin when residents didn't want to take it because they knew that would make them drop lower and I was documenting it as 11, which is wrong, and they told me in the in-service today. I did come in today and have the in-service with the DON. We went over neglect, insulin long and short acting, parameters with short acting, that we will call doctors if we have concerns, changes in condition, medication errors and making sure we notify doctors and families. We did an insulin demonstration too. Residents Affected - Some During a telephone interview on 7/5/2023 at 2:35 PM, Staff D, LPN, stated, I did hold insulin for low blood sugars. Just through the years I was told that if the blood sugars are less than 150 not to administer the insulin because it would drop it lower. I did not have a doctor's order to hold the insulin and I did not call when I wasn't giving the insulin. I should have administered the insulin if there were no parameters to hold it. I was not following doctors' orders when I held those insulins if there were no parameters written in the orders. During an interview on 7/6/2023 at 10:35 AM, the MD stated, I was not aware that nurses were holding long-acting insulins outside of my written parameters. I write an order for accuchecks and to be notified if they are below 60 or above 400. I do not write specific hold orders. I expect them to administer the insulin. If they are symptomatic meaning, they are dizzy, lightheaded, I expect to be called and notified. I do expect the staff to inform me anytime they hold medications. The risk of not administering long-acting insulin would most obviously be hyperglycemia, going into HHNK if they have any infection brewing. It is and can be catastrophic in the right setting. Residents would need to get hospitalized if the hyperglycemia were severe enough, they risk dehydration with persistent hyperglycemia and diabetics poorly controlled are at risk for worsening kidney failure, electrolyte abnormalities, worsening eyesight, worsening peripheral neuropathy, coma and sometimes death. We need to provide this education and training to the nurses. During a telephone interview on 7/6/2023 at 11:00 AM, Staff E, LPN, stated, I was holding the Levemir and Lantus and would document that insulin was not needed because blood sugars were low. They weren't really low, not in the 50s, but below 150. I didn't know I wasn't supposed to do that. I did not call or notify the doctor when I held those. I should have. There were not any parameters to hold the insulin. I was not following the doctors' orders. I should have followed the orders. I thought I was doing the right thing. I would never want to hurt anyone at all. I was provided one on one education about neglect, long and short acting insulin, what parameters are for holding insulin, calling doctors with any time we need to hold medications, or they are refused, changes in condition notifications, medication errors and reporting them to doctors. We had to do an insulin and five rights of medication administration demonstration for the DON. During a telephone interview on 7/6/2023 at 11:30 AM, Staff F, LPN, stated, I did hold insulin when the blood sugars were low, less than 150. I was taught that we don't give insulin for anything less than 150. I don't think that the orders had any parameters from the doctor. I did not call the doctor and I would have documented if they had any symptoms. There were no orders to hold the insulin, I was not following doctors' orders. I should have given the insulin and followed the orders. I have been in-serviced today on neglect, the f[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105846 If continuation sheet Page 12 of 36 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 105846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baya Pointe Nursing and Rehabilitation Center 587 SE Ermine Ave Lake City, FL 32025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews with a resident and staff, resident record reviews and review of the facility policies and procedures, the facility failed to ensure the residents who required insulin administration received treatment in accordance with professional standards of practice by administering the wrong insulin and/or failing to administer long-acting insulin per physician orders for 6 of 7 residents receiving insulin, Residents #1, #2, #3, #4, #5 and #6. The body must have insulin working 24 hours a day. If there is no long-acting insulin administered and rapid acting insulin is not given within the past 3-4 hours, it is likely that the body will make ketones and will be at risk of developing life-threatening diabetic ketoacidosis (DKA) or Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS). Extremely high blood glucose can lead to Hyperosmolar Hyperglycemic Nonketotic Coma (HHNK), a life-threatening complication of uncontrolled diabetes mellitus. This syndrome is characterized by severe hyperglycemia, a marked increase in serum osmolality, and clinical evidence of dehydration without significant accumulation of keto acids, which can result when diabetic medications aren't taken as directed. DKA is caused by an overload of ketones present in your blood. When the cells don't get the glucose they need for energy, the body begins to burn fat for energy, which produces ketones. Ketones are chemicals that the body creates when it breaks down fat to use for energy. DKA is a life-threatening problem that affects people with diabetes. It occurs when the body starts breaking down fat at a rate that is much too fast. The liver processes the fat into a fuel called ketones, which causes the blood to become acidic. Residents Affected - Some Findings include: Review of the medical record for Resident #6 documented diagnosis to include type 2 diabetes mellitus. Review of the physician orders for Resident #6 dated 7/13/2022 read, Lantus Solostar Subcutaneous Solution Pen-injector 100 unit/ml [milliliter] (Insulin Glargine) inject 10 units subcutaneously in the morning related to type 2 diabetes mellitus without complications. Review of the physician orders for Resident #6 dated 7/14/2022 read, Lantus Solostar Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine) inject 25 units subcutaneously at bedtime related to type 2 diabetes mellitus without complications. Review of the Medication Administration Record (MAR) for Resident #6 for the period of 4/1/2023 to 7/5/2023 showed on 4/1/2023 at 6:00 AM, Staff D, LPN (Licensed Practical Nurse) documented 11 (held per parameters) for Lantus Insulin, 4/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/2/23 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/3/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/4/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/4/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/5/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/7/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/8/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/8/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/9/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/9/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/10/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/13/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105846 If continuation sheet Page 13 of 36 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 105846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baya Pointe Nursing and Rehabilitation Center 587 SE Ermine Ave Lake City, FL 32025 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some for Lantus Insulin, 4/13/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/14/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/17/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/18/2023 at 6:00 AM, Staff, C LPN, documented 11 (held per parameters) for Lantus Insulin, 4/18/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/19/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/21/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/22/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/22/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/23/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/23/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/24/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/26/2023 at 9:00 PM, Staff, C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/27/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/27/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/28/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/2/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/3/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/5/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/6/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/7/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/7/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/8/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/10/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/11/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/11/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/12/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/15/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/16/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/24/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/3/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/5/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/6/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/6/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/7/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/14/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/14/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/19/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/20/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/21/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/21/2023 at 9:00 PM, Staff, D LPN, documented 11 (held per parameters) for Lantus Insulin, 6/22/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 7/1/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 7/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 7/3/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin. Review of the medical record for Resident #4 documented diagnosis to include type 2 diabetes mellitus. Review of the physician orders for Resident #4 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105846 If continuation sheet Page 14 of 36 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 105846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baya Pointe Nursing and Rehabilitation Center 587 SE Ermine Ave Lake City, FL 32025 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some dated 3/7/2023 read, Levemir Flexpen Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Detemir) inject 35 units subcutaneously at bedtime related to Type 2 diabetes mellitus without complications. Review of the MAR for Resident #4 for the period of 4/1/2023 to 7/5/2023 showed on 4/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/3/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/4/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/7/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/8/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/9/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/12/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/13/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/17/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/18/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/21/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/22/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/23/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/26/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/27/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/1/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/2/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/5/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/6/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/16/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/22/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/25/2023 at 9:00 PM, Staff A, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/30/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/2/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/3/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/5/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/6/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/7/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/19/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/20/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/21/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/26/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/30/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 7/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen. Review of the medical record for Resident #5 documented diagnosis to include type 2 diabetes mellitus. Review of the physician orders for Resident #5 dated 4/5/2023 read, Lantus Solostar Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine) inject 45 units subcutaneously every morning and at bedtime related to type 2 diabetes mellitus without complications. Review of the MAR for Resident #5 for the period of 4/1/2023 to 7/5/2023 showed on 4/7/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/8/2023 at 8:00 PM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/9/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/11/2023 at 8:00 PM, Staff E, LPN, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105846 If continuation sheet Page 15 of 36 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 105846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baya Pointe Nursing and Rehabilitation Center 587 SE Ermine Ave Lake City, FL 32025 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some documented 12 (insulin not required) for Lantus Solostar, 4/12/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/13/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/13/2023 at 8:00 PM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/17/2023 at 6:00 AM, Staff F, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/18/2023 at 8:00 PM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/19/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/21/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 4/21/2023 at 8:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 4/22/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 4/23/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Solostar, 4/25/2023 at 8:00 PM, Staff G, LPN, documented 11 (held per parameters) for Lantus Solostar, 4/26/2023 at 6:00 AM, Staff G, LPN, documented 5 (hold see nurses notes) for Lantus Solostar, 4/27/2023 at 6:00 AM, Staff E, LPN, documented 11 (held per parameters) for Lantus Solostar, 5/2/2023 at 6:00 AM, Staff E, LPN, documented 11 (held per parameters) for Lantus Solostar, 5/5/2023 at 8:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 5/6/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 5/11/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 5/12/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 5/15/2023 at 8:00 PM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 5/17/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 5/20/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 6/2/2023 at 8:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 6/3/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 6/9/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 6/13/2023 at 6:00 AM, Staff H, LPN, documented 12 (insulin not required) for Lantus Solostar, 6/15/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 6/19/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 6/23/2023 at 6:00 AM, Staff H, LPN, documented 9 (other see nursing note) for Lantus Solostar, 6/30/2023 at 8:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Solostar, 7/1/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar. Review of the medical record for Resident #2 documented diagnosis to include type 2 diabetes mellitus. Review of the physician orders for Resident #2 dated 4/6/2023 read, Levemir Flexpen Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Detemir) inject 35 units subcutaneously at bedtime related to type 2 diabetes mellitus without complications. Review of the MAR for Resident #2 for the period of 6/1/2023 to 6/19/2023 showed on 6/6/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/14/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen. Review of the medical record for Resident #3 documented diagnosis to include type 2 diabetes mellitus. Review of the physician orders for Resident #3 dated 3/10/2023 read, Insulin Glargine Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine) inject 35 units subcutaneously at bedtime related to Type 2 diabetes mellitus without complications. Review of the MAR for Resident #3 for the period of 5/1/2023 to 6/19/2023 showed on 5/1/2023 at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105846 If continuation sheet Page 16 of 36 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 105846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baya Pointe Nursing and Rehabilitation Center 587 SE Ermine Ave Lake City, FL 32025 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/2/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/6/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/7/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/10/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/11/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/16/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/20/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/29/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/4/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/2/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/8/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/12/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/13/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/16/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin. Review of the medical record for Resident #1 documented diagnosis to include type 2 diabetes mellitus and diabetic neuropathy. Review of the physician orders for Resident #1 dated 5/26/2023 read, Insulin Aspart Flexpen Subcutaneous Solution Pen- injector 100 unit/ml (Insulin Aspart) inject 21 units subcutaneously before meals related to type 2 diabetes mellitus with diabetic neuropathy. Review of the physician orders for Resident #1 dated 5/26/2023 read, Insulin Glargine Solostar Subcutaneous Solution Pen- injector 100 unit/ml (Insulin Glargine) inject 25 units subcutaneously at bedtime related to type 2 diabetes mellitus with diabetic neuropathy. Review of the MAR for Resident #1 for the period of 6/1/2023 to 6/4/2023 showed on 6/4/2023 at 6:00 AM, Staff A, LPN, documented 9 (other see nurses notes). Review of the nursing progress notes did not reveal a progress note on 6/4/2023 for 6:00 AM written by Staff A, LPN. Review of the change of condition SBAR (Situation, Background, Assessment and Recommendation) dated 6/4/2023 at 2:13 PM for Resident #1 read, A. Situation: 1 . gave Lantus instead of NovoLog this AM [morning]. 2. This started on: 06/04/2023 . C. Review and Notify. 1. Primary clinician notified: [Doctor's name]. 2. Date and Time notified: 06/04/2023 14:20 [2:20 PM]. 3. Recommendations of Primary Clinician (if any): no new orders . 7. Nursing Notes (for additional information on the Change in Condition): Notified MD [Medical Doctor], no new orders, informed him that family chose to take resident to ER [Emergency Room] in Gainesville. Review of the nursing progress note authored by Staff B, Registered Nurse (RN), dated 6/4/2023 at 5:33 PM for Resident #1 read, Resident stated that the night nurse had given her the wrong insulin. She stated that she told the nurse that it was the wrong insulin before the nurse gave it to her. Resident then complained of having chest pains and a stomachache around 0800 [8:00 AM]. I checked the residents [Sic.] blood sugar and it was 301. The residents [Sic.] daughter called facility upset and stated that no one notified her of the medication error and that she was going to come take her mother to [hospital's name and city of location] because she is too high risk to go to [local hospital's name]. The daughter told me to not give her mother anymore insulin or medication until she takes her to [hospital's name]. The daughter also stated that she was going to call the police and her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105846 If continuation sheet Page 17 of 36 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 105846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baya Pointe Nursing and Rehabilitation Center 587 SE Ermine Ave Lake City, FL 32025 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some attorney. At approximately 1130 [11:30 AM] the daughter arrived with a police officer [Resident #1's name] walked out of the facility with her daughter at approximately 1200 [noon]. During an interview on 6/19/2023 at 11:00 AM, Staff I, Director of Nursing (DON), stated, Insulin is a high-risk medication that an error can cause problems with low blood sugars or with high blood sugars if they administer too much, the wrong kind or none. I was not aware that nurses were not administering insulin and documenting that it was being held because of parameters. There are no parameters for long-acting insulins in the residents' records. They should be administering these or at the very least calling and asking the doctor if they should administer the insulin when they do accuchecks [blood sugar monitoring]. This [medication error] was not reported to the physician when this occurred by the night nurse at 6:15 AM. It was not reported until about 11:30 in the morning. She came back in when [Assistant Director of Nursing's name] got hold of her. The staff should have called the doctor when the mistake occurred and obtained orders then. I can't tell you why she didn't. I'm not sure when the day shift nurse found out about the error. We did not look at all the residents' receiving insulin when the medication error was made. I didn't know that I needed to evaluate anyone else after [Staff A's name] made the mistake. They just don't know or have any common sense that would make them call the doctor. They clearly don't understand the difference between long and short acting insulins. I guess we need to train them. During an interview on 6/19/2023 at 11:41 AM, Staff A, LPN, stated, I was helping out that night. I usually work days and usually work the LTC [long term care] unit and picked up a shift. I read her order and she had two different insulins. One insulin looked like it was in the wrong bag. I thought it was too much insulin, I gave it, the long acting the Lantus. Then I reread the order after the resident told me she didn't get that kind until the night. After that I just waited for the day nurse. I did not notify the doctor. I guess I just didn't think it was necessary and then I spoke with the day nurse, and she didn't say to call the doctor. She said, well we will just wait and see what her blood sugar does. I should have called. [Assistant Director of Nursing's name] messaged me and asked about it. I told him what happened and came in to write the progress note and I called the doctor then. I explained what happened. He did not give any new orders because the resident was leaving with her daughter, who was taking her to the hospital. I did tell the oncoming nurse and she didn't seem too concerned because it was a long-acting insulin. She did not tell me to call the doctor before I left. The resident said to me after I told her what I administered that she took that [Lantus insulin] at night not in the morning. I double checked the MAR and saw she was right. She had been given her Lantus the evening before. I just didn't think about it at all. During a telephone interview on 6/19/2023 at 11:50 AM, Staff B, RN, stated, I came on shift and the night shift nurse told me she had given the wrong insulin. I didn't tell her to call the doctor, said she notified him. At about 8 AM [Resident #1's name] was going to breakfast, and she told me about the med error. At that time, she was complaining she was weak and had a stomachache. I didn't check her blood sugar then; she was going to eat, and I told her if she didn't feel better to let me know. When she was coming back from breakfast, she was still feeling that way, so I got her to lay down. I went to do something else with another resident and then her daughter was on the phone, and I spoke to her. She was very upset, so I talked to her. After I got off the phone, I checked her insulin, and it was 301 at that time. After that, I spoke with her daughter and her daughter insisted I not give her anything more and stated she would take her to the ER because she didn't want her to go to anywhere but [hospital's name]. She told another nurse she was having chest pain sometime around then, but I wasn't worried about chest pain. I don't know why. I guess because her daughter was going to take her to the ER. I did not call the doctor about the chest pain or any other symptoms (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105846 If continuation sheet Page 18 of 36 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 105846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baya Pointe Nursing and Rehabilitation Center 587 SE Ermine Ave Lake City, FL 32025 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some that she had. I should have called him. He was going to send her out and they would take her to [hospital's name] and I knew her daughter didn't want her to go there and so I just didn't think to call and notify him. I did not think to call 911 and let the resident or daughter refuse to go to the hospital. I should have. During a telephone interview on 6/19/2023 at 12:10 PM, the MD stated, I was not notified of this error when it occurred. I absolutely should have been notified and I would have ordered more frequent blood sugars to determine if there was a pattern of hypoglycemia [low blood sugar] and we would have been able to treat any potential hypoglycemic events. I was not aware that she had any episodes of chest pain or pressure, fatigue or abdominal discomfort. Again, I should have been notified and I would have had them send her to the hospital. During a telephone interview on 6/19/2023 at 12:30 PM, Resident #1 stated, I was having chest pain, sweating, and nausea when I left [NAME] Pointe because I was given the wrong insulin. So, my daughter brought me to [hospital's name] ED [Emergency Department]. I am still in the hospital now. But I'm not feeling too good. I don't think that my blood sugar was too low when I got to the hospital. I told them that they were giving me the wrong kind of insulin, but they didn't listen. They did not check my blood sugar after they did that. I told them when I went to breakfast that I wasn't feeling good, but they didn't listen. After breakfast, I told them again that I was having chest pains and feeling dizzy and nauseous, but they didn't listen until my daughter called. After that is when they checked on me. During an interview on 6/19/2023 at 1:41 PM, the Assistant Director of Nursing (ADON) stated, I was on call that day and don't remember what exact time I was called. Staff told me that the resident was being taken to the emergency room and that there had been a med error and what the error was. That the error was that Lantus had been given instead of the ordered insulin. I contacted the nurse, [Staff A's name], asked what happened. She explained everything. She did let me know that she had not contacted the doctor or completed any documentation. I told her that she needed to make sure she had an SBAR and MD notification documented. She stated she would come here immediately and come work on it. She should have immediately called the physician. I found out that the patient had chest pain also and that's why the family was so upset. We should have documented any symptoms and called the physician when she was having chest pain, and got an order to leave to the ED. If her daughter refused, because she didn't want to go to the nearest hospital, then she refused. But we did not call and get orders to send her out of the facility to the hospital and we should have. During an interview conducted on 6/19/2023 at 3:20 PM, Staff I, Director of Nursing (DON), stated, Each time 11 is documented the medication was not given per parameters, the nurses did not administer the long-acting insulin. Reviewing the orders, I see that there are no parameters to hold the medication and the insulin should have been administered. They were not following doctors' orders. They were not following the policies for medication administration and holding medications. They should have called the doctor if they were concerned about administering the medications. I have no idea why they would have held the insulin. I guess this is an education thing. They just don't know any better. I just don't know why they did this. During a telephone interview on 7/5/2023 at 2:10 PM, Staff C, LPN, stated, I was not really given a good in-service about insulin or medication errors. She told me to sign a piece of paper, the other DON. I did not get any text messages. I didn't know that we shouldn't hold the insulin, that we needed parameters to hold it. My understanding was that anything under 150, we should not administer the insulin. I guess I just assumed that from the sliding scales maybe. Also, I was holding some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105846 If continuation sheet Page 19 of 36 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 105846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baya Pointe Nursing and Rehabilitation Center 587 SE Ermine Ave Lake City, FL 32025 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some insulin when residents didn't want to take it because they knew that would make them drop lower and I was documenting it as 11, which is wrong, and they told me in the in-service today. I did come in today and have the in-service with the DON. We went over neglect, insulin long and short acting, parameters with short acting, that we will call doctors if we have concerns, changes in condition, medication errors and making sure we notify doctors and families. We did an insulin demonstration too. During a telephone interview on 7/5/2023 at 2:35 PM, Staff D, LPN, stated, I did hold insulin for low blood sugars. Just through the years I was told that if the blood sugars are less than 150 not to administer the insulin because it would drop it lower. I did not have a doctor's order to hold the insulin and I did not call when I wasn't giving the insulin. I should have administered the insulin if there were no parameters to hold it. I was not following doctors' orders when I held those insulins if there were no parameters written in the orders. During an interview on 7/6/2023 at 10:35 AM, the MD stated, I was not aware that nurses were holding long-acting insulins outside of my written parameters. I write an order for accuchecks and to be notified if they are below 60 or above 400. I do not write specific hold orders. I expect them to administer the insulin. If they are symptomatic meaning, they are dizzy, lightheaded, I expect to be called and notified. I do expect the staff to inform me anytime they hold medications. The risk of not administering long-acting insulin would most obviously be hyperglycemia, going into HHNK if they have any infection brewing. It is and can be catastrophic in the right setting. Residents would need to get hospitalized if the hyperglycemia were severe enough, they risk dehydration with persistent hyperglycemia and diabetics poorly controlled are at risk for worsening kidney failure, electrolyte abnormalities, worsening eyesight, worsening peripheral neuropathy, coma and sometimes death. We need to provide this education and training to the nurses. During a telephone interview on 7/6/2023 at 11:00 AM, Staff E, LPN, stated, I was holding the Levemir and Lantus and would document that insulin was not needed because blood sugars were low. They weren't really low, not in the 50s, but below 150. I didn't know I wasn't supposed to do that. I did not call or notify the doctor when I held those. I should have. There were not any parameters to hold the insulin. I was not following the doctors' orders. I should have followed the orders. I thought I was doing the right thing. I would never want to hurt anyone at all. I was provided one on one education about neglect, long and short acting insulin, what parameters are for holding insulin, calling doctors with any time we need to hold medications, or they are refused, changes in condition notifications, medication errors and reporting them to doctors. We had to do an insulin and five rights of medication administration demonstration for the DON. During a telephone interview on 7/6/2023 at 11:30 AM, Staff F, LPN, stated, I did hold insulin when the blood sugars were low, less than 150. I was taught that we don't give insulin for anything less than 150. I don't think that the orders had any parameters from the doctor. I did not call the doctor and I would have documented if they had any symptoms. There were no orders to hold the insulin, I was not following doctors' orders. I should have given the insulin and followed the orders. I have been in-serviced today on neglect, the five rights of medication adminis[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105846 If continuation sheet Page 20 of 36 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 105846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baya Pointe Nursing and Rehabilitation Center 587 SE Ermine Ave Lake City, FL 32025 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews with a resident and staff, resident record reviews and review of the facility policies and procedures, the facility administration failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical wellbeing of each resident when not assuming full responsibility for the day-to-day operations of the facility. The facility failed to ensure residents were provided physician ordered insulin for 6 of 7 residents, Residents #1, #2, #3, #4, #5 and #6. Resident #1 was administered the wrong insulin and Residents #2, #3, #4, #5, and #6 were not administered physician ordered long-acting insulin. The body must have insulin working 24 hours a day. If there is no long-acting insulin administered and rapid acting insulin is not given within the past 3-4 hours, it is likely that the body will make ketones and will be at risk of developing life-threatening diabetic ketoacidosis (DKA) or Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS). Extremely high blood glucose can lead to Hyperosmolar Hyperglycemic Nonketotic Coma (HHNK), a life-threatening complication of uncontrolled diabetes mellitus. This syndrome is characterized by severe hyperglycemia, a marked increase in serum osmolality, and clinical evidence of dehydration without significant accumulation of keto acids, which can result when diabetic medications aren't taken as directed. DKA is caused by an overload of ketones present in your blood. When the cells don't get the glucose they need for energy, the body begins to burn fat for energy, which produces ketones. Ketones are chemicals that the body creates when it breaks down fat to use for energy. DKA is a life-threatening problem that affects people with diabetes. It occurs when the body starts breaking down fat at a rate that is much too fast. The liver processes the fat into a fuel called ketones, which causes the blood to become acidic. Residents Affected - Some Findings include: Review of the job description for the Executive Director (Administrator) read, Purpose of Your Job Position: The Executive Director is responsible for management of the facility in a manner which exemplifies Raydiant Health Care's standard of operational excellence, to include but not limited to creating an environment in which employees demonstrate Honesty, Authentic Innovative, Compassion, Diversity, Equity & Inclusion. The primary purpose of the Executive Director is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to ensure that the highest degree of quality care can be provided to our residents at all times. You are entrusted to provide innovative, responsible healthcare with the creation and implementation of new ideas and concepts that continually improve systems and processes to achieve superior results. Job functions: As Executive Director, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Responsible for day-to-day clinical and administrative activities of the facility, including profit and loss responsibility and ensure compliance with all state and federal regulations. Supervises Director of Clinical Services, Business Office Manager, Business Office Coordinator, Director of Admission, Director of Rehabilitation Services, Director of Resident and Family Services, Director of Therapeutic Recreational Services, Director of Hospitality Services, Director of Dining Services, Director of Environmental Services, Customer Service Associate. You will also provide leadership to all facility staff in meeting the goal of providing quality resident care. This job description does not list all the duties of your job. You may be asked by the supervisors or managers to perform other duties. You will be evaluated in part based upon your performance of the tasks listed in this job description at anytime. This job description is not a contract for employment and either you or the employer may terminate employment at any time for any reason. Duties and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105846 If continuation sheet Page 21 of 36 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 105846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baya Pointe Nursing and Rehabilitation Center 587 SE Ermine Ave Lake City, FL 32025 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 0835 Level of Harm - Immediate jeopardy to resident health or safety Responsibilities . 2. Establish financial and programmatic goals for the facility and conduct an annual evaluation of goal achievement . 7. Schedule regular meeting with direct report staff to provide supervision, ensure communication and to monitor facility operations . 9. Maintain and guide the implementation of facility policies and procedures in compliance with corporate, state, federal, and other regulatory guidelines . 11. Support and guide the facility's quality improvement process . 23. Adhere to facility policies and procedures and participate in facility quality improvement and safety programs. Residents Affected - Some Review of the job description for Director of Nursing I read, Purpose of Your Job Position . The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines and regulations that govern our facility and as may be directed by the Executive Director to ensure that the highest degree of quality care is maintained at all times. You are entrusted to provide innovative responsible healthcare with the creation and implementation of new ideas and concepts that continually improve systems and processes to achieve superior results. Job Functions: As Director of Nursing I, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Responsible for planning, organizing, and directing the functions for the nursing department. You will assume the primary role in ensuring the delivery of high quality efficient nursing care. Supervises Nurse Practitioner, Assistant Director of Nursing, Clinical Nurses, and Nurse Techs. In the absence of the Executive Director, you are charged with carrying out the resident care policies established by this facility. This job description does not list all the duties of the job. You may be asked by the supervisors or managers to perform other duties. Duties and Responsibilities . 5. Set and monitor achievement of goals and objectives for the nursing department consistent with the established philosophy and standards of practice. 7. Establish, implement, and continually update competency/skills checklists for nursing staff . 9. Maintain and guide the implementation of current policies and procedures, which reflect adherence to corporate and external regulatory guidelines . 11. Establish and monitor compliance with an effective medical record documentation system . 14. Actively participate in the quality improvement process for the facility. 15. Participate in and/or provide inservice education sessions. Review of the medical record for Resident #6 documented diagnosis to include type 2 diabetes mellitus. Review of the physician orders for Resident #6 dated 7/13/2022 read, Lantus Solostar Subcutaneous Solution Pen-injector 100 unit/ml [milliliter] (Insulin Glargine) inject 10 units subcutaneously in the morning related to type 2 diabetes mellitus without complications. Review of the physician orders for Resident #6 dated 7/14/2022 read, Lantus Solostar Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine) inject 25 units subcutaneously at bedtime related to type 2 diabetes mellitus without complications. Review of the Medication Administration Record (MAR) for Resident #6 for the period of 4/1/2023 to 7/5/2023 showed on 4/1/2023 at 6:00 AM, Staff D, LPN (Licensed Practical Nurse) documented 11 (held per parameters) for Lantus Insulin, 4/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/2/23 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/3/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/4/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/4/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/5/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/7/2023 at 9:00 PM, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105846 If continuation sheet Page 22 of 36 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 105846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baya Pointe Nursing and Rehabilitation Center 587 SE Ermine Ave Lake City, FL 32025 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 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/8/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/8/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/9/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/9/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/10/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/13/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/13/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/14/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/17/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/18/2023 at 6:00 AM, Staff, C LPN, documented 11 (held per parameters) for Lantus Insulin, 4/18/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/19/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/21/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/22/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/22/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/23/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/23/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/24/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/26/2023 at 9:00 PM, Staff, C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/27/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/27/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/28/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/2/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/3/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/5/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/6/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/7/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/7/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/8/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/10/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/11/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/11/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/12/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/15/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/16/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/24/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/3/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/5/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/6/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/6/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/7/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/14/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/14/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/19/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/20/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/21/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/21/2023 at 9:00 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105846 If continuation sheet Page 23 of 36 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 105846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baya Pointe Nursing and Rehabilitation Center 587 SE Ermine Ave Lake City, FL 32025 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 0835 Level of Harm - Immediate jeopardy to resident health or safety PM, Staff, D LPN, documented 11 (held per parameters) for Lantus Insulin, 6/22/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 7/1/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 7/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 7/3/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin. Residents Affected - Some Review of the medical record for Resident #4 documented diagnosis to include type 2 diabetes mellitus. Review of the physician orders for Resident #4 dated 3/7/2023 read, Levemir Flexpen Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Detemir) inject 35 units subcutaneously at bedtime related to Type 2 diabetes mellitus without complications. Review of the MAR for Resident #4 for the period of 4/1/2023 to 7/5/2023 showed on 4/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/3/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/4/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/7/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/8/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/9/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/12/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/13/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/17/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/18/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/21/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/22/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/23/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/26/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/27/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/1/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/2/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/5/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/6/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/16/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/22/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/25/2023 at 9:00 PM, Staff A, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/30/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/2/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/3/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/5/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/6/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/7/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/19/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/20/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/21/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/26/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/30/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 7/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen. Review of the medical record for Resident #5 documented diagnosis to include type 2 diabetes mellitus. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105846 If continuation sheet Page 24 of 36 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 105846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baya Pointe Nursing and Rehabilitation Center 587 SE Ermine Ave Lake City, FL 32025 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 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Review of the physician orders for Resident #5 dated 4/5/2023 read, Lantus Solostar Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine) inject 45 units subcutaneously every morning and at bedtime related to type 2 diabetes mellitus without complications. Review of the MAR for Resident #5 for the period of 4/1/2023 to 7/5/2023 showed on 4/7/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/8/2023 at 8:00 PM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/9/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/11/2023 at 8:00 PM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/12/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/13/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/13/2023 at 8:00 PM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/17/2023 at 6:00 AM, Staff F, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/18/2023 at 8:00 PM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/19/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/21/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 4/21/2023 at 8:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 4/22/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 4/23/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Solostar, 4/25/2023 at 8:00 PM, Staff G, LPN, documented 11 (held per parameters) for Lantus Solostar, 4/26/2023 at 6:00 AM, Staff G, LPN, documented 5 (hold see nurses notes) for Lantus Solostar, 4/27/2023 at 6:00 AM, Staff E, LPN, documented 11 (held per parameters) for Lantus Solostar, 5/2/2023 at 6:00 AM, Staff E, LPN, documented 11 (held per parameters) for Lantus Solostar, 5/5/2023 at 8:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 5/6/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 5/11/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 5/12/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 5/15/2023 at 8:00 PM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 5/17/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 5/20/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 6/2/2023 at 8:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 6/3/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 6/9/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 6/13/2023 at 6:00 AM, Staff H, LPN, documented 12 (insulin not required) for Lantus Solostar, 6/15/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 6/19/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 6/23/2023 at 6:00 AM, Staff H, LPN, documented 9 (other see nursing note) for Lantus Solostar, 6/30/2023 at 8:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Solostar, 7/1/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar. Review of the medical record for Resident #2 documented diagnosis to include type 2 diabetes mellitus. Review of the physician orders for Resident #2 dated 4/6/2023 read, Levemir Flexpen Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Detemir) inject 35 units subcutaneously at bedtime related to type 2 diabetes mellitus without complications. Review of the MAR for Resident #2 for the period of 6/1/2023 to 6/19/2023 showed on 6/6/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/14/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105846 If continuation sheet Page 25 of 36 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 105846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baya Pointe Nursing and Rehabilitation Center 587 SE Ermine Ave Lake City, FL 32025 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 0835 Review of the medical record for Resident #3 documented diagnosis to include type 2 diabetes mellitus. Level of Harm - Immediate jeopardy to resident health or safety Review of the physician orders for Resident #3 dated 3/10/2023 read, Insulin Glargine Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine) inject 35 units subcutaneously at bedtime related to Type 2 diabetes mellitus without complications. Residents Affected - Some Review of the MAR for Resident #3 for the period of 5/1/2023 to 6/19/2023 showed on 5/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/2/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/6/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/7/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/10/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/11/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/16/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/20/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/29/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/4/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/2/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/8/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/12/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/13/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/16/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin. Review of the medical record for Resident #1 documented diagnosis to include type 2 diabetes mellitus and diabetic neuropathy. Review of the physician orders for Resident #1 dated 5/26/2023 read, Insulin Aspart Flexpen Subcutaneous Solution Pen- injector 100 unit/ml (Insulin Aspart) inject 21 units subcutaneously before meals related to type 2 diabetes mellitus with diabetic neuropathy. Review of the physician orders for Resident #1 dated 5/26/2023 read, Insulin Glargine Solostar Subcutaneous Solution Pen- injector 100 unit/ml (Insulin Glargine) inject 25 units subcutaneously at bedtime related to type 2 diabetes mellitus with diabetic neuropathy. Review of the MAR for Resident #1 for the period of 6/1/2023 to 6/4/2023 showed on 6/4/2023 at 6:00 AM, Staff A, LPN, documented 9 (other see nurses notes). Review of the nursing progress notes did not reveal a progress note on 6/4/2023 for 6:00 AM written by Staff A, LPN. Review of the change of condition SBAR (Situation, Background, Assessment and Recommendation) dated 6/4/2023 at 2:13 PM for Resident #1 read, A. Situation: 1 . gave Lantus instead of NovoLog this AM [morning]. 2. This started on: 06/04/2023 . C. Review and Notify. 1. Primary clinician notified: [Doctor's name]. 2. Date and Time notified: 06/04/2023 14:20 [2:20 PM]. 3. Recommendations of Primary Clinician (if any): no new orders . 7. Nursing Notes (for additional information on the Change in Condition): Notified MD [Medical Doctor], no new orders, informed him that family chose to take resident to ER [Emergency Room] in Gainesville. Review of the nursing progress note authored by Staff B, Registered Nurse (RN), dated 6/4/2023 at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105846 If continuation sheet Page 26 of 36 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 105846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baya Pointe Nursing and Rehabilitation Center 587 SE Ermine Ave Lake City, FL 32025 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 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 5:33 PM for Resident #1 read, Resident stated that the night nurse had given her the wrong insulin. She stated that she told the nurse that it was the wrong insulin before the nurse gave it to her. Resident then complained of having chest pains and a stomachache around 0800 [8:00 AM]. I checked the residents [Sic.] blood sugar and it was 301. The residents [Sic.] daughter called facility upset and stated that no one notified her of the medication error and that she was going to come take her mother to [hospital's name and city of location] because she is too high risk to go to [local hospital's name]. The daughter told me to not give her mother anymore insulin or medication until she takes her to [hospital's name]. The daughter also stated that she was going to call the police and her attorney. At approximately 1130 [11:30 AM] the daughter arrived with a police officer [Resident #1's name] walked out of the facility with her daughter at approximately 1200 [noon]. During an interview on 6/19/2023 at 11:00 AM, Staff I, Director of Nursing (DON), stated, Insulin is a high-risk medication that an error can cause problems with low blood sugars or with high blood sugars if they administer too much, the wrong kind or none. I was not aware that nurses were not administering insulin and documenting that it was being held because of parameters. There are no parameters for long-acting insulins in the residents' records. They should be administering these or at the very least calling and asking the doctor if they should administer the insulin when they do accuchecks [blood sugar monitoring]. This [medication error] was not reported to the physician when this occurred by the night nurse at 6:15 AM. It was not reported until about 11:30 in the morning. She came back in when [Assistant Director of Nursing's name] got hold of her. The staff should have called the doctor when the mistake occurred and obtained orders then. I can't tell you why she didn't. I'm not sure when the day shift nurse found out about the error. We did not look at all the residents' receiving insulin when the medication error was made. I didn't know that I needed to evaluate anyone else after [Staff A's name] made the mistake. They just don't know or have any common sense that would make them call the doctor. They clearly don't understand the difference between long and short acting insulins. I guess we need to train them. During an interview on 6/19/2023 at 11:41 AM, Staff A, LPN, stated, I was helping out that night. I usually work days and usually work the LTC [long term care] unit and picked up a shift. I read her order and she had two different insulins. One insulin looked like it was in the wrong bag. I thought it was too much insulin, I gave it, the long acting the Lantus. Then I reread the order after the resident told me she didn't get that kind until the night. After that I just waited for the day nurse. I did not notify the doctor. I guess I just didn't think it was necessary and then I spoke with the day nurse, and she didn't say to call the doctor. She said, well we will just wait and see what her blood sugar does. I should have called. [Assistant Director of Nursing's name] messaged me and asked about it. I told him what happened and came in to write the progress note and I called the doctor then. I explained what happened. He did not give any new orders because the resident was leaving with her daughter, who was taking her to the hospital. I did tell the oncoming nurse and she didn't seem too concerned because it was a long-acting insulin. She did not tell me to call the doctor before I left. The resident said to me after I told her what I administered that she took that [Lantus insulin] at night not in the morning. I double checked the MAR and saw she was right. She had been given her Lantus the evening before. I just didn't think about it at all. During a telephone interview on 6/19/2023 at 11:50 AM, Staff B, RN, stated, I came on shift and the night shift nurse told me she had given the wrong insulin. I didn't tell her to call the doctor, said she notified him. At about 8 AM [Resident #1's name] was going to breakfast, and she told me about the med error. At that time, she was complaining she was weak and had a stomachache. I didn't check her blood sugar then; she was going to eat, and I told her if she didn't feel better to let (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105846 If continuation sheet Page 27 of 36 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 105846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baya Pointe Nursing and Rehabilitation Center 587 SE Ermine Ave Lake City, FL 32025 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 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some me know. When she was coming back from breakfast, she was still feeling that way, so I got her to lay down. I went to do something else with another resident and then her daughter was on the phone, and I spoke to her. She was very upset, so I talked to her. After I got off the phone, I checked her insulin, and it was 301 at that time. After that, I spoke with her daughter and her daughter insisted I not give her anything more and stated she would take her to the ER because she didn't want her to go to anywhere but [hospital's name]. She told another nurse she was having chest pain sometime around then, but I wasn't worried about chest pain. I don't know why. I guess because her daughter was going to take her to the ER. I did not call the doctor about the chest pain or any other symptoms that she had. I should have called him. He was going to send her out and they would take her to [hospital's name] and I knew her daughter didn't want her to go there and so I just didn't think to call and notify him. I did not think to call 911 and let the resident or daughter refuse to go to the hospital. I should have. During a telephone interview on 6/19/2023 at 12:10 PM, the MD stated, I was not notified of this error when it occurred. I absolutely should have been notified and I would have ordered more frequent blood sugars to determine if there was a pattern of hypoglycemia [low blood sugar] and we would have been able to treat any potential hypoglycemic events. I was not aware that she had any episodes of chest pain or pressure, fatigue or abdominal discomfort. Again, I should have been notified and I would have had them send her to the hospital. During a telephone interview on 6/19/2023 at 12:30 PM, Resident #1 stated, I was having chest pain, sweating, and nausea when I left [NAME] Pointe because I was given the wrong insulin. So, my daughter brought me to [hospital's name] ED [Emergency Department]. I am still in the hospital now. But I'm not feeling too good. I don't think that my blood sugar was too low when I got to the hospital. I told them that they were giving me the wrong kind of insulin, but they didn't listen. They did not check my blood sugar after they did that. I told them when I went to breakfast that I wasn't feeling good, but they didn't listen. After breakfast, I told them again that I was having chest pains and feeling dizzy and nauseous, but they didn't listen until my daughter called. After that is when they checked on me. During an interview on 6/19/2023 at 1:41 PM, the Assistant Director of Nursing (ADON) stated, I was on call that day and don't remember what exact time I was called. Staff told me that the resident was being taken to the emergency room and that there had been a med error and what the error was. That the error was that Lantus had been given instead of the ordered insulin. I contacted the nurse, [Staff A's name], asked what happened. She explained everything. She did let me know that she had not contacted the doctor or completed any documentation. I told her that she needed to make sure she had an SBAR and MD notification documented. She stated she would come here immediately and come work on it. She should have immediately called the physician. I found out that the patient had chest pain also and that's why the family was so upset. We should have documented any symptoms and called the physician when she was having chest pain, and got an order to leave to the ED. If her daughter refused, because she didn't want [TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105846 If continuation sheet Page 28 of 36 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 105846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baya Pointe Nursing and Rehabilitation Center 587 SE Ermine Ave Lake City, FL 32025 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 0867 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews with a resident and staff, resident record reviews and review of the facility policies and procedures, the facility failed to develop and implement an appropriate plan of action to correct an identified quality deficiency when it was identified Resident #1 was administered a long-acting-insulin when a short acting insulin was ordered by the physician, and failed to identity 5 of 7 residents, Residents #2, #3, #4, #5, #6, were not administered physician ordered long-acting-insulin. The body must have insulin working 24 hours a day. If there is no long-acting insulin administered and rapid acting insulin is not given within the past 3-4 hours, it is likely that the body will make ketones and will be at risk of developing life-threatening diabetic ketoacidosis (DKA) or Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS). Extremely high blood glucose can lead to Hyperosmolar Hyperglycemic Nonketotic Coma (HHNK), a life-threatening complication of uncontrolled diabetes mellitus. This syndrome is characterized by severe hyperglycemia, a marked increase in serum osmolality, and clinical evidence of dehydration without significant accumulation of keto acids, which can result when diabetic medications aren't taken as directed. DKA is caused by an overload of ketones present in your blood. When the cells don't get the glucose they need for energy, the body begins to burn fat for energy, which produces ketones. Ketones are chemicals that the body creates when it breaks down fat to use for energy. DKA is a life-threatening problem that affects people with diabetes. It occurs when the body starts breaking down fat at a rate that is much too fast. The liver processes the fat into a fuel called ketones, which causes the blood to become acidic. Findings include: Review of the medical record for Resident #1 documented diagnosis to include type 2 diabetes mellitus and diabetic neuropathy. Review of the physician orders for Resident #1 dated 5/26/2023 read, Insulin Aspart Flexpen Subcutaneous Solution Pen- injector 100 unit/ml (Insulin Aspart) inject 21 units subcutaneously before meals related to type 2 diabetes mellitus with diabetic neuropathy. Review of the physician orders for Resident #1 dated 5/26/2023 read, Insulin Glargine Solostar Subcutaneous Solution Pen- injector 100 unit/ml (Insulin Glargine) inject 25 units subcutaneously at bedtime related to type 2 diabetes mellitus with diabetic neuropathy. Review of the MAR for Resident #1 for the period of 6/1/2023 to 6/4/2023 showed on 6/4/2023 at 6:00 AM, Staff A, LPN, documented 9 (other see nurses notes). Review of the nursing progress notes did not reveal a progress note on 6/4/2023 for 6:00 AM written by Staff A, LPN. Review of the change of condition SBAR (Situation, Background, Assessment and Recommendation) dated 6/4/2023 at 2:13 PM for Resident #1 read, A. Situation: 1 . gave Lantus instead of NovoLog this AM [morning]. 2. This started on: 06/04/2023 . C. Review and Notify. 1. Primary clinician notified: [Doctor's name]. 2. Date and Time notified: 06/04/2023 14:20 [2:20 PM]. 3. Recommendations of Primary Clinician (if any): no new orders . 7. Nursing Notes (for additional information on the Change in Condition): Notified MD [Medical Doctor], no new orders, informed him that family chose to take resident to ER [Emergency Room] in Gainesville. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105846 If continuation sheet Page 29 of 36 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 105846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baya Pointe Nursing and Rehabilitation Center 587 SE Ermine Ave Lake City, FL 32025 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 0867 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Review of the nursing progress note authored by Staff B, Registered Nurse (RN), dated 6/4/2023 at 5:33 PM for Resident #1 read, Resident stated that the night nurse had given her the wrong insulin. She stated that she told the nurse that it was the wrong insulin before the nurse gave it to her. Resident then complained of having chest pains and a stomachache around 0800 [8:00 AM]. I checked the residents [Sic.] blood sugar and it was 301. The residents [Sic.] daughter called facility upset and stated that no one notified her of the medication error and that she was going to come take her mother to [hospital's name and city of location] because she is too high risk to go to [local hospital's name]. The daughter told me to not give her mother anymore insulin or medication until she takes her to [hospital's name]. The daughter also stated that she was going to call the police and her attorney. At approximately 1130 [11:30 AM] the daughter arrived with a police officer [Resident #1's name] walked out of the facility with her daughter at approximately 1200 [noon]. Review of the medical record for Resident #6 documented diagnosis to include type 2 diabetes mellitus. Review of the physician orders for Resident #6 dated 7/13/2022 read, Lantus Solostar Subcutaneous Solution Pen-injector 100 unit/ml [milliliter] (Insulin Glargine) inject 10 units subcutaneously in the morning related to type 2 diabetes mellitus without complications. Review of the physician orders for Resident #6 dated 7/14/2022 read, Lantus Solostar Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine) inject 25 units subcutaneously at bedtime related to type 2 diabetes mellitus without complications. Review of the Medication Administration Record (MAR) for Resident #6 for the period of 4/1/2023 to 7/5/2023 showed on 4/1/2023 at 6:00 AM, Staff D, LPN (Licensed Practical Nurse) documented 11 (held per parameters) for Lantus Insulin, 4/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/2/23 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/3/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/4/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/4/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/5/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/7/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/8/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/8/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/9/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/9/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/10/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/13/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/13/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/14/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/17/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/18/2023 at 6:00 AM, Staff, C LPN, documented 11 (held per parameters) for Lantus Insulin, 4/18/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/19/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/21/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/22/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/22/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/23/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/23/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/24/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/26/2023 at 9:00 PM, Staff, C, LPN, documented 11 (held per parameters) for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105846 If continuation sheet Page 30 of 36 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 105846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baya Pointe Nursing and Rehabilitation Center 587 SE Ermine Ave Lake City, FL 32025 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 0867 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Lantus Insulin, 4/27/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/27/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 4/28/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/2/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/3/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/5/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/6/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/7/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/7/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/8/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/10/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/11/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/11/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/12/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/15/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/16/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/24/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/3/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/5/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/6/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/6/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/7/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/14/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/14/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/19/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/20/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/21/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/21/2023 at 9:00 PM, Staff, D LPN, documented 11 (held per parameters) for Lantus Insulin, 6/22/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Insulin, 7/1/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 7/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 7/3/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin. Review of the medical record for Resident #4 documented diagnosis to include type 2 diabetes mellitus. Review of the physician orders for Resident #4 dated 3/7/2023 read, Levemir Flexpen Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Detemir) inject 35 units subcutaneously at bedtime related to Type 2 diabetes mellitus without complications. Review of the MAR for Resident #4 for the period of 4/1/2023 to 7/5/2023 showed on 4/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/3/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/4/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/7/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/8/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/9/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/12/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/13/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/17/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/18/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105846 If continuation sheet Page 31 of 36 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 105846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baya Pointe Nursing and Rehabilitation Center 587 SE Ermine Ave Lake City, FL 32025 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 0867 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Levemir Flexpen, 4/21/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/22/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/23/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/26/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 4/27/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/1/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/2/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/5/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/6/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/16/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/22/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/25/2023 at 9:00 PM, Staff A, LPN, documented 11 (held per parameters) for Levemir Flexpen, 5/30/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/2/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/3/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/5/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/6/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/7/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/19/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/20/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/21/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/26/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/30/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen, 7/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Levemir Flexpen. Review of the medical record for Resident #5 documented diagnosis to include type 2 diabetes mellitus. Review of the physician orders for Resident #5 dated 4/5/2023 read, Lantus Solostar Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine) inject 45 units subcutaneously every morning and at bedtime related to type 2 diabetes mellitus without complications. Review of the MAR for Resident #5 for the period of 4/1/2023 to 7/5/2023 showed on 4/7/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/8/2023 at 8:00 PM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/9/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/11/2023 at 8:00 PM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/12/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/13/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/13/2023 at 8:00 PM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/17/2023 at 6:00 AM, Staff F, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/18/2023 at 8:00 PM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/19/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 4/21/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 4/21/2023 at 8:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 4/22/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 4/23/2023 at 6:00 AM, Staff C, LPN, documented 11 (held per parameters) for Lantus Solostar, 4/25/2023 at 8:00 PM, Staff G, LPN, documented 11 (held per parameters) for Lantus Solostar, 4/26/2023 at 6:00 AM, Staff G, LPN, documented 5 (hold see nurses notes) for Lantus Solostar, 4/27/2023 at 6:00 AM, Staff E, LPN, documented 11 (held per parameters) for Lantus Solostar, 5/2/2023 at 6:00 AM, Staff E, LPN, documented 11 (held per parameters) for Lantus Solostar, 5/5/2023 at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105846 If continuation sheet Page 32 of 36 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 105846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baya Pointe Nursing and Rehabilitation Center 587 SE Ermine Ave Lake City, FL 32025 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 0867 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 8:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 5/6/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 5/11/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 5/12/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 5/15/2023 at 8:00 PM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 5/17/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 5/20/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 6/2/2023 at 8:00 PM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 6/3/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 6/9/2023 at 6:00 AM, Staff E, LPN, documented 12 (insulin not required) for Lantus Solostar, 6/13/2023 at 6:00 AM, Staff H, LPN, documented 12 (insulin not required) for Lantus Solostar, 6/15/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 6/19/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar, 6/23/2023 at 6:00 AM, Staff H, LPN, documented 9 (other see nursing note) for Lantus Solostar, 6/30/2023 at 8:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Solostar, 7/1/2023 at 6:00 AM, Staff D, LPN, documented 11 (held per parameters) for Lantus Solostar. Review of the medical record for Resident #2 documented diagnosis to include type 2 diabetes mellitus. Review of the physician orders for Resident #2 dated 4/6/2023 read, Levemir Flexpen Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Detemir) inject 35 units subcutaneously at bedtime related to type 2 diabetes mellitus without complications. Review of the MAR for Resident #2 for the period of 6/1/2023 to 6/19/2023 showed on 6/6/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen, 6/14/2023 at 9:00 PM, Staff D, LPN, documented 11 (held per parameters) for Levemir Flexpen. Review of the medical record for Resident #3 documented diagnosis to include type 2 diabetes mellitus. Review of the physician orders for Resident #3 dated 3/10/2023 read, Insulin Glargine Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine) inject 35 units subcutaneously at bedtime related to Type 2 diabetes mellitus without complications. Review of the MAR for Resident #3 for the period of 5/1/2023 to 6/19/2023 showed on 5/1/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/2/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/6/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/7/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/10/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/11/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/16/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/20/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 5/29/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/4/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/2/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/8/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/12/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/13/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin, 6/16/2023 at 9:00 PM, Staff C, LPN, documented 11 (held per parameters) for Lantus Insulin. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105846 If continuation sheet Page 33 of 36 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 105846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baya Pointe Nursing and Rehabilitation Center 587 SE Ermine Ave Lake City, FL 32025 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 0867 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some During an interview on 6/19/2023 at 11:00 AM, Staff I, Director of Nursing (DON), stated, Insulin is a high-risk medication that an error can cause problems with low blood sugars or with high blood sugars if they administer too much, the wrong kind or none. I was not aware that nurses were not administering insulin and documenting that it was being held because of parameters. There are no parameters for long-acting insulins in the residents' records. They should be administering these or at the very least calling and asking the doctor if they should administer the insulin when they do accuchecks [blood sugar monitoring]. This [medication error] was not reported to the physician when this occurred by the night nurse at 6:15 AM. It was not reported until about 11:30 in the morning. She came back in when [Assistant Director of Nursing's name] got hold of her. The staff should have called the doctor when the mistake occurred and obtained orders then. I can't tell you why she didn't. I'm not sure when the day shift nurse found out about the error. We did not look at all the residents' receiving insulin when the medication error was made. I didn't know that I needed to evaluate anyone else after [Staff A's name] made the mistake. They just don't know or have any common sense that would make them call the doctor. They clearly don't understand the difference between long and short acting insulins. I guess we need to train them. During an interview on 6/19/2023 at 11:41 AM, Staff A, LPN, stated, I was helping out that night. I usually work days and usually work the LTC [long term care] unit and picked up a shift. I read her order and she had two different insulins. One insulin looked like it was in the wrong bag. I thought it was too much insulin, I gave it, the long acting the Lantus. Then I reread the order after the resident told me she didn't get that kind until the night. After that I just waited for the day nurse. I did not notify the doctor. I guess I just didn't think it was necessary and then I spoke with the day nurse, and she didn't say to call the doctor. She said, well we will just wait and see what her blood sugar does. I should have called. [Assistant Director of Nursing's name] messaged me and asked about it. I told him what happened and came in to write the progress note and I called the doctor then. I explained what happened. He did not give any new orders because the resident was leaving with her daughter, who was taking her to the hospital. I did tell the oncoming nurse and she didn't seem too concerned because it was a long-acting insulin. She did not tell me to call the doctor before I left. The resident said to me after I told her what I administered that she took that [Lantus insulin] at night not in the morning. I double checked the MAR and saw she was right. She had been given her Lantus the evening before. I just didn't think about it at all. During a telephone interview on 6/19/2023 at 11:50 AM, Staff B, RN, stated, I came on shift and the night shift nurse told me she had given the wrong insulin. I didn't tell her to call the doctor, said she notified him. At about 8 AM [Resident #1's name] was going to breakfast, and she told me about the med error. At that time, she was complaining she was weak and had a stomachache. I didn't check her blood sugar then; she was going to eat, and I told her if she didn't feel better to let me know. When she was coming back from breakfast, she was still feeling that way, so I got her to lay down. I went to do something else with another resident and then her daughter was on the phone, and I spoke to her. She was very upset, so I talked to her. After I got off the phone, I checked her insulin, and it was 301 at that time. After that, I spoke with her daughter and her daughter insisted I not give her anything more and stated she would take her to the ER because she didn't want her to go to anywhere but [hospital's name]. She told another nurse she was having chest pain sometime around then, but I wasn't worried about chest pain. I don't know why. I guess because her daughter was going to take her to the ER. I did not call the doctor about the chest pain or any other symptoms that she had. I should have called him. He was going to send her out and they would take her to [hospital's name] and I knew her daughter didn't want her to go there and so I just (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105846 If continuation sheet Page 34 of 36 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 105846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baya Pointe Nursing and Rehabilitation Center 587 SE Ermine Ave Lake City, FL 32025 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 0867 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some didn't think to call and notify him. I did not think to call 911 and let the resident or daughter refuse to go to the hospital. I should have. During a telephone interview on 6/19/2023 at 12:10 PM, the MD stated, I was not notified of this error when it occurred. I absolutely should have been notified and I would have ordered more frequent blood sugars to determine if there was a pattern of hypoglycemia [low blood sugar] and we would have been able to treat any potential hypoglycemic events. I was not aware that she had any episodes of chest pain or pressure, fatigue or abdominal discomfort. Again, I should have been notified and I would have had them send her to the hospital. During a telephone interview on 6/19/2023 at 12:30 PM, Resident #1 stated, I was having chest pain, sweating, and nausea when I left [NAME] Pointe because I was given the wrong insulin. So, my daughter brought me to [hospital's name] ED [Emergency Department]. I am still in the hospital now. But I'm not feeling too good. I don't think that my blood sugar was too low when I got to the hospital. I told them that they were giving me the wrong kind of insulin, but they didn't listen. They did not check my blood sugar after they did that. I told them when I went to breakfast that I wasn't feeling good, but they didn't listen. After breakfast, I told them again that I was having chest pains and feeling dizzy and nauseous, but they didn't listen until my daughter called. After that is when they checked on me. During an interview on 6/19/2023 at 1:41 PM, the Assistant Director of Nursing (ADON) stated, I was on call that day and don't remember what exact time I was called. Staff told me that the resident was being taken to the emergency room and that there had been a med error and what the error was. That the error was that Lantus had been given instead of the ordered insulin. I contacted the nurse, [Staff A's name], asked what happened. She explained everything. She did let me know that she had not contacted the doctor or completed any documentation. I told her that she needed to make sure she had an SBAR and MD notification documented. She stated she would come here immediately and come work on it. She should have immediately called the physician. I found out that the patient had chest pain also and that's why the family was so upset. We should have documented any symptoms and called the physician when she was having chest pain, and got an order to leave to the ED. If her daughter refused, because she didn't want to go to the nearest hospital, then she refused. But we did not call and get orders to send her out of the facility to the hospital and we should have. During an interview conducted on 6/19/2023 at 3:20 PM, Staff I, Director of Nursing (DON), stated, Each time 11 is documented the medication was not given per parameters, the nurses did not administer the long-acting insulin. Reviewing the orders, I see that there are no parameters to hold the medication and the insulin should have been administered. They were not following doctors' orders. They were not following the policies for medication administration and holding medications. They should have called the doctor if they were concerned about administering the medications. I have no idea why they would have held the insulin. I guess this is an education thing. They just don't know any better. I just don't know why they did this. During an interview on 7/5/2023 at 10:30 AM, the Administrator stated, I don't know exactly what has been done. I know that the DON left and that we have a new interim DON. She does know about this. There are no additional medication observations that have been done. There are no audits that I can find. I have given you everything that we have done since your last visit. I do have the ultimate responsibility for this along with the DON. We have not met about what was completed and what was not done. We were going to have another QAPI on Friday. I don't know if we evaluated residents who needed insulin to see the extent of our problem. I don't see any audits were completed. I don't see that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105846 If continuation sheet Page 35 of 36 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 105846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baya Pointe Nursing and Rehabilitation Center 587 SE Ermine Ave Lake City, FL 32025 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 0867 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some we notified the resident representative or the doctors that residents weren't being given their insulin and we weren't following doctor's orders. I don't think we notified the medical director. We should have done all of that. During an interview on 7/5/2023 at 11:55 AM, Staff J, DON, stated, We don't have any additional training or education to show you. We don't have any audits of residents who are getting insulin to see if they were administered their insulin correctly after the medication error for that resident. I do see that staff are still holding long-acting insulins for parameters that don't exist. There really wasn't any investigation into why they were doing this that I am able to find. I do see that some staff have been trained in medication administration and insulin use, but not enough. There are no other medication observations done. There are only four with one that is a repeated staff, so only three staff have had the medication pass observation done. I can't find any audits and I'm not sure what was audited. We have called all staff and asked them to come in to be in-serviced and observed, so we are starting that. I will look at all residents who are on insulin to see how big a problem we have, to see if it's just a few staff or more than that. I am planning to reeducate them, and I will do an RCA [Root Cause Analysis] to figure out any other problems we are having or anything else we might need to do. I literally just started on Friday and didn't realize how little was completed. There is no reason why the insulins were held on any of the residents. We do not have any parameters for holding long-acting insulin. There were no physician orders for parameters to hold the insulin. We should have been following doctors' orders. We should have called the doctors and asked. This was not done. During a telephone interview on 7/5/2023 at 2:10 PM, Staff C, LPN, stated, I was not really given a good in-service about insulin or medication errors. She told me to sign a piece of paper, the other DON. I did not get any text messages. I didn't know that we shouldn't hold the insulin, that we needed parameters to hold it. My understanding was that anything under 150, we should not administer the insulin. I guess I just assumed that from the sliding scales maybe. Also, I was holding some insulin when residents didn't want to take it because they knew that would make them drop lower and I was documenting it as 11, which is wrong, and they told me in the in-service today. I did come in today and have the in-service with the DON. We went over neglect, insulin long and short acting, parameters with short acting, that we will call doctors if we have concerns, changes in condition, medication errors and making sure we notify doctors and families. We did an insulin demonstration too. During a telephone interview on 7/5/2023 at 2:35 PM, Staff D, LPN, stated, I did hold insulin for low blood sugars. Just through the years I was told that if the blood sugars are less than 150 not to administer the insulin because it would drop it lower. I did not have a doctor's order to hold the insulin and I did not call when I wasn't giving the insulin. I should have administered the insulin if there were no parameters to hold it. I was not following doctors' orders when I held those insulins if there were no parameters written in the orders. [TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105846 If continuation sheet Page 36 of 36