Health inspection·August 14, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to administer medications as ordered by the physician for 1 of 5 residents, Resident #2, reviewed for unnecessary medications.Findings include:Review of Resident #2's admission record documented diagnosis that include end stage renal disease, chronic systolic congestive heart failure, type 2 diabetes mellitus with diabetic chronic kidney disease, and essential primary hypertension.Review of Resident #2's physician order dated 4/29/25 read, Entresto Oral Tablet 24-26 MG [milligrams] (Sacubitril-Valsartan) Give 0.5 tablet by mouth two times a day related to essential primary hypertension.Review of Resident #2's August Medication Administration Record documented Entresto had a chart of code 4 (4=outside parameters) on 8/2/2025 at 0900 (9:00 AM), on 8/3/2025 at 0900 and 2100 (9:00 PM), and on 8/6/2025 at 0900. Review of Resident #2's nursing and medication administration notes for the period of 8/1/2025 through 8/9/2025 did not contain documentation of the physician being notified the Entresto was not being administered as ordered by the physician.During an interview on 8/12/2025 at 2:20 PM Staff F, Registered Nurse (RN), one of the licensed staff who was documented as not administering the Entresto, stated, I did hold her [Resident #2] blood pressure medication. Her pressure was low. There are no parameters for that medication. I could have called the doctor to see. I should follow all doctors' orders.During an interview on 8/13/2025 at 1:05 PM Staff G, Licensed Practical Nurse (LPN), one of the licensed staff who was documented as not administering the Entresto, stated, I did hold her [Resident #2] medicine. I don't see that there are any parameters. I wasn't following the orders to give the med. I should follow them. I didn't call anyone I just held it.Review of the policy and procedure titled, Medication Administration with a last approval date of 4/25/2025 read, Standard: Medications are ordered and administered safely and as prescribed. Procedure: 16. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document the rational in the resident's medical record and notify the physician and responsible party. Residents Affected - Few Page 1 of 6 105846 105846 08/14/2025 Baya Pointe Nursing and Rehabilitation Center 587 SE Ermine Ave Lake City, FL 32025

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide respiratory services consistent with professional standards of practice for oxygen administration for 2 of 5 residents, Residents #86 and #87, reviewed for oxygen therapy.Findings include:During an observation on 8/12/2025 at 9:37 AM Resident #87 was observed being administered oxygen via tracheostomy mask at 4 liters per minute by an oxygen concentrator. On the oxygen concentrator was a humidification bottle (used to hold distilled water to add moisture to the oxygen therapy airflow to prevent dryness and irritation that can occur from breathing dry oxygen for extended periods) dated 8/12/25 and the bottle was empty. During an observation on 8/12/2025 at 11:35 AM Resident #87 was observed in bed with the head of bed elevated, and was observed with oxygen being administered via tracheostomy mask at 4 liters of oxygen per minute by an oxygen concentrator. On the oxygen concentrator was a humidification bottle dated 8/12/25 and the bottle was empty. Review of Resident #87's admission record documents diagnosis that include encephalopathy, unspecified, acute respiratory failure unspecified whether with hypoxia or hypercapnia, pneumonia due to other specified bacteria, chronic respiratory failure unspecified whether with hypoxia or hypercapnia, and tracheostomy.Review of Resident #87's physician order dated 8/7/2025 read, Trach [tracheostomy]: Encourage and assist resident with use of humidified oxygen 28%/5 liters via trach collar.Review of Resident #87's physician order dated 8/7/2025 read, Trach: Change Oxygen tubing/humidification bottle/mask, etc. Q [every] week and PRN [as needed] every night shift every Sun [Sunday] and as needed.Review of Resident #87's care plan documented a focus of, Resident has a tracheostomy and is at risk for complications regarding tracheostomy status and interventions that include administer O2 [oxygen] as ordered.During an interview on 8/12/2025 at 12:47 PM Staff D, Licensed Practical Nurse (LPN) stated, The amount of oxygen is not right. I will check the order. The humification is empty, I need to change that.During an interview on 8/14/2025 at 1:00 PM the Director of Nursing (DON) stated, They [licensed nursing staff] should be checking oxygen levels and making sure they are accurate. They should follow physician orders. We should have the tracheostomy with humidification at all times and not have it empty. During an observation on 8/11/2025 at 12:32 PM Resident #86 was observed in bed with the head of bed elevated and oxygen being administered at 4 liters per minute via nasal cannula by an oxygen concentrator. The oxygen concentrator was on the side of the bed, not within the resident's reach.During an observation on 8/12/2025 at 8:03 AM Resident #86 was observed having oxygen administered at 4 liters via nasal cannula by an oxygen concentrator. The concentrator was not within the resident's reach.Review of Resident #86's admission record documented diagnosis that include chronic obstructive pulmonary disease (COPD) unspecified, type 2 diabetes mellitus without complications, heart failure unspecified, anemia unspecified, and essential primary hypertension.Review of Resident #86's physician order dated 8/6/2025 read, Respiratory-Oxygen: NC [nasal cannula]/Mask. Encourage and assist resident to use O2 [oxygen] @ [at] 2 (specify Liters) via (specify NC/Mask) as needed for SOB [shortness of breath]/DOE [dyspnea on exertion].Review of Resident #86's comprehensive care plan documented a focus of, The resident is at risk for altered respiratory status/difficulty breathing r/t [related to] COPD/Emphysema. Interventions: administer oxygen as ordered.During an interview on 8/12/2025 at 8:05 AM Staff E, RN stated, Her oxygen [order] is for 2 liters. Staff E confirmed the concentrator was administering oxygen to Resident #86 at 4 liters, then stated, I don't know how that happened.Review of the policy and procedure titled, Oxygen Administration, with a last approval date of 4/25/2025 read, Standard: The purpose of this procedure is to provide guidelines for oxygen administration. Procedure: 1. Review the physician's order for oxygen administration. General guidelines: 3. Adjust the oxygen delivery device so that it is comfortable on Residents Affected - Few 105846 Page 2 of 6 105846 08/14/2025 Baya Pointe Nursing and Rehabilitation Center 587 SE Ermine Ave Lake City, FL 32025

F 0695 the resident and the appropriate flow of oxygen is being administered according to the resident's needs. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105846 Page 3 of 6 105846 08/14/2025 Baya Pointe Nursing and Rehabilitation Center 587 SE Ermine Ave Lake City, FL 32025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to prevent the possible spread of infection when failing to ensure staff followed infection control standards for enhanced barrier precautions for 1 of 3 residents, Resident #88 reviewed for incontinence care and failing to ensure hand hygiene was performed during medication administration for 2 of 6 observations of medication administration.Findings Include Residents Affected - Few During an observation on 8/13/2025 at 9:22 AM there was a sign on Resident #88’s door which read, “Enhanced Barrier Precautions (a set of infection control practices designed to reduce the spread of multidrug-resistant organisms).” Staff A, Licensed Practical Nurse (LPN) and Staff B, Certified Nursing Assistant (CNA) were observed providing incontinent care for Resident #88. Staff A and Staff B were not wearing gowns. During an interview on 8/13/2025 at 9:30 AM the Director of Nursing (DON) verified Resident #88 had a physician’s order for enhanced barrier precautions and staff should have worn a gown and gloves when providing direct patient care. During an interview on 8/13/2025 at 9:33 AM Staff B, CNA stated, “When a resident is on enhanced barrier precautions, we should wear gloves and a gown when providing patient care. When I changed [Resident #88’s name] I was not wearing a gown. I should have been wearing a gown” During an interview on 8/13/2025 at 9:35 AM Staff A, LPN confirmed she and [Staff B, CNA’s name] were changing [Resident #88’s name] and were not wearing gowns. Staff A, LPN stated, “When a resident is on enhanced barrier precautions, we should wear gloves and a gown while providing incontinence care.” Review of Resident #88 medical record documented an admission date of 8/7/2025 with medical diagnoses including gastrostomy (also known as a g-tube, is a surgical procedure that creates an opening in the stomach through the abdominal wall to provide nutrition and medications directly into the stomach). Review of Resident #88’s physician order dated 8/12/2025 read, Enhanced Barrier: Encourage and assist resident to maintain enhanced barrier precautions for GTUBE Review of Resident #88’s care plan dated 8/8/2025 read, Focus: Resident requires Enhanced Barrier Precautions during high contact resident care activities r/t [related to] wounds when colonization or actual MDRO [Multi-Drug Resistant Organism] is present, indwelling medical devices examples include, but are not limited to central lines, indwelling urinary catheters, feeding tubes, tracheostomy tubes. Interventions- Enhanced Barrier Precautions DURING HIGH CONTACT CARE ACTIVITIES dressing, bathing, showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting. Review of the policy and procedure titled, “Enhanced Barrier Precautions” with a review date of 4/25/2025 read, “Guideline: The facility will decrease the transmission of multidrug-resistant organisms (MDRO) by maintaining infection control standards. Definitions: Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multi-drug resistant organisms that employs targeted gown and glove use during high contact resident care activities. 1. Enhanced Barrier Precautions (EBP) are used for residents with any of the 105846 Page 4 of 6 105846 08/14/2025 Baya Pointe Nursing and Rehabilitation Center 587 SE Ermine Ave Lake City, FL 32025

F 0880 Level of Harm - Minimal harm or potential for actual harm following: Wounds and/or indwelling medical devices even if the resident is not known to be colonized with MDRO. Indwelling Medical Devices include the following: c. Feeding tubes. 9. Appropriate Personal Protective Equipment (PPE) for EBP would include: a. Gown b. Gloves. 10. Employees should wear appropriate PPE when performing the following duties for residents requiring EBP: a. Dressing. b. Providing hygiene; e. Changing linens; f. Providing pericare such as changing briefs” Residents Affected - Few During an observation of medication administration on 8/14/2025 at 5:05 AM for Resident #88 Staff C, LPN approached the medication cart, reached into their uniform pocket, removed the keys, unlocked the medication cart, activated the computer and typed on the computer without performing hand hygiene. Staff C, LPN removed all the medications order for Resident #88 and crushed each medication separately. Staff C, LPN entered Resident #88's room without performing hand hygiene, moved the bedside table closer to the resident and assembled all the gastrostomy tube supplies. Staff C, LPN returned to the medication cart, did not perform hand hygiene, unlocked the cart, and removed additional supplies. Staff C, LPN then donned gloves and a gown without performing hand hygiene and entered the resident’s room. Staff C, LPN administered the medications, repositioned Resident #88 in the bed, doffed the gown and gloves and returned to the medication cart without performing hand hygiene and began to prepare medications for another resident. During an observation of medication administration on 8/14/2025 at 5:13 AM Staff C, LPN did not perform hand hygiene, prepared Resident #37’s medications and supplies to take a blood pressure and to perform an accucheck (used to monitor blood sugar levels). Staff C entered Resident #37's room without performing hand hygiene, donned gloves without performing hand hygiene, used an alcohol swabbed on the resident’s finger and performed an accucheck. Staff C exited the resident’s room after removing the gloves, went to the medication cart, removed the keys for the medication cart from their pocket, was not able to locate the ordered insulin, lock the medication cart and went to the medication room. Staff C, LPN unlocked the medication room door, obtained the ordered insulin, returned to the medication cart, unlocked the cart after retrieving the keys from their pocket, opened the computer, typed and reviewed the insulin orders. Staff C, LPN returned to the Resident #37's room, donned gloves without performing hand hygiene and administered the insulin and oral medications. Staff C doffed the gloves and returned to the medication cart without performing hand hygiene and began to prepare medications for another resident. During an interview on 8/14/2025 at 5:45 AM Staff C, LPN stated, I should have used the hand sanitizer every time I got the medicines, and before and after I put on or took off my gloves. Review of the policy and procedure tilted “Hand Hygiene Infection Control” with a last approval date of 4/25/2025 read, “Standard: Hand hygiene is the single most important measure for preventing the spread of infection. Guideline: This facility shall require facility personnel to use accepted hand hygiene after each direct resident contact for which hand hygiene is indicated. Procedure: The Facility acknowledges the CDC (Centers for Disease Control) guidelines to improve adherence to hand hygiene in health care settings. The hand hygiene guidelines are part of an overall CDC strategy to reduce infections in healthcare settings to promote resident safety. These guidelines state that hand washing is necessary when healthcare personnel's hands are visibly soiled. When hands are not visibly soiled, the CDC recommends the use of alcohol based hand rubs by health care personnel for resident care to address the obstacles that health care professionals face when taking care of residents. Patients that require hand hygiene include, but are not limited to: before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice): before and after performing any invasive procedure (e.g. finger stick blood sampling): upon and after coming in contact with residents intact skin (e.g. when taking a pulse or blood pressure, and 105846 Page 5 of 6 105846 08/14/2025 Baya Pointe Nursing and Rehabilitation Center 587 SE Ermine Ave Lake City, FL 32025

F 0880 lifting a resident) Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105846 Page 6 of 6