Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0600
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment,
and neglect by anybody.
Level of Harm - Actual harm
Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to protect the resident's right to be free from neglect for one
resident (#1) out of seven sampled residents. Resident #1 sustained an unwitnessed fall on 08/21/25 and
was not assessed after the fall. Resident #1 complained of hip pain on 08/23/25, an X-ray was obtained on
08/24/25 and Resident #1 was transferred to a higher level of care due to a right hip fracture on 08/24/25
and required surgical intervention.Findings included: An interview was conducted with Resident #2 on
09/02/2025 at 10:08a.m. Resident #2 was the roommate of Resident #1 and recalled the events of
08/21/2025 when Resident #1 had a fall. She stated the night of her roommate's fall; she was starting to fall
asleep when she heard a loud sound and heard her roommate grunting ouch. Resident #2 said she
remembered seeing her roommate in her wheelchair near the door shortly before the fall, but she was
unsure as to what she was doing when the actual fall occurred. After she heard her roommate grunting
ouch she immediately pushed her call light to get help and began yelling out for help. Resident #2 said it
took ten minutes for staff to respond. Resident #2 stated she heard someone come into the room and then
call for a second person to assist. She assumed the facility was following their protocol and taking care of
the roommate until two days later when other staff members asked her if Resident #1 had fallen. Resident
#2 said after the fall she had mentioned to staff, more than once, that her roommate seemed to be in pain
and then she later found out she had broken her hip.An interview was attempted with Resident #1 on
09/02/25 at 9:25 AM, 1:30 PM, and 2:45 PM. Resident #1 was in bed with eyes closed for all three interview
attempts.Review of Resident #1's admission Record revealed an admission date of 01/14/25 and
readmitted on [DATE]. Resident #1's diagnoses included fracture of unspecified part of the neck of right
femur with an onset date of 08/27/25. Other diagnoses included muscle weakness, reactive arthropathies,
unspecified site., dementia without behavioral disturbances, osteoarthritis, anxiety disorder, arthritis,
abnormalities of gait and mobility, lack of coordination, and metabolic encephalopathy. Review of Resident
#1's Minimum Data Set (MDS), dated [DATE], Section C Cognitive Patterns, revealed a Brief Interview for
Mental Status (BIMS) score of 11 out of 15 indicating moderate cognitive impairment. Review of Resident
#1's medical record did not reveal any documentation or assessments related to a fall on 08/21/25.Review
of Resident #1's progress notes revealed the following:On 08/23/25 at 10:10 AM a late entry note revealed,
Resident's [family] was called at 10:07AM. I informed [family] that [Resident #1's] hip was broken and asked
him what hospital he wanted her sent out to, .said [Hospital].On 08/23/25 at 5:00 PM revealed The Change
In Condition/s reported on this CIC [change in condition] are/were: Falls.On 08/23/25 at 5:12 PM revealed
Resident has a fall in room according to roommate. Resident is c/o [complaint of] Right hip/pelvis pain when
leg is moved. MD [Medical Doctor] called and X-Ray ordered.On 08/23/25 at 5:20 PM a late entry note
revealed Resident's [family] was called also and made aware that X-ray was being done due to possible fall
with injuries. Pain medication was given
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
105117
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
105117
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/02/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
South Heritage Health & Rehabilitation Center
718 Lakeview Ave S
Saint Petersburg, FL 33705
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 - Actual harm
Residents Affected - Few
Tylenol 500mg [milligrams] two tabs for pain with effective results. Resident stopped crying out and was
lying in bed quietly.On 08/24/25 at 10:17 AM revealed Resident is being sent out to [Hospital] due to
fracture of right hip.On 8/27/25 at 7:15 PM revealed patient returned from hospital via stretcher
accompanied by EMS [Emergency medical Service] team.On 8/28/25 at 3:38 AM revealed, Resident status
post right hip hemiarthroplasty with multiple sutures on right hip clean dry dressing intact. Abdominal binder
in place due to replacement of peg tube that was dislodged while in hospital. Resident in bed at this time
wither periods of moaning. PRN [as needed] medication administered for pain. Will continue to monitor.A
review of Resident #1's hospital records revealed the following Assessment/Plan: Patient presented to
hospital initially after sustaining a hip fracture after ground-level fall, underwent repair on 8/25/2025.
Indication for surgery: Right displaced femoral neck fracture. Scheduled Procedure: 8/25/25 12:30 PM right
hip hemiarthroplasty.Fortunately her PEG tube has become dislodged.will plan for EGD
[esophagogastroduodenoscopy] with PEG [percutaneous endoscopic gastrostomy] insertion today,
8/26/2025.Risks, benefits and alternatives of endoscopic procedure discussed.including but not limited to
infection, bleeding, perforation and need for surgery or repeat procedures or blood transfusion or
hospitalization. Other risks include complications related to sedation. Death is a rare event.An interview was
conducted on 09/02/2025 at 1:20 PM with the Nursing Home Administrator (NHA), Director of Nursing
(DON), and the Risk Manager. The NHA stated around 11:20 p.m. on Sunday 08/23/2025 she received a
phone call notifying her that Resident #1 had fallen a few days prior and had been experiencing pain.
Orders for an x-ray had been put in and the next morning the x-ray showed the resident to have a hip
fracture. The NHA stated at that point they immediately began an investigation, filed an injury of unknown
origin report was filed. Their investigation revealed the resident did have a fall, but the nurse who was
assigned to Resident #1, Staff F, Registered Nurse (RN), put the resident back in bed with the assistance of
the Certified Nursing Assistant (CNA), but never completed the post-fall assessment as was required by the
facilities protocol. No documentation about the fall was made and the nurse did not notify anyone after the
fall. The Risk Manager stated all fall precautions were in place prior to the resident falling, however they
recognized room for improvement on what happened after the fall. The NHA stated Resident #1 went to the
hospital, had hip surgery, came back to the facility and had been kept comfortable with pain medication.An
interview was conducted with the DON on 09/02/2025 at 2:35 PM. The DON stated her expectation for the
staff after finding a resident on the floor after an unwitnessed fall would be a full post-fall assessment be
performed with neuro checks and range of motion to the extremities before ever moving that resident back
into bed. The DON said if Resident #1 was complaining of any pain or if there was any suspected injury
they should have immediately called 911 and not moved the resident at all. The DON said in the instance of
Resident #1's fall on 08/21/25, the DON should have been notified as well as the NHA, the doctor, and
family or responsible party. The DON said she knew the ball was definitely dropped in Resident #1's
situation and unfortunately, they had to let go of three nurses because of it. An attempt was made on
09/02/25 to interview Resident #1's physician as well as Staff F, RN via phone. Neither the Physician nor
Staff F, RN, returned the call. Review of the facility's Fall and Injury Reduction Policy, with an effective date
of March 2023 revealed: The facility has designated and implemented processes, which strive to reduce the
risk for falls and injuries.This policy guides the identification, implementation of appropriate interventions,
and management. It is expected that this policy will assist the facility with reducing the likelihood of a fall or
injury while maintaining or maximizing dignity and independence through education of staff and residents,
early identification of risk factors by collecting data, identifying resident behavior which may increase the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105117
If continuation sheet
Page 2 of 3
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
105117
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/02/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
South Heritage Health & Rehabilitation Center
718 Lakeview Ave S
Saint Petersburg, FL 33705
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 - Actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
likelihood of such occurrence.Guidelines.Status Post witnessed/unwitnessed Fall or observed on floor
eventNurse will evaluate the resident for signs/symptoms of injury.Do no[sic] move the resident from the
floor until a nurse has evaluated.If no signs/symptoms of injury assist resident from floor using a
Mechanical lift unless resident is can actively assist in getting off the floor.Notification of Resident/patient
Change in ConditionNurses will notify the resident/residents representative., if there is a crucial/significant
change in the resident condition. If the change in the resident's condition is not crucial or significant, the
resident's Physician, resident representative or legal representative will be notified at the earliest
convenient time during regular business hours.Procedure1. Notify the Physician resident/resident
representative, and case management when indicated, if there is a significant change in condition,
regardless of the time of day.a. If the nurse responsible for the care of the resident is remaining with the
resident and is unable to place the telephone calls, another nurse will place the calls.2. Document the
Nurses' Notes, the time notification was made and the names of the person(s) to whom you spoke.Serious
Injury1. If there are signs/symptoms of serious injury,Signs/symptoms of a serious injury, may include, but
not limited to:a. fracture/broken/displaced bone,b. head injury identified by change in mental status, change
in neuro checks such as one pupil larger than the other, experience weakness, numbness, decreased
coordination, convulsions, or seizure, have slurred speech or unusual behavior have a headache that gets
worse and does not go away or vomit repeatedly.c. Skin or tissue injury with blood loss greater than that of
a skin tear or minor injury, etc.Provide first aide if needed.2. Ask the resident and/or witnesses what
happened.3. Obtain vital signs and document in the medical record.4. Start neurological checks.5. Notify
Supervisor6. Notify physician with evaluation and request further instruction.7. Notify the resident
representative of the fall, new intervention, and/or care given, or location transferred.8. Update the care
plan with new intervention, communicate to the care staff to the oncoming nurses and C.N. A's during
shift-to-shift report.9. Verify the newly determined interventions have been implemented10. Educate
resident/resident representative/ family, as appropriate.11. Document the event in the medical record.
Review of the facility's Clinical Guidelines Manual, with an effective date of October 2021 revealed,
Notification of Resident/Patient Change in ConditionPolicyNurses will notify the resident/resident
representative, if there is a crucial/significant change in the resident condition. If the change in the
resident's condition is not crucial or significant, the resident's Physician, resident representative or legal
representative will be notified at the earliest convenient time during regular business hours.Procedure1.
Notify the Physician resident/resident representative, and case management when indicated, if there is a
significant change in condition, regardless of the time of day.a. If the nurse responsible for the care of the
resident is remaining with the resident and is unable to place the telephone calls, another nurse will place
the calls.2. Document the Nurses' Notes, the time notification was made and the names of the person(s) to
whom you spoke.
Event ID:
Facility ID:
105117
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
FAQ · About this visit
Common questions about this visit
What happened during the September 2, 2025 survey of SOUTH HERITAGE HEALTH & REHABILITATION CENTER?
This was a inspection survey of SOUTH HERITAGE HEALTH & REHABILITATION CENTER on September 2, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SOUTH HERITAGE HEALTH & REHABILITATION CENTER on September 2, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect b..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.