Health inspection·September 2, 2025

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 Page 1 of 3 105117 105117 09/02/2025 South Heritage Health & Rehabilitation Center 718 Lakeview Ave S Saint Petersburg, FL 33705

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 105117 Page 2 of 3 105117 09/02/2025 South Heritage Health & Rehabilitation Center 718 Lakeview Ave S Saint Petersburg, FL 33705

F 0600 Level of Harm - Actual harm Residents Affected - Few 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. 105117 Page 3 of 3