Inspection visit
Inspection
11 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 11 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0585
Level of Harm - Minimal harm
or potential for actual harm
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must
establish a grievance policy and make prompt efforts to resolve grievances.
Based on observation, interview and medical record review, the facility failed to ensure a grievance was
responded to in a timely manner for one (#4) of thirty-four sampled residents.
Residents Affected - Few
Findings include:
On 05/3/22 at 3:20 p.m. an interview was conducted with Resident #4 family members, who said they visit
the resident four to five times a week and stay between two to three hours. Both family members spoke
about the resident's missing upper dentures, stating it happened within a month after she was admitted to
the facility, and they were never located. The family members confirmed they had reported the missing
dentures to the Social Worker (SW) and the SW had provided a quoted cost for the teeth. The family
members said they had called the SW to follow-up on the quoted cost, but the SW had not followed up with
them. During the interview the resident smiled listening to her daughters speak. Resident #4 was noted with
a cognitive deficit as she verbalized at times with confusion. When she spoke, no upper teeth were present
with a few lower teeth in place.
On 5/4/22 at 12:15 p.m. Resident #4 was observed sitting in bed eating her lunch meal. She smiled as she
was eating a cup of pudding; the meal on the plate was not touched. The meat was in small pieces and the
remaining food was of a soft texture.
Review of the Grievance Tracking Log revealed on 11/04/2021 a concern was voiced by Resident #4's
family member. The nature of the concern read Dental, missing items. The log indicated the Responsible
Department was housekeeping (HSKING) and social services (SS). The Log's Resolution was omitted of
any documentation.
Medical record review reflected the admission Record for Resident #4. The form indicated the resident was
admitted to the facility in late April 2021. The form contained a photograph of the resident smiling, which
revealed she had upper teeth.
On 5/5/22 at 10:48 a.m. an interview was conducted with the SW. She confirmed the Grievance Log
indicated a concern about Resident #4's dentures. She stated it was about the resident seeing a dentist
and other missing items, not missing dentures. The SW said she had informed the resident daughters that
a dentist would see the resident in December, and it would cost $1200.00 to replace the dentures. She said
that she had attempted to make an appointment for the dentist, stating I sent over the paperwork that was
needed. But I was told they could not see her because of pending Medicaid. And Medicare will not cover
dental services. The SW confirmed she was aware the resident had missing dentures. She said the last
Administrator would always look at resident's inventory form, and she confirmed the resident did not have a
completed inventory form when she was admitted . The SW said the
(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 13
Event ID:
105202
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
105202
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/05/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Apollo Healthcare & Rehabilitation Center
1000 24th St N
Saint Petersburg, FL 33713
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 0585
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
facility was hesitant on replacing her dentures. The Nursing Home Administrator was present during the
interview and stated we are paying for another resident's dentures. We'll pay for Resident #4's dentures.
At 1:23 p.m. on 5/5/22, the SW reviewed Resident #4's admission Record form that contained a picture of
the resident; the picture revealed the resident with upper teeth in place. The SW was unable to produce any
documentation related to the resident's missing dentures nor any documentation of communication with the
resident's family members. She additionally confirmed no dental services had been provided to the
resident.
Review of the facility-provided policy titled Grievances/Complaints, Filing, with a revision date of 5/2020
revealed:
Policy Statement:
Residents and their representative have to right to file grievances, either orally or in writing, to the facility
staff or the agency designated to hear grievance (e.g., the State Ombudsman). The Administrator and staff
will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative.
Policy Interpretation and Implementation:
5. Upon receipt of a grievance and/or complaint, the Grievance Officer will review and investigate the
allegations and submit a written report of such findings to the Administrator within five (5) working days of
receiving the grievance and/or compliant.
7. The Administrator will review the findings with Grievance Officer to determine what corrective action, if
any, need to be taken.
8. The resident, or the person filing the grievance and/or complaint on behalf of the resident, will be
informed verbally upon close of the investigation of the findings and the actions that will be taken to correct
any identified problems. A written summary of the investigation will be provided to the resident/responsible
party upon request.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105202
If continuation sheet
Page 2 of 13
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
105202
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/05/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Apollo Healthcare & Rehabilitation Center
1000 24th St N
Saint Petersburg, FL 33713
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 0655
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being
admitted
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interviews and record review, the facility failed to develop a baseline care plan related to falls for one (#395)
of thirty-four sampled residents.
Findings include:
A review of the clinical record for Resident #395 indicated a fall on 5/1/22, which resulted in the resident
being sent to the hospital for evaluation. A review of the resident's care plans showed a care plan and
interventions for falls risk was not initiated until 5/2/22.
A review of admission records indicated Resident #395 had an initial admission date of 4/13/2022 and a
re-admission date of 4/28/22 with diagnoses including anemia, unsteadiness on feet, muscle weakness,
atrial fibrillation, and acute embolism and thrombosis of unspecified deep veins of right lower extremity.
A review of Resident #395's admission Nursing Comprehensive Evaluation revealed a completion date of
4/14/22 by Staff A, Registered Nurse (RN,) Assistant Director of Nursing (ADON.) The evaluation indicated
resident was not a fall risk. A review of the Baseline Care Plan/Summary indicated the following goal: I will
remain free from fall related injury. The only intervention listed was, provide therapy to me as ordered. An
updated evaluation or baseline care plan was not completed for the re-admission on [DATE].
A review of the resident's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer
Form (AHCA-3008) dated 4/20/22 for transfer on 4/28/22 indicated Resident #395 had a risk alert for falls.
A review was conducted of Resident #395's Physical Therapy (PT) Evaluation and Plan of Treatment
completed on 4/29/22. The evaluation indicated the resident was a fall risk. For standing balance the
evaluation indicated resident's static standing was fair and dynamic standing was poor. Under Gait, the
evaluation stated: Level Surfaces = Min (A); Distance Level Surfaces = 60 feet; Assistive Device = Front
wheeled walker. The gait analysis indicated fall predictors including, reduced proactive balance, and
reduced reactive balance. The evaluation also indicated: risk factors due to the documented physical
impairments and associated functional deficits, the patient is at risk for; further decline in function and falls.
An interview was conducted with Staff L, Physical Therapist on 05/05/22 at 3:04 p.m. Staff L explained the
physical therapist must look at the AHCA-3008 form, but also do their own evaluation. He confirmed
Resident #395 was evaluated on 4/29/22 by PT. Staff L confirmed the evaluation showed Resident #395
was a fall risk. The Physical Therapist explained the evaluation report related to gait. He stated the gait
evaluation indicated resident can walk 60 feet with minimum assistance with a walker. He explained this is
equivalent to a one person assist. Staff L stated the evaluation is typically performed in the resident's room
and when the therapist finishes the evaluation, they educate the resident (if cognitively intact) on their
safety and risks. Staff L said the therapist goes to the clinical staff prior to leaving the unit and lets them
know the areas of concern and risks, including if the resident is a fall risk.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105202
If continuation sheet
Page 3 of 13
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
105202
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/05/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Apollo Healthcare & Rehabilitation Center
1000 24th St N
Saint Petersburg, FL 33713
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 0655
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
An interview was conducted with Staff A, ADON on 5/4/22 at 3:32 p.m. Staff A stated when a resident
comes to the facility a nursing evaluation is completed, if the resident scores a 10 or above they are
considered a fall risk. If the AHCA-3008 form from the hospital transfer indicated they are a fall risk, but the
nursing evaluation does not, they would put interventions in place. She confirmed she completed Resident
#395's nursing evaluation on 4/14/22, stating the resident was alert and oriented and didn't score high
enough to be a falls risk. Staff A reviewed the AHCA-3008 form and confirmed it stated the resident was a
fall risk.
On 5/5/22 at 11:55 a.m. interview was conducted with Resident #395's emergency contact, due to resident
currently being in the hospital. The family member stated the resident had a scan of her head done at the
hospital and there were no bleeds.
An interview was conducted with Staff J, Licensed Practical Nurse (LPN) on 5/5/22 at 1:06 p.m. Staff J
confirmed she cared for Resident #395 prior to her fall. She stated there were no fall interventions in place
for the resident. She said, the resident seemed to move around ok, she never called for help, so I guess
she moved around on her own.
A review was conducted of the facility policy titled Falls and Fall Risk, Managing, dated March 2018. The
policy stated: Based on previous evaluations and current data, the staff will identify interventions related to
the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize the
complications from falling.
A review was conducted of the facility policy titled Care Plans, Comprehensive Person-Centered, dated
December 2016. The policy stated: A comprehensive, person-centered care plan that includes measurable
objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed
and implemented for each resident. 2. The care plan interventions are derived from a thorough analysis of
the information gathered as part of the comprehensive assessment.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105202
If continuation sheet
Page 4 of 13
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
105202
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/05/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Apollo Healthcare & Rehabilitation Center
1000 24th St N
Saint Petersburg, FL 33713
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 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM
and/or mobility, unless a decline is for a medical reason.
Based on observation, interview, and medical record review, the facility failed to ensure a splinting device
was utilized for one (#48) out of three residents sampled for positioning and limited range of motion as
evidenced by not scheduling the order accurately.
Findings include:
On 05/02/22 at 1:50 p.m. Resident #48 was observed in his wheelchair sitting in the street directly across
from the facility entrance. He was alert and receptive to an interview. Resident #48 said that his left arm and
hand did not work. He stated see as he picked up his left forearm and then let go of it as it dropped back on
his lap. His left hand was contracted. Resident #48 confirmed he had a splint for his left-hand. He stated,
the therapy department gave me one, but I can't put it on by myself.
On 05/03/22 at 10:54 a.m. Resident #48 was in his bedroom; no splint was observed in place to his left
hand. No splint was observed in his bedroom.
On 05/03/22 at 1:00 p.m. Resident #48 was observed seated across the street from the facility with his
peers; no splint was observed in place.
On 05/04/22 at 3:00 p.m. Resident #48 was sitting in his bedroom with his splint lying on top of the bed. He
confirmed it was his splint and said the therapy department are the ones that put it on. He denied the nurse
or certified nursing assistants have ever applied it. He stated, they could do it; I just can't do it by myself.
Medical record review of the admission Record form that revealed Resident #48 was admitted to the facility
in March 2022. The diagnosis information listed hemiplegia and hemiparesis following cerebral infarction
affecting left non-dominant side.
Review of Physician orders revealed, Donn Left (L) hand splint in morning (AM) and doff in evening (PM) as
tolerated. Splint may be removed as needed for activities of daily living (ADL), care and to check skin
integrity dated 4/22/2022.
On 05/04/22 at 4:00 p.m. an interview was conducted with the Director of the Therapy Department, who
said she would follow-up in the morning about the resident's splint.
Review of the Treatment Administration Record (TAR) dated April 2022 revealed the Physician order in
place for the left-hand splint. The Hours/ scheduled section in the TAR for the donning and doffing were
omitted.
Further review of the TAR for May 2022 revealed the Physician order for the left-hand splint. The
hours/schedule for May 2022 additionally reflected omitted data.
On 5/5/22 at 9:50 a.m. a second interview was conducted with the Director of the Therapy Department. She
stated The Occupational Therapist had input the order in the TAR for the splint. But the details time of on
and off were not scheduled. She said the scheduling part is a separate area that was not added. The
Director confirmed the TAR contained no documentation from April 2022 to 5/5/22 on the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105202
If continuation sheet
Page 5 of 13
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
105202
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/05/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Apollo Healthcare & Rehabilitation Center
1000 24th St N
Saint Petersburg, FL 33713
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 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
donning and doffing of the hand splint. She was asked for a copy of his assessment that would be
conducted. No assessment was provided prior to the exit of the facility.
On 5/05/22 at 2:00 p.m. during an interview with the Minimal Data Sheet Coordinator (DISC), she
confirmed after review of Resident #48's care plans, no care plan was in place for the resident's splinting
device.
Event ID:
Facility ID:
105202
If continuation sheet
Page 6 of 13
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
105202
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/05/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Apollo Healthcare & Rehabilitation Center
1000 24th St N
Saint Petersburg, FL 33713
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 0698
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interviews, the facility failed to ensure Dialysis Communication Forms were completed for
one resident (Resident #50) out of the sampled three residents.
Residents Affected - Few
Findings include:
A review of the admission Record revealed Resident #50 was initially admitted into the facility on [DATE]
with diagnoses that included but were not limited to hypertensive chronic kidney disease with stage 5
chronic kidney disease or end stage renal disease and acute kidney failure.
Section C Cognitive Patterns of the Minimum Data Set (MDS) dated [DATE] revealed Resident #50 had a
Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact. Section O of the MDS
revealed the resident received dialysis while a resident.
Review of Physician Orders for Resident #50 revealed:
Diagnosis for dialysis: ESRD (End Stage Renal Disease) or Renal Failure
Dialysis on Tuesday, Thursday, and Saturday
A review of the Dialysis Communication Forms revealed no documentation was completed on 3/19/22,
03/22/22, 03/24/22, 03/26/22, 03/31/22, 04/16/22, 04/23/22, 04/26/22, and 05/03/22.
A review of the Progress Notes from March to May 2022 did not reflect any documentation related to
Resident #50 refusing to go to dialysis on the days the Dialysis Communication Forms were not completed.
A review of the care plan related to dialysis initiated on 03/15/22 revealed the following intervention:
Complete dialysis communication tool on dialysis days and review upon return form dialysis.
On 05/05/22 at 9:33 a.m., during an interview with Staff J, Licensed Practical Nurse (LPN), she said she
was responsible for completing the Dialysis Communication Forms and the forms are sent via fax. Staff J,
LPN, reported she documents vital signs and medications administered. She stated Resident #50 was
transferred from the South Unit and was not able to provide any additional Dialysis Communication Forms
from that wing.
On 05/04/22 at 11:27 a.m., the Regional Clinical Director confirmed that Resident #50 did not have any
progress notes related to refusals for dialysis. He confirmed Dialysis Communication Sheets were not
completed on the dates in question.
On 05/05/22 at 9:27 a.m., the Director of Nursing (DON) reported the nurses should be completing the
Dialysis Communication Forms prior to the resident going to dialysis and when the resident returned from
dialysis.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105202
If continuation sheet
Page 7 of 13
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
105202
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/05/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Apollo Healthcare & Rehabilitation Center
1000 24th St N
Saint Petersburg, FL 33713
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 0757
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and medical record review, the facility failed to prevent duplicate therapy
for one (#48) of five sampled residents, as evidenced by the application of a topical nicotine patch in
conjunction with inhaled nicotine.
Residents Affected - Few
Findings include:
On 05/02/22 1:50 p.m. Resident # 48 was observed in his wheelchair sitting in the street directly across
from the facility entrance. He was alert and receptive to an interview. The resident said he was waiting for a
someone to come out and to bum a cigarette. He stated he smokes daily, but the administration says it can't
be on the property. The resident said the facility holds the cigarettes at the receptionist desk in a locked
box.
On 05/03/22 at 1:00 p.m. Resident #48 was observed smoking a cigarette with his peers directly across the
street from the facility.
On 05/04/22 at 10:45 a.m. Resident #48 was observed across the street smoking a cigarette.
Medical record review of the admission Record form revealed Resident #48 was admitted to the facility in
March 2022. The diagnosis information listed hemiplegia and hemiparesis following cerebral infarction
affecting left non-dominant side, type 2 diabetes mellitus, heart disease, and hypertension.
Review of Physician orders revealed Nicotine Patch 24-hour 21 mg/24 HR apply 1 patch transdermally one
time a day for smoking cessation/craving and remove per schedule. Apply 0900 Remove 0859 dated
3/29/2022. The medication administration record revealed daily administration of the patch.
On 05/04/22 at 2:00 p.m. an interview was conducted with the Director of Nursing. Related to the nicotine
patch, she stated he doesn't get that anymore.
At 2:10 p.m. on 05/04/22, Resident #48 was observed in his bedroom, and confirmed he wears a nicotine
patch; he said it was on his left arm. The resident said he smokes from 10 to 15 cigarettes a day, and
stated, I'm aware of smoking while on the patch. I know I can have a heart attack. The Assistant Director of
Nursing (ADON) was present and assisted the resident with his shirt to reveal a nicotine patch located on
his left upper arm.
At 2:24 p.m. on 05/04/22 an interview was conducted with Staff Member C. who was sitting at the entrance
of the facility, and said she was filling in for the receptionist during her break. She opened a small tackle box
that revealed five packages of cigarettes for Resident #48. She said when a resident leaves the facility for a
Leave of Absence, they have to sign out on the 4 hour leave form. Staff C said she gives the residents their
pack of cigarettes when they leave and locks them when they return. Staff C said they do not keep count on
how many cigarettes the resident starts with or returns with.
On 05/04/22 at 2:33 p.m. an interview was conducted with the Nursing Home Administrator. He stated he
had spoken to Resident #48 about the risks of smoking and wearing the patch. He confirmed that there was
documentation.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105202
If continuation sheet
Page 8 of 13
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
105202
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/05/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Apollo Healthcare & Rehabilitation Center
1000 24th St N
Saint Petersburg, FL 33713
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 0757
Level of Harm - Minimal harm
or potential for actual harm
Review of the Resident/Family Education Tool V2 dated 04/22/2022 revealed: Pt [patient] educated on the
importance of smoking while on a smoking patch. Pt states he knows and doesn't need anyone telling him
what to do. Writer explained the risk including return to hospital (RTH), pt. showed no interest. Writer asked
pt. if he would like the smoking patch discontinued and he stated no, he wants the patch. MD [medical
doctor] made aware.
Residents Affected - Few
Review of Physician Progress Notes dated 04/18/2022 revealed: Treatment 8. Nicotine Dependence,
cigarettes, with other nicotine-induced disorders. Notes: -History of [h/o] smoking 2 packs per day [ppd].
Agreeable to quit and so nicotine patch prescribed to help with cravings. Additionally, I informed him that he
is not to smoke while using the patch. Expressed understanding. Nurse at bedside.
On 05/04/22 at 3:45 p.m. an interview was conducted with the Regional Nurse and the Director of Nursing.
The Regional Nurse stated, we are aware the resident is smoking while on the nicotine patch. And if you
look under the resident family education tool you would find that. He stated. he was educated on smoking
while on the nicotine patch. He is aware of the risk. If he wants the patch, it is his right. He knows the risk
when he leaves the facility. The Regional Nurse said, the doctor knows about it, and he has the right on his
leave of absence (LOA). The Regional Nurse further stated they have been aware of it for two weeks.
On 05/04/2022 at 4:04 p.m. a phone interview was conducted with the facility Pharmacist. He said the
nicotine patch is designed to aid with the side effects from the withdrawal of nicotine. He said if the facility
does not know how much the resident is smoking, there are certain risks factors they should be aware of,
such as increased heart rate and blood pressure. The Pharmacist said the Physician should be made
aware the facility is administering the resident a nicotine patch while he is smoking.
On 05/04/22 at 4:14 p.m. a phone interview was conducted with the Physician. She confirmed she knew
Resident #48 and said that it sounded like him when informed the resident was smoking cigarettes. She
said he is his own person, and we give education when we prescribe nicotine patches. The Physician
stated, I recommend to the building the patch for an as needed basis or scheduled. Then added its best on
an as needed basis. The Physician said the facility must have informed an on-call MD, as she was not
aware. She confirmed she would have changed the nicotine patch order but said today was the first time
the facility had notified her that the resident was smoking. She stated, If the resident wants to start
smoking, I would stop the patch.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105202
If continuation sheet
Page 9 of 13
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
105202
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/05/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Apollo Healthcare & Rehabilitation Center
1000 24th St N
Saint Petersburg, FL 33713
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations and interviews, the facility failed to store medications in a locked compartment for one (East
Unit) of four medication carts, one (East Unit) of four wound treatment carts, two bags of pharmacy return
medications, and failed to store controlled medication in separate locked compartment in one (Rapid Unit)
of two medication storage rooms.
Findings include:
An observation was made on [DATE] at 10:15 a.m. of three bags of unsecured pharmacy return medication
sitting on a cart in the East Unit nurses' station. This nurses' station was near the main entrance of the
facility. All visitors must pass this station upon entering and leaving the facility. The nurses' station was also
located on a main hall of resident rooms.
An observation was made on [DATE] at 1:48 p.m. of the East Unit nurses' station. The three bags of
medication remained unsecured, sitting on top of a wound treatment cart. One bag was labeled Used IV
Pump and two bags were labeled Pharmacy Returns. The wound treatment cart was also unlocked with
prescription medications in the drawer. No staff were in sight of the nurses' station (Photographic evidence
obtained).
An additional observation was made of the East Unit station nurses' station on [DATE] at 3:08 p.m. The
pharmacy return bags remained unsecured on the wound treatment cart. The bags were opened and
confirmed to be 37 bubble packs of resident medication. (Photographic evidence obtained). At that time, an
interview was conducted with Staff I, Licensed Practical Nurse (LPN). Staff I stated the bags should be in
the medication storage room on the Rapid Unit. She stated, pharmacy comes to pick the returns up around
3:00 p.m. and sometimes people forget they are in the storage room, so they get brought to the East Unit
nurses' station or reception and left. She confirmed there was no place to lock the pharmacy return
medications at the East Unit nurses' station and they should be locked up (Photographic evidence
obtained). Staff I proceeded to take the medications to the locked medication storage room on the Rapid
Unit.
An interview was conducted on [DATE] at 3:20 p.m. with the Rapid Unit nurse, Staff J, LPN. Staff J
confirmed all the pharmacy returns should be in the locked in the medication storage room and stated that
is where she puts hers. She stated she never takes her pharmacy returns to the East nurses' station. She
stated, they have to stay locked up.
On [DATE] at 3:50 p.m. an observation was made of the East Unit medication cart. The medication cart was
unlocked with no staff members in sight. Residents were moving through the hallway. Residents and visitors
must pass this medication cart upon entering and exiting the building. This cart sits along a main resident
hallway.
On [DATE] at 3:55 p.m. an interview was conducted with Staff K, LPN. Staff K stated she knew the policy
and the cart should be locked. She stated she had just started coming to this facility and the carts are
different than what she is use too. She stated she forgot to push the button because she isn't used to the
two-step locking process.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105202
If continuation sheet
Page 10 of 13
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
105202
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/05/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Apollo Healthcare & Rehabilitation Center
1000 24th St N
Saint Petersburg, FL 33713
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
An observation was completed of the Rapid Unit medication storage room on [DATE] at 10:55 a.m. The
narcotics box was attached to the inside of the refrigerator; however, the box was unlocked with narcotics
inside. The door to the storage room was locked and there was no additional lock on the refrigerator. An
interview was conducted at that time with Staff J. Staff J confirmed narcotics were inside the narcotics box
and the box was unlocked. She stated the box should be locked. Staff J locked the narcotics box and
confirmed the lock functioned properly (Photographic evidence obtained).
An interview was conducted on [DATE] at 12:46 p.m. with the Director of Nursing (DON). The DON stated
medication should be stored properly and not expired. She stated medication carts should always be locked
when left unattended. The DON confirmed pharmacy returns are picked up daily and the returns should be
locked in one of the two medication storage rooms. The DON stated pharmacy return medications should
not be left at the nurses' station or the front desk. The DON stated narcotics should be locked in a separate
box which is secured to the refrigerator inside of the locked medication storage room.
An observation was conducted on [DATE] at 9:06 a.m. at the East Unit nurses' station. The wound
treatment cart was unlocked with medication in the top drawer. No staff are in sight; however, a resident and
a visitor were observed walking past the cart.
The Assistant Director of Nursing (ADON) provided a facility policy titled Storage of Medications, revised
[DATE]. The policy stated:
1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature,
light, and humidity controls. Only persons authorized to prepare and administer medications have access
[NAME] locked medications.
3. Nursing staff is responsible for maintain medication storage and preparation areas in a clean, safe, and
sanitary manner.
6. Compartments (including, but not limited to, drawers, cabinets, rooms, a refrigerators, carts, and boxes)
containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left
unattended.
8. Schedule II-V controlled medications are store in separately locked, permanently affixed compartments.
Access to controlled medication is separate from access to non-controlled medications.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105202
If continuation sheet
Page 11 of 13
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
105202
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/05/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Apollo Healthcare & Rehabilitation Center
1000 24th St N
Saint Petersburg, FL 33713
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observations, interviews, and record review, the facility failed to ensure one of one kitchen dish
washing machines was maintained in accordance with manufacturer recommendations, related to the wash
and rinse temperature.
Findings include:
On 05/02/22 at 10:16 a.m., an initial tour of the kitchen was conducted with the Certified Dietary Manager
(CDM).
During the observed timeframe, two staff members were observed working in the dishwashing area. One
staff member was observed placing soiled dishes on a crate to load into the dish machine and one staff
member was removing clean dishes from a crate that had just came through the dish machine.
The CDM was asked to demonstrate a washing/rinsing cycle. The following was observed:
First Demonstration:
The digital temperature panel indicated the wash cycle temperature reaching 132 degrees Fahrenheit; and
the rinse cycle temperature reaching 114F. The CDM revealed he identified there was an issue with the dish
machine this morning and called the dish washing machine repair company. The CDM was asked to
provide confirmation of the work order submitted to the dish washing machine repair company.
Second Demonstration:
The digital temperature panel indicated the wash cycle temperature reaching 132 degrees Fahrenheit; and
the rinse cycle temperature reaching 116 degrees Fahrenheit.
Third Demonstration:
The digital temperature panel indicated the wash cycle temperature reaching 132 degrees Fahrenheit; and
the rinse cycle temperature reaching 118 degrees Fahrenheit.
Continued observations of the dish machine revealed a specifications plate was not attached to the
machine (photographic evidence obtained). This was confirmed by the CDM.
The CDM stated he would pull paper products for lunch, and he would provide confirmation that the dish
washing machine repair company was contacted this morning prior to the surveyor entering the kitchen.
On 05/03/22 at 11:00 a.m., the CDM provided documentation from the dish washing machine repair
company dated 05/02/22 at 11:58 am (after surveyor entered the kitchen). He reported he did not have any
documentation that indicated the dish washing repair company was contacted prior to the survey.
The work order dated 05/02/22 at 11:58 a.m. revealed the following:
The rinse aid dispenser was over filled and had wrong (solid brilliance) rinse aid in the dispenser
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105202
If continuation sheet
Page 12 of 13
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
105202
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/05/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Apollo Healthcare & Rehabilitation Center
1000 24th St N
Saint Petersburg, FL 33713
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 0812
The rinse aid dispenser was leaking.
Level of Harm - Minimal harm
or potential for actual harm
Wash motor was leaking, rinse aid water line solenoid and the housing was faulty and corroded, and the
incoming water line for dish machine was leaking.
Residents Affected - Many
A rinse jet was clogged.
Squeeze tubes were worn for chlorine sanitizer and rinse aid.
The deter dispenser sensor was faulty.
On 05/04/22 at 12:06 p.m., the CDM reported the dish washing machine repair company worked on the
machine from 10:00 a.m. to 5:00 p.m. He stated he did not have documentation of when he initially put the
work order in prior to the survey.
On 05/04/22 at 2:36 p.m., the CDM reported he would check to see if the dish washing machine was a low
temperature or high temperature machine. He stated the machine was leased so he did not know.
On 05/04/22 at 3:00 p.m., the CDM reported he contacted the dish washing machine repair company and
they reported the temperatures were in the work order he provided me. The work order indicated the wash
temperature was 140 degrees Fahrenheit and the rinse temperature was 125 degrees Fahrenheit. The dish
washing repair company also reported that the machine was low temperature, and they were going to order
stickers indicating the manufacturers recommendation for temperatures. The CDM stated he would post
signs in the kitchen with the recommended temperatures.
On 05/05/22 at 1:14 p.m., the CDM stated he found the specifications plate and it was underneath the
machine.
The specifications plate read:
Hot Water Sanitizing- 160 degrees Fahrenheit for the minimum wash tank temperature
180 degrees Fahrenheit for minimum final rinse temperature
Chemical Sanitizing- 140 degrees Fahrenheit for the minimum wash tank temperature
120 degrees Fahrenheit for minimum final rinse temperature.
On 05/05/22 at 10:18 a.m., the Administrator stated he would expect staff to not use the dish washing
machine and use paper products until the machine was fixed.
The policy provided by the facility Ware Washing dated October 2019 revealed the following:
2. The Dining Services Director ensures that all the dish machine water temperatures are maintained in
accordance with manufacturer recommendations for high temperature or low temperature machines.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105202
If continuation sheet
Page 13 of 13
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
11 citations 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.
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F585 - Grievances
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- 0004GeneralS&S Fpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0293GeneralS&S Dpotential for harm
Have properly located and lighted "Exit" signs.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F741 - The facility must have sufficient staff who provide direct services to
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
FAQ · About this visit
Common questions about this visit
What happened during the May 5, 2022 survey of APOLLO HEALTHCARE & REHABILITATION CENTER?
This was a inspection survey of APOLLO HEALTHCARE & REHABILITATION CENTER on May 5, 2022. The surveyor cited 11 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at APOLLO HEALTHCARE & REHABILITATION CENTER on May 5, 2022?
Yes, 11 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted"
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
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.