Inspection visit
Inspection
15 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 15 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, record reviews, and interviews, the facility failed to treat residents with respect and dignity for
two (Residents #167 and #102) of sixty one sampled residents related to the lack of privacy for Resident
#167 that was left in bed unclothed and Resident #102 that did not have a privacy cover on his urinary
drainage bag.
Findings included:
1. On 03/02/21 at 1:01 p.m., Resident #167 was observed in bed completely nude without anything
covering him. Resident #167's roommate was in the room in his bed at this time. The resident could be
seen unclothed with his entire body exposed from the hallway. Staff N, Certified Nursing Assistant (CNA),
stated, That's what he likes to do. Staff N, CNA, did not attempt to cover the resident. A privacy curtain was
not observed in the room.
On 03/04/21 at 2:23 p.m., Resident #167 was observed in bed unclothed from the hallway. A privacy curtain
was not observed in the room. Staff O, Housekeeping, was outside of the room at this time and stated, He
is like that every day. She stated that she was not sure when the privacy curtain was removed. Staff P,
Housekeeping, stated he did not know why the room did not have a privacy curtain. At 2:37 p.m., Staff N,
CNA, stated that there was no privacy curtain in the room because the resident swings on the curtain.
A review of the admission Record revealed that Resident #167 was initially admitted into the facility on
[DATE] with a primary diagnosis of cerebral palsy. Other diagnoses included but were not limited to
schizophrenia, visual loss in both eyes, hearing loss, and altered mental status.
Section C- Cognitive Patterns of the Minimum Data Set (MDS) dated [DATE] indicated that the resident was
rarely/never understood.
The resident had a care plan in place for behaviors related to Resident #167 taking off clothes and throwing
them on the floor initiated on 11/12/20. Interventions included: administer medications as ordered,
anticipate and meet the resident's needs, approach/speak in a calm manner, encourage the resident to
express feelings appropriately, explain all procedures to the resident, explain/reinforce why behavior is
inappropriate, intervene as necessary, and remove the resident from the situation.
On 03/05/21 at 10:08 a.m., the Director of Nursing (DON) reported that her expectations would be to make
sure to cover the resident and continue to cover him. Staff should be doing checks for privacy curtains.
(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 9
Event ID:
105390
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
105390
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Balanced Healthcare
4250 66th St N
Saint Petersburg, FL 33709
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 0550
The policy provided by the facility Promoting/Maintaining Resident Dignity undated revealed the following:
Level of Harm - Minimal harm
or potential for actual harm
Policy:
Residents Affected - Few
It is the practice of this facility to protect and promote resident rights and treat each resident with respect
and dignity as well as care for each resident in a manner and in an environment, that maintains or
enhances resident's quality of life by recognizing each resident's individuality.
Compliance Guidelines:
1. All staff members are involved in providing care to resident to promote and maintain resident dignity and
respect resident rights.
12. Maintain resident privacy
2. On 03/04/21 at 2:06 p.m. an observation of Resident #102 revealed the resident had an indwelling urine
catheter. The drainage bag was visible from the open room door and did not have a privacy cover.
Review of the clinical record for Resident #102 showed an admission date of 03/29/2019 and diagnoses
that included, Dementia, Parkinson's Disease and Neuromuscular Dysfunction of Bladder, as per the
admission face sheet. The 5-day Minimum Data Set (MDS) dated [DATE], revealed under Section H the
resident had an indwelling urinary catheter; and under Section I had a diagnosis of Neurogenic Bladder.
Further review of the clinical record revealed no documentation of the indwelling urine catheter on the Care
Plan, as well as no interventions or goals for the catheter and care.
On 03/04/21 at 2:11 p.m., an interview with Staff C, Licensed Practical Nurse (LPN) confirmed the resident
had an indwelling urine catheter. She further stated the drainage bag should be covered with a privacy
cover.
On 03/05/21 at 11:15 a.m. during an interview with the Director of Nursing (DON), she stated it was her
expectation that the indwelling catheter drain bag was covered in a vanity cover to preserve the resident's
dignity.
The facility provided an undated policy titled, Catheter Care. The policy did not address the use of a privacy
cover for the drain bag.
The facility provided an undated policy titled, Promoting/Maintaining Resident Dignity. The policy did not
address the use of a privacy cover for the drain bag.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105390
If continuation sheet
Page 2 of 9
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
105390
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Balanced Healthcare
4250 66th St N
Saint Petersburg, FL 33709
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 0573
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Let each resident or the resident's legal representative access or purchase copies of all the resident's
records.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
resident interviews, staff interviews, and policy review, the facility failed to honor a request for one (Resident
#553) of two sampled residents to obtain copies of their medical record.
Findings include:
A medical record review was conducted for resident #553 and revealed that the resident had been admitted
to the facility on [DATE] with a discharge date of 6/22/2020. During a telephone interview with Resident
#553, she reported that at various times she had requested a copy of her medical records.
Resident #553 reported that she had made a request for her medical records at the time of her discharge
and during several follow up calls. The facility had not responded to her requests as of 03/05/21.
On 03/05/21 at 10:00 a.m., an interview was conducted with the Social Service Director who confirmed that
the resident had called her several times requesting a copy of her medical records, however, she did not
work in medical records, so she would transfer the calls to medical records department.
On 03/05/21 at 10:06 a.m., an interview with Staff B, Medical Records Manager, was conducted in regard
to Resident #553 requesting copies of her medical records. Staff B confirmed that she did receive a request
from the resident and mailed out the consent form. Staff B also received a telephone call from Resident
#553 and the resident was informed that there would be a fee for the medical records. Staff B never heard
back from the resident. Staff B was asked if she had any documented evidence to this event and she
confirmed that she had not made any notes.
The Director of nursing was made aware of the current findings and asked to provide a copy of the facility
policy for Release of Medical Records.
Review of the Facility for Release of Medical Records Policy revealed that Medical records will be released
with a valid request and in accordance with State and federal laws.
#3- Upon request for medical record, the facility should review the authorization to ascertain access rights
of that person. Authority to access or release records is only granted by the resident or the legal
representative.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105390
If continuation sheet
Page 3 of 9
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
105390
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Balanced Healthcare
4250 66th St N
Saint Petersburg, FL 33709
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 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
Based on observations, policy review, and staff interview, the facility failed to ensure a safe, clean,
comfortable and homelike environment as evidence by, chipped paint, broken cabinet doors, a missing
cabinet drawer, and dusty ceiling vents at the entrance to the kitchen and in nourishment rooms on three (1
East, 2 East, and Lifestyle 2) of five occupied units.
Findings included:
On 03/02/21 starting at 9:51 a.m., a tour of the kitchen and the nourishment rooms was conducted with the
Certified Dietary Manager (CDM). Chipped paint was observed around the ceiling vent above the entry
door to the kitchen. The CDM stated that the chipped paint was probably from condensation. The 1 East
nourishment room was observed with broken cabinet doors and a dusty ceiling vent. The Lifestyle 2
nourishment room was observed with a missing cabinet drawer. The 2 East nourishment room was
observed with an excessive amount of dust on the ceiling vent (photographic evidence obtained).
Observations were confirmed by the CDM.
The policy Preventative Maintenance Program undated revealed the following:
2. The Maintenance Director shall assess all aspects of the physical plant to determine if Preventative
Maintenance is required. Required PM may be determined from manufacturer's recommendations,
maintenance requests, grand rounds, life safety requirements, or experience.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105390
If continuation sheet
Page 4 of 9
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
105390
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Balanced Healthcare
4250 66th St N
Saint Petersburg, FL 33709
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to implement a care plan for three (Residents
#102, #152, and #52) of 61 sampled residents related to 1). A urine catheter for Resident #102, 2). A
wander alarm for Resident #152, and 3). Nutritional behaviors for Resident #52.
Findings included:
1. On 03/04/21 at 2:06 p.m., an observation of Resident #102 revealed that he had an indwelling urine
catheter.
Review of the clinical record for Resident #102 showed an admission date of 03/29/2019 and diagnoses
that included, Dementia, Parkinson's Disease and Neuromuscular Dysfunction of Bladder, as per the
admission face sheet. The 5-day Minimum Data Set (MDS) dated [DATE], revealed under Section H the
resident had an indwelling urinary catheter; and under Section I had a diagnosis of Neurogenic Bladder.
Further review of the clinical record revealed no documentation of the indwelling urine catheter on the Care
Plan, as well as no interventions or goals for the catheter and care.
Review of the Physician's Order Summary revealed orders that included:
-Change catheter size - 16fr [French] - and 30 cc [cubic centimeters], PRN [as needed] if dislodged,
clogged or leaking dated 02/24/2021
-Change catheter drainage bag PRN blockage or leakage dated 02/24/2021
-Catheter bag - may convert to leg bag while up PRN dated 02/24/2021
-Irrigate [urine] catheter with 30 ml [milliliters] NS [Normal Saline] as needed for blockage or sluggishness
dated 02/24/2021
-Catheter care with soap and water dated 02/24/2021
On 03/04/21 at 2:11 p.m., an interview with Staff C, Licensed Practical Nurse (LPN) confirmed the resident
had an indwelling urinary catheter. She further stated the resident returned from the hospital with the
catheter. She said she was unaware that the catheter was not listed on the resident's care plan.
On 03/05/21 11:15 a.m., an interview was conducted with the Director of Nursing (DON). She confirmed it
was her expectation that a focus, goals and interventions be included on a resident's care plan if they had a
urinary catheter.
Review of facility-provided undated policy titled, Comprehensive Care Plans showed:
Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan
for each resident, consistent with resident rights, that includes measurable goals and timeframes to meet a
resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's
comprehensive assessment.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105390
If continuation sheet
Page 5 of 9
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
105390
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Balanced Healthcare
4250 66th St N
Saint Petersburg, FL 33709
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 0656
3. The comprehensive care plan will describe, at a minimum, the following:
Level of Harm - Minimal harm
or potential for actual harm
a. The services that are to be furnished to attain or maintain the resident's highest practicable physical,
mental and psychosocial well-being.
Residents Affected - Few
2. On 03/03/21 at 1:10 p.m., Resident #152 was observed wandering through the facility with a purse on
her shoulder.
On 03/04/21 at 3:40 p.m., she was observed in bed. No wander guard was observed on the resident.
On 03/05/21 at 11:05 a.m., Resident #152 was observed in the elevator and stated she wanted to go home.
The admission Record revealed that Resident #152 was admitted into the facility 02/06/20 with diagnoses
that included but were not limited to anxiety disorder, schizophrenia, and mood disorder.
Section C-Cognitive Patterns of the quarterly Minimum Data Set (MDS) dated [DATE], revealed that the
resident had a Brief Interview for Mental Status (BIMS) score of 06 out of 15 indicating severe impairment.
Section P indicated that an alarm was not used.
A review of the Order Summary Report with active orders as of 03/05/21 did not reveal an order for an
audible alarm system.
A review of the Elopement Evaluation dated 12/11/20 revealed that the resident was risk to wander.
A review of the care plan for elopement revealed that the resident had an audible alarm system for
wandering.
On 03/04/21 at 3:44 p.m., Staff Q, Licensed Practical Nurse (LPN), reported that he did not remember
signing off or ever checking off for a wander guard.
On 03/05/21 at 10:14 a.m., the DON stated the resident did not have a wander guard and that the care plan
needed to be updated.
3. A review of the admission Record for Resident #52 revealed that the resident was initially admitted into
the facility on [DATE] with a diagnosis that included but was not limited to dysphagia.
A review of the Order Summary Report with active orders as of 03/05/21, revealed an order for regular diet,
pureed texture, pudding/spoon thick consistency.
The annual Nutritional assessment dated [DATE], revealed that Resident #52 had swallowing difficulties
with choking on thin liquids.
A progress note dated 01/19/21, revealed the following: Resident was not adhering to his diet and has been
taking his roommates food and drink, including taking items out of the garbage.
A progress note dated 01/13/21, revealed the following: Resident continues not to adhere to his prescribe
diet as he continues to choke with water that he is drinking from his bathroom sink and going into other
residents rooms while food trays are present. Resident was redirected several times with
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105390
If continuation sheet
Page 6 of 9
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
105390
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Balanced Healthcare
4250 66th St N
Saint Petersburg, FL 33709
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 0656
aggressive posturing.
Level of Harm - Minimal harm
or potential for actual harm
A progress note dated 01/11/21, revealed the following: Resident continues to drink and eat outside of diet.
Social services found the resident red and short of breath while in the bathroom because he was choking
with solid food and clear liquid.
Residents Affected - Few
A progress note dated 01/07/21, revealed the following: Resident continues to not adhere to current dietary
restriction eating food from other rooms including garbage and food cart.
A progress note dated 01/05/21, revealed the following: Resident continues to not follow diet restrictions.
A progress note dated 12/31/20, revealed the following: Resident continues to not follow diet. Resident was
found eating roommate's meals and drinking water from the sink.
A progress note dated 12/07/20, revealed the following: Meals are encouraged in the main dining room for
lunch and dinner. This note was from the Interdisciplinary Team Meeting.
The care plan for nutrition initiated on 09/16/20 revealed that Resident #52 chooses to not follow the
recommended diet consistency. He would take beverages from peers that may not be appropriate for his
diet. An intervention was discussed in the Interdisciplinary Team Meeting to encourage the resident to eat in
the main dining room for lunch and dinner and this intervention was not listed on the care plan.
On 03/05/21 at 11:00 a.m., the Director of Nursing (DON) reported that the care plan should have been
updated. It was discussed to have the resident eat in the dining room. It should have been on the care plan
and the Certified Nursing Assistant (CNA) Kardex.
The policy provided by the facility Care Plan Revisions Upon Status Change undated revealed the
following:
1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experience a
status change.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105390
If continuation sheet
Page 7 of 9
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
105390
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Balanced Healthcare
4250 66th St N
Saint Petersburg, FL 33709
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 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure behavioral monitoring for psychotropic
medications was performed for one (Resident #82) of five residents reviewed.
Findings included:
Record review for Resident #82 revealed an admission date of 12/24/2020 and diagnoses that included
dementia, mood disorder and anxiety as per the admission face sheet. The admission Minimum Data Set
(MDS) dated [DATE] showed under Section C a Brief Interview for Mental Status (BIMS) score of 08,
indicating moderate cognitive impairment; Section E, delusions [yes]; Section I, diagnosis of Anxiety; and
Section N, antipsychotics and antidepressants were received during 6 of the past 7 days. Review of the
Care Plan revealed foci that included: 1) [Resident] has a mood problem, with interventions that included
administer medications as ordered, monitor/document and report increased anger, labile mood or agitation,
feelings of being threatened by others, thoughts of harming someone; and, 2) Psychotropic Medication
Use, and interventions that included administer medications, monitor for effectiveness of psychotropic
drugs , observe for s/s [signs and symptoms] of drug related antidepressant side effects , observe for s/s of
drug related antipsychotic side effects , report negative outcomes associated with drug use to MD [Medical
Doctor].
A review of the Medication Administration Record (MAR) and the Physician Order Summary showed:
- Trazadone 50 milligrams (mg) orally daily for Major Depressive Disorder (MDD), with a start date of
02/11/2021
- Depakote 125 mg 2 tablets orally twice daily for Mood Disorder, with a start date of 02/10/2021
Further review of the MAR revealed no behavioral monitoring, or monitoring for medication side-effects, or
effectiveness since the medication start dates.
On 03/04/21 at 2:25 p.m., Resident #82 was observed seated on his bed and watching TV. He was dressed
and groomed, with no odors noted. An interview was attempted; however, no response was obtained.
An interview with Staff C, Licensed Practical Nurse (LPN) on 03/04/21 at 2:35 p.m. revealed the resident
had exhibited no recent behavior issues.
During an interview with the Director of Nursing (DON) on 03/05/21 at 11:15 a.m., she stated it was her
expectation that behavior monitoring was completed and documented on the MAR for effects and side
effects of antidepressants and mood stabilizers.
In a telephone interview with the Consultant Pharmacist on 03/05/21 at 1:42 p.m., he stated it would be his
expectation that behaviors and side effects were monitored at least daily for residents taking Trazodone.
Review of a facility-provided policy titled 'Use of Psychotropic Drugs', and undated showed:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105390
If continuation sheet
Page 8 of 9
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
105390
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/05/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Balanced Healthcare
4250 66th St N
Saint Petersburg, FL 33709
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 0758
Level of Harm - Minimal harm
or potential for actual harm
1. Psychotropic drugs include but are not limited to the following categories: antipsychotics,
antidepressants, anti-anxiety and hypnotics.
9. The effects of the psychotropic medications on the resident's physical, mental and psychological
well-being will be evaluated on an ongoing basis such as:
Residents Affected - Few
d. In accordance with nurse assessments and medication monitoring parameters consistent with clinical
standards of practice, manufacturer's specifications, and the resident's comprehensive plan of care.
The policy did not address monitoring for medication side-effects.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105390
If continuation sheet
Page 9 of 9
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Back to topCitations
15 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.
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.
- 0004GeneralS&S Dpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0222GeneralS&S Dpotential for harm
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- 0223GeneralS&S Dpotential for harm
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- 0291GeneralS&S Dpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0325GeneralS&S Dpotential for harm
Have properly installed hallway dispensers for alcohol-based hand rub.
- 0541GeneralS&S Dpotential for harm
Install properly constructed and protected linen or trash chutes.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F761 - Labeling of Drugs and Biologicals
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
F914 - Be designed or equipped to assure full visual privacy for each
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F573 - The resident has the right to access personal and medical records pertaining
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
FAQ · About this visit
Common questions about this visit
What happened during the March 5, 2021 survey of BALANCED HEALTHCARE?
This was a inspection survey of BALANCED HEALTHCARE on March 5, 2021. The surveyor cited 15 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at BALANCED HEALTHCARE on March 5, 2021?
Yes, 15 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed."
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.