Inspection·October 9, 2020

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 10/09/20 at 10:04 a.m. with the Director of Nursing (DON), she verified that Resident #17 had a fall in September. The DON reviewed the fall documentation and the Interdisciplinary Team (IDT) note showing the new intervention was to use a floor mat on the door side. She stated that Resident #17 had fallen while on the 4th floor when she was restless. After the fall, she had therapy and once they started getting her up she became less restless. She stated that when she was transferred back to the third floor, they did not bring the floor mat for her bedside. The DON stated that the expectation post a fall was for a new intervention to be put into place and for that intervention to be documented on the care plan. If the intervention was discontinued, it should be discontinued from the care plan. Resident #17 was admitted on [DATE] and readmitted on [DATE]. Record showed diagnoses included but not limited to vascular dementia, diabetes, chronic kidney disease, and history of falls. Review of the annual MDS dated [DATE] showed a BIMS score of 06 (severe impairment). Review of the falls care plan showed interventions included but not limited to on 09/12/20, add to falling [NAME] program and on 09/20/20 floor mat to door side of bed. The progress notes showed on 09/23/20 a IDT note showing resident to have door side floor mat. 3. Record review of the facility's policy, Care Plan-Inter-disciplinary Process, dated 01/2020 revealed the comprehensive care plan is based on a thorough assessment that includes, but is not limited to, review of Medical Records, interview with staff and resident and / or resident legal representative / family and at times the MDS. Care Plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying source (s) of the problem area (s), rather than addressing only symptoms or triggers. It is recognized that care planning individual symptoms or Care Area Triggers in isolation may have little, if any, benefit for the resident. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering, proper sequencing of events and complex clinical decision making. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105504 If continuation sheet Page 2 of 7 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 105504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marion and Bernard L Samson Nursing Center 255 59th St N Saint Petersburg, FL 33710 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice related to tracheostomy care for one (#117) of one resident with a tracheostomy and not maintaining tubing for oxygen off the floor for 5 (#108, #117, 99, 35, 104) of 18 residents on respiratory treatments. Residents Affected - Few Findings included: 1. Observation on 10/08/20 at 10:10 a.m. of Staff I, Registered Nurse (RN) with Resident #117. The resident was lying in bed with the head of the bed elevated. Staff I washed her hands and announced herself. She donned a gown and gloves, she already had on a mask and face shield. The resident's oxygen saturation was 93%. She opened a sterile tracheostomy (trach) kit on a sterile barrier on the bedside table. She then removed her gloves and sanitized hands During the donning of the sterile gloves she ripped one and had to open another sterile trach kit. Using her left hand, she poured normal saline and hydrogen peroxide into one side of the sterile container and normal saline into the other side of the sterile container (left glove is now contaminated). She untied the string from the trach and removed the cannula with her left hand. She placed the cannula in the sterile container of hydrogen peroxide and saline. Staff I cleaned the cannula by holding it with her left hand and using the brushes with her right hand inside and outside of the cannula. She then wiped the cannula with gauze to dry it. She re-inserted the cannula back into trach. She re-tied the strings. She then placed the trash into the trash can. She removed her gloves and washed her hands. She then opened another sterile kit and donned sterile gloves and placed a sterile barrier down on the table. She moved the tape that was lying on the table with her left hand. She placed the gauze from the kit onto the sterile barrier. She opened another dressing kit and dumped it on the sterile barrier. She poured normal saline into sterile container and removed the old dressing and sponge from the resident's trach and put it into the trash. She cleaned around the stoma twice and then used gauze to clean outside of the stoma. She dried around the stoma using gauze. She replaced the sponge under the ties. She obtained a barrier from the side chest of drawers with the same gloves she had used to perform the cleaning and dressing change of the trach. She placed the barrier under the resident's neck. Staff I placed a dated piece of tape on the gauze. She moved the hydrogen peroxide container. She placed the hand sanitizer, tape, and pulse oximeter on a barrier. She then removed her used sterile gloves and placed them in the trash. She picked up the bag of trash and placed it in the red biohazard container. She removed her gown and placed it in the red container. She placed the pulse oximeter and hand sanitizer in her pocket and washed her hands. After the observation she was asked to locate all equipment needed for an emergency. She was able to locate the ambu bag and suction machine. The water condensation bottle was on the floor. She was unable to locate the extra cannula. Staff I, RN left the room and went to the nurse's station to find Staff J, RN, Unit Manager (UM). She asked her if she knew where the emergency cannula was. The UM stated it was in the top drawer of chest of drawers. Staff I looked in all 4 drawers of the chest of drawers and was unable to locate the cannula. She again left the room and went back to nurse's station and told the UM that she was unable to locate it. Staff J, RN, UM was observed calling someone regarding the extra cannula. Staff I, RN stated that respiratory therapy was there two days ago. Staff I, stated, This was not good, should be readily accessible. Staff I, RN found the cannula under the wheel of the resident's bed. She stated, It was not properly secured to the wall. She stated that she will tape it to the wall and was observed doing so. She sanitized her hands and left the room. On interview post care, Staff I RN stated that she Failed the resident because the cannula was not available. She stated that she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105504 If continuation sheet Page 3 of 7 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 105504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marion and Bernard L Samson Nursing Center 255 59th St N Saint Petersburg, FL 33710 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few felt she did well with the gloves, with dominant and non-dominant hands, and reassessing the resident. She stated that, Overall I did okay. On 10/09/20 at 10:04 a.m., an interview was conducted with the Director of Nursing (DON) regarding the tracheostomy care observation with the DON. She stated that once the nurse touched the hydrogen peroxide bottle and normal saline bottle her gloves were contaminated. The DON stated that the nurse should have changed her sterile gloves during the procedure. When informed the condensation bottle was observed on the floor. The DON stated that they should not be on the floor. The DON stated that either of these could possibly be an infection control issue. When asked about the location of the emergency cannula she stated that it was to be kept taped on the wall. She stated that they had one in the central supply, but even that could take up to 5-10 minutes to retrieve. Resident #117 was admitted on [DATE] and readmitted on [DATE]. Record review of the admission showed her diagnoses included but were not limited to Cerebral Vascular Accident (CVA) with hemiparesis, dysphagia, trach and gastrostomy insertion, chronic respiratory failure, heart failure, diabetes, epilepsy and hypertension. Review of the admissions, Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 0 (resident is rarely / never understood). Section G, Functional Status showed she was totally dependent related to bed mobility, transfers, eating, and toileting. Section O, Special Treatments, Procedures, and Programs showed she was on oxygen therapy and had a tracheostomy. Review of the physician orders dated 02/05/19, showed orders for trach care every shift and as needed, change split sponge with trach care every shift. Record review of the care plans, initiated on 12/05/19 and revised on 05/12/20, showed Resident #117 had a tracheostomy related to impaired breathing mechanics and a diagnosis of respiratory failure. Resident will have no signs and symptoms of infection. Interventions included but not limited to change inner cannula (tracheostomy) every night for prophylaxis of blockage or infection and every 24 hours as needed for prophylaxis of blockage or infection; check respiratory equipment (oxygen tubing, neb mask/tubing) and ensure that it is dated; ambu bag at bedside at all times; trach care every shift and as needed change split sponge with trach care; TUBE OUT PROCEDURES: keep extra trach tube and obturator at bedside; if tube is coughed out, open stoma with hemostat, if tube cannot be reinserted, monitor / document for signs of respiratory distress. Record review of facility's policy, Tracheostomy Care, revised August 2013 showed a replacement tracheostomy tube must be available at the bedside at all times. Preparation and Assessment: check physician order. Explain procedure to resident. Wash hands. Put exam gloves on both hands. Remove supplemental oxygen mask from tracheostomy. Inspect skin and stoma site for signs or symptoms of infection, leakage, subcutaneous crepitus, or dislodged tube. Assess resident for respiratory distress. Remove old dressings. Pull soiled glove over dressing and discard into appropriate receptacle. Wash hands. Clean the Removable Inner Cannula. Open tracheostomy cleaning kit. Set up supplies on sterile field. Maintaining sterile field, pour equal parts hydrogen peroxide and normal saline in one compartment of opened kit. Pour normal saline in another compartment. Open four gauze pads and saturate with hydrogen peroxide. Open two gauze pads and saturate with antiseptic solution. Open two gauze pads and saturate with sterile saline. Open two gauze pads; keep them dry. Put on sterile gloves. Secure the outer neck plate with non-dominate gloved hand. Gently remove the inner cannula, rotating counterclockwise while lifting away from the resident. Soak the cannula in hydrogen peroxide / saline mixture. Clean with brush. Rinse with saline and dry with pipe cleaners. Remove and discard gloves into appropriate receptacle. Wash hands and put on fresh gloves. Replace the cannula carefully and lock in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105504 If continuation sheet Page 4 of 7 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 105504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marion and Bernard L Samson Nursing Center 255 59th St N Saint Petersburg, FL 33710 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 0695 Level of Harm - Minimal harm or potential for actual harm place. Ensure there is emergency tracheostomy set up at resident's bedside Site and Stoma Care: apply clean gloves. clean the stoma with two peroxide-soaked gauze pads. Rinse the stoma with saline-soaked gauze pads. Wipe with dry gauze. Apply a fenestrated gauze pad around the insertion site. Replace supplemental oxygen mask over tracheostomy. Remove gloves and discard into appropriate receptacle. Wash hands. Residents Affected - Few 2. Observation on 10/07/20 at 5:15 p.m. Resident #108 was lying in bed dressed and groomed. Resident had oxygen via nasal cannula. The oxygen tubing was on the floor. Observation on 10/08/2020 at 11:00 a.m. Resident #108 was lying in bed with his oxygen in place. The oxygen tubing was on the floor. Observation on 10/08/20 at 4:54 p.m. Resident #108 was lying in bed with his eyes closed. His head of the bed was elevated. His oxygen tubing was lying on the floor. On observation and interview with Staff K, RN, she verified the oxygen tubing was on the floor. She stated, No it shouldn't (oxygen tubing) be on the floor, It is way too long. A shorter line is needed. Resident #108 was admitted on [DATE]. Record review showed diagnoses included but not limited to heart failure, chronic kidney disease, Cerebral Vascular Accident (CVA), Chronic Obstructive Pulmonary Disease (COPD), and dementia. Record review of the quarterly MDS dated [DATE] showed a BIMS score of 09 (moderately impaired). Section G, Functional Status showed the resident total dependent related to bed mobility, transfers, and extensive assistance for toileting. Section O, Special Treatments, Procedures, and Programs showed the resident relied on oxygen. 3. Review of Resident #35's record revealed that this resident was admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS) dated 9/15/20 with a score of 15. Continued review of the residents record revealed that this resident had current orders that included: O2 at 2L via NC (nasal cannula) continuous every shift related to Chronic Respiratory Failure with hypoxia Review of Resident #35's care plan dated 7/23/18 with a revision date of 8/14/20 revealed that it addresses respiratory status/difficulty breathing. Observations on 10/07/20 at 12:22 p.m. of Resident #35 revealed the resident lying on her bed. Closer observations of the resident and her surroundings revealed that the resident was receiving oxygen via nasal cannula, and the concentrator was noted to be on and running. It was noted that the residents oxygen concentrator was against the wall and the residents bed was approximately 6 feet from the concentrator. The residents oxygen tubing was noted to be lying across the residents bedroom floor from the bed to the concentrator. Observations on 10/08/20 at 7:50 a.m. revealed Resident #35 lying on her bed with her eyes open and her morning meal tray present. Interview with the resident at this time revealed that she had oxygen on all the time, and that the concentrator was usually kept against the wall. Continued observation at this time revealed that the resident's oxygen tubing was lying across the floor about 6 feet from the resident's bed to the concentrator. Observations on 10/09/20 at 8:25 a.m. revealed that the resident was lying in bed. Resident #35's oxygen was noted to be on and in use. The oxygen tubing was noted to be resting on the floor. (Photographic Evidence Obtained). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105504 If continuation sheet Page 5 of 7 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 105504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marion and Bernard L Samson Nursing Center 255 59th St N Saint Petersburg, FL 33710 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 0695 Level of Harm - Minimal harm or potential for actual harm Interview with Staff A, Certified Nursing Assistant (CNA), revealed that she was not aware that the oxygen tubing should not be on the floor. Observation of the resident's oxygen tubing with Staff B, LPN confirmed that the resident's oxygen tubing was on the floor. Staff B verified that the oxygen tubing should not be on the floor. Residents Affected - Few 4. Review of Resident #99's record revealed that this resident was admitted to the facility on [DATE] and had a BIMS dated 9/28/20 with a score of 14. Continued review of the resident record revealed that this resident had current physician orders that included: O2 @ 2L PRN to maintain SPO2> (greater than) 90% every shift Review of the residents care plan dated 9/25/20 revealed that it addresses the residents diagnosis of Chronic Obstructive Pulmonary Disease (COPD), with interventions that include the use of oxygen. Observations of Resident #99 on 10/06/20 at 11:41 a.m. revealed that the resident was sitting up in his wheelchair next to his bed and that his oxygen tubing was noted to be on the floor. Observations on 10/07/20 at 12:17 p.m., revealed Resident #99 was seated up in his wheelchair with his oxygen on and running. The oxygen tubing was noted to be on the floor. Observations on 10/09/20 at 8:58 a.m. of the resident revealed him lying in bed asleep. The residents oxygen was noted to be in use via nasal cannula, the excess tubing was unbagged and resting on the floor across the room. The concentrator was noted to be running. Observation on 10/09/20 at 9:00 a.m. of the oxygen tubing on the floor with Staff D, RN present. She confirmed that the oxygen tubing was on the floor. Interview with Staff D at this time revealed that the oxygen tubing should not be on the floor. 5. Review of Resident #104's record revealed that this resident was admitted to the facility on [DATE], had a BIMS dated 9/10/20 with a score of 12. The resident has current physician orders that include: -O2 at 2L via NC to maintain SPO2> (greater than) 92% every shift Review of the resident's care plan dated 7/29/19, with a revision on 4/29/20, revealed that it addressed the resident's altered respiratory status/difficulty breathing, dx of COPD, with interventions that included the use of oxygen. Observations 10/09/20 at 8:39 a.m. of Resident #104 lying in bed. The resident's nasal cannula was noted to be unbagged and attached to the bed rail, the remainder of the tubing was noted to be resting on the garbage can and resting on the floor. A CNA was present in the room and noted to be straightening up the room and the area around the concentrator. The concentrator was noted to be running. Interview with the resident at this time revealed that the concentrator was running and that she could not reach to turn it off but took off her nasal cannula. Interview on 10/09/20 at 8:40 a.m. with Staff C, CNA revealed that she was not aware that the oxygen tubing should not be on the floor. Interview on 10/09/20 at 8:42 a.m. with Staff D, RN revealed that oxygen tubing was changed weekly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105504 If continuation sheet Page 6 of 7 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 105504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marion and Bernard L Samson Nursing Center 255 59th St N Saint Petersburg, FL 33710 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete by the respiratory vendor. Observation of Resident #104's room at this time with Staff D present confirmed that the oxygen tubing was on the floor. She reported that it should not be on the floor and should never be on the floor. 6. Interview on 10/09/20 at 3:12 p.m. with the DON revealed that she did not have a policy related to the appropriate storage of oxygen tubing on the floor. She reported That's a given, not to have the oxygen tubing on the floor. Event ID: Facility ID: 105504 If continuation sheet Page 7 of 7