F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Based on observation, interview, and record review the facility failed to ensure the immediate surrounding
environment for one (Resident #61) of two residents with diet orders of nothing by mouth (NPO) was free of
accident hazards.
Findings included:
An interview on 12/15/21 at 8:11 a.m. with Resident #61's Power of Attorney (POA) revealed the resident is
non-verbal and is unable to swallow, meaning the resident cannot intake anything by mouth. Resident #61's
movement and ability to reach is limited and post-stroke requires extensive assistance from staff.
A document review of Resident #61's admission record revealed the resident was admitted to the facility in
October 2021 with medical diagnosis of dysphasia (difficulty swallowing) following cerebral infraction,
Parkinson's disease, dementia, and muscle weakness. The resident's Minimum Data Set (MDS)
assessment, dated 10/27/21, revealed the resident had severe cognitive impairment with total dependence
on staff for bed mobility and eating.
A document review of Resident #61's Order Summary Report revealed an active physician order of NPO
diet, started on 10/20/21.
Resident #61's care plan revealed a focus area, initiated on 10/20/21 of self-care performance deficits
related to right hemiplegia, being non-ambulatory, and having Parkinson's disease. An intervention for this
focus area is oral care daily, NPO.
Further review of the care plan revealed a focus area, initiated on 10/24/21, of . requires tube feeding r/t
[related to] Dysphasia asisatrisk [at risk] for aspiration . NPO [nothing by mouth].
During an observation on 12/15/21 at 7:50 a.m. with Staff B, Licensed Practical Nurse (LPN) Resident #61
was lying in bed non-responsive to communication. A cup with a drinking straw, dated 12/15/21 with
Resident #61's room and bed letter written on the cup, was noted placed on the right bedside table out of
the resident's reach; photographic evidence was obtained. Staff B, LPN confirmed the cup at the resident's
bedside was for drinking water and filled with ice. Staff B picked up the cup, shaking it lightly to reveal the
cup was full of water and ice. Reviewing Resident #61's online medical record, Staff B, LPN confirmed the
resident was physician ordered for nothing by mouth and stated the cup should not have been placed at the
resident's bedside.
An interview on 12/15/21 at 7:55 a.m. with Staff A, Certified Nursing Assistant (CNA) revealed
(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 2
Event ID:
105504
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
12/16/2021
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Resident #61 required total assistance by staff and had a diet order for nothing by mouth. Staff A, CNA
stated she has not provided any water to Resident #61 and that the water at the resident's bedside should
not be there. Staff A, CNA stated that the water cup must have been placed at the resident's bedside on the
11:00 p.m. to 7:00 a.m. shift.
An interview with Staff C, Unit Manager on 12/15/21 at 8:00 a.m. confirmed Resident #61 should have
nothing by the bedside which contradicted her diet order of NPO.
An interview on 12/15/21 at 8:42 a.m. with Staff D, CNA confirmed the CNA was the assigned staff member
to Resident #61 on the 11:00p.m. to 7:00 a.m. shift. Staff D, CNA stated ice water cups were passed out in
mass to all the residents on his assignment sheet. While he did assist some residents with drinking water,
he did not assist those residents with tube feedings because they are normally nothing by mouth.
An interview on 12/15/21 at 8:05 a.m. with the Director of Nursing (DON) confirmed that no drinking water
should have been placed at Resident #61's beside due to having an NPO order in place and being at risk
for aspiration.
A policy review of Safety Program, with a most recent revision date of 02/24/17, revealed It is the policy of
[Facility Name] to provide a system for monitoring and maintaining a safe environment for residents,
personnel, and visitors. The nursing center shall maintain an organized safety program which shall be
monitored by the Administrator, Director of Quality Services, and his/her designated alternative . This plan
describes how the organization provides a hazard free physical environment and managers activities to
reduce the risk of injury . Maintaining and supervising all grounds and equipment . identifying an
individual(s) to intervene whenever conditions pose an immediate threat to lift or health . providing an
orientation and education program that addresses: 1. General safety process. 2. Area-specific safety .
A policy review of Diet Changes, with a most recent revision date of 06/28/16, revealed The Registered
Dietitian, Nursing and Rehab Departments are responsible for communicating changes to a resident's diet.
These changes include, but are not limited to, communicating diet orders, diet modifications, and additional
of adaptive equipment, food preferences, restrictions or allergies .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105504
If continuation sheet
Page 2 of 2
