Health inspection·December 16, 2021

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 Page 1 of 2 105504 105504 12/16/2021 Marion and Bernard L Samson Nursing Center 255 59th St N Saint Petersburg, FL 33710

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 . 105504 Page 2 of 2