Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0610
Respond appropriately to all alleged violations.
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 interview, the facility failed to provide sufficient evidence that all alleged violations were
thoroughly investigated related to obtaining information from all relevant staff members for three (#1, #2,
and #3) of seven residents reviewed for alleged violations.
Residents Affected - Few
Findings included:
Review of the undated facility policy with the subject Abuse, Neglect, Exploitation, Mistreatment,
Misappropriation of Property and Injury of Unknown Source Prevention (ANEMMI) revealed the following:
Section VI. Reporting/Response, 3. Have evidence that all alleged violations are thoroughly investigated.
1. Review of Resident #1's record revealed the resident was admitted to the facility on [DATE], and had
diagnoses that included Alzheimer's, Dementia, and Adult failure to thrive. The resident had a Brief
Interview for Mental Status (BIMS) score of 0.0 (Severe Impairment) dated 12/15/22.
Review of the reportable incident log revealed that Resident # 1 had an injury of unknown origin on 3/1/23.
Review of the Incident note dated 3/1/23 at 8:14 a.m., revealed At 7:15 day center CNA while Transporting
resident to dining room noticed hair matted to back of head. Upon investigation dry blood observed, area
moisten with water, small bump felt on left occipital area with 1cm skin tear noted. Supervisor notified, LPN
Manager notified, Risk Manager notified and all came to view resident.
Review of the Health Status Report dated 3/1/23 9:00 [a.m.] revealed the following: IDT-While performing
resident care and transfers, staff to make sure that all extremities are properly placed and objects are not in
the way to help reduce skin impairments
Review of the investigation packet revealed five staff persons provided written statements. Closer review of
the staff statements revealed that Staff A, Certified Nurses Assistant (CNA) wrote I worked the 11-7:30 am
shift. I didn't view anything out of the ordinary on 3/1/23 at 5am I got the patient [Resident #1] dressed and
then used her hoyer lift sling under her then raised on hoyer lift to get her in wheelchair. [Resident #1] was
safely placed in wheel-chair.
Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was Total
Dependence of 2+ persons for transfers.
(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 4
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
07/07/2023
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 0610
Level of Harm - Minimal harm
or potential for actual harm
Review of the annual MDS dated [DATE] revealed the resident was Total Dependence of 2+ persons for
transfers.
Review of the quarterly MDS dated [DATE] revealed the resident was Total Dependence of 2+ persons for
transfers.
Residents Affected - Few
Review of Resident #1's care plan revealed a care plan with an initiated date of 8/31/18 and a revision date
of 9/20/22, related to ADL self-care performance deficit r/t fatigue, Impaired balance, requires assist with all
ADL's, non-ambulatory, quadriplegia. The care plan was noted to include the following interventions:
-Transfer: Total x 2 Hoyer 9/18/2018
-Bed Mobility: The resident requires two persons with bed mobility
Review of the care plan with an initiated plan dated 9/6/18 and a revision date of 11/29/21 showed the
resident was at risk for falls r/t confusion gait/balance, unaware of safety needs, osteoporosis The care plan
was noted to include the following: Vanderlift x 2 persons for all transfers) with a initiated date of 9/18/18,
and a revision date of 10/2/18.
Review of the care plan related to the resident's potential for skin impairments: rosacea dx fragile skin,
incontinence, assist needed with all ADL, hx frequent skin tears, and bruising, rosacea. with an initiated
date of 10/2/18, and a revision date of 6/21/23 showed interventions that included:
-Avoid bumping objects while transferring and educate staff on safety precautions when transferring
resident. 7/10/19
-Continue to provide safe handling during resident care and transfers to help prevent skin impairments.
2/8/21
-During transfers, make sure hoyer pad or clothing is not pressing against or tight around the neck to help
reduce skin impairments 10/25/21
-During resident care, staff to be aware of residents extremities to help reduce skin impairments, 10/31/21
-Continue to use gentle touch approach when handling resident during transfers. Continue to ensure that
extremities are not in the way of mechanical lifts or objects to help minimize skin tears., 12/14/22
-Staff to make sure they are using the proper mechanical lift during resident care/transfers. 12/24/21
-Continue to provide safe handling during resident care and transfers to help prevent skin impairments.
2/27/23
Continue with all skin safety precautions. Provide safe handling during resident care and transfers to help
prevent skin impairments. 5/19/23
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105504
If continuation sheet
Page 2 of 4
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
07/07/2023
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 0610
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During an interview on 7/6/23 at 1:54 p.m. with the Nursing Home Administrator (NHA), Director of Nursing
(DON), and the Assistant Nursing Home Administrator (ANHA), the ANHA confirmed she interviewed Staff
A who was an agency CNA, who reported that she used the mechanical lift to get the resident into her chair
on the morning of the incident. The ANHA said she was unable to confirm Staff A was assisted by another
staff person to complete the transfer and that was the reason Staff A was educated on the use of the lift.
She reported she did not interview any other staff related to the resident's transfer.
2. Review of Resident #2's record revealed the resident was admitted to the facility on [DATE] and
re-admitted on [DATE]. The resident had diagnoses that included Hemiplegia, unspecified affecting
unspecified side, Convulsions, History of convulsions, Major Depression Disorder, Anxiety disorder, and
Contracture. The resident had a BIMS score of 1.0 (Severe Impairment)
Review of the facility incident log revealed the resident had an injury of unknown origin on 3/29/23.
Review of the investigation revealed the resident was observed by staff with a swollen left leg on 3/29/23.
The physician was notified and a x- ray was ordered on 3/29/23 of left hip, left femur , knee, left lower ext.
Review of the X-ray results revealed Acute fractures of the tibial plateau and head of fibula. Severe
osteoporosis. Review of the progress note dated 3/29/23 21:07 (9:07 p.m.) revealed the
Resident unable to state how injury occurred.
Review of the care plan dated 8/31/21 indicated that the resident has behaviors during care yelling at staff,
resistance
Review of the residents care plan showed, ADL self-care performance deficit r/t need for assistance from
staff with all ADL care, [Resident #2] likes to put legs in air, kickout often, w/c use, decreased ROM of right
hand, ADL decline may be unavoidable due to end stage condition/Hospice care, left tibial fracture. Initiated
date of 9/11/18 with a revision on 5/4/23.
Review of the care plan showed risk for falls r/t weakness, hemiplegia, impaired cognition. Initiated date of
3/7/19 and a revised date of 11/29/19.
Review of care plan dated 3/7/19 with a revised date of 12/30/21 revealed that the resident has dx of
osteoporosis and is at risk for fractures.
On 7/6/23 at 1:54 p.m., an interview was conducted with the NHA, ANHA, and DON. The ANHA confirmed
she did not have written statements from staff who might have encountered the resident during the time of
the incident.
3. Review of Resident #3's record revealed she was admitted to the facility on [DATE] with diagnoses that
included Fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with
routine healing, presence of left artificial hip joint, Dementia, Age-related Physical debility, Abnormal gait,
Personal history of (healed) osteoporosis fracture, protein-calorie malnutrition and History of falling. The
record revealed a 5-day MDS dated [DATE] which included a BIMS evaluation which reflected a score of 9
(Moderately impaired).
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105504
If continuation sheet
Page 3 of 4
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
07/07/2023
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 0610
Review of the facility incident log revealed the resident had was found on the floor on 5/3/23.
Level of Harm - Minimal harm
or potential for actual harm
Review of the investigation revealed the resident was observed lying on her left side on the floor beside her
bed on 5/3/23 at approximately 11:30 p.m. and the physician was notified and ordered X-rays which
indicated a result of possible dislocation of left hip.
Residents Affected - Few
Review of the residents care plan revealed a plan dated 5/3/23 with a revision date of 5/8/23 related to ADL
self-care performance deficit r/t left femur fracture s/p left hip replacement, ambulates with assist, shortness
of air with exertion at times, posterior hip dislocation/left hip
Review of the resident care plan revealed a plan dated 4/24/23 related to the resident being at risk for falls
r/t hx of falls
An interview was conducted on 7/6/23 at 9:00 a.m. with the NHA, ANHA, and the DON. The facility team
reviewed the incident involving Resident #3 and provided one written statement from the nurse that found
the resident on the floor. The ANHA was unable to verbalize or provide any other documentation that would
indicate all relevant persons were interviewed in relation to the incident. The ANHA reported she would
have to look in an alternate file to determine if she had anymore statements.
During a interview on 7/7/23 at 1:20 p.m. with the NHA, ANHA, and the DON, the ANHA reported the only
statement obtained related to this incident was the one from the nurse who reported she observed the
resident lying on the floor. She reported she had no other statements related to this incident.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105504
If continuation sheet
Page 4 of 4
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
1 citation 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.
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
FAQ · About this visit
Common questions about this visit
What happened during the July 7, 2023 survey of MARION AND BERNARD L SAMSON NURSING CENTER?
This was a inspection survey of MARION AND BERNARD L SAMSON NURSING CENTER on July 7, 2023. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at MARION AND BERNARD L SAMSON NURSING CENTER on July 7, 2023?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Respond appropriately to all alleged violations."
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.