Health inspection·July 7, 2023

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. Page 1 of 4 105504 105504 07/07/2023 Marion and Bernard L Samson Nursing Center 255 59th St N Saint Petersburg, FL 33710

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 105504 Page 2 of 4 105504 07/07/2023 Marion and Bernard L Samson Nursing Center 255 59th St N Saint Petersburg, FL 33710

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). 105504 Page 3 of 4 105504 07/07/2023 Marion and Bernard L Samson Nursing Center 255 59th St N Saint Petersburg, FL 33710

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. 105504 Page 4 of 4