Inspection·December 30, 2020

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, and interviews, the facility failed to respect the right to dignity for three (#56, #59, and #60) of 16 residents receiving extensive or total assistance with eating as evidenced by staff members standing over, in front of, and to the side of the residents while assisting them with mid-day nutrition. Findings included: On 12/29/20 at 1:00 p.m., an observation was conducted of Staff Member F, Certified Nursing Assistant (CNA), standing in front of Resident #56 while assisting with eating. The observation revealed the resident was dependent on the staff member with oral intake and she did not attempt to feed herself. During this observation, Resident #56's roommate, Resident #59, was assisted with the mid-day meal by Staff Member G, CNA. Resident #59 was sitting in a wheelchair with an over-the-bed (obt) table in front of her wheelchair. The staff member was standing on the other side of the obt. Resident #59 held a carton of milk but did not attempt to use utensils or fingers to feed herself. At 1:00 p.m., the resident room next to Resident #56's and 59 was also observed. Resident #60 was sitting in a wheelchair with the short side of an obt in front of her. Standing to the side of Resident #60 and in front of the long side of the obt was Staff Member E, CNA. The meal tray was sitting on the obt in front of the staff member. Resident #60 did not attempt to feed herself. At 1:02 p.m., Staff Member F brought Resident #56's lunch tray out of the room and placed it in the meal cart. Staff Member F reported that it was common for staff to stand up while assisting residents with eating. At 1:07 p.m., while Staff E was assisting Resident #60, a chair was observed in the resident's room approximately 4 foot from the staff member. At 1:12 p.m., Staff E & G continued to stand while assisting Resident #59 and Resident #60 with the lunch meal. Staff Member E removed the meal tray, at 1:14 p.m., from Resident #60's room. The staff member stated that they (CNA's) sat with the residents in the dining room to assist them with eating but now there was no chair in the room. Following this statement, Staff E acknowledged that there was a chair in Resident #60's room and stated, well there is. Staff E reported that she was educated on how to assist residents with eating and confirmed that the education included not standing while assisting the residents. At 1:21 p.m., after finishing the lunch meal with Resident #59, Staff G confirmed she had been educated on how to assist residents with eating and staff members were to be sitting. She reported (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 3 Event ID: 105700 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 105700 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/30/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northdale Rehabilitation Center 3030 Bearss Ave Tampa, FL 33618 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)