Health inspection·May 9, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment in six (105, 106, 109, 110, 111, and 112) out of eleven resident rooms and the medication room. Findings Included: During a facility tour on 5/7/24 at 9:30 a.m. the following observations were made: In room [ROOM NUMBER] there was a hole in the wall next to the resident's bed. Around the bed the wire mold was split and there were exposed wires. The base board next to the sink was separating from the wall. (Photographic Evidence Obtained). In room [ROOM NUMBER] there was a deep hole in the wall where the concrete infrastructure was observed next to the resident's bed. (Photographic Evidence Obtained). On 5/7/2024 at 9:40 a.m. during a tour of common areas and resident rooms, the following observations were made in resident rooms 109, 110, 111 and 112. Each room accommodated up to 4 residents, with a shared toilet and sink for up to eight residents. rooms [ROOM NUMBERS] and rooms [ROOM NUMBERS] shared two separate bathrooms. The doorframes and doors had gouges, chipped paint, scruff marks, the surface had a rough texture, and discoloration from dust on the texture ridges. The bedroom walls were cracked and had holes of various sizes. Wires were hanging from the walls above and around the residents' beds. The wire mold behind headboard was rusted, grimy, halfway detached and hanging from the wall. Portions of the base boards were cracked, dusty, grimy, and peeling from the walls. Grime was built up on the horizontal surfaces of the baseboards and wire molding. The walls appeared to have moisture damage, the paint had a bubble appearance. Dusty vents air vents were observed. (Photographic Evidence Obtained). On 5/8/24 the observations described above were present in the facility. On 5/9/24 the observations described above were present in the facility. On 5/8/24 during medication room observation and interview with the Director of Nursing (DON), dust was hanging from the air vent. Many wires, including cut wires were hanging tangled against the wall from various outlet sources. The DON said, I never noticed the wires on the wall, I come in here often There was dusty battery powered lanterns stored on the floor as well as trash. The sink drain Page 1 of 7 105714 105714 05/09/2024 Concordia Manor 321 13th Ave N Saint Petersburg, FL 33701

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some area contained black and grimy particles, the faucet was turned on and the water was draining slowly. The DON said, I did not know the sink was clogged, staff do not use it. The DON attempted to unclog the drain by removing particles and said staff did not use the sink, but she would let maintenance know the sink was clogged. (Photographic Evidence Obtained) On 5/8/24 at 12:35 p.m. during an interview and observation with the DON in room [ROOM NUMBER], she said, I agree this is not a homelike environment. On 5/8/24 at 3:18 p.m. during an interview with Staff G, Maintenance Director and Staff H, housekeeping supervisor, Staff H said the dusters the housekeeping staff used to clean the air vent covers could not go through the slots on the vents. Staff H said the facility's leadership was aware the dusters could not clean the bathroom fan vents because the duster knocks against the fan blades The housekeeping staff was responsible for dusting the outside of the vents and maintenance staff were responsible to clean the inside of the air vent covers. Staff G said the inside of the air vent covers were cleaned when staff brought the issue to his attention. He was the only maintenance staff member and was onsite at the facility two days each week. Staff G rounds in the facility and prioritized preventative maintenance tasks. Staff G removed a pocket size spiral ring notebook and said this was used to track tasks. On 5/8/24 at 3:25 p.m. during an interview and observation in room [ROOM NUMBER], the Nursing Home Administrator (NHA) said the room was not homelike. On 5/9/24 at 12:20 p.m. during an interview, Staff G was shown photos of resident rooms [ROOM NUMBERS]. He said he checked three resident rooms each week and prioritized issues by safety concerns. He prioritized broken electrical outlets, leaks, and work order-based issues. Staff G said the exposed wires in room [ROOM NUMBER] were low voltage and not a priority. He said he was not aware of the issues in the rooms [ROOM NUMBERS]. Staff G said there was a sheet at nurses' station with instructions on how to log work orders. He referred to the pictures and said he did not expect resident rooms to be in that condition. Staff G said he was assigned to two different facilities and was the only maintenance person for both buildings. A review of the policy entitled, Physical Environment, effective January 1, 2020, showed A safe, clean, comfortable, and home life environment is provided for each resident/patient allowing the use of personal belongings to the greatest extent possible. Sufficient space and equipment in dining, health services, recreation and program areas are provided to enable staff to provide residents with needed services. All essential mechanical, electrical, and resident care equipment is maintained in safe operating condition through the facility's 'Preventative Maintenance Program'. 105714 Page 2 of 7 105714 05/09/2024 Concordia Manor 321 13th Ave N Saint Petersburg, FL 33701

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure the resident and resident representative received a bed hold notification prior to and upon transfer to the hospital for one (Resident #29) of two residents reviewed for bed hold notification. Findings included: Review of the admission Record for Resident #29 revealed an original admission date in January of 2024, a transfer to the hospital on [DATE], and a readmission to the facility on [DATE]. A review of the contact information revealed the resident's name and a second name labeled as Responsible Party/Health Care Proxy/and Emergency Contact #1. Review of a document titled, Health Care Proxy Designation and Acceptance Letter (FL) dated 01/12/24 confirmed the contact listed on the admission Record was the designated health care decision maker for Resident #29. Review of a document titled, BED HOLD AND IN-HOUSE TRANSFER POLICY, showed a form with Resident #29's name at the top. The area to list the Resident Representative's name was blank, and the signature line/date line was blank to acknowledge the document was received and understood. An interview was conducted on 05/08/24 at 3:33 PM with the Director of Nursing (DON). She reviewed Resident #29's record and confirmed there was no evidence the resident and the representative had been notified of the bed-hold upon transfer to the hospital on 3/18/24. She stated the staff should complete bed holds at the time the resident's sent out. She stated the resident or responsible party should sign off acknowledging the notification and if they were unable to sign, it should be documented on the form. On 05/08/24 at 3:50 PM, Staff A, Regional Nurse Consultant (RNC) confirmed their practice was to notify the resident or representative of the bed-hold at the time of transfer. Review of the October 2023 policy and procedure titled Bed Hold - Florida showed POLICY The facility provides the resident/resident representative notice of bed hold in advance of transfer. An additional notice, which specifies the duration of the bed hold, will be provided upon transfer to the hospital . Review of the procedure showed: 1. Provide the resident/resident representative with a written notice of bed-hold upon admission - in electronic admission Packet. 3. Upon transfer, provide an additional bed hold specifying the duration of the bed hold. 4. In cases of emergency transfer, written notification of bed hold policy will be provided to the resident/representative within 24 hours of the transfer. 105714 Page 3 of 7 105714 05/09/2024 Concordia Manor 321 13th Ave N Saint Petersburg, FL 33701

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility's policy PASRR Requirements Level I & Level II, the facility failed to ensure seven (Residents #3, #5, #13, #18, #19, #20 and #26) of fourteen sample residents reviewed for PASRR screens had an accurate Level 1 Pre-admission Screening & Resident Review (PASRR). Residents Affected - Few Findings included: 1. A review of the admission Record showed Resident #3 was admitted to the facility on [DATE] with diagnoses that included but not limited to Hypertension, Major Depressive Disorder, Recurrent, Generalized Anxiety Disorder, Alzheimer's Disease and Persistent Mood [Affective] Disorder. Review of Resident #3's Level I PASRR not dated revealed, Section 1. Guide for determining an indication of a diagnoses of a serious mental illness- check those that apply showed Anxiety Disorder and Major Depression was not checked. A review of the admission Record showed Resident #26 was admitted to the facility on [DATE] with diagnoses that included but not limited to Malignant Neoplasm of pancreas, Abdominal Aortic Aneurysm without rupture and Generalized Anxiety Disorder. Review of Resident #26's Level I PASRR dated 02/06/24 revealed, Section 1 A. Mental Illness (MI) or suspected MI check all that apply showed Anxiety Disorder was not checked. During an interview on 05/09/24 at 9:00 a.m., the Director of Nursing (DON) stated she was responsible for the accuracy of all PASRRs in the facility. The DON stated there was a discrepancy with Residents #3 and #26's PASRRs as neither PASRR reflected the resident's current diagnoses in section 1 A. 2. A review of the admission Record showed Resident #13 was admitted to the facility on [DATE] with diagnoses that included but not limited to Major Depressive Disorder, recurrent, unspecified, Dementia, Schizophrenia, Mood Disorder and Anxiety Disorder. Review of Resident #13's Level I PASRR dated 2/21/18 revealed, Section 1. Guide for determining an indication of a diagnoses of a serious mental illness- check those that apply showed schizophrenia was unchecked. Section IV PASRR screen completion-check one of the following showed no diagnosis or suspicion of serious mental illness (SMI) or Intellectual Disability (ID) indicated. Level II PASRR evaluation not required. A review of the admission Record showed Resident #20 was admitted to the facility on [DATE] with diagnoses that included but not limited to Mood Affective Disorder, Persistent, Major Depressive Disorder, and anxiety disorder. Review of Resident #20's Level I PASRR dated 02/06/24 revealed, Section 1 A. Mental Illness (MI) or suspected MI check all that apply showed Anxiety Disorder, Bipolar Disorder and Substance Abuse were checked. Section IV PASRR screen completion-check one of the following revealed no diagnosis or suspicion of serious mental illness (SMI) or Intellectual Disability (ID) indicated. Level II PASRR evaluation not required. 105714 Page 4 of 7 105714 05/09/2024 Concordia Manor 321 13th Ave N Saint Petersburg, FL 33701

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 05/09/24 at 9:09 a.m. with the Director of Nursing (DON) and Staff A, Regional Clinical Nurse (RCN). The DON said there were discrepancies with Residents #13 and #20's PASRRs as neither PASRRs reflected A Level II PASRR evaluation must be completed. The DON said she was not fully aware of all the indications for residents to have Level II PASRR screening. 3. Review of Resident #5's admission record showed she was readmitted to the facility on [DATE] with diagnosis to include major depressive disorder. Review of a level I PASRR for Resident #5 dated 02/04/20 revealed an incomplete PASRR with the qualifying diagnosis not checked. Review of Resident #19's admission record showed she was admitted to the facility on [DATE] with diagnoses to include major depressive disorder, anxiety disorder, epilepsy, and other seizures. Review of a level I PASRR for Resident #19 dated 04/27/20 showed an incomplete PASRR with the qualifying diagnoses of anxiety disorder and epilepsy not checked. Review of Resident #18's admission record showed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, schizophrenia, unspecified dementia, psychotic disturbance, mood disorder and anxiety. Review of a level I PASRR for Resident #18 dated 01/25/24 showed an incomplete PASRR. The qualifying diagnoses of Alzheimer's disease, unspecified dementia, psychotic disturbance, and anxiety were not checked. The review further showed a level II PASRR was not submitted for consideration. On 05/08/24 at 03:18 p.m., an interview was conducted with Staff B, Director of Nursing (DON) from a sister facility. She stated she was assisting this facility's DON. She confirmed the reviewed PASRRS were incomplete. She said, Yes, if the resident has qualifying diagnosis, their PASRR should be checked. She stated if a Resident needed a level II PASRR, it should be submitted as soon as the diagnoses were identified. An interview was conducted with the DON on 05/08/24 at 3:25 p.m. She revealed she was responsible for ensuring the PASRRs were completed fully and in a timely manner. She stated she was a new DON and was working on updating PASRRs among other duties. On 05/08/24 at 3:32 p.m., an interview was conducted with Staff A Regional Nurse Consultant (RNC). She stated they would be putting a plan in place to ensure all PASRRs were reviewed and updated accordingly. Review of a facility policy titled, PASRR Requirements Level I and Level II, dated February 2021, showed preadmission screening will be conducted prior to admission as the PASRR is federally mandated pre-admission screening program require to be performed on all individuals prior to admission to a nursing home. The screening is reviewed by admissions for suspicion of serious mental illness and intellectual disability to ensure appropriate placement in the least restrictive environment and to identify the need for provide applicants with needed specialized services. PASRR screening applies to all new admissions . regardless of payer source. 105714 Page 5 of 7 105714 05/09/2024 Concordia Manor 321 13th Ave N Saint Petersburg, FL 33701

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, interview and review of the facility's policy Policy and Procedure: Topic Safety the facility failed to ensure kitchen equipment was being utilized in safe operating conditions. Residents Affected - Some Findings included: An observation on 05/07/24 at 9:30 a.m., revealed a two-door reach in refrigerator that had standing water sitting at the bottom of the refrigerator. There was a constant water drip coming from the top of the refrigerator. The water was observed dripping on a container of strawberries and then running off into the floor of refrigerator where standing water was present. Photographic evidence obtained. An observation on 05/07/24 at 9:35 a.m., revealed a sink that had a plastic cup with bottom cut out to fit over the faucet. The plastic cup sat over the bottom portion of the sink facet. A water drip was observed and continued to drip out of the faucet where the cup was placed. Photographic evidence obtained. An observation on 05/07/24 at 9:40 a.m., revealed a one-door reach in refrigerator that had standing water sitting at the bottom of the refrigerator. There was a constant water drip coming from the top of the refrigerator. The water was observed falling from the top of the refrigerator and falling to the bottom of the refrigerator where the water was accumulating. Photographic evidence obtained. During an interview on 05/07/24 at 9:45 a.m., Staff E, Dietary Manager (DM) stated that she was aware that both the Refrigerators' drip and that the refrigerators had been doing that a while. During an interview on 05/07/24 at 9:47 a.m., Staff D, [NAME] stated that maintenance had been in to fix the water drips in the refrigerators several times but it just never seemed to help. Staff D, [NAME] stated that refrigerators have had a water drip for about five to six months now. Staff D, [NAME] stated the sink had a plastic cup over the faucet to keep water from squirting on the kitchen staff when the sink was turned on. The cup would catch the water and force it back into the sink. Staff D, [NAME] stated the plastic cup would redirect water squirting upward back down into the sink basin. An observation on 05/07/24 at 9:50 a.m., revealed as the kitchen sink was turned on water would flow out of the faucet upwards. The plastic cup would deflect the water as it hit the cup making the water flow into the sink basin. During an interview on 05/08/24 at 12:54 p.m., Staff F, Maintenance Director (MD) stated, I am only here a couple days a week on Tuesdays and Thursdays. Staff F, MD stated there was no other maintenance staff in this facility he was the only staff in the maintenance department. Staff F, MD stated he did work in a sister facility as the MD on Monday, Wednesdays and Fridays. Staff F, MD stated that he heard about the sink faucet when he arrived at the facility on 05/08/24 and just replaced the sink facet in the prep sink this morning. Staff F, MD stated when he first started the position as MD back in February 2024 anything that needed to be fixed was told to me by word of mouth. Staff F, MD stated I remember I had fixed a gasket in the two-door refrigerator that should have helped seal the refrigerator from getting condensation and dipping. Staff F, MD stated the gasket replacement was not logged on the Maintenance Log because the facility quit doing work orders while there was no 105714 Page 6 of 7 105714 05/09/2024 Concordia Manor 321 13th Ave N Saint Petersburg, FL 33701

F 0908 maintenance staff in the facility but work orders were restarted shortly after my start date. Level of Harm - Minimal harm or potential for actual harm A review of Work Orders on the Maintenance Log revealed two entries for the kitchen area as followed: Prep sink, need cold water- 04/12/24 Residents Affected - Some Light in kitchen-04/11/24 The work orders on the maintenance log reflected a gap in work orders being submitted between the dated of 08/30/24-03/12/24. Review of the Facility's policy Policy and Procedure Topic: Safety effective date January 2021 revealed, Procedure: .4. Maintain equipment in proper working order. Report malfunctions immediately to the Maintenance Department. During an interview on 05/09/24 at 9:10 a.m., the Administrator stated that the refrigerators and sink should be in good working order. The Administrator reviewed the photographic evidence obtained of the kitchen sink and the two refrigerators. The Administrator stated that he was getting bids for the one refrigerator and if the other refrigerator was deemed unfixable then he would get bids for that refrigerator as well. 105714 Page 7 of 7