Health inspection·March 2, 2022

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement the comprehensive care plan related to hearing for one resident (#15) of one resident sampled for hearing. Findings included: An interview was attempted with Resident #15 on 02/28/2022 at 10:42 a.m. Resident #15 was making the bed and when asked questions she continually stated she did not understand due to hearing issues. The resident stated she did not have hearing aids. A review of Resident #15's admission Record revealed an admission date of 01/10/2020 with medical diagnoses of unspecified dementia, and major depressive disorder. A review of Resident #15's care plan, initiated on 1/13/2020, revealed a communication deficit related to hearing loss and deafness in the right ear. This focus area had a target date of 03/30/2022. Interventions for this deficit included ensuring availability of adaptive communication equipment and ensuring a left hearing aid was in place. A review of Resident #15's Quarterly Minimum Data Set (MDS), dated [DATE], revealed in Section C Cognitive Patterns the resident had a Brief Interview for Mental Status score of 14. A score of 14 indicated the resident had intact cognition without signs of disorganized thinking. Further review of the MDS revealed in Section B - Hearing, Speech, and Vision the resident used a hearing aid. An interview with Resident #15's Responsible Party confirmed the resident was hard of hearing and never had hearing aids . she never got them. Interviews conducted with Staff A, Certified Nursing Assistant on 03/01/2022 at 10:40 a.m., and Staff B, Registered Nurse on 03/01/2022 at 10:55 a.m. confirmed the resident was extremely hard of hearing, however, neither direct staff member were aware of any hearing aids belonging to Resident #15. An interview on 03/01/2022 at 11:01 a.m. with the Social Services Director (SSD) revealed Resident #15 never had hearing aids and confirmed both the resident's care plan and MDS indicated the resident had hearing aids. The SSD was unsure how the care plan was created and the MDS indicating the resident had hearing aids when she never did. On 03/01/2022 at 11:27 a.m. the Director of Nursing (DON) stated the MDS and the care plan had incorrect information. The DON stated she contacted the Responsible Party who did not think Resident #15 (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 5 Event ID: 105959 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 105959 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Addington Place at College Harbor 4600 54th Ave S Saint Petersburg, FL 33711 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)