Concordia Manor

F-F609)

Findings included:

1. Review of a hospital visit summary for Resident #1 dated 03/23/25 at 3:22 a.m. showed Resident #1 was seen due to a fall with diagnoses of fall, initial encounter, resulting in a head injury.

Review of the admission Record for Resident #1 revealed he was originally admitted to the facility in 2013 and readmitted on [DATE REDACTED] with diagnoses to include muscle wasting and atrophy, cerebral infarction due to unspecified occlusion, weakness, sepsis, muscle wasting, nontraumatic intracranial hemorrhage unspecified, hemiplegia and hemiparesis, aphasia and unspecified dementia.

On 04/23/25 at 11:42 a.m., an interview was conducted with Staff A, Certified Nursing Assistant (CNA) assigned to Resident #1 the day the resident fell on [DATE REDACTED]. She stated she had worked 3 p.m. - 11 p.m. and Resident #1 was her last resident to provide care for. She said, I was changing the bed when he started to fall off the bed. I tried to catch him to save the fall, but I could not. She stated, As I wrote in my statement, I lowered the bed and was trying to lower it some more as I was holding on to him. I was alone in the room. I knew he needed two people. He cannot do anything for himself. Staff A stated Resident #1 could not hold on to the side rail/enabler because his right hand was contracted. She said, I know I should have asked for help.

It was my fault. I take responsibility for not asking for help. The CNA stated they were understaffed that day because someone called off and there was no replacement. Staff A stated she was suspended on 03/24/25.

She stated not much was said to her at the time, and she was not asked to give a statement at the time. She stated she was contacted on 03/26/25 and asked to come in and give a statement on 3/27/25.

An interview was conducted with the Nursing Home Administrator (NHA) on 04/23/25 at 1:26 p.m. revealed

she did not initiate the investigation for the incident on 03/22/25 until 03/27/25. She stated she could not answer to why staff did not call her that weekend. She stated she thought they had notified the Director of Nursing (DON). She revealed she was notified by corporate on March 27th that she needed to file a report.

She stated corporate said to obtain interviews and have the DON start education. The NHA said, I did not do

a timeline. The incident was reported to AHCA [Agency for Health Care Administration] on 03/27/25. It was late. She stated she became aware of the incident on Monday, 03/24/25, but it had occurred on 03/22/25. When asked why it took two days to be notified, The NHA stated it was the weekend, and the DON, and the Director of Rehab were on leave. The NHA stated when she became aware she notified corporate on 03/24/25 and suspended the CNA pending investigation. She stated she did not start her investigation then.

She stated she did not interview any other residents and did not interview the staff at the time. The NHA stated their process was to wait until corporate gave her the go-ahead before contacting AHCA or DCF (Department of Children and Families). The NHA stated this process affects her reporting and investigation timeline.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 15 105714 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105714 B. Wing 04/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Concordia Manor 321 13th Ave N Saint Petersburg, FL 33701

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 On 04/23/25 at 11:35 a.m. an interview was conducted with Resident #3. She stated she had reported some staff member for being rough and loud with her. She said, They can't talk to me just anyhow. She stated she Level of Harm - Minimal harm or did not know if the issue was resolved. She stated she did not know what they did about it, but she had filed potential for actual harm a grievance.

Residents Affected - Few 2. Review of Resident #3's admission record revealed an original admission on 12/14/24 with diagnoses to include encephalopathy, muscle wasting and atrophy, weakness and morbid (severe) obesity. An MDS (Minimum Data Set) assessment dated [DATE REDACTED] showed the resident had a BIMS (Brief Interview for Mental Status) score of 15 out of 15, indicating intact mental cognition.

Review of a grievance concern report for Resident #3 showed on 03/05/25 the Social Serviced Director (SSD) had received a grievance showing, Resident did not like the CNA's approach. Under action taken, the form showed the SSD, Spoke to the CNA [Staff F], he said he came in and provided care to the resident and there were no issues. Under resolution, it showed the NHA reported the incident as a reportable, CNA was suspended, and the grievance was marked resolved the same day. The SSD stated the incident had happened the previous day. He did not know why it was not reported until 03/05/25.

An interview on 4/23/25 at 12:30 p.m. with the NHA revealed on 03/04/25 Resident #3 stated the CNA (Staff F) was rough with her when providing care and she did not like the CNA's approach. The NHA stated the resident was receiving care on 03/04/25, and the NHA was notified on 03/05/25 sometime in the afternoon.

She stated she reported the allegation on 3/5/25 at 3:50 p.m. She stated it was a day late. The NHA stated

she reviewed the grievance form. She stated she did not ask the perpetrator to write a statement. She did not ask the CNA what rough with her meant. She stated she did not speak to any other staff about it. She said, I see. I could have asked more questions. The NHA stated she did not report this allegation of abuse.

On 04/23/25 at 12:56 p.m., Staff F, CNA said I had her that Friday night. Staff F stated he found out the following Monday there was a problem. He said, I was told not to go to that room, they said she was making comments against me and to protect myself, I should stay away. He stated the resident had made allegation about another male employee before. He said, I did not take it seriously. Staff F stated he did not write a statement. He stated no one said anything about a statement. He stated that week he did not go back to the room. He said, I was suspended 8 days. When I returned, I made sure to avoid her. I still do if I am scheduled to care for her, I switch out. Staff F stated he did not receive education regarding this incident. He said, I just resumed my normal life. I just avoid her.

A follow-up interview with the NHA on 04/23/25 at 1:04 p.m. revealed she did not have statements from other staff or residents regarding the allegation of abuse for Resident #3. She stated she was unable to find them at this moment. She said, I do not have them right now. The NHA confirmed she had not conducted an investigation to the allegation of abuse. She confirmed they did not educate staff regarding the incident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 15 105714 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105714 B. Wing 04/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Concordia Manor 321 13th Ave N Saint Petersburg, FL 33701

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 On 04/23/25 at 3:02 p.m., an interview with the NHA regarding a second incident for Resident #3 that occurred on 02/28/25 was conducted. The NHA stated DCF had came to the facility to investigate an Level of Harm - Minimal harm or allegation of abuse. She stated a family member had contacted DCF to report that the therapist (Staff G, potential for actual harm Occupational Therapist - OT) physically shakes and yells at the resident to wake her up when he is in her room. The NHA stated DCF interviewed the resident and did not substantiate the allegation. The NHA stated Residents Affected - Few DCF did not interview Staff G. The NHA stated she did not obtain a statement from Staff G, OT. She stated

she interviewed one CNA who generally worked in the area where Resident #3 resided. She stated the CNA (Staff H) stated on a few occasions (Resident #3) said she does not want to get up because she does not like them (referring to therapy). The CNA stated she yells, get out, don't touch me and therapy staff leaves and comes back later. The NHA stated she did not follow-up on these statements. She stated she did not

interview any other staff on the day Resident #3 alleged abuse from Staff G, OT.

On 04/03/25 at 3:20 p.m. an interview was conducted with Staff G, OT. He said, I was accused of raising my voice with her [Resident #3]. He stated he spoke with the NHA briefly but did not provide a statement to the NHA or DCF. He stated neither of them interviewed him. He stated he was suspended for 5 days and when

he returned, he was told everything was not founded. He stated he did not receive any education.

On 04/03/25 at 3:23 p.m. an interview with the Regional Risk Manager revealed they should have asked the perpetrators (Staff F, CNA and Staff G, OT) to provide statements. She stated they should have spoken to other staff.

During an interview on 04/03/25 at 3:28 p.m., the NHA confirmed she should have obtained statements and educated all staff.

Review of a facility policy titled, Abuse Prevention Program, reviewed November 2024 showed the facility has designated and implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment, and misappropriation of resident's property. These policies guide the identification, management, and reporting of suspected, or alleged, abuse, neglect, mistreatment, and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation, and misappropriation of resident's property through education of staff and residents, as well as early identification of staff bum out, or resident behavior which may increase the likelihood of such events.

Investigation: An Event Report is initiated. NHA or designee is notified and will initiate and conclude a complete and thorough investigation within the specified timeframe.

Investigation may include, but may not be limited to:

- Resident statements/interviews.

- Employee statements/interviews.

- Visitor statements/interviews.

- Observation of resident(s), staff, environment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 15 105714 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105714 B. Wing 04/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Concordia Manor 321 13th Ave N Saint Petersburg, FL 33701

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 - Document review i.e., chart reviews, policy review, education programs, appropriate resource review (such as medical literature); and Level of Harm - Minimal harm or potential for actual harm - Re-enactment of event.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 15 105714 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105714 B. Wing 04/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Concordia Manor 321 13th Ave N Saint Petersburg, FL 33701

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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43453

Residents Affected - Few Based on interviews and record review, the facility failed to maintain medical records in accordance with professional standards and policy for weekly skin evaluations and assessments for one (#1) of two residents sampled.

Findings included:

Review of a facility policy titled, Wound Prevention and Treatment Overview, effective October 2021 showed - The facility strives to ensure that a Resident/Patient entering the facility without ulcers does not develop them unless the individual's clinical condition demonstrates they were unavoidable. The facility implements

the following interventions to prevent the development of pressure ulcers:

- Identify Residents/Patients at risk & the specific factors placing them at risk then implement an individualized Plan of Care based on the identified factors.

- Reduce occurrence of pressure over bony prominences to minimize injury.

- Protect against the adverse effects of external mechanical forces (pressure, friction, shear).

- Increase the awareness of ulcer prevention through educational programs.

The facility also recognizes the most vigilant nursing care may not prevent the development &/or worsening of ulcers in high-risk categories. In those cases, efforts will be directed at the following: Managing risk factors. Providing therapeutic intervention. Providing treatment. Procedure: Review skin integrity on a weekly basis as a proactive approach enabling the facility staff to identify possible changes in skin integrity/condition.

Review of weekly skin checks for Resident #1 revealed four skin checks had been completed in a period of four months (January 2025 through April 2025), most recently on 03/29/25 showing the resident had a knot

on forehead, top of scalp, and on 03/28/25 showing the resident has a knot on forehead, face.

Review of the admission record for Resident #1 revealed he was admitted to the facility in 2013 and readmitted on [DATE REDACTED] with diagnoses to include muscle wasting and atrophy, cerebral infarction due to unspecified occlusion, weakness, sepsis, nontraumatic intracranial hemorrhage unspecified, hemiplegia and hemiparesis, aphasia, unspecified dementia and contracture of right shoulder and elbow.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 15 105714 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105714 B. Wing 04/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Concordia Manor 321 13th Ave N Saint Petersburg, FL 33701

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 0842 On 04/23/25 at 3:40 p.m. an interview was conducted with the Director of Nursing (DON). The DON stated Resident #1's skin checks should be completed weekly as scheduled. The DON reviewed Resident #1's Level of Harm - Minimal harm or electronic record for the months of January 2025 through April 2025 and stated there were only four skin potential for actual harm assessments documented on 1/4/25, 2/2/25, 3/28/25 and 3/29/25. The DON said, There should be more than that. They should be documented weekly. I see they are not done. I don't know what to tell you. We Residents Affected - Few missed it. The DON stated they should have assessed and documented skin checks for Resident #1 on a weekly basis per their facility policy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 15 105714

F-F610)

Findings included:

1. Review of a hospital visit summary for Resident #1 dated 03/23/25 at 3:22 a.m. showed Resident #1 was seen due to a fall with diagnoses of fall, initial encounter, resulting in a head injury.

Review of the admission Record for Resident #1 revealed he was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses to include muscle wasting and atrophy, cerebral infarction due to unspecified occlusion, weakness, sepsis, muscle wasting, nontraumatic intracranial hemorrhage unspecified, hemiplegia and hemiparesis, aphasia and unspecified Dementia.

An interview was conducted with the Nursing Home Administrator (NHA) on 04/23/25 at 1:26 p.m. revealed

she did not initiate the investigation for the incident on 03/22/25 until 03/27/25. She stated she could not answer to why staff did not call her that weekend when the incident occurred. She stated she thought they had notified the Director of Nursing (DON). She revealed she was notified by corporate on the 27th [of March 2025] that she needed to file a report. She stated corporate said to obtain interviews and have the DON start education. The NHA said, I did not do a timeline. The incident was reported to AHCA [Agency for Health Care Administration] on 03/27/25. It was late. She stated she became aware of the incident on Monday, 03/24/25, but it had occurred on 03/22/25. When asked why it took two days to be notified, the NHA stated it was the weekend, and the DON, and the Director of Rehab were on leave. The NHA stated when she became aware, she notified corporate on 03/24/25 and suspended the Certified Nursing Assistant (CNA) pending investigation. She stated she did not start her investigation then. She stated she did not interview any other residents and did not interview the staff at the time. The NHA stated their process was to wait until corporate gave her the go-ahead before contacting state agencies. The NHA stated this process affects her reporting and investigation timeline. She said, That is why the reporting was late.

2. On 04/23/25 at 11:35 a.m. an interview was conducted with Resident #3. She stated she had reported some staff member for being rough and loud with her. She said, They can't talk to me just anyhow. She stated she did not know if the issue was resolved. She stated she did not know what they did about it, but

she had filed a grievance.

Review of Resident #3's admission record showed she was originally admitted on [DATE REDACTED] with diagnoses to include encephalopathy, muscle wasting and atrophy, weakness and morbid (severe) obesity. A MDS (Minimum Data Set) assessment dated [DATE REDACTED] showed the resident had a BIMS (Brief Interview for Mental Status) score of 15 out of 15, indicating intact mental cognition.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 15 105714 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105714 B. Wing 04/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Concordia Manor 321 13th Ave N Saint Petersburg, FL 33701

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 0609 An interview on 4/23/25 at 12:30 p.m. with the NHA revealed on 03/04/25 Resident #3 stated the CNA (Staff F) was rough with her when providing care, and she did not like the CNA's approach. The NHA stated the Level of Harm - Minimal harm or resident was receiving care on 03/04/25 and the NHA was notified on 03/05/25 sometime in the afternoon. potential for actual harm She stated she reported the allegation on 3/5/25 at 3:50 p.m. She stated it was a day late. The NHA stated

she reviewed the grievance form. She stated she did not ask the perpetrator to write a statement. She did Residents Affected - Few not ask the CNA what rough with her meant. She stated she did not speak to any other staff about it. She said, I see. I could have asked more questions. The NHA stated she did not report this allegation of abuse.

On 04/23/25 at 3:02 p.m. an interview was conducted with the NHA regarding a second incident for Resident #3 that occurred on 02/28/25. The NHA stated the state agency for adult protective investigations had come to the facility to investigate an allegation of abuse. She stated a family member had contacted the state agency to report that the therapist (Staff G, Occupational Therapist - OT) physically shakes and yells at the resident to wake her up when he is in her room. The NHA stated the state agency interviewed the resident and did not substantiate the allegation. The NHA stated state agency did not interview Staff G. The NHA stated she did not obtain a statement from Staff G, OT. She stated she interviewed one CNA who generally works the area. She stated the CNA (Staff H) stated on a few occasions (Resident #3) said she does not want to get up because she does not like them (referring to therapy). The CNA stated she yells, get out, don't touch me and therapy staff leave and come back later. The NHA stated she did not follow-up on these statements. She stated she did not interview any other staff on the day Resident #3 alleged abuse from Staff G, OT.

An interview on 4/23/25 at 3:33 p.m. with the Regional Risk Manager revealed Resident #3's incident with Staff G, OT was reported to the facility by the state agency on 02/28/25. The Risk Manager stated the incident happened on 2/21/25. The Risk Manager stated this was not reported timely. She stated, I need to ask why. It does not make sense.

An interview was conducted with the NHA on 4/23/25 at 3:49 p.m. The NHA stated regarding the incident with Staff F, CNA, they did not substantiate it. She stated we resolved it the same day. We did not report.

The NHA stated, an allegation is an allegation. We should have reported. She stated corporate has to review incidents prior to reporting them, which affects their reporting timeline.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 15 105714 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105714 B. Wing 04/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Concordia Manor 321 13th Ave N Saint Petersburg, FL 33701

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 Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43453 potential for actual harm Based on interviews and record review, the facility failed to investigate thoroughly and timely allegations of Residents Affected - Few abuse for two (#1 and #3) of two residents sampled for abuse and neglect.

(Cross reference