Concordia Manor
CONCORDIA MANOR in SAINT PETERSBURG, FL — inspection on April 23, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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] 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].
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.
105714
Form Approved OMB
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
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] and readmitted on [DATE] 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] with diagnoses to include encephalopathy, muscle wasting and atrophy, weakness and morbid (severe) obesity. A MDS (Minimum Data Set) assessment dated [DATE] showed the resident had a BIMS (Brief Interview for Mental Status) score of 15 out of 15, indicating intact mental cognition.
105714
Form Approved OMB
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