South Heritage Health & Rehabilitation Center
SOUTH HERITAGE HEALTH & REHABILITATION CENTER in SAINT PETERSBURG, FL — inspection on April 25, 2026.
Found 3 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
removal.
Patient reports in the last 24 hours she began to have significant increase in abdominal pain,
(Pulse) RR: 15 BP: 106/63 SpO2: 100% HT: 149.86 cm HT: 59-inch(es) WT: 60.8 kg BMI: 27.1.
The
symptoms following removal of the drain.
Evaluation revealed leukocytosis with left shift and Computed Tomography (CT) imaging showing gastritis with inflammation near the prior drain site as well as two postoperative fluid collections or possible pseudocysts.
Given her symptoms and imaging findings, concern is raised for postoperative complications such as infected fluid collections versus recurrent pancreatitis-related issues.
Further review of the assessment plan showed abdominal pain, with evidence of a fluid collection and differential of pseudocyst versus surgical collection, chronic pancreatitis post Whipple's procedure and splenectomy.An interview was conducted with Staff B, Registered Nurse (RN)/Unit Manager on 4/25/26 at 12:42 p.m.
Staff B said Resident #5 was here for recovery after laparoscopic.
She stated the resident had complications and had been discharged from the hospital to home. Resident #5 had complications at home and was readmitted to the hospital, needing a drain, the drain was subsequently removed, without complications. Resident #5 developed pain afterwards.
Staff B said there was an order for dressing which came off and she was fine.
Staff B stated if a resident has a change, and they want to go to the ER, We assess first, we look at the entire picture and review vital signs, we look if we can treat the issue here at the facility.
Staff B said, Resident #5 was given pain and nausea medication.
Staff B said Resident #5 ended up going to the hospital, having called 911 herself.
Staff B stated usually the nurse would call.
She said, I don't know what happened.
Staff B stated she did not know Resident #5's condition upon admission to the hospital.
She said the Director of Nursing (DON) calls after they leave to check on them.An interview with Staff D, Licensed Practical Nurse (LPN) revealed Resident #5 stayed in her room but would come out for smoking.
She stated she heard the resident was sick and was throwing up, she does not remember the timeline, and whether she was sent out immediately or not.An interview was conducted with Staff A, Certified Nursing Assistant (CNA) on 4/25/2026 at 11:20 a.m.
She stated she remembered Resident #5 and said, She was ambulatory.
She was getting sick towards the end, . she was too sickly, like throwing up all the time. On 4/25/26 at 11:38 a.m. an interview was conducted with Staff C, CNA.
Staff C said Resident #5 was independent with care.
Staff C said, Resident #5 got sick, throwing up. An interview was conducted with the Director of Nursing (DON) on 4/25/26 at 3:24 p.m.
The DON stated if the doctor would have ordered for Resident #5 to go to the hospital, they would have documented.
She stated she heard about her being sick.
She said, I did hear about it. I heard the police were here for Resident #5, I did not get any details.
The DON confirmed if someone wanted to go to the hospital, the nurse would assess and notify the physician.
She stated there should be notes showing the assessment and monitoring following a change in condition.
The DON stated the nurses should have documented the monitoring and vitals obtained during the period of the change.
The DON said, I agree, if it is not documented it did not happen.
The nurse should have documented vitals, if the resident wanted to be sent out, assess, call the doctor and send them out. the DON confirmed the resident has a right to seek medical care and should be assisted if they choose to do so.Review of a facility policy titled, Resident Rights, effective August 2025, revealed a policy: The facility strives to ensure that each resident has a dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the facility.
The facility will protect and promote the rights of each resident.
The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.
The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising bis or her rights and to be supported by the facility in the exercise of his or her rights.Procedure: 5.
Assist the resident with such things including, but not limited to, the following: b.
Maintaining communication with outside agencies.
105117 04/25/2026
South Heritage Health & Rehabilitation Center 718 Lakeview Ave S Saint Petersburg, FL 33705
diagnosis of the resident.
The DON said nail care is provided as needed.
She stated staff would
not aware where completion of nail care was documented.
The DON stated if a resident refused nail
stated nail care was, Part of hygiene and infection control.
She said she had attempted to assist with cutting Resident #4's nails but he would not let staff.
She said she could not confirm if that was documented.
Staff B, RN/UM said she thought the resident refusing nail care was in his care plan.
The facility did not provide a policy related to ADLs or nail care.
105117 04/25/2026
South Heritage Health & Rehabilitation Center 718 Lakeview Ave S Saint Petersburg, FL 33705
included: On 4/25/26 at 12:30 p.m., an observation of Resident #4's lunch meal revealed the meal
record showed an admission date of 1/20/26.
Further review of the admission record showed diagnoses to include quadriplegia, unspecified, muscle wasting and atrophy, not elsewhere classified, multiple sites, and other lack of coordination. A review of Resident #4's physician orders revealed the following: House diet Regular texture, Regular(Thin) consistency, No pork, lactose intolerant, no dairy (milk or cheese), with a start date of 1/26/26.
Resident may have double portions for all meals six times a day, with a start date of 3/7/26. A review of Resident #4's care plan revealed the following: NUTRITIONAL: [Resident #4] has a potential nutritional problem r/t [related to] Diagnoses - Quadriplegia, Spinal Stenosis, HTN [hypertension], Hyperlipidemia, Hypotension.
Weight - Elevated BMI [body mass index] - IBW [ideal body weight] adjusted for quadriplegia - Resident requests large entree portions at meals.
Medications - Duloxetine, may impact appetite.
Date Initiated: 01/22/2026 Revision on: 01/26/2026. A review of Resident #4's nutrition evaluation, dated 1/26/26, revealed the following: New admit [admission] 1/21. CBW [current body weight] 249.8 lbs [pounds] (1/21). BMI 34.8. IBW adjusted for quadriplegia.
Resident reports his UBW [usual body weight] prior to his recent hospitalization was 270 lbs.
House diet, regular textures, thin liquids.
Resident requests large entree portions at meals. No problems chewing/swallowing reported.
Dependent with meals. On duloxetine, which may impact appetite.
Continue with diet as ordered.
Large entree portions provided, per resident request.
Resident denied the need for additional snacks/supplements at this time.
Tray ticket updated with food preferences.
Will monitor weights weekly, per new admit.On 4/25/26 at 2:30 p.m., an interview was conducted with the Food Service Manager (FSM). He said Resident #4 received large portions for breakfast, but not with the other meals.
The FSM provided today's meal tickets which showed, Large Portion, for breakfast. A review of Resident #4's lunch and dinner meal ticket did not show large portions was documented.On 4/25/26 at 2:48 p.m., a follow-up interview was conducted with the FSM. He said all dietary orders are placed in the electronic medical record and automatically transferred to the food service meal tracker system. He said the meal tracker system printed the meal tickets.
The FSM said he was not able to adjust the orders. He said the orders needed to be placed in the electronic medical record by the nursing staff or the registered dietitian (RD). He said he received a notification everyday if there was a change to the resident's diet order.
The FSM said he did not see the order for double portions for all meals as it was categorized as, other, not under dietary. On 4/25/26 at 3:33 p.m., an interview was conducted with the Director of Nursing (DON).
She said the DON, nurse, or unit manager (UM) would put in a resident's diet order.
She said the order is documented on a dietary slip and provided to the dietary personnel.
She said the FSM has a list of the residents' diet orders.
The DON said whoever put in Resident #4's order for double portions for all meals, put it under the other, category.
She stated, Other orders floats in the nursing space.
The DON confirmed the order for double portions for all meals should have been put under the dietary category.
She said the diet slip should have been written and handed off to the dietary personnel as well.
The facility did not provide a policy related to physician orders or dietary orders.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.