Pinellas Park Fl Opco, LLC

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure medications were stored under proper temperature controls in the two medication storage rooms (2nd and 3rd) of two facility medication storage rooms observed. Findings Included: On 6/3/26 at 8:54 a.m., during a tour of the 2nd floor medication room, the Maintenance Director (DOM) checked the ambient temperature, which measured 82.20 F.On 6/3/26 at 9:27 a.m., during a tour of the 3rd floor medication room, Regional Maintenance Director (RDOM) checked the ambient temperature, which measured 85.2 F.During an interview on 6/3/26 at 8:54 a.m. the DOM said the air conditioning unit for the 2nd floor medication rooms has been out of service for approximately one month. He stated after the facility received three repair proposals, the repairs were approved the previous week, and the work would be completed soon. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to address and respond to resident council members, related to grievances voiced in their council meetings for four months (January, February, March, and April 2026) of five months reviewed and failed to respond to grievances for one resident (#84) of one resident reviewed.

Inspectors wroteBased on observation and interview, the facility failed to ensure the resident environment was free from accident hazards in one unsecured utility rooms (third floor) of two observed.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure sanitation requirements were met in 1 out of 1 kitchens observed.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain an effective pest control program in one kitchen (Main) out of one kitchen observed.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain a safe, clean, comfortable and homelike environment in four resident rooms (235, 251, 304 and 324) of 36 rooms observed.

Inspectors wroteBased on record review and staff interview, the facility failed to complete/update the Pre-admission Screening and Resident Reviews (PASARRs) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnoses for two residents (#1 and #85) of 4 residents reviewed for PASARRs.

Inspectors wroteBased on record review and interviews, the facility failed to ensure dialysis residents were provided with snacks/meals consistent with professional standards of practice and the care plan for one resident (#8) of one sampled.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure the medication error rate was not greater than 5%. A total of 28 opportunities were observed with 2 errors constituting an error rate of 7.14%.

Inspectors wroteBased on interviews and record review, the facility failed to protect the residents' right to be free from neglect by failing to honor a resident's expressed Advanced Directive for end of life by failing to ensure life saving measures of cardiopulmonary resuscitation (CPR) were performed, for one resident (#3) of two residents sampled. The failure to initiate CPR for approximately 35 minutes resulted in physical pain and ultimate death for Resident #3. On [DATE] Resident #3 was found unresponsive and absent of vital signs by facility staff and CPR was not performed. On [DATE] Resident #3 had a meeting with the facility's Advanced Practical Registered Nurse (APRN) and expressed his Advance Care wishes. The progress note read, We had an extensive conversation concerning full code vs. (versus) DNR (Do Not Resuscitate) status. [...]

Inspectors wroteBased on interviews and record review, the facility failed to honor a resident's expressed Advanced Directive for end of life by failing to ensure life saving measures of cardiopulmonary resuscitation (CPR) were performed, for one resident (#3) of two residents sampled. The failure to initiate CPR for approximately 35 minutes resulted in physical pain and ultimate death for Resident #3. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to Resident #3 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to a D after verification of removal of immediacy of harm. Cross reference to F600 and F726.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure nursing staff demonstrated competency in ensuring life saving measures of cardiopulmonary resuscitation (CPR) were performed, for one resident (#3) of two residents sampled. The facility staff's failure to initiate CPR for approximately 35 minutes resulted in physical pain and ultimate death for Resident #3. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to Resident #3 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to a D after verification of removal of immediacy of harm. Cross reference to F600 and F678Findings included: [...]

Inspectors wroteBased on record review and interviews the facility failed to maintain complete and accurate medical records related to documentation of activities of daily living (ADLs) for one resident (#2) out of two residents reviewed.

Inspectors wroteBased on observations, interviews, and policy reviews, the facility failed to ensure kitchen equipment and surfaces were maintained in a clean and sanitary manner, hand washing sink was accessible with the supplies needed, and the overhead lighting was adequate in one of one kitchen.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure all drugs used in the facility were labeled in accordance with clinical professional standards, on two of two floors and two of six medication carts.

Inspectors wrote6. Review of the admission Record showed Resident #22 was admitted on [DATE], with diagnoses to include major depressive disorder recurrent moderate, schizoaffective disorder bipolar type and generalized anxiety. Review of the PASARR Level I, completed on 10/24/19, showed, in Section 1 Part A, anxiety as the only listed diagnosis. Section IV PASARR Screen Completion showed that a Level II PASARR was not required. Review of the electronic medical record (EMR) revealed the diagnosis of schizoaffective disorder, bipolar type was added on 5/16/23. On 5/25/23 diagnoses of major depressive disorder and generalized anxiety were added to the EMR. Review of the medical record revealed Resident #22 was not assessed for a PASARR Level II when the new diagnoses were added to resident's EMR in May of 2023. [...]

Inspectors wroteBased on observation, interview, and review of the facility's policy, the facility failed to ensure opened food was labeled and dated in one of one kitchen.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the care plan for one resident (#18) out of 36 sampled residents was reviewed and revised to accurately reflect the fluid intake of the resident.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure one resident (#17) of one sampled resident, who was diagnosed with Post Traumatic Stress Disorder (PTSD), was provided care and services to account for experiences and preferences, nor did staff address the resident's needs by minimizing triggers and/or re-traumatization. Resident #17's direct care staff were unaware of trauma behaviors, and were not aware of what to monitor for, with relation to PTSD behaviors.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to administer antibiotics for the duration as prescribed by the provider for one resident (#72) out of five residents sampled for unnecessary medications.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure the medication error rate was less than 5.00%. Thirty-three medication administration opportunities were observed and seven errors were identified for three residents (#30, #77, and #64) of five residents observed. These errors constituted a 21.21% medication error rate.

Inspectors wroteBased on observations, interviews, record review, physician interview, and facility policy review the facility failed to protect the resident's right to be free from neglect, to ensure one Resident (#1) out of 13 residents with hemiparesis and hemiplegia diagnoses was provided care and assistance to prevent an injury from a burn during meal service times. Resident #1 suffered pain, infection of the skin and subcutaneous issue, and permanent body disfigurement related to scarring as a result of the facility's neglect to ensure this resident's safety during meal service. The facility neglected to provide care and services during a meal to a vulnerable resident with physical limitations, resulting in findings of Immediate Jeopardy on 8/16/23. [...]

Inspectors wroteBased on observations, interviews, record review, physician interview, and facility policy review, the facility failed to ensure one Resident (#1) out of 13 residents with hemiparesis and hemiplegia diagnoses were free from hazards during meal service. Resident #1 is a vulnerable adult with a history of hemiplegia and hemiparesis affecting the left non-dominant side, dysphagia, and muscle weakness. On 08/16/23, during evening meal service, Resident #1 requested a bowl of soup. The facility staff provided Resident #1 with a cup of bubbling hot tomato soup that had been warmed in a microwave for approximately 3-4 minutes and was not cooled prior to serving. The soup was served in an 8-ounce disposable foam cup and was not checked for temperature before it was served to Resident #1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 1. one newly admitted resident (#161) out of 11 new admissions sampled received physician ordered medications for pain and chronic obstructive pulmonary disease (COPD) the night of admission, and 2. failed to ensure three low air loss mattresses for residents (#90, #76 & #82) were set according to the residents' needs and manufacturer's instructions for three of four days observed of sixteen residents with air mattresses.

Inspectors wroteBased on interview and record review the facility failed to provide care and services consisted with professional standards of practice related to the provision of hemodialysis when they failed to ensure communication with the dialysis facility regarding care and services for one resident (#5) out of seven facility residents receiving hemodialysis.

Inspectors wroteBased on observation, interview and facility policy review, the facility failed to store a medication in a sanitary manner for one resident (#262) of eight residents sampled during the task of medication administration.