Life Care Center of Sarasota

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide adequate supervision to prevent a fall resulting in major injury and hospitalization for one resident (#11) of two residents reviewed. Findings Included:Review of Resident #11's medical record revealed the resident was admitted to the facility on [DATE] and was readmitted on [DATE] with a primary diagnosis of displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing. Other diagnoses included encounter for other orthopedic aftercare, muscle weakness, need for assistance with personal care, end stage renal disease, history of falling, and repeated falls. Review of a hospital history and physical for Resident #11 dated 09/09/2025 showed .the patient presented from nursing facility after having an outpatient X-ray that showed a femoral neck fracture. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide one resident (#100) of thirty-nine sampled residents with a bed that met his height needs and comfort during three days (9/8/2025, 9/9/2025 and 9/10/2025) of four days observed.

Inspectors wroteBased on record review, interviews and policy review, the facility failed to report an injury of unknown origin for one resident (#11) of two residents sampled. Findings Included: On 09/09/2025 at 03:05 p.m. an interview was conducted with Staff M Licensed Practical Nurse (LPN) and Unit Manager (UM), of the Manatee unit. Staff M stated Resident #11 experienced a fall on 09/06/2025. Staff M stated the fall was not observed by staff. Staff M stated resident #11 went to the hospital on [DATE] after the resident complained of pain and an x-ray showed the resident had a hip fracture. On 09/10/2025 at 04:18 p.m. an interview was conducted with Staff R, Certified Nursing Assistant (CNA). Staff R explained seeing Resident #11 on the floor on the right side of the resident's bed and laying on their right side. Staff R stated Resident #11 was not seen falling to the floor. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to implement care plan interventions related to the use of orthotics for one resident (#100) of two residents reviewed during three days (9/8/2025, 9/9/2025, and 9/10/2025) of four days observed.

Inspectors wroteBased on observations, interviews and record review, the facility failed to to ensure care was provided in accordance with professional standards related to the use of orthotics for one resident (#100) of two residents reviewed during three days (9/8/2025, 9/9/2025, and 9/10/2025) of four days observed.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5%. Thirty medication opportunities were observed, and four errors were identified for our residents (#39, #41, #71 and #88) out of eight residents resulting in an error rate of 13.33%.

Inspectors wroteBased on observations, interviews, record reviews, and the Plan of Correction (POC) review, the facility's Quality Assurance Performance Improvement Program (QAPI) failed to implement an effective plan of correction to correct deficient practice identified during the recertification survey originally conducted 9/11/2025 to 9/18/2025 as evidenced by: 1) to ensure two of six sampled residents (#2 and #10) had updated care plan interventions in place related to falls and 2) failed to: 1) prevent a fall with major injury for two Residents (#1 and #2) and, 2) prevent multiple falls for one Resident (#10) out of four residents sampled for injuries and accidents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide adequate supervision to prevent one resident (#1) from exposure to the sun/heat, resulting in an altered mental status and skin damage to the legs, arms, and head, out of three residents sampled for outdoor activities. On 5/2/2025 Resident #1 was seated in a wheelchair in the courtyard area of the facility for approximately one hour from 2:45 p.m. to 3:45 p.m., during the hottest part of the day. Resident #1 was discovered to be unresponsive and had to be transferred to a higher level of care for treatment from sun/heat exposure.

Inspectors wroteBased on record review, interview, and review of the facility's policy, the facility failed to 1.) ensure the accuracy of a Preadmission Screening and Resident Review (PASARR) Level I for three (Residents #97, #43 and #13) of five residents admitted with mental health diagnoses and sampled for PASARR; and 2.) complete a PASARR Level II within 30 days for one (Resident #20) admitted to the facility under a 'hospital discharge exemption' of five residents sampled for PASARR.

Inspectors wroteBased on record review, interview, and review of the facility's policy, the facility failed to complete the Preadmission Screening and Resident Review (PASARR) Level I upon a new qualifying mental health diagnosis for one (Resident #3) of five residents sampled for PASARRs .

Inspectors wroteBased on observation, interview, medical record review, and policy on Indwelling Urinary Catheter Management, the facility failed to ensure one (Resident #52) of three residents sampled for indwelling urinary catheters was provided timely treatment and care in accordance with professional standards of practice. Findings Included: On 04/11/2023 at 11:01 a.m., an interview was conducted with Resident #52. She said her catheter was for urinary retention. She said she was a nurse for many years and knew about retention. She said she was not able to void, and nothing was coming out. She said she could feel distention in her bladder so she went to the hospital. Resident #52 stated, they straight cathed me and removed 4000 cubic centimeter (cc) of urine. They had performed tests at the hospital and found I had a cord compression to my spine. The compression was causing retention to my bladder. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure pre and post dialysis care was provided for one (Resident #68) of four dialysis residents.

Inspectors wroteBased on record review and interview, the facility failed to provide rationale for long term use or limit the use of as needed antianxiety medications to less than 14 days for two (Residents #29 and #91) of five residents surveyed for unnecessary medications.

Inspectors wroteBased on observations, interviews and records review, the facility did not ensure dignity was maintained related to catheter care for 1 out of 8 residents with an indwelling catheter, (Resident #32).

Inspectors wroteBased on record review, and staff interviews the facility failed to provide two (#41, #86) of five residents sampled, or their representatives, with a written copy of the notice of transfer when they were transferred to an acute care facility.

Inspectors wroteBased on record review, and staff interviews the facility failed to provide one (#41) of five residents sampled, or their representatives, with a bed hold notice when they were transferred to an acute care facility.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that nail care was provided for one (#41) of 28 residents sampled as evidenced by the observations of the long fingernails on Resident #41's left hand and documentation from the record and interviews related to the condition of Resident #41's fingernails and toenails.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that a mechanically altered therapeutic diet was provided according to orders for one (Resident #97) out of eight sampled residents.

Inspectors wroteBased on interview and record review the facility failed to ensure that orders and implementation for behavior monitoring were in place for psychotropic medications for one (Resident #10) out of five sampled residents.