Sarasota Health and Rehabilitation Center

Inspectors wroteBased on interviews and record review the facility failed to follow infection control procedures to prevent the potential spread of scabies to residents, staff and visitors in 1 (Memory Care Unit) of 3 units.

Inspectors wroteBased on record review and interviews, the facility failed to have documentation of a thorough investigation for an injury of unknown origin for 1 (Resident #2) of 3 residents reviewed.

Inspectors wroteBased on observation, review of facility's policies and procedures, and staff interviews, the facility failed to protect the residents' right to be free from abuse. The facility neglected to have effective processes in place in the secured unit to supervise 15 (Residents #13, #6, #14, #1, #2, #15, #16, #17, #3, #4, #7, #8, #10, #9, #12) of 15 cognitively impaired residents with aggressive behaviors resulting in multiple avoidable resident-to-resident altercations. On 3/12/25, Resident #13 with known aggressive behavior towards others was not adequately supervised. Resident #6 was blocking the door to the hallway. Resident #13 hit Resident #6 to get past him. On 3/12/25, Resident #14 with known aggressive behavior towards others was not adequately supervised. Resident #14 ran into Resident #13 with her wheelchair then hit Resident #13. [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to implement processes on the secured dementia unit to ensure adequate supervision of 15 (Residents #13, #6, #14, #1, #2, #15, #16, #17, #3, #4, #7, #8, #10, #9, #12) of 15 cognitively impaired residents with aggressive behaviors to prevent multiple avoidable incidents of resident-to-resident physical altercations. On 3/12/25, Resident #13 was not adequately supervised. Resident #6 was blocking the door to the hallway. Resident #13 hit Resident #6 to get past him. On 3/12/25, Resident #14 was not adequately supervised. Resident #14 ran into Resident #13 with her wheelchair then hit Resident #13. On 3/14/25, Resident #2 wandered unsupervised into Resident #1's room. Resident #2 scratched Resident #1's cheek when she asked him to leave the room. [...]

Inspectors wroteBased on review of the facility's policies and procedures and staff interviews, the facility failed to protect the health, welfare and rights of each resident by failing to ensure 1 (Staff A) of 5 staff reviewed was screened for a history of abuse, neglect, exploitation, or misappropriation of resident property before beginning employment.

Inspectors wroteBased on interview and record review, the facility failed to honor the resident or the responsible party's right to be informed of the risks, benefits, side effects, and alternatives of psychotropic medications administered by the facility to 1 resident (#7) of 3 reviewed for informed consent for psychotropic medications.

Inspectors wroteBased on interview and record review the facility failed to thoroughly investigate one (Resident #1) of two residents surveyed for an injury of unknown origin when the injury was identified as being an older injury the facility failed to look back at an injury which had occurred three days prior to the injury being assessed and investigate if the injury had occurred during that same time period.

Inspectors wroteBased on interview and record review, the facility failed to provide the delivery of social services for discharge and transfer assistance for 1 (Resident #7) of 3 residents reviewed for discharge and transfer from the facility.

Inspectors wroteBased on record review, and staff interviews, the facility failed to ensure they maintained communication between the nursing facility and the dialysis center related to the ongoing assessment of a dialysis resident before and after each dialysis treatment for 1 (Resident #24) of 1 resident who was receiving dialysis.

Inspectors wroteBased on observation, record review, review of facility's policies and procedures, residents and staff interviews, the facility failed to provide or obtain dental services to meet the needs of 4 (Resident #25, #44, #45, #94) of 6 residents reviewed for dental services.

Inspectors wroteBased on a review of the facility's policy and procedure and staff interview, the facility licensed for 169 beds failed to ensure the full-time social worker had the required qualifications.

Inspectors wroteBased on clinical record review, and staff interviews the facility failed to obtain a Do Not Resuscitate Order (DNRO) in accordance with the advanced directives of 1(Resident #92) of 2 residents reviewed for code status and advanced directives.

Inspectors wroteBased on observation, clinical record review, and staff interview, the facility failed to ensure the MDS (Minimum Data Set) assessment accurately reflected the dental status for 1 (Resident #25) of 4 residents reviewed for accurate dental assessment. Inaccurate MDS assessments could result in a resident not receiving or a delay in the appropriate health care.

Inspectors wroteBased on observation, record review and staff interview the facility failed to provide necessary assistance with grooming and nail care for 2 (Resident #29 and #44) of 3 dependent residents reviewed for activities of daily living.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure 2 Residents (#24, and #106) of 5 residents reviewed for attended activities of their choice, to ensure they maintained and/or improved their psychosocial well-being and independence.

Inspectors wroteBased on observations, record review, review of facility's policy and procedure, resident and staff interviews, the facility failed to provide timely assistance to address lost prescription glasses for 1 (Resident #94) of 2 residents reviewed for vision services.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide care and services to prevent a decline in range of motion for 1(Resident #23) of 3 sampled residents with limited range of motion.

Inspectors wroteBased on observations, record review and staff interview the facility failed to ensure the required nursing staff information was posted daily and failed to maintain the posted daily nurse staffing data for 18 months as required.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide adequate supervision to prevent repeated falls for 3 (Residents #1, #2 and #3) of 3 residents identified to be at risk for falls and sustained multiple falls at the facility, including falls with injuries requiring emergent transfers to acute care hospitals.

Inspectors wroteBased on observations, records review, staff interviews and facility policy review the facility failed to provide personal hygiene care and incontinence care for 5 ( Residents #1, #3, #4, #5, and #6) of 6 residents reviewed for personal hygiene and incontinence care.

Inspectors wroteBased on record review, review of policies and procedures, observation, and staff interviews, the facility failed to provide oxygen therapy in accordance with physician's orders for 2 (Resident #82 and #94) of 4 residents reviewed for oxygen administration. Failure to follow prescribed oxygen therapy may result in inadequate oxygen treatment or increased risk of side effects and complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure common practice standards were followed for timely dressing changes for a PICC (Peripherally Inserted Central Catheter) inserted into the arm through a vein into a larger vein in the chest for 1 Resident (#313) of 1 resident reviewed with a PICC line. Timely dressing changes decrease the risk of complications including local and systemic infection related to the intravenous catheter.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain a safe and comfortable environment for residents by not ensuring chairs were cleaned, closets and dresser drawers were functional, overbed tables were free from rust, walls and doors were maintained without damage and air vents were cleaned and uncovered on 1(Memory Care Unit) of 1 Memory Care Unit reviewed.