Bay Village Of Sarasota

The facility failed to prepare, and store food in a sanitary manner by failing to cover and date food in 2 walk-in coolers and 1 refrigerator. The facility failed to ensure staff used the three compartment sink appropriately including use of the proper sanitizing agent. The facility failed to ensure staff wear hair restraints during preparation of food. The facililty failed to service and maintain ice machines in the main dining room and three of three nourishment rooms. The findings included: 1. The facility policy and procedure for Walking Cooler, documented to protect and ensure that food is free from foodborne illness, contamination, and hazards. All foods stored in coolers are labeled and dated. During an initial tour of the kitchen with the Certified Dietary Manager (CDM) and the Director of Dining (DOD) on 4/15/24 at 9:20 a.m., the following was observed: a.) In the line reach in refrigerator was a box of muffins without a date and sitting on top of the muffins was another box containing empty plastic cups. The observation was confirmed the CDM. Photographic evidence…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interviews, resident interviews, and resident council meeting notes, the facility failed to serve food that was palatable and at the appropriate temperature for 4 (Residents Resident #23, #26, #259, and #261) of 4 residents interviewed and Resident Council concerns reviewed from 1/2023 through 12/2023 for food palatability and appropriate temperature. This had the potential of decline in health due to poor nutrition. The findings included: On 4/16/24 at 12:25 p.m., Resident #26 was observed with a sandwich and pot roast stew. She said the sandwich is warm today, and the pot roast stew needs heated. Her meal ticket has a tossed salad listed and there was no salad on Resident #26's tray. During an interview on 4/15/24 at 2:18 p.m., Resident #26 said the food is not good. The grilled cheese is cold. The bread does not look like it is grilled, and the cheese is not melted. The bun was ice cold on a sandwich. The mac and cheese was served cold. During an interview on 4/15/24 at 9:30 a.m., Resident #259 stated the food is up and down. The list they gave to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, review of facility policy and procedures, record review and staff interviews, the facility failed to maintain a urinary catheter in a safe and sanitary manner for 1 (Resident #5) of 1 resident reviewed with an indwelling urinary catheter. The findings included: The facility policy Catheter Care documented The purpose of this procedure is to prevent urinary catheter associated complications, including urinary tract infections. Use aseptic technique when handling or manipulating the drainage system. Be sure the catheter tubing and drainage bag are kept off the floor. Review of the clinical record documented Resident #5 had an admission date of 7/31/22 with diagnoses including schizophrenia, type 2 diabetes mellitus, hypertensive heart disease. The record revealed the resident was receiving hospice services. The record showed a physician order dated 4/13/24 instructing staff to insert an indwelling urinary catheter to promote wound healing of a pressure wound on the resident's coccyx. On 4/16/24 at 9:33 a.m., Resident #5 was observed in her room in bed and was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interviews, and record reviews, the facility failed to ensure its medication error rate remained below 5%. Five licensed nurses with 26 opportunities were observed. Two medication errors were identified resulting in a 7.69% error rate. The findings included: On 4/18/24 at 8:34 a.m., Licensed Practical Nurse (LPN) Staff Q was observed administering medications to Resident #261. LPN Staff Q administered 1 chewable 81 milligram (mg) aspirin to Resident #261. The physician's order was ordered for aspirin 81 mg delayed release. On 4/18/24 at 8:20 a.m., LPN Staff P was observed administering medications to Resident #23. LPN Staff P administered 1 tablet, vitamin D 25 micrograms (mcg,) for Resident #23. The physician's order was vitamin D3 25 mcg (1,000 unit) tablet, 6 tablets by mouth once daily for vitamin deficiency. An interview on 4/18/24 at 8:55 a.m., with LPN Staff Q, she confirmed she gave a chewable 81 mg aspirin to Resident #261 and the physician's order is aspirin 81 mg tablet, delayed release, 1 tablet by mouth once daily for cerebral infarction. An…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and resident and staff interviews, the facility failed to ensure 1 (Resident #19) of 3 residents reviewed for dental services received appropriate care and services for broken teeth. The findings included: On 4/15/24 at 12:43 p.m., Resident #19 revealed she had missing upper and lower teeth. The resident said she lost several of her teeth several months ago, and because of the missing teeth, her diet was changed to mechanical soft so she could eat her food. She said she would like to eat regular food, but due to her missing teeth, she is unable to eat a regular diet. A review of Resident #19's medical record revealed her original admission to the facility was on 11/16/17 and a readmission on [DATE]. The Nursing admission assessment dated [DATE] stated Resident #19 had no broken or loosely fitting full or partial dentures, natural teeth or tooth fragments, or chewing or swallowing difficulty. A dietary progress note dated 10/24/22, said Resident #19 had lost three front teeth,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based observation on interview record review and policy the facility failed to provide supervision to prevent the elopement of one resident (Resident #162) of one resident surveyed for elopement and failed to ensure four of four residents assessed as an elopement risk currently residing at the facility had appropriate interventions to prevent the potential for an elopement. Findings included: Resident #162 is a [AGE] year-old female who was admitted to the facility on [DATE] with a history of cognitive communication deficit, abnormal gait, lack of coordination, and hypertensive heart disease. Review of the Elopement/Wander Risk Screen dated 12/21/23 shows Resident #162 was assessed with being a risk for elopement. The intervention listed as being initiated on 12/21/23 was a wanderguard was put in place at that time. According to the timeline provided in the facility's investigation, on 12/24/23 at approximately 9:30 a.m., Resident #162 was last seen in her room by staff who were attempting to administer her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview and record review, the facility failed to ensure 5 (Staff C, D, E, F and G) of 10 staff reviewed had the required education and training in abuse, neglect, and exploitation. Failure to provide staff with abuse, neglect, and exploitation training prior to working with facility residents could lead to staff not knowing how to prevent and report abuse, neglect, and exploitation. The findings included: On 6/21/22, review of Administrator (ADM) Staff C's employee record revealed her start date was 7/15/19. Review of her employee training records revealed she did not receive education or training in abuse, neglect, and exploitation prior to working with the facility residents. On 6/21/22, review of Dietary Aid (DA) Staff D's employee record revealed her start date was 5/2/22. Review of her employee training records revealed she did not receive education or training in abuse, neglect, and exploitation prior to working with the facility residents. On 6/21/22, review of Security Guard (SG) Staff E's employee record revealed her start date was 2/21/22. Review of her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation, staff and resident interview, the facility failed to ensure timely response to call lights to meet the needs of 2 (Resident #94 and #96) of 2 residents reviewed. The findings included: On 6/20/22 at 1:42 p.m., Resident #94 said staff did not respond to the call light at night in a timely manner. Resident #94 said it would take 10 to 15 minutes for staff to respond to his call light. He said it happened every night and it was worse on the weekends. On 6/21/22 at 9:01 a.m., the restroom call light for Resident #94 on the Magnolia hallway observed sounding and flashing rapidly from the nursing station. Registered Nurse Staff B was observed standing at a medication cart directly in front of the nursing station. At 9:06 a.m., Resident 94's restroom call light continued to flash and sound. Staff B continued to stand at the medication cart and did not respond to the call light. Licensed Practical Nurse Staff A was observed walking to the nursing station, converse, and wash her hands at a sink next to the nursing station. After several minutes Staff A…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview the facility failed to complete a level one Pre admission Screening and Resident Review (PASARR), and report significant mental illness changes to the appropriate state agencies (KEPRO) for 2 (Resident #10 and #25) of 3 residents reviewed with newly diagnosed psychiatric disorder. The findings included: Record review revealed Resident #10 was a [AGE] year-old female who was admitted to the facility on [DATE]. There was no diagnosis of psychotic disorder or schizophrenia noted at the time of admission. The Physician's order dated 12/17/21 showed Resident #10 had a new order for Risperidone 0.25 milligram (mg) twice daily for delirium, and psychotic agitation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10's cognition was moderately impaired. Resident #10 was taking an Antipsychotic medication six days a week. The active diagnoses listed included non Alzheimer's dementia, and anxiety disorder. On 2/23/22, the physician issued an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview the facility failed to ensure a psychotropic (medication that affects brain activity) as needed medication (PRN) had a fixed duration of time for 1 (Resident #10) of 5 residents reviewed for unnecessary medications. The findings included: Review of the monthly pharmacy review for Resident #10 revealed a pharmacy recommendation printed on 4/12/22 to the physician that read, Lorazepam 1 mg [milligram] by mouth every 4 hours as needed for severe anxiety. (Since 3/22/22). The new Mega Rule guidelines require PRN psychoactive orders to have a duration of 14 days for the initial order. Then the resident should be seen by the prescriber who may reorder the medication for a fixed duration after fully documenting the need for the medication by the resident. There was no documentation in Resident #10's medical record the as needed Lorazepam was changed and no documentation from the physician of the benefit of the lorazepam or the set duration of the medication. The order for the PRN Ativan remained in place. The monthly pharmacy recommendation printed on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation, and staff interview, the facility failed to follow physician orders, to promote healing of a pressure ulcer for 1 (Resident #30) of 3 residents reviewed for pressure ulcers. The findings included: Review of the facility's policy for Pressure Ulcers/Skin Breakdown (undated) read the physician . will order pertinent wound treatments, including pressure reduction surfaces . Review of the facility's policy and procedure on Skin Evaluations (effective date 6/10/19) read 3. Licensed wound care nurse, RN or ARNP will review to ensure necessary treatments are implemented. 5. Any resident with a prescribed positioning or medical device will have a CMS [Color, Movement, Sensation] tool initiated for further evaluation of skin to prevent potential impairment. Review of the Minimum Data Set (tool used to assess and plan care) dated 11/5/20 showed Resident #30 was at risk of pressure ulcers/injuries. Review of the clinical record showed on 11/19/20 Resident #30 developed a stage II pressure ulcer (ulcer that expands into deep layers of the skin). A physician…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.