Inn At Sarasota Bay Club

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure 3 (Residents #21, #25, and #180) of 5 residents reviewed received care in accordance with professional standards of practice. The findings included: 1. Review of the clinical record for Resident #21 revealed an admission date of 10/4/23. The physician's orders dated 7/27/24 included to weigh Resident #21 weekly on Tuesdays starting on 8/1/24 for a diagnosis of malnutrition. The physician's orders dated 7/27/24 also included to obtain the resident's vital signs (Temperature, pulse, respiration, blood pressure) and weight monthly. The clinical record lacked documentation the facility clarified the physician's orders related to the frequency of monitoring the resident's weight. On 8/14/24, review of the weight summary showed Resident #21's weight was obtained on 8/2/24. No other weight was documented after 8/2/24. The clinical record lacked documentation of the reason for the missing weekly weights. On 8/14/24 at 5:09 p.m., in 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 resident and staff interview, the facility failed to ensure the facilities binding arbitration agreement explicitly informed the residents of their rights to have it explained to them in a manner that was understood, that the agreement could be rescinded within 30 calendar days of signing, that the agreement did not have to be signed or that it was not a condition of admission or continued care in the facility, and that the resident would be allowed to communicate with federal, state or local ombudsman for 3 (Resident #10, #12 and #330) of 13 resident reviewed who had signed the facility binding arbitration agreement. The findings included: On review of Facilities binding arbitration agreement, it did not indicate the following: Explained in a from and manner that the resident understood. That the agreement may be rescinded within 30 calendar days of signing. That the agreement was not required to be signed or that it was a condition of admission or continued care in the facility. The resident or their representative could still communicate with federal,…

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 resident and staff interview, the facility failed to ensure the facility's binding arbitration agreement signed by 3 (Residents #10, #12 and #330) of 13 resident reviewed explicitly informed residents of their rights to select a neutral arbitrator and participate in the select of venue for dispute resolution that both parties agreed upon. The findings included: Review of the clinical record for Residents #10, #12, and #330 revealed the residents signed the facility's binding agreement upon admission. On review of Facilities binding arbitration agreement, it did not indicate the following: 1. That the resident has a right to be included in selecting a neutral arbitrator agreed upon by both parties 2. That the resident has the right to be included in selecting a venue that is convenient to both parties. During an interview on 8/14/24 at 10:34 a.m., Community Liaison (admission person) stated that he has not ever explained to a resident or their representative about the Binding Arbitration agreement. He said he usually has a stack of things from the admission…

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, clinical record review, review of facility policy, resident and staff interviews, the facility failed to maintain a sanitary environment for 1 (Resident # 22) of 20 residents' rooms observed by failure to ensure the resident's room was free from foul odor. The findings included: The facility's policy and procedure for Housekeeping Expectations revealed to clean all resident bathrooms daily; Clean resident occupied rooms, a minimum of once weekly and as directed or deemed necessary; Clean vacated rooms as directed to prepare for admission ready. A complete room cleaning is performed, please speak with Admissions for any special cleaning requirements. The policy and procedure for the (Brand name) Urine Collection Systems (non-invasive urine collection system for women with urinary incontinence) with and effective date of 10/01/2018 stated, The facility does not provide any [Brand name] Collection systems, parts or supplies. Should a resident be clinically appropriate for the use of this type of urine collection system, the resident understands that they accept…

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, interview and record review, the facility failed to develop a person-centered comprehensive care plan to meet the needs of 1 (Resident #11) of 3 residents reviewed for care plans. The findings included: Review of the clinical record for Resident #11 revealed an admission date of 3/5/24. The nursing progress note dated 3/5/24 at 4:43 p.m., noted Resident #11 had a cardiac pacemaker (implanted device to help control the heart's rhythm and rate). The physician's order summary documented the presence of a cardiac pacemaker. The admission Minimum Data Set (MDS) assessment dated [DATE] noted Resident #11's cardiac diagnoses included abnormal heart rhythm. The MDS did not document the presence of the cardiac pacemaker in the active diagnoses, or cardiopulmonary procedures. The assessment noted Resident #11's cognition was intact with a Brief Interview for Mental Status score of 15. The comprehensive care plan initiated on 3/21/24 did not address the presence of the cardiac pacemaker with goals,…

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, interview and record review, the facility failed to ensure the error rate was less than 5%. 25 opportunities were observed, two medication errors were identified resulting in a medication error rate of 8%. The findings included: 1. On 8/13/24 at 8:00 a.m., observed Registered Nurse (RN) Staff H administer 1 tablet of Vitamin B12 - 500 micrograms (mcg) to Resident #21. On 8/14/24 at 8:50 a.m., review of the physician's order summary for Resident #21 revealed a current order to give 2 tablets of Vitamin B12 - 500 mcg one time a day for B12 deficiency. On 8/14/24 at 9:01 a.m., review of the Medication Administration Record (MAR) for August 2024 revealed Staff H signed off she administered 2 tablets of Vitamin B12 500 mcg. on 8/13/24. On 8/14/24 at 11:33 a.m., during an interview with Staff H she said she thought Resident #21's order for B12 was for 1 tablet, so she gave her one tablet during the observation on 8/13/24. Staff H looked at the order on her computer screen and said, you're correct, the order is for two tablets; my error. Review of the physician's…

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 and staff interview, the facility failed to ensure proper cleaning and sanitizing of equipment in the kitchen. The findings included: On 5/1/2023 at 9:15 a.m., during a tour of the kitchen conducted with the Certified Dietary Manager (CDM), the following observations were made: Ceiling vents with dust build-up. Photographic evidence obtained. Ice machine with dust build up on vent. Photographic evidence obtained. Stove area and flat cooktop were covered in grease and grime build up. Photographic evidence obtained. There was a container of melted butter sitting on flat cook top that was also covered in grease and grime. Photographic evidence obtained. At the time of the observation, the CDM said the melted butter gets changed before each meal. Oven and exhaust fan over oven, both had build-up of grease and grime. Photographic evidence obtained. At the time of the observation, the CDM said the staff take turns cleaning and would provide cleaning schedule. He said they had been shorthanded recently. On 5/4/2023 at 1:20 p.m., the Administrator reviewed the…

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 and resident interviews, and record review, the facility failed to attempt alternatives prior to the use of bed rails for 4 (Resident #4, #12, #142, and #192) of 6 residents reviewed for bed rails. The findings included: 1. On 5/1/2023 at 10:25 a.m., observation revealed Resident #4 asleep in the bed with bilateral upper bed rails in the up position. On 5/4/2023 at 11:30 a.m., observation revealed Resident #4 sitting up in bedside chair. Both bed rails were in the up position. Record review for Resident #4 revealed no evidence alternatives were attempted prior to use of bed rails on the bed of Resident #4. 2. On 5/4/2023 at 11:40 a.m., observation revealed Resident #12 in her bed sleeping with bilateral upper bed rails in the up position. Record review for Resident #4 revealed no evidence alternatives were attempted prior to use of bed rails on the bed of Resident #4. 3. On 5/1/2023 at 11:00 a.m., observation revealed bilateral bed rails in the up position on the bed of Resident #192. On 5/1/2023 at 11:10 a.m., in an interview, Resident #192, said he…

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 and resident interviews and record reviews, the facility failed to ensure all drugs and biological were labeled or stored in a locked compartment for 2 (Resident #4 and #191) of 2 residents reviewed. The findings included: The facility policy Medication Storage in the Facility: ID3 Bedside Medication Storage with an effective date of March 2022 states bedside medication storage is permitted for residents who wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate in the judgement of the facility's interdisciplinary resident assessment team. The manner of storage prevents access by other residents. 1. On 5/1/2023 at 10:25 a.m., observation revealed Resident #4 asleep in the bed. There was an uneaten breakfast tray sitting on the dresser with unlabeled pills in a medicine cup on the breakfast tray. *Photographic evidence obtained. On 5/1/2023 at 11:30 a.m., Licensed Practical Nurse (LPN) Staff B said Resident #4 was asleep during medication pass so she left…

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 staff interview, the facility failed to obtain a Do Not Resuscitate Order (DNRO) in accordance with the advanced directives of 1 (Residents #31) of 1 resident reviewed for advance directives. The failure to have accurate physician orders has the potential to lead to confusion in regards to the resident's end of life advance directive being honored. The findings included: The facility's policy for Advance Directives- revised procedure for processing an advance directive, dated [DATE]; noted Social Services Director (SSD) documents in the medical record a note that the advance directive document was received and details of the documents. SSD updates the log for DNR orders and delivers a copy of the advance directive to the charge nurse of on the unit where the resident resides. The charge nurse documents receipt of the advance directive by putting the order into the record and changing the Code status if appropriate. Director of Nursing/Assistant Director of Nursing follows up with the…

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 and staff interview, the facility failed to store resident medications in a manner to prevent loss and efficacy of the medications for 3 of 3 medication carts. The findings included: The facility's Medication Storage In The Facility policy, ID1: Storage Of Medications, dated March 2019 stated, all medications dispensed by the pharmacy are stored in the container with the pharmacy label. Orally administered medications are kept separate from externally used medications and treatments such as ointments and creams. 1. On 10/5/21 at 9:14 a.m., observation of the Coral Unit medication cart revealed an open unlabeled plastic medication cup with 3 different medications inside the top drawer. Licensed Practical Nurse (LPN) Staff K was present during the observation and said she was the only nurse administering medications from the cart and did not put the pills there or know to which resident they belonged. LPN Staff K immediately removed the pills and disposed of them without attempting to identify the medications or if they were intended for a resident who did not…

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.