Sarasota Point Rehabilitation Center

Based on observation, record review and staff interviews, the facility failed to ensure 1 (Dietary Staff B) of 1 dietary staff observed operating the dishwasher was trained, and competent to test the sanitizing solution of the low temp dishwasher to ensure dishes were properly sanitized to prevent foodborne illnesses of residents consuming an oral diet. The findings included: The facility's policy and procedure titled, Testing Sanitizer & Temperature in Low Temp Dish Machines revised 8/2023 noted, Test sanitizing solution and temperature before cleaning each meal's dishes . Test the sanitizer with chlorine test strips obtained by the chemical vendor or food distributor. A proper level is 50 ppm (part per million) chlorine in the rinse water. An appropriated temperature is 120 - 160 F (Fahrenheit) . Record water temperature and sanitizer levels on the Dishwashing Temperature/Sanitizer Record. On 10/24/2024 at 9:20 a.m., during a tour of the kitchen with the Certified Dietary Manager (CDM), Food and Nutrition Aide Staff B was observed using the low temp dishwasher. In an interview…

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, resident and staff interview, the facility failed to update the care plan to accurately reflect safety precautions for 1 (Resident #30) of 2 sampled residents at risk for elopement. The findings included: Review of the clinical record revealed Resident #30 was admitted to the facility on [DATE]. Diagnoses included non-Alzheimer's dementia. The Elopement risk evaluations completed on 4/26/24, 5/21/24, and 10/14/24 noted Resident #30 scored 2, indicating the resident was at risk for elopement. Review of the care plan initiated on 5/21/24 and revised on 10/14/24 noted Resident #30 was at risk for elopement. The goal was Attempts to prevent resident from eloping from facility will be provided. The interventions included an alerting bracelet (alerts staff when the resident leaves a designated safe area) placed to the right ankle. The care plan specified to check the alerting bracelet function and placement every day. Review of the Order Summary Report revealed a physician's order…

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, record review, resident and staff interviews, the facility failed to provide care and services in accordance with physician's orders to meet the needs of 1 (Resident #30) of 1 resident observed with edema (swelling) of the legs. The findings included: Review of the clinical record for Resident #30 revealed an admission to the facility of 4/25/24. Diagnoses included heart failure. The physician's orders dated 6/10/24 noted to apply [NAME] hose (compression garment to legs to help circulation and lower swelling) in the morning and off in the evening for edema. The care plan initiated on 4/25/24 noted Resident #30 was at risk for altered cardiovascular status related to hypertension and congestive heart failure. The goal was for the resident to have decreased risk of signs and symptoms of cardiac complications. The interventions included to observe for changes in lung sounds, edema or changes in weight. The care plan initiated on 5/6/24 noted Resident #30 is resistive to care and medications related to adjustment to admission, and new environment, and on 6/10/24…

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 of medication administration, record review, staff and resident interviews, the facility failed to ensure 2 (Residents #74 and #38) of 3 sampled residents were free from significant medication error related to the administration of transdermal pain patches. The findings included: 1. Review of the clinical record for Resident #74 revealed a physician's order dated 5/25/23 for Lidocaine (topical anesthetic) External Patch 4%, apply to hip topically in the morning for pain and remove per schedule. Review of the Medication Administration Record (MAR) for October 2024 revealed the Lidocaine Patch was scheduled to be applied every day at 6:00 a.m. and removed every day at 6:00 p.m. The MAR for October 2024 had an order dated 5/12/23 to validate the Lidocaine Patch to the right hip was present every shift. The diagnoses for the Lidocaine Patch was fracture of the right femur. On 10/22/24 at 9:10 a.m., Licensed Practical Nurse (LPN) Staff A was observed administering medications to Resident #74. An undated Lidocaine Patch was observed on the resident's right thigh, near…

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 and interview, the facility failed to ensure a safe, functional, sanitary and comfortable environment for residents, staff and the public in 3 (Halls 100, 300 and 400) of 4 halls observed. The findings included: During a tour of the facility on 6/4/24 multiple environmental issues were observed, including: Common hallways with tiles cracked, missing or stained throughout the building. Photographic evidence obtained The hallway handrail near the activity director room was missing with an exposed nail. Photographic evidence obtained rooms [ROOM NUMBER] were observed with damage to the wall near the window and electrical outlet for the air conditioning unit with wall plaster missing, cracked, peeled paint and dirty surfaces. Photographic evidence obtained Rooms 330, 105, 328 and 408 had cracked tiles in the residents' rooms and bathrooms. photographic evidence obtained room [ROOM NUMBER]'s bathroom had plaster missing off the wall and peeled paint. Photographic evidence obtained room [ROOM…

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, review of facility's policies and procedures, staff and resident interviews , the facility failed to immediately report an alleged violation that could constitute neglect within specified time frame to the State Survey and Certification Agency for 1 (Resident #75) of 3 residents reviewed for incidents. The findings included: The Facility policy titled, Incident Reporting for Residents or Visitors revised 1/13/2017 noted, All accidents and unusual occurrences involving a resident or visitor will be documented and reported so as to meet all regulatory (state and federal) . requirements. Unusual Occurrence or Event. Any event not consistent with routine resident care; Any event reportable to federal and state agencies as defined by those agencies; An event or happening involving a resident . with unintended, undesirable, or unexpected results or outcomes. Review of the clinical record revealed Resident #75 was admitted to the facility on [DATE]. The 5-day scheduled Minimum Data Set (MDS)…

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, and staff interviews, the facility failed to ensure its medication error rate remained below 5%. Three errors occurred while observing five licensed nurses on two different shifts with 27 medication administration opportunities. Three medication errors were identified resulting in an 11.11% error rate. The failure to administer medications as per the pharmacy labeling and manufacture guidelines placed the residents at risk for harmful errors, sub-optimal therapy, or pharmacological effects. The findings included: Facility policy SHCRC30004.01 Medication Pass Guidelines (revised 4/25/2017) specified The nurse is responsible to read and follow precautionary or instructions on prescription labels and Check the Do Not Crush list before crushing medications. 1. On 2/1/21 at 10:15 a.m., the Director of Nursing (DON) was observed administering nine different medications to Resident #486 including Ventolin 90 micrograms inhaler (used to prevent and treat shortness of breath), and Trelegy EL (100-62.5-25) inhaler (used for chronic lung…

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, record review and interview the facility failed to maintain evidence of investigation and resolution of expressed grievances for 1 (Resident #60) of 6 residents reviewed for grievances. The findings included: Review of the facility's policy 'Grievances' (revised 10/30/19) read: 2. Grievances may be submitted orally or in writing; they may be submitted anonymously. The resident, or anyone acting on their behalf submitting the grievance, should be encouraged to utilize the Grievance Report. When a grievance is submitted orally, the facility employee accepting the grievance must document it on the Grievance Report. 5. The Grievance Official will document receipt of all grievances on the Grievance QAPI Log. 7. The Grievance Official will review the conclusion with the person investigating the grievance to determine what corrective actions need to be taken. 8. The resident, or anyone acting on their behalf filing the grievance, will be communicated with regarding the conclusion of the investigation and the corrective actions that will be taken. On 2/1/21 at 10:30…

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 secure medications in 2 of 3 (Lido and Siesta halls)) medication carts reviewed. The facility also failed to have a system of record keeping ensuring an accurate inventory and reconciliation of controlled substances stored for destruction. The findings included: 1. On 2/1/21 at 11:00 a.m., observation of the Lido 2 medication cart with Licensed Practical Nurse (LPN) Staff U revealed five whole unidentified pills and four half tablets of unidentified pills in drawer of the medication cart. LPN Staff U confirmed the observation of loose, unidentified pills in the drawers. Photographic evidence obtained. 2. On 2/1/21 at 11:42 a.m., the medication cart on the Siesta hall was observed unlocked and unattended. Several staff and 2 residents were observed passing by the unlocked cart. The cart contained medications used for residents on the Siesta hall. On 2/2/21 at 11:47 a.m., the Director of Nursing confirmed the medication cart was unlocked and unattended. She proceeded to lock the cart. Photographic evidence obtained. 3.…

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.