Inspection·January 12, 2023

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, and interviews, the facility failed to provide oxygen therapy as ordered to meet the needs of 1 (Resident #82) of 2 residents reviewed for oxygen administration. Residents Affected - Few The findings included: Record review of the Quarterly Minimum Data Set (MDS) assessment with a target date of 11/11/22 revealed Resident #82's cognition was intact. Diagnoses included heart failure. Resident #82 required extensive physical assistance of two persons for bed mobility. The physician's orders dated 12/27/22 included to administer Oxygen at 2 liters via nasal cannula as needed to keep saturation above 91% for shortness of breath. On 1/9/23 at 9:45 a.m., Resident #82 was observed on his back in bed, receiving Oxygen at four liters via nasal cannula. Resident #82 said he should be receiving oxygen at two liters, and was not able to reach the flow meter. On 1/10/23 at 8:56 a.m., Resident #82 was observed in bed receiving oxygen at four liters via nasal cannula. The flow meter was not within reach of the resident. On 1/11/23 at 7:54 a.m., resident #82 was observed in bed sleeping with oxygen on at four liters via nasal cannula. On 1/11/23 at 9:15 a.m., Registered Nurse (RN) Staff W verified Resident #82's oxygen was set at four liters. She confirmed the physician's order specified to administer oxygen at 2 liters via nasal cannula. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105147 If continuation sheet Page 2 of 5 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pines of Sarasota 1501 N Orange Ave Sarasota, FL 34236 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Based on observation, record review, policy review, staff and resident interviews, the facility failed to ensure 2 (Resident #58, and #141) of 6 residents observed with siderails were assessed for alternative interventions prior to the use of the siderails and informed consent explaining the risks and benefits was obtained prior to installation of the bedrails. The facility failed to have documentation of routine maintenance of the bed rails to ensure they remained safe for residents' use. The findings included: The facility policy Bedrails, (revised 9/19) specified: 1. The facility will attempt to use appropriate alternatives prior to installing a side or bed rail. 2. If a bed or side rail is used, the facility will ensure correct installation, use and maintenance of bed rails, including but not limited to the following elements. a. Assess the resident for risk of entrapment from bed rails prior to installation. B. Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent. ac. Ensure that the beds dimensions are appropriate for the resident's size and weight. d. Follow the manufacturers recommendations and specifications for installing and maintaining bed rails. 1. Review of the clinical record revealed Resident #58 had an admission date of 2/2/22 with diagnoses including dementia and Alzheimer's disease. On 1/9/23 at 1:43 p.m., Resident #58 was observed in bed with grab bar/side rails on both sides in the raised position. Resident #58 said she did not know what the side rails were. Further review of the clinical record showed no documentation of a signed consent or alternatives attempted prior to the use of the grab bars. On 1/11/23 at 10:49 a.m., the Director of Nursing verified the lack of documentation of alternatives attempted and informed consent prior to the use of the side rails for Resident #58. 2. Review of the clinical record revealed Resident #141 an admission date of 10/7/21 with diagnoses including dementia, delirium and wandering. Resident #141 resided in the secured unit of the facility. The Annual Minimum Data Set (MDS) assessment with a target date of 10/12/22 noted the resident scored a 5 on the Brief Interview for Mental Status, indicative of severe cognitive impairment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105147 If continuation sheet Page 3 of 5 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pines of Sarasota 1501 N Orange Ave Sarasota, FL 34236 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Level of Harm - Minimal harm or potential for actual harm On 1/9/23 at 1:22 p.m., and 1/10/23 at 8:27 a.m., Resident #141 was observed in bed with grab bars on both sides of the bed in the raised position. Resident #141 was not able to answer questions. Further review of the clinical record showed no documentation of alternatives attempted or an informed consent was obtained prior to the use of the side rails. Residents Affected - Few On 1/11/23 at 10:49 a.m., the DON verified the lack of documentation of alternatives attempted and informed consent prior to the installation of the side rails. The DON provided a siderail evaluation and consent form obtained and dated 1/11/23 for Resident #58 and #141. The form did not list alternatives attempted prior to the installation of the siderails for the residents. 3. On 1/11/23 at 10:50 a.m., the Maintenance Director said he had no documentation of periodic maintenance for the grab bars or siderails. He confirmed he did not check to see if the grab bars were loose, needed repair or were safe. 4. On 1/11/2023 at 10:50 a.m., the Maintenance Director stated the beds are checked for zones of entrapment once a year, and are not resident specific. The Maintenance Director said the facility did not keep documentation of the inspection and maintenance of the bed rails. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105147 If continuation sheet Page 4 of 5 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pines of Sarasota 1501 N Orange Ave Sarasota, FL 34236 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on Observation and interviews the facility failed to ensure the medication cart remained secured when not in direct view of the nurse for 1 (5100 hall Medication cart) of 9 medication carts. The findings included: On 1/9/23, at 3:50 p.m., observed an unlocked, unattended medication cart in the 5100 hall with the top drawer opened. The screen of the computer mounted on the medication cart was opened displaying residents' private information. Registered Nurse Staff Q was observed in a resident's room administering medication. The medication cart was not within eyesight of the nurse. The Nurse was completely in the resident's room administering medication. Photographic evidence obtained On 1/9/22, at 3:55 p.m., Registered Nurse Staff Q verified the medication cart was unlocked and unattended and the medications in the cart were easily accessible to unauthorized staff, visitors or residents. The nurse also verified the computer screen was left opened displaying residents' private health information. Staff Q said the medication cart should be locked when unattended. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105147 If continuation sheet Page 5 of 5