Health inspection·January 25, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Residents Affected - Some The findings included: 1. Review of clinical records for Resident #1 admitted to the facility on [DATE] and transferred to the hospital on 1/19/2024. Resident care plan documents Resident #1 has an ADL (Activities of Daily Living) Self Care Performance Deficit due to pain, weakness. Interventions included Assist of one for personal hygiene and an assist of two staff for toileting. Review of past 30-day Certified Nursing Assistant (CNA) Point of Care (POC) documentation (documents care provided) from the transfer to the hospital on 1/19/24 showed 57 opportunities to provide personal hygiene care with 15 shifts documented and 42 shifts with no documentation. Review of incontinence care provided to resident showed 57 opportunities for CNAs to provide care,17 shifts documented and 40 shifts with no documentation. No resident refusals for care were documented in the clinical record. 2. Review of clinical record for Resident #3 admitted to the facility on [DATE]. Resident care plan documents Resident #3 has an ADL (Activities of Daily Living) Self Care Performance Deficit. Interventions included Assist of one for personal hygiene and an assist of one staff for toileting. Review of the Certified Nursing Assistant (CNA) Point of Care (POC) documentation for December 2023 and January 2024 (Past 30 days) for providing resident personal hygiene care showed 60 opportunities to provide personal hygiene care with 30 shifts documented and 30 shifts with no documentation. Review of incontinence care provided to resident showed 60 opportunities for CNAs to provide care, 30 shifts documented and 30 shifts with no documentation. No resident refusals for care were documented in the clinical record. On 1/25/24 at 10:30 a.m., Resident #3 was observed in bed in a hospital gown. She was not able to answer questions. Her hair was uncombed. 3. Review of clinical records for Resident #4 admitted to the facility on [DATE]. Resident care plan documents Resident #4 has an ADL (Activities of Daily Living) Self Care Performance Deficit. Interventions included resident is dependent on staff for both personal hygiene and toileting. Review of Page 1 of 3 105155 105155 01/25/2024 Sarasota Health and Rehabilitation Center 1524 East Avenue South Sarasota, FL 34239

F 0677 Level of Harm - Minimal harm or potential for actual harm the Certified Nursing Assistant (CNA) Point of Care (POC) documentation for January 2024 for providing resident personal hygiene care showed 42 opportunities since admission to provide personal hygiene care with 17 shifts documented and 25 shifts with no documentation. Review of incontinence care provided to resident showed 42 opportunities for CNAs to provide care, 17 shifts documented and 25 shifts with no documentation. No resident refusals for care were documented in the clinical record. Residents Affected - Some On 1/25/24 at 10:15 a.m., observed resident #4 in bed wearing hospital gown. Resident seemed confused and was not able to answer questions when asked if staff kept her clean and dry and if the staff offers her help with personal hygiene care such as washing her face and brushing her teeth. 4. Review of clinical records for Resident #5 admitted to the facility on [DATE]. Resident care plan documents Resident #5 has an ADL (Activities of Daily Living) Self Care Performance Deficit due to cognitive impairment. Interventions included resident is an assist of one staff member for both personal hygiene and toileting. Review of the Certified Nursing Assistant (CNA) Point of Care (POC) documentation for December 2023 and January 2024 (Past 30 days reviewed) for providing resident personal hygiene care showed 60 opportunities to provide personal hygiene care with 41 shifts documented and 19 shifts with no documentation. Review of incontinence care provided to resident showed 60 opportunities for CNAs to provide care, 40 shifts documented and 20 shifts with no documentation. No resident refusals for care to be provided were documented in the clinical record. On 1/25/24 at 11:15 a.m., observed Resident #5 in wheelchair in hall by the nurse's station. The resident's hair was disheveled. Resident #5 was dressed in shorts and a shirt with stains. Resident #5 was not able to answer questions. 5. Review of clinical records for Resident #6 admitted to the facility on [DATE]. Resident care plan documents Resident #6 has an ADL (Activities of Daily Living) Self Care Performance Deficit. Interventions included resident is dependent on staff member for both personal hygiene and toileting. Review of past 30-day (from 1/25/24) Certified Nursing Assistant (CNA) Point of Care (POC) documentation for providing resident personal hygiene care showed 60 opportunities to provide personal hygiene care with 31 shifts documented and 29 shifts with no documentation. No resident refusals for care to be provided were documented in the clinical record. On 1/25/24 at 11:30 a.m., observed resident #6 in bed asleep with hospital gown on. The resident was unshaved with hair disheveled. On 1/25/24 at 11:00 a.m., interviewed CNA Staff A who confirmed CNAs are expected to check and change residents every two hours for incontinence. Confirmed that if a resident refuses care for ADLs she is to document and report to the nurse. Said she documents the cares that she provides in POC. On 1/25/24 at 12:05 p.m., interviewed facility clinical educator who confirmed staff have been educated to document resident care provided in the clinical records. Saying, Staff know to document if a resident refuses care, including CNAs for POC documentation of bathing, bowel and bladder. On 1/25/24 at 12:15 p.m., interviewed CNA Staff D who confirmed she had taken care of Resident #1 many times. Said she did not usually refuse care for keeping clean and dry. She refused other care but not that. CNA Staff D confirmed the expectation is to document the care provided in POC. If a resident refused care, it is reported to the nurse. On 1/25/24 at 12:25 p.m., interviewed Licensed Practical Nurse (LPN) Staff E who was assigned 105155 Page 2 of 3 105155 01/25/2024 Sarasota Health and Rehabilitation Center 1524 East Avenue South Sarasota, FL 34239

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #1 many times. LPN Staff E confirmed that the resident refused to do therapy but did not recall resident refusing hygiene cares. Confirmed the expectation is if a resident is refusing care that the CNAs tell him so he can assess the resident to see why they are refusing. He would also write a note and let the physician know about the refusals. On 1/25/24 at 12:40 p.m., during an interview with Interim Director of Nursing (DON) the clinical records for Resident #1 were reviewed including POC documentation for personal hygiene and bladder incontinence care. The Interim DON validated that the records did not show Resident #1 receiving care as expected. The DON said, The expectation is to have personal hygiene and incontinence care offered and it should be documented every shift. The Interim DON reviewed bowel and bladder POC documentation for Resident #1 and said, there is missing documentation. When asked how she would know the care was provided as expected, the Interim DON replied, We have to assume that we don't know if it was provided or not. The Interim Director of Nursing (ADON) said, Risks of not having appropriate incontinence care includes skin breakdown, and infection. On 1/25/24 at 3:00 p.m., during an interview the Interim DON reviewed the clinical records for Residents #3, #4, #5, and #6. The Interim DON confirmed Residents #3, #4, #5, and #6 did not have the expected care documented making it impossible to know if the care had been provided or not. 105155 Page 3 of 3