Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0689
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Level of Harm - Actual harm
Residents Affected - Few
Based on observation, record review and interview, the facility failed to provide adequate supervision to
prevent repeated falls for 3 (Residents #1, #2 and #3) of 3 residents identified to be at risk for falls and
sustained multiple falls at the facility, including falls with injuries requiring emergent transfers to acute care
hospitals.
The findings included:
The facility policy titled Fall and Injury Reduction Policy, effective March 2023 indicated the policy was to
assist the facility with reducing the likelihood of a fall or injury while maintaining or maximizing dignity and
independence through education of staff and residents, early identification of risk factors by collecting data,
identifying resident behaviors which may increase the likelihood of such occurrence.
1. Review of Resident #1's clinical record revealed an admission date of 11/1/23. Diagnoses included
vascular dementia, generalized anxiety disorder, and insomnia.
Review of the admission Minimum Data Set (MDS) Assessment with an assessment reference date of
11/8/23 noted the resident's cognition was severely impaired with a Brief Interview for Mental Status (BIMS)
score of 03. Resident #1 required substantial/maximal assistance to roll left and right, sitting on the side of
the bed to lying flat on the bed, safely move from lying on the back to sitting on the side of the bed, safely
stand from sitting position, toilet transfer and showers.
The care plan initiated on 11/1/23 noted the resident was at risk for falls or fall related injuries due to a
history of fall prior to admission, psychoactive drug use, and weakness. The goal was to minimize the risk
of falls and have no untreated fall related injury. The interventions included to encourage the resident to
wear non-skid socks, shoes when out of bed; lock brakes on the bed and chair before transferring, observe
for side effects of drugs such as gait disturbance, weakness, sedation, drop in blood pressure,
lightheadedness, dizziness and change in mental status; call light within reach, adequate lighting, and area
free of clutter.
Review of the progress notes revealed Resident #1 sustained six falls from 12/9/23 through 2/17/24.
Fall #1:
On 12/9/23 at 6:50 p.m., a nursing progress note documented the nurse was sitting at the nurse's station
when she heard someone yelling for help. She ran down the hallway and found the resident
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 10
Event ID:
105155
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
105155
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sarasota Health and Rehabilitation Center
1524 East Avenue South
Sarasota, FL 34239
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 0689
laying on the floor. The resident did not sustain any injuries. She was assisted off the floor by two nurses
into a wheelchair and assisted to bed by a Certified Nursing Assistant (CNA).
Level of Harm - Actual harm
Residents Affected - Few
The Interdisciplinary Team (IDT) progress note dated 12/11/23, two days after the fall showed the fall
occurred around start of dinner meal. Resident to be encouraged to eat meals in dining room.
On 12/11/23 the care plan was updated to encourage the resident to eat meals in the dining room.
Fall #2:
On 12/17/23 at 8:30 a.m., a nursing progress note documented the nurse was called to the resident's room.
Resident #1 was on the floor. Upon entering the room Resident #1 was sitting on her bottom on the floor
next to the bed. Resident #1 had non-slip footwear on. Resident was ambulating without her walker. She
had previously been sitting in her wheelchair in the room eating breakfast. No visible injuries were noted.
The progress note dated 12/19/23 at 9:10 a.m., (two days after the fall) noted the IDT reviewed due to
recent fall. Resident #1 was receiving Hospice services. A nutritional review was completed. The resident
had a recent decrease of oral intake. Shakes were added and a perimeter mattress (raised, define
perimeter for enhanced fall prevention) was added.
On 12/19/23 the care plan was updated to include a perimeter mattress.
Fall #3:
On 12/30/23 at 5:50 p.m., a nursing progress note showed Resident #1 was observed sitting on the shower
room floor having a bowel movement on the floor. Resident #1 was assessed and denied injuries.
On 1/2/24 at 8:58 a.m., three days after the fall, the IDT progress note documented the resident was
reviewed due to recent fall. Resident had taken herself to the shower room which she thought was a
bathroom. Staff to toilet resident on a routine schedule.
On 1/2/24, toilet upon rising, before and after meals, at bedtime and as needed was added to the care plan.
On 3/6/24 at 10:16 a.m., in an interview the Director of Nursing (DON) said on 12/30/23 at approximately
3:30 p.m., Resident #1 went to the shower room next to the nurse's station. She thought it was the
bathroom. She was found on the floor in the shower room. The intervention added was routine toileting
because she was looking for a bathroom.
Fall #4:
On 1/10/24 at 2:15 a.m., a nursing progress note documented Resident #1 had an unwitnessed fall. At 2:15
a.m., the CNA observed resident on the floor next to the bed. The nurse observed the resident sitting in a
wheelchair holding her head. Resident #1 complained of pain when assessing the head. A bump was noted
to the right side of the head.
On 1/10/24 at 9:23 a.m., the IDT progress note documented the perimeter mattress was in place. Will
implement floor mats to prevent injury. Resident had a recent weight loss and the Registered
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105155
If continuation sheet
Page 2 of 10
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
105155
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sarasota Health and Rehabilitation Center
1524 East Avenue South
Sarasota, FL 34239
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 0689
Dietitian was to evaluate for nutritional supplement.
Level of Harm - Actual harm
On 1/10/24 the care plan was updated to reflect, Floor mats to sides of bed while in bed.
Residents Affected - Few
Fall #5:
On 1/31/24 at 12:15 p.m., a nursing progress note documented Resident #1 was observed lying on the
floor in the resident's room next to the bed. Resident had been laying down on bed. The resident was
wearing nonskid socks, the walker was at the resident's said. Resident #1 had a raised 5.5 centimeters
(cm) by 6.0 cm raised area to the back of the head.
On 2/1/24 at 8:49 a.m., the IDT progress note documented the resident was reviewed due to recent fall
from bed. The perimeter mattress was in place as well as fall mats next to the bed. The DON documented
in the note she will obtain orders for routine anti-anxiety medication as well as routine analgesic.
The care plan was not updated with safety measures, including supervision to minimize the risk of further
falls.
Fall #6:
On 2/17/24 at 6:41 p.m., a nursing progress note documented Resident #1 was following another resident
into a room. The nurse observed Resident #1 turn around to exit the room. The nurse went to assist the
other resident out of the room. She then heard Resident #1 yell I'm falling. She noted Resident #1's head
was bleeding. She called EMS to transfer Resident #1 to the emergency room for evaluation and treatment.
Resident #1 was admitted to the hospital and has not returned to the facility.
Review of the hospital record for Resident #1 dated 2/17/24 showed Resident #1 was diagnosed with a
small parietal (Top posterior) scalp hematoma (Pool of blood in tissue).
The hospital progress note documented Resident #1 was admitted for further evaluation and additional
testing.
On 3/5/24 at 1:33 p.m., in an interview the Director of Nursing (DON) said Resident #1 did not have a real
steady gait. She often forgot her walker. Staff would have to go back and get her walker. They encouraged
her to eat her meals in the dining room, put a perimeter mattress. In January they initiated a routine toileting
schedule and added fall mats. They also asked hospice to review her medications.
On 3/6/24 at 11:49 a.m., in an interview Registered Nurse (RN) Staff A said he remembered Resident #1.
She was very confused, used a walker and did not have good balance at all. She also had very poor
hearing.
2. Review of the clinical record for Resident #2 revealed an admission date of 11/8/22.
Review of the Annual MDS assessment with a target date of 11/16/23 noted Resident #2's cognition was
severely impaired with a BIMS score of 03.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105155
If continuation sheet
Page 3 of 10
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
105155
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sarasota Health and Rehabilitation Center
1524 East Avenue South
Sarasota, FL 34239
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 0689
Diagnoses included osteoporosis (weak, brittle bones), fracture, unspecified dementia, mood disturbance,
anxiety, lack of coordination and abnormal posture.
Level of Harm - Actual harm
Residents Affected - Few
The resident required substantial/maximal assistance for Activities of Daily Living, including toileting,
dressing showering, roll left and right. Resident #2 was dependent for transfers.
The care plan initiated on 11/9/22 noted the resident was at risk for falls or fall related injury because of
history of fall prior to admission, deconditioning, gait, balance problems, psychoactive drug use and
weakness.
The goal was to minimize the risk of falls, and not have untreated fall related injury.
The interventions included to encourage meals in the dining room (11/11/22); Encourage participation in
activities after lunch as tolerated (4/21/23); Neuro follow up (3/20/23); Perimeter mattress (2/27/23);
Therapy screen (1/23/23); Therapy to assess for wheelchair positioning (11/11/22); Assess wheelchair for
auto-locks (1/23/23); Encourage to wear non-skid socks/shoes when out of bed (11/9/22).
Review of the progress notes revealed Resident #2 sustained seven falls from 1/4/24 through 2/28/24.
Fall #1:
On 1/4/24 at 5:30 p.m., a progress note documented the nurse heard Resident #2 yell out from the room,
Help I fell. The nurse observed the resident sitting upright on his bottom with his back against the side of
the bed. The bed was in low position. No visible injuries.
On 1/4/24 the care plan was updated with the use of fall mats to side of the bed while in bed.
On 1/9/24 (five days after the fall), the IDT note documented IDT review due to fall from bed. Resident has
perimeter mattress in place. Floor mats placed next to bed. Resident had been placed in bed 30 minutes
prior to fall. A nutritional review was completed. Resident has episodes of anxiety and yells out.
Fall #2:
On 1/24/24 at 4:49 p.m., a progress note documented the nurse was informed by another nurse that
Resident #2 was noted on the floor sitting in front of his wheelchair. The resident was assisted back to the
wheelchair. No injuries were noted.
No update to the care plan was noted for 1/24/24.
Fall #3:
On 1/26/24 at 5:15 p.m., a progress note documented a therapist alerted the nurse the resident was on the
floor. Resident #2 was observed sitting up against the bed on his buttocks with one non-skid sock on. No
injury noted.
On 1/29/24 the IDT note documented Initial intervention after the fall on 1/24/24 was to lay
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105155
If continuation sheet
Page 4 of 10
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
105155
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sarasota Health and Rehabilitation Center
1524 East Avenue South
Sarasota, FL 34239
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 0689
Level of Harm - Actual harm
resident down after meals. Most recent fall was from bed. Resident has perimeter mattress and floor mats
in place. Nutritional review was completed. As needed anxiolytic ordered due to increased restlessness and
yelling out. Assess for pain and discuss with physician routine analgesics.
Residents Affected - Few
On 1/26/24 the care plan was updated to lie resident down after meals.
Fall #4:
On 2/7/24 at 6:45 p.m., a progress note documented Resident #2 was observed sitting on his bottom in the
room in front of his wheelchair with his back up against the bed. Resident had previously been sitting up in
wheelchair. No injuries noted. The resident was brought to the nursing station for monitoring.
A 15 minute observation log showed Resident #2 was on 15 minutes check which started on 2/7/24 at 7:00
p.m., and ended on 2/8/24 at 6:45 a.m.
On 2/8/24 the IDT note documented Resident #2 was reviewed after falling from the wheelchair in his room.
Staff to encourage resident to stay in common area when up in wheelchair.
On 2/8/24 the care plan was updated to encourage the resident to stay in common area when up in
wheelchair.
Fall #5:
On 2/10/24 at 12:20 p.m., a progress note documented Resident #2 was observed laying on his right side
on the floor next to his wheelchair in the dining room. The resident was not able to describe the event.
On 2/12/24 the IDT progress note documented Resident #2 had taken self to the dining room. Resident has
had increased restlessness, contact psych (psychiatry) to order anxiolytic routine. Continue with other
interventions as resident tolerates.
On 2/12/24 the care plan noted Psych eval and medication review.
Fall #6:
On 2/25/24 at 6:39 p.m., a progress note documented Resident #2 was observed lying on the floor next to
the dining room. The cushion of the chair was near the edge of the chair as if it was sliding out. No injuries
noted.
On 2/26/24 the IDT progress note documented the resident was reviewed due to recent fall from wheelchair
outside of the dining room. Therapy to assess proper wheelchair positioning and devices.
On 2/26/24 the care plan noted, Therapy to assess for wheelchair positioning.
Fall #7:
On 2/28/24 at 11:30 a.m., a progress note documented Resident #2 was observed lying on his right side in
front of his wheelchair on the floor in the dining room. No visible injuries. The resident was
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105155
If continuation sheet
Page 5 of 10
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
105155
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sarasota Health and Rehabilitation Center
1524 East Avenue South
Sarasota, FL 34239
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 0689
confused per baseline. Resident #2 was brought to the nurse's station for closer monitoring.
Level of Harm - Actual harm
On 2/29/24 the IDT progress note documented the resident was reviewed due to recent fall from
wheelchair. Resident was previously in his room. Resident made his way to the dining room. Will contact
physician for routine pain medication and psych for change in anxiolytic. Continue current fall prevention
interventions.
Residents Affected - Few
On 3/5/24 at 1:41 p.m., Resident #2 was observed in his room in a wheelchair unsupervised watching
television.
On 3/6/24 at 11:47 a.m., Resident #2 was observed in a wheelchair in his room with the Occupational
Therapist.
On 3/6/24 at 11:49 a.m., in an interview Registered Nurse (RN) Staff A said Resident #2 spins himself in
the wheelchair, will have his legs over the arm rest. Staff has to help him sit back into the wheelchair. He
gets restless, is impulsive and screams out for his wife.
3. Review of the clinical record for Resident #3 revealed an admission date of 10/18/23.
The admission MDS with a target date of 10/20/23 noted Resident #3's cognition was intact with a BIMS
score of 15. Diagnoses included Dementia, unspecified lack of coordination and other neurological
conditions. Resident #3 required partial/moderate assistance with activities of daily living, transfer, toilet
transfer, shower, walking.
The MDS noted the resident had a fall in the last month prior to admission, and one fall with injury (except
major injury) since admission to the facility.
The care plan initiated on 10/19/23 noted Resident #3 was at risk for falls or fall related injury because of
poor safety awareness, psychotropic medication use, and weakness.
The goal was to minimize the risk of fall and have no untreated fall related injury.
The 5-day scheduled MDS assessment with a target date of 11/13/23 noted the resident's BIMS score was
12, indicative of moderate cognitive impairment.
The care plan initiated on 11/13/23 noted Resident #3 had impaired cognitive function/dementia or
impaired thought processes related to dementia and BIMS score of 8-12.
Review of the progress notes revealed Resident #3 sustained 11 falls from 11/1/23 through 2/23/24.
Fall #1:
On 11/1/23 at 4:59 p.m., a progress note documented a CNA witnessed Resident #3 slide out of the chair
onto the floor. No injuries were noted.
On 11/2/23 the IDT progress note documented Resident #3 has been having difficulty sleeping, and had a
recent medication change to assist with sleep. The resident was also referred to Physical and Occupational
therapy.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105155
If continuation sheet
Page 6 of 10
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
105155
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sarasota Health and Rehabilitation Center
1524 East Avenue South
Sarasota, FL 34239
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 0689
The care plan was updated to toilet upon rising, before and after meals, at bedtime and as needed
(11/1/23); encourage fluid intake (11/2/23).
Level of Harm - Actual harm
Fall #2:
Residents Affected - Few
On 11/4/23 at 3:40 p.m., a progress note documented the nurse was notified by staff that Resident #3 had
a fall. The resident stood up in common area lost her balance and fell on her right knee. Resident #3
complained of right knee pain. The physician was notified and ordered a right knee X-ray.
On 11/6/23 the IDT progress note documented Resident #3 was reviewed due to recent fall from
wheelchair, Will have resident in common area during waking hours and initiate 15 minutes checks.
Encourage fluids.
Review of the 15 minute observation log for Resident #3 showed Resident #3 was observed every 15
minutes starting on 11/6/23 at 11:00 p.m., and ending on 11/7/23 at 11:00 p.m.
On 11/8/23 at 1:34 p.m., a progress note documented staff reported to the nurse Resident #3 was in pain.
The resident said her right leg hurts, I'm in so much pain. The resident yelled out ouch during passive range
of motion to the right upper leg in the hip/femur area. Resident #3 stated she has not had any more falls
since Saturday and her leg was not injured during care or any other way. The Advanced Practice
Registered Nurse was notified and ordered an X-ray of the right hip, and right femur (thigh bone).
On 11/8/23 at 5:15 p.m., a progress note documented the X-ray showed a right hip fracture. Resident #3
was transferred to the emergency room for evaluation.
On 11/11/23 at 3:56 p.m., a progress note documented the resident came back after a hospital stay for a
right hip replacement.
Fall #3:
On 11/30/23 at 1:30 p.m., a progress note documented Resident #3 was sitting in a wheelchair in the
hallway in front of the nurse's station. The resident was observed standing up from the wheelchair without
assistance and sit down on the floor before staff member could get to her from behind the nurse's station.
The brakes were locked and the resident was wearing non-skid socks. No visible injuries were noted.
On 12/1/23 the IDT progress note documented Resident #3 was reviewed due to recent fall from
wheelchair. Resident #3 was sitting at the nurse's station when she stood up quickly from her chair and fell
to the floor before staff could reach her. Resident is impulsive and at times restless. The physician renewed
the anxiolytic order. Current interventions are high back wheelchair, perimeter mattress, floor mats, keep in
common area while awake. Resident receives analgesics as needed. She is able to ask for the medication
when she is in pain.
On 12/1/23 the care plan was updated to include incontinence or toileting plan and a high back reclining
wheelchair.
Fall #4:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105155
If continuation sheet
Page 7 of 10
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
105155
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sarasota Health and Rehabilitation Center
1524 East Avenue South
Sarasota, FL 34239
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 0689
Level of Harm - Actual harm
Residents Affected - Few
On 12/10/23 at 7:17 p.m., a progress note documented Resident #3 was noted sitting on the floor in the
hallway in front of the door. Resident stated she was trying to go home. No obvious injuries were noted.
Resident was wearing non-skid socks at the time of the fall.
On 12/11/23 the IDT progress note documented Resident #3 was in a common area. Dinner meal was
being served. The physician to evaluate for routine anxiolytic as well as routine pain medication. Continue
all other current interventions.
On 12/11/23 the care plan was updated to include the physician's evaluation for routine anxiolytic.
Fall #5:
On 12/14/23 at 7:48 p.m., a progress note documented Resident #3 was noted lying on the right side on
the floor mats. Resident stated she was trying to go to the county fair. Resident reopened skin tear to left
elbow and a small new skin tear to the left forearm. No other injuries noted.
On 12/15/23 an IDT progress note documented Resident #3 was reviewed due to recent fall from bed.
Resident had been resting in bed prior to the fall. Nurse removed the staples so she was woken up for that
procedure. Continue to encourage rest periods after meals. Continue all other current interventions.
On 12/15/23 the care plan was updated to offer rest periods after meals.
Fall #6:
On 12/29/23 at 5:01 a.m., a post event note documented Resident #3 had an unwitnessed fall on 12/29/23
at 3:45 a.m., in the hallway. The resident was last toileted on 12/29/23 at 12:00 a.m.
Fall #7:
On 12/29/23 at 11:55 a.m., a progress note documented staff notified the nurse Resident #3 was on the
floor. The nurse observed the resident on the floor in a sitting position. Resident #3 sustained a laceration to
the right eyebrow and a skin tear to the right elbow. The resident was not able to give a description on what
occurred.
Fall #8:
On 12/29/23 at 8:27 p.m., a progress note documented the nurse observed Resident #3 on the floor in a
sitting position in the hallway with the wheelchair nearby. The resident was not able to give a description on
what occurred. Resident #3 sustained a skin tear to the left hand and thumb area.
The care plan was updated on 1/1/24 for a lap buddy (pillow that snugs into the frame of the wheelchair to
prevent falls) when in wheelchair due to poor safety awareness and release during meals.
On 1/2/24 an IDT progress note documented Resident #3 was reviewed due to recent falls. Resident has
poor safety awareness due to cognitive deficits. Lab buddy was initiated. Floor mats in place and psych to
follow up.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105155
If continuation sheet
Page 8 of 10
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
105155
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sarasota Health and Rehabilitation Center
1524 East Avenue South
Sarasota, FL 34239
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 0689
Fall #9:
Level of Harm - Actual harm
On 1/19/24 at 3:19 p.m., a progress note documented the nurse was behind the nurse's station when, I
heard the resident [sic] help. By the time she got to the resident, she had fallen on her left side and
obtained a skin tear to her left wrist. Resident #3 was assisted back in the wheelchair.
Residents Affected - Few
On 1/22/24 an IDT progress note documented the resident was reviewed due to recent fall from the
wheelchair. Resident was in a common area. The physician to evaluate for medication changes to routine
anxiolytic and pain medications.
Fall #10:
On 2/4/24 at 10:48 a.m., a progress note documented Resident #3 was noted lying on the floor on her right
side on the side of her bed on the floor mats. Bed was in low position. No injuries noted. A skin check was
performed 30 minutes prior to fall.
On 2/5/24 an IDT progress note documented Resident #3 was reviewed due to a recent fall from the bed.
Resident stated she was getting up for the day. Resident is an early riser. Interventions were in place to
prevent falls as well as injury. A nutritional review was completed. Resident #3 to be assisted out of bed
earlier in the morning per her preference.
Fall #11:
On 2/23/24 at 10:22 a.m., a progress note documented staff notified the nurse Resident #3 was on the
floor. Resident #3 was observed on the floor in her room in a sitting position. Resident #3 sustained an
abrasion to the right side of the forehead. Resident #3 was assisted to her wheelchair.
On 2/26/24 an IDT progress note documented current interventions were perimeter mattress, floor mats,
routine analgesics, routine anxiolytic, lap buddy to the wheelchair. Resident continues to be restless at
times. Medications were reviewed with psych for possible increase in Clonazepam (psychotropic medication
for anxiety).
On 3/5/24 at 1:50 p.m., Resident #3 was observed unsupervised in the hallway in a wheelchair with a lap
buddy on the wheelchair.
On 3/6/24 at 10:16 a.m., the Director of Nursing (DON) said, if there is a fall, they dig in, they have an Inter
Disciplinary Team (IDT) meeting. They put in IDT notes and come up with new interventions and the care
plan coordinator updates the care plan during the meeting. She said they do referrals for vision, the
Dietitian does a nutritional review, and some residents are referred to neurology.
On 3/6/24 at 11:56 a.m., in an interview the Director of Rehabilitation said Residents #2 and #3 both have
fallen from their wheelchairs. They both were assessed for cushions. Both are very impulsive. Resident #2
was still receiving therapy with some improvement on bed mobility transition. He said he attended the IDT
meetings and no changes were needed to the residents' wheelchairs. He said Resident #3's therapy
stopped on January third since she plateaued. She requires moderate to maximum assistance depending
on her level of alertness.
On 3/6/24 at 1:24 p.m., in an interview the DON said she felt they were seeing a decrease in the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105155
If continuation sheet
Page 9 of 10
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
105155
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sarasota Health and Rehabilitation Center
1524 East Avenue South
Sarasota, FL 34239
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 0689
Level of Harm - Actual harm
falls over two to three months. She said a clinical meeting was held each morning and if something is in
place they know if it is effective or not. She said she felt the interventions were effective, but the
circumstances around each fall for each resident differed and they continued to add interventions. She said
the CNAs sit in the hallways to do charting so they can keep an eye on the hallways for added supervision.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105155
If continuation sheet
Page 10 of 10
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
FAQ · About this visit
Common questions about this visit
What happened during the March 6, 2024 survey of SARASOTA HEALTH AND REHABILITATION CENTER?
This was a inspection survey of SARASOTA HEALTH AND REHABILITATION CENTER on March 6, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SARASOTA HEALTH AND REHABILITATION CENTER on March 6, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.