Health inspection·May 6, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wait for staff assistance with transfers, ambulation, toileting, etc., as indicated. Obtained labs as ordered and notify physician. Encourage and assist the resident to wear appropriate footwear. The care plan noted the resident had behaviors including urinating in halls, wandering into other resident rooms and combative during care. The interventions instructed staff to acknowledge/commend the residents progress/improvement in behavior. Administer medications as ordered. Explain procedures to the resident before starting and allow the resident to adjust to changes as needed. Intervene and or redirect resident behavior as necessary. Approach/speak in a clam manner. Divert attention. Monitor behavior episodes and attempt to determine underlying cause. The nursing progress note dated 4/13/25 Late entry at 7:16 a.m., documented, When I arrived at work I made my morning rounds. When I got to the back hallway I heard yelling from the resident. I immediately went to his room and noted him on the floor in front of the bathroom door on his back with his head pointing towards the room entrance. I assessed the resident and noted left leg pain. The call light was not engaged. He was attempting to go to the bathroom unassisted. New order to transfer to ER for evaluation. The local emergency room identified Resident #850 sustained a fracture of the left femur requiring hospital admission and surgical repair. The resident returned to the facility on 4/18/25. On 5/6/25 at 3:45 p.m., in an interview Registered Nurse Staff D said I found him at 7 in the morning because I arrive early and I make a round every single day and I heard somebody screaming and I found him on the floor. He was very confused, and he walked by himself from the bed to the bathroom. He said, I'm in pain. He did not say how he fell. He just kept saying he had to go to the bathroom, and he had pain. He is not supposed to go the bathroom by himself, because he is blind. No one told me he was having issues with his bowels that day or that he was up wandering before I got to work. He did not have 1 to 1 supervision at the time. On 5/6/25 at 9:25 a.m., Resident #850 was observed in bed, he did not respond when spoken to. The room door was open slightly and the privacy curtain was pulled obscuring the resident from view from the doorway. The call light was not in reach, and was located on the floor behind an oxygen concentrator. On 5/6/25 at 1:09 p.m., in an interview the Director of Nursing (DON) said Resident #850 was legally blind and had no prior falls since his admission on e year ago. The DON said we had interventions in place, toileting times for him were in place. He was known to be incontinent. The DON said the new interventions after the fall were discussed with him in an Interdisciplinary Team meeting. She said after the fall we could not assist him to the toilet because of the left leg fracture, and so we initiated incontinent care. His room was at the end of the hall and now he is closer to the nursing station. After he returned, we had to notify the certified nursing assistants (CNA's) that he was no longer able to do that, we took away the toileting after the fall and it is just incontinent care now. We were keeping more frequent monitoring of him. I don't know if we have documentation of the frequency, there was no set times for someone to check on him. We moved him so everyone can keep him in view. He can physically use the call light, but he is confused and does not always have the cognition to use it. We did not have specific interventions added to the care plan when he returned, just better supervision and better surveillance as evidence by no further falls. We check on him as we go up and down the halls. We did education for fall prevention. He had a fall in another facility which is why the daughter brought him here. We don't have documentation of supervision or monitoring, there are no set times, everyone just looks in as they pass his room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105389 If continuation sheet Page 2 of 3 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 105389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchwood Health and Rehabilitation Center 3250 12th St Sarasota, FL 34237 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 - Minimal harm or potential for actual harm Residents Affected - Few Review of the Quality Assurance Performance Improvement Plan provided by the DON for March 2025 revealed 16 documented falls, this is the same number as the previous month. The DON said after the resident returned from the hospital we did education as part of Quality Assurance. Review of the education in-service dated 4/30/25 documented We have too many falls!!! Please see attached education for decreasing falls and keeping residents safe. 23 employees sign the in-service education record that they received the Fall Prevention Intervention List. On 5/6/26 at 1:50 p.m., in an interview the Administrator said the resident was now bedbound and not able to get up. He said the number of falls was decreasing in the facility and they have reviewed the care plan for the resident. He said there is nothing else they can put into place to prevent falls for him because he is non ambulatory since the fall. When informed of the observation of the residents' call light on the floor today and not within the resident's reach, the Administrator said he did not believe the resident could roll out of bed or get up due to the left femur fracture. He said we moved him closer to the nursing station, which is around the hall and ½ way down the hall, not in view the nurse's station. The Administrator agreed the roommate of Resident #850 likes the privacy curtain pulled and the room door closed making observation of Resident #850 difficult. The Administrator said you are right, I know the room mate wants the door closed and the curtain pulled. On 5/6/25 at 2:30 p.m., in an interview the DON said the root cause of Resident #850's fall was the resident had 2 bowel movements. One at 4:45 a.m., and a second one at 5:15 a.m., he was cleaned up and assisted to bed, and we believe he was trying to go to the bathroom. He had gastric issues, and we should have addressed it but we didn't. A review of the CNA documentation revealed on 4/12/25 the resident had no bowel movement. On 4/13/25 he was incontinent of bowel at 1:17 a.m. and received care. On 5/6/25 at 3:15 p.m., in an interview the Director of Rehab said Resident #850 was seen a year ago and was on services. She said at that time he was able to ambulate with supervision and guidance because he could not see. He needed minimum help going from lying to sitting on the side of bed. He was seen today, and he requires maximum assistance with everything. He is slow now due to pain. He can roll over in bed from side to side with minimal assistance and he can get up from bed with assistance. On 5/6/25 at 3:25 p.m., in an interview Licensed Practical Nurse Staff A said monitoring and supervision is every couple of hours. I peek in on Resident #850 when I walk by. He can get up and walk but he is not steady on his feet. On 5/6/25 at 3:35 in an interview CNA Staff C said increased monitoring depends on the individual. The CNA said Resident #850 used to walk, and can see shadows. She said when he needed to use the toilet he would walk out of his room because he did not know where the bathroom was. Review of Resident #850's care plan confirmed no new care plan interventions had been put into place to prevent further falls for Resident #850. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105389 If continuation sheet Page 3 of 3