Inspection visit
Inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0582
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Level of Harm - Minimal harm
or potential for actual harm
Based on record review and staff interview, the facility failed to issue in writing the Notice of Medicare
Non-Coverage (NOMNC) and/or the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage
(SNFABN) for 3 (Residents #17, #463, and #464) of 3 residents reviewed for advanced beneficiary notices.
This had the potential for residents to not be aware of the right to appeal the facility decision to terminate
Medicare services.
Residents Affected - Some
The findings included:
The facility policy Advanced Beneficiary Notices documented, It is the policy of this facility to provide timely
notices regarding Medicare eligibility and coverage . A Notice of Medicare Non-Coverage (NOMNC) Form
shall be issued to the resident/representative when Medicare covered service(s) are ending, no matter if
the resident is leaving the facility or remaining in the facility. This informs the resident on how to request an
appeal or expedited determination from their Quality Improvement Organization .
The notice shall be written legibly in a language and or format that the resident/representative understands.
Verbal explanations detailing the reasons for non-coverage shall be provided . If the notice cannot be
hand-delivered, a telephone notice shall be made, followed up immediately with a mailed, emailed, faxed or
hand-delivered notice. Documentation shall comply with form instructions regarding telephone notices.
1. Review of the clinical record for Resident #17 revealed a PPS (Prospective Payment System) Minimum
Data Set (MDS) Part A discharge assessment with a target date of 12/15/23. The MDS noted the resident's
most recent Medicare stay started on 10/2/23 and ended on 12/14/23. Resident #17 remained at the facility.
On 2/20/24 at 3:40 p.m., the Skilled Nursing Facility (SNF) Beneficiary Notification Review form provided by
the facility noted Medicare Part A Skilled Services Episode started on 10/2/23, and the last covered day
was 12/15/23. The form noted the facility initiated the discharge from Medicare Part A services when the
benefit days were not exhausted.
The facility provided a SNFABN and a NOMNC form which noted Resident #17 was unable to sign the
notice due to significant cognitive impairment and the information was conveyed to the resident's power of
attorney via telephone on 12/13/23. She said she started employment at the facility on 11/2/23 and the
information for the NOMNC was done verbally in a phone conversation.
On 2/20/24 at 3:35 p.m., in an interview the Social Service Director (SSD) verified the clinical
(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 8
Event ID:
105407
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
105407
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/23/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Siesta Key Health and Rehabilitation Center
4602 Northgate Court
Sarasota, FL 34234
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 0582
Level of Harm - Minimal harm
or potential for actual harm
record contained no documentation the facility provided the required notice to the resident or representative
in writing.
2. Review of the clinical record for Resident #463 revealed a Discharge MDS assessment with a target date
of 11/4/23 for a planned discharge, return not anticipated.
Residents Affected - Some
On 2/20/24 the SNF Beneficiary Notification Review form provided by the facility noted Medicare Part A
Skilled Services start date was 10/2/23 and the last covered day of Part A services was 11/3/23.
The form noted, Cannot determine from record if D/C (discharge) was self-initiated.
On 2/20/24 at 3:55 p.m., the Social Service Director (SSD) said she could not locate documentation the
facility provided Resident #463 with the required SNFABN or NOMNC form.
3. Review of the clinical record for Resident #464 revealed a Part A discharge MDS assessment with a
target date of 9/14/23. The MDS noted the most recent Medicare Stay started on 9/1/23 and ended on
9/14/23. Resident #464 remained at the facility until 12/26/23.
On 2/20/24 review of the SNF Beneficiary Notification Review form provided by the facility showed the
facility initiated the discharge from Medicare Part A Services when benefit days were not exhausted. The
form noted the SNFABN notice was not given. Under Other/Explain the facility noted, Unknown.
Review of the NOMNC form showed the resident's guardian was notified via telephone on 9/11/23.
On 2/20/24 at 3:55 p.m., in an interview the SSD verified the Notice of Medicare Non-Coverage was not
given in writing to the resident's guardian.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105407
If continuation sheet
Page 2 of 8
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
105407
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/23/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Siesta Key Health and Rehabilitation Center
4602 Northgate Court
Sarasota, FL 34234
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 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
observation, review of the clinical record and resident and staff interviews, the facility failed to provide the
necessary care and services to maintain personal hygiene for 3 (Residents #7, #12 and #461) of 3
residents reviewed for Activities of Daily Living (ADL).
Residents Affected - Some
The findings included:
The facility policy Activities of Daily Living (ADL's) (Revised 11/29/22) documented, The facility will, based
on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure
a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable. A resident who is
unable to carry out activities of daily living will receive the necessary services to maintain good nutrition,
grooming and personal and oral hygiene.
1. Review of the clinical record revealed Resident #7 was had an admission date of 5/26/22. Diagnoses
included Parkinson's disease, Huntington's disease, dementia, and schizoaffective disorder.
The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in
nursing home residents) with an assessment reference date (ARD) of 12/7/23 documented Resident #7
was dependent on staff for all care.
The MDS noted Resident #7's cognitive skills for daily decision making were severely impaired.
On 2/19/24 at 9:56 a.m., Resident #7 was observed in the television (TV) room on the South Nursing Unit
in a specialized reclining wheelchair. He was nonverbal and made no eye contact. The resident had a very
strong odor of feces and had approximately 2-3 days growth of facial hair. Resident #7 appeared unkempt
with greasy, uncombed hair.
On 2/19/24 at 10:00 a.m., Certified Nursing Assistant (CNA) Staff E who was present during the
observation verified Resident #7 had a very strong odor of feces, two to three days growth of facial hair,
looked unkempt with greasy, uncombed hair. CNA Staff E did not remove Resident #7 from the television
room.
On 2/19/24 at 12:34 p.m., Resident #7 was observed in the main dining room for the noon meal. He
remained with a strong odor of feces.
On 2/20/24 during random observations at 10:03 a.m., 10:49 a.m., and 12:06 p.m., Resident #7 was
observed in the day room. He had approximately three to four days of facial hair growth.
Review of the CNA documentation revealed Resident #7 received personal hygiene assistance, was
shaved on 2/19/24 and 2/20/24.
On 2/21/24 at 9:07 a.m., in an interview and observation, the Assistant Director of Nursing (ADON),
confirmed Resident #7 had approximately five days of facial hair growth. The ADON said, we are waiting for
an electric razor to shave him and have asked the guardian to bring one for him. The ADON said it is hard
to shave him because of the constant movements of his head and we don't want to hurt him.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105407
If continuation sheet
Page 3 of 8
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
105407
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/23/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Siesta Key Health and Rehabilitation Center
4602 Northgate Court
Sarasota, FL 34234
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 0677
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
The clinical record showed no documentation of contact with Resident #7's representative to request an
electric razor.
Review of the CNA documentation for January 2024 revealed Resident #7's shower days were Tuesdays
and Fridays on the 3:00 p.m., to 11:00 p.m., shift. The document showed on 1/2/24, 1/16/24, 1/26/24 and
1/30/24 Resident # 7 received a bed bath in lieu of the scheduled shower.
Review of the CNA documentation from 2/1/24 to 2/20/24 revealed Resident #7 received a bed bath
instead of the scheduled shower on 2/2/24, 2/9/24, 2/13/24 and 2/20/24. There was no documentation in
the clinical record Resident #7 refused the scheduled showers.
2. Review of the clinical record revealed Resident #12 had an admission date of 8/1/22. Diagnoses included
dementia, major depressive disorder, anxiety, and adjustment disorder.
The Annual MDS with an ARD of 1/30/24 documented Resident #12 cognitive skills for daily decision
making were severely impaired.
Review of the care plan revealed Resident #12 required assistance from staff for toileting, bathing, and
personal hygiene.
On 2/19/24 at 9:20 a.m., Resident #12 was observed in the television room on the South Unit, across from
the nursing desk sitting in a wheelchair. He was facing away from the television. Resident #12 had a strong
urine smell, and an accumulation of a brown substance under his nails. Resident #12 had approximately
three days of facial hair growth.
On 2/19/24 form 11:00 a.m., to approximately 12:00 p.m., observation showed Resident #12 remained in
the television room on the South Unit, across from the nursing desk sitting in a wheelchair, facing away
from the television. Resident #12 had obvious sign of incontinence, and a strong urine smell. The resident's
pants were wet with urine dripping on the floor forming a puddle under the resident's wheelchair.
On 2/19/24 at approximately 12:00 p.m., Licensed Practical Nurse (LPN) Staff G entered the television
room and stepped in the puddle of urine on the floor. LPN Staff G took the resident to his room and left him
there. LPN Staff G was observed walking down the hall and calling for a CNA.
On 2/20/24 at 9:00 a.m., to 11:00 a.m., Resident #12 was observed sitting in a wheelchair in the South Unit
television room, facing the wall. No staff were observed in the television room.
On 2/20/24 at 12:00 p.m., Resident #12 remained in the television room in his wheelchair, facing the wall. A
staff member took the resident to the main dining room for lunch.
On 2/20/24 at 2:41 p.m., in an interview CNA Staff D said, Residents are changed every two hours, some
are offered to be changed or toileted more frequently if they request it of if you know they are heavy
wetters.
3. Review of the clinical record revealed Resident #461 was admitted on [DATE]. Diagnoses included acute
respiratory failure, complete small bowel obstruction, Myasthenia Gravis, anxiety, and need for assistance
with personal care.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105407
If continuation sheet
Page 4 of 8
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
105407
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/23/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Siesta Key Health and Rehabilitation Center
4602 Northgate Court
Sarasota, FL 34234
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 0677
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
The 5-day MDS dated [DATE] documented the resident required partial to moderate assistance with ADL's
including showers. The MDS indicated Resident #461's cognitive skills for daily decision making were
severely impaired.
On 2/19/24 at 10:23 a.m., Resident #461 was observed in his room in his wheelchair. He had approximately
two days of facial hair growth. The resident had an accumulation of brown substance under his nails. In an
interview Resident #461 said he received one shower since his admission.
On 2/20/24 at 8:47 a.m., Resident #461 was observed in his room in his wheelchair. Resident #461 had
approximately three days of facial hair growth. The resident was wearing pajama pants and lifting his shirt.
Resident #461 lifted his upper body clothing showing he was wearing five shirts.
Review of the CNA documentation for February 2024 revealed the residents scheduled shower days were
Tuesdays and Fridays on the day shift. The documentation from 2/8/24 to 2/20/24 revealed Resident #461
received one shower (2/20/24) since his admission on [DATE]. The documentation showed he received a
bed bath on 2/8/24, 2/9/24 and 2/16/24. On 2/13/24 the CNA documented N/A (not applicable).
The clinical record showed no documentation Resident #461 had refused his scheduled showers.
On 2/21/24 at 10:23 a.m., in an interview CNA Staff E said, men are shaved on shower days and at least
every other day. Staff E explained the showers are located in the CNA assignment books; it goes by room
numbers and there are 2 books. The shower list is also in the documentation we do on the computer. We
also fill out a shower sheet, the CNA provided and demonstrated how she would mark any skin changes
and if the resident refused the shower, you would write it on the sheet and in the electronic record.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105407
If continuation sheet
Page 5 of 8
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
105407
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/23/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Siesta Key Health and Rehabilitation Center
4602 Northgate Court
Sarasota, FL 34234
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 0679
Provide activities to meet all resident's needs.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, review of the clinical records, review of facility policies and procedures, and staff interviews,
the facility the facility failed to implement meaningful resident centered activities to meet the interest and
wellbeing of 2 (Resident #7 and #12) of 2 residents reviewed for activities. The lack of an individualized
activity program has the potential to cause social isolation, boredom, agitation, and frustration.
Residents Affected - Few
The findings included:
The facility policy Activities implemented 11/2023 (revised 2/24) documented, It is the policy of this facility
to provide an ongoing program to support residents in their choice of activities based on their
comprehensive assessment, care plan and preferences. Facility sponsored group, individual and
independent activities will be designed to meet the interests of each resident, as well as support their
physical, mental, and psychosocial well-being.
1. Each resident's interest and needs will be assessed on a routine basis. The assessment shall include,
but not limited to:
b. Activity assessment to include residents interest, preferences and needed adaptations.
2. Activities will be designed with the intent to:
a. Enhance the resident's sense of well-being, belonging and usefulness.
b. Create opportunities for each resident to have a meaningful life.
1. Review of the clinical record revealed Resident #7 was [AGE] years old with an admission date of
5/26/22. Diagnoses included Parkinson's disease, Huntington's disease, dementia, and schizoaffective
disorder.
The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in
nursing home residents) with an assessment reference date (ARD) of 12/7/23 documented Resident #7
was dependent on staff for all care.
The MDS noted Resident #7's cognitive skills for daily decision making were severely impaired.
On 2/19/24 at 9:55 a.m., Resident #7 was observed in the South Unit television room (TV) room across
from the nurse's station. He was in a special reclining chair. The TV was on, and 4 other residents were in
the room.
Certified Nursing Assistant (CNA) Staff E said, the ones who can't talk or do much, we bring them in here
and they watch TV. The resident does not speak, occasionally he might say a word and he is total care with
everything.
On 2/20/24 at 10:22 a.m., and 10:47 a.m., Resident #7 was observed in the TV room with 3 other residents
sitting in a reclined position since 8:30 a.m. The resident had uncontrollable movements and was not able
to watch the television. No staff was observed interacting with him.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105407
If continuation sheet
Page 6 of 8
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
105407
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/23/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Siesta Key Health and Rehabilitation Center
4602 Northgate Court
Sarasota, FL 34234
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 0679
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Review of the activity calendar specified at 9:30 a.m., coffee social and at 10:00 a.m., and Movin and
Grooving.
On 2/20/24 at 3:07 p.m., in an interview with Licensed Practical Nurse Staff C said the residents in the TV
room are there to watch TV. It is not a fall or increased supervision room; it is just a TV room where they go
to watch TV.
During random observations on 2/21/24 at 8:51 a.m., and 9:47 a.m., Resident #7 was in a wheelchair in the
TV room, the TV was on but he was not meaningfully engaged and was not looking in the direction of the
TV.
The activity calendar specified at 9:30 a.m., coffee social and Catholic mass at 10:00 a.m.
The initial activity assessment dated [DATE] specified the resident enjoyed music, watching movies, going
outside and exercise (active games) as appropriate. He enjoys most of all leisure activities but has cognitive
and physical limitations where staff encouragement and support is needed for participation. He needs staff
involvement daily to participate in leisure programs and needs staff to encourage and bring him to groups
of interest.
Review of the Activity documentation for January 2024 revealed Resident #7 had no one to one activities
on the day shift on 1/1/24, 1/4/24, 1/5/24, 1/6/24, 1/7/24, 1/12/24, 1/14/24, 1/15/24, 1/17/24, 1/23/24,
1/26/24, 1/27/24, 1/28/24 and 1/31/34.
On the 3-11 shift Resident #7 had one documented one to one activity on 1/14/24, and one group activity
on 1/13/24.
On 2/22/24 during random observations at 9:14 a.m., 9:40 a.m., and 10:12 a.m., Resident #7 was in the TV
room but not watching the television. The calendar on the wall documented coffee social at 9:30 a.m. and
moving and grooving at 10:00 a.m.
2. Review of the clinical record revealed Resident #12 had an admission date of 8/1/22. Diagnoses included
dementia, major depressive disorder, anxiety, and adjustment disorder.
The Annual MDS with an ARD of 1/30/24 documented Resident #12 cognitive skills for daily decision
making were severely impaired.
The initial activity assessment dated [DATE] documented the resident enjoys music, going outside,
interacting with staff and others, watching TV (movies & shows). He was not very active in leisure pursuits
prior to admission. Lead a sedentary leisure lifestyle at home. He is alert but confused. Needs staff and
family assistance for any leisure involvement and needs cues to participate, eat or receive care. He
verbalizes but most times not appropriate or accurate.
On 2/19/24 at 10:00 a.m., Resident #12 was observed in the TV room on the South Unit sitting in a
wheelchair, facing away from the television.
Review of the activity calendar specified coffee social at 9:30 a.m., and trivia at 10:00 a.m.
On 2/20/24 at 11:33 a.m., Resident #12 was observed in the TV room on the South Unit with three other
residents. Resident #12 said he did not know what it was he was watching and did not know what
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105407
If continuation sheet
Page 7 of 8
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
105407
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/23/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Siesta Key Health and Rehabilitation Center
4602 Northgate Court
Sarasota, FL 34234
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 0679
was supposed to be on the TV.
Level of Harm - Minimal harm
or potential for actual harm
On 2/21/24 from 9:11 a.m., to 11:25 a.m., Resident #12 was observed in the TV room. The television was
on, but he was not watching the television.
Residents Affected - Few
The activity calendar specified coffee social at 9:30 a.m., and Catholic mass at 10:00 a.m.
During observations on 2/22/24 at 9:18 a.m., and 9:41 a.m., Resident #12 was seated in his w/c in the TV
room on the south unit. The TV was on. Resident #12 was in his wheelchair at the back of the room and
looking around. No facility staff was in the television room interacting with the resident.
The activity calendar specified coffee social at 9:30 a.m.
Review of the Activity Documentation for January 2024 revealed Resident #12 attended no group activities
on 1/1/24, 1/4/24, 1/5/24, 1/6/24, 1/7/24, 1/10/24, 1/11/24, 1/12/24, 1/13/24, 1/14/24, 1/15/24, 1/17/24,
1/18/24, 1/19/24, 1/20/24, 1/21/24, 1/22/24, 1/23/24, 1/24/24, 1/25/24, 1/26/24, 1/27/24, 1/28/24 and
1/31/24.
There was no documentation Resident #12 participated in one to one activities on 1/1/24, 1/2/24, 1/5/24,
1/6/24, 1/7/24, 1/8/24, 1/9/24, 1/10/24, 1/12/24, 1/15/24, 1/16/24, 1/17/24, 1/20/24, 1/23/24, 1/26/24,
1/27/24, 1/28/24, 1/29/24, 1/30/24 and 1/30/24.
Review of the February 2024 Activity Documentation revealed Resident #12 had no participation in group
activities 2/1/24 through 2/7/24, on 2/10/24, 2/12/24, 2/15/24, 2/17/24 and 2/21/24.
No one-to-one activities were documented on 2/1/24, 2/3/24, 2/4/24, 2/5/24, 2/9/24, 2/13/24, 2/14/24,
2/16/24, 1/17/24 and 2/21/24.
On 2/20/24 at 3:08 p.m., in an interview the Activity Director said, The TV room is for the residents to watch
TV. There is no special calendar for the residents who are not cognitively able to participate in the daily
activities. The Activity Director said, we do take them to group activities so they can watch and be a part of
things. Right now, I have only one assistant and we are short two activity aides.
The Activity Director said she started employment at the facility a few weeks ago. She said she does
sensory items like watching television, touch balls and different items for five to ten minutes daily. The
Activity Director said she did not have a schedule for the sensory activities for the residents with impaired
cognition.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105407
If continuation sheet
Page 8 of 8
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
3 citations 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.
F582 - The facility must—
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F679 - Activities
Provide activities to meet all resident's needs.
FAQ · About this visit
Common questions about this visit
What happened during the February 23, 2024 survey of SIESTA KEY HEALTH AND REHABILITATION CENTER?
This was a inspection survey of SIESTA KEY HEALTH AND REHABILITATION CENTER on February 23, 2024. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SIESTA KEY HEALTH AND REHABILITATION CENTER on February 23, 2024?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered."
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.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.