Inspection·August 11, 2022

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and staff interview, the facility failed to ensure implementation of a person centered, meaningful activity program for 1 (Resident #72) of 7 residents reviewed for activities. Residents Affected - Few The findings included: Review of the clinical record for Resident #72 revealed an admission date of 3/17/17. The Annual Minimum Data Set (MDS) assessment with a target date of 3/8/22 revealed Resident #72 scored a 9 on the Brief Interview for Mental Status, indicative of moderate cognitive impairment. The MDS noted it was somewhat important for Resident #72 to keep up with news, do things with groups of people, do his favorite activities, and participate in religious services or practices. Resident #72 was totally dependent on physical assistance of staff for transfer and locomotion on and off unit. Diagnoses listed on the order summary report included major depressive disorder, dementia, Parkinson's disease, and age-related cataract (opacity of the lens resulting in blurred vision). The activity care plan initiated on 5/25/2017 with a target date of 9/23/22 noted the resident reported little interest or pleasure in doing things. He preferred independent activities such as a variety of music, card games, television, current events, movies, the outdoors and more. The goal was for Resident #72 to actively participate in independent activities of choice daily to promote overall positive well-being. The interventions included to assist in planning and/or encourage to plan own leisure time activities; Encourage participation in group activities of interest; Provide 1:1 (one to one) activity visits for support and socialization; Provide supplies/materials for leisure activities as needed/requested. On 8/9/22 at 11:14 a.m., and 2:51 p.m., Resident #72 was observed in bed. The resident was not participating in any activity. The television wasn't turned on or any radio observed in the resident's room. On 8/10/22 at 3:00 p.m., Resident #72 was observed in bed, on his back. The resident was not observed in any activity. The television wasn't on or any radio on. Resident #72 was leaning to the right in bed and requested a drink. On 8/11/22 at 8:59 a.m., and 9:57 a.m., Resident #72 was observed in bed, on his back. No activity, television or music observed. (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 6 Event ID: 105454 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 105454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Creekside Health and Rehabilitation Center 5511 Swift Road Sarasota, FL 34231 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)