Health inspection·August 19, 2025

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, record review, review of facility policy, resident and staff interviews, the facility failed to provide the necessary care and services for personal hygiene and incontinent care for 2 (Resident #100 and #2) of 3 residents reviewed for activities of daily living.The findings included:Review of the facility's policy, Standards and Guidelines: ADL Care and Services, initiated 4/2020 (revised 1/24) revealed, Residents who are unable to carry out activities of daily living (ADL's) independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with including but not limited to:Hygiene (bathing/showers, dressing, grooming and oral care).Elimination (toileting).The resident has the right to refuse any and all ADL care. The refusal of care will be documented in the resident's medical record with appropriate notification including the physician and resident representative. 1. Review of the clinical record revealed Resident #100 was readmitted on [DATE]. Diagnoses included chronic kidney disease, major depressive disorder, type 2 diabetes mellitus, severe morbid obesity, and anxiety disorder.Review of the Quarterly Minimum Data Set (MDS), standardized assessment tool used in nursing homes to evaluate a resident's health and functional abilities with a target date of 6/29/25 revealed Resident #100 was always incontinent of bowel and bladder and was dependent for bathing. The MDS indicated the resident's cognitive skills for daily decision making were intact.On 8/18/25 at 9:25 a.m., Resident #100 was observed in her room in bed. She had very foul breath and a strong, offensive body odor noted from three feet away.In an interview, Resident #100 said the staff do not brush her teeth because she has too many broken teeth. The resident said the dentist wanted to extract her teeth, but she did not want that. Resident #100 said she rinses her mouth every morning with mouth wash. Resident #100 said the staff do not give her showers because she can't walk. They say it is too much work. The resident said, I get bed baths. No, I don't like bed baths but what can I do? They say I like to complain a lot but if I don't, no one pays attention to me. I am wet all the time because they are not changing me.A review of the certified nursing assistant (CNA) documentation for June 2025, July 2025 and August 2025 revealed no documentation incontinent care was provided:On the 7:00 a.m., to 3:00 p.m. shift on 6/7/25, 6/10/25, 6/11/25, and 6/25/25. 7/3/25, 7/9/25, 7/11/25, 7/20/25, 7/23/25, 7/26/25, 7/30/35, 7/31/25, 8/3/25, 8/6/25, 8/7/25 and 8/16/25.On the 3:00 p.m., to 11:00 p.m. shift on 6/1/25, 6/15/25, 7/3/25, 7/18/25, 7/20/25, 8/10/25 and 8/16/25.On the 11:00 p.m., to 7:00 a.m. shift on 6/1/25, 6/6/25, 6/8/25, 6/17/25, 6/18/25, 6/23/25, 6/29/25, 6/30/25. 7/3/25, 7/7/25, 7/8/25, 7/11/25, 7/12/25, 7/13/25, 7/21/25, 7/29/25, 7/31/25, 8/1/25, 8/4/25, 8/5/25, 8/8/25, 8/9/25, 8/10/25, 8/14/25, and 8/16/25.A review of the shower schedule revealed Resident #100's scheduled showers were on Mondays, Wednesdays and Fridays during the 7:00 a.m., to 3:00 p.m. shift.Review of the CNA documentation for Residents Affected - Some Page 1 of 2 105454 105454 08/19/2025 Creekside Health and Rehabilitation Center 5511 Swift Road Sarasota, FL 34231

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some bathing for June 2025, July 2025 and August 2025 revealed Resident #100 received a bed bath on the scheduled shower days on Mondays ( 6/2/25, 6/9/25, 7/7/25, 7/14/25, 7/21/25, 8/4/25, 8/11/25), Wednesdays (6/4/25, 6/16/25, 6/30/25, 7/2/25, 7/16/25, 7/30/25, 8/13/25), Fridays (6/6/25, 6/18/25, 7/4/25, 7/18/25, 7/25/25, 8/1/25, 8/8/25, 8/15/25).There was no documentation of care provided on 6/11/25,6/25/25, 7/9/25, 7/11/25, 7/23/25, 7/30/25, and 8/6/25.On 8/18/25 at 2:00 p.m., in an interview CNA Staff D said, I work 7-3 and I have Resident #100 every day, 5 days a week, she is mine. Residents get changed twice a shift. Resident #100 can wash her face and feed herself, that is about it. She is dependent for everything else. She is not able to walk. I give her a full bed bath every day. Now I can't say anything about the other shifts because I don't know, I don't work them unless I do a double. I don't know why she does not get showers, sometimes we don't have 2 people to do it. You can't shower her by yourself.On 8/18/25 at 2:10 p.m., in an interview the Director of Nursing (DON) said, We don't have set times or schedules the residents are to be changed. Usually, it's every 3-4 hours. With Resident #100, because she is such a large woman she takes two people, and it is not always easy to find help right away. We usually change her when she gets up and when she gets back to bed.2. Review of the clinical record revealed Resident #2 had a date of admission of 8/13/24. Diagnoses included senile degeneration of the brain, type 2 diabetes mellitus, Alzheimer's disease, and dementia.Review of the Quarterly MDS dated [DATE] revealed the resident was always incontinent of bowel and bladder and dependent for all care. The MDS noted Resident #2 was rarely, never understood. Review of the CNA documentation for June 2025, July 2025, and August 2025 revealed no documentation of incontinent care provided for Resident #2:On the 7:00 a.m. to 3:00 p.m. shift on 6/7/25, 6/8/25, 6/10/25, 6/11/25, 6/25/25, 7/3/25, 7/9/25, 7/11/25, 7/20/25, 7/23/25, 7/26/25, 7/30/25, 7/31/25, 8/3/25, 8/6/25, 8/7/25, 8/16/25 and 8/17/25 .On the 3:00 p.m., to 11:00 p.m. shift on 6/1/25, 6/10/25, 6/15/25, 7/3/25, 7/20/25, 8/10/25, and 8/16/25.On the 11:00 p.m., to 7:00 a.m. shift on 6/1/25, 6/2/25, 6/6/25, 6/8/25, 6/15/25, 6/17/25, 6/18/25, 6/23/25, 6/29/25, 6/30/25, 7/3/25, 7/8/25, 7/11/25, 7/12/25, 7/13/25, 7/21/25, 7/25/25, 7/31/25, 8/1/25, 8/4/25, 8/5/25, 8/8/25, 8/9/25, 8/10/25, 8/11/25, 8/12/25, 8/14/25 and 8/16/25.Review of shower schedule revealed Resident #2's scheduled showers were on Mondays, Wednesdays and Fridays during the 3:00 p.m., to 11:00 p.m. shift.Review of the CNA documentation for June 2025, July 2025 and August 2025 revealed Resident #2 received a sponge bath on 6/2/25, 6/4/25, 6/6/25, 6/9/25, 6/11/25, 6/13/25, 6/16/25, 6/20/25, 6/23/25, 6/25/25, 7/2/25, 7/4/25, 7/7/25, 7/9/25, 7/11/25, 7/14/25, 7/16/25, 7/18/25, 7/21/25, 7/28/25, 7/30/25, 8/4/25, 8/6/25, 8/8/25, 8/13/25, 8/15/25 and 8/18/25.On 6/16/25, 6/30/25, 7/23/25, 8/11/25 N/A (not applicable) was documented.On 8/18/25 at 1:42 p.m., in an interview CNA Staff C said, I only work on 7-3 shift and we change everyone every 2-3 hours and we turn them at the same time because you have to roll them to change them. 105454 Page 2 of 2