Inspection·May 13, 2021

F 0624 Prepare residents for a safe transfer or discharge from the nursing home. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy and procedure, resident and staff interview, the facility failed to follow the physician's discharge orders and ensure 1 (Resident #340) of 2 residents received home health services as ordered resulting in rehospitalization. Residents Affected - Few The findings included: The facility policy, Resident Transfer and Discharge (revised 4/21/21) specified, Social Services will collaborate with the resident/ resident representative the Physician and the Interdisciplinary Team (IDT) to assist in planning the discharge care and services for the resident. Review of the clinical record showed Resident #340 was admitted to the facility on [DATE] after a hospitalization for acute respiratory failure and discharged home on 2/13/21, where he lived independently. The discharge summary created on 2/10/21 and completed on 2/18/21 noted Resident #340 lived alone and was discharged home with Home Health Services. Further review of the clinical record showed Resident #340 was admitted to the hospital on [DATE] for hemorrhagic shock and abdominal wound and discharged to the facility on 4/15/21. Review of the hospital record revealed a physician's progress note dated 3/26/21 that read . He was discharged from [hospital name] 2 months ago to rehabilitation for 2 weeks, then went home where he lives alone. Sustained a burn to his abdominal wall skin, at the large hernia site 2 weeks ago from hot ball . Started bleeding last night . On my exam, removing the abdominal binder that is soaked with large quantity of red blood, he has a 3 cm [3 centimeters] round necrotic wound with oozing blood . Home medications: 1. Warfarin (anticoagulant). Past medical history: 1. Atrial fibrillation/flutter, on anticoagulation with Warfarin. He could not afford the recently prescribed Eliquis when he was discharged from [hospital name] early February 2021, has had difficulty monitoring his Warfarin at home with a nonfunctioning machine. A facility IDT discharge summary completed on 4/24/21 noted Resident #340 was alert, oriented and lived alone. The Discharge Summary included a physician's order dated 4/20/21 to discharge home on 4/24/21 with home health care, registered nurse to draw PT/INR (lab test to measure how long it takes for your blood to clot) every Monday and Thursday and report results to primary care physician. The physician's orders included a wound care to abdomen, clean with normal saline, pat dry, apply calcium alginate, and cover with sacral foam dressing daily. Further review of the record showed Resident #340 was admitted to the hospital on [DATE] and discharged to the facility on 5/7/21. Diagnoses listed in the clinical record included a burn of unspecified degree of abdominal wall, repeated falls, hypertensive heart disease with heart failure, dilated cardiomyopathy, unspecified atrial flutter, presence of cardiac implants and grafts, non-rheumatic aortic valve, and tricuspid valve insufficiency, hypertension, anticoagulant use, peripheral vascular disease, type 2 diabetes, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105584 If continuation sheet Page 2 of 9 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 105584 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sarasota Memorial Nursing & Rehabilitation Center 5640 Rand Blvd Sarasota, FL 34238 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 0624 chronic obstructive pulmonary disease. Level of Harm - Actual harm On 5/10/21 at 10:12 a.m., in an interview Resident #340 said this was his third admission to the facility in 4 months. Resident #340 said he was discharged home and was too weak to care for himself. He said he was bleeding from an abdominal wound and called 911. Resident #340 said he was supposed to receive Home Health services after each discharge but there was no follow through, and he did not receive it. Resident #340 said he lived alone, in a 1-bedroom apartment, on an upper floor, and required continuous oxygen. The resident said he needed the home health services and was not able to care for himself. Residents Affected - Few Resident #340 said he called for emergency transport to the hospital and was admitted to the hospital on [DATE]. He said the hospital discharged him to the facility because I was too weak and could not do anything. On 5/12/21 at 8:30 a.m., in an interview Resident #340 said he had an abdominal wound when he was discharged home on 4/24/21. He said Home Health never came and he was doing his own wound care even though he was not taught how. On 5/11/21 at 1:30 p.m., in an interview, the Social Service Director (SSD) said Resident #340 was on his 3rd admission to the facility. The SSD said the resident's insurance informs the facility of the resident's last covered day. The SSD said she talked with the resident and set up home health. The SSD said Resident #340 did not want to apply for Medicaid during the last admission for fear of having to get rid of his possessions and lose control of his money to live in an assisted living facility. The SSD said Resident #340 filed and lost an appeal during his last admission and was discharged on 4/24/21. The SSD said she faxed the physician's order for Home Health to Home Health Agency (HHA) A and called to make sure they had received it. The SSD said the facility did not provide follow up once the resident was discharged to ensure the resident received home health services as ordered. She said she would not be aware of a resident needing community resources or additional health care services. The SSD said the resident's insurance company was responsible to determine if the resident was safe to discharge home. The SSD also confirmed she had no documentation she notified the HHA of Resident #340's discharge orders. On 5/12/21 at 11:30 a.m., in an interview, the Administrator said the facility was aware the HHA did not accept Resident #340's insurance upon discharge on [DATE] and did not refer the resident to another HHA that would accept his insurance. The Administrator said, Normally it is the home health agency that will refer the resident to another agency that accepts the insurance of the resident. On 5/12/21 at 1:00 p.m., in an interview, Resident #340 confirmed he never received a home health (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105584 If continuation sheet Page 3 of 9 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 105584 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sarasota Memorial Nursing & Rehabilitation Center 5640 Rand Blvd Sarasota, FL 34238 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 0624 Level of Harm - Actual harm Residents Affected - Few visit after his discharge on [DATE] or 4/24/21. Resident #340 said, They told me I would get help, but I never did get any visit from home health. Resident #340 said the SSD did not tell him the HHA did not accept his insurance. He said he did not receive information regarding community services that would have provided him with assistance after discharge. Resident #340 said, They are planning to discharge me on 5/14/21 and I don't know what I will do. I have no phone and relatives in the area that can help me. I need help, even taking a shower after 3 minutes feels like an eternity. I don't know what I'm going do, I can't take care of myself. On 5/12/21 at 1:08 p.m., in a telephone interview, the home health director for home health agency A said there was no record of Resident #340 being referred to the HHA. The Home Health Director said, Even if we do not accept the patient, we would still put the referral into the electronic record system but there is no record the patient was ever referred. The Home Health Director said if they did not accept a referral's insurance plan, they would contact the facility, but the facility usually knew before they even got a referral, whether the HHA would accept the insurance. The Home Health Director confirmed there was no record Resident #340 was referred to the HHA upon discharge on [DATE] and 4/24/21. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105584 If continuation sheet Page 4 of 9 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 105584 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sarasota Memorial Nursing & Rehabilitation Center 5640 Rand Blvd Sarasota, FL 34238 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on record review, review of facility policy and procedure, resident and staff interview, the facility failed to provide necessary services and assistance to maintain continence for 1 (Resident #341) of 1 resident sampled. The failure to provide the needed incontinence care caused the resident embarrassment, and has the potential to cause anxiety, skin breakdown and psychological harm to the resident. The findings included: The facility policy, Bowel and Bladder Management Program (revised 4/12/21) specified, .All new admissions are evaluated for continence through the bowel and bladder assessment. A patterning assessment will be completed to assist in assessing the resident's continence.Based on the nursing assessment, facility will develop a plan of care based on residents' needs. On 5/10/21 at 10:10 a.m., in an interview, Resident #341 said it was hard for her to get help in the evening and she waited to be toileted. Resident #341 said she required assistance with toileting and during the night of 5/7/21 she waited over an hour for help and wet herself. The resident said she reported it to the nurse and said the facility staff tried to tell me I did not have my light on that long, but I still have my mind and I know how long I waited. I don't like to mess the bed. On 5/11/21 at 9:14 a.m., in an interview, Resident #341 said she waited over an hour the previous night to use the toilet. Resident #341 said, It is urgent for me, with my bladder I can't hold it. The resident said it was worse on the night shift to get the help she needed, and she reported it to the nurse. Resident #341 said, I can't hold it and I don't want to mess up the bed. On 5/12/21 at 8:42 a.m., in an interview, Resident #341 said the previous night she had a problem with her bladder and bowels. The resident said, It depends on the staff working. I have an urgent need and when I feel the urge, they cannot come fast enough because they are busy with other residents. I need them instantly when I feel the pressure to go but I know they cannot always be there. They had to clean me, and I don't like it. On 5/12/21 at 8:56 a.m., in an interview, the North Wing Unit Manager said there were no residents on the North Wing who were on a bladder program and said the procedure was all residents were toileted upon rising, before and after meals, and before bed, then as needed. The North Wing Unit Manager said she was notified on 5/11/21 of an incident with Resident #341 and her toileting needs that occurred over the weekend and she would discuss it with the resident. On 5/12/21 at 3:22 p.m., in an interview Certified Nursing Assistant (CNA) Staff E said she was working a 12-hour shift and had been an employee for 11 years. CNA Staff E said Resident #341 puts the call light on when she needs to use the toilet and I know when she puts the light on, she really needs to go. CNA Staff E said Resident #341 required extensive assistance with ambulating to the toilet. A review of the clinical record for Resident #341 showed a Bowel/Bladder Patterning Assessment for 5/7/21, 5/8/21 and 5/9/21 which documented Resident #341 was continent of bowel and bladder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105584 If continuation sheet Page 5 of 9 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 105584 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sarasota Memorial Nursing & Rehabilitation Center 5640 Rand Blvd Sarasota, FL 34238 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 5/12/21 the North Wing Unit Manager completed a Nursing Bladder Assessment Form created on 5/9/21 which noted Resident #341 was continent of bowel and bladder and no further assessment was necessary. On 5/13/21 at 8:50 a.m., in an interview, the North Wing Unit Manager said she went by what the CNAs had documented in their charting, to determine if the resident was continent or not. The North Wing Unit Manager said the process was, We have 7 days to assess a new admissions bowel and bladder pattern and determine if they are continent or incontinent. The North Wing Unit Manager said, I did not go and talk to Resident # 341. I heard she was incontinent a few days ago. Her family member called, and a grievance was filled out. I did not talk with Resident #341 when completing the bladder assessment, I went by the CNA documentation only. On 5/13/12 at 9:05 a.m., in an interview, the Director of Nursing (DON) said she received a grievance on 5/10/21 from a family member of Resident #341 regarding call lights and she placed a request with the Maintenance Director to check the call light to see if it was functioning correctly as no staff reported call lights not answered timely. A review of the Grievance/Complaint Investigation Report dated 5/10/21 for Resident #341 documented, 2 x's [two times] she had urinary urgency during the nighttime and had to wait too long for someone to come. She urinated and was embarrassed to have to be cleaned up. On 5/13/21 at 10:00 a.m., in an interview, the North Wing Unit Manager confirmed there were no interventions initiated once she was made aware of the grievance concerning Resident #341's bowel and bladder needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105584 If continuation sheet Page 6 of 9 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 105584 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sarasota Memorial Nursing & Rehabilitation Center 5640 Rand Blvd Sarasota, FL 34238 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, and record review, the facility failed to ensure its medication error rate remained below 5%. Four licensed nurses with 31 opportunities were observed. Two medication errors were identified resulting in a 6.45% error rate. Residents Affected - Few The findings included: The facility policy, Administering Medication (reviewed / revised 5/2/2021) specified, Medications shall be administered in a safe and timely manner, and as prescribed. Procedure item #6 said, The licensed nurse administering the medication must check the label to verify the following before administering the medication: (a)Right medication, (b)Right dosage, (c)Right time. (d)Right method of administration. 1. On 5/11/21 at 8:50 a.m., Licensed Practical Nurse (LPN) Staff G was observed administering four medications, including Ventolin HFA 90 mcg/actuation aerosol inhaler (medication used for management of chronic obstructive pulmonary disease) to Resident #4. LPN Staff G shook the Ventolin inhaler and handed the inhaler to Resident #4. Resident #4 took two puffs of medication orally, 5 seconds apart. Review of the pharmacy packaging revealed documentation to Wait 1 minute between puffs. Review of the Ventolin manufacturer's insert revealed in the instructions for use, If your healthcare provider has told you to use more sprays, wait 1 minute and shake the inhaler again. On 5/11/21 at 9:00 a.m., in an interview LPN Staff G confirmed the pharmacy packaging for the Ventolin inhaler specified to, Wait 1 minute between puffs. LPN Staff G confirmed she did not wait or instruct Resident #4 to wait 1 minute between puffs per the pharmacy label or manufacturer's specification. 2. On 5/11/21 at 9:05 a.m., LPN Staff H was observed administering 11 medications, including Advair HFA 45 mcg-21 mcg/actuation aerosol inhaler to treat COPD to Resident #9. LPN Staff H shook the Advair inhaler and handed the dispenser to Resident #9. Resident #9 inhaled two puffs orally, 7 seconds apart. Review of the pharmacy label revealed to Wait 1 minute between puffs. Review of the manufacturer's specification for use of the Advair inhaler revealed to Push the top of the metal canister firmly all the way down while you breathe in deeply and slowly through your mouth . Breathe out slowly as long as you can. Wait about 30 seconds and shake the inhaler well for 5 seconds . Repeat steps 2 through 6. On 5/11/21 at approximately 9:15 a.m., LPN Staff H confirmed the pharmacy packaging for the inhaler specified to, Wait 1 minute between puffs. LPN Staff H confirmed she did not wait or instruct the Resident #9 to wait 1 minute between puffs per specification on the pharmacy label. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105584 If continuation sheet Page 7 of 9 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 105584 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sarasota Memorial Nursing & Rehabilitation Center 5640 Rand Blvd Sarasota, FL 34238 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 0759 Level of Harm - Minimal harm or potential for actual harm On 5/13/21 at 10:20 a.m., in an interview, the Director of Nursing (DON) confirmed the nurses were expected to follow the instructions on the medication label. The DON said, It would be a medication error if a nurse did not follow labeled pharmacy instructions. **Photographic Evidence Obtained** Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105584 If continuation sheet Page 8 of 9 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 105584 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sarasota Memorial Nursing & Rehabilitation Center 5640 Rand Blvd Sarasota, FL 34238 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 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. Based on observation, record review, and staff interview, the facility failed to assess for compatibility of the bed frame and mattress to identify areas of possible entrapment for 1 (Resident #239) of 1 resident reviewed for accident hazards. The findings included: The Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment for Industry and Food and Drug Administration (FDA) issued on March 2006, identified the area between the head or foot board and the end of the mattress a risk for head entrapment. Entrapment is a situation where an individual can become caught by their head, neck, chest, or other body parts. The FDA Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment document can be found at: https://www.fda.gov/downloads/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/UCM072729.pdf On 5/10/21 at 11:32 a.m., Resident #239 was observed lying in bed. Resident #239 was confused and unable to be interviewed. A 6-inch gap was observed between the footboard and frame/mattress with an open area to floor, creating a large area for potential entrapment. On 5/11/21 at 1:55 p.m., in an interview, Licensed Practical Nurse (LPN) Staff K said Resident #239 was confused and could be restless in bed. On 5/11/21 at 2:11 p.m., in an interview, Certified Nursing Assistant (CNA) Staff I said Resident #239 was confused most of the time. When he first came, he tried to get up unassisted, so a bed alarm was placed on him to alert staff if he did try to get up. Resident #239's clinical record revealed a Nursing admission Data Collection form completed on 4/21/21. The form included a Fall Risk Assessment, which identified the resident as high risk for falls. On 5/12/21 at 8:38 a.m., in an interview, the facility's Project Coordinator said he used the FDA Bed Safety measuring kit to check for entrapment zones in the bed environment. He said all the beds were checked annually and/or if any change or if bed rails were required. Nursing notified him of any issues. Resident #239's bed was measured by the Project Coordinator at the time of the interview and he confirmed a 6-inch gap was present between the bed frame/mattress and footboard. He said it was way too much of a gap and the bed frame needed to be adjusted to fit the mattress. He also confirmed the mattress was slippery on the bed and could easily move on the frame. On 5/13/21 at 8:54 a.m., in a follow up interview, Project Coordinator said he used the FDA guidelines for bed safety to check for entrapment zones, including zone 7 (area between mattress and footboard). The guidelines did not specify the size of the space but if it was too large the risk increased. He would consider 4 and 3/4 inches a potential entrapment zone (the measurement guide for between the mattress and a bed rail if in use). **Photographic Evidence Obtained** FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105584 If continuation sheet Page 9 of 9