Inspection·April 29, 2021

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure appropriate documentation of advance directives for 1 (Resident #65) of 6 residents reviewed for advanced directives. The findings included: A review of the Advance Care Planning-Code Status Clinical insight FYI (For your information) #65 August 2019, provided by the facility revealed documentation Social Service should ensure code status has been established and is appropriately communicated within the medical and electronic record. Ultimately, it is important Social Service does a thorough screen regarding the patient's wishes. A review of the resident record for Resident #65 revealed the resident was admitted on [DATE] with diagnoses including Senile Degeneration of the Brain. A review of Resident #65's physician orders, dated 3/26/21, revealed Resident #65 was a full code. A review of the Social Services assessment dated [DATE] revealed, Resident #65 and the spouse provided the information. The advance care planning listed Durable Power of Attorney-Health Care (DPOA-HC). The form was signed by Social Services Coordinator Staff B. The admission Minimum Data Set (MDS) Assessment, dated 4/2/21, revealed Resident #65 had a BIMS score of 5 (severe cognitive impairment). On 4/27/21 at 12:24 p.m., during a telephone interview, Resident #65's spouse said she was the resident's Power of Attorney for Health Care (POA-HC) and Resident #65's code status was Do Not Resuscitate (DNR). On 4/28/21 at 9:04 a.m., in an interview, the Admissions Coordinator said if a resident's BIMS was 5, they would get a Certificate of Incapacity and the resident's POA would make all healthcare decisions, including DNR status. She said she did not ask Resident #65's spouse about the DNR. On 4/28/21 at 9:17 a.m., in an interview, the Social Services Coordinator Staff B said she met with Resident #65 and signed the Social Service Assessment, but did not conduct the interviews for the assessment. She said she does not think he (Resident #65) could tell if he was a DNR or not. She said the facility was going to the spouse and son for decision making. She said the resident's BIMS score of 5 (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 7 Event ID: 105842 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 105842 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crescent Health and Rehabilitation Center 5401 Sawyer Rd Sarasota, FL 34233 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)