F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, clinical record review, and staff interviews the facility failed to ensure staff consistently
implemented individualized interventions to meet the needs and prevent avoidable accidents for 1
(Resident #41) of 4 sampled residents reviewed for falls.
The findings included:
Review of the clinical record revealed Resident #41 was readmitted on [DATE] with diagnoses including
diabetes and hypothyroidism.
The Quarterly Minimum Data Set (MDS) assessment with a reference date of 8/22/22 noted the required
extensive physical assistance of two persons for bed mobility and transfer.
Review of the progress notes revealed on 8/26/22 at 6:15 a.m., the resident rolled out of bed during care
and landed in supine position (face down) on the right side of the bed.
The investigation report dated 8/26/22 noted the resident rolled onto the side facing away from the aide.
The resident attempted to assist and rolled out of bed. The aide was changing the resident by herself.
The Certified Nursing Assistants (CNAs) [NAME] (Document that provides a summary and overview of the
resident's care) for the most recent admission of 9/15/22 specified in bold letters the resident required
extensive assist of two for bed mobility.
Review of the CNA documentation from 11/2/22 through 11/14/22 revealed 17 times Resident #41 was
toileted with one-person physical assist.
On 11/15/22 at 7:50 a.m., CNA Staff C was observed providing incontinent care and changing the
resident's brief in the bed by herself.
On 11/16/22 at 12:27 p.m., CNA Staff C said she knew there should be two persons to move him. She said
she received the training but sometimes it is difficult to get some help. She also said she has asked another
CNA or a Licensed Practical Nurse (LPN) for help.
On 11/17/22 at 7:55 a.m., Licensed Practical Nurse (LPN) Staff F said, there should always be two persons
assisting with a resident who required extensive assistance of two persons. The LPN said they received
education on it.
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 3
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
11/17/2022
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)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, facility policy review, resident and staff interviews, the facility failed to maintain proper
medication storage for 1 (Resident #82) of 1 resident observed with unsecured, unlabeled medication at
the bedside. The facility failed to properly label opened medication in 1 ([NAME] medication cart) of 3
medication carts reviewed.
The findings included:
Review of facility policy titled, Storage and Expiration Dating of Drugs, Biological, syringes and Needles,
revised 08/2018 which stated, The Nursing Center should ensure that drugs and biologicals are stored in
an orderly manner in cabinets, drawers, carts, refrigerators/ freezers of sufficient size to prevent crowding
.The Nursing Center should ensure that all drugs and biologicals, including treatment items, are securely
stored in a locked cabinet/ cart or locked medication room, inaccessible by residents and visitors .Once any
drug or biological package is opened the Nursing Center should follow manufacturer guidelines with respect
to expiration dates for opened medications. Nursing staff should record the date opened on the medication
container. Nursing Center personnel should inspect nursing station storage areas for proper storage
compliance on a regularly scheduled basis.
Review of facility policy titled, Medication and Treatment Administration Guidelines, revised 03/2018 which
stated, Medications and biologicals are securely stored in a locked cabinet, cart or medication room,
accessible to only licensed nursing staff and pharmacist or authorized pharmacy staff and maintained
under a lock system when not actively utilized and attended to by nursing staff for medication
administration, receipting or disposal.
1. Review of facility policy titled, General Dose Preparation and Medication Administration, revised 08/2018
which stated, Medication Administration .Observe the resident's consumption of the medication(s).
On 11/14/22 at 9:30 a.m., observed Resident #82 with medicine cup containing seven pills at her bedside.
Resident #82 said she needed ice water to take her pills. Resident #82 said the pills included medication for
high blood pressure, baby aspirin, zinc and vitamin C.
Photographic evidence obtained
On 11/14/22 at 10:03 a.m., Registered Nurse (RN), Staff A verified he left the pills with Resident #82. He
stated, I thought she took them while I was in there . That was my error. I was rushing and the therapist was
helping her get back to bed.
2. On 11/16/22 at 10:13 a.m., reviewed [NAME] 500 hall medication cart with Licensed Practical Nurse
(LPN), Staff B.
An opened medication (Breztri aerosphere inhaler) for Resident #36 was observed in the cart. The
medication was not labeled with the date opened.
Photographic evidence obtained
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105842
If continuation sheet
Page 2 of 3
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
11/17/2022
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)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
LPN, Staff B, stated, I will need to throw this away. It should be dated when opened. I don't know how long it
has been opened. I will reorder it now.
Review of the manufacturer's insert for Breztri aerosphere (a medication used to help treat lung disease)
noted; Throw away Breztri aerosphere 3 months after you open the foil pouch (for the 120-inhalation
canister), or 3 weeks after you open the foil pouch (for the 28 inhalation canister) or when the dose
indicator reaches zero 0, whichever comes first.
On 11/16/22 at 12:44 p.m., in an interview, the Director of Nursing (DON) said medications should not be
left at the resident's bedside.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105842
If continuation sheet
Page 3 of 3
