Health inspection·February 22, 2024

F 0725 Level of Harm - Minimal harm or potential for actual harm Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on observation and interview, the facility failed to ensure sufficient qualified nursing staff to meet residents' needs in a timely manner for 2 (Residents #3, and #4) of 5 residents interviewed. Residents Affected - Few The findings included: On 2/21/24 11:16 a.m., in an interview Resident #3 said the facility could definitely use more help. She said she didn't know what happened or if people call off, but it puts a lot of stress and strain on the Certified Nursing Assistants (CNA). She said the prior evening around 7:00 p.m., she waited around 45 minutes for someone to answer the call light. She finally rolled herself out into the hallway to find help. She said it has become continuously worse since she arrived. Resident #3 said she was incontinent and was trying to train her bladder and bowel. She said she would prefer to use the bathroom more often to assist with that. On 2/21/24 a call light was observed on in hallway at 11:00 a.m. in Resident #4's room. On 2/21/24 at 11:20 a.m., the light was still on and no one had responded to the call light. On 2/21/24 at 11:20 a.m., Resident #4 said someone had come in a while ago and said they would find the aide assigned to her to help. She said she had been told not to go to the bathroom by herself so she had to wait. On 2/21/24 at 11:25 a.m., CNA Staff A, and CNA Staff B were observed walking by Resident #4's room. They did not respond to the light. On 2/21/24 at 11:30 a.m., the Speech Therapist entered the room to work with Resident #4's roommate, and assisted her to the bathroom. On 2/21/24 at 12:36 p.m., Resident #4 said she usually has to wait 15 to 20 minutes for help. Resident #4 said she only needs one person to assist her in the bathroom and the first person who came in the room could have helped her. On 2/22/24 at 9:30 a.m., Resident #10 (Resident Council President ) said staffing had been discussed in Resident Council. She said there had been a period where they would hit the call bell and they would cut it off at the desk and not respond. She said a couple of residents told her that week that the issue was ongoing. Page 1 of 7 105842 105842 02/22/2024 Crescent Health and Rehabilitation Center 5401 Sawyer Rd Sarasota, FL 34233

F 0725 Level of Harm - Minimal harm or potential for actual harm On 2/22/24 at approximately 10:49 a.m., the Administrator said she was not aware of problems with call bells. She said staff should not walk by any room with a call bell on, they should enter and offer help or return timely with assistance. Residents Affected - Few 105842 Page 2 of 7 105842 02/22/2024 Crescent Health and Rehabilitation Center 5401 Sawyer Rd Sarasota, FL 34233

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. Based on observation, record review and interview, the facility failed to ensure medications were not left unattended and remained under the direct observation of the person administering the medications for 2 (Residents #2 and #3) of 2 residents with medications observed unsecured at bedside. The findings included: Facility policy titled Administering Oral Medications, revision date October 2010, indicated under bullet #21: Remain with the resident until all medications have been taken. 1. On 2/21/24 at 11:48 a.m., a pill was observed unattended in a medication cup on Resident #2's bedside table. There was no nursing staff in the room with the resident. On 2/21/24 at 12:03 p.m., the Assistant Director of Nursing (ADON) and Administrator came in room and observed the unsecured medication in the cup at bedside. Resident #2 explained the medication was Creon (assists with digestion of food) and has to be taken with his meal. Resident #2 said said if they didn't leave it for him, he didn't think he would get it on time. He said there was no set time when the meal will arrive as it differs each day and the nursing staff left the medication at his bedside everyday for all three meals. On 2/21/24 at 12:26 p.m., Registered Nurse (RN) Staff A said the therapist was bringing Resident #2 back to his room and Resident #2 asked for his Creon. Staff A said he handed the medication to the resident and left for lunch. Staff A verified he documented the medication as given, despite not actually observing the resident take the medication. Staff A said he was aware medications are not to be left at bedside. 2. On 2/21/24 at 1:34 p.m., two pills in a medication cup were observed on Resident #3's bedside table. No nursing staff was in the room with the resident observing the medication. Resident #3 said the medication was her Primidone (medication for tremors) and the nurse had come in and left it there. On 2/21/24 at 1:40 p.m., the ADON and Administrator observed and verified the medication was left unattended at the resident's bedside. On 2/21/24 at approximately 1:45 p.m., Staff A entered Resident #3's room and verified he left the medication unattended to get a cup of water. He said he was aware he should have taken the medications with him. Review of the Medication Administration Record (MAR) with the Administrator revealed the medication had been documented as given. 105842 Page 3 of 7 105842 02/22/2024 Crescent Health and Rehabilitation Center 5401 Sawyer Rd Sarasota, FL 34233

F 0761 On 2/21/24 at 12:03 p.m., the Administrator said medications are not to be left at bedside and should be documented as given only when given. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105842 Page 4 of 7 105842 02/22/2024 Crescent Health and Rehabilitation Center 5401 Sawyer Rd Sarasota, FL 34233

F 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on observation, record review and interview, the facility failed to ensure 7 (Residents #2, #1, #3, #5, #12, #8, and #10) of 7 residents interviewed were provided meals at regular times comparable to normal mealtimes in the community. The findings included; On 2/21/24 the Administrator provided a schedule for meal delivery times. The schedule indicated breakfast was delivered to the various wings starting at 7:30 a.m. and last delivery would be 8:20 a.m. in the dining room,. Lunch was delivered to the various wings starting at 11:30 a.m., with the last delivery at 12:20 p.m. Dinner would begin being delivered at 5:30 p.m. with last delivery at 6:20 p.m. On 2/21/24 at 11:48 a.m., a medication cup was on Resident #2's bedside table with a pill in it. Resident #2 explained the medication was Creon (assists with digestion of food) and needed to be taken with his meal. In an interview, Resident #2 said said if they didn't leave it for him, he didn't think he would get it on time. He said there was no set time when the meal will arrive as it differed each day and the nursing staff left it for him everyday for all three meals. On 2/21/24 at 10:50 a.m., in an interview Resident #1 said as far as she knew there was no set time for meals and the day prior lunch was delivered at 2:00 p.m. She said the meals are not hot when they arrive, warm but not hot. She said she has her family bring her food. On 2/21/24 at 11:16 a.m., in an interview Resident #3 said she felt the food was terrible. She said it was not balanced and sometimes unappetizing to look at. Resident #3 said the meals do not always come on time and lately it had been bad. She said the day prior she didn't get breakfast until 10:00 a.m. and lunch was at 2:00 p.m. She said when the food arrived, it was not very warm. She said, They do have the little thing over it that's supposed to keep it warm, but sometimes it's sitting for a while before it gets to the patient and it will be cold or lukewarm. Resident #3 said she ordered food delivery a lot. On 2/21/23 at 11:33 a.m., Resident #5's significant other said there were concerns with the food quality, temperature and timing. He said the day prior breakfast came at 10:30 a.m., and this morning arrived around 9:30 a.m., to 10:00 a.m. He said the food was cold when it arrived. On 2/21/23 at 1:55 p.m., Resident #12 was observed not to have received a lunch tray yet. He said 105842 Page 5 of 7 105842 02/22/2024 Crescent Health and Rehabilitation Center 5401 Sawyer Rd Sarasota, FL 34233

F 0809 Level of Harm - Minimal harm or potential for actual harm he couldn't tell when they were supposed to have lunch. He said it varied everyday, seemed to be getting later and later and it arrived cold. On 2/21/24 at 3:46 p.m., Resident #8 said the food didn't always come on time and was often cold. He said that day lunch arrived somewhere between 1:30 p.m., to 2:00 p.m. Residents Affected - Some On 2/22/24 at 9:30 a.m., Resident #10 (Resident Council President ) said there has been big time complaints about the food. She said it was really bad and nothing nutritious. She said the meals were never on time and arrived sometimes warm, sometimes cold, just no consistency. She said they had breakfast one day this week at 10:00 a.m., and lunch was around 2:30 p.m., to 3:00 p.m. On 2/21/24 an observation was made of lunch delivery. At 1:00 p.m., there had been no lunch delivery on East wing. The residents seated in the Garden dining room were waiting for their meal and there had been no lunch delivery on [NAME] wing. On 2/21/24 at 1:20 p.m., the first cart was delivered to East wing 300 hall, the Garden dining room, and a cart had been delivered to the [NAME] wing. On 2/21/24 at 1:35 p.m., a second cart was delivered to the 100 hall on the East wing. On 2/21/24 at 1:50 p.m., a third cart was delivered to East wing 200 hall. The last tray was delivered to Resident #8 at 2:05 p.m. Resident #8 said the rice was ice cold, meat was lukewarm, the veggies were the hottest thing on the plate. On 2/22/24 at approximately 1:30 p.m., in an interview the Administrator said she was not aware of problems with meal delivery times. She said on 2/21/24 there had been a problem with the dishwashing machine. It had to be repaired causing the delay. She agreed the inconsistency in meal time can especially affect those residents requiring medications be taken at certain times based on meal intake. 105842 Page 6 of 7 105842 02/22/2024 Crescent Health and Rehabilitation Center 5401 Sawyer Rd Sarasota, FL 34233

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observation, record review and interview, the facility failed to ensure that the clinical record was accurately documented for 1 (Residents #2) of 2 residents observed with unsecured and unattended medications at bedside. The findings included: Facility policy titled Administering Oral Medications, revision date October 2010, indicated under bullet #21: Remain with the resident until all medications have been taken. On 2/21/24 at 11:48 a.m., a medication cup was on Resident #2's bedside table with a pill in it. There was no nursing staff in the room with the resident observing the medication. At 12:03 p.m., the Assistant Director of Nursing (ADON) and Administrator came in room and observed the medication cup at bedside. Resident #2 explained the medication was Creon (assists with digestion of food) and it needed to be taken with his meal. Resident #2 said said if they didn't leave it for him, he didn't think he would get it on time. He said there was no set time when the meal will arrive as it differs each day and the nursing staff leave it for him everyday for all three meals. On 2/21/24 at 12:08 p.m., the Assistant Director of Nursing (ADON) removed, and discarded the medication. A review of the Medication Administration Record (MAR) with the ADON revealed the medication had been documented as given, despite being found on the bedside table. On 2/21/24 at 12:26 p.m., Registered Nurse (RN) Staff A said the therapist was bringing Resident #2 back to his room and he asked for his Creon. Staff A said he handed the Creon to him and left for lunch. Staff A verified he documented the medication as given, despite not observing the resident take the medication. Staff A said he was aware medications were not to be left unattended at bedside. On 2/21/24 at 12:03 p.m., the Administrator said medications are not to be left at bedside and should be documented as given only when given. 105842 Page 7 of 7