Inspection·May 16, 2023

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 review of the clinical record and staff interviews, the facility failed to have processes in place to ensure an accurate evaluation of cognitively impaired residents upon admission to accurately reflect smoking status and implement adequate interventions to prevent avoidable accidents related to smoking for 1(Resident #999) of 4 newly admitted residents. The findings included: A review of Resident #999's clinical record documented an initial admission to the facility on 3/4/23. Diagnoses included chronic obstructive pulmonary disease, major depressive disorder, alcohol abuse and schizoaffective disorder. The smoking evaluation completed on 3/4/23 noted the resident was not able to light the cigarette safely, smoke safely, or utilize ashtray safely and properly. The resident was not able to extinguish the cigarette safely and completely. The evaluation documented in comments, Resident chooses not to smoke at this time due to respiratory condition and use of oxygen. Declines patch at this time. The rest of the evaluation was not completed since the resident chose not to smoke at this time. Resident #999 was discharged from the facility on 3/27/23, return not anticipated. The hospital history and physical dated 4/5/23 noted Resident #999 was admitted to the hospital on [DATE], and noted the resident had a 50-year smoking history and almost daily alcohol however unknown amount. Reports he is still smoking. The facility record showed the resident was admitted to the facility on [DATE] from the acute care hospital. The clinical record revealed an admission Data Collection signed on 4/14/23 at 9:56 p.m. The nurse completing the admission data collection noted the resident's level of consciousness as lethargic. The resident was oriented to person and place. The data collection form also noted the Resident was on continuous use of 4 Liters(L) of oxygen via nasal cannula. In the hot liquid risk indicators section, the nurse checked Yes noting the resident had severe cognitive impairment or no safety awareness or Brief Interview for Mental Status score of less than 8. (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 3 Event ID: 105983 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 105983 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harborview Sarasota 4783 Fruitville Road Sarasota, FL 34232 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)