Health inspection·May 4, 2023

F 0700 Level of Harm - Minimal harm or potential for actual harm Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. 4. On 5/1/23 at 12:33 p.m., Resident #142 was observed in bed with bilateral upper rails in the up position. Residents Affected - Some On 5/2/23 at 9:38 a.m., Resident #142 was observed his recliner, his bed was made with bilateral upper rails in the up position. On 5/3/23 at 3:05 p.m., Resident #142 was observed in bed sleeping with bilateral bed rails in the up position. rails in the up position. Record review of Resident #142 revealed no signed consent for use of the bed rails. On 5/4/23 at 12:20 p.m., the Director of Nursing confirmed there was no evidence the facility obtained informed consent for the use of bed rails for Resident #142 or attempted alternatives prior to the use of bed rails on the beds of Residents #4, 12 and 192. Based on observation, staff and resident interviews, and record review, the facility failed to attempt alternatives prior to the use of bed rails for 4 (Resident #4, #12, #142, and #192) of 6 residents reviewed for bed rails. The findings included: 1. On 5/1/2023 at 10:25 a.m., observation revealed Resident #4 asleep in the bed with bilateral upper bed rails in the up position. On 5/4/2023 at 11:30 a.m., observation revealed Resident #4 sitting up in bedside chair. Both bed rails were in the up position. Record review for Resident #4 revealed no evidence alternatives were attempted prior to use of bed rails on the bed of Resident #4. 2. On 5/4/2023 at 11:40 a.m., observation revealed Resident #12 in her bed sleeping with bilateral upper bed rails in the up position. Record review for Resident #4 revealed no evidence alternatives were attempted prior to use of bed rails on the bed of Resident #4. Page 1 of 4 106035 106035 05/04/2023 Inn at Sarasota Bay Club 1303 North Tamiami Trail Sarasota, FL 34236

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. On 5/1/2023 at 11:00 a.m., observation revealed bilateral bed rails in the up position on the bed of Resident #192. On 5/1/2023 at 11:10 a.m., in an interview, Resident #192, said he hates the side rails. He said he has had the side rails on his bed since admission and has not been given any reasons why he has the side rails or signed any consents and never had a choice. He also said he bent over to get something that had fallen underneath his bed and his head got caught under the side rail. Record review for Resident #192 revealed no evidence alternatives were attempted prior to use of bed rails on the bed of Resident #192. 106035 Page 2 of 4 106035 05/04/2023 Inn at Sarasota Bay Club 1303 North Tamiami Trail Sarasota, FL 34236

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, staff and resident interviews and record reviews, the facility failed to ensure all drugs and biological were labeled or stored in a locked compartment for 2 (Resident #4 and #191) of 2 residents reviewed. The findings included: The facility policy Medication Storage in the Facility: ID3 Bedside Medication Storage with an effective date of March 2022 states bedside medication storage is permitted for residents who wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate in the judgement of the facility's interdisciplinary resident assessment team. The manner of storage prevents access by other residents. 1. On 5/1/2023 at 10:25 a.m., observation revealed Resident #4 asleep in the bed. There was an uneaten breakfast tray sitting on the dresser with unlabeled pills in a medicine cup on the breakfast tray. *Photographic evidence obtained. On 5/1/2023 at 11:30 a.m., Licensed Practical Nurse (LPN) Staff B said Resident #4 was asleep during medication pass so she left her morning pills in the pill container in the resident's room so they would be there when she woke up because Resident #4 does things on her own time. 2. On 5/1/2023 at 10:00 a.m., observation revealed two bottles of eye drops on the bedside table of Resident #191. *Photographic evidence obtained. On 5/1/23 at approximately 10:02 a.m., Resident #191 said the eye drops were for his glaucoma. He said he was told by his doctor to bring them to the facility. He said he usually administers the drops himself, but sometimes the nurses do it. He said the drops stay in his room at all times. On 5/2/2023 at 12:10 p.m., the Director of Nursing said there are no residents in the facility at this time who self-administer medications. She said the process would be for the resident to have an assessment completed, obtain a physician order, then the medication would go into a locked container. She also said medications are not to be left in a resident's room. The nurse should stay with the resident until the medications have been taken. 106035 Page 3 of 4 106035 05/04/2023 Inn at Sarasota Bay Club 1303 North Tamiami Trail Sarasota, FL 34236

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interview, the facility failed to ensure proper cleaning and sanitizing of equipment in the kitchen. Residents Affected - Many The findings included: On 5/1/2023 at 9:15 a.m., during a tour of the kitchen conducted with the Certified Dietary Manager (CDM), the following observations were made: Ceiling vents with dust build-up. Photographic evidence obtained. Ice machine with dust build up on vent. Photographic evidence obtained. Stove area and flat cooktop were covered in grease and grime build up. Photographic evidence obtained. There was a container of melted butter sitting on flat cook top that was also covered in grease and grime. Photographic evidence obtained. At the time of the observation, the CDM said the melted butter gets changed before each meal. Oven and exhaust fan over oven, both had build-up of grease and grime. Photographic evidence obtained. At the time of the observation, the CDM said the staff take turns cleaning and would provide cleaning schedule. He said they had been shorthanded recently. On 5/4/2023 at 1:20 p.m., the Administrator reviewed the photographic evidence of the kitchen and said she would not eat a grilled cheese sandwich from the kitchen. 106035 Page 4 of 4