F 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM
and/or mobility, unless a decline is for a medical reason.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, review of facility policy and procedures, resident and staff interview, the facility
failed to implement necessary restorative care to prevent the decline in range of motion or mobility for 1
(Resident #17) of 3 residents reviewed with limited range of motion.
The findings included:
The facility policy,10-1140 (4/23/18) for Nursing Services Restorative/Maintenance Program specified, the
facility shall have a Restorative/Maintenance Program for the purpose of restoring and maintaining optimum
level of function for residents at risk. The policy specified the Restorative Care Coordinator shall attend
weekly Minimum Data Set (MDS) (a clinical assessment of all residents to assess a resident's functional
capabilities) meeting to maintain current communication relating to resident mobility or related problems.
Maintain ongoing communication with the interdisciplinary team.
Review of the clinical record revealed Resident #17 had a history of cerebral infarction (stroke) with
hemiparesis (weakness) affecting the right side.
The MDS (Minimum Data Set) admission assessment completed on 3/9/21 noted Resident #17 had
functional limitation in range of motion of both upper extremities. Resident #17 required extensive physical
assistance of 1 for activities of daily living.
Review of the functional maintenance program dated 3/19/21 revealed instructions to provide range of
motion (ROM) to bilateral upper and lower extremities during activities of daily living and to keep a rolled
cloth in hand for skin integrity.
The Certified Nursing Assistant (CNA) [NAME] (provides direction for care) noted to keep a rolled cloth in
hand for skin integrity.
On 5/17/21 at 2:18 p.m., 5/18/21 at 9:02 a.m., 5/18/21 at 1:42 p.m., and 5/19/21 at 1:42 p.m., Resident
#17's right hand's fingers were observed curled toward his palm. Resident #17 did not have the rolled cloth
in his hand.
On 5/18/21 at 9:02 a.m., in an interview Resident #17 said he could not remember the last time anyone
placed the rolled cloth in his hand.
On 5/19/21 review of the daily charting revealed the CNAs placed their initials from 5/1/21 through 5/19/21
indicating the rolled cloth was in place in the resident's hand for skin integrity.
(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:
106053
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
106053
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/20/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sunnyside Nursing Home
5201 Bahia Vista Street
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)
F 0688
Level of Harm - Minimal harm
or potential for actual harm
On 5/19/21 at 3:00 p.m., Registered Nurse (RN) Staff A verified Resident #17 did not have a rolled cloth in
his hand. She said the nurses and CNAs were responsible to place the rolled cloth in the resident's hand
and she checked to ensure it was in place. RN Staff A said although she oversaw the restorative program,
she did not have set meetings to review the residents' progress. She said she also participated in stand-up
meetings in the morning but did not discuss or review residents on a restorative program.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106053
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
106053
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/20/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sunnyside Nursing Home
5201 Bahia Vista Street
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)
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, review of facility policy and procedure, resident and staff interview, the facility failed
to store continuous positive airway pressure (CPAP) machines masks in a sanitary manner for 1 (Resident
#37) of 1 resident who use a CPAP machine (helps you breathe more easily when you sleep). This has the
potential to cause respiratory infection.
Residents Affected - Few
The findings included:
A review of the clinical record documented a Physician order for the care of Resident #37's CPAP machine.
The order specified, wash CPAP weekly with soap and water and obtain new storage bag every day shift
every Tuesday for infection control.
On 5/17/21 at 11:58 a.m., during an observation, Resident #37's CPAP mask and tubing were stored
uncovered in the open drawer of the nightstand with other personal items.
**Photographic Evidence Obtained**
Observations on 5/18/21 at 9:00 a.m., and 5/19/21 at 9:07 a.m., Resident #37's CPAP mask remained
uncovered in the opened nightstand drawer.
**Photographic Evidence Obtained**
On 5/19/21 at 10:12 a.m., in an interview, Licensed Practical Nurse (LPN) Staff B said the nurse was
responsible to place the CPAP mask in a plastic bag when not in use.
On 5/19/21 at 10:24 a.m., during an observation and interview, Registered Nurse (RN) Unit Manager Staff
A confirmed the CPAP mask for Resident #37 was in the open nightstand drawer and was uncovered. RN
Staff A verified the CPAP mask should be in a plastic bag and not in contact with other items in the drawer.
On 5/19/21 at 11:12 a.m., in an interview, the Director of Nursing said the facility had no policy on the care
of CPAP machines.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106053
If continuation sheet
Page 3 of 3
