Inspection·May 30, 2025

F 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review, Health Care Representative and staff interviews, the facility failed to ensure the facility's binding arbitration agreement informed the resident or their representative they were not required to agree with arbitration agreement as part of the resident admission to the facility and they could rescind the arbitration agreement within 30 days of signing for 3 (Resident #8, #40 and #404) of 3 residents reviewed who had signed the facility binding arbitration agreement. Residents Affected - Some The findings included: On 5/29/25 a review of the Agreement For Care contract signed by the resident or their representative prior to admission to the facility, #12 stated the arbitration clause is optional and if the parities to the agreement do not wish to include the following arbitration provision, are required to indicate so by marking an X through this clause. Any controversy or claim arising out of or relating to the Agreement, or the breach shall be settled by arbitration, with the provisions of the Florida Arbitration Code found at Chapter 682, Florida Statutes. Further review of the Agreement For Care contract revealed the Arbitration Clause noted it did not indicate the arbitration agreement was not required as part of the admission to the facility, and the arbitration agreement may be rescinded within 30 calendar days of signing. 1. Review of Resident #40's medical record revealed his initial admission to the facility was on 12/20/24. Resident #40's wife, signed by Resident #40's Agreement For Care contract on 12/20/24. The arbitration clause in section #12 of the Agreement For Care contract was not X out. On 5/29/25 at 9:51 a.m., in an interview with Resident #40's wife, she confirmed she had signed her husband's Agreement For Care contract on 12/20/24 as one of multiple documentation she was required to sign the day her husband (Resident #40) was admitted to the facility. She said she did not remember the Social Service Assistant explaining to her she was not required to agree with the arbitration clause in section #12 in the Agreement For Care contract and she was not informed she could rescind the arbitration agreement within 30 days of signing the Agreement For Care contract. 2. Review of Resident #404's medical record revealed she was admitted to the facility on [DATE]. Resident #404's Agreement For Care contract was signed by Resident #404 on 5/24/25. The arbitration clause in section #12 of the Agreement For Care contract was not X out. On 5/29/25 at 10:05 a.m. during an interview with Resident #404 said she was admitted a couple of days ago and she had not been informed that she didn't have to agree to the arbitration clause in the (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 5 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 05/30/2025 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)