Health inspection·December 17, 2020

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation, and staff interview, the facility failed to follow physician orders, to promote healing of a pressure ulcer for 1 (Resident #30) of 3 residents reviewed for pressure ulcers. Residents Affected - Few The findings included: Review of the facility's policy for Pressure Ulcers/Skin Breakdown (undated) read the physician . will order pertinent wound treatments, including pressure reduction surfaces . Review of the facility's policy and procedure on Skin Evaluations (effective date 6/10/19) read 3. Licensed wound care nurse, RN or ARNP will review to ensure necessary treatments are implemented. 5. Any resident with a prescribed positioning or medical device will have a CMS [Color, Movement, Sensation] tool initiated for further evaluation of skin to prevent potential impairment. Review of the Minimum Data Set (tool used to assess and plan care) dated 11/5/20 showed Resident #30 was at risk of pressure ulcers/injuries. Review of the clinical record showed on 11/19/20 Resident #30 developed a stage II pressure ulcer (ulcer that expands into deep layers of the skin). A physician order dated 11/19/20 included a gel overlay mattress (device applied to mattress to help in prevention of pressure ulcers) be put in place. On 12/14/20 review of Resident #30's treatment administration record from 11/19/20 through 11/30/20 and from 12/1/20 through 12/14/20 showed daily documentation the Specialty Mattress for Bed Gel Overlay was in place. Review of the skin evaluation form dated 12/14/20 revealed documentation Wound to left posterior thigh resurfaced with epithelial tissue, area closed, resolved, skin is dry, smal [sic] scab present. APRN (Advanced Practice Registered Nurse) informed . Will continue skin prep to area X 10 days preventative. On 12/14/20 at 10:02 a.m., Resident #30 was observed in his room, with no overlaying gel mattress on his bed. On 12/15/20 at 11:14 a.m., Resident #30 was observed in his room, with no overlaying gel mattress on his bed. On 12/15/20 at 11:19 a.m., during an interview Registered Nurse (RN) Staff K said Resident #30 was (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 2 Event ID: 106085 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 106085 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bay Village of Sarasota 8400 Vamo Road Sarasota, FL 34231 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)