Health inspection·January 13, 2025

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm Based on staff interview, resident interview, observations and resident medical record review, it was determined that the facility failed to ensure the residents' right to call light access for two residents (Resident #3 and Resident #4) out of eight residents observed during the survey. Residents Affected - Few The findings included: During an initial tour of the facility which commenced on 1/13/25 at 10:00 a.m., Resident #3 was observed sitting up in her wheelchair on the window side (left side) of her bed. There was no call light observed within her reach. In an interview with Resident #3 conducted on 1/13/25 at 10:05 a.m., she was asked how she would get the staff's attention if she needed anything. She stated I guess I'd push the button. Oh, wait this is the TV remote. I don't know where the button is. The call light was observed to be on the floor, on the opposite (right) side of her bed from where she was sitting, out of her reach. She was asked if she could reach her call light where it was. She smiled and said, No, how could I get there? She was asked if her call light was usually within her reach. She stated, Not always. I can't reach it now. Photographic evidence obtained. Employee A, a certified nurses' aide (CNA) entered the room at 10:17 a.m. He was asked if he was caring for Resident #3 today. He stated yes. He was asked if she had access to a call light. He looked around and stated, Oh, it's on the floor. He was asked to confirm the call light was out of the resident's reach. He stated, When I made her bed earlier, I forgot it. I usually only work the weekends, so she is usually in bed when I am working, and I usually attach her to her blankets. She got up today and I must have forgot it because I'm not used to her being up. A medical record review conducted for Resident #3 revealed: An MDS (Minimum Data Set) admission assessment conducted on 12/27/24 revealed a Brief Interview for Mental Status (BIMS) score of 10. A score of 8-10 suggests moderate cognitive impairment. Further record review for Resident #3 revealed a care plan which showed: Focus: (12/28/24): I have impaired balance and weakness. I have impaired cognition. Goal: I will have no falls with current interventions through the next review date. Page 1 of 2 106090 106090 01/13/2025 Benderson Family Skilled Nursing and Rehab Center 1959 N Honore Ave Sarasota, FL 34235

F 0919 Interventions: Call light in reach when in bed and bedside chair. Level of Harm - Minimal harm or potential for actual harm Focus: (12/28/24): I was admitted with occasional incontinence. Residents Affected - Few Goal: I will have no complications related to incontinence with current interventions through the next review date. Interventions: Call light in reach when in bed and bedside chair, remind to call for assistance with urge to use the bathroom and answer promptly. On 1/13/25 at 10:23 a.m., Resident #4 was observed in her room, lying in bed, awake with the television on. Her call light was observed not within reach. It was observed clipped to back of the head of her mattress. Resident #4 presented as unable to interview. She was saying words but not answering simple questions correctly. Photographic evidence obtained. A medical record review conducted for Resident #4 revealed: An MDS (Minimum Data Set) admission assessment conducted on 12/7/24 revealed a Brief Interview for Mental Status (BIMS) score of 07. A score of 0-8 suggests severe cognitive impairment. Further record review for Resident #4 revealed a care plan which showed: Focus: (12/26/24) I was re-admitted with a decline in functional mobility related to increased weakness and decreased balance from recent hospitalization for UTI (urinary tract infection), gastroparesis (delayed gastric emptying), poor nutrition. I am under the care of Continuum Hospice. I do not want to get OOB (out of bed). Goals: My daily care needs will be anticipated and met by staff daily as evidenced by a clean, well-groomed, and odor free appearance through the next review date Interventions: Encourage the resident to use bell to call for assistance. A policy regarding call lights was requested at the entrance conference. In an interview with the Administrator on 1/13/25 at 10:44 a.m., she stated the facility does not have a policy. She stated this is covered during orientation. She stated they are able to monitor call light answer times with their system, which records each call light by room that is activated and how long in minutes it takes for the call light to be answered. In a second interview on 1/13/25 at 2:13 p.m., she was asked if the facility monitors call light placement to ensure the call lights remain within the resident's reach. She provided documentation for Resident #1 and stated they had kept track of this Resident's call light placement for approximately two weeks in response to a family member's complaint that they call light was found out of reach of three occasions. The record revealed this occurred April 22, 2024 through May 2, 2024. She was asked if there was any documentation of any other call light placement audits. She stated no. 106090 Page 2 of 2