Health inspection·June 12, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure quality of care by not following physicians' orders for 3 residents (#13, #133, and #29) of 3 residents reviewed for following physician's orders. Residents Affected - Few The findings included: Review of the Policy for Physician Services dated 11/28/17 #8 revealed, All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record during that shift. 1. Review of the medical revealed Resident #13 was admitted on [DATE]. The Quarterly Minimum Data Set (MDS) with a target date of 5/12/25 revealed Resident #13's Brief Interview for Mental Status (BIMS) score was 11, indicating moderate cognitive impairment. The MDS revealed Resident #13 did not reject care and was dependent on staff for dressing of the lower body. The MDS included, but was not limited to, hyperlipidemia, dementia, and asthma. Review of the physician's orders revealed an active order dated 3/14/25 for Ted hose on during day, off at night. (TED hose, also known as thrombo-embolic deterrent hose, is an acronym that refers to a type of compression hosiery. They are specifically designed to help prevent blood clots, or thromboembolism, by applying pressure to the legs and feet.) Review of the Medication Administration Record for June 2025 revealed on 6/1/25, 6/2/25, 6/3/25, 6/4/25, 6/5/25, 6/6/25, 6/7/25, 6/8/25, 6/9/25, and 6/10/25 the nurses documented the [NAME] hose were applied to the resident's legs. Review of Resident #13's medical record did not reveal information that the resident refused the [NAME] hose. On 6/9/25 at 12:05 p.m., observed Resident #13 in the activity dining room area sitting in the wheelchair. Resident #13 was not wearing the [NAME] hose. On 6/9/25 at 2:49 p.m., Resident #13 was observed in the wheelchair being pushed down the hall by a friend. Resident #13 was not wearing the [NAME] hose. On 6/10/25 at 9:53 a.m., observed Resident #13 sitting in the wheelchair watching TV in the bedroom. The [NAME] hose were not applied to the legs. During an interview, the resident said she never wears [NAME] hose. She said she wore them years ago but does not wear them now and no one applies them. Page 1 of 5 106090 106090 06/12/2025 Benderson Family Skilled Nursing and Rehab Center 1959 N Honore Ave Sarasota, FL 34235

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few She said if someone told her to wear them, she would refuse. Resident #13's private duty aid was sitting in the chair near the resident. The private duty aid said she dressed the resident this morning and did not apply the [NAME] Hose. The private aid said no one ever told her to apply them. * On 6/10/25 at 2:58 p.m., during an interview Certified Nursing Assistant (CNA) Staff A said if the resident refuses to put on the [NAME] hose, you tell the nurse. She said the nurse, or the CNA can apply them. Staff A said Resident #13 has a private duty sitter that dresses her and puts on the compression hose. She said the nurse would tell her to put them on if she needed them. Staff A said no one told her to apply the [NAME] Hose. On 6/10/25 at 3:23 p.m., Registered Nurse (RN) Staff C said she documented in the MAR (Medication Administration Record) the [NAME] hose were applied to Resident #13, but she was not sure they were applied. She said she thought the private duty aid applied them. On 6/10/25 at 3:30 p.m., RN Staff C went to the room and saw Resident #13 was not wearing the [NAME] hose. On 6/10/25 at 4:04 p.m. the Director of Nursing (DON) said the RNs should not document any treatment that was not completed, including the [NAME] hose. If the resident refuses a treatment or the [NAME] hose, the nurse should document the refusal in the medical record and notify the physician. On 6/11/25 at 9:58 a.m., the DON said private duty sitters do not apply [NAME] hose for the residents. 2. Review of the medical revealed Resident #133 was admitted on [DATE]. Diagnoses included aftercare following joint replacement and left artificial knee joint with a history of atherosclerotic heart disease. Review of the physician's orders revealed an active order dated 6/6/25 at 7:00 p.m. for Knee high ted hose both legs every shift. Review of the MAR for June 2025 revealed the nurses documented the [NAME] hose were applied on 6/7/25, 6/8/25, 6/9/25, and 6/10/25. Review of Resident #113's medical record did not contain information that the resident refused the [NAME] hose. On 6/09/25 at 12:17 p.m., observed Resident #133 in the room wearing shorts. There were no [NAME] hose applied to the legs. The resident said he does not wear [NAME] Hose, and no one asked him to wear them. He said he came to the facility with an Ace Wrap for the left leg, but it was removed the next morning and there has been nothing else for the legs since then. The original surgical dressing was observed to the left leg. On 6/10/25 at 10:12 a.m., observed Resident #133 in the room wearing shorts. The resident was not wearing [NAME] Hose. * On 6/10/25 at 2:56 p.m., observed Resident #133 in the room wearing shorts. The resident was not wearing [NAME] Hose. * 106090 Page 2 of 5 106090 06/12/2025 Benderson Family Skilled Nursing and Rehab Center 1959 N Honore Ave Sarasota, FL 34235

F 0684 Level of Harm - Minimal harm or potential for actual harm On 6/10/25 at 3:04 p.m., CNA Staff B said she has taken care of Resident #133. She said the nurse did not tell her to apply the [NAME] hose and she has not. On 6/10/25 at 3:36 p.m., observed Resident #133 in the room wearing shorts. The resident was not wearing [NAME] Hose. * Residents Affected - Few On 6/10/25 at 3:34 p.m. RN Staff C confirmed she documented in the MAR Resident #133 was wearing the [NAME] hose, when the resident was not wearing them. Staff C said she had not put them on the resident, and she did not instruct the CNA to do it. Staff C looked for a pair of [NAME] hose in the room, but there were none. On 6/10/25 at 4:04 p.m., the DON said the nurses should not be documenting the hose were on if the hose were not. The DON said the medical record was inaccurate. 3. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE]. Review of the record revealed an order dated 12/7/24 for Depakote Sprinkles 125 milligrams (mg) Give 250mg by mouth every 12 hours for mood disturbance. On 1/14/25 the physician ordered a Depakote blood level to be drawn in the morning. Review of the laboratory results, progress notes, and MARS revealed the facility had not obtained the Depakote blood level in the morning on 1/15/25. Review of the medical record revealed the nurse had not documented why the blood level was not obtained. Review of the laboratory results revealed a Depakote blood level was collected on 4/2/25. On 6/11/25 at 12:32 p.m., the DON said the facility had not obtained the Depakote blood level in the morning of 1/15/25 as the physician ordered. He said he expects the nurses to follow the orders and document in the medical record the reason if the nurse could not follow the physician's order. *Photographic evidence obtained 106090 Page 3 of 5 106090 06/12/2025 Benderson Family Skilled Nursing and Rehab Center 1959 N Honore Ave Sarasota, FL 34235

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure accurate medical records for 2 residents (#13 and #133) of 3 residents reviewed for accuracy of medical records. The findings included: 1. Review of the medical revealed Resident #13 was admitted on [DATE]. The Quarterly Minimum Data Set (MDS) with a target date of 5/12/25 revealed Resident #13's Brief Interview for Mental Status (BIMS) score was 11, indicating moderate cognitive impairment. The MDS revealed Resident #13 did not reject care and was dependent on staff for dressing of the lower body. The MDS diagnoses included, but was not limited to, hyperlipidemia, dementia, and asthma. Review of the physician's orders revealed an active order dated 3/14/25 for Ted hose on during day, off at night. (TED hose, also known as thrombo-embolic deterrent hose, is an acronym that refers to a type of compression hosiery. They are specifically designed to help prevent blood clots, or thromboembolism, by applying pressure to the legs and feet.) Review of the Medication Administration Record for June 2025 revealed the nurses documented the [NAME] Hose were applied on 6/1/25, 6/2/25, 6/3/25, 6/4/25, 6/5/25, 6/6/25, 6/7/25, 6/8/25, 6/9/25. On 6/9/25 at 12:05 p.m., observed Resident #13 in the activity dining room area sitting in the wheelchair. Resident #13 was not wearing the [NAME] hose. On 6/9/25 at 2:49 p.m., Resident #13 was observed in the wheelchair being pushed down the hall by a friend. Resident #13 was not wearing the [NAME] hose. On 6/10/25 at 9:53 a.m., observed Resident #13 sitting in the wheelchair watching TV in the bedroom. The [NAME] hose were not applied to the legs. During an interview, the resident said she never wears [NAME] hose. She said she wore them years ago but does not wear them now and no one applies them. She said if someone told her to wear them, she would refuse. Resident #13's private duty aide was sitting in the chair near the resident. The private duty aide said she dressed the resident this morning and did not apply the [NAME] Hose. The private aide said no one ever told her to apply them. * On 6/10/25 at 2:58 p.m., during an interview with Certified Nursing Assistant (CNA) Staff A, she said if the resident refuses to put on the [NAME] hose, you tell the nurse. She said the nurse, or the CNA can apply them. Staff A said Resident #13 has a private duty sitter that dresses her and puts on the compression hose. She said the nurse would tell her to put them on if she needed them. Staff A said no one told her to apply the [NAME] Hose. On 6/10/25 at 3:23 p.m. Registered Nurse (RN) Staff C said she documented in the MAR (Medication Administration Record) that the [NAME] hose were applied to Resident #13. Staff C said the hose were not applied and the MAR is not accurate. On 6/10/25 at 3:30 p.m., RN Staff C went to the room and saw Resident #13 was not wearing the [NAME] hose. 106090 Page 4 of 5 106090 06/12/2025 Benderson Family Skilled Nursing and Rehab Center 1959 N Honore Ave Sarasota, FL 34235

F 0842 Level of Harm - Minimal harm or potential for actual harm On 6/10/25 at 4:04 p.m. the Director of Nursing (DON) said the RNs should not document any treatment that was not completed, including the [NAME] hose. The DON said the MAR was not accurate. 2. Review of the medical revealed Resident #133 was admitted on [DATE]. Diagnoses included aftercare following joint replacement, left artificial knee joint, and history of atherosclerotic heart disease. Residents Affected - Few Review of the physician's orders revealed an active order dated 6/6/25 at 7:00 p.m. for Knee high ted hose both legs every shift. Review of the MAR for June 2025 revealed the nurses documented the [NAME] Hose were applied on 6/7/25, 6/8/25, 6/9/25, and 6/10/25. On 6/09/25 at 12:17 p.m., observed Resident #133 in the room wearing shorts. The resident was not wearing the [NAME] Hose. The resident said he has not worn [NAME] Hose at the facility and does not have a pair. The resident said no one at the facility told him to wear them. He said he came to the facility with an Ace Wrap for the left leg, but it was removed the next morning, and he had not worn anything since. The original surgical dressing was observed to the left leg only. On 6/10/25 at 10:12 a.m., observed Resident #133 in the room wearing shorts. The resident was not wearing [NAME] Hose. * On 6/10/25 at 2:56 p.m., observed Resident #133 in the room wearing shorts. The resident was not wearing [NAME] Hose. * On 6/10/25 at 3:04 p.m., CNA Staff B said she has taken care of Resident #133. She said the nurse did not tell her to apply the [NAME] hose and she has not. On 6/10/25 at 3:36 p.m., observed Resident #133 in the room wearing shorts. The resident was not wearing [NAME] Hose. * On 6/10/25 at 3:34 p.m., RN Staff C confirmed she documented in the MAR Resident #133 was wearing the [NAME] Hose, but she had not confirmed the resident had them on. Staff C said they did not put them on the resident or ask the CNA to do it. Staff C looked for a pair of [NAME] Hose in the room, but there were none. On 6/10/25 at 4:04 p.m., the DON said the nurses should not be documenting the [NAME] Hose were applied to the resident if they were not. The DON said the medical record was inaccurate. *Photographic evidence obtained 106090 Page 5 of 5