Inspection·March 28, 2024

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interview and facility policy and medical record review the facility failed to implement adequate individualized interventions to prevent falls, including fall with major injury for 1 (Resident #43) of 4 residents reviewed for falls. The findings included: Review of the facility Policy titled Incident Management (no initiation date) stated, An incident is any occurrence which is not consistent with the routine operation of the facility or the routine care of a particular resident. It may involve an injury or damage to property. Incidents/accidents to be recorded, using the incident report form, and reported according to the Reporting Guidelines include but not limited to falls/found on floor. Review of the facility Policy titled Risk Management - Post Incident Evaluation, Root Cause Analysis and Plan (no initiation date) stated, The facility will use a consistent approach for post incident evaluations which will include a thorough investigation to determine how and why the incident occurred. Root Cause Analysis is a process for identifying the basic or contributing causal factors that are responsible for incidents. Root causes will guide changes in systems or processes to reduce the risk of the event recurring. Post Incident Evaluation includes Immediately following any incident - actions to support resident safety will be the priority. For falls, the Fall Risk Reduction Program will be followed to include post fall intervention and care; Incidents will be recorded according to policy; Incidents will be reported according to the reporting guideline. The Risk Manager or designee will be notified per the reporting guidelines and will be responsible for investigating and reporting any allegations of abuse, neglect, exploitation, injuries of unknown origin and or any adverse incidents as defined by State or Federal Regulation according to facility policy. Review of the clinical record for Resident #43 revealed a date of admission of 9/28/2023. Diagnoses included Cerebral Infarction (stroke), Aphasia (language disorder), Dysphagia (swallowing disorder), and Osteoarthritis. Resident #43 shared a room with his wife (Resident #37). Review of the significant change in status Minimum Data Set assessment dated [DATE] noted Resident #43 was cognitively impaired and unable to answer questions with a Brief Interview for Mental Status (BIMS) score of 99. The assessment noted Resident #43 had short term and long term memory problems. A check mark on the assessment noted Resident #43's cognitive skills for daily decision making were moderately impaired-decisions poor, cues/supervision required. (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 4 Event ID: 106098 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 106098 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Center for Rehab & Healing of Sarasota 5381 Desoto Road Sarasota, FL 34235 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)