Health inspection·September 1, 2022

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility's policies and procedures, staff and resident interviews , the facility failed to immediately report an alleged violation that could constitute neglect within specified time frame to the State Survey and Certification Agency for 1 (Resident #75) of 3 residents reviewed for incidents. The findings included: The Facility policy titled, Incident Reporting for Residents or Visitors revised 1/13/2017 noted, All accidents and unusual occurrences involving a resident or visitor will be documented and reported so as to meet all regulatory (state and federal) . requirements. Unusual Occurrence or Event. Any event not consistent with routine resident care; Any event reportable to federal and state agencies as defined by those agencies; An event or happening involving a resident . with unintended, undesirable, or unexpected results or outcomes. Review of the clinical record revealed Resident #75 was admitted to the facility on [DATE]. The 5-day scheduled Minimum Data Set (MDS) assessment with a target date of 8/24/2022 noted Resident #75 scored 15 on the Brief Interview for Mental Status, indicating intact cognition. Resident #75 required extensive physical assistance of two persons for transfers (How resident moves between surfaces, including to and from bed, wheelchair). The Care Plan initiated on 12/8/21 noted Resident #75 was at risk for falls related to impaired mobility secondary to paraplegia (paralysis of the lower body) due to lumbar osteomyelitis (inflammation of bone caused by infection). The care plan was revised on 2/7/22 and documented, Fall with injury noted. On 2/13/22 the care plan noted Hip fractured [sic] noted via radiology report. The facility's investigation for the incident of 2/7/22 included a typewritten statement dated 2/8/22 noting Resident #75 was interviewed related to the pain in his leg. Resident #75 stated during the transfer via the Hoyer lift (Total body electric lift) he was uncomfortable and demanded to be lowered to the floor. When lowered to the floor his right leg was to the right side of the lift and while on the ground he noted to be in pain. The Nurses Progress Note dated 2/8/22 at 10:03 a.m., noted Resident #75 reported pain to the right lower extremity. Resident has been medicated with routine pain medications per orders. The physician was notified, and new orders received to send the resident to the emergency room for evaluation and treatment. The Emergency Department physician's note dated 2/8/22 at 10:41 a.m., noted Resident #75 stated at Page 1 of 4 106102 106102 09/01/2022 Sarasota Point Rehabilitation Center 2600 Courtland Street Sarasota, FL 34237

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few his nursing facility staff was trying to lift him with a Hoyer lift and his leg got caught resulting in significant amount of pain in his right anterior thigh. concerned because this morning he woke up with excruciating leg pain and increasing swelling. The X-Ray of the pelvis dated 2/8/22 noted, Clinical Indication: Fall. Hip pain. Result: Generalized osteopenia (reduced bone mass). No acute fracture or dislocation is seen. The Nurses Progress Note dated 2/8/22 at 3:09 p.m., noted Resident #75 returned from the hospital with no acute changes. No acute fractures found from the X-ray. The Nurses Progress Note dated 2/13/22 at 3:30 p.m., noted Resident #75 called EMS (Emergency Medical Services) to be transferred to the hospital, due to pain. The Hospitalist History and Physical report with a date of service of 2/13/2022 noted Resident #75 . presented to the Emergency Department with complaints of right thigh pain. Patient was dropped while trying to move into a Hoyer lift, after which he developed right thigh pain. Patient was seen in the Emergency Department about 4 days ago where he had an x-ray and venous doppler were both negative for acute findings he was discharged back to the nursing facility. CT (Computerized Tomography) right hip subcapital right femoral neck fracture. and soft tissue swelling . On 8/29/2022 at 11:25 a.m., Resident #75 said he sustained a broken right femur on February 7, 2022, when he was dropped from the Hoyer lift. The resident said four staff members manually picked up each corner of the Hoyer sling. The sling slipped out of their hands, and he was dropped to the ground. He said he immediately felt pain. Resident #75 said he was sent to the hospital on 2/8/22 but the right hip X-ray came back negative for a fracture. He was discharged back to the facility but continued to have pain and bruising to his right upper leg. He continually complained of pain to everyone, including his doctor on 2/13/22. Resident #75 said he called 911 himself on 2/13/22 because he was in severe pain. The CT scan done at the emergency room showed a right femur (thigh bone) fracture. On 8/30/2022 at 10:45 a.m., the Administrator said the facility did not report the incident to the State Survey Agency. He said Resident #75 was not dropped, he was lowered to the ground. He said there was no documentation of the incident in the Resident's medical record. He said he conducted a full investigation after the incident. The resident told him he was flailing in the Hoyer lift and asked to be lowered to the ground. After landing on the ground, he developed right upper leg pain. He said the resident then agreed to let staff move him from the floor to the bed using the Hoyer lift. He said the resident was complaining of pain the next morning, so he was sent to the hospital for evaluation. He said his first x-ray report was negative. The incident was never reported to anyone by the involved staff. The Administrator said he concluded the incident was not avoidable, so it was not reported. 106102 Page 2 of 4 106102 09/01/2022 Sarasota Point Rehabilitation Center 2600 Courtland Street Sarasota, FL 34237

F 0791 Provide or obtain dental services for each resident. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility's policies and procedures, observation, staff, and resident interview the facility failed to promptly obtain needed dental services for 1 (Resident #18) of 1 resident reviewed with repeated requests to see a dentist for dental pain. Residents Affected - Few The findings included: The facility policy Dental Services SHC04004.08 revised 8/29/2017 read, The facility provides each resident with access to dental services. Residents will be referred to a dentist based on assessed need. The facility will obtain services of a qualified dental provider.Basic services will be provided in-house. Facility staff will assess dental status through the interdisciplinary resident assessment process and daily provision of care. The physician, residents and family/responsibility party may request dental services at any time . Social Services designee will be responsible for coordinating dental services in the facility. Review of the clinical record revealed Resident #18 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment with a target date of 12/29/21 noted Resident #18 had no natural teeth or tooth fragments (edentulous). The Quarterly MDS assessment with a target date of 6/29/22 noted the resident scored 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. The care plan initiated on 12/20/21 noted Resident #18 had dental health problems related to being edentulous. The goal was for the resident to be able to eat and drink free of pain through the next review date. The interventions included to monitor for signs and symptoms of oral/dental problems such as pain to gums, toothache, palate, abscess, teeth missing, loose, broken, eroded, decayed. Coordinate arrangements for dental care, transportation as needed/ordered. On 8/29/22 at 2:30 p.m., Resident #18 said for the past eight months she has repeatedly asked to see a dentist since her admission to the facility. The Resident said she had missing teeth and her gums hurt. Observation of the resident's mouth on 8/29/22 at 2:35 p.m., with her permission showed red gums and small pieces of damaged teeth. Resident #18 said she has not seen a dentist since her admission to the facility. On 8/31/22 at 10:38 a.m., Resident #18 said she has pain when chewing and when the food goes into the open pockets in her gums. The staff give her Tylenol, but feels she needs something stronger. Resident #18 said her brother has also called to find out why they have not done anything with her teeth since she has been here for almost a year. Resident #18 said she spoke to the social worker again one week ago about her teeth and seeing a dentist. Review of progress notes revealed on 4/1/22 the dentist documented, Unable to locate patient-attempted twice. 106102 Page 3 of 4 106102 09/01/2022 Sarasota Point Rehabilitation Center 2600 Courtland Street Sarasota, FL 34237

F 0791 Level of Harm - Actual harm Residents Affected - Few On 5/2/2022 the dental hygienist documented Resident #18 stated she has pain all over and would like dental care. Finding/Observation: . Possible fistula (abnormal passage) #7 facial, generalized root tips and severe gingival (gums) redness and swelling. Very large bilateral mandibular [NAME] (bumps in both sides of the lower jaw made of bone tissue covered by gum tissue). She needs to be seen by a dentist and have radiographs to review. On 6/7/22 the dental hygienist documented Resident #18, stated she has pain all over and would like dental care. Finding/Observation: . She pointed to the root tips on the upper anterior and 31 area root tip. She expressed more interest in the area on the lower right (31) causing pain. She asked about pain medication. The floor nurse stated she will administer Tylenol. Informed the floor nurse she needs the dentist to examine and radiographs to determine treatment plan. I stressed the need for the dentist to examine the patient. Informed the resident of severe gingival swelling and redness especially lower right . Possible fistula #7 facial, generalized root tips and severe gingival redness and swelling . On 9/1/22 at 8:57 a.m., the Social Services Director said the dentist and or the dental hygienist are at the facility every month. He confirmed Resident #18 had not seen the dentist since her admission on [DATE] and said, I apologize for that. He said since Resident #18's admission, the only intervention implemented for her dental issues/pain was Tylenol. The Social Services Director said there was no system in place to follow up and ensure residents who need dental services were seen by the dentist. He said Resident #18 asks him to see the dentist almost every day. He has sent multiple emails to the dentist on her behalf. On 9/1/22 at 9:53 a.m., Certified Nursing Assistant (CNA) Staff H said Resident #18 complains of teeth pain at least twice a week and she informs the nurses. On 9/1/22 at 12:04 p.m., the Director of Nursing (DON) said she was aware of Resident #18's requests to see the dentist. She said, She did ask me to see the dentist. The DON said she thought the resident's request for dental care was being addressed. The Administrator who was present during the interview said, I am not the person to ask about a reasonable time frame when asked about suitable time frame to see a dentist. The DON said they will have Resident #18 see the dentist immediately. 106102 Page 4 of 4