The incident at Sarasota Health and Rehabilitation Center involved Resident #2, who staff discovered on October 31 with what a certified nursing assistant described as "a large black bruise" covering a significant portion of her right leg. The facility's investigation was riddled with missing documentation and contradictory accounts.
CNA Staff B found the bruising during evening rounds around 3:00 p.m. when she was putting the resident to bed. She immediately reported it to the licensed practical nurse on duty. The bruise extended from the resident's mid-thigh to halfway down her shin - a substantial area of injury that should have triggered a thorough investigation.
The facility's incident report, completed at 9:02 p.m. that evening, attributed the injury to the resident hitting her leg on a dining room table. The report noted "Blue/purple color skin discoloration noted to Right medial knee/shin, placement consistent on table in dining room today."
Nobody witnessed the alleged table incident.
The investigation form documented that the resident was "unable to give description" of what happened. Despite this lack of witness testimony or resident account, staff concluded the injury was consistent with hitting the dining table and recommended increasing the table height or using an overbed table instead.
Licensed Practical Nurse Staff C assessed the resident that evening and found what she described as "a blue and yellow bruise on her right knee that was approximately 3.0 centimeters x 1.0 cm." Her assessment was notably smaller than what CNA Staff B observed - the extensive bruising from thigh to shin.
LPN Staff C acknowledged the uncertainty around the injury's cause. "It was consistent with hitting the table but, We cannot assume anything," she told inspectors. She said she wrote a statement about her observations and left it at the nurse's station.
When federal inspectors arrived on November 12, the Director of Nursing could not locate the statements that should have been collected from staff who discovered and assessed the injury. The DON admitted that while the Unit Manager had verbally asked staff about the incident, nothing was documented.
The DON told inspectors he "usually investigates, goes back to the previous shifts and obtain statements from staff" for incidents like this. He did not do so in this case.
CNA Staff B, who discovered the extensive bruising, told inspectors she never saw the resident in her wheelchair on October 31 and did not witness any table collision. She said the DON only called her to request a written statement on November 12 - the day inspectors arrived, nearly two weeks after the incident.
The facility took some immediate action, ordering an X-ray "out of abundance of precaution" and determining the resident did not need hospitalization. Staff noted the resident reported no pain from the injury.
The case highlights a fundamental breakdown in the nursing home's incident investigation process. Federal regulations require facilities to investigate injuries to residents and document their findings. When a resident sustains unexplained bruising covering a large area of their body, proper protocol demands collecting witness statements, reviewing circumstances, and maintaining detailed records.
Instead, Sarasota Health and Rehabilitation Center created a narrative about a dining table collision that nobody witnessed, failed to collect statements from key staff members who discovered and assessed the injury, and only began requesting documentation when federal inspectors arrived.
The DON's admission that he "didn't know where or when the resident sustained the bruising" but believed it was "consistent with the resident hitting her leg on the table" exemplifies the facility's approach - reaching conclusions without conducting a proper investigation.
LPN Staff C's statement that "We cannot assume anything" about the injury's cause stands in stark contrast to the facility's quick attribution to a table collision. Her written statement, which she said she left at the nurse's station, was among the missing documentation inspectors could not locate.
The resident involved was unable to provide her own account of what happened, making the staff investigation even more critical. When residents cannot advocate for themselves or explain their injuries, nursing homes bear greater responsibility for thorough, documented investigations.
Federal inspectors cited the facility for failing to conduct an adequate investigation and maintain proper documentation of the incident. The violation affected few residents but represented minimal harm or potential for actual harm - a rating that reflects the investigative failures rather than the resident's physical injury.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sarasota Health and Rehabilitation Center from 2025-11-12 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Sarasota Health and Rehabilitation Center
- Browse all FL nursing home inspections